Fieldset
TB in Belarus: "Discuss, argue and take patients seriously"

Overcoming tuberculosis (TB) requires a lengthy and careful treatment. However, in Belarus, many patients are also battling another issue: alcohol addiction. German psychotherapist Christian Falkenstein writes about putting patients at the centre of their own care… 

An MSF team member examines a patient with multidrug-resistant TB in Minsk

How do we formulate simple principles that we believe will make us successful in the fight against tuberculosis?

Yes, it's about medication, research, and making treatments shorter, more effective, and more patient-friendly.

How do we ensure that no further resistance to the available antibiotics develops?

Well, at the regional tuberculosis symposium in Tashkent, Uzbekistan, which I visited at the end of February, I was deeply impressed with the progress made and the zeal with which doctors and scientists from all over the world cooperate to win the fight against tuberculosis.  

Tuberculosis can be overcome by ingesting substances. Addiction cannot be overcome; one can only refrain from taking substances. We must be aware of this contradiction and reflect it in our treatment. 

However, at the same time, we must learn to put patients at the centre of our efforts, because it is they who take their medications and conquer the infection. 

Prior to the symposium, I was asked to give a talk on the effects of alcohol dependence on tuberculosis treatment.

Together with the project managers and the medical advisers in Minsk and Moscow, we decided to take a courageous step and instead of a list of figures, evidence and studies, put forward some key ideas that I - admittedly with soft knees - introduced in Tashkent...

Two very different diseases 

Alcohol and drug use are the biggest risk factors in tuberculosis treatment.  

Tuberculosis is curable, addictions are chronic. And so not completely curable.  

Tuberculosis is diagnosed by the doctor on the basis of laboratory tests. An addiction disorder must be diagnosed by the patient themselves, by naming core symptoms and behaviours with the help of a psychiatrist or therapist.  

Tuberculosis can be overcome by ingesting substances. Addiction cannot be overcome; one can only refrain from taking substances. We must be aware of this contradiction and reflect it in our treatment. 

It's not just about making a diagnosis and prescribing medication, but about helping the person master their illness and their individual destiny with dignity and freedom. 

Patients stop using alcohol and drugs only when they want to. That is when they have an understanding of their dependence. 

Our patients are seeking treatment for their tuberculosis, not because of their alcohol consumption.

If I go to the bakery to buy bread, I will not be thrilled if it is only for sale to people who are also willing to buy a pair of shoes. Even if I come barefoot in the winter, what I think is the priority is still my business, right?  

This “bread and shoes” example sounds paradoxical, but it resembles our challenge to motivate patients to engage in drug addiction management. 

So, what does that mean for our patient-centred approach? 

Giving patients the power to decide

When it comes to the choice to begin addiction management, we give our tuberculosis patients all the information they need to make an informed decision about their treatment.  

We make the consequences of their decisions clear, and we accept their decision without "ifs and buts" - even if we disagree or think they are wrong.  

We must be content to minimize the effects of addiction and limit harm when patients cannot or do not want to gain insight into their behaviour.  

Bluntly speaking, people have the right to drink themselves to death or to die from tuberculosis if they decide to. But they do not have the right to harm or infect others. 

These key messages were well received at the tuberculosis symposium in Tashkent. Since then, we have been conducting numerous discussions and lively exchanges across the country, project and organisational boundaries.  

Of course, there are different opinions, not everyone agrees. But we have achieved something: the patient, their rights, their wishes and their responsibilities are the focus of our discussion.  

It's not just about making a diagnosis and prescribing medication, but about helping the person master their illness and their individual destiny with dignity and freedom. 

There will be a long way to go to achieve patient-centred care sustainably. I think it is not a luxury, but a fundamental right to which I am committed.

We will all have to rethink things, but I'm confident and I'm not alone.