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Cablegate: The Challenges of Combating Tb in Burma

VZCZCXRO2447
RR RUEHCHI RUEHDT RUEHHM RUEHLN RUEHMA RUEHNH RUEHPB RUEHPOD
DE RUEHGO #0278/01 1131020
ZNR UUUUU ZZH
R 221020Z APR 08
FM AMEMBASSY RANGOON
TO RUEHC/SECSTATE WASHDC 7411
RUCNASE/ASEAN MEMBER COLLECTIVE
RUEHZN/ENVIRONMENT SCIENCE AND TECHNOLOGY COLLECTIVE
RUEHBJ/AMEMBASSY BEIJING 1813
RUEHBY/AMEMBASSY CANBERRA 1064
RUEHKA/AMEMBASSY DHAKA 4822
RUEHLO/AMEMBASSY LONDON 2011
RUEHNE/AMEMBASSY NEW DELHI 4612
RUEHUL/AMEMBASSY SEOUL 8152
RUEHTC/AMEMBASSY THE HAGUE 0665
RUEHKO/AMEMBASSY TOKYO 5713
RUEHRO/AMEMBASSY ROME 0149
RUEHFR/AMEMBASSY PARIS 0568
RUEHCN/AMCONSUL CHENGDU 1416
RUEHCHI/AMCONSUL CHIANG MAI 1506
RUEHCI/AMCONSUL KOLKATA 0274
RUEAUSA/DEPT OF HHS WASHDC
RHHMUNA/CDR USPACOM HONOLULU HI
RUEHPH/CDC ATLANTA GA
RUCLRFA/USDA WASHDC
RUEHRC/USDA FAS WASHDC
RHEHNSC/NSC WASHDC
RUCNDT/USMISSION USUN NEW YORK 1467
RUEKJCS/SECDEF WASHDC
RUEHBS/USEU BRUSSELS
RUEKJCS/JOINT STAFF WASHDC

UNCLAS SECTION 01 OF 04 RANGOON 000278

SENSITIVE
SIPDIS

DEPT FOR EAP/EX; EAP/MLS; EAP/EP; EAP/PD
DEPT FOR OES/STC/MGOLDBERG AND PBATES; OES/PCI/ASTEWART;
OES/IHA/DSINGER AND NCOMELLA
DEPT PASS TO USAID/ANE/CLEMENTS AND GH/CARROLL
CDC ATLANTA FOR COGH SDOWELL and NCID/IB AMOEN
USDA FOR OSEC AND APHIS
USDA FOR FAS/DLP/HWETZEL AND FAS/ICD/LAIDIG
USDA/FAS FOR FAA/YOUNG, MOLSTAD, ICD/PETTRIE, ROSENBLUM
DOD FOR OSD/ISA/AP FOR LEW STERN
PARIS FOR FAS/AG MINISTER COUNSELOR/OIE
ROME FOR FAO
BANGKOK FOR REO OFFICE, USAID/RDMA HEALTH OFFICE - JMACARTHUR,
CBOWES
TOKYO FOR HEALTH OFFICER
PACOM FOR FPA

E.O. 12958:N/A
TAGS: ECON TBIO EAID SOCI PGOV AMED BM
SUBJECT: THE CHALLENGES OF COMBATING TB IN BURMA

REF: A) 07 RANGOON 1027 B) 07 RANGOON 1120 C) 07 RANGOON 588

RANGOON 00000278 001.22 OF 004


1. (SBU) Summary. Tuberculosis is a growing health concern in
Burma, with more than 130,000 new cases of TB diagnosed a year. The
WHO estimates that more than 40 percent of Burma's population could
be infected with the disease. The Burmese Government, through its
National TB Program (NTP) is working hard to meet the current TB
burden, but falls short. Health experts warn that any increase in
the TB incidence rate, particularly of multi-drug resistant TB
(MDR-TB) and TB/HIV co-infection, will overburden an already
overstretched and underfunded NTP. During a two-week assessment of
Burma's TB program, we observed several weaknesses -- including
securing first-line TB drugs past 2009, strengthening the NTP,
enhancing surveillance, implementing infection control measures,
improving national laboratory capacity for culture and drug
sensitivity testing, and expanding education and outreach efforts --
before the NTP can successfully prevent and treat TB. End Summary.


Conducting a TB Assessment
--------------------------

2. (SBU) The World Health Organization (WHO) considers Burma to be
one of 22 tuberculosis high-burden countries in the world. While
the true prevalence of TB in the country is unknown, the Ministry of
Health reported that the National Tuberculosis Program (NTP)
diagnosed more than 130,000 new TB cases in 2007 (Ref A); however, a
recent prevalence survey in Rangoon estimates the numbers to be
three times higher. The WHO estimates that 40 percent of Burma's
population may have TB, although NGOs working in the health sector
argue that the incidence rate is much higher, around 60 percent.
Burma's high TB rates have implications for the region; there have
been several instances in the past year of Burmese migrants with
MDR-TB traveling to neighboring countries to find work (Ref B).
USAID Health Officer John MacArthur traveled to Burma March 30-April
10 to conduct a gap analysis of Burma's TB program. During meetings
with officials from the Ministry of Health, NTP, WHO, and NGOs, as
well as site visits to public and private medical clinics, we
observed that while the NTP and private sector are working hard to
meet the current TB burden, they have fallen short. Several
weaknesses must be addressed before the NTP can successfully prevent
and treat TB.

Mind the Gaps
-------------

3. (SBU) Dr. Frank Smithious, Country Director of MSF-Holland
(which runs 24 full-service medical clinics in Burma), told us that
one of Burma's greatest challenges is raising awareness about the

RANGOON 00000278 002.12 OF 004


dangers of TB. Most TB cases in Burma go undetected, as the Burmese
tend to not seek medical treatment for mild symptoms. Only when TB
symptoms become worse do people seek treatment, even though TB
treatment in both the NTP and private sector clinics is free. More
education and outreach about the disease is needed, he stressed.
The NTP spends only 7 percent of its $400,000 annual budget on
outreach and instead relies on NGOs to conduct education awareness.
Until 2008, Population Services International (PSI), an
international NGO that treats approximately 10 percent of Burma's TB
patients annually, conducted the majority of TB awareness campaigns
throughout the country. However, because PSI's TB funding under the
3 Diseases Fund ended on March 31, 2008 (Ref C), PSI was forced to
halt its awareness programs and reprogram resources to cover its TB
patients, PSI Country Director John Hetherington explained. Without
funding for its programs, PSI will suspend its communications
program, creating a large gap in TB education. Awareness programs
have been shown to reduce the number of TB cases, Smithious
emphasized. Cutting TB education programs will only exacerbate the
current situation.

4. (SBU) During visits to medical clinics and the Aung San TB
Hospital in Rangoon, we observed how the country needed to improve
its infection control measures. Most clinics in Burma, including
the NTP clinics and PSI's Sun Clinic network, are small one or two
room offices where patients come for diagnosis and treatment.
Patients, regardless of their symptoms, wait with others in small,
often unventilated, rooms before seeing a doctor. During one visit
to a clinic, we saw a patient with MDR-TB waiting with several
HIV/AIDS patients - there was no concern about whether the TB
patient would infect the other patients or even the doctor. During
a separate visit to the Aung San Hospital, we met an MDR-TB patient
who had contracted the disease from her late husband; he had worked
in the TB hospital only to contract and die from the disease. Dr.
Pino, Director of the Aung San TB Hospital, admitted that due to
poor infection control, several of his staff have contracted and
died from TB during the past several years. The TB hospitals, NTP,
and most of the private clinics all lacked basic infection controls,
including the use of N95 masks and the ability to separate patients
by disease. Without good infection control practices, the rate of
TB infection is likely to increase, WHO TB Officer Dr. Hans Kluge
told us.

5. (SBU) Burma has two national reference TB labs in Rangoon and
Mandalay, which provide culture and sputum tests for the NTP and
private clinics throughout the country. During our tour of the
Rangoon laboratory, we noticed that the laboratory was well-equipped
with up-to-date technology, a donation from the International Union
Against TB and Lung Disease (IUATLD) in 2003. The Rangoon
laboratory does need some technological upgrades, such as a new

RANGOON 00000278 003.12 OF 004


centrifuge or generator, Reference Laboratory Director Dr. Ti Ti
told us. However, strengthening the laboratory through improved
capacity building training is a more urgent need, she emphasized.
Officials from the WHO, PSI, and MSF-Holland all noted with some
concern that Dr. Ti Ti, who ensures quality control at the lab, will
retire in late 2008. While she is currently training her successor,
the WHO and NGOs argue that as the laboratory increases its case
detection, it will need to hire additional qualified staff to handle
the work load. Improving the National Reference Laboratory's staff
capacity will benefit not just the Ministry of Health and the NTP,
but every private clinic that uses the lab, Hetherington
underscored.

6. (SBU) Dr. Kluge confirmed that while the NTP has been successful
at detecting and treating new cases of TB, there remains room for
improvement. The NTP, which is active in all 324 townships, has
increased the number of staff to 1028, but approximately 24 percent
of positions are vacant due to budgetary limitations. The Ministry
of Health has increased its TB budget by more than 2,500 percent
since 1995, from $14,500 to $400,000 in FY2008. However, this
amount, coupled by substantial contributions by international
donors, does not cover the amount needed to run a successful TB
program.

--------------------------------------------- -------
Burma's TB Budget (FY06-FY08*)
In US Dollars
--------------------------------------------- -------
Available Funding FY06 FY07 FY08
------------------------- ---------------------------
Burmese Govt 421,111 421,111 421,111
GDF 3,587,277 4,186,700 --
JICA 93,000 93,000 93,000
WHO 239,200 239,200 239,200
IUATLD 200,000 200,000 200,000
3D Fund 4,000,000 4,000,000 4,000,000
--------------------------------------------- --------
Total Funding 8,540,588 9,140,011 4,953,311
--------------------------------------------- --------
Amount Required 13,467,871 18,809,752 18,477,025
Funding Gap 4,927,283 9,669,741 13,523,714
--------------------------------------------- --------
Source: WHO, 2008
*Burma's Fiscal Year runs from April 1-March 31.

7. (SBU) However, during the course of our meetings, we learned
that the greatest challenge to Burma's TB program is the
unavailability of first-line TB drugs after 2009. Burma currently
receives TB drugs for 150,000 patients annually, worth $4 million,

RANGOON 00000278 004.10 OF 004


through a grant from the Global Drug Facility (GDF). GDF's
commitment to Burma will end in 2009 and there are currently few
options for drug procurement (More details to be provided septel.)
Without first-line drugs, which both the public and private clinics
provide to TB patients free of charge, TB patients would be forced
to either purchase inferior quality drugs on the local market or
forgo treatment due to the expense. (Note: First-line TB drugs cost
approximately $20 per patient while second-line drugs for MDR-TB
costs up to $3000 per person. End Note.) Thus, the first priority
should be to secure first-line drugs after 2009, as they are
necessary to prevent the spread of TB. The GOB is considering
applying for a Round 9 grant from the Global Fund, which would start
in 2011. However, even if it receives a commitment from the Global
Fund, there will still be a two-year gap for TB drugs, Kluge
emphasized.

Comment
-------

8. (SBU) The NTP has had some success at combating TB with its
limited resources, but continues to rely heavily on foreign-funded
NGOs to fill the gaps in the National Program's outreach activities
and health services. This funding and service gap prevents Burma
from successfully managing its ever-growing TB problem. Outbreaks
of TB, including MDR-TB, are a growing regional health risk.
Failure to properly address Burma's TB epidemic could lead to a
regional epidemic, as more Burmese migrate abroad looking for work
or leave to flee abuses. Embassy Rangoon recognizes the politically
charged debate surrounding humanitarian assistance to Burma,
including in the health sector. Through the 3D Fund, the Europeans
are assisting the Burmese to address in part the TB epidemic. We
note that ASSK's NLD party approved the 3D Fund's activities in
Burma. Sick and dying people are in no condition to fight for
democracy in Burma. The U.S. should consider increasing our
humanitarian assistance to address the growing regional threat of
Burma's TB epidemic and assisting those Burmese most in need. By
taking this opportunity to help the WHO, NGOs, and NTP combat and
prevent TB outbreaks in Burma, we can halt the spread of infection
and increasing drug resistance from Burma to the region and
ultimately to the wider world, including the United States.

VILLAROSA

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