March 19, 2008  Tuberculosis - Good Neighbours, Conflict and Disease
By David Downham

Sometime in the fall of last year a meeting was held between the Medical Department at Cynthia's Mae Tao Clinic, Dr. Cynthia, and some senior members of the TB unit of MSF, that has been working in Mae Sot for the last several years. They had to report that a decision had been made at the MSF Paris Desk that they could no longer support treatment of TB for patients coming from Burma. The up-front reason for this, was that, because of lack of patient compliance, too many drug resistant forms of the bacteria were appearing.

MSF has been doing an excellent job here in Mae Sot in the treatment of TB, which because of poverty, the minimal standards of hygiene and malnutrition, all due to the continued conflict, is extremely common. Some members of MSF might have wondered what they were doing anyway, treating a chronic disease, when normally their mission was to deal with the health effects around the world of crisis and war, of which at present there is no shortage and which must be stretching MSF's resources to the limit. In spite of this, MSF is continuing to diagnose and treat patients from the refugee camps, migrant workers and their families, and those with an address in Thailand. They also cooperate closely, as does the Mae Tao Clinic with the Mae Sot General Hospital. Ward rounds with the members of the TB Clinic are conducted twice a week together in the Clinic's Medical wards and advice and drugs are provided. As far as the origins of those patients that are presented at this round is concerned, the Clinic obviously has to follow MSF's changed criteria.

It has been stated that WHO is now supplying anti-tuberculous drugs to certain Hospitals and Clinics in Burma, although not in areas that have been labeled as conflict zones. Attempts to find out which Hospitals and Clinics these are and what constitutes a ‘Conflict Zone' have not so far been successful, although the information is vital, to Medics and physicians faced with the continuing positive diagnosis and need for treatment of TB in patients coming across the border.

Perhaps adding salt to this wound, it is worth pointing out that a young activist Win Tin, who has been a political prisoner since 1999, died in prison in Burma, of TB a few days ago. Medical care of patients in Burmese prisons is known to be appalling. The Burmese government is not interested. This is the reality.

Again to illustrate the existential discomfort into which one can be plunged, another recent case is worth citing. My wife, who spends her time, with the very generous support of many friends in Simcoe County, Ontario, caring for and involved in the continuing education of about 140 ‘displaced children', was recently rung up by a very distressed ex-student. Her 23 year old cousin is a small farmer in Karen State. They are very close as she grew up with him after both her parents were killed and before coming to live at the Hostel we sponsor. Some good neighbors in the village had brought him to Cynthia's Clinic because he had suddenly become paralyzed below the waist. Astonishingly the whole village also accepted the responsibility of borrowing from a lender in Bangkok money to take care at least of the initial expenses for his illness - money they had very little likelihood of being able to pay back without great and damaging sacrifice. The medics strongly suspected he had TB spine, which put them in a potentially difficult position. They made a sensible although short term decision to send him to Mae Sot General Hospital. Fortunately my wife came on the scene at that point and accepted the financial responsibility for his investigation and care, and the return of moneys to the village and the money lender. In a very short time after treatment started he began to regain the use of his legs. But he will need to be on his back for at least 2 months and then a process of gradual rehabilitation. It is a bit problematic as to whether he will be able to farm again. Because of the vagaries of the present situation, he could not be brought back to Medical IPD in the Clinic. Fortunately the medics in surgery do not labour under the same stringencies and so we have him with us in Trauma, and I have the pleasure of watching his daily improvement. But this unhappily has not been so in other cases. It is these other cases that are my real concern and the reason for describing the situation – in the hope that maybe someone will have some ideas.

Called a symbiotic relationship, some bacteria live to the mutual benefit of themselves and their animal and human hosts, others are not so sensible and cause sickness, immune responses and maybe death to their hosts, thereby largely ensuring their own. People seem to have the habit of the same varieties of behavior, when they get together, as well.

The tubercule bacillus divides most rapidly when there is a good oxygen supply which is when there is little resistance being provided by the host – in other words, if there is little or inadequate treatment, when the food supply is poor or when other diseases are joining in, and most frequently with both of the last two. It is then too that there is the greatest chance of mutation and the development of resistant forms.

It is very dangerous, very expensive and physically very exhausting to travel any distance in Burma; so much so that the lack of compliance of patients is almost inevitable. Add to this the difficulty of thinking clearly when one is tired, sick and hungry, worried because you have left your children in the care of your thirteen year old daughter, and you are trying to talk to someone you cannot really take seriously because of the funny language he speaks. There are many things clearly that have to be put right here besides TB. TB is just one of a number of interlocking problems.

But there are one or two things that are clearly apparent.

First, you are not going to lessen the risk of disease to yourself by denying help to your neighbor. In fact you are going to increase it.

TB in Burma as everywhere else is the classic disease of poor civics and Burma is not at all alone in this although certainly is one of the front runners.

And lastly, for the moment anyway, the large NGO's , in this case MSF and WHO should try to give good and well publicized notice of their intended actions so that there might be a possibility of others stepping in or a new policy developing and in that manner avoid a sudden withdrawal that has made in this case a bad situation much worse.