Corruption, Lack of Referral System Hinder TB Detection

Cambodia’s ability to detect new cases of tuberculosis is dangerously low, hampered by corruption in the public health system and the absence of a referral system from local pharmacies to public health centers, government officials and NGO workers said.

The result, they said, is high mortality and in­creased risk of multidrug-resistant TB emerging because of the poor administering of medicines.

According to data released by the Japanese In­­ternational Cooperation Agency at a meeting on Saturday with private health professionals, on­ly 59 percent of TB cases were detected and treated in 2004. Nationwide, an estimated 76,000 people contracted TB last year and 15,000 died. Worldwide, 1.7 billion people harbor TB infections, according to the UN. TB rates have been rising since about 1990, mostly due to the increase of TB infection in HIV sufferers and the emergence of drug-resistant strains of the disease.

Transmitted by inhaling cough droplets from an infected person, TB bacteria lodge in the lungs. The disease often spreads to other parts of the body before becoming fatal. The chief symptom of TB is bloody sputum resulting from persistent cough. It is diagnosed through laboratory tests of the sputum.

TB treatment is free of charge in public health centers in Cambodia. But most poor peo­ple are deterred from going to public hospitals, JICA’s chief adviser on TB Kosuke Okada said Saturday, leading 88 percent of TB pa­tients to go first to private pharmacies and clinics. Forty percent of Phnom Penh pharmacies sur­veyed by JICA are illegally selling TB drugs to patients. “Formally, the government prohibits the sale of TB drugs in the marketplace,” Okada said on Monday. “When the public hospital administers the drugs, it strictly follows the World Health Organization guidelines. But the drug sellers do not. They give the wrong course of treatment and the wrong dosage.”

Okada said the WHO requires six months of treatment for TB, and Cambodian regulations re­­­­quire that the drugs are taken in the presence of a health provider. The drugs isoniazid, ri­fampin, ethambutol and pyrazinamide are ad­ministered daily for two months, and the drugs isoniazid and rifampin are given for the following four months.

According to Okada, the Japanese government has provided $700,000 for TB drugs ad­min­istered without charge by the Ministry of Health between 2004 and 2006.

Patients who miss doses or abandon the treatment will not be cured and may cause a pub­lic health emergency by fostering drug re­sistant strains of TB. Only 25 percent of Phnom Penh pharmacists surveyed have ever received any TB training, and most of them do not have monitoring systems in place to oversee TB treatment. “This is very risky,” Okada said.

Currently, the incidence of multidrug-resistant TB is very low at 0.6 percent in Cambodia, according to JICA, but that could increase.

“We guess that many in this country had no ac­cess to TB treatment formerly so they have ne­ver been treated and drug resistance has not developed,” Okada said. Mortality rate for resistant TB is 80 percent, officials said.

Currently 850 public health centers offer monitored TB treatment nationwide. But JICA and the Ministry of Health are just in the beginning stages of developing a system whereby pharmacists would send suspected TB patients to the health centers. “Our detection rate goal is 75 percent in 2005,” Undersecretary of State for the Ministry of Health Sau Sok Khonn said Saturday. “This is difficult because some people have stigma. They do not go to the health cen­ter because they want to hide their HIV status especially.”

Sau Sok Khonn said that corruption was also de­terring poor people from seeking free TB treatment. “[There are] doctors who give un­ne­cessary injections when a tablet is called for…doctors exag­gerate a disease in order to gain profit by doing expensive procedures,” he said. He added that some nurses have been caught illegally charging patients for TB treatment.

Municipal Health Department Director Veng Thai said that at private clinics, poor pa­tients are especially at risk. “If they go to a private clinic that charges them $10 a day without knowing that treatment is free in the public hospital, there is a strong chance they will not complete the treatment,” he said.

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