Dr. Juliet Sekandi, a native Ugandan, is conducting research that explores how cell phones and artificial intelligence can be used to improve patient compliance with tuberculosis treatment and curb the spread of the highly contagious disease. (Photo by Jason Thrasher)

Juliet Sekandi and the case of the treatable yet rapidly spreading disease

Tuberculosis is rampant in Uganda, where nearly 80,000 people develop the disease every year. While practicing there as the attending physician in charge of the public hospital’s TB clinic, Dr. Juliet Sekandi, assistant professor in the UGA College of Public Health, noticed that when people with TB came to her clinic, they often had been suffering for months from the painful breathing, extreme and persistent coughing, fatigue, and fever. Moreover, after the patients went home with their treatment, they would soon return with a household member (or two) who now also had TB.

TB is a highly contagious disease that spreads when the bacteria are ejected from a person’s lungs when they cough or even just speak. So, in a household of four or more people, it was unlikely that it would infect only one person. What’s more, the longer someone remains undetected, the further they spread the disease. What was it, Sekandi wondered, that was keeping people from seeking treatment, helping TB spread like wildfire? That question led her on an ongoing 15-year quest to understand the factors underlying people’s resistance to seeking help, and has spurred a solution using cell phones and artificial intelligence.

At the time, she was trained as an M.D., a field that focuses on finding and treating patients. But that approach wasn’t solving the larger issue of TB spreading throughout the community. For that, she knew she would need to use a public health perspective, which could both seek to prevent the disease from spreading and get care to people who didn’t have good access to it.

Using an exercise called active case finding, she went door to door in one of the capital city of Kampala’s poorest slums, asking people about their cough and to give her samples of their spit. She found that, of those who’d had a chronic cough for at least two weeks, 20% tested positive for TB. She also tested people for HIV and discovered that 30% of those found to have TB also had HIV—most of them unaware they were positive.

“Now, we have very effective medicine to treat TB,” said Sekandi. “So, if one in five is not showing up for treatment, it was clear we needed to find a way to improve our case detection.”

TB causes disease by attacking the body’s CD4 immune cells. As it turns out, so does the human-immunodeficiency virus (HIV), which can lead to AIDS. People with HIV/AIDS are more susceptible to catching TB because their CD4 cells are already depleted.

What was going on that led people to avoid medical treatment for two diseases that, either alone or together, can be fatal when left untreated, yet can be well-controlled if they are medicated properly? The answer was twofold: avoiding the health clinic and not finishing their medication.

patient signing in with nurse at clinic
A nurse enrolls a study volunteer in the DOT Selfie system, which is used to monitor TB patients as they take months-long courses of medication. Patients often stop taking their medicine when they feel better, leading to recurrent illness and drug-resistant strains of TB. With DOT Selfie, patients use their smartphones to record videos as evidence that they’ve taken their medication. (Photo courtesy of Juliet Sekandi)