Mr. Mahmud (pseudonym), 59, the Tuberculosis & Leprosy Controller Assistant (TLCA) at one of the TB centers on the outskirts – a 70-kilometer drive from the capital Dhaka – reflecting on his journey in combating TB, asserted that if people stopped using tobacco products, the number of TB cases in his area could have been reduced by half. In Bangladesh’s health system, TLCAs are the frontline workers who directly engage with TB patients, overseeing operations at the grassroots level. While numerous non-governmental organizations such as Brac, Damien Foundation, and ARK Foundation now support the government’s initiatives, TLCAs remain the first responders for patients.
With over three decades of experience, Mr. Mahmud noted that although public ignorance about TB persists, the situation has significantly improved in the last 20 years, largely due to grassroots healthcare workers’ vehement efforts. But has this progress reached the lives of these frontline workers themselves? Have the services and benefits needed to combat TB developed accordingly? We asked these questions to Mahmud, who responded with a faint grin and a question of his own: ‘I started my job in an 8-by-6-foot office, and now, 30 years later, I’m still working in the same 8-by-6-foot space. Would you call this progress?’
We spoke with Hamida (pseudonym), a female TLCA on her 30s leading a team of more than six field workers. Despite her busy schedule, she made time to speak with us with openly sharing the ground realities. When we asked if discussing these issues might pose a problem for her in the future, Hamida remarked, ‘Maybe you people should come more often and talk to us more – we do need such discussions.’
This is the story of individuals like Mahmud and Hamida, who tirelessly work on the frontlines in a country where over 360,000 people are affected by TB each year, placing it sixth in global TB prevalence and causing over 40,000 deaths annually. In this piece, we try to unfold the untold stories of the TB centers and the lives intertwined with them.
The Dualities of Scenes on the Ground
On our journey to gather the stories of those combating TB, we visited several TB centers across both rural and urban settings. Though each place, from Keraniganj to Narayanganj, offered its own intrinsic uniqueness, it was the scenic beauty surrounding the TB centers in this particular zone that left us in awe. One of these facilities, located in the town center, is bordered by the Jamuna River on one side and lush paddy fields on the other. Though this facility currently lacks a permanent TLCA, a development partner official – Hamida – has taken on the role.
Speaking with her, it became clear that TB remains a significant communicable disease in the area. According to her, the center she manages sees over 900 people tested for TB each month, with around 100 testing positive. Observing this trend, she sighed, acknowledging that, despite the extensive drive of the healthcare workers, these numbers aren’t lowering, Hamida explained that most of the positive cases are male, attributing this disparity to factors such as greater ignorance among men, lifestyle habits, and power dynamics within families.
Figure 1: View from the Town Center TB Center
Further exploration revealed that, while TB awareness campaigns have made progress, their reach still falls short in more remote areas. Additionally, many male patients are heavy smokers, and a significant number are involved in substance abuse. In one area under Hamida’s supervision, a fishing community, drug addiction is prevalent, sometimes involving entire families. Illicit drug use contributes to malnutrition and reduces the effectiveness of prescribed medications. Hamida also noted that, in patriarchal societies, men are typically seen as the heads of households, often making the final decisions about whether to follow medical guidance. This dynamic frequently hinders progress, as many male patients are reluctant to heed the advice of family members or healthcare workers. In her words, ‘this resistance is a critical factor in the ongoing struggle against TB in this area.’
Figure 2: Interview of Hamida (pseudonym)
Hamida also highlighted a major issue concerning male TB patients: most of them are drivers. Due to the nature of their job, they travel frequently and come into contact with many people, which increases the risk of spreading the disease. On the other hand, Hamida noted that many female patients are young girls, whose families are particularly concerned about the social stigma associated with TB. These families remain in close contact with healthcare workers, as they worry that if the information becomes public, it could affect the girls’ future marriage prospects. To protect patient confidentiality, Hamida and her team take utmost care in handling these cases.
Hamida shared a success story of a young female patient who had been diagnosed with multidrug-resistant TB (MDR-TB) but despite her family’s fears, the patient diligently followed her medication regime and was declared TB-free within nine months. Hamida noted that younger patients tend to be more aware of TB, often following medical advice closely and attending follow-up appointments independently.
Figure 3: Lab Room of Town Center TB Center
Discussing patient behaviors, Hamida emphasized that awareness about TB has improved, though knowledge remains limited in poorer neighborhoods. She recalled a village where five women showed severe symptoms yet were reluctant to undergo tests, including x-rays. Hamida personally engaged with them, explaining the risks they might be carrying, and eventually persuaded them to get tested. She added that her patients come from various social backgrounds, including, interestingly, local prisoners. Before the recent protest-related prison break in July 2024, her field staff regularly collected samples from the prison.
Hamida also spoke about government support and the condition of infrastructure of her center, which comprises two rooms – one for the TLCA and another used as a testing area. She noted that she maintains regular contact with the Civil Surgeon, who, along with their office, provides support to her team. While she feels the center’s setup is generally sufficient, we pointed out that the location of her office on the first floor can be challenging for patients in urgent need. However, she responded that her team offers alternatives: patients in critical condition can send samples from home, and healthcare workers deliver medication when necessary.
Figure 4: A Researcher of ARK Foundation Performing Cotinine Dipstick Test
Hamida highlighted improvements in diagnostics, mentioning that over 100 x-rays are now performed free of charge. The team also has access to portable x-ray machines, which make testing more accessible. Additionally, there are three health facilities in the area equipped to conduct GenXpert tests—a newer diagnostic tool for tuberculosis. This test not only detects TB but also identifies resistance to rifampicin, one of the primary TB medications. Hamida also mentioned that the Global Fund is now covering the transportation cost, supporting the families of TB patients with little allowance and giving the nutrition support.
The Outskirts
After finishing our interview with Hamida, we started a one-and-a-half-hour ride to another TB center in a rural part of that area. We were greeted warmly by TLCA Mr. Mahmud (pseudonym), who shared that, in his 30-year career, he has witnessed hundreds of TB-related deaths, with recoveries totaling three times as many.
During our conversation, we were surprised to learn that his only laptop for registering and tracking patients had been out of order for a long time, forcing him to manage everything manually. This is an enormous task for a center that receives over 1,000 presumptive TB cases monthly. And that was just the start of the surprises. Mahmud revealed that the office he operates in wasn’t originally intended for him; it was a guard’s restroom that he later managed to repurpose as a TB DOT room or ‘TB corner.’ His TB facility consists of two rooms: an 8-by-6-foot room and a shared laboratory where all hospital tests are conducted. Though the facility has GenXpert testing capabilities, handling over 10 tests per day, the area is in poor condition, with damp walls and aging infrastructure.
Figure 5: The TB Corner/DOT Room of Mahmud (pseudonym)
When we visited Hamida’s facility, we observed only minor operational difficulties. In contrast, Mahmud’s center faces severe structural and functional limitations, which compromise the TB treatment process. According to Mahmud, “I don’t even have a designated room; they didn’t consider a TB center when constructing the hospital. We have a shared drug store for the entire hospital, with no dedicated lab room for TB. Our tests are conducted in the central lab where all other tests happen. Although there’s a separate GenXpert testing spot, its condition is very poor.”
Despite limited resources, Mahmud and his healthcare team work efficiently, yet progress is hindered by the lack of digital tools. Without a functioning computer, Mahmud can’t provide accurate data for his center, relying on development partners for data management, including updates on patient cards and follow-ups. When asked if he had reported these issues, Mahmud smiled sadly and replied, “I reached out to my supervisor, who initially assured me of support but later admitted that government funds don’t cover our needs, let alone the TB program.”
He added that both of the center’s x-ray machines are currently out of order, requiring them to send patients to other facilities for x-rays. Reflecting on operational oversight, Mahmud mentioned that quarterly meetings among TLCAs are supposed to be held but now occur only twice a year, and sometimes they’re delayed, leaving urgent issues unaddressed.
About the TB conditions in his area, Mahmud shared that his center serves patients from 24 unions, including many chars (small islands). He cited the lack of education as a key factor in TB prevalence, noting that tea stalls are primary zones for TB transmission. “People here spend hours at tea shacks chatting with friends and peers, which is when TB bacteria spread. While the number of infectious cases is low, the overall number of TB cases remains high.”
Mahmud expressed gratitude for government initiatives offering x-ray services to potential TB patients, as these x-rays lead to genome testing, helping to identify individuals at risk for TB. Portable x-ray services have enabled Mahmud’s team to test more people in remote areas, including some chars accessible by ferry, though he regrets that some areas remain out of reach, as they are too remote for portable x-ray machines.
Mahmud pointed out that malnutrition among the poor contributes to persistent TB cases. Although most patients are aged 40 to 60, we also encountered cases involving patients as young as two months and as old as 90. Interestingly, Mahmud noted a rise in female patients in his area. He explained that women tend to be more concerned about health screenings than men, so they are getting tested more frequently. In contrast, male patients typically seek care only when they are in serious or advanced stages of the disease.
End of the Journey …
Figure 6: A Patient and His Caregiver Came for Follow-up
During our trip, we spoke with multiple patients, regardless of gender, who are currently undergoing treatment. One of them, Mr. Rahim (aged 78), expressed confidence that he would defeat TB even at his age. When asked about the source of this confidence, Rahim explained that he was previously a chain smoker, smoking over 25 cigarettes daily; since his TB diagnosis, he has ‘successfully’ reduced his smoking to just 3 cigarettes a day – a victory, he believes, in his journey. When we encouraged him to quit smoking entirely, Rahim promised he would be able to stop very soon.
Though the shortcomings and malfunctions in multiple layers within and outside the health system of Bangladesh still exist, the work of the fieldworkers stands a testament to the strength of community-driven efforts that bring about real change. As resources and awareness reach even the most remote areas, Bangladesh edge closer to a future where TB no longer threatens lives. We believe that with the government’s vision and support in partnership with non-governmental organizations, the dreams of people like Mahmud and Hamida will come true, and Bangladesh will soon become a TB-free country where stories like Mahmud’s and Hamida’s become part of a proud legacy of resilience and hope.
- Abdullah Muhammad Rafi (Research Uptake & Communication Manager of ARK Foundation, Bangladesh)
