Fighting Tuberculosis in Pakistan: A Conversation on Diagnos

Tuberculosis (TB) remains one of Pakistan's most persistent public health challenges, accounting for thousands of preventable deaths each year Interviewee: Dr. Zaheer Akhtar, Head of Department, Pulmonology, Ghulab Devi Hospital Interviewers: Amani Tanvir Mirza, Aahil Saleem Nasir Acknowledgements: 1. Dr. Shaper's Lab, LUMS 2. Dr. Shaper Mirza, LUMS Department of Microbiology, Epidemiology and Molecular Biology Tuberculosis (TB) remains one of Pakistan's most persistent public health challenges, accounting for thousands of preventable deaths each year despite widespread government intervention. While medical technology continues to advance, frontline clinicians often face structural barriers that go far beyond the lab bench—ranging from severe patient delay to deep-seated nutritional deficits. As part of an ongoing project at Dr. Shaper's Lab to develop an accessible optical sensor-based diagnostic tool for rural communities, we sat down with Dr. Zaheer, a leading pulmonologist and TB specialist, to discuss the realities of diagnosis on the ground, why free treatment isn't always enough, and where the real battle against TB must be fought. The Diagnostic Pathway and Clinical Presentation Q: What is the current diagnostic pathway in Pakistan for a patient presenting with potential tuberculosis? Dr. Zaheer: It begins with thorough history-taking and a physical examination—we actually consider a good medical history to be our first diagnostic tool. If a patient presents with typical symptoms such as fever, cough, sputum production, and weight loss lasting for more than 15 days, along with a family history or contact with a known TB patient in the last 15 days, there is a very high likelihood of tuberculosis. After taking a history and performing an examination, we collect a sputum sample. For patients with symptoms of chest disease, we run an Acid-Fast Bacilli (AFB) smear to detect Mycobacterium tuberculosis, the primary bacteria responsible for TB. We simultaneously perform a GeneXpert test, which provides a definitive diagnosis within two hours. If a patient with pulmonary tuberculosis provides a good-quality sputum sample, there is a 90% chance the GeneXpert test will detect it. Q: Do you also rely on imaging and scans to confirm the diagnosis? Dr. Zaheer: Yes, along with sputum tests, we perform a chest X-ray to look for typical visual indicators. On a standard chest X-ray, normal lung tissue appears dark, but in a TB patient, you see distinct white shadows and density changes. A classic, typical feature of tuberculosis is cavity formation in the lungs. In some cases, we also order a CT scan, which gives us a clearer look at these cavities and bilateral lung involvement. On microscopic sputum slides, the bacteria appear as distinct pink or red dots—a single slide can sometimes show more than 100 TB bacteria. When the clinical history, X-ray findings, and sputum results all align, we have a fully confirmed case and initiate treatment immediately. Treatment Protocols and Dosing Q: How is the treatment regimen structured once a patient is diagnosed? Dr. Zaheer: Treatment is strictly weight-based. We use fixed-dose combination tablets that combine four primary anti-TB drugs into a single pill: rifampicin, isoniazid, ethambutol, and pyrazinamide. The daily dosage depends on body mass: * Up to 40 kg: 2 tablets daily * 40 to 54 kg: 3 tablets daily * Above 54 kg (regardless of whether the patient is 70 kg or 150 kg): 4 tablets daily This four-drug combination is given for the first two months (the intensive phase). After two months, we switch the patient to a three-drug combination (such as Rifaport) for the remaining four months by removing pyrazinamide, leaving rifampicin, isoniazid, and ethambutol. The total treatment duration is six months. Financial Costs and Primary Limitations Q: What is the cost per patient for these diagnostic tests and medications? Dr. Zaheer: In Pakistan, and particularly in Punjab, TB diagnosis and treatment are 100% free at public health centers. A patient with symptoms simply needs to go to a government TB center, where sputum testing, GeneXpert, X-rays, and the complete six-month drug supply are provided at zero cost. If someone were to pay out-of-pocket in the private sector, diagnostics would cost roughly 10,000 PKR, and monthly treatment ranges from 6,000 to 7,000 PKR—bringing the total private cost to around 50,000 PKR. TB is perhaps the only major disease in Pakistan where both investigation and complete treatment are entirely funded by the government. Q: Given that care is free, what would you say is the biggest limitation of current diagnostic and treatment efforts? Dr. Zaheer: The single biggest challenge is patient health education and awareness. Patients often continue coughing for months without seeking medical attention. I recently treated a patient who experienced fever, cough, and sputum production for eight months before seeing a physician. She was simply taking over-the-counter cough syrups and fever reducers while continuing her daily routine. By the time she arrived at our clinic, both lungs were destroyed and she was critically ill. Beyond awareness, there are two other main barriers: 1. Travel Costs and Priorities: While tests and medicines are free, patients visiting our center often travel 100 to 200 kilometers. The travel cost itself becomes a hurdle—not necessarily because patients are destitute, but because health is not made a financial priority over everyday expenses. 2. Treatment Duration: Standard antibiotic courses last 7 to 14 days, but TB therapy requires six full months. Patients often take medicine for a month, feel better, and stop. They relapse, take it for another two months, and stop again. Interrupting treatment leads to severe complications and drug resistance. Resistance, Malnutrition, and Demographic Factors Q: What percentage of your caseload involves drug-resistant TB? Dr. Zaheer: Among previously treated patients—people who had standard TB, took medication, but did not complete it properly—drug resistance is approximately 15%. For new cases who have never taken anti-TB drugs before, primary drug resistance sits at around 4%. Q: How frequently do you see severe malnutrition, and how does it impact recovery? Dr. Zaheer: More than 80% of our patients are undernourished. TB is fundamentally a disease linked to reduced immunity, and immunity relies heavily on proper nutrition. Because of poverty and a lack of nutritional awareness, many patients consume a diet composed almost entirely of carbohydrates—such as daily roti—while neglecting essential proteins like eggs or pulses/lentils, which are relatively affordable. This chronic undernourishment lowers immune defenses, making the body significantly more vulnerable to developing active TB. Q: Are there noticeable differences in how TB presents between urban and rural populations? Dr. Zaheer: Yes. In urban areas, people often live in smaller, high-density homes, allowing TB to spread more easily between family members. However, because health facilities are nearby, urban residents tend to see a doctor earlier and get diagnosed sooner, resulting in less advanced disease at presentation. In rural areas, living spaces are larger and more open, so the rate of transmission is lower. However, rural patients present to hospitals much later in their illness due to distance, meaning they arrive with far more severe lung damage. Additionally, overcrowded environments like slums, madrassas, prisons, and congested rural schools represent the highest-risk pockets for rapid transmission across the country. Proposed Prospects Q: If you could change one major thing about the current TB diagnostic landscape, what would it be? Dr. Zaheer: We already have accessible diagnostics and medication—they are neither overly complex nor expensive. What we lack is a continuous, aggressive public information campaign. We need to treat TB control like a war strategy. During the COVID-19 pandemic, public health messaging was everywhere—on mobile phones, news broadcasts, print media, and social platforms. TB requires that exact same level of urgency. Government health authorities must continuously inform the public: if you have had a cough for 15 days, do not treat it at home; visit a free government clinic immediately. Informing and alerting the public will save far more lives than new clinical technology alone. End of Interview Dialogue As our conversation came to a close, Dr. Zaheer expressed optimism for the next generation of researchers working to innovate in healthcare, leaving us with a compelling reminder: while technological advances in diagnostics are essential, the long-term elimination of tuberculosis in Pakistan will ultimately depend on empowering communities through education, strengthening public health systems, and ensuring that patients seek medical care as early as possible. This perspective closely aligns with the motivation behind our project at the LUMS Department of Microbiology in Dr. Shaper's Lab. Our interdisciplinary team is working towards the development of a low-cost, optical sensor-based diagnostic device capable of providing rapid, accessible TB detection. By reducing the barriers of cost, infrastructure, and diagnostic delay, such technology has the potential to bring reliable testing closer to the communities that need it most, particularly in resource-limited settings where the burden of disease remains highest. However, as Dr. Zaheer emphasised, innovation alone is not enough. During the COVID-19 pandemic, governments successfully mobilised text alerts, television broadcasts, and social media campaigns to educate the public and encourage early testing. Tuberculosis demands the same level of urgency. If public health messaging consistently reinforced that a cough lasting more than two weeks warrants immediate, free evaluation, far more patients would present before irreversible lung damage occurs, treatment could begin sooner, and transmission within households and communities could be dramatically reduced. Ultimately, our project represents one piece of a much larger solution. While advances in rapid diagnostics can transform how quickly TB is detected, meaningful progress against the disease will require these innovations to be integrated with widespread public awareness, robust healthcare infrastructure, and coordinated national policy. Only through this combined approach can Pakistan hope to substantially reduce its tuberculosis burden and move towards eventual elimination.