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Pacific TB rates continue to climb

regional TB
A regional tuberculosis treatment centre in PNG (World Vision)

| SBS News

PNG has already seen the emergence and spread of highly-drug resistant TB strains

SYDNEY - While all eyes are on the Covid-19 crisis, one of the world's deadliest diseases continues to haunt the Pacific.

Tuberculosis, or TB, is a highly-contagious airborne bacterial infection that attacks the lungs.

It killed 1.5 million people last year - more than any other infectious disease except for Covid – in what has been called the 'silent' or 'hidden' epidemic.

"A lot of focus has gone to Covid, and funding has gone to Covid, and diseases such as tuberculosis have been left behind," said Dr Hemant Bogati, who works on tuberculosis control for Doctors Without Borders in Papua New Guinea.

Tuberculosis is typically treated with a cocktail of antibiotics that must be taken daily for nine months or longer.

But drug-resistant strains that are much harder to treat are starting to emerge in Papua New Guinea.

"As of 2016 there were about 2,000 new cases of drug-resistant tuberculosis in the country, and it's slowly increasing," Dr Bogati said.

"Globally, drug-resistant TB patients have a treatment success of less than 50%, and the cost of treatment is 100 times higher."

Helem Waenesai, a member of World Vision's TB control program in Port Moresby said a key challenge was spreading awareness amongst communities.

"We are mobilising the community to know what TB is, and how we can help in treating and curing it," she told SBS News.

According to World Vision, some 3,000 people die from TB in PNG each year.

The Marshall Islands in the Pacific have the eighth highest TB incidence in the world, with 4.5 cases per 1,000 people.

PNG has the 10th highest incidence, with 4.4 cases per 1,000 people..

By comparison Australia has an incidence of just 0.7 cases per 1,000.

Tuberculosis thrives in crowded areas and Daru Island in PNG’s Western Province has seen many cases, including of the multi-drug resistant variety.

Worldwide, the Covid pandemic has had a major impact on tuberculosis control efforts.

For the first time since 2005, there has been a year-on-year increase in the number of people dying from TB.

"We still have to uncover the full impact of Covid on global tuberculosis rates,” said Professor Ben Marais, an infectious disease expert.

“We know that TB was the number one infectious disease killer before Covid arrived, and that TB hasn't gone away.”

"Provisional data suggests there is not only a dramatic increase in TB cases, but also in TB deaths.

"TB control efforts will be put back by 10 to 20 years."

Covid testing centre in Port Moresby (PNG Department of Health)

While drug-resistant TB was not yet a widespread problem in most of the Pacific, Prof Marais said it was crucial to remain vigilant.

"In PNG already we have seen the emergence and spread of highly-drug resistant TB strains.

"The same can happen in other Pacific locations.

“That would be a catastrophe for TB control, because these countries are not prepared for the added sophistication required in the management of people with drug-resistant tuberculosis."


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Stephen Charteris

TB is a real tragedy in PNG and seemingly an intractable problem. While preventable and treatable, TB has been able to proliferate in settings that health services rarely reach. Unless solutions that enable universal coverage are tried the situation is likely to get worse.

An inability to monitor treatment compliance or ensure follow up to treatment has resulted in the rise of drug resistant and extensively drug resistant strains in some communities.

These outcomes are symptomatic of a severely under resourced health sector with limited capacity to monitor or follow patients up.

It is not a reflection upon the health workers with insufficient tools or support to do the job. Workers I have spoken to are embarrassed, despondent and even distressed by the situation. They understand the gravity of the issue but are generally powerless to do much about it.

Health managers are also hamstrung. They cannot rely upon receiving the quantities of medicines needed, nor do they have the numbers of workers required to deliver the proactive service necessary to tackle TB.

Time and again patients diagnosed with TB that is treatable with 1st line drugs are forced into treatment holidays before completing treatment plans because medicines run out. Resulting in some progressing to drug resistant and extensively drug resistant strains.

The inability of successive governments to allocate sufficient resources is at the root of this crisis. The situation highlights the need for a rethink about the way primary healthcare services are funded and delivered in rural PNG.

By itself the top-down model of service delivery is unable to provide universal coverage or meet demand. An honest assessment of the contributing factors raises the question of whether it realistically ever will.

Either funding for health and health worker training is increased by an order of magnitude or something else is tried. Since the former invokes magical thinking it is worth considering what else could be done.

It is apparent that where money is mobilised, private services proliferate. Port Moresby and Lae are obvious examples. This is not to suggest that private services hold the key in rural areas, but rather economic empowerment might.

Over the decades there has been a history of grower cooperatives some of which have brought a measure of economic independence to remote rural communities. North Fly Rubber Growers Cooperative in Western Province is an example.

Communities in remote Middle Fly District, up to five days travel by canoe from the health centre at Obo on the Fly River are nonetheless the owners of family rubber blocks where they are visited by the grower’s ship to buy their cup lump rubber.

There are no roads, no airstrips, just scattered communities across thousands of square kilometres of flooded wetlands. If buying rubber from these communities is commercial, then delivering services to communities everywhere is possible. The key is economic empowerment.

The North Fly Rubber model is a blueprint for similar effort elsewhere. Create economic empowerment through the application of appropriate technologies, collect semi processed crops, fish, agricultural raw materials for further processing and sale and on the back of this activity deliver basic services.

Every setting is different and has its own potential solutions. With careful planning, community consultation and participation this model is worth considering. The economic potential has to be demonstrable with the capacity to meet transport costs when operating at scale.

At the time of writing plans to implement this model across scattered communities in a maritime province are close to implementation.

The goal is straight forward: use solar powered technology to facilitate economic activity where presently there is none.

Collect and market local produce and use a portion of the income generated to support community-based services backed up by registered health workers via outreach patrols.

At economies of scale, this approach has the potential to enable people in remote settings play an active part in facilitating the delivery of the services they need and enable government health workers reach settings presently beyond their reach.

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