Seventeen-year-old Wasil is one of the 76,000 Afghans with a new, active tuberculosis (TB) case this year; without treatment half of those infected will succumb to the disease. As a child, Wasil watched his mother die of TB, but when her all-too-familiar symptoms—persistent cough, loss of appetite, weight loss, and fever—frighteningly became his own, Wasil had access to a Comprehensive Health Center (CHC) operated by IMC, a REACH NGO grantee. At the CHC, sputum smear examination confirmed a diagnosis of TB, and Wasil began directly observed therapy, short course (DOTS).

Rural Expansion of Afghanistan's Community-based Healthcare (REACH) is a USAID-funded program implemented by Management Sciences for Health (MSH) and the Afghan Ministry of Public Health (MOPH). Partners include the Academy for Educational Development (AED); JHPIEGO; Technical Assistance, Inc. (TAI); and the University of Massachusetts/Amherst.

Globally recognized as the best way to cure TB and control its spread, DOTS is a 6-8 month regimen during which health providers directly administer TB medications in the proper dosage to the patient, and closely monitor patient progress. Effective in 86 percent of cases treated in Afghanistan, DOTS requires TB patients like Wasil to commit to daily treatment at the clinic for two months, and twice weekly treatment for six months thereafter.

For Seema, a 36-year-old mother of five, compliance is not easy, yet each day for the past two months, she has put her husband, totally disabled by a war wound, and her small children in the care of a relative and walked for two hours to reach the clinic.

Although globally TB affects more men than women, in Afghanistan, the highest incidence of the disease is among females of reproductive age (15-49). The cause of Afghan women's increased susceptibility is not well understood; however, risk factors may include frequent, un-spaced childbearing, malnutrition, crowded living conditions, illiteracy, and culturally imposed restrictions on mobility.

Because TB is infectious, clinic staff members also urge patients to bring family members to the CHC for sputum smear examination. Children exposed to active TB cases, in whom TB may be latent, can now receive drugs to prevent active TB from presenting later in life, as it did with Wasil.

Unlike Wasil, many Afghans neither recognize the symptoms of TB nor have access to health facilities where TB can be diagnosed and treated. Through REACH, MSH has helped develop and actively support Afghanistan's National TB Control Program (NTP). This technical assistance is aimed at expanding the detection and treatment of active TB cases. Currently, only 36 percent of active cases are detected. More specifically, MSH REACH provides technical assistance in support of the NTP's objectives: to upgrade laboratories, to provide training to health workers on TB detection and treatment guidelines, and to increase the number of DOTS-capable facilities. Though such tasks are challenging in a post-conflict country like Afghanistan, whose health system was virtually destroyed in decades of war, the results of these efforts are encouraging.

To heighten public awareness of TB and other infectious diseases, the REACH project is providing large posters for display at clinics and other public sites. Clinic staff members have also been trained to conduct health education sessions for all people who visit the health facility for any reason. Seema had been ill for over two years when a neighbor, returning from the Shakardara CHC, told her what she had learned and persuaded Seema to make her initial visit.

Throughout Afghanistan, access to DOTS is expanding. In the thirteen USAID-supported provinces, the number of DOTS-capable health facilities operated by REACH NGO grantees has steadily risen, from 15 in early 2004 to 121 in January 2006. Health facility staff members are trained to ask every visitor—regardless of the purpose of their visit—one simple question: “Have you had a cough for more than 15 days?” Those answering yes provide sputum samples for examination, the first step toward diagnosis and treatment. In 2005, the number of TB cases detected and reported by the REACH grantee health facilities tripled those detected and reported in 2004.

As of December 2005, 6,036 Community Health Workers (CHWs) trained under REACH are working in the thirteen supported provinces; 53 percent of the CHWs are women. CHWs play a vital role in Afghanistan's fight against TB. All CHWs are trained to spot people exhibiting symptoms of TB and to refer suspected cases to the local health facility for examination.

CHWs are also being supplied with REACH-produced flip cards and charts, whose pictures help CHWs during home visits describe TB symptoms, explain how TB is transmitted and how to avoid transmittal, and spread the good news that, with treatment, TB can be cured. In addition, CHWs foster DOTS compliance: during the final six months of DOTS, CHWs visit TB patients twice weekly in their homes to administer medication and to observe patients taking their medicines. These home visits spare patients the daily trips to the clinic made during the first two months of the regimen.

Much work lies ahead in Afghanistan's battle against TB. Living conditions in the country's crowded urban areas are conducive to TB and its spread, while at the same time, many in Afghanistan's often rugged and remote rural areas lack access to facilities where TB can be detected and treated. Nevertheless, important inroads are being made. Public knowledge about TB is growing, the TB detection rate and number of DOTS-capable health facilities is rising, and TB patients like Seema and Wasil are staying the course, completing DOTS, and claiming longer, healthier lives.

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