Examining roles of men in heightening TB cases

The World health Organisation (WHO) observes that Nigeria is one of the countries with the highest TB caseloads globally and number one in Africa.

Also, the National Tuberculosis and Leprosy Control Programme (NTBLCP) expresses concerns about the high burden of TB in the country.

Worried by this, NTBLCP has declared that "Nigeria is sitting on a keg of gunpowder with 440, 000 new infections recorded yearly."

Medical experts have, therefore, noted that TB cases have been on steady increase and there ought to be a mechanism to check the growth.

Medical statistics released by authorities show that no fewer than 207, 000 new cases of TB were identified in 2021, while there are almost 300, 000 unattended cases of TB in the country yearly.

These 300,000 cases are alleged not detected or reported and observers note that the carriers could be transmitting the disease to the society.

NTBLCP also cautioned that one un-intervened case of TB has the capacity to affect 25 other people, observing that only 27 per cent of Nigerians know that they have tuberculosis.

Medical sociologist note that the prevalent rate of TB spread by men is worrisome because of fear of social stigma in the event of diagnosis that results in being positive.

According to them, most men delay getting tested for the disease or refuse to go for test even when the symptoms are evident.

They note further that in some cases, "when married men test positive for TB, they may withhold the information from their family, increasing the rate of its spread."

Experts note that the bacteria that cause tuberculosis are spread from person to person through tiny droplets released into the air via coughs and sneezes.

The bacteria are spread when an infected person coughs or sneezes.

The symptoms occur include a cough (sometimes blood-tinged), weight loss, night sweats and fever.

Healthcare Practitioners Abatan Matthew and Ogunsakin Adesoji posit that in addition to men accounting for more than 60 per cent of those who developed TB, men also accounted for more than 63 per cent of deaths among people who had TB.

The National Tuberculosis and Leprosy Control Director, Dr Chukwuma Anyaike, notes that stigma can affect men's health-seeking behaviour in the country and is a factor that drives the global burden of TB.

Anyaike believes that stigma does not only harm the men affected by TB but reduce healthcare workers' commitment to high-quality healthcare service delivery in the country.

"Excessive stress, with probable undernutrition, gives room to TB infection," he notes.

However, experts say the ailment is curable in most cases if the right treatment is available even as drug-resistant TB is becoming more prevalent and can be fatal.

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 Isah Dogara, 39, a miner from Iowa community about 35km from Gwagwalada in the Federal Capital Territory, said his belief in traditional medicine made him to infect his wife and the late mother with TB because he feared that being diagnosed with the disease would make him vulnerable.

Dogara believed he was cursed when he started coughing and preferred to take 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.

He failed to recognise that the symptoms were due to TB because he called it an ordinary cough but had suffered from it for more than two years before he reported at the University of Abuja Teaching Hospital Gwagwalada, after a prolonged period of self-medication with local herbs.

According to him, it was after nine appointments with the doctors that he was finally diagnosed with TB.

He, however, said that his cousins doubted the diagnosis and advised him to go for higher traditional medication apart from the one he took earlier.

"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 said.

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

Another TB victim, Mrs Paula Bitrus, 54, who was a teacher, said she was diagnosed with multi-drug resistant TB (MDR-TB) and HIV and spent more than 21 months caring for her late husband who was paralysed and down with TB but refused to go to the hospital because of the stigma associated with it.

Bitrus noted that she 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.

She said her husband died because of 'what people will say' syndrome, adding that her husband was afraid of taking back seat in the church and later died from inflammation in his lungs induced by severe coughing.

"The bacteria induce fevers and sweats, particularly at night. We suffered. No drug was 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.

Mr Khali Adamu of Bwari Local Government Area in the FCT, narrated 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. In spite of the availability of free treatment, 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 and 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.

Buttressing this claim, 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.

"Health workers find it difficult to enroll men in treatment once they were diagnosed, 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.

She said that men always complain about the duration of treatment and they easily believed that TB was not caused by bacteria, but rather caused by poisoning and witchcraft.

"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 had a much better prognosis than those who show up too late to health facilities.

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 believed that in terms of healthcare, women and children were given special treatment, while men are left out.

They believed 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.

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

Anyaike added that "excessive stress, with probable under-nutrition, give room to TB infection".

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

The 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.

"Government still maintains the equitable distribution of healthcare delivery in the country," Anyaike said.

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.

Also to change the narrative, an awareness campaign should be intensified to educate Nigerians on the realities of TB and for them to know that it can be prevented, treated and cured if diagnosed early; and the services are free. Thus, there is a need for an improved working relationship between the media and the health sector to sensitise the citizens on the prevention and treatment of TB and where they can access free treatment.

Any measure that would enhance universal access to treatment and drugs for TB patients should be pursued.