by Helmy Haja Mydin. First published in The New Straits Times 27 August 2015
Humans have had to contend with tuberculosis (TB) since the dawn of civilisation. The oldest evidence of human infection, a female specimen of the Neolithic era, dates from 9000 years ago. The disease’s high mortality rate was noted by no less than the father of modern medicine himself, Hippocrates. He identified it as the most common cause of illness during his time and even forbade physicians to visit TB patients in order to protect their reputations.
The dissemination of TB continued unhindered until two key features of modern infectious disease control were implemented. The first factor was improved sanitary conditions, particularly in the con-text of areas with high population densities.
The second factor was the introduction of antibiotics, which helped reverse millennia of nihilism. The identification of streptomycin in 1943 as the first antibiotic effective against TB was greeted with pro-found joy. The next decades saw further innovations and the realisation that the tenacity of TB meant that patients had to consume a cocktail of antibiotics over a prolonged period of time. Those who did not follow this regimen never fully recovered and the disease often relapsed.
Unfortunately, the optimism that greeted the introduction of antibiotics has faded away for the pre-cise reason that patients who need treatment are oft-times not given the right type or duration of an-tibiotics. In Malaysia, almost 25 000 cases were notified in 2013, a figure that is likely to represent an underestimation. There is also increasing worry about the rise of multidrug-resistant TB (MDR-TB), a more virulent form of the disease that occurs when there is failure to appropriately or correctly use antibiotics in treating TB. The number of MDR-TB cases reached 480 000 globally in 2013, predominantly in countries with failed healthcare systems such as those from the former Soviet Union.
Increasing globalisation and freedom of labour movement is generally hailed as a good thing but it does have the downside of increasing the spread of infectious diseases such as TB. This increases the financial and logistical burden of recipient healthcare systems. For example, cases of MDR-TB from Ukraine are far more likely to be diagnosed and treated appropriately if the individual is in UK. Similar-ly, cases of TB from Myanmar are far from likely to be treated to completion if the individual is based in Malaysia. The services are not entirely altruistic – preventing the spread of an infectious disease has as much of a bearing on the health of society as it does on the individual patient.
It is within this context that the recent statement by YB Datuk Seri Dr S Subramaniam, the Minister of Health, on the need to decrease subsidies for the treatment of foreign workers raised alarm bells. Concerns were raised regarding the ability of foreign workers to pay for treatment and the likelihood that payment will lead to greater reluctance in seeking treatment.
In Malaysia, half of those with poor treatment outcomes either default from treatment or are lost to follow-up following a transfer. The majority are foreign citizens, which is unsurprisingly given that na-tional health policy dictate that foreigners with active TB should be deported within a month. Those who are desperate and/or unaware of the severity of their condition are far more likely to disappear from the system.
The reality is that we do not have the financial resources to cater to all the healthcare needs of foreign workers. However, special dispensations should be made when it comes to aspects of public health for the benefit of the rakyat. Targeted subsidies may be more appropriate than in such circumstances.
The American Centers for Disease Control and Prevention advocate targeted screening and treatment of TB in high-risk populations, including close contacts of those with active TB, immigrants from regions where TB has a high prevalence rate, the homeless and those with low immune systems. One ap-proach would be to establish mobile units that can cater to areas of high prevalence or perhaps even empower local primary care centres to perform outreach services i.e. get medical professionals to go to the patents rather than the other way around. Although the costs to set up these centres may ap-pear to be prohibitive, it is likely to be minuscule compared to the effects of uncontrolled TB spread.
While it is important that those who require medication are able to access it, more stringent mecha-nisms should also be set in place to minimise the numbers lost to follow-up. This may include the crea-tion of an openly-shared electronic database or the use of mobile health to track patients. Those who are deemed to be of higher risk should be quarantined, forcefully if necessary. Taking a few steps back, the relevant agencies should also ensure that patients are adequately screened prior to com-mencement of labour.
The gulf between policy and implementation does mean that stringent infection control measures can sometimes be lacking. However, the control of infectious disease is not just an issue of public health, but one of national security. If such scenarios are not addressed adequately, the end loser is nobody else but the rakyat ourselves.
– – –
Helmy Haja Mydin is a founding associate of IDEAS