Medical News Today: A doctor's life-enhancing experience of working on a humanitarian TB project

Dr. Mark McNicol, a middle grade specialty doctor from Northern Ireland, recently spent 9 months working for Medicines Sans Frontières/Doctors Without Borders. In an interview with Medical News Today, he explains that the stigma of disease and the suffering of sick people living in poverty made a significant impression on him while treating patients with tuberculosis in the Eurasian country of Georgia.
Dr. Mark McNicol spoke with us about his time working on a humanitarian TB project in Georgia.

Dr. McNicol, who has a special interest in infectious diseases, found that working on a humanitarian project focusing on tuberculosis (TB) was rewarding and interesting, but challenging.

"One of the main risk factors for TB is poverty, so the patients we were seeing were usually quite ill and vulnerable," he told MNT. "Patients with TB typically have other diseases such as HIV or Hepatitis C, are people who abuse drugs, have problems with alcohol, are homeless, or have been in prison."

Dr. McNicol was working in a team with five local doctors of different ages and educational experiences, some of whom had trained under the old Soviet education system. He said that they were all able to share and learn from each other's experiences. "That was really good for my growth as a doctor," he said.

However, did his professional exposure to different people and ways of working have an impact on his personal development?

Fighting multidrug-resistant TB in Georgia

During his time in Georgia, Dr. McNicol worked on two of the study aims of endTB (expanding new drug markets for TB), a collaborative project run by Partners in Health, Medicines Sans Frontières/Doctors Without Borders (MSF), Interactive Research and Development, and financial partner UNITAID.

EndTB output 1 aims to treat 2,600 patients with the first TB drugs developed in almost 50 years - bedaquiline, delamanid, and other repurposed drugs - to try to improve cure rates in 15 countries with high multidrug-resistant TB (MDR-TB) levels. Patients receiving the new drugs will be assessed in an accompanying observational study.

Dr. McNicol's role was to give clinical advice on patient care, the treatment of patients with MDR-TB, management of any co-infections such as HIV and Hepatitis C, and to advise on managing any drug side effects and interactions.

He was also involved in reporting adverse drug reactions to a central pharmacovigilance unit and collecting information regarding patients' treatment for endTB output 1.

Current treatments for MDR-TB must be taken for up to 24 months and sometimes achieve a success rate of only 50 percent. Patients endure months of painful daily injections and take up to 14,600 pills throughout the treatment course. Side effects are often severe and can include acute psychosis, permanent deafness, and kidney failure. Treatment results in an effective cure in around 52 percent of patients.

The cost, difficulty, and length of these standard treatments make them difficult to implement in resource-poor countries with high rates of TB - of which Georgia is a prime example.

New hope for patients

EndTB output 2 is a clinical trial, run in collaboration with Epicenter, Harvard Medical School, and the Institute of Tropical Medicine Antwerp. The trial, launched in March 2017, will enroll 750 patients to participate. This will take place across six countries, including Georgia, and it will investigate new drug combinations with shorter treatment times than those of the current MDR-TB treatments.

"At times it can break your heart working with these patients. Most of them didn't have much, they were very sick and had often had TB for a long time. They had to endure the long, toxic treatment for TB and even when we were able to cure the disease, they were often left with long-term sequelae. Side effects of the medication included chronic breathlessness or problems with their nerves. It wasn't unusual for us to see patients who had been treated for TB for 10 or 20 years."

Dr. McNicol

Dr. McNicol said that diagnosis of TB in Georgia was free, but if patients needed medication for side effects and for other medical conditions, they would need to pay for them, which was often a problem for those with little money. There was a voucher system in place from the Global Fund that allows patients to receive money every month to help pay for their medications. If patients were not able to access this, however, they either had to find the money themselves or rely on charities and nongovernmental organizations to help them.

Sometimes, patients were required to travel to the medical center for their treatments twice per day and many struggled to pay the transport costs. "Patients with tuberculosis a lot of the time are unable to work, they can't get a job, and supporting their families could be tough," he explains.

Dr. McNicol feels that despite these challenges, he was able to make a difference during his time in Georgia. "Tuberculosis is not a sprint, it is a marathon, it's a slow-growing chronic disease and it can take a long time before patients start to improve."

He added, however, that "[he] did see patients who had been treated on multiple occasions with the standard drugs but then being able to treat them successfully with the new drugs and seeing them doing very well on them was very encouraging." Dr. McNicol was pleased to report that the new drugs appeared to instil new hope in patients with TB.

He said that he learned a lot while working in Georgia, and on many different levels. The key lessons were understanding the way that TB impacts the patient. Since arriving back in the United Kingdom to work in the acute assessment unit at Antrim Area Hospital, he said that he is now more aware that the U.K. is a low-prevalence area for TB, Hepatitis C, and HIV.

After returning from Georgia

Dr. McNicol told MNT that the most important experience for him was witnessing the impact that the stigma of the illness had on the patients he met and treated, noting that people seem to be scared of the disease.

"Now I notice that when you see someone sitting in a wheelchair or they are on oxygen, for example, in a GP surgery or a shopping center, how people automatically think there is something really wrong with them and there is a lot of stigma with little understanding. At the end of the day, these are just people and the same as our TB patients. They are people like you and me, only they have been unlucky that they have caught a horrible disease."

Dr. McNicol

He added that he now wholly understands the criticality of being kind to those with TB and other conditions, mentioning that since his experience in Georgia, he makes a conscious effort not to evade these people in public.

His experience of working with interpreters has improved his communication skills, he noted. "It is not easy talking to patients through an interpreter. There are cultural issues and expressions that you need to understand in order to form a bond with the patient and I now realise how important these are."

He told us that having to depend on interpreters in Georgia was a difficult but somewhat unavoidable task. The feat was made easier, however, because of the interpreters' skills in conveying "empathy, compassion, and [...] accurate medical advice."

Working with MSF enabled Dr. McNicol to work with doctors from different parts of the world, which he said enriched his experience of working in Georgia. "The people working on the endTB project were not motivated by money or status. Their aim was to help people who were suffering - these people were really inspiring to work with on a day-to-day basis."

He also had the opportunity to work with some prominent experts in the TB world, who provided education and insight into the management of some of the most difficult cases.

Dr. McNicol's long-term career plan is to return to his National Health Service (NHS) post and undertake further training in infectious diseases and microbiology. However, he also wants to continue working with MSF on other projects around the world. He is currently awaiting departure to work with MSF in South Sudan.

"Working on projects like this gives you a wider world view, shows you how other people live, and can be humbling at times. Exposure to other doctors and different styles of working definitely improves you both as a doctor and a person."

Dr. McNicol

Medical News Today would like to thank Dr. McNicol for sharing how his experience has enriched both his professional and personal development.

Learn more about ongoing humanitarian projects and how to get involved.

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