Download Tuberculosis in Indonesia, Beard

Kathryn Beard
Tuberculosis in Indonesia
From: Secretary of Health, Indonesia
To: Minister of Finance, Indonesia
Introduction:
Indonesia has the third highest TB infection rate in the world.i The rate of Multi Drug
Resistant-TB is increasing and the prevalence of TB patients that test positive for HIV is
substantially higher than the national HIV infection rate.ii Very poor adults suffer
disproportionally from TB due to their urban living conditions. Malnourished children and
prisoners in jails also have higher incidence rates. The lack of health services in Indonesia,
including clinics or a national HIV treatment plan, increases the risk of TB, as people are not
able to seek treatment or diagnosis. Indonesia’s poor are at higher risk of contracting TB due to
their lack of an education and poor living conditions. The disease causes great financial loss to
the Indonesian government and its society. To lower the impact of TB, the government must
institute a five-year strategy to increase funding for the DOTS program, expand health services
throughout the country and create a national HIV/TB treatment plan. In a complementary effort
to help prevent MDR-TB, the government must increase TB education by engaging community
support groups and increasing anti-poverty programs.
Nature and Magnitude of the Problem:
Over half a million people develop TB each year in Indonesia, the third highest rate of
infection globally.iii The number of smear positive cases has increased from 57 percent in 2007
to 59 percent today.iv TB accounts for 6.3 percent of the total burden of disease for Indonesia,
compared with 3.2 percent for all of Southeast Asia.v An estimated 140,000 Indonesian people
die from TB each year. Nearly 300 people die every day.vi The national HIV prevalence rate is at
0.6 percent, however three percent of TB patients test positive for HIV.vii Around two percent of
newly diagnosed TB cases are multi-drug resistant. 20 percent of all re-treated cases of TB are
MDR-TB.viii
Affected Populations:
Adults and the very poor are most affected by TB. It is the second leading cause of death
for adults in Indonesia.ix The TB prevalence rate for adults age 15 to 49 is three times higher than
adults over age 49.x The prevalence rate is twice as high in Indonesian men as women.xi Children
are also affected due to their high rates of malnutrition.
TB is a disease of the poor due to living conditions that encourage transmission of the TB
bacteria. Fifty-three percent of Indonesia’s population earns less than two dollars a day and 37
million people live below the poverty line.xii The TB incidence rate is higher in urban cities as
the disease is spread easily in crowded areas.
Risk Factors:
Poverty and the lack of health services greatly increase the risk of contracting HIV. The
lack of an effective national health care system and trained doctors increase the likelihood that
Indonesians will not seek treatment for TB. Only 37 percent of hospitals in Indonesia practice
DOTS therapy.xiii There are only 13 doctors per 100,000 people in Indonesia, one of the lowest
ratios in Asia.xiv Citizens living on the remote islands of Papua and Maluku have higher rates of
1
TB due to the lack of medical facilities on the islands.xv Further compounding the TB crisis is
that 75 percent of HIV cases in Indonesia are not being treated with antiretroviral therapy.xvi HIV
patients are naturally at higher risk of TB due to their weakened immune system. The lack of
HIV drugs provided by the government increases the risk that those people will contract TB.
Poverty and its subsequent effects of a lack of education, malnutrition and poor living
conditions further increases the risk of becoming infected with TB. The very poor often do not
receive a primary education and are less educated about diseases. 76 percent of Indonesians
polled said they knew about TB and that it was curable, but only 16 percent knew three or more
correct symptoms and the means to which one is infected.xvii Un-educated people are more likely
to not adhere to the drug regime if given TB treatment. Non-adherence increases the risk of drug
resistance and increases the amount of time patients remain infectious. 47 percent of Indonesians
polled said they stopped taking the drugs when they started feeling better. Inadequate living
conditions spawned by poverty further spread TB due to crowded and unventilated rooms that
increase the amount of bacilli people are exposed too. xviiiMalnutrition, especially in children,
increases the risk of contracting TB due to the weakened immune system.
Social and Economic Consequences:
TB restricts the growth of Indonesia’s economy and is associated with numerous social
stigmas. It is estimated that TB will cost the world’s poorest countries one to three trillion dollars
over the next 10 years. The increasing costs of treating TB drain the Indonesian government of
millions of dollars. About 70 percent of Indonesians infected with TB are in the productive age
bracket between the ages of 15 and 49. TB prevents many of them from working and without
jobs they are not able to earn an income. This further entraps them in a cycle of poverty.
Many stigmas are associated with TB that isolate its sufferers from their family and
society. Many Indonesian people think that TB is an inherited disease and incurable. Others
believe TB is a curse placed on the individual for their evil wrongdoings.xix Adults will not seek
treatment in order to prevent the social consequences of a diagnosis.
Priority Action Steps:
Three critical actions are required to successfully combat TB. First, the government must
institute a five-year strategy to increase funding for the DOTS program. Second, the government
must leverage these funding increases in order to expand the DOTS program and health services
throughout the country. Third, the DOTS strategy must include a national HIV/TB treatment
plan combining a successful diagnosis program. In 1999, the Indonesian government announced
the Gerdunas program that first introduced DOTS treatment to the country. The program has
been very successful with a treatment success rate of 90 percent.xx Indonesia was the first
Southeast Asian country to reach the WHO TB detection goal of 70 percent and the treatment
success goal of 85 percent.xxi However, the government needs to increase spending on health
services to expand DOTS therapy to all hospitals and high TB-burden areas. By focusing on
expanding DOTS therapy, the government can further reduce TB across the country.
Complementing this three-point strategy, Indonesia must address the education and
poverty links to TB. On a local level, support groups and community campaigns need to be
developed to increase TB education and decrease TB stigma. Care International established 19
support groups on Java. Leaders provided information about the disease and encouraged
treatment.xxii Health workers also helped monitor patients through the groups to ensure the
completion of drug regimes to help prevent MDR-TB. The government needs to expand these
2
programs to the other islands and to needy populations. For the poor, the government must work
to address the overall causes of poverty through new programs created with NGOs. Only by
reducing poverty can TB truly be eradicated. The government should work to create new job and
housing programs to better improve the living conditions of Indonesian’s poorest citizens.
i
"USAID Health: Infectious Diseases, Tuberculosis, Countries, Indonesia." U.S. Agency for
International Development. May 2009. Web. 07 Dec. 2010.
<http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/asia/indonesia_profile.
html>.
ii
Ibid.
iii
Ibid.
iv
"Indonesia TB." Country Profile World Health Organization. 2009. Web. 07 Dec. 2010.
<http://apps.who.int/globalatlas/predefinedReports/TB/PDF_Files/idn.pdf>.
v
"USAID Health: Infectious Diseases, Tuberculosis, Countries, Indonesia." U.S. Agency for
International Development. May 2009. Web. 07 Dec. 2010.
<http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/asia/indonesia_profile.
html>.
vi
"Indonesia: Overcrowding Fuels TB in Prisons." UNHCR. 25 Jan. 2010. Web. 07 Dec. 2010.
<http://www.unhcr.org/refworld/country,,,,IDN,,4b61b24914,0.html>.
vii
"USAID Health: Infectious Diseases, Tuberculosis, Countries, Indonesia." U.S. Agency for
International Development. May 2009. Web. 07 Dec. 2010.
<http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/asia/indonesia_profile.
html>.
viii
Ibid.
ix
"Indonesia: Overcrowding Fuels TB in Prisons." UNHCR. 25 Jan. 2010. Web. 07 Dec. 2010.
<http://www.unhcr.org/refworld/country,,,,IDN,,4b61b24914,0.html>.
x
"Three-fold Reduction in the Prevalence of Tuberculosis over 25 Years in Indonesia." World
Health Organization Indonesia. 2007. Web. 07 Dec. 2010. <Three-fold reduction in the
prevalence of tuberculosis over 25 years in Indonesia>.
xi
Ibid.
xii
"TB Factsheet." World Health Organization. 2006. Web. 07 Dec. 2010.
<http://www.tbindonesia.or.id/pdf/TB_Fact_Sheet.pdf>.
xiii
"TB Factsheet." World Health Organization. 2006. Web. 07 Dec. 2010.
<http://www.tbindonesia.or.id/pdf/TB_Fact_Sheet.pdf>.
xiv
"A Brief History of TB Control in Indonesia." World Health Organization. 2009. Web. 07
Dec. 2010. <http://whqlibdoc.who.int/publications/2009/9789241598798_eng.pdf>.
xv
Ibid.
xvi
Ibid.
xvii
ibid.
xviii
Ibid.
xix
"Indonesia: Fighting TB Stigma." UN Office for the Coordination of Humanitarian Affairs. 09
Apr. 2010. Web. 07 Dec. 2010. <http://ww.irinnews.org/Report.aspx?ReportId=88754>.
xx
"A Brief History of TB Control in Indonesia." World Health Organization. 2009. Web. 07
Dec. 2010. <http://whqlibdoc.who.int/publications/2009/9789241598798_eng.pdf>.
xxi
Ibid.
3
xxii
"Indonesia: Fighting TB Stigma." UN Office for the Coordination of Humanitarian Affairs.
09 Apr. 2010. Web. 07 Dec. 2010. <http://ww.irinnews.org/Report.aspx?ReportId=88754>.
Works Cited
"A Brief History of TB Control in Indonesia." World Health Organization. 2009. Web. 07 Dec.
2010. <http://whqlibdoc.who.int/publications/2009/9789241598798_eng.pdf>.
"INDONESIA: Fighting TB Stigma." UN Office for the Coordination of Humanitarian Affairs.
09 Apr. 2010. Web. 07 Dec. 2010.
<http://ww.irinnews.org/Report.aspx?ReportId=88754>.
"Indonesia: Overcrowding Fuels TB in Prisons." UNHCR. 25 Jan. 2010. Web. 07 Dec. 2010.
<http://www.unhcr.org/refworld/country,,,,IDN,,4b61b24914,0.html>.
"Indonesia TB." Country Profile World Health Organization. 2009. Web. 07 Dec. 2010.
<http://apps.who.int/globalatlas/predefinedReports/TB/PDF_Files/idn.pdf>.
"TB Factsheet." World Health Organization. 2006. Web. 07 Dec. 2010.
<http://www.tbindonesia.or.id/pdf/TB_Fact_Sheet.pdf>.
"Three-fold Reduction in the Prevalence of Tuberculosis over 25 Years in Indonesia." World
Health Organization Indonesia. 2007. Web. 07 Dec. 2010. <Three-fold reduction in the
prevalence of tuberculosis over 25 years in Indonesia>.
"USAID Health: Infectious Diseases, Tuberculosis, Countries, Indonesia." U.S. Agency for
International Development. May 2009. Web. 07 Dec. 2010.
<http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/asia/indonesia_
profile.html>.
4