Stopping TB in South and Southeast Asia

Santi W.E. Soekanto, Journalist, Kathmandu

The following is a report from Kathmandu, Nepal, following the launch of a book, Stopping a Killer: Combating Tuberculosis in South and Southeast Asia (Panos South Asia, Kathmandu, 2003) in which the writer included a chapter on Indonesia. On March 24, the world commemorates Tuberculosis Day.

Death stalks destitute Unti Devi, a woman in her 20s living in the city of Dhanbad in the Indian state of Jharkhand. She has drug-resistant tuberculosis. Lying in a semi-comatose state on a bloodstained bed sheet in the TB ward of Patlipura Medical College Hospital, she has been considered incurable by her doctors. Keeping vigil at her hospital bedside is her elderly mother. The man she married three years ago, Bhim Bandi of Katras, and her in-laws kicked her out as soon as it was known that she had TB, which, ironically, she contracted from her mother-in-law.

Janakwa Devi, 65, often coughs up blood. A poor woman, she has been deserted by her only son -- whom she has served like a king since he was a boy. Tetri Devi, 55, served her father-in-law and husband -- both terminal TB cases -- for years before she too became sick. She soon found herself in the tuberculosis ward of a hospital with no one looking after her and paying for her bill.

Runki works an eight-hour shift in a coal field before returning home to cook for her two small children and mother-in- law. Then, late in the evening, she goes to the TB ward of the hospital to sit by the bedside of her husband, Santosh Kumar. The cruel thing is that Runki herself is suffering from TB -- but since she has to run the household, she suffers the effects of the disease in silence. She thinks her husband's life is more important than hers, and her husband only says, "Runki is only doing her duty. It does not matter whether she is ill or not."

The common thread binding these cases is TB, poverty and gender, as cited in the recently launched Stopping a Killer: Combating Tuberculosis in South and Southeast Asia. Written by Binod Dubey, a journalist with the Hindustan Times, the chapter on TB in India explored how the highly variable communicable disease has become "the biased killer".

In a workshop preceding the book launch, Malika Samaratunga, a research officer at the South Asian Association for Regional Cooperation (SAARC) TB Center in Kathmandu, described how women were often the more difficult to reach in TB treatment. Gender inequalities persist in many South Asian societies, which are male-dominated, and women have a lower status, less access to education, restricted mobility and poor control over household economy.

For instance, more men than women are diagnosed and notified -- and thus treated -- for TB. Fewer women undergo laboratory examinations because of selection bias on the part of the service providers. In addition, a smaller number of women complete treatment after they are diagnosed; the cases of Indian women cited above explains why. The prevalence of infection is higher in males after adolescence, however, progression from infection to disease is higher in females of reproductive age.

"TB is one of the leading killers of women of reproductive age," Samaratunga said.

Organized by a Kathamandu-based NGO, Panos South Asia, in cooperation with the World Health Organization (WHO), the book compiles reports on TB progression in various countries in the region and the various obstacles facing the implementation of the Direct Observed Treatment Short Course (DOTS) for community groups, such as commercial sex workers, refugees and children. The chapter on Indonesia, titled "Double Trouble", studies the absence of basic health services -- much less the DOTS -- in war- torn communities, such as Poso, Ambon, Ternate and Sampang.

It is estimated that TB kills nearly two million people every year. That translates into 750,000 deaths in South and Southeast Asian countries. Its impact is clearly devastating -- most of those who die are poor.

But where do poverty, women and TB meet? Does TB result from poverty, given how some 60 percent of all TB cases are those in the poorest layer of any society. Hence, last year's theme for TB Day on March 24: "Stop TB, Fight Poverty." Or is it TB that causes poverty? Why do women suffer more from TB? Does poverty contribute to the lack or failure of national control programs? Along with cure rates and detection figures in controlling the growth of the epidemic, it is the dearth of answers to these questions that are emerging as important issues in the campaign against TB.

It is estimated that a person with active TB can infect an average of 15 people every year. TB is known to thrive in conditions of poverty and overcrowding. TB affects those who are malnourished and with low immunity -- which is why it forms a deadly, "unholy partnership" with HIV.

The United Nations has recently estimated the impact of TB in broad terms and they have come up with a deadly reading: The average loss of income is about 20 percent to 30 percent per patient per year; the average loss of a family's earning capacity after one of its members dies from TB is about 15 years. These losses could amount to almost one percent of GDP, the same margin by which developing countries are trying to escape the poverty trap. The impact of the loss is obvious.

At the family and community level, this translates into discontinued education, childhood marriages, loss of skills, poor job opportunities, more child workers, inadequate child care, mortality due to other opportunistic infections, stigma and family breakups, to name but a few.

TB kills the patient and devastates the rest.

The DOTS treatment strategy cures patients, saves lives, prevents the spread of drug resistance and reduces disease transmission. Yet, according to WHO estimates based on 2001 data, only 30 percent of active TB cases are being diagnosed and treated under DOTS programs. The global targets of 70 percent case detections and 85 percent cure rates for those detected must be reached by 2005 in order to halve TB prevalence and deaths by 2010.

What about Indonesia? WHO estimates that almost 600,000 new cases of TB emerge in Indonesia every year and treatment for them is fraught with challenges. Indonesia has the third largest burden of TB in the world after India and China. Unfortunately, detection rate is only about 20 percent and out of these cases, some 80 percent are treated successfully.

Lung specialist Tjandra Yoga Aditama attributed recently the low detection rate to uneven recording and reporting of TB cases in health facilities. The 20 percent figure comes from the reported TB patients that seek services at village-level health clinics. "The recording system outside of Puskesmas is not suitable for TB patients," Tjandra said.

All other health facilities should instead employ a system that enables them to record the progress and developments of TB patients for up to 6 months of treatment, he said. They should assign an officer to make complete recording, he added.

Indonesia began to apply DOTS in 1995, introduced a comprehensive strategic plan to fight TB and even initiated the Gerdunas TBC, a national campaign against TB. Yet, Tjandra said, less than 10 percent of all hospitals across the country implement the DOTS -- which, Tjandra admitted, faces such challenges as the fact that patients often drop out before the six-month period of treatment is up.

What is next? The United Nations has established the Global Fund for Malaria, AIDS and TB -- therefore, in terms of financial support for an anti-TB campaign, Indonesia would also benefit. But journalists gathering in Kathmandu for the workshop in early March identified just how great a challenge is facing TB control policy, and agreed that more people should take part in the campaign against this poverty-induced disease -- which coincided with the theme for this year's TB Day: "People with TB".

-- With additional reporting by Ratih Sayidun in Jakarta.