The response to tuberculosis is in our hands<\/p>\n
By Chris W. Green<\/p>\n
Each year tuberculosis takes the lives of up to three million
\npeople worldwide, and in Indonesia it remains a major killer,
\nranking third in recent years on mortality lists. In observance of
\nWorld Tuberculosis Day on March 24, The Jakarta Post is running
\nthree articles to help raise awareness about this disease.<\/p>\n
JAKARTA (JP): More people are dying of tuberculosis (TB) now
\nthan ever before. TB is the single biggest killer of young women;
\nover one million women will die needlessly from TB this year.
\nOver 100,000 children will also die from TB this year, and
\nhundreds of thousands more will become TB orphans.<\/p>\n
Once again, World TB Day is upon us. On March 24, 1882, Dr.
\nRobert Koch announced his discovery of the TB bacillus in Berlin.
\nOn the centenary of that discovery, March 24 was officially
\ndesignated as World TB Day.<\/p>\n
TB still kills 8,000 people every day around the world, making
\nit the biggest killer of young people and adults. TB infects one
\nthird of the world's population. In Indonesia, the World Health
\nOrganization (WHO) estimates that there were around 1.6 million
\npeople infected with TB in 1997, the last year for which reports
\nare published. At least 175,000 people in the country die from
\nthe disease each year -- equivalent to 500 each and every day.<\/p>\n
According to a report released in 1999 by WHO, Indonesia still
\noccupies the third position in the world rankings of countries
\nwith the highest number of new cases of TB, after India and
\nChina. The number continues to rise. It is estimated that 583,000
\npeople in Indonesia became infected with TB in 1997, up by more
\nthan 30 percent in one year. And it is very probable that this
\nnumber has increased significantly since then. This is partly due
\nto the explosion in drug use around the country; because of their
\nlifestyle, injecting drug users are more than usually prone to
\ninfection by TB -- and can just as easily spread the infection to
\nnon drug-using members of the population. In addition, TB is very
\ncommon among people infected with HIV, the virus that causes
\nAIDS. Increasing prevalence of HIV, partly driven by the sharing
\nof needles by IV drug users, will certainly increase the
\nincidence of TB.<\/p>\n
There has been a cure for TB for many years now. The medicines
\nare available free of charge at 3,698 government-run health care
\nclinics around the country. But even the shortest course of
\ntreatment requires taking the pills for six months to eight
\nmonths. If this course of treatment is not completed, there is a
\nrisk that the disease may return in a resistant form which is
\nmuch more difficult and expensive to treat.<\/p>\n
The only proven way to attack TB is by a program called
\nDirectly Observed Therapy, Short Course, or DOTS. Under this
\nprogram, which is strongly supported by WHO, each patient is
\nassigned an observer. The task of the observer is to help
\npatients take their medicines regularly and continue with the
\ntreatment until they are proven free of disease. If implemented
\neffectively, DOTS can quickly reduce the number of infections,
\nalthough progress toward eradication does require long-term
\ncommitment to the program.<\/p>\n
The good news is that the proportion of people in Indonesia
\nwho are covered by DOTS rose from 6 percent in 1995 to 28 percent
\nin 1997. Unfortunately, there is evidence that this additional
\ncoverage has come at the expense of quality: only 81 percent of
\ncases treated by DOTS in 1996 completed the treatment
\n(down from 94 percent in 1994), and only 67 percent were checked
\nto prove they had been cured.<\/p>\n
Last year, in an article in The Jakarta Post to mark World TB
\nDay, I wondered if Indonesia could develop and maintain the
\npolitical commitment required to make an impact on this disease.
\nWhat has changed in the last 12 months?<\/p>\n
Clearly the effect of the 1997 monetary crisis continues to
\nbite. There is no doubt that there has been a reduction in the
\nresources applied to TB, both human and financial. Publicity
\ncampaigns to raise public awareness and reduce the stigma
\nassociated with the disease have been curtailed. But perhaps the
\ngreatest threats are to come, resulting from the policy of
\ndecentralization of government, together with the new emphasis on
\nthe preservation of health rather than treatment of sickness.<\/p>\n
There is no doubt that these policies are long overdue. The
\nprovision of more autonomy to the regions is essential. And the
\nmove toward a new paradigm in health care is, well, healthy. But
\nin some areas, decentralization may be progressing faster than
\nthe regional administrations are ready to accept their new
\nresponsibilities. There is genuine fear that this may result in
\neven less attention to some of the major challenges to health.
\nAnd preservation of health is dependent upon eliminating, or at
\nleast significantly reducing, such contagious diseases as TB.<\/p>\n
The concept of DOTS is often not well understood even at a
\nnational level. It is often thought to consist only of \"watching
\npeople take their medicines\". In fact, the WHO makes clear that
\nit includes five essential elements: political commitment to
\nensure a strong program; provision of testing services to
\ndetermine if the bacteria is present, constant availability of
\ndrugs to treat the disease; monitoring systems; and direct
\nobservation of patients taking their pills. And failure to
\nimplement any of these has been proved again and again to reduce
\nsignificantly the success of the program.<\/p>\n
The first item on the list, political commitment, was in doubt
\neven before decentralization, as my comments last year make
\nclear. Is it reasonable to expect that regional administrations,
\nfaced with huge challenges in taking over their new
\nresponsibilities, will demonstrate increased commitment over the
\nnext few years? There must be doubts. But if we are to see
\nprogress in controlling this eminently controllable disease which
\nis killing so many people, the general public must play a much
\ngreater role in advocating for closer attention and urgent
\naction. The intent of decentralization is to put many of the
\n\"social\" problems, including health, into the hands of the
\ncommunity. It is up to us to accept them.<\/p>\n
Failure will lay us open to an uncontrolled epidemic of TB.<\/p>\n
-- The writer is an AIDS activist in Indonesia, and publishes
\nseveral newsletters in Indonesian on AIDS and related matters.<\/p>",
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