TB Takes its Toll

A Preventable Disease Cambodia Can’t Stop

Kao Kong, 60, tried to treat himself for tuberculosis back in 1985. The Phnom Penh laundry shop owner walked into a pharmacy and bought some medicine, and was cured—or so he thought.

Seven months ago, however, he started coughing again. A Kandal province hospice diagnosed water in his lungs, and started pumping. But, said his wife Pech Caea, 57, “all that came out was air.” And Kao Kong returned to work, hacking away as he washed clothing.

Now he is in the intensive care section of the Preah Bath Norodom Sihanouk Hospital tuberculosis ward, a skeletal figure bathed in a thin sheen of sweat, naked except for a small green-checked cloth covering his hips.

His tuberculosis from 1985 had come out of remission—fiercer than before.

Kao Kong’s not atypical case history illustrates some of the problems a developing country such as Cambodia faces in fighting such a highly infectious disease.

The effect of tuberculosis, or TB, on society is so serious the Ministry of Health considers its treatment its first priority, with Prime Minister Hun Sen acting as the program steering committee’s honorary chairman. But the irony and tragedy of tuberculosis is that while health experts say it is curable, indeed eradicable, it is killing more Cambodians than AIDS or malaria—and it’s spreading.

­            “If you look at the total population of Cambodia, it’s more prevalent than malaria, AIDS, and [can affect] all people,” said Dr Georg Petersen, the World Health Or­g­anization representative in Cam­bodia. “If you ask people in the countryside, tuberculosis is more familiar to them than AIDS. Everyone has a family member with tuberculosis, or knows someone with tuberculosis.”

Last week, the participants of the Global Congress on Lung Health in Bangkok, the largest meeting of lung disease experts held in Asia in more than a de­­cade, gave a warning. Asia, they declared, is the epicenter of the world’s tuberculosis epidemic, ac­counting for more than half of the 8 million tuberculosis cases diagnosed each year globally.

Factors such as the financial crisis squeezing the region, HIV and multidrug-resistant tuberculosis are making it increasingly difficult to battle the epidemic, accor­ding to WHO Director-General Dr Gro Harlem Brundtland.

In Cambodia, a 1996 Unicef re­port described tuberculosis as “a leading cause of mortality among [Cambodian] young adults with an estimated 13,000 deaths a year” and that the transmission rate in Cambodia was among the highest in the world.

The report estimated that up to 50 percent of Cambodian children are exposed to the virus and have the potential of falling sick to tuberculosis at a later stage in their lives. The report expected 40,000 new cases of TB each year, and estimated about 20,000 of those could be contagious pulmonary TB.

Following several years of modest growth, the Cambodian economy began to constrict in 1997 and hasn’t recovered. Some health-care professionals are concerned about the ramifications of an economic climate dogged by perceived political instability and a serious regional downturn.

As long as the economy re­mains flat, people will not be able to better their standard of living and maintain a normal immune system. Nor will the government have enough resources to develop an adequate, functioning na­tional health system, ensuring qualified medical workers are paid sufficient salaries to treat all patients equally.

“The long-term strategy will have to do with the development of the country. It’s not the only reason, but it’s a factor connected to it,” said Petersen, recalling the time when the US, Britain and Japan, among other countries, had high tuberculosis infection rates.

For tuberculosis patients, the constraints of poverty, both at the state and individual levels, has meant difficulty affording and continuing treatment. Even if treatment is ostensibly free, a patient in a sickbed must be ta­ken care of, using up dear financial re­sources and work time from the family without contri­buting in return.

In Cambodia, Pe­tersen said, combating tuberculosis has not yet gone beyond treating people who voluntarily arrive at clinics.

“We have to get people with the symptoms, because they’re still coming in [to the clinics]. We have not yet started active case-finding, because there are so many. If we went out and found everyone, there would not be any capacity [to treat all of them].”

Similarly, because the government has not yet started to check the population, no one knows the exact number of Cambodians who carry the bacillus, the bacterium that causes tuberculosis.

Meanwhile, health experts said those who don’t go to the clinic spread the disease to others in un­known numbers.

A major difficulty in containing the disease is that many become infected but do not necessarily get sick. Or when they do be­come ill, it is thought to be something other than tuberculosis.

But to successfully combat the disease, every tuberculosis carrier must be treated, doctors said.

Leslie Simon, a pediatric surgeon who encountered some tu­berculosis cases while working for the UN Development Pro­gram, said the early symptoms of tuberculosis can be deceptive.

“The problem is, it’s not too painful. A slight fever in the eve­ning, some sweating, a slight cough, people think, maybe they’re just tired…so treatment can come too late,” he said.

At Preah Bath Norodom Si­hanouk Hospital, several hospitalized patients said they had come to the hospital only after their traditional medicine had failed. A doctor with Kao Kong said even at his seriously ad­vanced stage of tuberculosis, the man had not wanted to stay at the hospital, insisting he could cure himself.

Interrupting treat­ment midway, how­ever, makes the tuberculosis drug-resistant and even harder to com­bat, said Dr Kaing Sor, head of the hospital’s pulmonary ward, who agreed with Si­mon’s assessment. He added that pa­tients can be im­patient to recover, and do not undergo the full treatment necessary to fully destroy the bacillus in their bodies. “After two months, they feel the TB has gone and they go home [from the hospital] and rarely come back for new medicine,” Kaing Sor said.

To deal with the epidemic, the government has decreed tuberculosis patients should be treated for free. With a budget of about $2 million, an $8 million loan from the World Bank and food donations for tuberculosis patients from the World Food Program, Dr Kong Kim San, director of the National Tuber­culosis Program, insisted there is enough money to treat everyone who goes to the clinics.

Since 1994, the government adopted a strategy where public health workers counsel and watch patients swallow their medicine and monitor the patients’ progress until each is cured. Since the program started in Cam­bodia, 136 of the nation’s 176 tuberculosis clinics now use the strategy, according to Kong Kim San. And of the tuberculosis patients the clinics treat, the success rate is upward of 85 percent.

Health experts have praised the program. Peterson still cautions, however, that facilities are still limited.

“At this stage, the level of training and facilities all amounts to a huge tuberculosis problem. You need a health system that works so everyone [with tuberculosis] can get in. Little more than half the health centers are operational,” he said.

Petersen also said while he had not received any reports about unauthorized charges specifically for tuberculosis treatment, the Ministry of Health is currently “trying to get control of the informal payment” system where poorly paid medical workers exact money from patients for otherwise free medicine and treatment.

Petersen did not rule out the possibility of the informal payment system sometimes operating for tuberculosis patients as well.

The clinics, furthermore, do not cover everyone, health-care pro­fes­sionals say.

Among the worst hit are children, who are not usually served by the tuberculosis clinics, which focus primarily on adults, said Dr Beat Richner, founder and director of Kantha Bopha Children’s Hospital in Phnom Penh.

However, doctors say adults with tuberculosis often carried the disease as children.

Richner called tuberculosis “the biggest health problem of Cambodia’s children” and “the largest hidden minefield” within the children’s bodies.

While WHO officials said the vast majority of tuberculosis cases occur in people between the ages of 25 and 65, Richner countered that the numbers for children are obscured because tuberculosis is difficult to diagnose in children.

“This hospital is the only place in Cambodia where children with tuberculosis can be correctly di­agnosed and treated. And every year we discover 5,000 new cases just among the hospitalized children,” he said.

Richner’s specially equipped out­patient tuberculosis wing, where he said 100 to 250 TB patients are examined every afternoon, was filled this week with scores of mothers and children patiently awaiting their turn in line.

Pointing to the hospital’s intensive care beds filled with inert children attached to intravenous drips, he explained that most of the hospitalized children have tuberculosis.

“Children usually don’t come in with just tuberculosis,” he said. “But with meningitis and tuberculosis, dengue and tuber­culo­s­is…both [illnesses] become much stronger, much more serious.”

A mounting problem facing the government is how to deal with tuberculosis cases among the rapidly increasing numbers of HIV-positive Cambodians.

According to Kong Kim San, generally there is only a 10-percent chance a person exposed to the air-borne tuberculosis bacillus will acquire the illness. For HIV-positive people, the infection rate is 50 percent to 80 percent.

And the WHO says tuberculosis is the leading killer for HIV pa­tients in the developing world, ac­counting for one-third of all deaths.

The growing numbers of HIV-positive Cambodians could strain the National Tuberculosis Pro­gram’s resources.

Cambodia now has the highest rate of HIV infection in Asia, and 1.3 percent of the general population is already believed to be infected with HIV.

“The number of tuberculosis cases in Cambodia will increase due to AIDS,” said Kong Kim San.

To the question of how the program plans to cope with the influx of HIV patients who will contract tuberculosis as an opportunistic infection, however, the director of the National Tuberculosis Pro­gram had no answer.

David Awcock, an adviser to the program, said the increase in facilities could be matched by a similar increase in cases, so it would be a race for the facilities to contain the disease.

Back at Preah Bath Norodom Sihanouk Hospital, Kaing Sor said one of the main reasons why his tuberculosis patients were often so reluctant to be hospitalized or undergo treatment was they couldn’t afford not to work.

Hovering by Kao Kong’s bedside, his wife said she and her daughter must now spend time and money caring for him at the hospital every day, affordable only because his son has now taken over the laundry shop.

Furthermore, Petersen said the cramped and unsanitary conditions of many of those living in developing countries provided an additional medium for tuberculosis transmission.

“For AIDS, we focus on changing sexual behavior. For tuberculosis, you can teach people not to spit on the ground, but you can’t help living with your grandmother,” he explained.

But Petersen did not want to be fatalistic. Using the word “if” as a gesture of encouragement almost to prod a wish into reality, he said Cambodia just needs the proper conditions to successfully combat tuberculosis.

“I don’t like to come up with doomsday scenarios,” Petersen said. “Now, with the new government formed, if investment comes in, and if aid comes in for socioeconomic development, then yes, I think Cambodia will be able to deal with tuberculosis in the long term.”

(Additional reporting by Khuy Sokhoeun and Heng Sinith)