Poverty and shame hinder TB control campaign

Poverty and shame hinder TB control campaign

Dumilah Ayuningtyas and Ratih Sayidun, Contributors, Jakarta

A resident of Ciamis, West Java, was shocked upon finding out
that she had tuberculosis (TB) -- "the disease of the poor" as
some people call it. So great was her shame that she then
traveled all the way to Yogyakarta to seek medical help there.

True, there were no nosy neighbors to uncover her condition
and look down on her, but the extra burden of paying for the
travel and lodging, in addition to the cost of the health care,
all contributed to the possibility of her dropping out of
treatment.

Fauzi Kasim, a public health expert at the University of
Indonesia, told this story to illustrate the various constraints
facing the government's campaign to control TB. He also told the
story of a man who simply refused to seek help or to take drugs,
because he believed that contracting TB meant certain death.

Another public health expert, Alex Papilaya, related the
problems facing a puskesmas (community health center) in Jakarta;
the health workers refused to collect the sputum of TB patients
for fear that they too would be infected!

Lung specialist Tjandra Yoga Aditama of the Persahabatan
Hospital, in East Jakarta, explained that TB patients must take
their medication rigorously for six months, without missing a
single day. Thus, to control TB, monitoring the patient with
extreme care is essential.

"In Indonesia, it is usually a family member that monitors the
patient, which often leads to poor discipline in taking the
medicine," he said. "Really, somebody from outside the family
should monitor them."

Tjandra said in order to halve the prevalence of TB, and
deaths related to the illness, by 2010, 75 percent of new cases
must be detected early, and 85 percent of those cases must be
treated.

In reality, however, only 30 percent of all projected new
cases are discovered here -- mostly those who receive free
medication at puskesmas -- although it is true that some 85
percent of those cases are eventually cured through the Direct
Observation Treatment, Short-course (DOTS).

Tjandra said that the increased detection of new cases was
essential and that strategies for managing the disease needed to
be improved without delay. "We need to ask, for instance, where
do TB patients go for help? Hospitals should be involved and
provide the health care needed for TB patients, rather than
letting only the puskesmas handle TB, but this calls for
commitment."

"We also need to provide the proper monitoring of patients and
have puskesmas increase public education on the disease. The 30
percent figure largely comes from TB patients that have sought
services at village-level health clinics."

"The system of monitoring patients at places other than
puskesmas is not suitable for TB patients," Tjandra said.

Other health facilities should employ a system that enables
them to record the progress and development of TB patients for up
to six months of treatment, he said. Adding that, they should
assign an officer to oversee the recording.

Indonesia began to apply DOTS in 1995, introduced a
comprehensive strategy to fight TB and even initiated the
Gerdunas TBC, a national campaign against TB.
However, Tjandra admitted that less than 10 percent of
hospitals across the country implement DOTS, and patients often
dropped out before their six-month period of treatment was up.

This year, the government allocated approximately US$19.5
million (including $6.1 million for drugs) out of the required
$31.8 million to control TB. Loans and grants amounting to $9.5
million also contributed toward the required figure, leaving a
shortfall of $2.8 million, that is yet to be addressed.

Nevertheless, Fauzi remains optimistic. "Regarding the first
element of DOTS, namely political commitment, we really should be
proud because over the past few years the government has
prioritized the campaign against TB."

"The budget allocated for the campaign is quite adequate, but
unfortunately there are weaknesses in policy, planning and
implementation, including infrastructures," he said.

He cited, as an example, that a poor Jakartan, suspected to
have contracted TB by health workers at a puskesmas in Gondangdia
Lama would have to be referred to a health center in Cikini for
further tests, and again referred, to another facility in
Jatinegara for x-rays.

"These factors increase the likelihood that patients will
simply drop out of treatment," Fauzi said.