Cindy Gibb is a nurse and has worked in Tajikistan
When I arrive in the Médecins Sans Frontières office at 8am it’s already quite hot. Today a high of 40C is expected, even though summer is still to arrive. As I sit in the baking sun I try to remember that this is a welcome change from winter, when temperatures were as low as -20C. I have been working as a nurse here in Dushanbe for seven months. Our project is new, having started last October. Tajikistan has the highest estimated prevalence of tuberculosis (TB) in the World Health Organization’s European Region. It is also thought to have one of the highest rates of multi-drug resistant TB (MDR-TB) in the world. Yet until our project began, TB treatment was only available to adults who met certain criteria, and not to children. Tuberculosis is difficult to diagnose in children, mostly because they generally do not produce sputum, which is required for diagnostic testing. Also MDR-TB in children is a relatively neglected disease, with little worldwide research.
Our project is significant – both for Médecins Sans Frontières and globally – because we are developing guidelines and strategies which previously haven’t existed. This poses several challenges, but for each of these I receive numerous rewards from this country. The scenery alone is stunningly beautiful (with 93% of the country covered in mountains there is a postcard view everywhere you go), and the people are the most hospitable I have ever encountered. Seeing how gracious the men are, how cheeky the children are and how beautiful the women are in their bright floral dresses and headscarves it can be easy to forget the daily struggles that people here face. But with 83% of the population living below the poverty line, you don’t have to look far to be reminded. My job includes overseeing the nursing care in the two paediatric facilities we work in, with the aim of increasing the quality of care. I also coordinate outpatient care and establish connections and train people within Ministry of Health and community health facilities. I also write reports and paediatric TB treatment policy papers, coordinate case finding and contact tracing and review the epidemiology database.
"Tuberculosis is difficult to diagnose in children, mostly because they generally do not produce sputum, which is required for diagnostic testing. Also MDR-TB in children is a relatively neglected disease, with little worldwide research."
At 9:30am today I’m with our paediatrician reviewing the children admitted to the paediatric TB hospital. Today there are 27 children, some of whom will call this place home for six months. As well as overseeing the treatment given by nurses, I note how the children deal with side effects such as vomiting, dizziness and joint pain. I also pay close attention to the intensive care needs of children with TB meningitis. After reviewing the inpatients, it’s time for lunch in the office. This is when the whole team comes together. Today we are having osh (or plov) - the national dish of rice fried with lamb, carrots and juniper berries – served with fresh bread, salad and locally grown watermelon. I practice speaking Tajik and although I still rely heavily on my translator, Shabnam, I love that I can communicate directly with colleagues and the families we work with. However at times this is bittersweet as I recall my first Tajik lesson with our first MDR-TB patient – a 7-year-old boy with the longest eyelashes I have ever seen, who sadly passed away earlier this year. Each time I count in Tajik I remember him fondly.
Our outpatient program has been busy lately – it recently grew from 10 to 13 patients within a week as patients were discharged from hospital. Yesterday I visited Nazira and her young son, who are both receiving MDR-TB treatment. Nazira’s family lives in a hard-to-reach village north of Dushanbe. The journey involves one hour driving on a sealed highway, an hour on a dirt road on a cliff edge, followed by an uphill walk for 20 minutes, which is a struggle best suited to the donkeys that overtake us. But every time we come here we are amazed by the almost unbearable beauty of the untouched mountains surrounding us. In winter, this community will be virtually cut off by snow, so we are already considering the need to do part of the journey by donkey. The home visit went well. This family has no health facility nearby so we have trained a community volunteer to provide the daily medications and monitor side effects. This is a big undertaking as it means directly observing Nazira and her son taking a handful of medications six days a week. They also both need a daily injection for the first six months at least. Nazira is courageous and compliant with her treatment, but for her 4-year-old son some days are easier than others.
Next week I’m going to visit Nazira’s sister’s family, who live on the other side of Dushanbe. This family is a mosaic of ‘family TB’. This sister and her two children are all sick with MDR-TB, and last year one of Nazira’s other sisters died from this disease. Identifying close family contacts is an important part of the project, given the strong family ties in the region and the tradition of many families living in one household. As we enter Ramadan I’m looking forward to becoming more immersed in this rich culture. But for now it’s time to leave on a home visit. It’s far away… I’ll be back tomorrow.