Tuberculosis is the disease that has been forgotten but has not gone away. While Oman has been one of the more successful nations in curbing rates of infection, Team Y finds out why doctors still face a challenge in containing a contagion that can kill.
Old habits die hard, and customs have laid the foundations for the great nation that is Oman.
But observing tradition when it comes to nutrition and healthcare can lead to an early grave.
There is a disease that has long existed, costs billions of lives and has largely been forgotten – tuberculosis.
But it hasn’t gone away, and the consumption of two of Oman’s favourite drinks – unpasteurised milk and laban – has been cited as a possible cause and risk factor for its resurgence.
Moreover, tuberculosis is seldom discussed despite affecting a quarter of the world’s population. As a health topic in schools and education classes, it is relatively under wraps.
However, when a patient is infected, it can result in his or her complete isolation from their peers.
And the extent to which the consumption of tainted milk has affected locals and residents has yet to be determined.
However, one doctor with the Ministry of Health (MoH) who wishes to remain anonymous, says there are plenty of unreported cases of the disease in the outskirts of the country.
He says: “There are two reasons for this: one, because of the lack of education among the elderly population; and two, the increase in home remedies that may or may not be medically certified.
“There was one time when I was on a weekend break in my hometown in Saham when I was called by a family member to their house. There, we met the head of the family, who was coughing up blood.
“My initial response was to take him to a hospital for a biopsy and CT scan to see if he was suffering from any other disease or cirrhosis. But, as it turned out, it was TB, and he’d been taking homemade medicines from a local ‘healer’.
“Not only did this risk his life, it put others around him at risk too. I reported this incident to the MoH, and was given a prompt response.
“We’ve since isolated him and are constantly keeping a track of the family members.
“But, I must say that the man is in the latter stages, and is finding this a hard battle. Thankfully, we got to him at the right time.”
Adnan al Habsi is one patient who has opened up about his fight with TB. He tells us: “I was diagnosed with TB in 2018, and as a tour guide who operates in Oman, it meant that I was no longer fit for my job.
“How I contracted the bacteria is a mystery, but my doctor says that it may have been down to my consumption of raw and unpasteurised milk that is used to make laban.
“When I was told that I had TB, I thought it was the world. I was contemplating suicide even to get away from the shame. My parents kept me away from the house and I was living in a flat in Barka that my friend had lent me.
“By the grace of God, I was completely cured in about eight months and after several tests confirming that my body was safe, I could return back home.
“But, there were challenges: such as teaching my parents how I was cured and how TB is actually a curable disease, and how it wouldn’t reoccur unless we were exposed to the bacteria again.”
In an interview with Dr. Ahmed al Zadjali*, a medical professional, we have learned that there is some cause for concern over a possible rise in cases.
He explains: “Tuberculosis is an infection that persists worldwide, and as expected, it has shown itself in this country too. It’s a situation – some call it a pandemic or a plague – that has been tackled up to an extent worldwide but is still a challenge in some countries.
“Thankfully, Oman isn’t one of those countries as it constantly strives and undertakes precautionary measures and has also set up facilities for detection and treatment. Albeit, the habit of consuming unpasteurised milk and its derivative products can lead to tuberculosis.
“When contracted from an animal product or meat, it is still termed tuberculosis, even though you’re exposed to a closely-related strand of the bacteria that causes bovine tuberculosis (bTB) in animals.
“This mode of transmission of the disease is quite rare worldwide – but owing to Oman’s method of milk consumption, this could pose a problem. It’s also incredibly easy to spread this or live with it for years before you even get to know that you’ve been infected.
“All of this comes down to tradition. It’s a widely believed that unpasteurised milk that is taken fresh from the udder of the animal is the most untainted and unadulterated. And while that may be true to an extent, the milk itself can host several pathogens – tuberculosis being one of them.”
As per the National Health Service (NHS) in the United Kingdom, Bovine Tuberculosis – or ‘bTB’ – is an infectious disease in cattle that primarily affects the lungs. It is thought to be transmitted within herds by the inhalation of aerosol droplets or the consumption of their milk without pasteurisation from infected cattle – but more importantly, this can infect humans too.
Humans can also contract the disease if they come into direct contact with the infected animal’s blood during slaughter through a wound on the person’s body.
Dr. Ahmed strongly stresses this point, too: “The recipe is simple. Pasteurised milk kills the bacteria and you’ll be safe – otherwise, you could put yourself and expose those around you to the killer disease.”
He’s not wrong in calling tuberculosis a ‘killer disease’ either. Despite advancements in healthcare and early detection, more than 1.3 million people succumbed to the infection in 2017, as per statistics supplied by the World Health Organisation (WHO).
Caused by a contagious bacterium called ‘Mycobacterium tuberculosis’ (MTB), the incubation of which can vary from a few weeks to two years or more, the disease generally affects the lungs and spreads to other parts of the body.
Stressing the point is Dr. John Jacob, a clinical physician and pathologist with a government hospital. He says: “The infection can show no symptoms sometimes, and that’s why the disease can be deemed as a dangerous one that sneaks up on a person when they least expect it.
“In such a case, it’s deemed a latent tuberculosis. While this means that the disease cannot be spread to other humans, it can develop into full-blown TB in the coming months or years.”
Dr Jacob then goes on to show us WHO statistics, which reveal that nearly 10 per cent of all people will have active TB in the coming years.
“The problem is detection and treatment,” he tells us. “TB, once it reaches the active stage, will show symptoms such as chronic cough accompanied by blood-filled sputum, fever, and the greatest one, weight loss.
“While those don’t seem like much, it can affect other organs. Moreover, if untreated, it can result in death arising from complications. We need to keep in mind that this was once a plague and was famously called ‘consumption’ because patients were consumed from the inside out, so drastic was the weight loss and the weakness the bacteria brought along.”
Oman is considered a ‘low incidence country’ since the late 2000s, owing to His Majesty’s healthcare plan that has helped curtail the nation’s tuberculosis outbreak from the late 1990s.
The plan has also been to provide free treatment to both active and latent tuberculosis (TB) patients for both nationals and residents as part of its ‘TB Elimination by 2050’ strategy.
In fact, Y’s research shows that Oman’s tuberculosis rate is below 10 per 100,000 population. As per WHO, this number has come down as low as 5.8 cases per 100,000 in 2016 (statistics beyond that haven’t been revealed), and the disease is being reduced by 2 per cent annually.
While those may seem like low numbers, we learn that between 2010 and 2016, nearly 2,352 people – of which 80 per cent were male and 60 per cent Omanis – were suffering from the illness and receiving treatment.
Dr. Ahmed also goes on to reveal how every government and private hospital can conduct a TB diagnosis with an X-Ray scan, allowing residents of the country to stay as safe as they can from the disease.
To reduce the influx of TB patients in Oman, the country also conducts stringent checks while admitting expats. As per the Omani law, every expat must undergo a TB test, among several others including HIV, and Hepatitis A, B, and C, when applying for a resident’s card.
All this implies Oman is moving towards becoming a TB-free nation –but we learn from a WHO report that nearly half of all TB patients in the Sultanate are aged over 60 and live in a ‘poor socio-economic state’.
However, the MoH doctor’s remarks are greeted with slightly raised eyebrows by two other members of his profession.
Dr Jacob believes that doctors in the interior regions of Oman are instructed to take X-Ray scans and report it to the authorities if they find TB marks or scarring in the lungs.
Dr. Ahmed adds: “One of the main reasons why a lot of cases of TB go unreported among Omanis is because of the wrong diagnosis.”
As per a medical expert of 20 years for TB, Dr. Prasad Kunnumbrath, who is a specialist at the NMC Specialty Hospital in Abu Dhabi, one great hindrance to detection is the “outdated” X-Ray diagnosis.
In an earlier interview with local media, he was quoted saying: “TB scars seen on X-Rays mainly arise when the outer layer of the lungs have been infected in the past but not necessarily by TB. Even pneumonia can result in a scar.
Accurate forms of detection currently include the long-used method called ‘sputum smear microscopy’, in which laboratory technicians look at sputum samples under a microscope to see if TB bacteria are present. However, this too can only detect half the number of TB cases worldwide.
As per WHO, the use of the rapid test – Xpert MTB/RIF – has expanded substantially since 2010. The test simultaneously detects TB and resistance to rifampicin, the most important TB medicine.
Diagnosis can be made within two hours and the test is now recommended by WHO as the initial diagnostic test in all persons with signs and symptoms of TB.
Yet, the Oman government still mandates the dated X-Ray diagnosis for expats during the medical procedures for obtaining a resident visa – although, several believe that it still helps cut the number of cases three-fold.
That said, Dr. Ahmed emphasises how all this is negated by the Oman law that doesn’t mandate a checkup for Omanis.
He adds, “Several of these people – both Omanis and expats – travel to other countries with higher TB rates – such as those in Africa, Asia, and certain parts of Europe – and can get infected. During these periods, both parties can potentially transmit the disease.”
According to TB Facts, a web resource dedicated to information on the illness, tuberculosis stands as a communicable disease and is easily transmitted from person to person by simply breathing in the bacteria.
This means, if a person with TB of the lungs or throat coughs, sneezes, sings or talks; droplets containing the bacteria are released into the air – and these can cause the disease to spread.
However, contrary to popular belief, not all people are equally infectious. Generally, only those with TB of the throat or lungs are infectious and treatment can dramatically reduce the infectious droplets released by a person.
As per Dr. Ahmed’s observation, residents of Oman are likely to get infected during ‘air travel or by public transport, especially during their frequent visits to endemic areas like African countries, and even Europe and North America’.
Even so, the doctor tells us that the disease is not as life threatening as it was just a decade ago.
“TB does not cure itself. It can be latent for several years, but I repeat: it will not cure itself,” the doctor says.
“But, one thing we need to keep in mind is that there is a cure for TB. There is a combination of drugs that you can take for the disease – such as Abitol and Isoniazid – and it will take around six months to cure.
“The only time TB cannot be cured is if the person is resistant to the drug, or if they don’t take medicines regularly and miss checkups.
“The chances of complications, however, depend on factors such as the immune system of the body and the age of the person.
“One of the greatest causes of TB-related deaths is HIV/AIDS – a disease that shatters one’s immune system.”
On the upside, though, the number of cases of drug-resistant patients in Oman has dropped by 39 per cent between 1990 and 2016.
“I have noticed that many people who fear that they’ve been infected with the disease and were in the active stages stayed put for several months and dealt with it themselves for fear of being judged by their peers (for expats) by having to leave the country.
“The reality is that early detection works best for TB, and for expats worrying about the government deporting you; that’s a myth. Oman government simply offers treatment to you – for free – until you’re cured.
But, as Dr. Ahmed says, TB can cause death if it isn’t dealt with in time, and urges anyone with the symptoms of TB to immediately head to the nearest hospital for a check-up.
As it stands today, WHO confirms that Oman is on the right track to early detection of the disease and its cure.
Oman is expected to be 100 per cent TB-free by 2035.