TB Program Dropout Rates
Sometimes you start things but you have no idea where they will go. That is what happened when we hired Ibu Hamisah to be one of our village health workers six years ago. She was a shy woman from a village about half an hour away from our clinic who had very little self confidence. Six years later, you won’t believe what has happened to her!
We were trying something very unusual in 2008. We wanted to hire women in the villages to help our tuberculosis patients take their medicines. This was critical because when we started treating tuberculosis about 50% of our patients dropped out of treatment. That meant they had a high chance of developing drug resistance and not only dying of TB but also spreading the resistant tuberculosis to others. What was unusual was that we were so strict about the rules of working for us. We fired our village health workers if they missed even one visit to their patients. So in the first few years we went through a lot of women, but then it settled down and we ended up with an amazing group of incredibly dedicated ladies who took great care of their patients.
We also gave them the book “Where there is no Doctor” in Indonesian and we conducted health training sessions every month in lots of different critical health topics — like how to treat diarrhea in the villages with oral rehydration solution, or how to know when a child probably had pneumonia.
After two years of Hamisah working for us, we were so impressed that we asked her to interview for the position of coordinator of the program. I still remember in that interview how much she lacked confidence and finally at the end she told us, “I just can’t do this. I would be afraid to talk to the department of health and other government officials, and I have never used a computer. I only have a middle school education. You will just have to find someone else.”
I was sad, because I thought she would be good, but we did end up hiring Ibu Lia who had a college degree. The TB control program continued to be a roaring success and every year the drop-out rate decreased until last year it was just 0.6% (in 2009 we stopped treating anyone with infectious lung TB without a DOTS worker, and in 2010 we stopped treating anyone without a DOTS worker).
Hamisah told me about how she managed to keep her most difficult patient from stopping his medicines. After cajoling and explaining the importance for months he finally just refused to take another pill. “I feel all better, I’m sick of taking these medicines! I’ve stopped coughing and gained weight. Stop coming here!” He said as he slammed the door in her face. Undeterred she came back the next day with a pair of ducks as a gift to him. Seeing the ducks, he calmed down and agreed to take his course of treatment. She says that now every time she sees him he warmly greets her and proudly tells her how healthy he is and how many ducks he now has from that original pair.
Then, you won’t believe what happened. Hamisah’s village nominated her to be the head of the village. She tells me that this is because the village saw how much she cared for them all. People often came to her even in the middle of the night when they or their children were sick, and using her book she would care for them. Then if they weren’t better in the morning, she would bring them to the clinic for further care. What you have to realize is that her being nominated to be village chief was wildly unusual. At that time, there was not a single other female chief of a village.
She says she didn’t campaign and didn’t even want it, but out of over 140 households in her village more than 130 voted for her. She said someone else even put up her picture at the ballot box. And now, after two years, they all want her to become the head of a group of four villages, and people are even talking about her running for the position of head of the regency!
The reason everyone is so excited about her is all the innovative things she is doing in her village. She leads a group of 52 women farmers who are all learning organic methods (even without training from our team yet) and she got the government to give them two hand tractors. They have a meeting once a week and Hamisah also passes on to them everything she learns about health and conservation at ASRI. Hamisah also made a rule that there would be no logging in her village, and she has managed to get the last loggers to stop. “I think these men listen to me because I’m a woman,” she told me.
Last year, we approached Hamisah again to ask if she would again consider the position of coordinator of our community health workers, because we wanted to promote Lia. This time she said yes! She has learned to use a computer and is so proficient at negotiating with the local government, she has gotten all six of the local government clinics to use OUR community health workers to help treat their patients with tuberculosis. She does a full day of work with us and then still takes great care of her village in the evenings and weekends. In the graph below you can see how TB rates are dropping in all the villages except in Siponti and Teluk Batang where we recently started working with the government clinics.
Is it any wonder, Ibu Hamisah’s village is so grateful to her? And we should all be grateful, because preventing drug-resistant tuberculosis is not just a benefit to the communities here, it is a benefit to the whole world because disease, like environmental disasters, don’t follow national boundaries.
Ibu Hamisah and one of her patients
New TB Cases by Village