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.