TB, a human rights concern?

By Chris W. Green

JAKARTA (JP): "Tuberculosis is deeply rooted in populations where human rights and dignity are limited. While anyone can contract TB, the disease thrives on the most vulnerable -- the marginalized, discriminated against populations, and people living in poverty." This is according a 2001 report by the World Health Organization.

If this is true, is it any surprise that Indonesia continues to occupy the third position in the world rankings of countries with the highest number of new cases of TB, after India and China?

Or that the WHO lumps Indonesia together with other countries with high rates of TB, such as the Russian Federation, as having inadequate TB control, caused mainly by lack of resources devoted to health care?

As World TB Day of March 24 comes round once again, commemorating the discovery of the TB bacillus in 1882, it is a good time to consider what progress we have made in the last 12 months. And the news is not good.

The WHO estimates that there were 591,000 new cases of TB infection in Indonesia in 1998, the last year for which figures are available. This is an increase of one third over the previous year. Over 140,000 died of the disease. But the WHO-supported anti-TB program identified only a few of the new infectious cases.

This program, called Directly Observed Treatment, Short-course or DOTS, is intended to provide a complete response, starting from political commitment, identification of TB infection, and treatment of those found to be infected.

Whereas this program has expanded rapidly, now covering 80 percent of the population, it has detected only 12 percent of the new cases. Even worse, only a little over half of these cases completed the six to eight months therapy needed to cure the disease, compared with 94 percent in the previous year.

Treatment that is not completed can add to the problem, by increasing the chances that a strain of TB may evolve which cannot be cured by standard therapy.

There are many reasons for this failure to make real progress. But it is clear that inadequate consideration of human rights has a major bearing on this.

Non-discrimination is a principle of human rights -- and public health -- that is fundamental to the response to TB. TB remains a highly stigmatized disease, little better than the Acquired Immune Deficiency Syndrome or leprosy. Because of the stigma, we prefer not to talk about it, not to understand it, and to ostracize people infected with TB.

Partly because of this stigma, we neglect the right to information. Many people are even unaware that TB can be cured, and with drugs that are relatively inexpensive and that should be widely available.

Of course, TB thrives among the most vulnerable sections of society -- the poor, women, children, refugees, people in prison, drug users and people with AIDS.

Malnutrition, crowding, and poor sanitation all increase the chances of infection with TB. We can only guess at the explosion of TB that is occurring in the refugee camps which are becoming more common as a result of the ethnic violence which is spreading so rapidly throughout the country. And in the prisons.

A recent survey in a prison on Bali found that almost 20 percent of those tested were infected with HIV. Since HIV and TB so often go hand in hand, we can be sure that TB infection rates are much higher than this throughout the overcrowded prisons of this country.

We cannot just leave the response to TB to the doctors, to the Ministry of Health. As Gro Harlem Bruntland, the WHO Director General, puts it, an effective response to TB calls for resources, an informed society and a functioning health system in its widest sense.

It appears that we in Indonesia are far from addressing any of these requirements.

The writer is an AIDS activist in Jakarta.