Condition Critical

As a global killer starts to make its presence felt in the north of the country, debate continues over where our first line of defence should be.

Story: Alex Doudy

The tuberculosis (TB) epidemic sweeping much of the globe has long left Australia untouched. But as our closest neighbours in Papua New Guinea struggle to cope with an outbreak of the disease, Australia’s approach to TB prevention is under the spotlight.

And with a young Papua New Guinean woman the first person in Australia to be killed by a rare, drug-resistant TB strain in March, scrutiny over the handling of the health crisis is intensifying.

Twenty year old Catherina Abraham died of ‘Extensively Drug-Resistant TB’ (or XDR-TB) at Cairns Base Hospital, where she arrived in May last year from Daru Island in PNG’s impoverished Western Province. She was pushed to make the lengthy, illegal journey after her friend died from the same disease. Federal MP Warren Entsch (Leichhardt, Qld) says Ms Abraham’s death is a tragic symbol of a problem needing urgent government attention.

“Papua New Guinean nationals, particularly those from the Western Province area, who have tuberculosis have been coming across the border seeking support and treatment in Queensland,” Mr Entsch says.

“If current policy continues unchanged, the health and safety of Torres Strait Islanders and other Australians will be in jeopardy, as evidenced by the recent arrival at Cairns Base Hospital of the first case of multi drug-resistant tuberculosis.”

Mr Entsch’s concerns were formally recognised in federal parliament in February when his private member’s motion calling for government action on the issue passed unopposed through the House of Representatives. He has been lobbying for a review of Australian TB aid arrangements since the government announced changes to disease management programs along the remote Australia-PNG border last year.

Of key contention is the government’s decision to close two TB health clinics in the Torres Strait Islands in favour of a new, AusAID-led program delivered across the border at PNG’s Daru Island Hospital. The Torres Strait clinics, which had been jointly funded by Queensland Health and the federal government for over a decade, were closed in June last year after the Queensland government withdrew its share of the funding.

The move sparked public outrage as 90 sick Papua New Guineans were returned home mid-treatment. Mr Entsch says the replacement AusAID program is failing to deliver the results promised by the government. He claims money channeled through AusAID to PNG is not reaching patients on the ground, and cites Ms Abraham’s case as an example of its failings.

“When her girlfriend died, she left and went to Port Moresby where she got a friend to sponsor her airfare and tourist visa to Australia,” Mr Entsch says.

“She jumped on an airplane out of desperation, flew into the Cairns international airport and was driven to Cairns Base Hospital where she knocked on the door and presented herself.

“Why would she, after already losing a friend, embark on a journey like that when she could just walk across the road to a facility that would save her life?

“Those months between when she got out of Daru and got to Australia could have been critical in saving her life. And yet the government says everything is fine,” he says.

Mr Entsch’s claims are strongly rebutted by federal MP Steve Georganas (Hindmarsh, SA), who travelled to PNG in March 2010 while serving as chair of the House of Representatives Health and Ageing Committee. Mr Georganas defends the AusAID program, which is based on the World Health Organisation’s established global standards for effective management of TB and multi drug-resistant TB (MDR-TB).

Among services already delivered by the program are a custom built ‘sea ambulance’, new infrastructure at Daru Hospital and funding for World Vision to deliver its ‘Stop TB in Western Province’ program, which supports TB specialist staff and trains and manages a network of local health workers.

“AusAID’s work is endorsed by public health experts, including the Commonwealth Chief Medical Officer and WHO,” Mr Georganas says.

“Let us be crystal clear: AusAID’s efforts in support of PNG’s approach to the effective management of TB in the Western Province are working.

“Advice is that TB mortality rates in the Western Province have fallen by 80 per cent in just one year and fewer Torres Strait people have TB.”

Queensland Chief Health Officer Dr Jeannette Young agrees, and claims re-opening the TB clinics in the Torres Strait would in fact increase the risk of cross-border infection for the Torres Strait.

 “A locally controlled program, as endorsed by the World Health Organisation, is the most effective method of combating TB in PNG,” Dr Young says.

“When PNG patients were previously receiving TB treatment through the Boigu and Saibai Island clinics, Queensland clinicians had no control or oversight over whether or not those patients continued to take their treatment once they returned to PNG.

“If that doesn’t occur and any drug treatment is interrupted, we know that there is a real risk that drug resistance can emerge. And, indeed, extremely drug-resistant TB can emerge.”

Approaches to TB management across the isolated Australia-PNG border have been examined recently as part of an inquiry into health issues across international borders by the House of Representatives Health and Ageing Committee. Director of Thoracic Medicine at Cairns Base Hospital Dr Stephen Vincent told the inquiry the closure of the clinics is having an impact.

“I guess we shot ourselves in the foot by having a good clinic up and running,” Dr Vincent said.

 “The people in PNG knew that, if they were sick with a TB type illness, coming to the Saibai chest clinics would be valuable, because 85 per cent of them were cured, 85 per cent of them survived, as opposed to one person dying every two hours in PNG.

“The worry now is that these people will present quite unwell and infect others and our TB clinics have no presence on Saibai or Boigu whatsoever, as opposed to the situation where every two weeks we had clinics up there.”

Mr Entsch is also worried about the fate of PNG patients after they were turned away from the former clinics on Saibai and Boigu.

“Now I’ve got the names of the 91 people that were turned away and referred to Daru, and I want the names of the people that they’ve treated at Daru and the success rate,” he says.

“I’ll put money on it that only a small portion of those 91 actually got there. The rest are either dying or dead because they’ve got nowhere else to go.”

Speaking at the committee inquiry, medical director at the Western Australian Tuberculosis Control Program, Dr Justin Waring also voiced concerns about the gap in time between the closure of the clinics and full operational effectiveness of the TB management program in PNG.

“The people are going to keep coming and, even if the activity in Western Province were to become successful, with their TB program becoming much more effective, it would take at least 20 to 30 years to get there,” Dr Waring said.

“In the meantime, you face the prospect of having the people not only coming legitimately across the border – they might be coming for the wrong reasons but they do have the right to cross the border – but coming with drug-resistant TB, which is much worse.”

In its report released in March, the committee notes the difficulties of managing one of the world’s most unique international borders.

“The porous nature of the border between PNG and the Torres Strait, having regard to the frequency of traditional movements, poses a unique challenge for Commonwealth agencies responsible for preventing the spread of infectious disease,” the report states.

The current border arrangement is overseen by a complicated treaty system which governs movement across the few kilometres of ocean separating Australia’s northernmost  territory and PNG. Under the Torres Strait Treaty, the islands are divided into two distinct zones – the Torres Strait Special Quarantine Zone and the Torres Strait Protected Zone.

The Quarantine Zone includes the southern Torres Strait Islands closest to the Australian mainland, including Thursday Island and Horn Island, and requires all entrants to undergo biosecurity checks. But in the Protected Zone to the north, traditional inhabitants of PNG can travel freely across the border without a passport or visa to attend cultural activities such as weddings and funerals.

Travel for medical treatment is not permitted, meaning any PNG national seeking entry to Australia for medical reasons must satisfy Australian immigration laws by applying for a medical visa. But, as the committee heard, this rule is often broken.

“AusAID understands that while the Torres Strait Treaty does not allow free movement to Australia for the purpose of seeking health care, residents from PNG Treaty Villages in the Torres Strait have done exactly this for a number of years,” the committee report states.

“AusAID’s response has been to support PNG in providing access to high quality health care in PNG, so that  PNG nationals will not feel a need to travel to the Torres Strait for treatment.”

Despite these efforts, infectious disease expert Professor John McBride says Papua New Guineans are continuing to make the mercy dash to Australia for medical assistance.

“There is a common saying in Papua New Guinea: ‘if you’ve got a pain, you get a plane’ and come down for medical attention, particularly in Cairns but also in other centres further south,” Professor McBride says.

“People arrive unofficially on tourist visas. They can get down from Port Moresby to Cairns very quickly and be in hospital. That is not the route we recommend people take if they know they are sick.

“However, if people do the right thing up in New Guinea and apply for a medical visa, it is a very long and tortuous process, so we can understand why people might travel down this way.”

The influx of PNG residents with highly contagious and potentially drug-resistant TB is also causing anxiety about its transmission to the Torres Strait and mainland Australia. Dr Stephen Vincent says the number of PNG patients presenting at Queensland hospitals has increased rapidly in the past decade as Western Province grapples with a tuberculosis epidemic.

“The growth of the number of patients coming across from PNG – those being PNG nationals – has exponentially grown to where we have had about 250 cases of drug-resistant TB in the last 10 years,” Dr Vincent says.

“It is a concern because there is a high prevalence of drug-resistant TB in the Western Province – probably about 40 per cent, we predict – and this is not only mono resistance but multidrug resistance, which generally requires at least two years of treatment and five or six different drugs, at great expense.

“There are grave concerns that, if drug-resistant TB gets into the Torres Strait, it is easy for it to get into Australia because there is a lot of back and forward movement.

“We suspect that there is multidrug-resistant TB in the population of the Torres Strait which just has not declared itself yet – but we are looking.”

The committee report recommends the establishment of a new set of protocols and procedures for identifying and treating TB and other infectious diseases in PNG and the Torres Strait. It also calls for further consideration of what clinical services should be available in both Papua New Guinea and Australia for the identification and treatment of tuberculosis and other infectious diseases.

In the meantime Mr Entsch says he will continue to lobby for an overhaul of the current aid arrangement to help prevent more cases like Catherina’s. “

Why should she die and just be discarded and nobody know why she died? Why are these lives any less important than anyone else’s?” he asks.

“And they’re right on our doorstep. You can see the village from Australia.”

The House of Representatives Health and Ageing Committee’s report into health issues across international borders is available at: www.aph.gov.au/haa

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