What Progress Since The Amsterdam Declaration?

INDIA; INDONESIA; SUDAN; PORTUGAL;
 SOUTH AFRICA

India -Dinesh Kumar

‘TB control is not a public movement in India even 18 months after the Amsterdam Declaration’

The number of non-government-organizations (NGOs) working in TB control is also insignificant in the country. Indian society remains insensitive to the issue and continues to regard TB control, a government responsibility.

The barriers to the change in attitudes are multiple. Tuberculosis is a long-standing public health problem in India. A person who develops TB is a social out caste in most communities. The families of TB patients tend to keep their problems under wraps and do not discuss them with their peers in the community. Thus TB remains a 'personal issue' rather than a community problem.

The low literacy rates and low per capita income in rural areas and urban slums adversely affect the treatment seeking behavior of TB patients and their families. The public health system is unable to bear the entire burden of TB patients and they are forced to seek treatment from private doctors. Most of these 'doctors' are either unqualified (quacks , as we call them in India) or practitioners of other systems of medicine but practicing allopathic system. The WHO regimens for treating TB or DOTS are a far cry. Most Indian doctors, NGO managers, social activists, media persons are not even aware of the Amsterdam Declaration. The points raised in the declaration have not appeared in print media, if they have, at least I am not aware of them (I read three national dailies regularly). The declaration might have been an issue discussed in the government circles at highest levels only.

In my viewpoint the key barriers in emergence of TB control as a national issue in India are:- Indian public has not been made aware of the magnitude of TB epidemic in the country. The national media, NGOs, politicians, professional organizations of doctors remain largely insensitive the issue.

• Health is a State subject in the country and response of the States varies from region to region.
  
• Revised National TB Control Programme has been expanding at a slow pace.
  
• Most Indian doctors/health workers are not aware of DOTS, its success in TB control in other countries and how it is being implemented in the country. The professional organization has not come forward to adopt DOTS and popularize it amongst their members. India has a large private health sector and ways and means to reach have not been identified.
  
• The electronic media in the country has grown by leaps and bounds and can play an important role in generating public awareness and debate on the issue of TB control. The programme managers in India have failed to utilize the full potential of this cost-effective medium. These barriers have been responsible for public complacency. TB control is not a public movement in India even 18 months after the Amsterdam Declaration.

Dr. Dinesh Kumar,Director,Health and Development Initiative-India

Email: dinesh_kumar@vsnl.com

Dr. Muherman Harun, Indonesia

Since 1968, the Indonesian Association for the Eradication of TB (PPTI), under the auspices of the Ministry of Health, has formulated and reformulated many TB Control Programs. The first and famous TB expert at that time was Dr K Toman who was also responsible in the formulation of the national Programmes. Progress has not been made due to a serious lack of overall commitment, discipline, and funds. Case detection was poor and results may depend on the commission provided. Treatment had been free of charge and in fact, even directly observed treatment, shortcourse was implemented from the seventies but deteriorated during the nineties with poor results: very low actual cure rates (despite excellent reports with so-called 100 % cure rates).

Periodical or annual reports could not objectively be evaluated hence corrective actions remained absent. Due to incompetent assessments of the Programme, the National TB Programmes were formulated and reformulated again and again so much so that there are doctors in TB Control who even claim, that TB whatever the disease can never be "totally" cured. TB is a disease most doctors do not like to treat. It is considered a disease of poor patients who cannot even afford to pay the doctor's fee, let alone the expensive TB drugs. Doctors find sputum examination unimportant and burdensome, also very expensive if carried out in the hospital or specialists clinics. Most doctors (pulmonologists, internists a.o.) immediately start treatment based on suspicious chest X-ray findings. TB is deemed to be very easy to treat, previous treatment was not considered relevant. Doctors would give a TB patient a monthly prescription to be iterated for 6 or even for 12 months without advice on the side effects, or asking patients or asking themselves whether patient is in a proper position to pay for the expensive (even generic) drugs.

Latest situation

In December of 1998, the Minister of Health proclaimed "WAR ON TB".

This was followed up by a Ministerial declaration of GERDUNAS TB (Concerted National Action against TB) on 24 March 1999. Not only the government sector (the public health centers and government hospitals) involved with TB patients but also private specialists and doctors are "obliged" to participate in the GERDUNAS TB. They are to implement DOTS strategy and will get anti-TB drugs free of charge for patients requiring anti-TB treatment. But the drugs were not available yet. As far as the St.Carolus hospital in Jakarta is concerned, the GERDUNAS anti-TB drugs were first supplied in March 2001 (in sufficient amount). Don't bother the proper implementation of DOTS strategy!

After the Amsterdam declaration, reading from the local newspapers, the Director General on communicable diseases has stated, that no new TB case-finding activities be carried out, before the already established centers have been improved as far as case finding and treatment are concerned.

The above statement sounds rational despite WHO's requirement of a minimum detection of 70% TB cases by the year 2005.For what is the sense of case finding, if cases found do not get anti-TB drugs? And if drugs were available, shall the patient be treated? . And once under treatment shouldn’t treatment be completed until the patient is declared "cured"?

Personally, I think that the responsibility to take the drugs regularly is not on the patient alone neither on the one supposed to directly observe the taking of drugs. It is also and it is the main responsibility of the provider (doctor/nurse/home-visitor) to get the patient cured or have the treatment completed. Providers have see to it that patient regularly takes the proper amount of drugs within the scheduled treatment period. If the patient failed to complete treatment, it is the provider who is to be blamed and not on the patient. The burden of having patient to take drugs regularly should be put mainly on the shoulders of the provider. This idea has not yet been fully understood, or has received little or no emphasis in any other TB control strategy I know of. Along these lines is Sir John Crofton himself in his book Clinical Tuberculosis, who stated that

"Tuberculosis can be cured, 
THE PATIENT'S LIFE DEPENDS ON YOU".

Any TB programme should start with empathy, by curing every TB patient found at all cost and energy! If TB patients get cured, more cases will come forward from farther away distances, increasing the detection rate ultimately, leading to the WHO minimum detection of 70% TB cases.

This is not a vigorous way to implement WHO TB Programme. Perhaps this is the only natural way, too slow to achieve WHO ideals within a short time.

Dr Muherman Harun

mhjkt@attglobal.net

Hatim Haseeb, Sudan

Difficulties that we are facing in controlling TB are:

1. Long distances from treatment centres to patient’s home and expensive
   transport fees mean that defaulting rates are high.
2. Unfullfilled-government commitment to the issue.
3. Interrupted drug supply & reagents for smear preparation in treatment
   facilities.
4. Free drugs are offered in hospitals for in-patients only, as DOTS
   strategy.
5. Lack of motivation for health workers.
   
   To me, in Sudan it is better to aim at better case holding than
   increasing detection rate, because we are unable now to offer excellent results,say 85% cure rate, because of the high defaulter rate. I am afraid that with our high defaulter rate that we will end with high MDR catastrophe.
   
   Dr.hatim.m.a.haseeb, 
   Email: hatimmhaseeb@hotmail.com

Emilia Valadas, Portugal

Dr. Elsa Balt-Tuberculosis control in Mpumalanga Province, South Africa

• One of the major problems is the compliance to treatment by patients
  living in remote rural areas. To address this issue a group of women
  (Nompilos), employed by farmers to help with minor first aid at the
  farms
  were trained as DOTS supporters. They helped to improve the smear
  conversion and cure rate of TB patients in that area.
  
• The traditional Healers also play an important role as DOTS
  supporters,
  and many have been trained. Traditional Healers are often the first
  person
  consulted by a patient and to get their cooperation in the management of
  TB can only benefit the patient.
  
• TB in prisons is of great concern to us. Due to overcrowding, the
  spread of TB is a great risk. A TB unit were opened at the prison in Standerton district. The smear conversion rate is 100% at this unit.
  Some inmates have been trained as DOTS supporters.
  
• The implementation of a "cough register" improved the case finding in
  one district. The "register" improved the awareness amongst staff at
  clinics to send sputum for TB microscopy of all patients presenting with
  a cough.
  
• Training of health-care workers in the management of tuberculosis is
  an ongoing process. A three day course has been implemented since 1996 and the aim is to have at least one trained staff member at every treatment
  unit in the province.
  

Permission to use this received via e-mail from Louise Berry

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