By PNG Echo
This writer is a non-medical, interested observer, of Tuberculosis (TB) who, having been expertly informed by leading global medicos and researchers (as an invited fellow of the National Press Foundation to the World Conference on Lung Health 2012 in Kuala Lumpur) and who having witnessed, first hand, its devastation in the district of Goilala, Central Province, has been been writing about it ever since.
In particular, I have bothered, cajoled, shamed (tried to) and bullied everyone and anyone I could with the purpose of getting a ‘GeneXpert’ diagnostic machine for the remote clinic in Tapini, Goilala in the Central Province.
It’s been to absolutely no avail.
Heartache by the (increasing) number
On reading in Post Courier (1 September, 2014) that:
Tubeculosis (sic) cases in Central Province are on the rise,
my frustration has become palpable.
That same article continues ominously,
…the province does not have any facilities to diagnose TB,
before going on to add:
They say that the cases maybe (sic) increasing because some who have defaulted [prematurely discontinued treatment] are lost and cannot be traced.
The source reported that one person diagnosed with MDRTB [Multi Drug Resistant Tuberculosis – see explanation hereunder] had since died.
I knew this two years ago – health officials have known it for much longer. The lackadaisical approach of the PNG authorities borders on criminal.
The seeds fell on stoney ground
After traveling to Tapini at the invitation of the Goilala Foundation, I presented a video to the conference (Kuala Lumpur) on their dire situation and wrote a feature article (two-page) for the National that was published in the ‘Weekender’ on October 12, 2012.
Last year ( March 2013), another full-page feature was published in the National after the death from XDRTB (see explanation this page) of Catherina Abraham in a Cairns hospital motivated my pen.
Earlier on in the wake of his theatrical visit to Tapini in a chartered helicopter – bearing gifts, I had attempted to shame the opposition leader, Belden Namah, the PNG Party and its then member for the area, Daniel Mona, to do something about the dire health situation in regards to TB in Goilala with an article published in PNG Blogs in September, 2012.
It fell on deaf ears, and Goilala MP Daniel Mona seems to have remained oblivious and unashamed even after eventually leaving the opposition in order to ‘gain access to his DSIP funds – it’s why I’m a staunch advocate of doing away altogether with DSIP funds.
Indeed I have lost track of the people I have approached (that include Australian politicians, PNG Ministers and captains of industry who are making a fortune from exploiting the resources of PNG) – it’s produced absolutely nothing.
TB – the facts. Blame it on the government
Tuberculosis is a disease of poverty. It’s opportunistic and it preys on the weak. The conditions that nurture this disease are found in PNG in spades where it’s found a strong foothold.
With a shamefully impoverished population who have very little recourse to adequate nutrition let alone health services, together with rampant sexually transmitted diseases, (amongst a plethora of other things that weaken the resistance) it’s found a perfect host.
But worse than allowing the conditions that encourage this disease to rage unchecked, the PNG government bears the direct responsibility for the appearance of the drug-resistant strains known as Multi Drug Resistant Tuberculosis (MDRTB) and Extensively Drug resistant Tuberculosis (XDRTB) in PNG.
These mutant strains occur where maltreatment of Tuberculosis is rife; whereby treatment is cut short (for a myriad of reasons – including the short supply of treating drugs) allowing the disease to mutate and become resistant to otherwise effective drugs.
These heinous strains are totally man-made. MDRTB is now well established in PNG and there are ever-increasing instances of XDRTB.
The rigorous and onerous drug treatment schedule of six months for drug-sensitive TB becomes more onerous (more drugs orally and via injection) double the treatment time (to12 months) for MDRTB which doubles again (to two years) for XDRTB – where the chances of cure decrease exponentially with the increase in treatment times.
The treatment cost for an XDRTB patient is estimated millions of kina with a very poor chance of a favourable outcome. They die.
And while statistics say that there is a 3 in 10 chance of recovery from TB without any drug therapy, not to treat is not a viable option. Infectious people, left untreated, will themselves infect 10-15 people per year. And while, with treatment, the person will lose their infectious status within weeks and feel a lot better, if they discontinue treatment there is a good chance that the disease will recur in the devastating mutated form.
The GeneXpert machine – such an easy part of the solution
The GeneXpert is a relatively inexpensive diagnostic machine (K25,000 – 50,000 depending on the number of slots for simultaneous diagnosis) that accurately diagnoses TB and also indicates the strain’s resistance to one of the front-line drugs Rifampicin – indicating MDRTB or maybe XDRTB.
In some major centres in PNG they are already in use – but they need to be spread to local areas to diagnose in situ or their efficacy is reduced back to the same as any other reliable form of remote testing.
For it is in the rapidity of diagnosis where this machine comes into its own and it’s ease of use.
This machine can make a diagnosis in less than two hours (maybe quicker by now) and I’m told by Cepheid, the company that manufactures them that they are very easy to operate and need no specialised knowledge to interpret the results.
Imagine its usefulness in a clinic that in 2012 (and probably still) relied on Community Health Workers to diagnose, purely on consultation and what a lifesaver it may be for sufferers, some who have walked for days to attend the clinic, who are unlikely to “come back next week/month,” for their test results but instead will return to the village and infect 10-15 additional people per year.
TB sufferers need a diagnosis before they leave the clinic with an instantaneous and appropriate drug supply and regime because, chances are, they won’t be back.
And while this is not the full answer – it has to be the starting point. The reluctance to roll out these machines by the government on a national basis beggars belief and is economically short sighted given the horrific cost of treating this disease – even if you don’t consider the human cost.
(As a follow up: Dr William Lagani is advocating keeping patients in hospital for the whole duration of their intensive phase treatment.)
It’s about time!
At a medical conference in Goroka this week Sir Puka Temu on behalf of the Prime Minister has reaffirmed his commitment to healthcare. What’s more, last week, Health Minister, Michael Malabag in his Ministerial Statement to Parliament said that the government should be shifting its focus to providing adequate funding and resources to the fight against TB.
But, what the heck have they all been waiting for…?
… the emergence of the mooted next worse strain labelled totally drug resistant (TDRTB) for obvious reasons?
Dr Andrew Vallely, speaking at the PNG institute of Medical Research recently warned:
Unless we control HIV our health systems could collapse and the disease could wipe out both the elite and working class of our country.
Exactly. But he failed to mention that while they may contract HIV, they die of Tuberculosis – ask Father Brian Cahill of the Catholic Diocese of Bereina (of which the Tapini Clinic is a part).
Please be aware Hon, Prime Minister and Hon. Minister for Health, that the road to Hell is paved with good intentions. The government needs to start paying this problem more than lip service: just buy a GeneXpert machine for the clinic in Tapini, for God’s sake!
The Ebola of the Pacific and PNG in particular!
Literally a ‘no-brainer’. A number of the cases I have known have been cerebral tb.
What is the status on cerebral TB in PNG? That is an interesting aspect area in TB to pursue in research
The laboratory i work under as a research student is focused in the area of TB, currently they are using their rapid detection kit in the rural areas of Zambia, Nepal, Thailand and Egypt. And it costs less than 1 dollar for one sample and can detect TB under 40mins. They have been able to use the detection kit in rural areas of Zambia. So in support to this, we really need the govt to expand boundaries and investigate ways to effectively control TB. And if its budget they are worried about, how about try some such diagnosis kits like this which is under 1 dollar and can be kept out in the rural clinics. Or better still, get that GeneXpert.
TB is no longer an epidemic in Goilala. It is endemic.
Having just returned after 5 months in Tapini, it has nurses and health workers diagnosing and treating patients based on symptoms, not pathology. Without accurate diagnosis capability, there is often an assumption of TB when a patient presents with a cough. It is often a correct diagnosis, presumably, but does treatment of a patient with a cough from a common cold with TB drugs further promote resistance to drugs? So, why don’t patients go to Port Moresby for accurate diagnosis? Cost and dislocation from community. Privatisation of the hospital means that patients pay K300 to attend there. Port Moresby is a days travel and takes patients away from family, community and support structures including the gardens that they rely on to live. They are mostly subsistence farmers who are well outside their comfort zone in Port Moresby.
What then of the diagnosis and difference of treatment for TB, MDRTB and XDRTB? There is no ability to even try this when TB can not be reliably diagnosed.
It sounds like a hopeless case but the first step to turn it around is cheap, accurate and reliable diagnosis. Once this occurs, the challenge is to get proper treatment. This is mostly reasonable as patients are issued their medication daily in Tapini during the intensive phase of the treatment. Patients from distant villages often stay in Tapini, too. However parts of Goilala are 3 days walk away from the health centre in Tapini. People from these areas have no health service and never receive treatment. When they contract TB, the simply keep living and passing it on as long as they can, then die.
It is problem without a simple solution but a GeneXpert or equivalent diagnosis is a vital part of the solution, NOW, please, anyone.
Bruce, the GeneXpert is a no-brainer for anyone with even a cursory understanding of what’s happening in Tapini. I believe you are no longer there – I was hoping that the money for one could be found while you were there – but no! I don’t understand why this is so hard. The cost is relatively small. It’s short-term thinking for the government to keep resisting – but they are.
If Goilala/Tapini is that bad than one can only imagine the situation in the rural gulf western province… Human Resource is paramount in every country and PNG needs to seriously consider health as priority.
Im from Goilala myself and yes I totally agree on whats being said. I’ve lost my small brother from this dreatful epidemic. Only the nearest clinics available in Goilala is Woitape Station, Tolukuma Gold Mine, Fane, Ononge, Kamulai (Guari LLG), Kerau Station (recently funded by Digicel Foundation and Local MP Daniel Mona) and of course Tapini Station funded by Ausaid. So you can imagine the plight goilala people face everyday. Dont know when Govt is going to intervene.
God bless GOILALA
Sorry to contradict you, Bernard. The situation is worse than you describe. There may have been clinics at all of these places at some point. There are health centre staff at Tapini, but none at Kerau or Kamalai. I do not know about the others for sure but doubt that many, if any, have any qualified people that make a building into a clinic. Staffing Tapini is difficult enough, let alone trying to attract staff to the more remote places.