The Thammasat University Libraries have acquired a timely new book dealing with public health issues.

This important book has an unpleasantly graphic title which should not discourage readers, Spitting Blood: the History of Tuberculosis. Its author, the British historian of science and medicine Dr. Helen Bynum, examines how tuberculosis affected the lives of many famous writers, including the poet John Keats, novelists Emily Brontë, Robert Louis Stevenson, and George Orwell. In such operas as Giuseppe Verdi’s La Traviata and Giacomo Puccini’s La Bohème, romantic heroines suffer from tuberculosis, and the famous novel The Magic Mountain by German author Thomas Mann is set in a hospital for people afflicted with the disease. Yet despite these associations with the Romantic era, tuberculosis is not just a disease of the past. Effective treatments had been developed by the 1950s, such as the early antibiotic streptomycin and the use of X-rays to diagnose the ailment. By the mid-70s, many observers considered tuberculosis a problem of the past. Yet poor health conditions worldwide for immigrant laborers and refugees, as well as the HIV pandemic, caused it to reappear. Today a method of treatment is standard, known as DOTS (directly observed therapy, short-course) meaning to keep an eye on sufferers and make sure they take their medication. Even so, annually almost nine million new TB infections take place, and 1.4 million people die of the disease.

In India, nearly 1000 people die of tuberculosis each day. 80 percent of TB cases occur in 22 countries, including India, China, Russia, Afghanistan, and the Democratic Republic of Congo. Adding to the problem, each year over 400,000 new cases appear of what is called multi-drug resistant TB. The usual medications that cure the ailment do not work in this variety of it. In some cases, more costly medications can do the job, but so-called extensively drug-resistant (XDR) tuberculosis cannot be cured with treatments that exist, and this XDR TB has been noted in 77 different countries, including India and South Africa. Dr. Bynum underlines that it is important to offer people effective health care, with free diagnosis and treatment. Since TB typically affects people who are poor and without resources, making them less vulnerable will ultimately help fight this ongoing epidemic, she explains. The World Health Organization has set a millennium development goal to decrease TB deaths by 50% this year, although it is not yet sure that this goal has been met. After this year, a Global Thematic Consultation on Health is making even more ambitious plans: for zero new TB infections, zero TB deaths, zero TB suffering and zero TB stigma and discrimination.

Thailand and tuberculosis.

In a 2001 article, Dr. Apirak Palwatwichai, a lung specialist at Phramongkutklao Hospital and College of Medicine in Bangkok points out that many authorities believed that TB would be eliminated by the end of the 20th century. Yet the HIV pandemic, affecting the immune systems of millions of people worldwide, has made TB a concern once again:

In Thailand, tuberculosis cases and deaths reduced year after year, until 1992 when the cases began to increase as a result of HIV infection. The annual risk of infection in 1997 was estimated at 1.4%, with approximately 100 000 new TB cases developing each year. Fifteen per cent of tuberculosis patients are seropositive for HIV infection. Increasing antituberculosis drug resistance has been correlated with the high prevalence of HIV infection in some parts of the country. In 1995, cure rate of this disease was approximately 50% and, since 1996, in order to cope with the worsening situation, the National Tuberculosis Programme (NTP) has adopted Directly Observed Treatment, Short-course (DOTS). Despite the current economic turmoil of the country, the programme has now been expanded to cover over 400 of the 810 districts of Thailand. Also, the economic effects of tuberculosis at the household level in Thailand were recently studied. Tuberculosis is a chronic disease that commonly affects the lower socioeconomic classes. Some patients were unable to follow the treatment regimens because of the financial burden. The low case detection and treatment completion rates are, in part, due to the inability of poor patients to cope with the expenditure.

Confronting these real problems, the World Vision Foundation of Thailand, among others, has devised new approaches. In April, an article in The Nation reported that volunteers of all ages, including small children, are getting involved to stop TB in some of Thailand’s poorest neighborhoods such as Lat Phrao 48 in Bangkok:

Name, 13, and his younger brother, eight-year-old Note, might be young but they are already well known to the other residents of the small community in Lat Phrao Soi 48. Neighbours regularly come to visit their home, a habit that is viewed with suspicion in this tightly packed settlement where drugs and crime are rife. But while the boys do indeed handle drugs, these are medications that save lives rather than endanger them. The boys are playing an active role in the fight to stop the spread of tuberculosis (TB) in their community. They are learning their “trade” from one of World Vision Foundation of Thailand (WVFT)’s TB Direct Observation Treatment (DOT) health volunteers close to home. That volunteer is their grandmother, Phitsamai, and she is arming the boys with crucial information to transform their community into a healthier place. The role of a DOT watcher is to ensure that TB patients under the programme take the prescribed medications regularly. The watchers give a combination of TB medicines and a glass of water to a patient and check that the pills have been swallowed every day. This taxing daily routine goes on for 6 months, when a patient completes the entire course of medication and is rid of the disease. “It looks easy but it’s not,” says Phitsamai. “Patients like to tuck the medicines at the back of their tongue then spit them out as soon as they are not being watched. They also need continuous follow-up to change their attitudes towards taking medication on top of their regular check up at health centres or hospitals.”

If patients start taking medication but do not complete the full treatment by taking all the prescribed drugs, the results can be harmful. When some patients start to feel better after beginning treatment, they may stop taking the pills, which can cause the illness to return in an even stronger and more difficult-to-cure form than before. So reminders are essential parts of any treatment program. WVFT’s National Director Chitra Thumborisuth told The Nation:

Community volunteers should take pride in the fact that they play a pivotal role in curing TB patients.

Their involvement and caring are so important, the article adds, because

TB still carries a formidable stigma. A case in point is one TB patient under Name’s watch who prefers to take medications before daybreak. “I have to give him his medicine package at 4am. He’s afraid that if other people find out about it, they will treat him as an outcast. I want to help grandma help her patients get well. So I told him that there’s no reason to fear. If he has the motivation to finish his medications, TB can be cured. Whenever I see a patient’s face light up, I feel good.”

Fortunately, the Kingdom is not alone in this challenging fight. On March 24, World Tuberculosis Day, the French Embassy in Bangkok announced that it would continue to assist Thailand in its goal to end TB. Thailand ranks number 17 among the 22 countries most affected by TB. The World Health Organisation (WHO) informs us that there are about 130, 000 new TB cases each year in Thailand, with only 16 percent of them people living with HIV. This may mean that unlike other parts of the world, in Thailand TB primarily infects people who have other health vulnerabilities, such as small children and old people. Fortunately, so far only 1.6 percent of newly diagnosed cases in people who never had TB before are multi-drug resistant. For those who have had TB and now have it again, the percentage of multi-drug resistant cases jumps to 34.5 percent.

One of the great challenges for the ASEAN community is how to prevent and treat TB, as The Nation pointed out last year. In the Asean region,

six of the 10 member nations – Cambodia, Indonesia, Myanmar, Thailand, The Philippines and Vietnam – are still reporting a high number of new infections every year.

Fortunately, TB remains less contagious than flu, and usually people must live in close proximity, such as a family living in the same house, to pass it on to one another by coughing and sneezing. Among those most likely to be infected are people with inadequate diets, those who suffer from diabetes, cigarette smokers, and inhabitants of homeless shelters and refugee camps. Treatments include a combination of 2 to 4 antibiotics for 6 months, or over 20 months if the TB is multi-resistant.

A 2009 article in The International Journal of Infectious Diseases, Tuberculosis in Thailand: epidemiology and program performance, 2001–2005, gave reasons for optimism and concern. The authors, Doctors Suksont Jittimanee and Jirawat Vorasingha of the Thai Ministry of Public Health, along with other colleagues, concluded:

Since DOTS implementation, Thailand has exceeded the international TB case detection target, but has remained well below the treatment success target. The large discrepancy between case finding and treatment success rates indicates that actions are urgently needed to reduce TB morbidity and prevent drug-resistant TB.

(all images courtesy of Wikimedia Commons)