Modern fight of ancient scourge

HANOI, VIETNAM – Dr. Bui Xuan Hiep, head of tuberculosis control in this city's Hoang Mai district, paged proudly through a large handwritten patient log. "This district's cure rate averages 90 percent," he said. Still, Bui could see problems.

Seven patients had turned up with multidrug-resistant tuberculosis; four had been cured, two had died — and one had simply disappeared.

It's a story repeated throughout Vietnam. The nation was once racked by a tuberculosis epidemic, but the country now boasts a 90 percent cure rate for uncomplicated cases and cures 75 percent of its drug-resistant cases, easily beating the global average, 50 percent.

Public health officials worldwide have made remarkable progress against tuberculosis, but Ban Ki-moon, U.N. secretary-general, warned that an estimated that 1.5 million worldwide would die of the disease this year.

There is no better example of how fragile this success may be than Vietnam. Hospital wards are packed dangerously full, raising the risk that drug-resistant strains will spread.

The easy-to-reach patients have been treated, and many of the rest are the hardest to help: heroin-addicted couriers and laborers from the Golden Triangle, and mountain villagers who are barely connected to the health care system. But the biggest threat is that the money is close to running out.

"Our TB program is cost-effective and has great impact," said Dr. Nguyen Viet Nhung, its national director. "But I always emphasize that this is a preliminary success. We need to sustain it."

To reach Vietnam's ambitious goal of pushing prevalence rates down to 20 cases per 100,000 residents — essentially eliminating tuberculosis as a public health problem — its program needs to spend at least $66 million a year. It now spends about $26 million a year.

About $19 million of that comes from foreign donors, with more than a third from the United States, Nguyen said.

After years in the shadow of the AIDS epidemic, tuberculosis is regaining its notoriety as one of the world's great killers: an airborne bacterium that spreads easily among people living crowded together — in jails, ships, mines, trenches or slums — and insinuates itself deep in the lungs and grows, slowly tearing apart the tissue until victims are coughing up blood.

Tuberculosis now kills more people around the world than AIDS, said the WHO: 4,100 a day, compared with 3,300 dying of AIDS, making tuberculosis the leading infectious cause of death in the world.

Mortality from both diseases is dropping, but tuberculosis deaths have fallen more slowly, especially in Asia.

Vietnam's success where so many other nations have failed is not just because of donor money, said Dr. Mario C. Raviglione, director of the WHO's global tuberculosis program.

"It succeeds because it's a Communist country," he said. "Socialist countries put a lot of resources into primary care. … And once central government adopts a thing, they really do it. They give orders."

Tuberculosis is an ideal disease for a regimented treatment approach. Almost all patients with tuberculosis that is not drug-resistant can be cured if they take a standard menu of four antibiotics every day for six months without fail.

In Vietnam, treatment standards set at the national level are followed by the entire public health network. The National Lung Disease Hospital in Hanoi oversees 64 provincial hospitals, which oversee 845 district hospitals, which oversee 11,065 neighborhood health clinics. Neighborhood clinics are as ubiquitous here as police stations and firehouses in the United States.

They treat many illnesses, but their role in tuberculosis is simple: Every tuberculosis patient in the district reports once a day to take his or her pills in front of a nurse. Each dose taken is checked off.

In New York City's outbreak of drug-resistant tuberculosis in the 1990s, officials legally locked up patients who refused to take their pills.

Patients with drug-resistant disease are especially hard to help. Their medicines, some of which are intravenous, must be taken for two years, and can cause deafness, psychosis and kidney failure. Patients must be hospitalized, their movements restricted. If they become worse, the prognosis is usually grim. Extensively drug-resistant disease, or XDR TB, requires even more toxic drugs costing 25 times as much. Most XDR TB patients here die.

In the Hanoi Lung Disease Hospital, Hoang Van Toan, a farmer looking older than his 49 years, sat wrapped in a blanket. He had taken all his pills, he said, but tuberculosis had somehow outwitted them. What made him saddest, he said, is that his grandchildren cannot visit.

Asked if he would make it through the next two years, he said "Yes. I was a soldier. I fought the enemy. I can fight this."