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      Reconstructing Tuberculosis Services after Major Conflict: Experiences and Lessons Learned in East Timor

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          Abstract

          Background

          Tuberculosis (TB) is a major public health problem in developing countries. Following the disruption to health services in East Timor due to violent political conflict in 1999, the National Tuberculosis Control Program was established, with a local non-government organisation as the lead agency. Within a few months, the TB program was operational in all districts.

          Methods and Findings

          Using the East Timor TB program as a case study, we have examined the enabling factors for the implementation of this type of communicable disease control program in a post-conflict setting. Stakeholder analysis was undertaken, and semi-structured interviews were conducted in 2003 with 24 key local and international stakeholders. Coordination, cooperation, and collaboration were identified as major contributors to the success of the TB program. The existing local structure and experience of the local non-government organisation, the commitment among local personnel and international advisors to establishing an effective program, and the willingness of international advisers and local counterparts to be flexible in their approach were also important factors. This success was achieved despite major impediments, including mass population displacement, lack of infrastructure, and the competing interests of organisations working in the health sector.

          Conclusions

          Five years after the conflict, the TB program continues to operate in all districts with high notification rates, although the lack of a feeling of ownership by government health workers remains a challenge. Lessons learned in East Timor may be applicable to other post-conflict settings where TB is highly prevalent, and may have relevance to other disease control programs.

          Abstract

          A qualitative study of re-introduction of tuberculosis services in East Timor in 1999, after a period of civil conflict, concluded coordination, cooperation, and collaboration contributed to the success achieved.

          Editors' Summary

          Background.

          Tuberculosis is an infectious disease and one of the world's most serious health problems. It causes between 2 million and 3 million deaths every year, most of them in developing countries. The success of national control programs has varied considerably between countries. In times of war or other emergencies, control efforts are considerably hampered. East Timor is a former Portuguese colony in Southeast Asia annexed by Indonesia in 1975. It is a small country of about 1 million people situated some 500 miles northwest of Australia. In 1999, following a referendum on independence from Indonesia, violent civil conflict led to the destruction of much of East Timor's health-care system. As tuberculosis was known to be one of the country's biggest health problems, efforts to improve treatment were launched during the transition to independence in 2002. Several organizations, led by a local non-government organization (NGO), Caritas East Timor, collaborated in the new program. Many difficulties had to be overcome, including the forced movement of people away from their homes during the fighting, the departure of many health-care workers from the country, and the destruction of health-care facilities. Nevertheless, in its first three years the program diagnosed and commenced treatment on 10,722 patients. The rate of treatment success reached 81% in 2003, which—in international terms—is regarded as very high.

          Why Was This Study Done?

          The researchers wanted to find out from the people involved with the program how well they thought it was performing, what its strengths were, and what remained to be achieved. The lessons learned could be of use in other countries, particularly those recovering from civil conflict and other emergencies.

          What Did the Researchers Do and Find?

          In 2003, the researchers reviewed all available documents that had been written about the tuberculosis program. They also carried out interviews with 24 senior people involved with the program. Some of them were East Timorese, and some were from international organizations. The questions asked in the interviews were semi-structured. In other words, the researchers wanted to make sure that certain topics were covered but also wanted the people they questioned to have freedom in the way they gave their answers; they were not restricted to answering only “yes” or “no.” This kind of approach, where there is no gathering of precise figures that can be mathematically analyzed, is known as qualitative research.

          The national tuberculosis program was considered to be working well in 2003. The researchers concluded that good coordination, cooperation, and collaboration were the most important factors contributing to the successes that had been achieved. The existing local structure and experience of the local NGO, the commitment among local personnel and international advisors to establishing an effective program, and the willingness of international advisers and local counterparts to be flexible in their approach were also important factors. The feeling among some government health workers that they lacked “ownership” of the program was one problem that still needed to be overcome.

          What Do These Findings Mean?

          Even after a major conflict, it was possible to launch an effective tuberculosis program in East Timor. Other countries in similar situations might be able to achieve success by applying the same approach. Unfortunately, renewed conflict broke out in East Timor in 2006. It will again be necessary to restore services, putting to use the lessons already learned.

          Additional Information.

          Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030383.

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          Most cited references33

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          The public health aspects of complex emergencies and refugee situations.

          Populations affected by armed conflict have experienced severe public health consequences mediated by population displacement, food scarcity, and the collapse of basic health services, giving rise to the term complex humanitarian emergencies. These public health effects have been most severe in underdeveloped countries in Africa, Asia, and Latin America. Refugees and internally displaced persons have experienced high mortality rates during the period immediately following their migration. In Africa, crude mortality rates have been as high as 80 times baseline rates. The most common causes of death have been diarrheal diseases, measles, acute respiratory infections, and malaria. High prevalences of acute malnutrition have contributed to high case fatality rates. In conflict-affected European countries, such as the former Yugoslavia, Georgia, Azerbaijan, and Chechnya, war-related injuries have been the most common cause of death among civilian populations; however, increased incidence of communicable diseases, neonatal health problems, and nutritional deficiencies (especially among the elderly) have been documented. The most effective measures to prevent mortality and morbidity in complex emergencies include protection from violence; the provision of adequate food rations, clean water and sanitation; diarrheal disease control; measles immunization; maternal and child health care, including the case management of common endemic communicable diseases; and selective feeding programs, when indicated.
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            Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level.

            A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.
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              Refugees and displaced persons. War, hunger, and public health.

              The number of refugees and internally displaced persons in need of protection and assistance has increased from 30 million in 1990 to more than 43 million today. War and civil strife have been largely responsible for this epidemic of mass migration that has affected almost every region of the world, including Europe. Since 1990, crude death rates (CDRs) during the early influx of refugees who crossed international borders have been somewhat lower than CDRs reported earlier among Cambodian and Ethiopian refugees. Nevertheless, CDRs among refugees arriving in Ethiopia, Kenya, Nepal, Malawi, and Zimbabwe since 1990 ranged from five to 12 times the baseline CDRs in the countries of origin. Among internally displaced populations in northern Iraq, Somalia, and Sudan, CDRs were extremely high, ranging from 12 to 25 times the baseline CDRs for the nondisplaced. Among both refugees and internally displaced persons, death rates among children less than 5 years of age were far higher than among older children and adults. In Bangladesh, the death rate in female Rohingya refugees was several times higher than in males. Preventable conditions such as diarrheal disease, measles, and acute respiratory infections, exacerbated often by malnutrition, caused most deaths. Although relief programs for refugees have improved since 1990, the situation among the internally displaced may have worsened. The international community should intervene earlier in the evolution of complex disasters involving civil war, human rights abuses, food shortages, and mass displacement. Relief programs need to be based on sound health and nutrition information and should focus on the provision of adequate shelter, food, water, sanitation, and public health programs that prevent mortality from diarrhea, measles, and other communicable diseases, especially among young children and women.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS Med
                pmed
                PLoS Medicine
                Public Library of Science (San Francisco, USA )
                1549-1277
                1549-1676
                October 2006
                22 August 2006
                : 3
                : 10
                : e383
                Affiliations
                [1 ]Menzies School of Health Research, Darwin, Northern Territory, Australia
                [2 ]Institute of Advanced Studies, Charles Darwin University, Darwin, Northern Territory, Australia
                [3 ]National Centre for Epidemiology and Population Health, College of Medicine and Health Sciences, Australian National University, Canberra, Australian Capital Territory, Australia
                [4 ]School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
                The University of Queensland, Australia
                Author notes
                * To whom correspondence should be addressed. E-mail: paul.kelly@ 123456anu.edu.au
                Article
                05-PLME-RA-0542R3 plme-03-10-01
                10.1371/journal.pmed.0030383
                1550733
                16933956
                3af40c83-0857-45e0-94d3-506c4c076a69
                Copyright: © 2006 Martins et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                : 6 October 2005
                : 10 July 2006
                Page count
                Pages: 11
                Categories
                Research Article
                Infectious Diseases
                Other
                Epidemiology/Public Health
                Health Policy
                Medicine in Developing Countries
                Infectious Diseases
                Public Health
                Epidemiology
                Health Policy
                Custom metadata
                Martins N, Kelly PM, Grace JA, Zwi AB (2006) Reconstructing tuberculosis services after major conflict: Experiences and lessons learned in East Timor. PLoS Med 3(10): e383. DOI: 10.1371/journal.pmed.0030383
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