The Big Issue

I first met Yevgeni outside the supermarket. I guessed him to be in his fifties though his unkempt grey beard and tired eyes made his face hard to read. He could have been much younger for all I knew, but life had weighted down his years. He wore a faded green army jacket and a warm, friendly smile. Yevgeni sold the homeless newspaper.

Every other week I would buy his latest issue and sometimes we would share a brief chat. Yevgeni took pride in his job. He was not very comfortable accepting charity and rather had that you bought his paper than gave him money. In our conversations Yevgeni told me in his rudimentary Dutch that he was originally from Belarus. I also learned he was plagued by back pains but that he did not belief in doctors. Some days I looked forward to seeing him, other days -when I was too tired or too cranky for small talk- I secretly hoped he wouldn't be there. Then one day he was gone. I never found out why he had come to the Netherlands or why he lived on the streets. I do know that in his own country Yevgeni would very possibly have had tuberculosis.

Once thought a disease of the past, TB is now rampant again throughout large parts of Eastern Europe and the former Soviet states. Especially homeless people, addicts and prisoners are at high risk of infection by this horrible disease. Thousands of people needlessly die of TB each year. Needlessly because the drugs to fight TB have been around for decades. The big problem is that patients have to take a handful of pills, several times a week and for months on end. Any interruption of this strenuous regime can lead to a recurrence of the disease and most alarmingly: to the appearance of drug-resistance. Ironically, those patients most likely to contract TB are also those most likely to default from their treatment; that is, they are for a variety of reasons unable to keep up with their medication.

My thesis centres on this problem with so-called treatment adherence. We are looking at why patients stop taking their medication and what can be done to help them stay on their treatment. One way of doing this is to offer them incentives. There have been examples in the US where patients receive a small sum of money or some grocery coupons to entice them to attend their clinic appointments. In the countries my thesis focuses on food support is an inherent part of most anti-TB programmes. At the moment most of these programmes are run by organisations like the Red Cross. For the long-term, however, it is important that countries absorb this sort of care into their own healthcare systems. The work we are doing will hopefully help towards understanding how TB care can best be organised to help those people most vulnerable. People like Yevgeni.