The forest for the trees: tuberculosis control efforts in west Kalimantan

Introduction

Medical care is a scarce commodity in Indonesia, which has two physicians per 10,000 people. ¹ In rural areas, such as the villages around the Gunung Palung National Park in west Kalimantan on the island of Borneo, the ratio is much worse. The scarcity of health-care resources, combined with the expense of traditional fee-for-service models, places medical attention out of reach for most people in the region. The average family income is US$13/month, far below the World Health Organization (WHO) standard of $1 per day for extreme poverty. Without a viable alternative, the people of west Kalimantan have turned to the forest as a source of food, fuel and income. Unfortunately, their harvesting practices are not sustainable – on the contrary, these activities place the Borneans' most valuable asset at risk of irrevocable destruction, a catastrophe that would have devastating consequences for their long-term health.

An ecosystem and the population at risk

The 90,000-hectare Gunung Palung National Park is comprised of a diverse array of habitats including mangrove forests, peat swamps, montane forests and lowland Dipterocarp forests. The Park is one of the few places on Earth where orangutans can still be observed in the wild. However, it has barely escaped the fate of other Bornean lowland forests. Illegal logging, encroachment and agricultural fires from neighbouring plantations continue to chew away at its edges and much of the reserve's buffer zone has now been destroyed. The loss of forest cover is affecting more than just the flora and fauna. Local people are dependent on the forests for food, building materials and jobs. As forests disappear, life gets harder for these already impoverished communities, many of which lack access to the most basic health care. Often the only work that is available is illegal logging, for which they earn a pittance and further deplete their resource base.

Paying for care by protecting the forest

These harsh realities are not unique to Borneo. However, a novel approach to the challenges of poverty, deforestation and illness is currently being deployed on the island with promising outcomes. Alam Sehat Lestari (ASRI), an Indonesian-American, non-profit organization located on the border of the park, is linking the delivery of health care to the conservation of natural resources.

ASRI, which translates as ‘harmoniously balanced’, combats deforestation through an incentive system in which discounted fees for medical care are provided to communities that help to protect the rainforest rather than log it. ASRI also has an alternative work programme whereby anyone who cannot pay cash at the clinic can, instead, work on conservation-promoting projects, including an organic farm and seedling nursery that is growing trees to be used in reforestation endeavors. This effort seems to be paying off. Since its opening in July 2007, 18 of 21 neighbouring villages have signed a memorandum of understanding agreement to participate. According to reports from the Park's Bureau Monitoring Program, these communities have indeed greatly cut back on illegal logging and burning activities. In exchange, the villagers are benefitting from monthly mobile clinic visits, a fast-track programme to dispense contraceptives, an ophthalmology initiative that has already distributed free secondhand spectacles to over 1000 people and a project to fight malaria by providing mosquito nets. To date, the ASRI has treated 8343 patients with a wide variety of illnesses. This approach empowers patients, improves access to health care and protects a vital natural resource. It may be a model that could be successfully adapted in other regions across the globe.

Tuberculosis pushes the model to it limits

Unfortunately, given current resources, this model has limitations, as demonstrated by ASRI's experience with tuberculosis (TB). Arguably, TB accounts for the region's most significant burden of infective illness. According to the WHO's Global Tuberculosis Control Report 2009, there were an estimated 528,063 new TB cases and an estimated incidence rate of 102 new sputum smear-positive (SS+) cases per 100,000 population in 2007. ² Based on WHO disability-adjusted life-year calculations, TB is responsible for 6.3% of the total disease burden in Indonesia, compared with 3.2% in the greater Southeast Asian region. ²

The ASRI's TB programme consists of a coordinator, three physicians, a laboratory technician and 14 village health workers who provide home visits three times a week that include directly observed therapy (DOTS). The clinic currently diagnoses and treats 10 to 13 new patients with active TB per month. By October 2009, 251 patients had begun anti-TB medication, with 65% completing at least six months of treatment. Globally, the reported rate of treatment success for new smear-positive cases treated in DOTS programmes in 2006 reached the target of 85% set by the WHO in 1991. ² Three regions – the Eastern Mediterranean (86%), Western Pacific (92%) and Southeast Asia (87%) – reported meeting this target. The treatment success rate was 75% in the African Region and the Region of the Americas and 70% in the European Region. Thus, in spite of significant advances in health-care delivery based on in-kind payment, ASRI has failed to bring the TB epidemic under acceptable control. This failure is associated with several factors.

First, the clinic's detection of new cases of TB is based on a provisional diagnosis by means of direct acid-fast bacilli testing of sputum smears, a diagnostic tool that can provide positive results in fewer than 50% of patients with newly diagnosed pulmonary TB confirmed by culture. ³ Furthermore, the sputum-smear test does not address the detection of those with drug-resistant strains of Mycobacterium tuberculosis. Therefore, ASRI's treatment of drug resistance is attempted only when there is no response to standard therapy. The loss of 9 to 12 months of the provision of appropriate drugs has several potentially critical consequences, including the failure of a response to therapy in the index case and the possibility of ongoing transmission in the community. Ideally, the clinic would prefer to offer definitive testing, such as the microscopic-observation-drug-susceptibility (MODS) assay, in which broth cultures are examined microscopically in order to detect characteristic growth patterns. However, the major obstacle to the implementation of this cultivation method is that of laboratory biosafety, which requires costly containment equipment. Furthermore, this procedure cannot be performed safely in ASRI's setting because the electricity supply for the containment hoods is unreliable. Thus, the introduction of the MODS assay or any new system requires the existence of a basic TB laboratory which highlights the need for a mix of private and public initiatives to contribute to the strengthening of the health system.

Second, treatment of drug-resistant TB requires injectable medications that can only be administered by trained nurses under Indonesian law. However, there is a great shortage of such personnel in the region which has resulted in a limited coverage for distant villages.

Finally, many of the patients are wary of continuing TB treatment because they do not want to be in debt to the programme and need to find other non-cash means to pay for therapy apart from working in the organic garden or the seedling nursery. Additional subsidization of TB drugs through international and local funding is crucial. Although the Indonesian authority does provide complimentary TB medication, there is still a shortage in the area: even the government-run clinic does not have adequate stock to treat its patients, let alone provide medications to ASRI. Like many nonprofit health-care organizations, ASRI is supported by private donations and small US foundations. This is a great partnership, but one that must continue to grow.

The ASRI experience shows that an unconventional ‘forests-for-health care’ incentive programme can provide a powerful way to break the cycle that links poverty, poor health and environmental destruction around Gunung Palung. This model may benefit similar communities in Indonesia and elsewhere. However, the challenges of preventing, diagnosing and treating TB in this setting remain considerable and success will still depend upon a multi-lateral collaborative approach.