Malnutrition and TB are intimately linked: Malnutrition weakens the immune system, increasing susceptibility to the disease, while TB reduces appetite, worsens the absorption of micronutrients and alters patients’ metabolism.
Donors suspended all but emergency assistance to Madagascar in 2009, after President Marc Ravalomanana was deposed in a coup d’etat. The paucity of donor funding has seen food assistance dwindle “to a very serious level”, said Xavier Poncin, head of the TB programme at the UN World Food Programme (WFP) in Madagascar.
The impact of Cyclone Haruna, which struck the country in February, has compounded the problem. Since the cyclone, the donors’ food supply chain has been intermittent, Poncin told IRIN.
TB cases are already appearing to increase. Voangy Rasoarinindrime, head of the TB treatment centre in Toliara, told IRIN that in the first three months of 2012, 56 new cases were registered for treatment, compared to 68 cases for the same period this year.
“Many people can come into contact with TB, but [do] not become sick if they are healthy enough to fight off the illness. But now that food is scarce after the cyclone, many people have low immunity and so the illness takes root,” she said.
Less food aid, less treatment
Madagascar’s National Programme Control of TB (PNLT) said 2012 saw 26,182 confirmed cases of TB, although the total number of infections is thought to be about 50,000.
About five percent of cases are fatal. Nine percent of those treated for TB do not complete the six-month treatment regime, risking the onset of multidrug-resistant tuberculosis (MDR-TB). WFP estimates that about 0.49 percent of all TB cases in Madagascar are MDR-TB.
Food supply at the TB treatment centre in Toliara was depleted in February, in the aftermath of Cyclone Haruna, said Rasoarinindrime. “People are unable to work during treatment, and they still need to feed themselves. We have some patients who left. They said since there was no more food aid here, they would have to go back to work to feed their families,” she said.
"I’m afraid fewer people will actually be completely cured and that this will cause an augmentation in the amount of cases"
Food aid “also encouraged people to come here and receive treatment in the first place. Now they are very upset that there is no more food. Some still come from the remote regions with their baskets ready to receive their rations,” Rasoarinindrime continued. “I’m afraid fewer people will actually be completely cured and that this will cause an augmentation in the amount of cases.” Some of Madagascar's TB patients receive food aid from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Others receive food from WFP’s Food by Prescription (FBP) programme, which targets 23,000 beneficiaries - both TB patients and their families - during the six months of treatment. But the FBP programme has been temporally suspended in 22 of 51 health facilities due to WFP Madagascar’s funding shortage.
“If the lack of funding persists, the situation might even worsen as food availability in the pipeline allows for programming in the few remaining partner health centre until September 2013,” said WFP’s Poncin.
Senaz Ratsimbazafy, a 26-year-old waitress in Toliara told IRIN she began feeling sick in November 2012. “I couldn’t breathe and I coughed all the time,” she recalls.
After she was diagnosed with TB, she left her job and was put on the six-month course of antibiotics. In the first months of treatment, she received food assistance for her and her 80-year-old grandmother. “Now, my father’s family have to help us, as there is no more food aid, and I can’t go back to work for another two months,” she said.
Waiting for improvement
According to a 28 March 2013 country briefing by the UN Food and Agriculture Organization’s (FAO) Global Information and Early Warning System (GIEWS), Cyclone Haruna affected about 42,000 households. Meanwhile, a locust infestation is thought to have affected half the country, and rains have been erratic. “An estimated 13 million persons [of the country’s 20 million people] are potentially at risk” from food insecurity in 2013-14, the briefing said.
"Despite an increasing number of people living below the poverty line, most international donors are still limiting their support due to the political situation"
“Despite an increasing number of people living below the poverty line, most international donors are still limiting their support due to the political situation. And this has direct consequences on WFP programmes,” Poncin said. More than three-quarters of the population now live on less than US$1 a day, according to government figures - up from 68 percent before the political crisis. Elections are scheduled for July; if they are judged “free and fair”, more donor support could be unlocked.
There are other barriers to TB treatment, as well. Eighty percent of the population is rural, and 65 percent live 10km or more from a health centre.
“We had a woman here recently who refused treatment completely,” Rasoarinindrime said. “She lived in a remote region and insisted she had to go back and take care of her family. I told her, ‘You will die and you will contaminate your family.’ Moreover, it might create and contribute [to] spreading multidrug-resistant TB, which is much more difficult to treat - but she left anyway.”
Laundry worker Celerine Ravaonirina, 46, lives 14km from the clinic where she is receiving treatment for TB. Because she has to care for her four children, she travels to the clinic and back each day. “In the beginning, we paid for a pousse-pousse [rickshaw], but now I’m able to walk,” she said. “However, I’m still not able to work.”
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