Vietnam’s Battle With Tuberculosis
Dr. Bui Xuan Hiep, the head of tuberculosis control in this city’s Hoang Mai district, paged proudly through a large handwritten patient log.
在河内市黄梅区，主管结核病控制的裴春协医生(Dr.Bui Xuan Hiep)自豪地翻着一大本手写的患者名录。
“This district’s cure rate averages 90 percent,” he said. Still, Dr. Bui could see problems.
Seven patients had turned up with multidrug-resistant tuberculosis; four had been cured, two had died — and one had simply disappeared.
It’s a story repeated throughout Vietnam. The nation was once racked by a tuberculosis epidemic, one of the worst in which H.I.V. was not the driving force. But officials fought back fiercely.
Twenty-five years ago, battered by the aftermath of a long war, chronic poverty and a heavy-handed government isolated from much of the world, Vietnam had nearly 600 cases of tuberculosis for every 100,000 residents. Today, it has less than 200.
The country boasts a 90 percent cure rate for uncomplicated tuberculosis and cures 75 percent of its drug-resistant cases, easily beating the global average, 50 percent.
Indeed, public health officials worldwide have made remarkable progress against tuberculosis. Deaths from the disease have fallen drastically since 2000, according to the World Health Organization. Tuberculosis has been halted or reversed in 16 of the 22 countries that account for the vast majority of cases.
的确，世界范围内的公共卫生机构在防治结核病方面取得了显著的进步。世界卫生组织(World Health Organization)称，自2000年以来，死于结核病的人已大幅减少。在绝大部分病例所在的22个国家中，已有16个国家阻止或扭转了结核病的蔓延趋势。
But Ban Ki-moon, secretary-general of the United Nations, last week warned that the fight was “only half won” and estimated that 1.5 million worldwide would die of the disease this year.
There is no better example of how fragile this success may be than Vietnam. Hospital wards here are packed dangerously full, raising the risk that drug-resistant strains will spread.
The easy-to-reach patients have been treated, and many of the rest are the hardest to help: heroin-addicted couriers and laborers from the poppy fields of the nearby Golden Triangle, and mountain villagers who do not speak Vietnamese and are barely connected to the health care system.
But the biggest threat is that the money is close to running out.
To reach Vietnam’s ambitious goal of pushing prevalence rates down to 20 cases per 100,000 residents — essentially eliminating tuberculosis as a public health problem — its tuberculosis-control program needs to spend at least $66 million a year. It now spends about $26 million a year.
About $19 million of that comes from foreign donors, with more than a third from the United States, Dr. Nguyen said. Evidence of donor help is everywhere.
The expensive diagnostic machines in hospital laboratories bear stickers from the United States Agency for International Development or from The Global Fund to Fight AIDS, Tuberculosis and Malaria, 30 percent of whose budget is paid by the United States. But The Global Fund, the chief support of the tuberculosis program here, is struggling and has promised support only through 2017. The White House, in its proposed budget for fiscal year 2016, reduced its contribution to the fund by 18 percent and to Usaid’s tuberculosis programs by 19 percent.
医院实验室里，昂贵的诊断机器上贴着来自美国国际开发署(United States Agency for International Development)或全球抗击艾滋病、结核病和疟疾基金（The Global Fund to Fight AIDS, Tuberculosis and Malaria，简称全球基金）的贴纸。这些机器的预算中，30%由美国支付。但作为越南结核病项目的主要支持者，全球基金自身举步维艰，只承诺在2017年结束前提供支持。在2016财年的预算提案中，白宫将对该基金和美国国际开发署结核病项目的捐款分别削减了18%和19%。
Officials here and at the W.H.O. fear that hard-won progress may soon be reversed and a remarkable success story may come apart, with deadly consequences.
After years in the shadow of the AIDS epidemic, tuberculosis is regaining its notoriety as one of the world’s great killers: an airborne bacterium that spreads easily among people living crowded together — in jails, ships, mines, trenches or slums — and insinuates itself deep in the lungs and grows, slowly tearing apart the tissue until victims are coughing up blood.
Tuberculosis now kills more people around the world than AIDS, according to the W.H.O.: 4,100 a day, compared with 3,300 dying of AIDS, making tuberculosis the leading infectious cause of death in the world.
Mortality from both diseases is dropping, but tuberculosis deaths have fallen more slowly, especially in Asia.
Vietnam’s success where so many other nations have failed is not just because of donor money, said Dr. Mario C. Raviglione, the director of the W.H.O.’s global tuberculosis program.
“It succeeds because it’s a Communist country,” he said. “Socialist countries put a lot of resources into primary care: lots of doctors, lots of clinics. And once central government adopts a thing, they really do it. They give orders.”
Tuberculosis is an ideal disease for a regimented treatment approach.
Almost all patients with “uncomplicated” tuberculosis — bacteria that are not drug-resistant — can be cured if they take a standard menu of four antibiotics every day for six months without fail.
In Vietnam, treatment standards set at the national level are followed by the entire public health network. The National Lung Disease Hospital in Hanoi oversees 64 provincial hospitals, which oversee 845 district hospitals, which oversee 11,065 neighborhood health clinics.
在越南，治疗标准由国家制定，整个公共卫生系统都要遵守。位于河内的国家肺病医院(National Lung Disease Hospital)管辖着64个省级医院，这些省级医院下面又管辖着845家地区医院，后者则负责管辖11065家社区卫生所。
The pharmaceutical-supply chain, the Achilles’ heel in many tuberculosis-ridden countries, is impressive. On a weeklong tour of urban and rural clinics, not one nurse or patient reported ever running out of drugs.
Those neighborhood clinics — usually just a few examining rooms, a small pharmacy and a parking lot — are as ubiquitous here as police stations and firehouses in the United States.
They treat many illnesses, but their role in tuberculosis is simple: Every tuberculosis patient in the district reports once a day to take his or her pills in front of a nurse. Each dose taken is checked off on a yellow card.
Patients with drug-resistant disease are especially hard to help. Their medicines, some of which are intravenous, must be taken for two years, and can cause deafness, psychosis and kidney failure. Patients must be hospitalized, their movements restricted to one or two corridors, sometimes for months until they are no longer coughing up live bacteria.
If they become worse instead of better, the prognosis is usually grim. Extensively drug-resistant disease (XDR TB) requires even more toxic drugs costing 25 times as much. Most XDR TB patients here die.
如果病情并未好转，而是发生恶化，预后通常都很严峻。广泛耐药肺结核（Extensively drug-resistant disease，简称XDR TB）的治疗甚至需要用毒性更强的药物。它们的价格是一般药物的25倍。在越南，大部分XDR TB患者都会丧命。
There are many signs that the national tuberculosis program here survives on a shoestring budget.
While its top laboratories have some modern equipment, the 64 provincial hospitals share only 60 rapid diagnostic machines, less than half the number they need, even though Vietnam pays only $17,000 for each, about a tenth of the American retail price.
More ominously, hospital wards are dangerously crowded. Seven patients a room, with beds only a foot apart, is not an uncommon sight. (That effectively means 14 inhabitants a room, as many patients have a relative sleeping on the floor or in a corridor to do nursing chores and bring food.)
Geography presents the tuberculosis-control program with another kind of obstacle. In the Shangri La-like valleys of Son La province, a six-hour drive west of Hanoi, some inhabitants live in villages with thatched roofs and speak only Hmong, Meo or Thai.
Finding and keeping them in treatment is hard, said Dr. Tong Van Hieu, the director of the Quyet Thang neighborhood clinic in Son La. Some believe tuberculosis is caused by fog or dust or gold mine fumes, and turn first to folk remedies.
山罗省厥升社区诊所主任宋文孝(Tong Van Hieu)说，找到他们并让其接受治疗很难。一些人认为结核病是大雾、灰尘或金矿冒出的烟造成的。他们首先会求助于民间偏方。
In the cities, a new problem is on the rise.
Vietnam’s growing prosperity lets some patients afford private doctors — who often ignore the official four-drug regimen and fail to insist their patients take every pill.
And sometimes, even when compliant patients play by the rules, treatment fails, anyway.