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?