Tuberculosis: nurses’ work continues

Abstract

During the 1950s when I began orthopaedic nurse training, the long-stay wards held many patients with tuberculosis (TB) of bone and joint, some as young as age two. Those early nursing experiences deeply impressed on me the intractable link between poverty and chronic infectious diseases such as TB. However, hope was on the horizon. We delivered the new ‘miracle’ chemotherapies that had recently become available. Ninety-day, combined courses of Streptomycin (involving painful, daily intramuscular injections), isoniazid and para-amino salicylic acid (that induced terrible nausea) were administered to patients alongside the ‘old technologies’ that had been used since early in the twentieth century. As students we learned the old mantra for TB treatment: ‘rest, prolonged, continuous and uninterrupted’. The majority of patients were still immobilised for two years or longer. Nutritious food was provided as far as possible (rationing of some items was still in place in the UK seven years after the end of the Second World War). Fresh air was encouraged irrespective of the weather. Nevertheless, we cared for patients with the expectation that new drug therapies would soon make TB a disease of the past. The current issue of INR illustrates how premature and perhaps naïve were our hopes and expectations. In his Guest Editorial, Dr Tesfamicael Ghebrehiwet reports how the terrible scourge of TB continues, often as a secondary disease burden accompanying AIDS. Two articles in this issue provide further evidence of TB’s continued presence. From Peru we hear of an eight-year ethnographic study, which involved observations of nurses and patients undergoing treatment for multidrug resistant TB (MDR-TB). As the authors point out, ‘neither the forms of emotional support nor the means used by nurses in resource-poor settings have been much written about’. In this article we learn that the excellent clinical outcomes to a two-year treatment process could be attributed in large measure to the ‘unique community orientation of the nursing team’. The nurses were concerned not only with physical health, but also the emotional and mental health needs of their patients. They encountered, and helped their patients deal with problems such as stigma, domestic violence, poverty and other barriers that had an impact on health outcomes and treatment. As a former community nurse, I felt proud to read of the detailed strategies employed by the nurses as they helped their patients to cope with the minutiae of their lives with MDR-TB. Equally important are the lessons in an article from South Africa on training for nurse trainers in an approach to lung health (involving four conditions, including TB). Crucially, in view of what we learn from Peru, the training programme aimed to ‘minimize didactic transference of information and to promote individual training style . . . to take full responsibility through interactive discussions . . . and applicability of key messages’. Feedback showed an increase in trainers’ self-awareness and self-confidence. These are essential attributes if nurses are to be empowered to work in patient-centred ways with populations in such great need and with so many difficult problems to overcome. Today the Directly Observed Therapy Short Course (DOTS) is strongly recommended to ensure that patients complete the various drug regimes and combinations. Success in DOTS, as nurses know, also depends on many other types of support for patients and their families. Fifty years after my nurse’s training, TB is far from a disease of the past. The articles from Peru and South Africa show us that nurses still provide excellent care for TB patients and their families. Even as technology develops and changes, informed, diligent nursing care for TB patients is as much needed today as ever before.