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14 Oct 2020

What can TB teach us about how to respond to COVID-19?

We are launching a new limited series of columns exploring lessons learned from previous infectious disease pandemics, and how we can apply them to the COVID-19 response.

Royal Melbourne Hospital's Associate Professor Justin Denholm, Director of the Victorian Tuberculosis Program kicks things off with this article.

Since February, I’ve often been heard to say that it would be nice to deal with only one pandemic at a time. Based at the Doherty Institute, the Victorian Tuberculosis Program continues to provide a state-wide service for managing TB (the ‘other pandemic’), including both supporting those who are themselves unwell, and providing a public health response to help protect families and communities. At times comparing our work now to that of last year has felt a little overwhelming, as COVID-19 has increased the degree of difficulty for most aspects considerably. It’s harder to visit people at home, harder to gather and meet with community groups, harder to work out over the phone whether that cough is TB. For readers of a certain age, it’s like the comparison of Ginger Rogers to Fred Astaire, who, when they danced, “did everything he did, but backwards and in high heels” (the rest of you, look it up!).   

However, it hasn’t all been one way traffic. While COVID-19 has indeed brought challenges for TB management, we’ve also realised that our long history of public health for TB has taught us critical lessons that we can use to help us respond better to COVID-19; here’s my top four.

1. Context matters. Systematic inequality matters

In both TB and in COVID-19, it’s easy sometimes to concentrate on people who are perceived to be at higher medical risk from infection, like those with diabetes or on immune suppressing drugs. This is important, of course, but the overwhelming impact comes from context. We recognise that physical context that allows one person to pass both infections to another easily in abattoirs, aged care homes and boarding houses, but we have to remember that it is social context that leads to overcrowding, financial vulnerability, fear and difficulty accessing services. Addressing both is critical for an effective response. We hear a lot that ‘we’re all in this together’, but the truth is that the impact of both the illness and the response are much harder on some than others. The burdens TB and COVID-19 bring are carried disproportionately by those already affected by poverty and marginalisation, and responding to these diseases must also emphasise provision for those most affected.

2. In our rush to care for the sickest, we can’t neglect long term impact

It’s natural to want to respond to the people most in need, and when someone is critically unwell with either COVID-19 or TB, it’s natural to make helping them a priority. In TB, while the disease is curable, not everyone’s issues go away afterwards. Some people can have long term damage to lungs or bones, and others have long term damage or relationships or work capacity caused by their illness. We’ve been realising, to our shame, that we’ve concentrated so much on treating people while they are sick, we’ve often failed to even ask about the long term impact.

COVID-19 is a new disease, and it will take some time to fully understand what the medium and long term impact of infection might be. It’s critical, though, that we start by asking affected people about their experience, and listening to what they tell us.

3. Beating a pandemic is a team game

It’s my great privilege to work with a wonderful group of healthcare workers from many professional backgrounds, and I know that our work is much more effective because of the insights that they bring. That core work, though, is supported by an incredible network of people who are called on from time to time in their own areas of expertise. Real estate agents have helped us find housing, lawyers have defended against job losses due to illness, religious ministers have coordinated food parcels, volunteer drivers offer transport to clinics, friends and family who help children take medicine. All of these contributions harmonise to create an environment in which sick people can get better, and transmission of infections can be blunted. When dealing with a pandemic, we need some experts who can devote themselves wholly to the task – but we all have expertise in some area that we can use meaningfully to help our community heal.  

4. Every sick person is both victim and vector

It’s common to hear sick people described in terms of the risk they pose to others, with media focusing on security guards or ride share drivers and the risk they might have spread infections. Every person who is sick, though, was infected by someone else, and I’m yet to see either TB or COVID-19 transmitted maliciously or deliberately. Sometimes, in a public health response, we need measures that reduce the risk of infections being spread (and as I write this from my own home, I’m grateful to all who are similarly locked down), but this should never be about punishing people for having a disease. We need compassion to make it through a pandemic – compassion for sick and worried people making all kinds of hard decisions, and compassion for ourselves as we support each other through this tough time.