Asma Elsony led the tuberculosis programme in Sudan at the same time as she took her doctoral degree under the supervision of Professor Gunnar Bjune of the Department of General Practice and Community Medicine, University of Oslo in Norway.
During her doctoral degree studies she became President of the International Union against Tuberculosis and Lung Disease as the first African and the first President from south of the globe. During her presidency the Board moved with the DOTs model to other public health lung problems – one of many other achievements.
One of the problems – and this applies to very many countries – is that it takes far too long to diagnose tuberculosis.
“The delay in diagnosis is considerable, regardless of whether people ask for medical help in Sudan, Ethiopia or in a western country such as Norway. Even though a person can already pass on the infection when the coughing starts, it takes on average two months for the correct diagnosis to be made. And then two weeks after the start of treatment for the risk of infecting others to pass,” Professor Bjune points out, to the research magazine Apollon at the University of Oslo in Norway.
Worst for the poor
Tuberculosis is an airborne infection and most frequently strikes poor people. The risk of infection is highest in cramped homes with little ventilation. Without treatment half of those infected die – most of them between the ages of 30 and 50.
In the nineties, between 20,000 and 27,000 thousand tuberculosis cases were detected annually in Sudan. The peak was reached in 1999 when so many had finally been treated that fewer were infected. Since then the trend has declined, and the annual figure has now fallen to 16,500.
A total of 230,000 people were treated between 1991 and 2005, when Dr Elsony left the tuberculosis programme.
“This means that under her leadership more than 100,000 people were saved by the tuberculosis programme. But this figure can be multiplied by three: when adults die, many of their children also die from poverty,” the professor tells us.
There is very little contact between Sudan’s 19 universities and the healthcare personnel in rural communities.
“So we really needed an institution that could combine research with public health. To learn more about how to prevent epidemics you need both statistical analyses and substantial contact between research environments and the healthcare personnel in the field,” says Dr Elsony.
Three years ago she founded an “epidemiological laboratory” called Epilab.
“It has become the long-awaited link between research and healthcare personnel out in the rural districts. The goal is to cover the whole field where the primary health service needs research support. If healthcare personnel try and fail, and only base their efforts on guidelines, there’s a risk of many mistakes occurring,” Professor Bjune tells us.
The institution was the first one of its kind in Africa. They used experience from combating tuberculosis to compile complete monitoring programmes for HIV, malaria, asthma and pneumonia as well as for diseases stemming from harm caused by tobacco and industrial pollution.
One problem in poor countries is under-registration. Statistical analyses often show more cases of tuberculosis among men than among women. Since men are not infected more easily than women, such figures often mean that the health service gives priority to men.
“So it’s important to study gender-dependent data to see whether the health system is functioning. In Sudan the figures are the same for both sexes. The figures also show that more children and old people are treated than was previously the case, which means that the health programme actually reaches areas where people live,” Dr Elsony points out.
Epilab is located in cramped and crowded offices in Khartoum. Up to now six students at Epilab have taken a degree in community health at the University of Oslo. Epilab also collaborates with 20 other universities worldwide. The students “pay back” their education by doing unpaid work for Epilab.
HIV has become the twin disease of tuberculosis: the diseases activate each other. The countries worst hit are those with a high incidence of HIV such as Ethiopia, Zambia, Malawi and Tanzania.
“More than half of those infected by HIV die from tuberculosis. So tuberculosis control is important in HIV-infected areas. If the intervention is made early in a HIV epidemic, tuberculosis can be controlled with quite small means – as Dr Elsony’s result show,” the professor tells us.
In North Sudan three to four per cent of those who are treated for tuberculosis die. In countries with many HIV cases the corresponding mortality rate is ten to twenty per cent.
If all those with coughs were to be examined for tuberculosis, the health service would be stretched beyond its limits. Less than a tenth of those who are examined have tuberculosis bacilli in their expectoration, i.e. in the mucus they cough up.
Among those who are infected, ten per cent develop the disease. Some of them only fall ill after 30 to 40 years. There is therefore no point in treating all those who are infected.
“In Norway between 300,000 and 400,000 people have latent tuberculosis. They will not benefit from medical treatment. A distinction must be made between latent infection and the actual disease. So we need a simple test that can quickly identify who needs a thorough examination for tuberculosis,” Professor Bjune points out.
The goal is to make something as simple as a strip of paper that changes colour if the person examined is ill.
“And the test must also be so cheap that developing countries can afford to use it.”
Asma Elsony recently visited Oslo along with a number of international tuberculosis researchers to apply for funds to develop a tuberculosis test. If the money materializes, the test can be ready in three to four years.
The search for a new vaccine
Today three out of four children in Sudan are vaccinated with the BCG vaccine. The vaccine only works on children. There are no vaccines against tuberculosis for adults.
BCG provides only limited protection. Despite being vaccinated, children can contract a latent infection that develops when they reach adulthood. Nor does BCG prevent the spread of the infection. Many researchers are therefore working on developing new vaccines against the disease.
“In order to be able to test whether the new vaccines work we need new tests that can distinguish between those who have tuberculosis and those who have developed antibodies through vaccination.”
Gunnar Bjune and Asma Elsony are now collaborating with a large international network to find out which antibodies distinguish ill people from healthy.
Asma Elsony’s work has at times been obstructed by the government in Khartoum. She is very concerned about human rights and about ensuring that everyone gets equal treatment – regardless of their political, religious or social affiliations.
In the ten-year dark period in Sudan, the Islamists ruled with no moderating influence. They wanted to have their own people in key positions. Dr Elsony’s husband spent seven years in prison for political opposition.
“The government often threatened to get rid of Asma Elsony and replace her with a yes-man who was loyal to the regime. But she had such good results that nobody dared replace her. In addition, through the University of Oslo she acquired international contacts who followed her progress carefully,” Professor Bjune tells us.
“Sometimes the government has made things difficult by harassing people from Epilab. But the government is now realising that Epilab is helping, so there hasn’t been any opposition over the past few years,” adds Dr Elsony.
Even during the civil war and the Darfur conflict she conducted the tuberculosis programme throughout the country.
“Even though it was impossible to travel from north to south during the civil war, she solved the problems by meeting the local healthcare workers from South Sudan and Darfur in Ethiopia where they exchanged results and discussed strategy. And she got medicines into the country,” Professor Bjune confirms.
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