Poor service, public ignorance allow bird flu virus to spread

Monday, January 08, 2007

Hera Diani, The Jakarta Post, Jakarta

When avian influenza became a major global issue in 2006, some foreign health experts thought it was over hyped.

They said that people should indeed be cautious about the disease because influenza spread easily and called for global funding efforts to stop the disease. "But I think it's been over hyped. There is no indication or evidence that it will become a global pandemic," said a U.S. HIV/AIDS researcher.

Other experts were concerned that fear of an avian influenza epidemic had caused other major health issues to be overlooked.

So is the bird flu threat nothing to be worried about?

Maybe. But in the case of Indonesia, the hype surrounding it was seen as necessary to bring it to the serious attention of the people and the government.
According to the World Health Organization, bird flu remains essentially an animal disease, but one that has infected more than 250 people worldwide since late 2003, killing more than 150 of them.

In Indonesia, the first cases of bird flu in fowl were detected in 2003, and the first cases in humans in 2005. The country now has the world's highest number of human deaths from the virulent H5N1 strain of bird flu, with 75 people infected and 57 dead. Most of the infections were contracted from domesticated fowl. The most recent, on Jan. 7, was a 14-year-old boy in Tangerang, west of Jakarta.

The country is on the front line in the battle against the disease. No other nation has counted more deaths than Indonesia, where millions of chickens roam backyards freely.

Indonesia has attracted international criticism for not doing enough to stamp out the virus or to inform people of the danger. Many experts see it as the weak link in global efforts to ward off a possible pandemic.

To be fair, the avian influenza problem is very complicated in Indonesia.
As a geographically big country with over 220 million people and billions of chickens and ducks, it requires a lot of resources to fight bird flu.

There are approximately 30 million homes which keep chickens in their backyards, and millions more birds out there, making widespread vaccination and mass preventive culling difficult.

The complexity of the problem has revealed how poor the nation's health system, animal health services and public awareness campaigns are.
Only after bird flu surfaced did the country establish a pandemic preparedness commission.

Delayed treatment due to poor public awareness of the virus has led to the significant mortality rate. In many cases in West Java, even doctors and nurses have failed to take the problem seriously and immediately treat patients showing bird flu symptoms, while officials have been late to arrive at infection sites after the disease is reported.

The bird flu public awareness campaign run through the mass media has been of little help. People are still relaxed about the threat and there have been instances of farmers refusing to hand over their birds to the authorities despite being promised compensation.

In North Sumatra, farmers refused to have their poultry vaccinated, saying that they were healthy. The men drank the animals' blood in a protest.
In addition to halting the spread of the deadly disease, the government should use this time to improve the health system, animal health services and public awareness campaigns.

Observers have said there is a need for detailed and non-reactionary or superficial programs. The government's recent plan to cage fowls in residential areas to curb the spread of the virus, for instance, is likely to be futile unless people keep the cages and surrounding areas clean.

They have also said that it is vital that vets in each district stay on the alert for bird flu cases and respond to them, which means reliable vaccination programs, as well as the efficient killing of infected birds and compensation provision.

Such initiatives have been difficult to introduce, however, particularly because local administrations now have greater authority over internal matters. There is a need to increase the level of activity at the provincial and district levels.

The public awareness campaign needs to be more aggressive, as people will only follow the example if they see that there have been bird flu victims in their areas.

There is also a need for biosecurity awareness, involving educational institutions, places of worship and community groups.

Labels: health

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Equitable treatment needed for physicians, patients

Thursday, May 18, 2006

At a seminar on health services in Bandung, West Java, last month, a hospital association chairman said, "Patients are our killers".

Apparently, the increasing numbers of cases of alleged malpractice have met with resistance from health service providers, including physicians, with no existing mechanisms to settle the disputes.

Developed countries like the United States have laws specifically dealing withmedical malpractice. Under English law, the issue of liability is a subset of professional negligence where, under the Bolam Test, a doctor will be liable unless shown to have acted in accordance with a reasonable body of medical opinion.

In Australia, this test has been replaced but the principles are comparable.

Malaysia also has mechanisms to settle malpractice disputes, including insurance schemes, and several associations dealing with malpractice, such as Medical Defense Malaysia.

The World Medical Association (www.wma.net) suggests the national medical associations in each country do the following to provide fair and equitable treatment for both physicians and patients:

Provide public education programs on the potential risks of new advances in treatment and surgery and professional education programs on the need to obtain a patient's informed consent to such treatments or surgery.

Provide public advocacy programs to demonstrate problems in medicine and the delivery of health care resulting from strict cost containment limitations.

Advocate general health education programs in school and communities.

Enhance the level and quality of medical education for all physicians, including improving clinical training experiences.

Develop and participate in programs for physicians designed to improve the quality of medical care and treatment.

Develop appropriate policy positions on remedial training for physicians with deficiency in knowledge or skills, including policy positions on limiting the physician's medical practice until the deficiencies are corrected.

Inform the public and government on the dangers that may appear from "defensive medicine", such as the multiplication of medical acts, the abstention of doctors from conducting particular medical procedures or the disaffection of young physicians for certain higher risk specialties.

Educate the public on possible injuries during medical treatment which cannot be foreseen and are not the result of physician malpractice.

Advocate legal protection for physicians when patients are injured by untoward results not caused by malpractice.

Participate in the development of laws and procedures applicable to medical malpractice claims.

Develop active opposition to frivolous claims and to contingency billing by lawyers.
Explore innovative procedures for handling medical malpractice claims, such as arbitration rather than court proceedings.

Encourage self-insurance by physicians against malpractice claims, to be paid by the practitioner himself or by the employer if the doctor is employed.

Participate in decisions relating to the advisability of providing compensation for patients injured during medical treatment without any malpractice. -- JP/Hera Diani

Labels: health

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Legal uncertainty keeps malpractice cases hanging

Thursday, May 18, 2006

Sisi C.K. Chalik from the National Movement for Patients' Safety broke down in tears when sharing her experience of undergoing surgery to remove a myoma in her uterus and coming home with a colostomy.

Addressing the participants in a recent seminar on medical malpractice, the 40-something woman said that her case had been hanging in the balance for six years.
It all started in 2000 when an obstetrician/gynecologist in a hospital in Bogor, West Java, found a myoma (benign tumor composed of muscle tissue) in her uterus and suggested surgery.

Four days after the surgery, Sisi's stomach bloated like she was five-months pregnant, so she underwent surgery the following day.

A few days later, her stomach bloated again, loosening the stitches from the second surgery. She was in a critical condition. She then had a third operation, but remained in a critical condition and was then transferred to Cempaka Putih Islamic Hospital where she was treated for 13 days.

The doctors planned another two operations on Sisi, who went home with a colostomy (surgical formation of an artificial anus where a hole is made in the abdominal wall and the person defecates into a bag strapped to the stomach).

"I haven't been well after all those operations. My hemoglobin has dropped. I am easily exhausted and run out of breath, and after the operations I couldn't even walk and had to move around in a wheelchair," Sisi said, sobbing.

What was more baffling for her, the last four operations were done on her intestines and not her uterus.

Sisi then filed a suit with the police, but the process of the investigation was lengthy. In between, both the police and prosecutor's office lost all her documents. Her condition worsened, and an examination by another ob-gyn showed that the myoma was still inside, and that her uterus was damaged and needed to be removed.
But the surgery had to be delayed due to her weak condition.

The surgeon offered to settle the case out of court and offered Rp 70 million (around US$7,800) as a token of "sympathy and humanity", but refused to take responsibility for his actions.

Sisi said no, and proceeded with the trial.

The latest development showed that her documents are still missing at the Jakarta Prosecutor's Office, and the case is far from settled.

"My condition still fluctuates. I still have to have blood transfusions from time to time. I really want to get well. I hope there is a just solution to this case," she said. -- JP/Hera Diani

Labels: health

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Malpractice cases dead on arrival amid lack of legislation

Thursday, May 18, 2006
Hera Diani, The Jakarta Post, Jakarta

Doctors have traditionally occupied a respected and trusted position in society. Yet the numerous stories of irresponsible, money-grubbing physicians would rank some of them in the hall of professional shame with ambulance-chasing lawyers.

The list of victims of their incompetence is long. A two-year-old girl died following the routine procedure of an appendectomy at a hospital in Bengkulu last March. A woman underwent five surgeries for the removal of a tumor from her uterus, only to discover that four of the operations were on her intestines.

Cicilia Djarwati, 70, went into a nearly yearlong coma last year before cataract surgery. Her prescribed medication was too harsh for her heart and caused blood vessels, weakened by a previous stroke, to rupture.

"She has regained consciousness, but can barely move, talk or is aware of anything. Doctors said she could not get any better so we brought her home. Besides, the cost has reached Rp 150 million (US$16,700)," said her daughter Chatarina Mariani Dwiwidyawati.

Her children sued a Tangerang hospital for malpractice, but the case was dismissed on a technicality.

"The judges said we should have filed suit against the hospital's foundation instead of the hospital's management. We're now appealing to a higher court," Chatarina said.
The hospital's director, however, was fired and Cicilia's family has been allowed to pay off the bill in installments.

The country's already complicated, frustrating legal system becomes even more so when involving malpractice or medical cases.

The commonly stated, basic definition of medical malpractice is an act or omission by a health care provider which deviates from accepted standards of practice in the medical community and causes injury to the patient.

But there is no single regulation in this country, including the 2004 Medical Practice Law and 1992 Health Law, that defines medical malpractice.

When a case makes it to court, it usually is tried as negligence or accidental injury.

The Indonesian Health Consumer Foundation handled 48 alleged malpractice case from 1998 to 2004, but most were settled out of court. Only two cases have gone to trial, in a lengthy process with the proceedings still continuing.

Aside from the problem of the lack of a legal definition of malpractice, there also are dissenting opinions about other legal issues.

The foundation's Marius Widjajarta said there were no stated standards for the profession, as well as government regulations governing medical and hospital standards.

"We have a medical law with no legal instrument, which is a government regulation, required as operational procedures," said Marius, also a physician.

Cases unravel when they reach court, he said, telling of his own experience as an expert witness in one suit.

"The judges only asked whether there were standards for the medical profession, medical service and hospital service. There are none, so the court then used the Criminal Code. It didn't feel right because doctors are considered the same as criminals."

The Health Ministry argues standards on medical and hospital services are regulated in a decree from the health minister.

"Such standards are very technical, therefore the ministerial decree would be enough," said the Health Ministry's legal bureau head, Arsil Rusli.

The chairman of the Indonesian Doctors Association, Farid Anfasa Moeloek, said it was not easy to set standards for the profession because it was related to a handful of other matters, such as medical service and ethics.

"Professional standards do not stand alone. We also are working to revise the competence standard to be included in the curriculum of medical schools. It's not easy to set a standard because we have a lot of work to do," he said.

According to Farid, who also is the chairman of the Indonesian Medical Council, the real issue was a doctor's dereliction of duty, including carrying out a medical procedure not in line with his or her competence or without complete facilities, like conducting surgery at home.

Of 100 cases of malpractice reported in the past year, he said, only one case was proven after it was "honestly" examined by the Indonesian Medical Honorary Council.
"Many doctors are at a loss because there is no single perception on malpractice. In an alleged case of malpractice, the doctor's reputation is damaged," he said.

Marius countered that patients suffered the most because of the unclear regulations.
"The IDI includes 33 doctor associations, so formulate standards of the profession," he said.

Farouk Muhammad, a professor at the Police Academy, said that health and medical practice laws put too much weight on administrative aspects, particularly on authority, with very few articles on competence or ability.

"Regulations on medical practice or health should have regulated various aspects within the framework of legal protection for all related parties. We need medical penal reform."

Experts recommend the prompt issuance of hospital legislation, now being drafted by the Health Ministry.

Physician Kartono Mohamad said doctors and hospitals tended to blame each other in alleged cases of malpractice.

The government needs to push hospitals to issue regulations on patients' safety to make it clear which party is responsible when malpractice occurs, the columnist added.

"The lack of hospital legislation gives no obligation for a hospital to enact control. Doctors work by themselves with no one keeping an eye on them and controlling them. You can lie in the ICU and the neurologist comes to give you medicine, and afterward another specialist prescribes another medicine even if they contradict each other."

There also is the fuzzy area of where to take complaints, such as to the police or the Indonesian Council on Medical Discipline.

The council tends to hand out disciplinarian action and holds to the profession's esprit de corps, he said, as if a breach of ethics was not a breach of the law.

Labels: health

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Overmedication of children does more harm than good

Tuesday, February 14, 2006
Hera Diani, The Jakarta Post, Jakarta

Whether it's a simple case of the sniffles or the worrying onset of
diarrhea, parents here are likely to trust a doctor and his prescription
pad to put their children right.

Yet it's children who stand to suffer the most as victims of the
chaotic drug situation in the country.

With doctors prescribing them medicines they do not need, and the
danger of significant side effects, the country's kids are considered
overmedicated.

In a society with a tradition of self-medication, a recent study showed
about 70 percent of parents gave their toddlers more than four kinds of
drugs at one time to treat their illnesses.

More than 35 percent of toddlers were taking from five to seven
different kinds of medicine, according to Foundation of Concerned Parents'
spokeswoman Purnamawati S. Pujiarto.

Moreover, 85 children in the study had taken antibiotics, on the advice
of doctors, for every malady they suffered.

"This phenomenon is dangerous. First, not all diseases can be treated
with medicines -- like influenza, for example. Second,
such an amount of consumed drugs could harm our children's
health, especially their livers," said the pulmonary specialist.

Pharmacologist and physician Iwan Darmansjah said there were few
clinical trials -- tests done on humans to determine the efficacy of a new
drug -- specifically for children.

Tests showing the different reactions of the drugs in adults and
children, whose smaller body mass would affect how they were absorbed, are
also extremely rare.

"It was only in 1998 and 1999 that the FDA required pharmaceutical
companies to do the study on all medicines for children," the professor
emeritus at the University of Indonesia said, referring to the U.S. food
and drug regulating body.

"Before then, the data was always based on adults. It's not like a
child is a small adult that you can just halve the adult dosage the
dosage."

There have been a few studies since, he said, but none conducted in
developing countries.

"That's why children in Jakarta go to the same doctor every
two weeks, with the same disease, to receive the same, wrong
medication which reduces their immunity," he said.

"Ninety-five percent of the children are suffering from cough,
fever and cold, which should've been treated with a symptomatic
drug instead of stuffing them with antibiotics."

Executive director of the International Pharmaceutical
Manufacturers Group Parulian Simanjuntak said that clinical
trials of children were difficult to conduct due to ethical
concerns.

"A trial must be carried out voluntarily, where a person knows
what s/he is doing, the risks and so on. It is still being
debated whether children can give informed consent, as an adult
could, or whether parents can decide for the children. That's why
studies on children are not as wide as adults," Parulian said.

"And it's why pharmaceutical industries estimate the dosage
for children based on the dosage for adults."

Parulian said developed countries have discussed "assent
consent", where children can say yes or no about participating in
trials.

"But so far, it's still only under discussion."

Labels: drugs, health

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Embattled BPOM chief says agency doing its job to monitor drugs

Tuesday, February 14, 2006

Although known for his Javanese politeness and fine manners, Food and Drug Monitoring Agency (BPOM) chief Sampurno was clearly irritated when asked about criticism his organization has failed to properly monitor and regulate the pharmaceutical industry.
"It's all talk with no proof," he said.

After the flak BPOM received last month, when carcinogenic formaldehyde was found being used to preserve tofu and other food, his sensitivity is understandable.
Many also fault the agency for the haphazard drug situation in the country, which is not limited to high pricing and overdosage.

Prof. Iwan Darmansjah of the University of Indonesia's medical school said the local market was awash with useless drugs which drained the funds of unwitting consumers.
"False drug claims and wrong doses are blatantly condoned and fill the pages of the formal drug information (guide) called MIMS Indonesia," said the pharmacologist and doctor.

For those who like to self medicate, cheap drugs are readily available on the black market, such as Pasar Pramuka in East Jakarta and Pasar Senen in Central Jakarta. There are dozens of drug stores, selling products of questionable quality, safety and efficacy over the counter.

Cases of fake drugs are rampant, as well as substandard drugs, which contain less active compounds than defined on their labeling.

"In Indonesia, governance of drugs has never been well organized. The BPOM never had the manpower and the organization to protect the public from the presence of bad drugs on the market. The BPOM has been closer to and more protective of the industry than the public," Iwan said.

Marius Widjajarta of the Indonesian Health Consumer Empowerment Foundation said the situation worsened after the BPOM was removed from the auspices of the Health Ministry in 2001.

The agency was separated to become a stronger, independent body (the only other country to do this is China) after butting heads with the ministry on authority.

"The agency liked to usurp the ministry's authority, from drug registration to
issuing permits to build pharmaceutical factories. From 2002 through 2004, the agency approved 240 import licenses, which they had no right to do. Monitoring drugs is already a gargantuan task, so why trespass on other's authority?" he said, adding the agency should be moved back to the health ministry.

Sampurno defended his ministry against all the allegations, saying the BPOM did its job. He noted it was selected the fourth best agency in the world according to the 2005 audit of WHO.

He denied drugs were too pricey here, saying there was a wide selection of products available with a varied price range but of similar quality.

"When it comes to generic drugs, it's very competitive. The key is to exercise patients' rights, so they don't just bow to doctors' prescription prices," Sampurno said.

Effectiveness of drugs, he added, was a subjective matter.
He also termed "an emotional recommendation" the calls to return the BPOM to the Health Ministry.

"Come on, compare the performance of the agency (now) to when it was still part of the ministry. You can see that we perform better as an independent body." -- JP/Hera Diani

Labels: drugs, health

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Pill-popping public 'victims of unregulated market'

Tuesday, February 14, 2006
Hera Diani, The Jakarta Post, Jakarta

If you are a health consumer in Indonesia some of these situations may be familiar to you.

-- You go to a doctor instead of self-medicating for your cold and fever and end up with three different types of medicines, plus vitamins, which cost you a cool Rp 400,000 (US$43.50).

-- You are stuck in an emergency room of a hospital with a bad case of food poisoning, when you get another reason to vomit -- the price of your bill for the medicines is Rp 700,000. Then the doctor gives you a shot and you feel fine, but annoyed.

-- You take your toddlers to the pediatrician almost every month, forking out good money for many packets of medicines to treat the same reoccurring cold and flu symptoms. Your pocket hurts and you worry about the effect the many pills are having on your children's development.

-- Unable to afford your medical bills, you pay half -- and get only half -- of the prescribed drugs. Or you risk all and go to the Pramuka black market in East Jakarta for cheaper medicine.

Health is wealth, as the saying goes, which in this country could translate to mean "getting sick can rob you blind".

Experts say doctors here often overprescribe drugs to unwary patients, who are also paying too much for medicines -- a situation they say is caused by a lack of regulations and monitoring.

University of Indonesia medical school professor and pharmacologist Dr. Iwan Darmansjah said an absence of regulations governing the retail prices of prescription drugs here had caused some doctors and companies to inflate prices to ridiculous, rip-off levels.

"The amoxycillin antibiotic, which in other countries only costs between Rp 400 and Rp 500 (about 4 U.S. cents) a tablet, is being sold here by several companies for as much as Rp 2,800 a pill. That's deceiving, unfair business," Iwan said.

Health Ministry rational drug use department director Husniah Rubiana Th-Akib said manufacturers were also taking advantage of the erroneous public perception that generic drugs were less effective than their patented counterparts.

Husniah said all drugs were categorized as either generic or patented. Patented drugs were generally the latest generation of a drug, and were usually more expensive. But generic drugs -- often made specifically for low-income consumers -- should be no less effective and prices should be considerably cheaper in most cases, she said.

Patented drugs have only a 2 to 3 percent market share but make up 15 percent of national drug revenue.

"What manufacturers do, however, is take a generic drug, make it more appealing with packaging and everything, and then slap a 'brand' and a high price on it. We can call this type of drug a 'branded' generic drug," Husniah said.

"For amoxycillin, for example, there are over 100 brands on the market, with (wildly) fluctuating prices, while the content (in the tablets) is the same."
Often cheaper generic drugs are sold at the same price as patented drugs -- or worse, were packaged as such, she said.

Marius Widjajarta of the Indonesian Health Consumer Empowerment Foundation said drug prices should not fluctuate much.

"(Prices) tend to decline because newer, more sophisticated drugs enter the market."
However, international Pharmaceutical Manufacturers Group director Parulian Simanjuntak said drug prices here were based on the simple market mechanisms of supply and demand.

Because health insurance is not common in Indonesia, about 80 percent of drugs are being bought by individuals or companies, Parulian said.

Large insurers, as big buyers of drugs, could help set market limits on prices, he said.

With a total market value of about $2 billion a year, many companies here are involved in drug manufacturing -- 34 multinational companies and another 170 local ones, according to data from the group.

In such a competitive market, companies often pay doctors commissions to prescribe drugs, meaning patients often get medicines they do not need.

Indonesian Doctors Association chairman Farid Anfasa Moeloek said the government should subsidize drugs for low-income groups, who were supposed to get free medical treatment.

Farid said the unregulated system, not doctors, was to blame for the high prices.
Husniah, meanwhile, said the Health Ministry planned to regulate the packaging of drugs to ensure consumers could easily tell the difference between generic and patented medicines.

Branding on generic packaging would be 20 percent smaller and retail prices and ingredients would also be listed, she said.

"It's important for consumers to know what is in the tablets they buy," she said. If they had a choice between three chemically identical drugs, they could then choose the cheapest one, she said.

Manufacturers are opposed to the new labeling rules, which they say are against trade laws and will only increase their costs.

Parulian said international manufacturers already labeled their drugs clearly and included tablet ingredients.

"The plan would change the layout of the whole packaging. Besides, (the idea) goes against the regulation for Trade-Related Intellectual Property Rights on brands."
"We need brands, we invest in them. By including a drug's generic name, it will weaken our brands. We are going to protest this plan," Parulian said.

The industry has yet to make up its mind on price labeling, but Parulian believes it would be difficult to impose.

"Price labeling already exists on the primary packaging that (doctors' buy and) consumers do not see. If there was a change in prices, it would be impossible for manufacturers to relabel the old stock."

Labels: drugs, health

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Redefining peer pressure with 'MTV'

Monday, December 19, 2005
Hera Diani, The Jakarta Post, New York

At a skateboard park somewhere in New York, three young men confronted a peer, pressuring him to do something.
"So, did you do the deed or not? I've done it, he's done it ... It's a part of being a man, man," said one of the boys.
The cornered boy claimed that he had done it that afternoon, but the others asked for proof. He then rolled up his sleeve, showing a plastered arm, which was welcomed by cheers and high-fives.
The advertisement was one of a number of public service announcements about HIV/AIDS produced by America's MTV. The clip closed with the tagline "Redefine peer pressure. Get tested."
While the content on the music television network may have become increasingly sexual during past years, the channel has also been praised for its groundbreaking programs to raise awareness about HIV/AIDS among youth.
In a recent interview with the channel, the United Nations Secretary-General Kofi Annan credited MTV for doing positive, preventive work with its target audience.
"Other channels came onboard a bit later, but you have made a real contribution in educating the young. And it is important because when you look at the statistics there's a high proportion of the young getting infected today, particularly between 14, 15 to 24, 25, and that is really the age group your station touches most," Annan told the MTV news correspondent John Norris.
There are an estimated 40 million people worldwide now living with some stage of HIV or AIDS.
Of all the new cases in the world, more than half of them are between 15 and 24 years old.
MTV first launched its "Staying Alive" campaign in 1998 that seeks to help prevent the spread of HIV/AIDS by empowering youth to protect themselves and fight the discrimination against people living with HIV/AIDS.
Partnering with several well-known sexual health organizations as well as other media, the Staying Alive campaign included long-format programming, such as documentaries, concert events, news specials, and discussion programs, public service announcements, sexual behavior polls, a website in 10 languages (www.staying-alive.org), and off-air marketing and grassroots promotion.
There is also MTV's "think:Sexual Health", the Emmy-Award winning campaign that encourages young people to make informed choices about the issues surrounding HIV/AIDS, other sexually transmitted diseases and unintended pregnancy.
According to research conducted by the U.S-based Kaiser Foundation for family health in 2002 and 2003, more than two out of three of the campaign viewers are now more likely to use condoms, nearly half of the viewers have talked to their partners about having safe sex, and almost one in four have been tested for HIV or other STDs.
MTV vice president for strategic partnerships and public affairs, Ian V. Rowe, said more than one million people had called the toll-free hotline (1-888-BE-SAFE-1) and there had been a 30 percent increase in HIV testing. Just less than two thirds of people surveyed said they had personally learned something new from the campaign, Rowe said.
"We have reached a one billion audience through the network, and hope for more."
MTV plays in more than 412 million households in 164 territories in the Asia Pacific region, Europe, Latin America, North America and Russia.
For more information on MTV AIDS campaigns, programs and booklets, visit www.think.mtv.com.

Labels: health, HIV/AIDS

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Finding an AIDS vaccine 'a marathon, not a sprint'

Monday, December 19, 2005
Hera Diani, The Jakarta Post, New York

In the history of infection, the only way to control a viral epidemic has been through the creation of a vaccine.
The same thing is true for HIV/AIDS -- a vaccine is seen as the best long-term solution to end the epidemic. This is particularly true because the current treatment systems, although they have advanced over the years, still remain unable to cure the disease and are financially unsustainable.
Yet, 24 years after the first HIV diagnosis -- the worst viral epidemic since the 14th century -- there has been only one vaccine type that has been fully tested to see if it works.
HIV/AIDS, meanwhile, continues to infect five million people a year, or 14,000 people daily, and the virus claims around three million lives annually.
Top AIDS scientist Seth Berkley, of the International AIDS Vaccine Initiative, said researchers faced huge challenges in creating a AIDS vaccine -- scientific ones mainly, but also economic and political obstacles.
Scientifically, Berkley said, the virus' genetic variabilities made it extraordinary difficult to deal with its separate strains.
"We know that on average people get infected, they have the virus circulated in their blood, and then that virus is held down until about a decade later until they get sick. So, we know that most people can control the virus, and the challenge is how to make that type of control more robust," he said at a workshop recently in New York.
With other vaccines, such as measles or polio, the alive, attenuated vaccine is given to people to give them a mild infection that does not make them sick but instead protects them.
"Nobody wanted to give weakened HIV to people. But we gave weakened HIV to monkeys and they actually were protected. Why does it work, what's the mechanism, and can we get the mechanism by some other means? The answer today is we don't know," Berkley said.
According to Berkley, there are more than 30 candidate vaccines in the pipeline and there is a lot of important science going on across the world. Vaccine trials are not only being conducted with animals but also with a small number of healthy human volunteers.
"If there are no side-effects, we'll move to a larger number of volunteers, including some people at high risk. But we will have to wait two to three years to see the reaction," he said.
Aside from the scientific challenges, there was also the market's failure to produce a vaccine, Berkley said.
While vaccines have extremely high social value, they have low economic value, which results in few parties being interested in investing in them.
"If you think of the economic value of creating new drugs, pharmaceuticals have a huge market and (drug companies) make a lot of money on AIDS as people have to take the drug every day of their lives.
"But with vaccine, you only give it once or a few times. And you can't charge a huge amount of money because otherwise people won't take it. We know that for HIV, the largest place that needs vaccines is in developing countries. So it ends up in a very small market," Berkley said.
AIDS is still a controversial disease and questions are frequently raised about should be vaccinated. There are ethical issues associated with vaccinating teenagers and adolescents let alone some elements of the high-risk population, sex workers and injecting drugs users.
"With all the combinations, the company says, 'I'd better stay away from this'," Berkley said.
Vaccines like the one for hepatitis B, used to be expensive but with increased production and better science they have dropped more than 100-fold in price. However, the hepatitis B vaccine has only been offered in developing countries during the past 11 years/it took 11 years to give the vaccine to developing countries.
Similarly AIDS drugs used to be very expensive but are now tracking down in price. However, they are still out of reach of some of the people who need them most.
Global access to these drugs had to be assured, Berkley said. Production must be dramatically stepped up, and systems needed to be created to reach sex workers and drug users, along with a regulatory framework that spans nearly 200 countries.
"Can you get developed countries to accept the fact that we would make the vaccine available at (an affordable) price in developing world? Say, it is OK to charge US$50 in the U.S., but 50 cents in developing world?"
Berkley said political support and leadership was needed to develop a vaccine, in what needed to be a global effort.
"The vaccine would be a small component in global health spending, only less than 1 percent, and in developing countries even smaller.
"We need to build a comprehensive agenda all the way, on all levels, with all the support. It takes long time financing. It's a marathon, not a sprint."

Labels: health, HIV/AIDS

Posted by hera at 12:34 AM | Permalinks | Comments

Rich nations leaving the poor to die of AIDS

Monday, December 19, 2005

In November, The Jakarta Post's Hera Diani joined 21 journalists from 17 countries at a one-week HIV/AIDS reporting workshop in New York, under the auspices of the Reuters Foundation. Below are reports from the workshop, which featured a number of high-caliber speakers, including top HIV/AIDS vaccine scientist Dr. Seth Berkley and economist Jeffrey Sachs, HIV/AIDS activists and health journalists, as well as MTV US producers who presented an HIV/AIDS awareness campaign directed at young people.

When he talked about his first professional encounter into AIDS issues in the mid-1990s in Africa, economist Jeffrey Sachs had a look of shock and bewilderment on his face.
"One of the things that I couldn't understand, truly, was how it seemed the disease had been de-medicalized, outside of the rail of medicine and public health," he addressed the workshop.
There was almost no spending for sick people, he said, and people were dying without any access to public health care whatsoever.
"What amazed me is that a lot of speeches have been given about AIDS, from the UN, World Bank and so on. I thought someone was doing something about it other than just giving speeches. And I found that wasn't the case," Sachs said.
The middle class was hardest hit at that time; doctors, nurses and farmers were lost to the disease and millions of children were orphaned.
"There was also the paradox of no spending at all to do something about it," he said.
Sachs and his team calculated the cost of health access for poor people and came up with the figure of US$3, which was being given for each infected individual per year in Africa in 1999.
The demand for more funding sparked anger from rich countries, which said it was not cost-effective.
"As if leaving 30 million people to die is cost-effective. The whole thing was a scandal. And it remains a scandal from top to bottom. Because rich people leave people to die on the planet," Sachs said.
Next year will mark 25 years since HIV was first diagnosed, and the epidemic continues to infect five million people a year, claiming three million lives annually. There are an estimated 40 million people worldwide now living with some stage of HIV or AIDS.
Sachs said that AIDS is part of a much general health crisis, which is part of a more general poverty crisis.
There is no effective health system in poor countries. The disease does more damage sooner because widespread hunger and undernutrition makes the body more susceptible to infection.
Some countries do not make the maximum effort with their meager budgets to provide an effective health system, but for most poor countries, the financial constraints are huge.
The health sector is deeply underfinanced and understaffed, with often one doctor for every 25,000 to 30,000 people, and one nurse for a ward of 70 to 100 patients.
According to Sachs, the cost of rich countries helping poor countries improve their health sector is about $25 billion per year. The figure, calculated in 2000/2001, is one tenth of 1 percent of the Gross National Product (GNP) of the rich world.
"That means if the rich world gave 10 cents out of every $100 of the GNP, that would translate not just into AIDS control, but malaria control, TB control, clinics, doctors, community health workers ... and we would save about eight million people per year from dying early of disease," Sachs said.
"Only 1/10 of 1 percent of the rich world's income."
Seems like a pathetically small amount of money, he said, but it is very, very hard politically because the rich countries are very strongly girded against helping the poor countries.
Many countries have not even carried out their promise to spend 0.7 percent of their gross domestic product (GDP) on AIDS, which means 70 cents of every $100 of GDP.
"There is strong resistance, particularly from the United States, and also from some other parts of the world. Europe is better, most tend to honor the obligation of 0.7 percent. The U.S. gives the smallest share of their national income to aid of any rich country. Just 0.16 percent of the GNP, while we spent 0.7 percent of the GNP on the war in Iraq," Sachs said.
With bird flu sparking a global bid to prevent a human pandemic, concerns have been raised over double standards in handling AIDS and avian influenza.
American Laurie Garrett, a leading medical journalist and Pulitzer Prize winner, said that while both avian flu and HIV/AIDS were pandemics, they were not treated in the same way.
"Suddenly Bush said it takes $7 billion for an avian flu pandemic, with half of that for pharmaceuticals and incentives (for the industry). There has never been such a big amount of money given for HIV/AIDS. Whereas we deal with a chronic disease phenomena, a contagious and ever-expanding disease. We've never been in a state of emergency for four decades," she said.
Top HIV/AIDS vaccine scientist Seth Berkley said that for every penny spent on avian flu, 10 times more than that should have been spent.
"It's too late, you should have done that 10 years ago. But the fact is we're going to buy Tamiflu for the United States and not worry about the rest of the world..
"While if the flu goes crazy in Africa, for instance, chances are the rest of the world is going to have it even if you do not care about Africa," he said.
Berkley pointed to the period right after Sept. 11 when there was an anthrax attack in the U.S., with four or five people infected. The U.S. government then stood up and said there should be compulsory licensing for every drug.
"Here was South Africa, sued by a different manufacturer because they said they wanted to provide antiretrovirals (ARV) to tens of thousands of people dying of AIDS. That's the kind of stuff that drives me crazy. That double standard is really a problem," Berkley said.

Labels: health, HIV/AIDS

Posted by hera at 12:30 AM | Permalinks | Comments

SARS fears sap life out of Thai tourism

Sunday, June 15, 2003
Hera Diani, The Jakarta Post, Bangkok

Wanchai Lerdnirundon does not have much to do these days, except stare out to sea from his deck chair on the unusually deserted beach in Pattaya.
With Severe Acute Respiratory Syndrome (SARS) scaring tourists away from Thai vacation spots, there are hardly any takers for Wanchai's 10 boats, which ferry visitors to outlying islands.
"Normally, there would be 100 customers daily. But since March, the best I can get is only one group of tourists per week, or only four to five people," Wanchai, 43, said last week.
He recently laid off 50 of his 60 employees, with those still at work having their wages halved.
"If they can stand the condition, good. If not, they are free to go," sighed Wanchai.
"This whole SARS thing, it's worse than the war in Iraq."
The first vague reports of SARS cases in China and Hong Kong in March fueled a fear of travel throughout the region. The Tourism Authority of Thailand (TAT) noted that in March, the number of tourist arrivals dropped about 11 percent -- equivalent to some 300,000 arrivals -- compared to the same period last year.
In April, the situation worsened with a 50 percent drop, and the figure was believed to be 52 percent in May.
The downturn is despite the fact that both the country's cases were contracted outside the country, and that the World Health Organization (WHO) has declared Thailand a SARS-free nation.
"This (May) is the worst month we've had," TAT's research and statistics division head Walailak Noypayak told a visiting contingent of Indonesian reporters recently.
"The World Tourism and Cultural Council said that the impact of SARS on Asian countries is five times higher than Sept. 11. If there is no campaign to help recover the situation, we will lose about 30 billion baht (about US$726.4 million)."
Tourism is the second highest foreign exchange earner for Thailand after computer parts. Like most Asian countries, it plunged into the region-wide economic crisis in 1998, but it had an increase of about 7 percent in the number of tourist arrivals.
In 2001, despite the global travel downturn after the Sept. 11 attacks, it recorded a 6 percent gain in tourist numbers.
Last year, it earned 323 billion baht from a total of 10.79 million tourists, 60 percent of them Asians. While the concerted efforts to draw Asian visitors in the wake of Sept. 11 paid off, they backfired when SARS struck Asia first.
Occupancy at hotels in Pattaya and Phuket, for instance, is hovering around 20 percent-30 percent, compared to the usual 75 percent.
Thai Airways has also suffered; as of May 30, the company recorded a decline of 300,000 passengers, losing an estimated five billion baht from April through May.
Passengers were not the only ones afraid of flying. Media reports also left airline crews nervous, and an education campaign was launched, explained Suraphon Israngura Na Ayuthya from Thai Airways' crisis management and operations center.
"Now that the crews are no longer afraid, they are asking to fly. Unfortunately, they can't because their schedules have been reduced as we had to cancel thousands of flights last month."
The airline is looking for alternative destinations from SARS-affected countries by conducting campaigns and promotions for Australia, Europe, India and the Middle East.
Walailak blames some in the media for scare-mongering.
"It's not Asian media, but that kind of media that are more interested in worldwide news..the 24-hour reports where we are all connected by satellite. It makes people fearful..of life."
On the agenda now is bringing tourism back to full health, with a crisis team holding weekly meetings.
The Ministry of Public Health also established a SARS information center, to which airlines, agencies and other parties have to report the latest developments. The center publishes a daily press release updating the situation.
"Whether the press will be interested to use it on that day or now, we still publish it. Or else, we get a lot of rumors and panic like in the previous months," said Supamit Chunsuttiwat from the ministry's disease control department.
In working with the airport, the ministry installed equipment and assigned medical staff to conduct screening at the arrival gates for passengers from affected countries.
"And at least starting June 15, we will also have predeparture screening," Supamit said.
The ministry has set out to strengthen the services of all hospitals in the country to deal with SARS cases. The government has also allocated an additional 600 million baht to help stimulate the tourism industry, with prime minister Thaksin Shinawatra offering compensation of one million baht to anyone who contracts the disease in Thailand.
TAT has teamed up with Thai Airways, the Thai Hotels Association and Association of Thai Travel Agents for a special tour package called "Thailand Smile Plus".
It offers a free-stay night for every one night paid for, as well as discounts of between 20 percent to 50 percent at golf courses, spas and resorts. There is also a lucky draw.
TAT is also promoting the domestic market through its "Unseen Thailand" campaign, and holding road shows in Japan, Australia and New Zealand.
Thai Airways has made hygiene a paramount focus, with a plan to install the most technologically advanced air-cleaning equipment.
"The problem at the moment is the fear itself, not the disease," Wailalak said. "We must realize that this disease is a fact of life. The media has the important role to tell people that SARS is not as dangerous as we expect."

Labels: health, travel

Posted by hera at 2:29 AM | Permalinks | Comments

Schizophrenia, not a beautiful experience

Sunday, December 01, 2002

Hera Diani, The Jakarta Post, Jakarta

The ward of the psychiatric department of state Cipto Mangunkusumo Hospital (RSCM) is no different from the rest of the place: It's grim, old and dirty.

As the faded wooden gate is unlocked and opened, its appearance, which is closer in resemblance to a refugee camp, is quickly disclosed. The smell of dust and worn out furniture permeate the air.

"This place is not really good enough for patients. We plan to renovate, but we don't have much funding," the hospital's psychiatrist, Martina Wiwie, explained on our visit to the ward recently.

We passed the left wing, which is reserved for male patients, and went straight to the right wing, where several female patients had gathered in the hall and were chatting. On a bench in a corner, a patient was talking to an intern in a firm tone.

"You know, I can see across thousands of kilometers. Wherever my mother is, I can tell what she's doing," said the patient, who said her name was Nelma.

A few minutes later she stood up hastily and walked away from the bench, but then returned to talk to the intern.

"Let me ask you, what is your religion? Catholic? Well, I feel so sorry for you, because you will never go to heaven. I know that for sure because I know the Koran by heart, and prophet Muhammad said so. Forgive me for saying this, but you guys will never go to heaven!" Nelma, who is in her 40s, said angrily.

She became furious after the intern told her that she was being paranoid. Nelma then said how religious she was and how she had tremendous supernatural power.

"That is a case of schizophrenia," Dr. Martina whispered.

Nelma is among the estimated 1.2 percent of Indonesia's population of more than 200 million who suffer from schizophrenia -- a mental disorder of which there is still low public awareness.

Like millions of other schizophrenics, Nelma is suffering from a mental disorder in which the personality is seriously disorganized, but not split as is often thought, and contact with reality is usually impaired.

You probably still remember last year's film A Beautiful Mind, which is a true story about schizophrenic mathematician John Nash who later learns to handle his constant hallucinations and delusions to win a Nobel Prize in physics.

While the severity of the illness varies greatly in individuals, most people diagnosed with schizophrenia will usually suffer from one or more of its symptoms.

The symptoms that require hospitalization occur during the acute stage and they are: delusions, a false belief that cannot be corrected by reason; hallucinations, usually in the form of nonexistent voices; disorganized speech, with frequent derailments or incoherence; and grossly disorganized or catatonic behavior.

People living with schizophrenia are often robbed of the pleasures in life, and they have less ability to experience feelings.

Long-term impairments for people living with schizophrenia include low levels of interest, motivation, emotional arousal, mental activity, social drive and speech.

"They lose their social skills, their jobs and are expelled from schools. They can be extremely aggressive, or unreasonably silent. But the most common type is intense paranoia," Martina said.

Schizophrenic patients are prone to saying things that do not always make sense and their intellectual capacity also shows a tendency to decline.

The disorder, however, is very individualistic, as no two cases of schizophrenia are exactly the same.

It is believed that the main cause of the illness is a neurochemical imbalance in the brain, although there are cases in which nothing was wrong with the patient's brain.

Stress and complications in pregnancy can also be a trigger of the disorder.

"When a parent is schizophrenic, the child has a 23 percent chance of suffering from it, too. If both parents are schizophrenic, that probability jumps to 49 percent," Martina said.

However, there are studies that suggest that an inherited predisposition to the disease is not necessarily a dominating factor.

While mental illness can hit at any age, symptoms of schizophrenia are most prevalent between the ages of 15 and 30.

"It is usually more distinguishable in men, because society puts extreme pressure on them. So they become stressful, which could trigger the disease," Martina said.

She said that it did not cause too much disruption to the lives of people who are introverted.

"They usually turn to religion or the supernatural. But when it becomes a full-blown case, patients may think that they are prophets or messengers from heaven. And others, who are unaware of the disease, think that the patient just can't handle that kind of knowledge (of religion and supernatural stuff)," Martina said.

The situation turns serious, however, when patients become extremely aggressive or the voices they hear urge them to become violent. As a result, many sufferers are confined to their homes by family members or have their legs shackled.

While the story of John Nash is heavily romanticized in A Beautiful Mind, the reality of a schizophrenic's life is harsher. The portrait of a faithful and patient wife of a schizophrenic, played by Oscar winner Jennifer Connely, is also a rare case.

Often, like what happens to so many patients at RSCM, sufferers of the disorder are discriminated against, their rights are violated and they are shunned by family members.

Saring Hadiono, who is in his 40s, said that he often wanted to kill his schizophrenic brother, Hariadi, who has been living with the disorder for over 12 years.

"I felt like it would have been better for him to die than to make the whole family suffer. My mother even said that it would be OK to dump him somewhere," he said.

Hariadi had been a smart, multitalented man who held a decent job, Saring said. He later turned obnoxious toward others, and that cost him his job and his family. The drastic changes in his behavior ranged from taking other people's food, excreting in a mosque to burning the television and even the house.

"I didn't think that he was mentally ill. I thought he was just plain annoying. We had tried many things, including putting him in an Islamic boarding school," Saring said.

It was only a couple years ago that the family discovered he was ill, and took him to a hospital where he was diagnosed with schizophrenia and treated for it.

"He is much better now. We should have brought him to the hospital a long time ago," Saring said.

Martina said the main cause of the illness was a chemical imbalance, and it needed to be countered with medicine to eliminate symptoms.

"The medicine has to be taken continuously at least for two years. There is no such thing as an addictive effect. It's just like diabetes, where you have to constantly take medicine. It might be expensive, but the patients can function normally and continue to hold a job," she said.

But the most important thing, she added, was to create a conducive and supportive environment for patients.

"The whole treatment is useless if a patient goes back to his or her family and is always criticized or mocked. Occupational therapy and sports are also important," Martina said.

Above all, she added, it has to be underlined that schizophrenics should not be feared and are important members of society.

Labels: health

Posted by hera at 12:46 AM | Permalinks | Comments

Remote Timika fights AIDS in its own way

Sunday, September 10, 2000

TIMIKA, Irian Jaya (JP): Behind Timika Community Health Center, there is a small house measuring five square meters.
A billboard outside says "Reproduction Clinic, Timika Community Health Center" and beneath it are posters about the dangers of HIV and AIDS.
Inside, there are two counseling rooms with beds and medical equipment. Brochures, condoms and a wooden penis are strewn about the front desk.
"We've been running this clinic for three years now," said Nurlan Silitonga, who, with four staff, is in charge in the clinic, five laboratory technicians and two field staff.
Nurlan's appearance is not one of a typical doctor. Tall and slim, her straight hair falls to her waist. She wore a bright red blouse and miniskirt, complete with red lipstick and high heels.
She said she was afraid of reporters.
"I'm afraid they will twist the facts. HIV and AIDS are very sensitive matters, especially here in Irian Jaya," she said.
This easternmost province has the highest number of HIV and AIDS cases inIndonesia.
The Ministry of Health recorded from 1996 to July this year, 393 cases ofHIV and AIDS in Irian Jaya, 19 more than Jakarta.
Irian Jaya, which has an area of 421,981 square kilometers, is three times larger than Java, and has a population of only 2,098,310, or almost aquarter of Jakarta's population.
Eighty-five percent of the people there live in rural areas which are difficult to reach.
Similar to general opinions about HIV and AIDS, many Irianese still thinkthe condition is related to sexual behavior.
"Many also think it's a curse, or worse: they think some people deliberately spread the (HIV) virus to cleanse the Irian people," Nurlan said.
An hours' flight from the capital of Jayapura, Timika is ranked third in the incidence of HIV and AIDS after Merauke and Fakfak, according to the Ministry of Health's provincial office.
Up to July this year, there have been 43 cases of HIV and four AIDS casesin Timika, which has an area of 19,592 square kilometers and a population of over 100,000.
Timika is a stopover for employees of giant mining company PT Freeport Indonesia, located in the mountainous Tembagapura, some 70 kilometers from here.
It is a developed town, providing visitors with a shopping mall, five-star hotel and an international airport. All of which are similar to those in Jakarta, or even better.
"Every weekend, there are buses full of Freeport employees who came down here from Tembagapura. The residents here call the bus bis kerinduan (longing bus)," Nurlan said.
Some employees visit their families, but some just have a good time in bars and the red-light district.
"These people are at a high risk of being infected with HIV," Nurlan said.
That's why Nurlan, in cooperation with the local administration and non-governmental organizations here, conducts a safety program to give information to Freeport employees and people in Timika.
The clinic provides brochures and comic books which illustrate the dangerof HIV/AIDS, and also gives out free condoms -- 16,500 so far.
Nurlan and her staff have also trained some 150 residents, including midwives, to inform the community.
"We haven't surveyed the program's effectiveness. But there are more people coming to our clinic for checkups or simply to ask for condoms. There has also been about a 16 percent decline in the number of people withsexually transmitted diseases in the past three years. We take that as a good indication," she added.
In the past three years, the clinic has been visited by about 19,000 people, with an average 600-700 visitors a month, ranging from prostitutes to employees and housewives.
"We also conduct AIDS awareness activities every year," Nurlan said.
What makes her worry is the high demand from local residents to close thered-light district and bars.
"It will be hard for us to control the prostitutes as they will work on the streets," she said, adding that most of the prostitutes come from otherislands, such as Java and Sulawesi.
The ministry's Director General of Communicable Disease Control and Environmental Health Umar Fahmi Achmadi also expressed his concern.
"These areas help control the condition. Prostitution is a matter of people's behavior. How can we control people's behavior? It's a very personal thing," Umar said.
An official of the local Ministry of Health office, Didik Irawan, said itwas unlikely that HIV and AIDS patients in Irian Jaya would survive more than a year, like in other provinces.
"The combination of poor health conditions and bad nutrition makes way for opportunist diseases that lead to AIDS and a quick death," he said.
-- Hera Diani

Labels: health, HIV/AIDS

Posted by hera at 3:39 AM | Permalinks | Comments