When will good news on TB arrive?<\/p>\n
Chris W. Green, Contributor, Jakarta<\/p>\n
To commemorate the anniversary of the identification of the
\nbacteria that causes tuberculosis (TB) by Alfred Koch in 1882,
\nMarch 24 is designated as World TB Day. As this day comes around
\nagain, let's look back at the progress being made to control this
\nterrible disease in Indonesia.<\/p>\n
The news is at best mixed. In 1999, the last year for which
\nWorld Health Organization (WHO) figures are available, there was
\nprogress in the implementation of DOTS (directly observed
\ntherapy, short course), the control method recommended by the
\nWHO. By then, 90 percent of Indonesia's population was reported
\nto be covered by DOTS, up from 80 percent in the previous year.<\/p>\n
Detection of infectious cases of TB was still very low at
\nunder 20 percent, even though this represented an increase over
\nthe previous year's 12 percent.<\/p>\n
The bad news is clearer: Indonesia remains number three in the
\nworld behind India and China in the total number of TB cases.
\nLess than 60 percent of registered infectious cases and only 9
\npercent of all new infectious cases were successfully treated.<\/p>\n
Since there are estimated to be 265,000 people with infectious
\nTB in Indonesia, and each of these can infect as many as 15
\nothers every year, the potential scale of the TB epidemic is
\nclear. It is therefore not surprising that this estimate shows an
\nincrease of one third over the last three years.<\/p>\n
The WHO gives Indonesia good marks for political commitment,
\nwith strong government support for Gerdunas TB (National
\nIntegrated TB Movement), a nationwide effort to mobilize a
\ndiversity of forces against TB. Gerdunas was set up on World TB
\nDay 1999, to demonstrate that TB was not only the problem of the
\nMinistry of Health.<\/p>\n
However, according to Dr. Tjandra Yoga Aditama, head of the
\nWHO Collaborating Center for TB at Persahabatan Hospital, as
\nrecently quoted in the Kompas daily, Gerdunas must be revitalized
\nand policy makers' commitment increased.<\/p>\n
One objective of Gerdunas is to make the drugs to cure TB
\navailable to all at no cost through the wide network of community
\nhealth centers (puskesmas). However, as Dr. Tjandra notes,
\neffective services for people with TB have yet to be provided
\nwidely in other medical facilities, such as hospitals, clinics
\nand by doctors.<\/p>\n
"At minimum," says Dr. Tjandra, "hospitals must provide free
\ndrugs for people with TB, and must set up reporting systems."<\/p>\n
Personal experience with three cases connected with HIV in
\nBatam, Jakarta and Makassar confirm that it is difficult if not
\nimpossible for patients to obtain the free drugs without
\npersonally visiting a puskesmas, a visit they are often loathe to
\nmake because of poor service and anticipated stigmatization.<\/p>\n
It is now well known that the TB and HIV epidemics are closely
\nallied. TB is the most common cause of death of people with
\nHIV\/AIDS, a cause that is almost totally preventable with the
\nfree drugs that should be available.<\/p>\n
Conversely, an HIV epidemic can significantly increase both
\nthe frequency and severity of TB outbreaks. Sadly, given the low
\nsuccess rate of TB treatment in Indonesia, it appears that this
\namplification effect of HIV on TB is greatly affected by the TB
\ntreatment rate. Research has shown that even with a relatively
\nsmall HIV epidemic (such as that in much of Indonesia), but with
\nlow or even moderate TB treatment rates, the average size of TB
\noutbreaks will double in comparison with what would be expected
\nwithout HIV.<\/p>\n
The theme for this year's World TB Day, "Stop TB, fight
\npoverty", is most appropriate for Indonesia. TB thrives in the
\ndark, narrow alleys of the slums in many parts of the country.
\nThe effects of the recent floods can only make these conditions
\nmore conducive for active TB disease to develop.<\/p>\n
And poverty adds to the stigma that prevents many sick people
\nfrom visiting the local puskesmas.<\/p>\n
But the theme is also intended to suggest that effective
\nresponses to TB can help address poverty. The loss of income
\nresulting from sickness for those employed in the informal sector
\ncan be devastating, including upon their families.<\/p>\n
As the WHO puts it, "poor laborers and farmers stay poor
\nif they are sick".<\/p>\n
TB is a contagious disease that spread through the air when
\npeople with active cases cough or sneeze. But many in Indonesia
\nstill believe it is a congenital disease, a misconception that
\nwas widely held in the West until quite recently. TB can be
\ncured, but an effective cure requires the medicines to be taken
\ncorrectly for an extended period of six to nine months.<\/p>\n
Last year, the WHO included Indonesia among a handful of
\ncountries that had failed to make significant progress in
\naddressing TB. The WHO continues to show concern about Indonesia;
\nits recently released annual report, Global Tuberculosis Report
\n2001, notes, "A wide range of improvements is evidently needed
\nbecause the data submitted to the WHO indicate low coverage,
\ndoubtful treatment outcomes and inconsistent reporting." I wonder
\nwhen we'll hear the good news?<\/p>",
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