What Progress Since The Amsterdam Declaration?
India -Dinesh Kumar
‘TB control is not a public movement in India
even 18 months after the Amsterdam Declaration’
|Tuberculosis control has not emerged as a major issue
in India at community or personal levels. It still remains an
The social, economic and public health implications of TB epidemic
have not been a focus of any national debate. Neither national
dailies nor TV channels have carried any news items to invite public
attention on the issue. The political involvement has been low key
and the parliamentarians or members of state legislatures have not
been very vocal on the issue.
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
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
- 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
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.
In December of 1998, the Minister of Health proclaimed "WAR
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
"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
Hatim Haseeb, Sudan
|Tuberculosis remains to be one of the main public
health problems in
Sudan. This vast country (one million square miles) with its meagre
resources, underdeveloped health infrastructure and civil war since
1955 has many hurdles in the way to achieve WHO standards of 70%
case detection and cure rate of 85%.
The best indicator of the extent of the tuberculosis in Sudan is the
average annual risk of infection (ARI). A tuberculin survey was
conducted in 1976 and then again in 1986 in children 0-14 years old.
An ARI of 1.8% corresponds to 90 per 100000 cases of smear positive
TB. The estimated average incidence of all forms of TB is 180 per
100000 and in a population of 24 400 000 in 1987 the total new cases
were estimated to be 43 000.
These figures lead to a detection rate coverage of 38.7% due to the
very low reporting of cases from war zones in southern Sudan. There
is no data among displaced populations. Data on TB drug resistance
in the population and on the extent and magnitude of HIV epidemic
among TB patients is not available
In Sudan TB control measures started since 1945 and it is very
difficult to change the ideas of the medical staff about such a
disease. The implementation of the newly advocated principals in NTP,
needs to be acceptable and gentle with a high amount of transparency
and sharing of the already existing system in the process is
In Sudan the NTP was first launched in 1986, following the WHO
for 8th.and 9th. Reports of expert committee on TB. The Sudan
National Tuberculosis Program has one central level. This level is
headed by a program director responsible for planning, training,
budgeting, preparing manuals and conducting surveys .Each region has
a regional coordinator. Each district level (health centres) is
headed by a district health officer.
The government commitment is strong but this is limited by lack of
funding. The government fails to make streptomycin & thiazina
available for the program as part of its commitment due to financial
difficulties. Even the international donors sometimes offer their
supplies after the patients run out of their drugs. This could be
due partly because of managerial difficulties here in local partners
side or international partners side.
Difficulties that we are facing in controlling TB are:
- Long distances from treatment centres to patient’s home and
transport fees mean that defaulting rates are high.
- Unfullfilled-government commitment to the issue.
- Interrupted drug supply & reagents for smear preparation
- Free drugs are offered in hospitals for in-patients only, as
- 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.
I am following this virtual forum with great interest. Working on TB
some years now, it is still very impressive to learn about the
"TB-reality" on other countries.
Despite the fact that in Portugal the DOTS strategy is implemented,
TB drugs are widely available and free, as is access to medical
Portugal has the highest incidence of TB in Western Europe
inhabitants). This is mainly due to the complacency to the TB
the last twenty
years the public health vigilance has waned and government support
prevention and research programmes is very scarce. This is further
complicated by a very high incidence of HIV infection (also the
Europe) and by the emergence of MDR strains. In some settings it
50%. At our Department, where around 100 TB patients are admitted
year, most of them are also HIV infected, MDR cases are increasing
(incidence around 20%). In the specific case of Portugal, a quite
organized national association against HIV exists, but the same is
true for TB. In our point of view, and in settings where TB and HIV
prevalent, a national strategy against both diseases is urgently
Prof. Emilia Valadas
Servico de Doencas Infecciosas
Hospital de Santa Maria
1600 Lisboa - Portugal
Dr. Elsa Balt-Tuberculosis control in Mpumalanga Province, South
|Some highlights in the management of TB:
- One of the major problems is the compliance to treatment by
living in remote rural areas. To address this issue a group of
(Nompilos), employed by farmers to help with minor first aid at
were trained as DOTS supporters. They helped to improve the
conversion and cure rate of TB patients in that area.
- The traditional Healers also play an important role as DOTS
and many have been trained. Traditional Healers are often the
consulted by a patient and to get their cooperation in the
TB can only benefit the patient.
- TB in prisons is of great concern to us. Due to overcrowding,
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
- Training of health-care workers in the management of
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.
Provincial TB coordinator
|"These messages have been taken
from the STOP-TB Forum which is being moderated
by Health & Development Networks in collaboration
with the STOP-TB Initiative and Health Systems
Discussion archives are available at:
The project description is available at:
Permission to use this received via e-mail from Louise Berry
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