When will good news on TB arrive?

When will good news on TB arrive?

Chris W. Green, Contributor, Jakarta

To commemorate the anniversary of the identification of the
bacteria that causes tuberculosis (TB) by Alfred Koch in 1882,
March 24 is designated as World TB Day. As this day comes around
again, let's look back at the progress being made to control this
terrible disease in Indonesia.

The news is at best mixed. In 1999, the last year for which
World Health Organization (WHO) figures are available, there was
progress in the implementation of DOTS (directly observed
therapy, short course), the control method recommended by the
WHO. By then, 90 percent of Indonesia's population was reported
to be covered by DOTS, up from 80 percent in the previous year.

Detection of infectious cases of TB was still very low at
under 20 percent, even though this represented an increase over
the previous year's 12 percent.

The bad news is clearer: Indonesia remains number three in the
world behind India and China in the total number of TB cases.
Less than 60 percent of registered infectious cases and only 9
percent of all new infectious cases were successfully treated.

Since there are estimated to be 265,000 people with infectious
TB in Indonesia, and each of these can infect as many as 15
others every year, the potential scale of the TB epidemic is
clear. It is therefore not surprising that this estimate shows an
increase of one third over the last three years.

The WHO gives Indonesia good marks for political commitment,
with strong government support for Gerdunas TB (National
Integrated TB Movement), a nationwide effort to mobilize a
diversity of forces against TB. Gerdunas was set up on World TB
Day 1999, to demonstrate that TB was not only the problem of the
Ministry of Health.

However, according to Dr. Tjandra Yoga Aditama, head of the
WHO Collaborating Center for TB at Persahabatan Hospital, as
recently quoted in the Kompas daily, Gerdunas must be revitalized
and policy makers' commitment increased.

One objective of Gerdunas is to make the drugs to cure TB
available to all at no cost through the wide network of community
health centers (puskesmas). However, as Dr. Tjandra notes,
effective services for people with TB have yet to be provided
widely in other medical facilities, such as hospitals, clinics
and by doctors.

"At minimum," says Dr. Tjandra, "hospitals must provide free
drugs for people with TB, and must set up reporting systems."

Personal experience with three cases connected with HIV in
Batam, Jakarta and Makassar confirm that it is difficult if not
impossible for patients to obtain the free drugs without
personally visiting a puskesmas, a visit they are often loathe to
make because of poor service and anticipated stigmatization.

It is now well known that the TB and HIV epidemics are closely
allied. TB is the most common cause of death of people with
HIV/AIDS, a cause that is almost totally preventable with the
free drugs that should be available.

Conversely, an HIV epidemic can significantly increase both
the frequency and severity of TB outbreaks. Sadly, given the low
success rate of TB treatment in Indonesia, it appears that this
amplification effect of HIV on TB is greatly affected by the TB
treatment rate. Research has shown that even with a relatively
small HIV epidemic (such as that in much of Indonesia), but with
low or even moderate TB treatment rates, the average size of TB
outbreaks will double in comparison with what would be expected
without HIV.

The theme for this year's World TB Day, "Stop TB, fight
poverty", is most appropriate for Indonesia. TB thrives in the
dark, narrow alleys of the slums in many parts of the country.
The effects of the recent floods can only make these conditions
more conducive for active TB disease to develop.

And poverty adds to the stigma that prevents many sick people
from visiting the local puskesmas.

But the theme is also intended to suggest that effective
responses to TB can help address poverty. The loss of income
resulting from sickness for those employed in the informal sector
can be devastating, including upon their families.

As the WHO puts it, "poor laborers and farmers stay poor
if they are sick".

TB is a contagious disease that spread through the air when
people with active cases cough or sneeze. But many in Indonesia
still believe it is a congenital disease, a misconception that
was widely held in the West until quite recently. TB can be
cured, but an effective cure requires the medicines to be taken
correctly for an extended period of six to nine months.

Last year, the WHO included Indonesia among a handful of
countries that had failed to make significant progress in
addressing TB. The WHO continues to show concern about Indonesia;
its recently released annual report, Global Tuberculosis Report
2001, notes, "A wide range of improvements is evidently needed
because the data submitted to the WHO indicate low coverage,
doubtful treatment outcomes and inconsistent reporting." I wonder
when we'll hear the good news?