Cambodia’s Uphill Battle Against Tuberculosis

More than 50 years since the first miracle drugs were invented to fight it, tuberculosis continues its horrific worldwide reign.

It runs through the globe, laying waste to entire populations, killing 9 million people worldwide every year. And it has made Cambodia a favorite stomping ground.

The statistics, numbing as they are, give some sense of its scale. Nearly one in three people here, as in the rest of the world, carry TB. In the first 20 years of this century, experts estimate it will have stricken almost 1 billion people, killing 35 million. Each year, nearly 10,000 Cambodians die from the disease.

And this is not just some archaic blip, in which a disease many in wealthy nations think of as belonging to a distant age has slipped through the cracks. In the last few years, more people worldwide have died from tuberculosis than in all its previous years. Seeing this health crisis spiraling in front of them, the World Health Organization nearly 10 years ago declared TB a global emergency. It has not been lifted.

“The TB problem here is enormous,” said Dr Ikushi Onozaki, an adviser to the government on tuberculosis.

For all of those figures and facts, the tragedy behind them is this: It is all preventable.
The TB crisis in Cambodia and in the world is fed upon, and in turn feeds, the twin crises of poverty and HIV/AIDS, Onozaki said.

Tuberculosis is a bacterial disease. It spreads through the air when an infected person coughs, spits or sneezes. It usually affects the lungs, tearing them apart and causing the well-known, blood-drenched coughing fits (this is why TB used to be known in the West as “consumption”).

Only 5 percent to 10 percent of people who carry tuberculosis ever actually develop it, and once it develops it can be cured.

But Southeast Asia-which leads the world in TB infections, with nearly 3 million new cases each year-has been swamped with the disease and Cambodia has been caught in the tide. Health experts say the breakdown of the Stalinist style of government, which has been followed by a breakdown in health care, an increase in travel and a rise in poverty, each of them fostering the other, has helped the disease soar to new heights.

Phnom Penh is a mirror of the trends and paradoxes in the fight against TB. As with land mines, the country’s victimization has given it a kind of expertise, but because of a lack of knowledge and a lack of funds, health care is fighting to a bare standoff.

On one end of the capital, for instance, is the year-and-a-half old National Center for Tuberculosis and Leprosy Control, an open air, state-of-the-art, multimillion-dollar building where patients rush in and out, picking up blue-tinted X-rays and getting the drugs they need to fight off the disease. Patients get free care and the World Food Program gives each one of them 15 kg or rice, 900 grams of oil and 900 grams of sardines, officials there said.

“The treatment here is really good,” Onozaki said of the center.

It has made a world of difference to those stricken with TB.

“I was worried when I learned I had tuberculosis. I coughed a lot at first,” Svay Rieng province farmer Ham Nary, 25, said. “Now I’m better and I was better within two weeks.”

On the other side of Phnom Penh is another story all together.

The tuberculosis ward at the Preah Ketoh Mealia Military Hospital stinks of sweat, garbage, feces and rotting food. The dark hallways, where only a few lights work, are littered with trash, muddy footprints and cockroaches scurrying to and from the cracks that pock the walls. Patients, bathing in a field of greens behind the ward, lumber up and down the corridors, their children in tow, fixing their meals, playing cards or buying cigarettes from a vendor who has set up her glass case at the ward’s main entrance.

Although many patients at the hospital have been cured, it’s not clear things are better. The time and money spent on healing-it takes up to two full months of intense treatment and six months of follow-up to cure TB-has devastated some. So, too, have the physical effects of the disease.

“I’ve gotten better, but if I work too hard-like washing clothes-I get worse again. I don’t cough so much, but I feel exhausted,” Im Van Hoeun, 40, said, stepping outside her clapboard room.

This, experts say, is one of the worst aspects of tuberculosis. Shadowing poor communities, TB usually hits people of “productive age,” which means that people can’t work, which in turns means they stay poor. Because people stay poor, they stay well within tuberculosis’s grasp.

In the year 2000, Southeast Asia lost more than 14.9 million life-years due to death or disability from tuberculosis, according to the American Lung Association.

Tuberculosis also aggravates poverty because it drains a nation’s resources to fight it-and this is true around the world.

“TB takes a heavy toll on our economy,” the American Lung Association Web site states, adding that the US-which has nowhere near Cambodia’s infection rate-loses nearly $1 billion in direct and indirect costs to tuberculosis every year.

In wealthy countries, which had consigned TB to the past and even sometimes given it a romantic gloss, a new nightmare has been born in the form of drug-resistant tuberculosis. The US saw a 20 percent increase in TB between 1985 and 1992, the American Lung Association reports. Japan saw comparable numbers, Onozaki said.

So far, this new strain of tuberculosis hasn’t washed up in Cambodia’s shores, experts say.

“We’re very, very lucky, actually,” Onozaki said.

All the same, 99 percent of TB deaths are in developing countries like Cambodia, the American Lung Association states. The 22 nations worst-hit by the disease, including Cambodia, account for 80 percent of the world’s tuberculosis cases, Onozaki said.

With this in mind, officials are racing to get the disease in check before its drug-resistant cousin can come. Right now, the government, supported by money from the Japanese International Cooperation Agency, is carrying out a national survey to find and treat tuberculosis, bringing X-rays and medicines to the countryside. It’s a major undertaking whose goal is to screen and treat TB cases in hopes of getting a handle on it, Onozaki said. As it stands, tuberculosis is Cambodia’s third biggest killer, the WHO reports.

Authorities here use what is called the DOTS program. It stands for Directly Observed Treatment-Short course, which the WHO bills as an aggressive way to check tuberculosis. The program is designed to get the word out about the disease, get it detected early, treat it with a battery of drugs on a tight schedule and bring the disease under control, keeping its drug-resistant variants from evolving.

“From a public health perspective, poorly supervised or incomplete treatment of TB is worse than no treatment at all,” the WHO Web site states.

This is urgent for poor countries like Cambodia. While short-course TB treatment takes millions of dollars and up to eight or nine months per patient, drug-resistant strains of the disease require up to two years of treatment and cost almost 100 times the treatment for “drug-susceptible” TB, the WHO reports.

Time and again, however, officials are finding themselves stymied by another disease, one which gets a lot more attention than TB: AIDS.

Tuberculosis is often called an “opportunistic infection” because it lays in wait for the right moment and springs on the weak. HIV/AIDS is one disease that preys on the immune system, and this makes the virus a perfect partner for TB, experts say.

“HIV and TB form a lethal combination, each speeding the other’s progress,” a WHO report states.

As it stands, nearly 70 percent of HIV or AIDS patients come down with tuberculosis, Onozaki said. According to the WHO, TB accounts for 11 percent of worldwide AIDS deaths.

This is because the tuberculosis bacilli has “a thick waxy coat” and “can lie dormant for years,” according to the WHO.

“When someone’s immune system is weakened, the chances of getting sick are greater,” the WHO report states.

This confounds public health officials.

“If they don’t have HIV/AIDS, we can probably cure them more than 98 percent of the time,” Onozaki said.

But the problem is getting the word out. Most of the people who die from TB die because “it goes undetected” until it’s too late, Onozaki said.

Cambodia has one of the highest HIV rates in the region, with about 160,000 adults infected. While condom campaigns and other public-service programs have helped keep the virus in check and the rate of HIV infection is going down, patients who first caught HIV in the mid-to-late 1990s are just now coming down with tuberculosis, Onozaki said.

And since HIV patients are more likely to develop TB, they are also more likely to spread it, Onozaki said.

“It will depend on how they can control it. If you cannot control AIDS, you cannot control TB,” he said.

That is a real challenge, because each person with “active” tuberculosis infects between 10 and 15 others, the WHO reports.

This, in turn, helps victimize one of Cambodia’s most marginal population, its women. Nearly 50 percent of Cambodia’s TB cases are those of women, who are less likely to get treatment and therefore more likely to spread the disease among others-especially their children. Tuberculosis kills more women than even pregnancy-related deaths, Onozaki said.

The family of RCAF Lieutenant Yen Bunthan has dodged that crisis so far. Although Yen Bunthan, living in the military hospital, is HIV-positive and has come down with TB repeatedly, his wife and children have managed to avoid it.

“I was shocked when I found out I had TB,” he said, coughing into the armpit of his blue-checkered polo shirt.

Yen Bunthan now is two months away from finishing his eight-month TB course, but he’s not sure if he’s done with the disease. This is his second trip to the military hospital for tuberculosis treatment. Every day, he takes a legion of pills the size of bullets, hoping this trip will be his last one.

“They taste awful,” he said, smiling. “Very bitter.”

For now, health officials in the multi-front battle are fighting to hold the line, hoping to stabilize infections and only dreaming of ending them.

As long as Cambodia lives under the full weight of poverty and HIV, though, it’s liable to be a long, drawn-out conflict, experts say.

“We could cure them,” Onozaki said. “But we can’t cut the links of infection.”

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