Tuberculosis

Speeches, interviews, published papers and other documentation relevant to tuberculosis in East Timor . Click on the title below.

INDEX

Tuberculosis Programme in Timor-Leste Prepares Hand-over to Government 2 August 2005

Kuluhun Tuberculosis Care Centre, Dili by Usma Khan August 30, 2004

Making a difference: Treating TB in East Timor by Hugo Fernandes from the CAFOD website

Doctor slams UN on E Timor tuberculosis Dr Dan Murphy Reuters January 13, 2000

Tuberculosis in ET: Problems and Solutions by Dr. Joao Martins and Dr Anna Ralph

WHO Tuberculosis Website 

WHO Leprosy Website

NATIONAL TUBERCULOSIS CONTROL PROGRAMME (NTP), TIMOR-LESTE CENTRAL MANAGEMENT UNIT ( CMU )

MEDIA RELEASE

Tuesday 2 August 2005 -- For Immediate Release

"Tuberculosis Programme in Timor-Leste Prepares Hand-over to Government"

The National TB Control Programme (NTP) in East Timor (Timor-Leste) arranged 28-29 July a workshop with District TB Coordinators (DTC) as part of the preparations to hand over the management of the programme to the Ministry of Health (MoH) by the end of this year.

The aim of the workshop was to strengthen the planning and analysis skills of the DTCs. Participants from all 13 districts went through exercises to produce district DOTS expansion plans, parts of the District Health Plans intending to improve the TB treatment. They also discussed analyses of data from the TB treatment, in order to better understand reasons for the results of TB treatment in their districts, so that necessary actions may be taken to improve the treatment.

NTP Director dr Jaime da Costa Sarmento conducted the workshop, assisted by his staff in the Central Management Unit (CMU) and by TB Officer Constantino Lopes in the Communicable Diseases Department (CDC) of the MoH. Dr Jaime expressed satisfaction with the workshop and commented the high degree of enthusiasm from the 20 participants. He claims the workshop to be "an important step towards handing over the responsibility for managing the NTP to the ministry" [MoH]. More responsibility has been given to the DTCs this year, including more decentralisation of the supervision of clinics implementing TB treatment.

Another important step is the establishment of a TB unit (the TB-CMU) in the CDC. The leader of this unit, TB Officer Constantino Lopes, is a former regional supervisor from dr Jaime's staff. He joined the MoH early this year, and has been organising the new TB-CMU there, preparing to take responsibility for organising the national programme from January 2006. "A daunting task", he admits, "but my team and I are working hard to be ready to assume this important role." The TB-CMU presently consists of the TB Officer and two Regional Supervisors, and will with support from the Global Fund 
for Aids, Tuberculosis and Malaria (GFATM) add two more supervisors and one administrative person. Mr Lopes anticipates that this team, supported by a local doctor and international advisers, will manage to uphold and eventually strengthen the treatment of tuberculosis.

Management of the national tuberculosis treatment has since December 1999 been outsourced to the Catholic church, and must be regarded as a very successful cooperation between the Government and the Church. Caritas Dili, the development organisation of the Catholic Diocese of Dili, established in 1996 a programme to support TB diagnosis and treatment through the network of Catholic clinics through East Timor , receiving technical and financial assistance from Caritas Norway . This programme, which followed international guidelines and standards, was still operative by the end of 1999, and was asked to take responsibility for the management of the national programme until the Ministry of Health could manage to take over this task.

Dr Jaime is looking forward to handing over the responsibility to the Government structure. "The NTP management is a government task," he says, "and Caritas needs to focus on implementation." The Diocese of Dili and the network of Catholic clinics will continue important activities in the fight against this terrible disease, as East Timor are amongst the countries with the highest rate of tuberculosis in the world. These tasks include training and use of volunteer village health workers, who will assist in the diagnosis and treatment of TB in addition to other important health tasks. They also includes organising treatment of people infected by TB which are resistant to the normal drugs used (MDRTB) -- a very complicated treatment, but Dr Jaime has teamed up with expertise in the Philippines and looks forward to this challenge. Dr Jaime will lead this work -- "a luta continua..."

FACTS ABOUT TUBERCULOSIS IN EAST TIMOR :

1) In 2004, a total of 3,725 people were diagnosed with TB in East Timor and started treatment. 1,000 of these were infectious (sputum positive, i.e could spread the diaease to others through coughing). This means that around 425 persons out of every 100,000 people in 
the country started TB treatment last year, which is a very high number.

2) The number of new, infectious (sputum positive) TB cases in East Timor is estimated to 250 per 100,000. The number actually starting treatment in 2004 is a little over 100 -- which means that there probably still are many cases of infectious TB not being found and treated.

3) The national success rate (the share of infectious patients who are considered cured at the end of the treatment) is around 80%, which is very close to the target. The drop-out rate (the share of infectious patients who do not complete the treatment) is around 10%, which is very good. This means that the results of the programme are good for the people who start treatment.

CMU / Caritas Dili
Dr Jaime da Costa Sarmento, NTP Director
Augusto Joaquim Pinto, Deputy NTP Director
E-mail: tb_prog@mail.timortelecom.tp
Phone and Fax: +670 3322895

TB-CMU / CDC, Ministry of Health
Constantino Lopes, TB Officer
Phone: +670 7248999

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Kuluhun Tuberculosis Care Centre, Dili

Written by Usma Khan, volunteer at Bairo Pite Clinic.

August 30, 2004

A full moon rose over a warm Dili evening, casting a spotlight on the stars of the night. Nine former TB patients of Dr. Dan Murphy's Bairo Pite Clinic have ´graduated´ to a healthy status—signalling their departure from the TB care centre, Kuluhun, in southeast Dili back to their homes in the surrounding mountainsides. The night was full of excitement, energy, and nostalgia as the TB patients and their families prepared for the night's events.

Kuluhun was created in 1997 out of a demand for in-patient health care. It is supported primarily by volunteers who are part of Sister Lourdes' order—a group of sisters who have dedicated themselves to the uplifting of Timorese people. Sister Julietta, who organized the night's events, has been running the centre for the past 6 months. She stressed that all people are welcome here, regardless of religion—“we are all family.” Additionally, Caritas, a Norwegian aid organization supplements some of Kuluhun's costs by providing money for the treatment of patients who have tuberculosis. 

At any one time there are about 30 patients staying at Kuluhun . The patients grow very close to each other, as they spend much of their time together. In addition to helping with the upkeep of the centre, the patients are taught different skills such as weaving and sewing in order to keep them occupied but also to provide them with skills that can be used when they return home. Around every two months Sister Julietta organizes a ceremony and party for those patients who have been on treatment for two months and are ready to go home. Sister Julietta told us the names of all nine patients that were ‘graduating' and leaving the family at Kuluhun. They are: Antonio, Riza, Duarte, Daniel, Maria, Antonio, Manuela, Clara, and Lourdes. In honour of their departure, the group of patients and their family members sang songs, performed skits, and participated in a traditional dance. Food was laid out on the long table, a prayer was said, and everyone feasted. 

The celebration concluded with a gift-giving ceremony and a speech given by Sister Julietta in which she spoke of her love for the family at Kuluhun and her hopes for their good health and success in the future.

Usma Khan works in Oakland, California has a Health Programs Planner at a clinic called La Clinica de La Raza. I have a masters in public health from Harvard University .

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Making a difference : Treating TB in East Timor

By Hugo Fernandes 

http://www.cafod.org.uk/about_cafod/people/partners_in_asia/treating_tb_in_east_timor 2004

In the clinic of the Saint Paulo sisters in Suai, a number of people sit on a long teak bench. Fernanda De Luz, 45, sits at the end of the bench, waiting her turn for the medicine which she must take every day for the next six months.  Fernanda wears a traditionally-woven blouse, her already-greying hair tied in a bun. Her eyes are tired, sometimes gazing far into the distance. Fernanda is suffering from tuberculosis (TB). Two months earlier she had been told that she must undergo an intensive eight month period of treatment at the TB clinic. "At first it was difficult to breathe and I couldn't sleep," says Fernanda. Cipriano Freitas, a nurse at the TB clinic, says that Fernanda must receive intensive treatment because the TB from which she is suffering is already chronic. 

Fernanda's hopes and dreams include working in the fields with her husband and doing traditional weaving, called tais. An undampened spirit still emanates from her eyes. She says: "I hope this clinic will remain in Suai – I don't want to die from TB."  The sun is covered by clouds, the wind blows softly and the occasional sound of thunder announces that it will rain. I take my leave to return to Dili, leaving behind that long bench in front of the clinic where a number of people still wait, no doubt full of the same hopes as Fernanda De Luz. 

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Doctor slams UN on E Timor tuberculosis
Reuters January 13, 2000

DILI — From his ramshackle clinic in one of Dili's backstreets, Dr Dan Murphy says the easily preventable disease tuberculosis is killing too many East Timorese. And he blames the United Nations administration. Murphy is the longest-serving Western doctor in the territory and worked without official permission from Indonesia until East Timor 's de facto independence in September.

"The UN is afraid it doesn't have the perfect program, but it won't have," he said. "This is a poor country which has just suffered a major trauma."

Murphy says the bacterial disease has reached epidemic proportions and is baffled why a UN program will not be in place until February or March to combat the disease, which has become East Timor 's number one killer. 

"I would estimate that it kills one fourth of those who die in East Timor every day, which is anywhere from 50 to 100. I would say that almost every Timorese person since September has been closely exposed to TB. 

"When families were forced from their homes into crowded conditions together with TB sufferers no longer receiving treatment, they were all sleeping together on the ground. In a crowded room with no circulation of air, that's great for TB."

An estimated 250,000 East Timorese fled or were forced from their homes to Indonesian West Timor in the maelstrom of violence that followed the August 30 vote for independence. The UN praises Murphy and his tuberculosis treatment program but maintains it is delaying for good reason.

"I don't think it's UN bureaucracy and I don't think it's lack of resources," said UN's Director of Social Services in East Timor , Cecilio Adorna. If we want to hand on to East Timor a good, functioning world class TB program then we need to start it off as well as we can—we definitely don't want to hand them drug resistant TB or a chaotic mixture of different agencies providing different drugs and different protocol, we want to hand on something that will keep working," Adorna said.

"We need to have laboratory services, we have to have drugs available in the country and we have to have people who can actually manage the programme...you can't abandon treatment because it's very hard to get them back on the treatment and there is a huge worry about creating drug resistance so we have to get all these things in place."

The UN disputes Murphy's claim that tuberculosis has reached epidemic proportions. At Dili's International Red Cross hospital, Health Co-ordinator Dr Kevin Kelly said he has seen more than 260 patients in the past three-and-a-half weeks who are likely to have tuberculosis. 

"I've been screaming like everyone else, ‘Let's start,' but you do need to have the right program in place, if you don't follow the treatment through, you risk resistance," Kelly said.

Most independent medical organizations had agreed to delay treatment where possible until the UN program was in place, he said.

"If we see people who we think are going to die before the program starts then we'll start treating them but otherwise we treat secondary ailments of TB. The UN has ordered the drugs, it has the money but TB programs are very difficult to run."

Difficult or not, Murphy cannot see why the UN still does not have a dedicated program in place four months after the violence.

"The UN knew TB would be the worst health problem in East Timor so they could've been prepared, the first week they came here it should've been the number one priority. This is the number one killer here. I see people all the time who are not going to last even a month, they're on their last legs, adults weighing 20 kilograms [44 pounds] and people coughing up blood, but you give them treatment and they come right back to life, it's beautiful."

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Tuberculosis in ET: Problems and Solutions
by Dr. Joao Martins

PREFACE

Tuberculosis (TB) has re-emerged during the last decade, drawing the world's attention once again to this difficult disease. The rising rate has been a phenomenon mainly of wealthy nations such as the United States where, until 1985, a declining prevalence had been observed.

Factors identified as contributing to the swing include: 

(a) immunosuppression amongst the HIV-affected population and others with compromised general health (homeless, poor, injecting drug users), who may succumb to TB, 

(b) the development of drug-resistant strains of the bacterium and 

(c) the effect on statistics of migration from high to low prevalence areas (e.g from South East Asia to Australia ).

The situation in countries such as East Timor is quite different. For example, the relative impact of HIV-associated cases of TB is less felt there, where there is already a high background prevalence of the disease. TB incidence has thus not shown such a change in non-Western countries, except where HIV cases are particularly numerous.

However, attention generated by the TB epidemic of wealthy nations has meant a renewed interest in public health aspects of the disease, which are as relevant in East Timor as anywhere. Of particular importance has been the recognition of drug resistant strains of the bacterium, and appreciation that the best way to combat this is strict adherence to appropriate treatment regimens. Hence this has led to the use of alternative antibiotics, and the development of strategies for encouraging medication compliance.

Even in the Australian context of a comparably well-funded health system and adequate access to antibiotics, TB control is problematic. Prompt diagnosis is often difficult (it can take up to six weeks to identify the organism in the laboratory), and treatment involves months of medication and monitoring. In his paper, Dr Martins reveals that problems with TB control in East Timor are magnified by factors such as the high prevalence rate (approx. 122 cases per 100 000 population compared with 5.9 per 100 000 in Australia), limited resources and drug availability, and the effects on the population of military occupation.

Based on his experience of working in East Timor , Dr Martins identifies four key problems in TB control: 

1. inadequate population screening resulting in missed cases, 

2. lack of access to medications, 

3. inadequate follow up with a high treatment drop-out rate and 

4. overcrowding in urban areas facilitating spread of infection. 

Dr Martins' recommendations are simple and direct. They draw on the needs for improved funding and implementation of skills and knowledge about TB gained in recent years, such as the Directly Observed Therapy method of medication administration. He also emphasises the difficulty of achieving positive public health outcomes in the environment of military occupation, where the health needs of the local population are not necessarily a priority.

Dr Martins has identified some key areas which, if targeted with resources, could significantly improve the TB morbidity and mortality figures in East Timor and be a significant step toward improved public health.

by Dr Anna Ralph

Dr. Anna Ralph is a young Australian doctor with experience working with indigenous communities in the Torres Strait and Central Australia, in Tasmania and is currently working at Royal Darwin Hospital, Australia.

1. BRIEF HISTORIC AND GEOGRAPHIC OVERVIEW OF EAST TIMOR

East Timor has often been in the news over the past 23 years, because of its political status. Since the invasion of Indonesia 's military into the territory, the issue of East Timor has become a very hot debate at the United Nations as well as in the Asia Pacific region.

East Timor is half the island of Timor , however its size and population are bigger than some small countries in South Pacific, such as the Solomon Islands and Fiji . In size East Timor is approximately 18,900 square kilometres, and is located at the south-eastern extremity of the Indonesian archipelago, between 8 degrees 15' and 10 degrees 30' S longitude and 123 degrees 20' and 127 degrees 10' E latitude (Budiardjo et al,1984).

The pre-invasion population figure was 688,711, based on figures published by the Catholic church in 1974 (Carey et al,. 1995). In December 1980 the population was 552,954, according to Indonesia 's Central Bureau of Statistics. This means that 15 % of the population died during the first five years of Indonesia 's occupation (Suter, 1982). The current population of East Timor is approximately 800,000 ( Depkes, 1997).

From 1596 to 1975, East Timor was an overseas colony of Portugal , which began trading in sandalwood with the islanders in the early 16th century. During 1974, political change in Portugal resulted in a hasty commencement to the decolonization process of East Timor , with a brief period of independent rule by the Fretilin government in 1975.

On 7 December 1975 , Indonesia invaded East Timor formally, after months of clandestine border action. Since then, over 200,000 Timorese people have died as a result of conflict with Indonesian armed forces. These deaths have been due to direct military operations, and the social and health breakdowns caused by the conflict resulting in starvation and widespread diseases such as malaria, tuberculosis, diarrhoea and malnutrition (Carey et al,. 1995).

The major health problems faced by East Timorese people are infectious diseases, malnutrition and poor environmental sanitation. Common infectious diseases are respiratory tract infection, malaria, tuberculosis, diarrhoea and helminthiasis.

In this essay, I will look at tuberculosis because it causes long-term suffering and requires long-term treatment, and has led to an increased mortality rate in East Timor .

2. EPIDEMIOLOGY OF TUBERCULOSIS

2.1. Aetiology and epidemiology of Tuberculosis

Tuberculosis is an infectious disease caused by inhalation of airborne bacilli (bacteria), predominantly Mycobacterium tuberculosis. The bacilli establish themselves in the lungs where they multiply, causing small lesions. In 95% of cases, these lesions simply heal, without causing any disease, and the person doesn't even know he/she has been affected. Such lesions can become reactivated at any later time in the person's life. In the remaining 5% of cases of initial infection (and in reactivated disease or reinfection), the body's immune defences cannot contain the bacilli, and the disease progresses to pulmonary tuberculosis (Ministry of Health NZ, 1996).

The World Health Organization (WHO) has estimated that in the 1990s there will be approximately 90 million new cases of tuberculosis worldwide, with approximately 30 million deaths. The HIV epidemic has had only a modest impact on tuberculosis rates to date, but the effect of the HIV pandemic is likely to grow in the coming years (Scharer,1995). Because of this trend, WHO declared TB a global emergency in 1993 (Ministry of Health NZ, 1996).

2.2. Epidemiology of Tuberculosis in the United States

In 1992, 26,673 cases were reported in the United States (10.5 cases per 100,000 population), which represents a 1.5% increase compared to 1991. The largest increases occurred in Virginia (20.6%), Illinois (6.5%), New York (3.3%), and California (2.1%).

Since 1985, reported TB cases have increased by 20.1% with the largest increases in New York (84.4%), California (54.2%) and Texas (32.7%). If the downward trend in cases observed between 1980 and 1984 had continued, approximately 51,700 fewer cases would have been expected between 1985 and 1992.

The unexpected increase in cases in the U.S. is thought to be related to the Human Immunodeficiency Virus (HIV) epidemic, but other factors such as homelessness, decreased funding for health departments and lack of access to medical care may also contribute. Similar increases in tuberculosis incidence have been seen in other developed countries. (Lutwick, 1995).

2.3. Epidemiology of Tuberculosis in New Zealand

The number of notified cases of tuberculosis in New Zealand has been declining for several decades. This decline reached a low point in 1988 when 295 cases were notified. Since then the annual number of notified cases has increased. Around 300-400 cases of tuberculosis are currently reported each year. Therefore the rate of TB was 11.7 per 100,000 population in 1995.

This rate is considerably higher than in Australia , which reported a rate of 5.9 per 100,000 in 1994 (Ministry, 1996). In 1997, the numbers of notified cases were 330, compared to 355 in 1996 and 374 in 1994.

The New Zealand Ministry of health also estimate an average 15 people die of TB every year (Lambert, Southland Times, 4 September 1998).

Tuberculosis appeared in the news again in New Zealand in 1998, after an outbreak in a South Auckland school. Because of this, mass tuberculosis screening is being carried out in some parts of the North Island . Some politicians argued that this outbreak was caused by immigrants (Otago Daily Times, 4 September 1998).

About 16% of cases notified in New Zealand are in Pacific Islands people, even though this group makes up less than 5% of the population (a rate of 39 per 100,000 population). Maori people also have a high notification rate (14 per 100,000, ) compared with New Zealanders of European origin (4 per 100,000). The other ethnic groups (Asian and African) have the highest notification rate at 128 per 100,000 (Ministry, 1996).

3. TUBERCULOSIS IN EAST TIMOR

Tuberculosis is most prevalent in East Timor . According to the (Indonesian) Provincial Public Health Service in East Timor , TB is considered the fourth most prevalent public health problem after upper respiratory tract infections, malaria, and diarrhoea.

In East Timor , the TB eradication programme is run by the Indonesian government's public health centre which is known as PUSKESMAS and the Catholic mission clinics. The PUSKESMAS clinics are scattered all over the territory, whereas the Catholic clinic works in certain regions such as Dili, Baucau, Suai and Lautem.

Tuberculosis statistics in East Timor during the Portuguese colonial era were not well recorded. Under the Indonesian occupation, TB data has been recorded since 1988, when the Indonesian government formally launched the programme of TB eradication in the territory. The notified cases recorded within the 3 latest years were : 1995 (932), 1996 (1039), and 1997 (978) (Depkes 1997).

It is unlikely that these figures present a clear picture of TB in East Timor , as many TB cases are not detected due to lack of resources and inadequate public health strategies.

The notified cases were nearly three times higher than those in New Zealand . The highest TB prevalence rate in these years was 129.9 per 100,000 population in 1996, the lowest only a slight decrease to 122.3 per 100,000 population in 1995. The prevalence rates of TB in East Timor in 1996 and 1997, based on infection per 100,000 people, were more than ten (10) times higher than in New Zealand in the same period.

When East Timor was under Portuguese administration, preventative programmes for TB were carried out through BCG vaccination for children. Now, under Indonesian occupation, PUSKESMAS clinics have a limited TB strategy. Access to medical clinics is nominally improved, as every subdistrict is equipped with PUSKESMAS clinics, and health providers carry out some health education and promotion work. However, the TB programme in East Timor has not substantially progressed because the emphasis is on simply vaccinating children and treating the TB patients who come to clinics. There is no pro-active campaign at the community level to eradicate TB.

4. PROBLEMS

According to my experience and observations, based on my 3 years tour of duty in East Timor , the major problems are:

4.1. Case finding is merely on a passive basis

Case finding of TB in East Timor is reliant on a passive strategy, where health workers wait for patients to come to their clinics when ill. There is no active process within communities of seeking and treating infected people, and examining those in close contact with infected people.

This results in many people infected with TB not being diagnosed. They are denied treatment, and of course they become a main source of spreading TB to other healthy people in the community.

4.2. Limited availability of anti-tuberculosis drugs

The inadequate supply of anti-TB drugs is a major problem for effective treatment. Such treatment relies on a combination of drugs, and it is very common for clinics, when they do receive supplies, to be missing some of the combination. This can lead to multi-drug resistance among patients.

The standard therapy for TB according to WHO consists of three combination drugs : 1. isoniazid (INH), 2. rifampicin ( Rif ), 3. either ethambutol (Etham), or streptomycin (PS), or pyrazinamide (PZA). The availability of those first line drugs is often disappointing.

Rifampicin is the most potent anti-TB drug, and is virtually never supplied to public health centers.

Either from complete or partial lack of anti-TB drugs, TB patients in East Timor have inadequate access to treatments.

4.3. Compliance: TB Patients tend to drop out from treatment

Many patients in East Timor are not aware of the necessity for discipline and compliance in treatment.

TB patients normally must be treated for at least a 6 month period if they use a combination of isoniazid, rifampicin and pyrazinamide or ethambutol. If they do not get a rifampicin regime they must comply with the treatment schedule for at least 24 months.

What frequently happens is that when these patients feel better, they cease their treatment.

This situation requires closer scrutiny and follow-up by health workers, and better and more appropriate health education directly to patients and at the community level.

Patients need to be taught that when the symptoms disappear it does not mean that they have already recovered from the disease, as the bacteria is still alive. If they stop the treatment before it is completed, the disease can become active again. This is very dangerous situation which can also generate multi-drug resistance in patients and hinder future treatment.

4.4. Overcrowded living conditions

The more crowded the area, the more chance there is to get infected by TB. TB is an airborne disease, so if one person is infected with the TB bacteria, it is easy for him/her to transmit this disease to other people who live in close surrounds.

Although East Timor is not a heavily populated territory, with 800,000 inhabitants, overcrowded living conditions have become a problem. This is directly attributable to the circumstances and strategies of the military occupation of East Timor .

It is a policy of the Indonesian administration, complying with military objectives, to require the people of East Timor to live in concentrated areas rather then spread across the territory and in remote areas. For political and security reasons this makes it easier to control the population. However, it also produces overcrowded and unhealthy living conditions, contributory factors that influence the spread of TB in such population.

5. SOLUTIONS

I have identified 4 major problems that affect the prevention of TB in East Timor . If we are going to overcome the TB problem in ET, we must overcome these 4 major obstacles.

5.1. Health workers should be encouraged to conduct active case finding, as well as passive case finding.

5.2. Drugs planning management should be based on the need of the public health centre not based on pharmacies' needs. Funding for the provision of treatment drugs should be increased, to allow the purchase of all recommended anti-TB drugs.

5.3. Health education with patients and in the wider community must be conducted on an extensive and regular basis. Health providers must frequently conduct health education to lay people, in order to increase their awareness of tuberculosis. Patients must be informed that irregular therapy or ceasing therapy before the required period, can result in inadequate treatment and multi-drug resistance, which may then worsen the condition of patients themselves.

Moreover, providing good education for the young generation will help to eliminate the occurrence of TB as they will understand the meaning of healthy living and the actions necessary to achieve this.

5.4. Families and communities should be informed not to live in one crowded house or area, particularly those with TB active members. Improving the environmental and sanitary health is also necessary, because it plays an important role in the transmission process of TB.

5.5. Health workers need ongoing training. In particular, this may influence their ability to detect early symptoms and asymptomatic patients.

5.6. In addition to these, an important strategy to reduce the TB prevalence rate is for health workers in East Timor to apply Directly Observed Therapy (DOT), as New Zealand does.

5.7. Improving the economic status of people and communities will help to decrease TB infections in the East Timor population in the long term, as it will enable them to better access education and information about health and make material changes to their living conditions.

6. RECOMMENDATIONS and CONCLUSION

There are three most important things that need to be done:

• 1. provide funding for the purchase of medicine and equipment;
• 2. provide appropriate public health education to lay people - both direct to TB patients to ensure effective treatment, and to the wider community in a preventative model;
• 3. provide qualified staff and ongoing training.

These strategies will help the efforts toward TB eradication in East Timor .

Last but not least, a political solution over the East Timor case is fundamental. The transformation of a society under military occupation, who have little control over their lives, into one responsible for its own future at all levels, will enable positive change in all aspects of Timorese life. This is the most powerful solution to overcome all the problems being faced by the East Timorese people, including the TB problem. An independent state of East Timor will better serve its population.

Dr. Joao Martins

Dr Joao Martins is an East Timorese Doctor currently studying a Master's Degree in Public Health.

REFERENCES

1. Budiardjo C, Liong LS. The War against East Timor . Zed Books Ltd 1984

2. Carey P, Bentley GC. East Timor at the Crossroads : The forging of a nation. University of Hawai'i Press, 1995.

3. Dunn J. Timor : A People Betrayed. The Jacaranda Press, 1983.

4. Departemen Kesehatan Republik Indonesia ( Depkes RI ), Prevalensi Tuberculosis di Indonesia. Pecetakan Depkes, 1997.

5. Holme CI. Trial by TB . Proceedings of the Royal College of Physicians of Edinburgh , Suppl.4 Vol.27 January 1997.

6. Lambert M. Tuberculosis, The White Plague Declining in New Zealand . The Southland Times, 5 September 1998 .

7. Lutwick LI. Tuberculosis : A clinical Handbook. Chapman & Hall Medical, New York , 1995.

8. Ministry of Health. Guidelines for Tuberculosis control in New Zealand . Ministry of Health, Wellington , 1996.

9. Rom WN et al,. Tuberculosis : First edition, Little, Brown and Company. New York , 1996.

10. Ross JD, Horne NW. Modern Drug Treatment in Tuberculosis, Fifth Edition. The Chest, Heart and Stroke Association, London , 1976.

11. Scharer LL, Mc Adam JM. Tuberculosis and Aids. Springer Publishing Company, New York , 1995.

12. Otago Daily Times . Mass Screening for TB. Friday, 4 September 1998 .

Published by ETRA, March 1999
With a Preface by Dr. Anna Ralph and edited by Kieran Dwyer

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