Home Features How men became the biggest TB casualties in Nigeria

How men became the biggest TB casualties in Nigeria

by Haruna Gimba

By Abujah Racheal 

Mr Isah Dogara, from Iowa community in the Federal Capital Territory, about 35km from Gwagwalada, said his macho attitude and belief in traditional medicine led to him infecting his wife and late mother with tuberculosis (TB) – all because he feared that being diagnosed with the disease would make him vulnerable.

Dogara, who is a 39-year-old miner, believed he was cursed when he started coughing and preferred to take “Baba Aisha” traditional medicine. Even though the cough became worse, he delayed seeking hospital care because he was told to give the medication some time to cure his uncontrollable cough.

“I failed to recognise my symptoms were due to TB, which I called an ordinary cough, which has kept me down for over two years now,” he said. “I finally reported at the Gwagwalada hospital only after a prolonged period of self-medication with Baba Aisha.”

“When I finally made up my mind to go to the hospital, it was after nine appointments with the doctors (that) I was finally diagnosed with TB. My cousins, with whom I work, doubted the diagnosis and advised me to go for a higher traditional medication apart from the Baba Aisha I took earlier,” he narrated.

“What my cousin claimed worked for other colleagues, that were also coughing, almost ended my own life, when I saw myself in the hospital,” he added.

Dogara said his wife and his late mother became infected, but never showed any symptoms of TB, adding: “But my mother died from co-morbidity of diabetes and high blood pressure while being treated for TB.”

According to the World Health Organization (WHO), TB is the 13th leading cause of death in the world and the second leading infectious killer after COVID-19 and HIV/AIDS. 

In 2020 about 6 in every ten persons infected with TB were male, with an estimated 10 million people (5.6 million men, 3.3 million women, and 1.1 million children) tested positive.

A total of 1.5 million people were lost to TB in the year. TB is an infectious disease caused by mycobacterium tuberculosis bacteria and affects the lungs of those it infects, but is curable and preventable. As an airborne disease, it spreads through cough, sneezing, or saliva. The disease affects all age groups.

Fear of the social stigma associated with a TB diagnosis makes men delay getting tested for the disease. 

In some cases, when married men test positive for TB, they may withhold the information from their family, increasing the likelihood of spreading the disease to their partner and children, who could otherwise have taken preventive action. 

It is curable in most cases, if the right treatment is available, however, drug-resistant TB is becoming more prevalent and can be fatal.

This was the case of 54-year-old, Mrs Paula Bitrus, at Abaji, a local government area, in the FCT. A former class teacher, she was diagnosed with multi-drug resistant TB (MDR-TB) and HIV and spent more than 21 months caring for her paralyzed husband who refused to go to the hospital, because of the stigma associated with TB. He later died of TB and HIV. 

Bitrus contracted the disease from her husband, who she said hid his diagnosis from her and never sought medical attention, because he was an elder in the church and concerned about possible loss of status.

“He died from ‘what will people say’ syndrome. He was afraid of getting a back seat in the church, and he died from inflammation in his lungs induced by severe coughing,” she said.

In such cases, lung function is severely diminished and corresponds to pronounced breathlessness.

“The bacteria induce fevers and sweats, particularly at night. We suffered. No drugs were working, accessing TB drugs without being registered in any of the health facilities was not possible…. Eventually, blood vessels feeding the lungs rupture, further diminishing functions and contributing to increasing anaemia. He suffered before he finally died from pride and ego,” she narrated.

The lack of knowledge of health care workers in managing TB cases and poor interpersonal relations and communication with people who have TB have negative effects on men who are expected to adhere to the long treatment schedule for TB.

Mr. Khali Adamu of Bwari local government area in the FCT, narrates his experiences as an ex-convict: “I remember how I broke out coughing, accompanied by catarrh and high fever which ended up to be a TB infection. Despite the free treatment I was told was available, I ran away from the Dantsoho Memorial Hospital, Kaduna, to Abuja, just because of isolation and maltreatment from health workers.

“I was poorly counselled on TB and my treatment ended up with poor outcomes because, the health workers throw my drugs at me, put my food by the door. I was not examined while I was there, they only ask me how I was feeling, from afar and they do so by speaking through the window.

“Such experience never made me to have hope in the treatment, so I stopped it. Sometimes, I can’t speak… because of the pains I feel around my neck to my chest. They kept on telling me to be a man, that I was acting like a woman inside the labour room, this was why I ran away.”

“When I got to Abuja, I met an NGO that gave me a better understanding of what I was feeling and how important it was for me to seek medical attention, that was the turnaround for me,” he added. 

Adamu, who had already been diagnosed with sickle cell disease had fluid building up in his lungs – a symptom typically associated with severe and long-term TB infections.

The idea of men being more resilient to illness also appears to be linked to perceptions about illness and severity. Men described a pattern of waiting to see if their condition would improve before they sought care, and only going to formal healthcare when the illness was at an advanced stage.

This was the case of Mr Augustine Ogar, who works with a construction company in Masaka district of Karu local government area, Nasarawa State. He said when he started coughing, he was not able to sleep at night, and suffered from severe chest pain.

Ogar, who is now a TB survivor, said that before he was diagnosed with the disease, he felt his problem was due to the harmattan season – and that it was the weather causing his cough.

“It is better to do a test to understand the type of sickness you have. Before I did the test, I used to go to private pharmacies and spend a lot of money. I spent up to N80,000. They were treating just the cough, but I didn’t feel better… I’m now receiving free treatment through financial support from the Global Fund, at the Institute of Human Virology Nigeria (IHVN) in collaboration with the Leprosy Mission of Nigeria.

The two organisations are supporting the private health facility where I receive treatment, Alheri Ifeoluwa Medical Centre in Masaka. I must say I am now feeling well,” he said.

Meanwhile, according to Dataphyte 30 countries are considered high burden TB countries as they accounted for 86 per cent of the new cases in 2020. Eight of these countries accounted for two-thirds of the total cases. India topped the list followed by China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa.

Continued investment in the fight against TB saw global cases fall by 2 per cent between 2015 and 2020. However, it is expected that $13 billion will be needed in 2022 to combat the scourge effectively.

It said the cost of treatment remains out of reach for those infected, as one in two TB-affected households spends more than 20 per cent more of their household income on treatment.

Dataphyte said that the TB caseload in Nigeria was attributed to five high-risk factors in 2020. The leading factor is undernourishment, followed by HIV, diabetes, smoking and alcohol use.

It said that treatment coverage is poor in the country as only about 30 per cent of TB cases were treated in 2020.

“This is a fall from the treatment success recorded in 2019, as it recorded an 88 per cent treatment success rate covering 117,150 cohorts. Thus, Nigeria is among the ten countries with the largest gap between notifications of new and relapse (incident) TB cases and the best estimates of TB incidence,” it stated.

Mrs Ekezie Eugenia, a focal person for drug resistance persons in Imo State, stressed there were differences in men’s health-seeking behaviour.

“Men have a higher prevalence of undiagnosed TB than women and can spend up to a year longer contributing to ongoing transmission in the community before receiving treatment,” she said.

“Health workers find it difficult to enrol men in treatment once they were diagnosed,” she said, adding that even once some had enrolled, they would later abscond.

“Health outcomes are often worse for patients with TB living in informal settlements, especially men,” Eugenia said. “In this job, I am yet to see a man who will not complain about the duration of treatment. They easily believe that TB is not caused by bacteria, but rather is caused by poisoning and witchcraft,” she added. 

“The consequence of men delaying seeking medical care, or keeping information from health workers, can be dire. This is the number one problem that leads them to miss the early warning signs of a more serious condition like TB. Especially when it comes to ‘silent symptoms,” Eugenia stated.

Dr Akyala Ishaku, Senior Lecturer in the Department of Microbiology at Nasarawa State University, said that men who were diagnosed with TB at an early stage have a much better prognosis than those who show up too late to health facilities.

“By putting those exams off, men patients find themselves in a much worse condition. A lot of men have the attitude of ‘I don’t need to see a doctor’. Many men convince themselves that their condition will improve on its own, not wanting to ‘bother’ a doctor in the meantime, for fear of the fact that ‘vulnerability sucks’,” Ishaku said.

Some men are worried about a bad diagnosis or a troublesome outcome.

“They see going to the health facility as a weakness. Some have the superhero syndrome., some men see themselves as forever strong and capable of handling anything,” he explained.

Ishaku stressed that first trying traditional healing also prevented many men from accessing health care facilities too.

“A major challenge that stops some men from visiting the hospital is belief in traditional medicine. Some men trust traditional medicine and oppose seeking treatment from healthcare facilities,” he said.

On the other hand, some health experts think that in terms of healthcare, women and children are given special treatment, while men are left out.

They believe that without the inclusion of men and boys in healthcare programmes, as well as greater recognition of how gender, a lack of awareness and poverty intersect to prevent diagnosis and treatment of TB, efforts to end this deadly disease will continue to be hindered.

According to the country director of the KNCV Tuberculosis Foundation Nigeria, Dr Bethrand Odume, there is a need for the government to improve men’s pathways to care. Odume said this would require interventions that consider contextual issues by addressing individual-level socioeconomic factors – but also broader structural factors of gender-related social dynamics and the health system environment throughout the country.

He said that TB is perceived and experienced as a virulent disease that hampers independent functioning, and whose treatment drains financial resources.

He said the government should look into interventions that would engage men with TB, including the need to include social protection mechanisms, promotion of wellness in the workplace and through men’s different work settings and promoting awareness, including highlighting the importance of early diagnosis and treatment.

“Engaging the private and informal sectors in the improvement of quality of TB care in these sectors, is critical to helping us to find the ‘missing patients’ with TB – including men in the country,” he advised.

According to the WHO, Nigeria is one of the countries with the highest TB caseloads in the World and number one in Africa. It does not help that the country has a high number of people living with HIV, TB’s biggest comorbidity.

Despite the decline of TB in the population, men are disproportionately affected. Some studies, such as one carried out by healthcare practitioners Abatan Matthew and Ogunsakin Adesoji, showed that in addition to men accounting for more than 60 per cent of those who developed TB, men also accounted for about 63 per cent of deaths among people who had TB, but were HIV negative.

The National Tuberculosis, Buruli Ulcer, and Leprosy Control Program (NTBLCP) Director and National Coordinator, Dr. Chukwuma Anyaike said stigma affects men’s health-seeking behaviour in the country and is a factor that drives the global burden of TB.

Anyaike said that stigma did not only harm the men affected by TB but reduced healthcare workers’ commitment to high-quality health care service delivery in the country. 

He added that “excessive stress, with probable undernutrition, give room to TB infection.”

Addressing the issue of why men became the biggest TB casualties in the country, he said they were mostly the breadwinners with the attendant exposure to environmental hazards that favoured TB infection.

He added that “excessive stress, with probable undernutrition, give room to TB infection.”

Lifestyles that may be risk factors for developing TB are smoking, and occupations such as mining, among others.

The National Director said that creating awareness and improved laboratory networks encouraged health-seeking behaviour among men, thereby showing improved case detection.

“Government is improving the strategies toward TB case detection in the country; more men coming up with TB is just confirming the obvious,” Anyaike said. “Government still maintains the equitable distribution of healthcare delivery in the country.” 

(NAN Features)

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