A BRIEF HISTORY AND ANALYSIS OF PAKISTAN’S TB CONTROL MECHANISMS

By

Dr Ghulam Nabi Kazi

As the world braces itself for the fallout of a serious pandemic of COVID-19, we must nevertheless not lose sight of another serious killer –Tuberculosis - that devours 4,500 people daily from around the world, nor the suffering TB patients who are at a much greater risk of contracting COVID-19.
Pakistan was initially slow in responding to the World Health Organization declaration of Tuberculosis as a global emergency in 1993. The Government of Sindh was the first to draw up a concrete 3-year plan from 2000-2003 based on the TB-Directly Observed Treatment Short Course (DOTS) methodology. The Federal Government and other provinces followed suit in 2001 and on World TB Day on March 24, 2001 the Ministry of Health led by Minister H. E. Dr Abdul Malik Kasi and Secretary H. E. Mr. Ejaz Rahim declared TB as a national emergency and issued the Islamabad Declaration, in the context of Pakistan.
The Islamabad Declaration was initially met with a great response from governmental agencies and the health development partners including robust technical support from the Word Health Organization, social mobilization from the Stop TB Partnership and financing support from the United States Agency for International Development (USAID), British Department for International Development (DFID), Family Health International (FHI), German Leprosy and Relief Association (GLRA), German Development Bank (KfW), German Technical Cooperation (GTZ), Japan Anti-Tuberculosis Association/Research Institute for Tuberculosis (JATA/RIT), Japanese International Cooperation Agency (JICA), Royal Netherlands Association for the Prevention of Tuberculosis (KNCV Tuberculosis Foundation) and the International Union Against Tuberculosis and Lung Disease (The Union). These agencies also took part in WHO-led reviews and their joint recommendations guided the follow-up action at the relevant operational level. The core elements of the National and Provincial Tuberculosis Control Programs were financed by the government. Subsequently, the major donors routed all their grants for Tuberculosis through the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM).
By 2005, the diagnostic and treatment facilities were established in all eligible public sector health facilities and were offered free of cost along with a significant amount of social mobilization. In April 2004, the WHO Inter-Country meeting of National Tuberculosis Control Program Managers was held in Lahore, indicating that Pakistan had come a long way. That was the finest hour of TB Control in Pakistan. Things had fallen into place, the facilities were strengthened, enhanced and expanded through public-private mix along with a remarkable show of commitment, dedication and a camaraderie of all stakeholders working towards a common cause just like family members.
Thereafter the program developed with greater facilities including the rampant use of GeneXpert – a molecular test for TB reducing the reliance on sputum smear microscopy by a great deal. Mobile Cad4TB Vans equipped with software that can automatically analyze chest radiographs for signs of tuberculosis. The latest technology provided by the Stop TB Partnership is in the Fuji-Xair technology, a hand held device armed with artificial intelligence, will be used for active case finding in coal miners and their associated communities in several parts of Pakistan.
The National Tuberculosis Program of Pakistan being nearly 19-20 years old is quite mature now and remains one of the country’s best performing programs. It would, however, be wrong to assume that everything is hunky-dory.
Let us try and analyze the results:
1.First and foremost, out of the estimated 560,000 cases in Pakistan around 200,000 cases are missed annually and are not being notified in the national or provincial programs. What is happening to these ‘missing’ patients is purely a matter of conjecture. It is possible those cases may be visiting private practitioners and hopefully getting cured but there is also the possibility that they are not getting any treatment at all or approaching quacks, faith healers or erroneously prescribing doctors making them TB carriers for life and spreading the disease to their contacts.
2.The last National TB prevalence survey – a colossal undertaking – left us with an incidence of 265 per 100,000 population. While there is a clamour from the provinces for a fresh prevalence survey, it appears to be an exercise in futility, while incurring a lot of expenditure as no change may have occurred in the intervening period since the last survey.
3.The overwhelming fact is that with a case notification rate of 65-70%, Pakistan has failed to make a dent in the incidence or prevalence and with the same level of effort, no significant change is likely. Thus while we may consider this effort as ‘controlling’ TB, any talk of elimination is a far cry at the moment and will require increasing the pace of effort manifold if the international commitments are to be honored.
4.By paying for only 3% of the estimated costs of the National Strategic Plan and with 31% of the costs being borne by international donors (read the Global Fund), Pakistan has not only 66% of its NSP go unfunded but has also allowed the program to be controlled from abroad. The current situation is highly untenable because if Pakistan doesn’t assume control and authority over its TB control mechanism and delays funding some of its important elements, it can never to hope to achieve the targets either of the health system as a whole or its programmatic targets.
5.Our case detection data clearly depicts that while the program funding was largely indigenous, the case notification was improving at a great pace, however, as soon as the bulk of the funding came from the Global Fund, the growth has plateaued off and come to a halt or even reduced somewhat keeping in view the population growth rate despite massive investment. Although in the first case it can be argued that the program was expanding to all districts of the country and therefore the case detection was simultaneously growing as well, that argument doesn’t hold for the period from 2010 onwards when the whole of the country had TB diagnostic and treatment coverage including some opportunities for public-private mix.
6.The good news is that Universal Health Coverage (UHC) index of essential coverage including TB care has grown from 50% in 2000 to over 75% in 2017, lowering the proportion of the population that is yet uncovered, while social protection is also growing. However, the TB treatment coverage was estimated at 64% in 2018.
At the operational level, the program is not a major priority within the district health system. The district being the hub of all programmatic activity, it has to have a multi-sectoral accountability framework headed by the Deputy Commissioner to bring about the necessary coordination among the social sectors and economic line departments. However, the role of the communities in creating awareness and urging people with cough and other TB related symptoms to seek help is sub-optimal if not totally lacking at present. This warrants the need to enhance community participation at all levels for the smooth functioning of the program.
The World Health Organization has remained a trusted partner of the National and Provincial TB Control Programs ever since the year 2000 and they usually provide the much needed technical support from all tiers of the organization, namely headquarters, the Regional Office for the Eastern Mediterranean and the Country Office for Pakistan that is functional since 1960. The current Special Assistant to the Prime Minister for Health Dr Zafar Mirza has remained a senior WHO staff member and has reiterated his commitment on several occasions to rid Pakistan of Tuberculosis as soon as practicable.
Here there is a need to make a mention of The Stop TB Partnership is a unique international body headed by its dynamic Executive Director Dr Lucica Ditiu has been aiming for a TB-free world. Founded in 2001, the Partnership has harnessed over 1700 partners in transforming the fight against TB in over 100 countries. A cornerstone of the Partnership's mission is to ensure that every TB patient has access to effective diagnosis, treatment and cure. This necessarily entails reducing the inequitable social and economic toll of TB, by placing the emphasis on the marginalized, deprived and hard-to-reach populations in all countries of the world. In addition to Pakistan, the Partnership has been working in high burden TB countries such as Angola, Bangladesh, Brazil, China, Democratic Peoples’ Republic of Korea, Democratic Republic of Congo, Ethiopia, India, Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Philippines, Russian Federation, South Africa, Thailand, Tanzania, Viet Nam, Cambodia, Central African Republic, Congo, Lesotho, Liberia, Namibia, Papua New Guinea, Sierra Leone, Zambia and Zimbabwe. Through its TB-REACH initiative several projects have been launched all over Pakistan with a view to provide TB care services to marginalized populations at their doorsteps through active case finding. The Dopasi Foundation is furthering the objectives of the Stop TB Partnership in Pakistan by creating enormous awareness in the general public, using celebrities as Stop TB Ambassadors, emphasizing on the need for providing TB Care as a basic human right and carrying out a prevalence survey of TB in coalminers and their associated communities all over the country and specifically in the targeted districts in each province by screening close to 400,000 persons.
To summarize, the way forward for TB Control and Elimination in Pakistan will comprise of activities to transform the political declarations into concrete End-TB Initiatives with costed work plans, the Federal and Provincial Governments will need to significantly increase their allocations to health and specifically for eliminating the funding gap in the TB response. A federal authority for TB, AIDS and Malaria will help in robustly pursuing the federal roles of laying down the policy guidelines, providing technical strength, carry out surveillance, and liaise with international donors and health partners. Such an authority will bring about better inter provincial harmony both at policy and implementation level and carry out intra-sectoral and multi-sectoral collaboration. Demand creation for TB services needs to be brought about by a structured community engagement. We also need to enhance the capacity of Provincial TB Control Programs so that they can spearhead the TB response across Pakistan. These steps are likely to increase the government ownership and reduce dependence on external financing.
As TB-Management Units (TB-MUs) may not be able to cater to the needs of peripheral or hard-to-reach populations, it is prudent to involve first level care facilities such as BHUs, Dispensaries and MNCH centers, and the Lady Health Workers (LHWs) linked to them, in the provision of TB services. This will also provide the pathway to universal health coverage. These facilities can help in identifying presumptive TB cases, arrange sample collection and transportation to TBMUs, carry out contact investigation, provide treatment to patients with active TB and preventive treatment to eligible persons identified with latent TB infection (LTBI). They can also help in tracing and retrieving TB patients who interrupt treatment.
At the district level, Deputy Commissioners should convene the district steering committee as ‘first amongst equals’, comprising of all economic and social sector line departments, civil society organizations, elected representatives, TB survivors, TB activists and media personalities. The District Health Officer may act as member/secretary of these steering committees and act as the secretariat by developing working papers. The Task Force should meet at least on a quarterly basis to review the program performance and the incremental benefit accruing from multi-sectoral collaboration.
Other priority tasks already on the government’s agenda include the formation of a Parliamentary Caucus on TB Control with a multi-mix of MNAs/Senators from all parties, genders and religions, headed by Dr Nausheen Hamid the parliamentary secretary for Health. The caucus will draft legislation on TB elimination issues such as mandatory notification of TB cases (already done in Sindh province) and restrict off-the-counter sale of TB medicines among other things.
The Government is also most anxious to avoid catastrophic health costs, particularly in TB patients to avoid their falling down the poverty line. Therefore, health insurance is being expanded to a greater proportion of persons in the low-income groups. Let’s hope all these measures prove enough to rid the country of this ancient disease, whose cause has been known since over a century, medication available since over 70 years and free services available throughout the country since almost two decades. We just need to cast the net more broadly to detect all the cases and provide user-friendly services to eliminate it once and for all times. It’s the least we can do for our children to provide them a safer and cleaner environment than we had. We simply cannot allow this deadly disease to devastate over 4,000 people and their families daily across the world and rob our coming generations of a TB-Free World. We are presently at the crossroads; what we do over the next ten years will determine how things shape by 2030. If missed, this chance will never come again and will have ghastly implications in terms of human and financial losses. IT’S TIME!

Copyright: Dr Ghulam Nabi Kazi

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THE SECOND UNITED NATIONS HIGH-LEVEL MEETING ON THE FIGHT TO END TB: ACTION IS NEEDED TO TURN THE TIDE BY 2030


Public Health Action,


Volume 13, Number 3, 21 September 2023,
pp. 65-66


Lucica Ditiu,
Executive Director, Stop TB Partnership

Ghulam Nabi Kazi
Editor in Chief, Public Health Action


TB affects billions of lives either directly or indirectly, damages national economies and continues to overwhelm health systems: it is unacceptable that TB has been allowed to persist in modern times. World leaders will gather to focus on TB at this year’s United Nations General Assembly at a pivotal moment – if we fail to accelerate the anti-TB response, our chances of eliminating this terrible affliction will be greatly diminished. Following the 2018 High-Level Meeting on the Fight Against Tuberculosis, the political commitments endorsed by the UN General Assembly were ambitious and manifold.1 Articulated within an official UN political declaration were commitments to successfully treat 40 million people with TB, including 1.5 million people with drug-resistant TB (DR-TB), provide preventive therapy to at least 30 million people, mobilise US$13 billion a year for TB care, and invest at least US$2 billion a year in research. These were to be delivered by 2022, but then COVID-19 struck. Historic levels of resources were mobilised to support the COVID-19 response, including the use of public health infrastructure previously used for TB care. At the same time, policies that restricted social movement, combined with people’s concerns about exposure to COVID-19 reduced access to health centres, disrupting the delivery of TB diagnosis, treatment and care.2,3 According to the WHO, the number of people diagnosed and treated for TB plummeted, with a 15% reduction in people treated for drug-resistant TB (DR-TB), a 21% decrease in people receiving TB preventive treatment and a 9% decrease in TB spending over the previous year.4 In 2021, WHO called attention to the first reported increase in global TB mortality in more than a decade – news that reverberated around the world.5 Adding to these challenges are new armed conflicts, a global migration crisis, increasing urbanisation and a spike in global poverty—all of which complicate the TB response.


At this year’s General Assembly, global leaders are expected to present their reflections and reaffirm their commitment to ending the TB pandemic. This must lead to action and catalyse interventions that accelerate progress toward TB elimination by 2030, the deadline for reaching the UN Sustainable Development Goals. From our perspective, the following are priorities for action that risk being overlooked in this critical phase of the global TB response:


1. The TB pandemic is multifaceted, requiring support for policies that enable biomedical interventions as well as interventions to address the social, environmental and economic determinants of TB.3 TB overwhelmingly affects countries, communities, families and individuals impacted by poverty and marginalisation. To leave no one behind, leaders must support national TB responses that are equitable, inclusive, gender-sensitive, rights-based and people-centred. The COVID-19 response provides an informative case study when it comes to equity and access to new tools. Wealthier nations stockpiled millions of vaccine doses to the detriment of people in low- and middle-income countries. Paradoxically, this action likely left the entire world less safe from the pandemic, and wealthier countries eventually saw massive quantities of these unused vaccines expire.6 As part of an increase in financing and support for TB research and development, leaders must advance policies and initiatives to ensure equitable access to new TB vaccines, diagnostics, and drugs and digital technologies, and make concerted efforts to reach vulnerable groups.

2. It is heartening to observe that world leaders will collaboratively address various global health challenges during the UN General Assembly session. These challenges include enhancing pandemic preparedness, strengthening health systems, achieving universal health coverage (UHC), and putting an end to TB. These areas overlap and require coordination at the political level. As countries work to recover from the COVID-19 pandemic, significant new investment is needed to speed up progress toward UHC, made available through efficient resource mobilisation and allocation based on where interventions will deliver the greatest good.7 Policies should enable TB care services to be integrated with efforts to attain UHC. One way is to require TB services to be included within essential health service packages that are delivered through primary health care.8

3. UN High-Level Meetings have positioned other related health challenges (such as HIV/AIDS, non-communicable diseases and antimicrobial resistance) as significant enough to require the highest level of political initiative, so heads of state and government have become increasingly important as public health leaders.9 Using their delegating authority and ability to inspire action through their offices, world leaders must mobilise additional political support for ending TB within their countries. As a corollary, they must embrace and foster a government-wide culture of accountability for results. Community led monitoring, which empowers affected communities with tools to analyse barriers to TB services, human rights violations, TB stigma (and other events and trends) and report challenges, has emerged as an invaluable aid to accountability, particularly in high-burden countries. In Pakistan, the salutary effect of involving parliamentarians and developing multi-sectoral accountability frameworks at the policymaking and service delivery tiers has been documented.10,11 Other countries have shown progress using similar approaches. For example, Indonesia issued a presidential decree to end TB in the country by 2030, creating a multisectoral coordinating team led by the Coordinating Ministry of Human Development and Cultural Affairs.12 In India, the drive to eliminate TB has been spearheaded by the Prime Minister himself, instilling a sense of urgency through the establishment of an accelerated national objective to eradicate TB by 2025. In March 2023, Prime Minister Modi launched several new TB initiatives at the One World TB Summit, including the TB Mukt Panchayat Abhiyan Initiative – a campaign to mobilise TB interventions at the community level.13 Domestic funding for India’s national TB programme has increased several fold in recent years, supported by public-facing health promotion campaigns, new initiatives in private sector TB care, provision of nutrition and other needs to people affected by TB at a unprecedented scale with an all-of-society approach, and incentives and enablers to provide more holistic care for vulnerable groups, among other interventions.

4. Along with increased support for TB research and development, leaders must support policies and allocate resources to facilitate the rapid dissemination of research data, findings and actionable insights. Effective knowledge dissemination is essential for designing policies, strategies and programmes to accelerate progress against TB, but also for implementing interventions more effectively. For example, Stop TB Partnership’s TB REACH and the Challenge Facility for Civil Society are key initiatives for funding local partners for the exploration of innovative approaches to TB detection, treatment and best practices for transforming the TB response. With more support and systems for dissemination, insights generated by such initiatives can better serve TB programmes and facilitate replication and scale-up of the most effective approaches.

5. As members of the TB community, we have consistently advocated for the regular convening of United Nations summits and high-level meetings. This concerted effort aims to maintain global public health as a prominent item on the agenda for heads of states and governments. Given how fundamental public health is to our collective peace and survival – and considering the challenges and needs outlined above – we reiterate this call. Sustained effort is critical to closing financing gaps, improving global health governance and achieving the vision of health for all.14,15


Finally, there is more to leadership than its political and economic dimensions. World leaders have an ethical and moral imperative, which they must embrace to end this pandemic by 2030.16 For many, this requires a change in mindsets. Those who fully take on the challenge will be able to impress upon citizens the urgent importance and profound benefit of ending TB, and powerfully positioned to move countries towards that overarching goal, together.

References
1. World Health Organization. Political declaration of the UN General-Assembly High-Level Meeting on the Fight Against Tuberculosis. Geneva, Switzerland: WHO, 2019.
2. Sahu S, Wandwalo E, Arinaminpathy N. Exploring the impact of the COVID-19 pandemic on tuberculosis care and prevention. J Pediatric Infect Dis Soc 2022;11:S67–71.
3. Pai M, Kasaeva T, Swaminathan S. Covid-19’s devastating effect on tuberculosis care—a path to recovery. N Engl J Med 2022;386(16):1490–1493.
4. World Health Organization. Global tuberculosis report, 2021. Geneva, Switzerland: WHO, 2021.
5. World Health Organization. Press release. Tuberculosis deaths rise for the first time in more than a decade due to the COVID-19 pandemic, 14 October 2021. Geneva, Switzerland: WHO, 2021. www.who.int/news/item/14-10-2021-tuberculosis-deaths-rise...(opens a new window). Accessed August 2023.
6. Quan NK, Anh NL, Taylor-Robinson AW. The global COVID-19 vaccine surplus: tackling expiring stockpiles. Infect Dis Poverty 2023;12:21.
7. Kodali PB. Achieving universal health coverage in low-and middle-income countries: challenges for policy post-pandemic and beyond. Risk Manag Healthc Policy 2023;16:607–621.
8. Soucat A, Tandon A, Pier EG. From Universal Health Coverage services packages to budget appropriation: the long journey to implementation. BMJ Global Health 2023;8(Suppl 1):e010755.
9. Rodi P, et al. Political rationale, aims, and outcomes of health-related high-level meetings and special sessions at the UN General Assembly: a policy research observational study. PLoS Med 2022;19(1):e1003873.
10. ul Eman K, et al. Establishing a parliamentary caucus to provide oversight to TB control in Pakistan. Pak J Public Health 2022;12(1):34–36.
11. ul Eman K, et al. Assessing the impact of a district multisectoral accountability framework for tuberculosis control in Pakistan. Pak J Public Health 2022;12(1):5–7.
12. World Health Organization. Indonesia commitment to eliminate TB by 2030 supported by the highest-level government, 28 November 2021. Geneva, Switzerland: WHO, 2021. www.who.int/indonesia/news/detail/28-11-2021-indonesia-co...(opens a new window). Accessed August 2023.
13. World Health Organization. WHO applauds Indian leadership on ending TB, 30 March 2023. Geneva, Switzerland: WHO, 2023. www.who.int/news/item/30-03-2023-who-applauds-indian-lead...(opens a new window) Accessed August 2023.
14. Akselrod S, et al. Getting health back on the highest political agenda—the UN High-level Meetings on health in 2023. Lancet Global Health 2023;11(6):e819–820.
15. Bloom G, et al. Deliberate next steps toward a new globalism for universal health coverage (UHC). 2030 Agenda for sustainable development. Osaka, Japan: G20 Japan, 2019.
16. Mussie KM. Tuberculosis: a historical and global bioethical perspective in tuberculosis. Integrated studies for a complex disease. New York, NY, USA: Springer Cham International Publishing, 2023: pp 1033–1046.

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DAILY TIMES, FEBRUARY 14, 2021

OP-ED
The absolute imperative of identifying and notifying cases of tuberculosis

Dr Ghulam Nabi Kazi

As we approach Valentine’s Day let us resolve to be compassionate and kind, spread solidarity and love in our work, ensure that nobody is stigmatized regardless of any consideration and not ostracize patients if they suffer from a communicable diseases like Tuberculosis. Above all let us resolve to speak up, stand up and step up our efforts for a brighter future for our children in a world free of Tuberculosis. And while gearing up efforts in that direction we must not forget the high proportion of our children suffering from Tuberculosis. To identify and cure those children represents the best manifestation of our love for them.

According to World Health Organization (WHO) estimates, an estimated 1 million children became ill with TB globally, while 233 000 of them die of TB every year. In all probability TB directly or indirectly leads to around 10 000 TB deaths among children under 15 years annually in Pakistan. These figures may, however, be underestimations given the complexities in diagnosing childhood TB and the lack of child-friendly diagnostic tools. WHO has called for sustained advocacy, greater commitment, mobilization of increased resources and a joint effort by all stakeholders involved in childcare and TB control.

Childhood Tuberculosis is a major public health problem in Pakistan with roughly 20% of the tuberculosis patients detected every year being under the age of 15 years. Initially policymakers may have neglected the issue on the premise that children do not transmit the disease to others, however, since more than a decade close attention is being paid to the issue globally and nationally.

The National TB Control Program (NTP) Pakistan with support from the WHO has been accordingly arranging capacity building courses since 2013 for pediatricians, chest physicians and medical officers with a view to increase case detection of TB in children within communities, improve the diagnosis and management of children with all forms of TB, increase implementation of child contact screening and preventive therapy, improve quality of child TB data and enhance child TB case reporting from the private sector.

While it is important to be familiar with the child TB epidemiology, latest diagnostic and management techniques for children with TB (including drug resistant TB) and the diagnostic algorithms, it is equally critical to realize the barriers in the process and common problems encountered in the case detection and notification process, particularly at the district and tehsil levels such as lack of coordination between pediatricians and chest physicians causing most of the diagnosed children to go unnotified in the national/provincial database or lost to follow-up for any reason.

As we approach the target date for ending TB by 2030 in Pakistan, a better understanding on important childhood TB issues is necessary both among parents and healthcare providers. This can be achieved by removing any inconsistencies in the standardized NTP guidelines through coordination with professional bodies such as the Pakistan Pediatrics Association. The need to integrate child TB training into regular NTP TB capacity building activities and medical school curricula constitutes the way forward.

Essentially the principles of TB treatment in children are same as for adults, the duration of treatment is also the same (mostly 6 months except for those with drug resistance) and children usually respond well with symptomatic improvement during treatment with good outcomes. There is also evidence to believe that verbal screening with clinical evaluation and provision of free diagnostics can identify children with TB who may otherwise be missed, particularly in rural health settings. The national guidelines have recommended use of fixed dose combinations of first line pediatric drugs already made available in Pakistan with fruit flavors to be more palatable and avoid complications in dosage encountered while crushing drugs meant for adults. It is also imperative to pay particular attention to children at risk of treatment failure by proper monitoring.

A TB diagnosis in children is usually made consistent with a comprehensive scoring system devised by the Pakistan Pediatric Association and adopted by NTP Pakistan in presumptive cases by giving weightage or scores to factors such as age, closeness of contact with TB patients, evidence of malnutrition, previous history of measles or whooping cough, HIV, immunosuppression for any reason, clinical manifestations, radio diagnostic imaging, tuberculin skin testing and Xpert testing or presence of granuloma.

While discussing these technical details, one is immediately struck between the awareness gaps within communities warranting methods for rectifying the position on the ground with speed and alacrity. Firstly, children with TB infection today represent the reservoir of TB disease tomorrow and if left alone children are more likely to develop more serious forms of TB such as miliary TB and TB meningitis resulting in high morbidity and mortality. It is also important to integrate TB care for children with the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) initiative in Pakistan, while impressing upon parents that the BCG vaccine has limited efficacy against the most common forms of childhood TB.

To address the current situation, the Stop TB Partnership (STP) has advised national TB programs to prioritize childhood TB in their plans while highlighting the need for health care providers to integrate this into their services. It has also encouraged donors and development partners to encourage collaboration with researchers, local communities, TB and HIV control programmes and other stakeholders to address the growing problem of childhood TB concentrating on innovative research to develop child-friendly TB diagnostics, drugs, biomarkers and vaccines and create a demand with the civil society for equitable prevention, diagnostics, treatment and care services for children with TB and to monitor the scale- up of these services.

Dr Lucica Ditiu, the dynamic and passionate Executive Director of the Stop TB Partnership has pointed out that: “The missed or late diagnosis of TB can have catastrophic health impacts for the child and increases their chances of mortality. Suboptimal diagnostic methods, poor screening compliance, and unrealistic treatment guidelines mean that children face even greater barriers to accessing care than adults, making this population even harder to reach. Children often exist as a vulnerable population within already vulnerable populations.

Therefore, it is imperative that TB finally be addressed head-on by policy makers, civil society and health professionals. Not only do children provide the reservoir from which future cases will develop, but continued inaction is costing lives!” Quite recently Dr Ditiu interacted with the well-known and decorated puppeteer Farooq Qaiser (Uncle Sargam) online and urged him to play a meaningful role in educating children and their parents to follow-up on his initiative to create TB advocacy since March 2020. Mr. Farooq Qaiser is known for highlighting important national issues closely wrapped up in his inimitable sense of humor and satire. Dr Lucica Ditiu also engaged with a female TB survivor from Pakistan who is now playing her role in the community for spreading the message that TB is curable if diagnosed at an early stage. Recently Hello Kitty has joined hands with the Stop TB Partnership in creating awareness about TB particularly in children and their parents.

The fact that girls are more susceptible for Tuberculosis, highlights the crucial role of mothers in reporting any disease symptoms, particularly in their female children to outreach health workers. On its part, NTP Pakistan can expand and roll out services for children across all districts after ensuring that the operational guidelines are available for all the public and private sector stakeholders. The childhood TB desk guide developed more than decade ago needs to be updated and distributed to all the prescribing doctors in every district.

Special attention also needs to be paid to children with any co-morbidities to ensure that they are not lost to follow-up and are adhering to their treatment course throughout its duration. Engagement of public sector tertiary care hospitals and private general practitioners is crucial to ensure that all the diagnosed cases are properly notified to the NTP database. Ethical issues often crop up while handling not just the diagnosis and treatment but also the provision of psycho-social support. Although children may not be transmitting the disease to others, it is yet warranted that they should be provided the best possible diagnostic and treatment care, accompanied by counselling and nutritional support, wherever necessary, on ethical grounds.

If Pakistan seriously intends to achieve the Sustainable Development Goal # 3 elating to universal health coverage, it will need to drastically reduce its TB incidence across the country without forgetting its children to a point where it ceases to be a public health problem. That is the best Valentine’s Day gift that parents can provide to their children so that when they grow up, they can breathe air free of Tuberculosis. And yet as the theme of the World TB Day 2021 warns us: The Clock is Ticking!

The author is a senior public health specialist of Pakistan

Tags:   VALENTINESDAY2021 CHILDHOOD TUBERCULOSIS PAKISTAN Ghulam Nabi Kazi

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Op-Ed Daily Times

Dr Ghulam Nabi Kazi
MARCH 31, 2021


She was a princess while her mother was the uncrowned queen of broadcasting in Pakistan. The mother Mohini Das had joined All India Radio in 1938 at the age of 16 years as a drama artist and later compere its children’s program from Lahore with the pseudonym “Apa Shameem”. She would perform the latter role for an uninterrupted 39 years. Meanwhile she married Mr. A. Hameed and came to be called Mohini Hameed. On Independence in 1947, she became the first woman broadcaster of Pakistan, and soon came to be known as the Nightingale of Broadcasting. In 1948, her princess given the name of Kanwal was born.
The Radio Pakistan, more specifically its boss Mr. Ahmed Shah ‘Patras’ Bokhari was impressed by her speeches and recognized the gifts within her, making sure her talents were utilized almost everywhere; be it in dramas and special announcements or other work. By 1963, BBC was calling Mohini Hameed the Golden Voice of Asia and she was decorated twice by the President of Pakistan with the ‘Tamgha-e-Imtiaz’, in addition to several other awards and accolades. Meanwhile her daughter Kanwal had taken to broadcasting since she was only seven years old from Radio Pakistan, Lahore.
The President of Pakistan Mohammad Ayub Khan indicated his willingness to inaugurate the television project in Lahore on November 26, 1964 and it was only that day that when a senior radio producer Mr. Fazal Kamal, who had been assigned to PTV, realized that only with two fixed cameras in the studio and with Mr. Tariq Aziz escorting the Presidential entourage, there would be no announcer within the studio to go live. He hurried to Mohini Hameed and said, “Apa, can we avail the services of Kanwal for just one day as she is quite articulate. I promise we will make the necessary arrangements from tomorrow onwards.” Kanwal Hameed was then only 16 or exactly the same as her mother’s age when the latter started her broadcasting career!
The initial announcement was terse, simple and delivered in flawless Urdu: “Assalam-o-Alaikum – this is Kanwal Hameed. I welcome you to the NEC Pilot Project and congratulate you on the launching of television in Pakistan.” As she would later recall, by the time she said this, the young Kanwal had nearly passed out as President Ayub Khan along with the Governor of West Pakistan the Nawab of Kalabagh, Foreign Minister Zulfikar Ali Bhutto and Finance Minister Muhammad Shoaib, in addition to several other dignitaries had entered the studio and were standing behind her.
Furthermore, her lovely voice modulations, perfect pronunciation and equal ease with which she could speak in English, Urdu or Punjabi soon made her a household name in Pakistan. Not yet realizing her potential and the mentorship capacity of Mr. Aslam Azhar, Kanwal made her mark very soon. The ‘arrangements’ promised by Mr. Fazal Kamal to her mother never materialized and were doomed to failure as nobody was good enough to replace her. Kanwal Hameed, later assuming the name of Kanwal Naseer on marrying an Army officer, would remain in Pakistan Television not just as an announcer but as an anchor, newscaster, drama artist and program compere as well. Her association with television and broadcasting would last for over 57 years until the time of her death.
Still in her teens, Kanwal had the good fortune to interact with personalities such as Madam Noor Jehan, Amanat Ali Khan, Reshma and Mehdi Hassan who had enchanted the country with their melodious voices. Her life was caught up between home, school, radio and later television. Faiz Ahmed Faiz lived very near the radio station and his daughter Moneeza would compere a children’s programme on every Sunday. She also came in touch with famous people like Yasmin Tahir, Naeem Tahir, Khalid Saeed Butt, Dr Anwar Sajjad and Ejaz Shafi. After a long innings with PTV she retired but remained associated with the organization in many ways. Like her mother, she was also decorated twice by the President of Pakistan. Kanwal Naseer’s name is today synonymous in Pakistan with television and broadcasting. Following in her mother’s footstep, Kanwal Naseer became a legend in her own right. She also worked as a stage compere in countless events, mainly in the Pakistan National Council of the Arts.
I first met Ms. Kanwal Naseer around three years ago in 2018 during the course of our organization’s End-TB efforts, which revealed to me the humanist side of her nature. She soon acquired the position of a celebrity Stop TB Ambassador and was so comfortable and knowledgeable with Tuberculosis facts that it was apparent she was absolutely dedicated to the elimination of this disease. She injected life even into listless sentences and read them with such emotion and passion that could mobilize her listeners to action. She was at the height of her maturity and would always perform at her best in any undertaking. Later on she linked up with Mr. Farooq Qaiser of Uncle Sargam fame to develop some marvelous skits that could easily appeal to the audience of any age group in Pakistan, as all of us have seen these eminent personalities ever since we were growing up. She never had any qualms or inhibitions about traveling to far flung places with us to organize TB awareness sessions in association with governmental authorities. We never failed to notice her attention to detail in all respects on all occasions be it in her speeches or demeanor. What struck us the most was her modest and down-to-earth nature. She always focused on the realities of life, and pride or self-importance were never a part of her character. She also had a very charitable nature known to her entire neighborhood. Wherever she accompanied us, she would run into persons who knew her and were evidently in awe of her. However, her disarming nature always made them very comfortable. She was always very proper, dignified and embodied the portrait of a lady!
Even during the COVID-19 pandemic, which struck Pakistan around 12th March 2020, did not deter her from planning World TB Day activities on and around the 24th of March last year. I last met her in early March this year and though absolutely fit, she seemed to have lost a lot of weight. Around that time, she jokingly told a female colleague of mine that when I die you must come to my place and weep. The remark was made in a light vein and was dismissed accordingly. This year, despite being on her deathbed, TB was on her mind. When I went for a radio talk on the SunoFM channel on World TB Day, I was deeply touched about her comments concerning myself to the compere of the program that very morning while she was in the Intensive Care Unit. And the next day she was gone! It came as a sharp blow to all of us just as if we had lost a family member. Condolences came from far and wide including Dr Lucica Ditiu the Executive Director of the Geneva-based Stop TB Partnership and several others. If I could take the liberty to just change a few words from Shakespeare to sum up a tribute to her unique personality, it would be:

Her life was gentle, and the elements
So mix’d in her that Nature might stand up
And say to all the world, “This was a woman!”

Farewell Ma’am Kanwal Naseer – we will always remember your wonderful accomplishments and health efforts with enormous gratitude and not allow them to go in vain!


The writer is a senior public health and public policy expert in Pakistan and can be reached at gnkaziumkc@gmail.com

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