Charlotte and I spent a fair bit of last week in the TB unit. Due to financial and staffing constraints, the hospital has not been able to commit a dedicated staff member to running the program. Dr. Elspeth Young, who also runs the HIV/AIDS clinic, has been trying to give some guidance, but she is very stretched with many other duties and is supposed to be only part time. I think I mentioned earlier that she and her family will be returning to Australia this summer indefinitely to help their son (who has grown up here in Nigeria, as Elspeth did) transition into university there. Pip Mychael, an occupational therapist also from Australia, has also been helping- but they will be leaving for at least 6 months later this year as well. Char and I attended a one day TB training put on by the state TB program a couple of weeks ago which was quite good. The state program is designed to be largely implemented by primary health care workers who may not even have nursing training, based on WHO/STOP TB materials. We are lucky that there is a fairly good infrastructure in place to support the TB program, with free drugs (except when they run out, which creates quite a mess). Unfortunately there is no compensation to the hospital for providing the TB services, other than it being an important community service. Most TB services are provided through the state run primary health centres. So it has been difficult for the hospital to prioritize a dedicated staff member for the program. It ends up that whichever nurse is in the outpatient department when someone comes for meds ends up going to the TB room to dispense them, but since they are often not familiar with the intricacies of the program many things end up getting missed. It has reached a point that the state program has suggested that they may transfer the TB program elsewhere. Although we are able to get chest x-rays at the hospital here, in the smaller centres, diagnosis is just by sending sputums for AFB’s. We do not have the ability to do cultures (at least routinely), so that makes things difficult- also no bronchoscopy. Many of the HIV patients end up being treated for a suspect CXR alone. Apparently here ½ of the HIV patients presenting have TB, and 1/3 of the TB patients have HIV. Contact tracing consists of letting patients know that any family members who are also having prolonged coughing should come in to be evaluated. Very little prophylactic treatment is done, although I did see that one infant of a positive mother is on prophylaxis. Patients who have defaulted are not routinely followed up on due to lack of resources, although I am hoping we can work at that in the future. The medications being dispensed are not tracked or recorded, much information is missing from the treatment records, and the hospital does not keep a current comprehensive record of patients being treated (although the state may have a record). There is only a box with close to a hundred treatment cards, at least a third of which look to be defaulted. Charlotte has agreed to focus her energies on the TB program along with a community health extension worker, so I am hoping that we can spend the next few weeks doing some focused training and improve the clinic functioning. It is satisfying work, since I have a fair bit of knowledge about the different components of TB management from a public health perspective, the problems we are seeing are very fixable, and it will likely be of significant benefit to the individuals in the TB program as well as the community at large. So I am hoping to focus my energies here for the next while, although I am also starting to help with some things for the HIV/AIDS clinic.