Typhoid and Tuberculosis: Depressing Bugs, Creative Solutions

As promised in my recent post, Vini and Dewi: Midwives of the Forest, I'm going to delve into two wickedly successful microbes, the criminal minds behind typhoid and tuberculosis. This post is the third in a series about ASRI's planetary health midwives working for human and rainforest health in the heart of Borneo.

Part One: Wiggly-Tailed Bandits

The river from Mengkilao to Mawang Metatai.

This sungai, or river, flows from Bukit Baka Bukit Raya National Park past nine villages where the ASRI midwives work. The 2,000 residents of these communities rely on the river for drinking water, bathing, and washing clothes. The river is also where human and pig wastes drain.

An elevated pig sty above the river.

Two residents of Beloyang village prepare to slaughter a pig in preparation for a thousand-guest wedding.

The ASRI midwives, Dewi and Vini, noticed a pattern in their patients. Vini, at her clinic in Nusa Poring, had admitted only a couple patients in her first six months as a midwife. Dewi, at her clinic in Beloyang, had admitted a dozen critically-ill patients, tending to their diarrhea, fevers, and other life-threatening symptoms with round-the-clock care. She set up beds by putting mattresses on the living room floor, and cooked and cleaned for the in-patients in addition to providing medical care.

On the first morning of our visit to the clinics, Dr. Kinari Webb asked Vini, "Why has Dewi's clinic had so many in-patients, and you've had so few?"

It was one of those direct, non-judgmental questions doctors are so practiced at asking.

"Dewi's village has lots of typhoid," Vini replied simply, speaking in bahasa Indonesia. "My village has less."

Typhoid is  a potentially-fatal gastrointestinal disease caused by the fecal bacterium Salmonella Typhi. (For those of you wondering at this strange version of scientific nomenclature: no it's not a typo! The bug's full name is Salmonella enterica subspescies enterica serotype Typhi. You can see why it goes by a nickname.)

A drawing of Salmonella Typhi from 1928.
Image credit: Wellcome Library, London, CC BY 4.0.

But, Dr. Kinari prompted, why would there be more typhoid in one village than another?

In a moment of inspiration, the women realized that Vini's village is upstream on the river — closer to its clean source in the rainforest of Bukit Baka Bukit Raya National Park — while Dewi's village is downstream.

Vini considered the nine villages along the river, from Mengkilao at the very border of the national park, to Mawang Metatai closer to the river's mouth.

"How much typhoid is there in Mengkilao?" Dr. Kinari asked.

"None," reported Vini.

"How much in Mawang Metatai?" she asked.

"More than anywhere else. That's where the most typhoid patients come from," said Vini.

Aha! The upriver village experienced almost no typhoid, the downriver community was plagued by it, and there was a gradient of cases in between. Here was evidence that Salmonella Typhi was getting into the river from the feces of humans and pigs along its banks, concentrating with every community into an increasingly sickening dose. The situation also illustrated how crucial the rainforest is to human health, by providing a clean source of drinking water.

Salmonella Typhi show off their long, wiggly flagella under a microscope.
Image credit: Roinujs, CC BY-SA 4.0.

A few months earlier, the downstream midwife, Dewi, had already come up with a potential solution. She had realized that community members were drinking untreated river water. She encouraged everyone to boil their water, but as I mentioned in my previous post, this practice was unpopular. Residents dislike the taste of boiled water, which they call air mati, "dead water," and prefer the flavor of unboiled water, called air hidup, "live water." So, instead of trying to change everyone's preference, Dewi came up with a creative alternative.

She installed five water filters, each one consisting of two plastic buckets, on her front porch. She held a community meeting to explain how to use the filters and ask the community how they should be responsibly used. The residents decided that the filters should be outside, available 24 hours a day, and free to use, but they shouldn't be stolen or moved. Whoever draws water from a filter is responsible for refilling it with river water, so they next family will have clean water ready to use.

Midwife Dewi stands with her innovative water-filtration system in front of her house-clinic in Beloyang village.

The system was an instant hit. The filtration buckets have been through a few growing pains — such as when the weak wooden table collapsed and broke its load of buckets — but Dewi has installed a new set, and she's working to expand the system to each of the nine villages. Community members say the filtered water tastes hidup, just as good as untreated river water. When I was visiting, I drank from these buckets and even my weak stomach did fine. Dewi, Vini, and everyone at ASRI hopes the filters will capture all the wiggly-tailed Salmonella Typhi and prevent more cases of typhoid downstream of Bukit Baka Bukit Raya National Park.

The river bank in Nusa Poring village.

Part Two: Wax-Coated Buggers

One day in the Beloyang house-clinic, Dr. Fitri asked a young boy about his persistent cough. She suspected tuberculosis, but there's no easy test to give here, so she used questions from a scoring system. Had his weight changed? Did he experience night sweats? When did the coughing start? Did anyone in his family have TB?

Midwife Dewi prescribed liquid medicine for a boy after his mother relayed his medical history. For patient confidentiality, none of the people photographed for this post were diagnosed with tuberculosis.

Dr. Fitri determined that the boy did indeed have tuberculosis. His father and brother had both been diagnosed with TB before him, and his brother’s case was so bad he'd needed to have his lungs surgically drained. Most worrying to Dr. Fitri, the boy's brother was still coughing and not gaining weight even after a six-month course of medicine, which meant the family probably had drug-resistant tuberculosis. This form of the bug is much harder to treat, requiring daily injections.

Indonesia is the nation with the second-highest incidence of tuberculosis. In 2016, over a million new cases were diagnosed in Indonesia alone.

The disease is caused by Mycobacterium tuberculosis, named for its waxy "fungus-like" coating. It's not related to fungi at all. Other members of its genus include a few usual suspects and some odd birds you've probably never heard of. Mycobacterium leprae is the pathogen behind leprosy. The free-swimming, ocean-dwelling organism Mycobacterium marinum causes fish-tank granuloma, a rare disease of aquarists' fingers.

But tuberculosis dwarfs these other diseases in terms of global impact. According to the WHO, tuberculosis is the world's leading cause of disease from a single infectious agent, ranking even higher than HIV/AIDS. (And, these two diseases often work in cahoots, as the HIV virus suppresses immune systems and makes people more susceptible to infectious lung diseases.)

Scanning electron micrograph of Mycobacterium tuberculosis, the bacterium that causes tuberculosis.
Image credit: NIAID, CC BY 2.0.

Dr. Kinari calls tuberculosis a “depressing disease.” As a healthcare provider and rainforest conservationist, it's one of her top priorities.

“When you have patients with TB, it just saps the energy of the whole community,” Dr. Kinari explained to me. “It takes so much to take care of these people. They don’t die quickly — you could have TB for five or ten years — but they can’t work. And of course, they’re infectious.”

She described tuberculosis patients without good healthcare as “wasting away, feeling terrible, coughing the whole time,” and usually the whole family will be infected. “Plus,” she added, “there can be stigma associated with it, so you feel like you’ve done something wrong.”

A scanning electron micrograph of Mycobacterium tuberculosis showing the waxy cell wall.
Image credit: Janice Carr, CDC/Dr. Ray Butler, public domain.

Before ASRI opened two clinics around Bukit Baka Bukit Raya National Park last fall, tuberculosis patients were responsible for picking up their medicine from the government clinic in Menukung, a two-hour drive down the terrible mud road. The Indonesian government will only dispense one month of medication at a time, nearly guaranteeing that families who start the treatment won’t finish it — a perfect storm for creating drug resistance. (When a patient takes only part of a course of antibiotics, the weak individual bacteria die but the strong survive, encouraging the species to evolve resistance to that particular antibiotic.)

Dr. Fitri and Midwife Vini organize pharmaceuticals in their pharmacy, a cabinet in Dewi's house-clinic.

ASRI faced this problem a decade ago at its flagship site outside Gunung Palung National Park. There, ASRI's solution was to implement a Directly Observed Treatment System, or DOTS. Three times per week, DOTS workers visit each tuberculosis patient to directly observe them taking their medicine. Around Gunung Palung, the ASRI DOTS program has treated hundreds of patients. The key to success is commitment.

Hamisah, the coordinator of ASRI's life-saving Directly Observed Treatment System for tuberculosis, stands in a rice paddy outside Gunung Palung National Park.
Image credit: Carolyn Beeler.

Hamisah, the head of ASRI's DOTS program, is a kick-ass healer who will accept nothing less than success for her patients. To read about some of her imaginative tactics, check out her story, Sometimes All You Need is a Pair of Ducks. Thanks to the dedicated DOTS team, only 1-2% of patients drop out of the program, meaning that nearly everyone completes the treatment.

When grown in a Petri dish, Mycobacterium tuberculosis clump together into rough, colorless lumps.
Image credit: CDC/Dr. George Kubica, public domain.

ASRI's low drop-out rate from tuberculosis treatment is especially impressive when compared to the extremely high national drop-out rate. It’s hard to know just how high, because the government doesn’t report accurate statistics. The official number is 10%, but Dr. Kinari’s experience is that the national drop-out rate is probably over 50%. Often, when government clinics provide tuberculosis medication, they simply ask a member of the family to watch the patient take it.

A patient awaits treatment at the ASRI clinic near Bukit Baka Bukit Raya National Park. For patient confidentiality, none of the people photographed for this post were diagnosed with tuberculosis.

It’s clear that a DOTS program is needed around Bukit Baka Bukit Raya National Park. Dewi and Vini are already diagnosing, treating, and directly observing tuberculosis patients. Dewi has trained her childcare helper, Santa, to assist as well. Now, ASRI is working to support a full DOTS program for these communities.

When you treat a community for tuberculosis, Dr. Kinari explained to me, you lift the health, energy, and quality of life for everyone, from human residents to old-growth ironwood trees and orangutans. She sees health as the foundation on which rainforest conservation must be built, because a community needs energy to learn new farming techniques and begin a transition from logging to alternative livelihoods.

A misty rainforest canopy on Indonesian Borneo, stewarded by healthy communities that ASRI supports.