The response to tuberculosis is in our hands

By Chris W. Green

Each year tuberculosis takes the lives of up to three million people worldwide, and in Indonesia it remains a major killer, ranking third in recent years on mortality lists. In observance of World Tuberculosis Day on March 24, The Jakarta Post is running three articles to help raise awareness about this disease.

JAKARTA (JP): More people are dying of tuberculosis (TB) now than ever before. TB is the single biggest killer of young women; over one million women will die needlessly from TB this year. Over 100,000 children will also die from TB this year, and hundreds of thousands more will become TB orphans.

Once again, World TB Day is upon us. On March 24, 1882, Dr. Robert Koch announced his discovery of the TB bacillus in Berlin. On the centenary of that discovery, March 24 was officially designated as World TB Day.

TB still kills 8,000 people every day around the world, making it the biggest killer of young people and adults. TB infects one third of the world's population. In Indonesia, the World Health Organization (WHO) estimates that there were around 1.6 million people infected with TB in 1997, the last year for which reports are published. At least 175,000 people in the country die from the disease each year -- equivalent to 500 each and every day.

According to a report released in 1999 by WHO, Indonesia still occupies the third position in the world rankings of countries with the highest number of new cases of TB, after India and China. The number continues to rise. It is estimated that 583,000 people in Indonesia became infected with TB in 1997, up by more than 30 percent in one year. And it is very probable that this number has increased significantly since then. This is partly due to the explosion in drug use around the country; because of their lifestyle, injecting drug users are more than usually prone to infection by TB -- and can just as easily spread the infection to non drug-using members of the population. In addition, TB is very common among people infected with HIV, the virus that causes AIDS. Increasing prevalence of HIV, partly driven by the sharing of needles by IV drug users, will certainly increase the incidence of TB.

There has been a cure for TB for many years now. The medicines are available free of charge at 3,698 government-run health care clinics around the country. But even the shortest course of treatment requires taking the pills for six months to eight months. If this course of treatment is not completed, there is a risk that the disease may return in a resistant form which is much more difficult and expensive to treat.

The only proven way to attack TB is by a program called Directly Observed Therapy, Short Course, or DOTS. Under this program, which is strongly supported by WHO, each patient is assigned an observer. The task of the observer is to help patients take their medicines regularly and continue with the treatment until they are proven free of disease. If implemented effectively, DOTS can quickly reduce the number of infections, although progress toward eradication does require long-term commitment to the program.

The good news is that the proportion of people in Indonesia who are covered by DOTS rose from 6 percent in 1995 to 28 percent in 1997. Unfortunately, there is evidence that this additional coverage has come at the expense of quality: only 81 percent of cases treated by DOTS in 1996 completed the treatment (down from 94 percent in 1994), and only 67 percent were checked to prove they had been cured.

Last year, in an article in The Jakarta Post to mark World TB Day, I wondered if Indonesia could develop and maintain the political commitment required to make an impact on this disease. What has changed in the last 12 months?

Clearly the effect of the 1997 monetary crisis continues to bite. There is no doubt that there has been a reduction in the resources applied to TB, both human and financial. Publicity campaigns to raise public awareness and reduce the stigma associated with the disease have been curtailed. But perhaps the greatest threats are to come, resulting from the policy of decentralization of government, together with the new emphasis on the preservation of health rather than treatment of sickness.

There is no doubt that these policies are long overdue. The provision of more autonomy to the regions is essential. And the move toward a new paradigm in health care is, well, healthy. But in some areas, decentralization may be progressing faster than the regional administrations are ready to accept their new responsibilities. There is genuine fear that this may result in even less attention to some of the major challenges to health. And preservation of health is dependent upon eliminating, or at least significantly reducing, such contagious diseases as TB.

The concept of DOTS is often not well understood even at a national level. It is often thought to consist only of "watching people take their medicines". In fact, the WHO makes clear that it includes five essential elements: political commitment to ensure a strong program; provision of testing services to determine if the bacteria is present, constant availability of drugs to treat the disease; monitoring systems; and direct observation of patients taking their pills. And failure to implement any of these has been proved again and again to reduce significantly the success of the program.

The first item on the list, political commitment, was in doubt even before decentralization, as my comments last year make clear. Is it reasonable to expect that regional administrations, faced with huge challenges in taking over their new responsibilities, will demonstrate increased commitment over the next few years? There must be doubts. But if we are to see progress in controlling this eminently controllable disease which is killing so many people, the general public must play a much greater role in advocating for closer attention and urgent action. The intent of decentralization is to put many of the "social" problems, including health, into the hands of the community. It is up to us to accept them.

Failure will lay us open to an uncontrolled epidemic of TB.

-- The writer is an AIDS activist in Indonesia, and publishes several newsletters in Indonesian on AIDS and related matters.