Stopping TB in South and Southeast Asia

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.