Short-sightedness puts Australia at risk

Take another look at the cover of this issue of the MJA and you will see just how close Papua New Guinea (PNG) is to Australia’s Boigu Island. In 2004, Queensland Health established tuberculosis (TB) clinics on Boigu and Saibai islands in the Torres Strait to provide medical care for PNG residents with multidrug-resistant TB (MDR-TB) (Queensland Health spokesman, personal communication, Oct 2011). The strategy has been extremely effective in treating these difficult cases and has, as Vincent states, been credited with “there being no MDR-TB cases detected in the Australian population in this region”.

It is not surprising, then, that TB experts are working to lobby the government to reconsider its decision to close these clinics by February 2012 and hand over care of these patients to services provided by PNG. PNG is a desperately poor country, ranked 137 out of 169 countries in the United Nations Human Development Index (http://hdr.undp.org/en/statistics). Its health services are largely in disarray.

The position statement in this issue of the Journal (Reynolds et al) invokes the World Health Organization ethical guidelines for care of patients with TB to call for free, equal and comprehensive care for patients with TB who present within our borders. It insists that transfer to the home country for ongoing care should only be contemplated when it is known that adequate care will be available. It recommends that Australia provide financial and technical support to neighbouring countries with endemic TB.

The authors of the position statement cite sound economic and scientific reasons, as well as the obvious humanitarian arguments, for their stand. For example, the WHO estimates that the cost of treating a patient with MDR-TB is about 100 times greater than that of treating a patient with drug-susceptible TB. According to the authors, substandard care of patients with TB is “the greatest contributing factor to the development of MDR-TB”.

Brolan and colleagues examine the Torres Strait treaty as it affects the provision of health care by Australian clinics to residents of PNG. They point out that, while providing such care is not strictly allowed, the practice meets our humanitarian obligations while offering protection to vulnerable Aboriginal communities in north Queensland.

While the Australian Government has pledged a large slab of financial support to improve PNG-based health services, and particularly to assist with providing TB treatment facilities in PNG’s Western Province (http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr11-nr-nr175.htm), more time is needed. As Vincent says, effective TB control requires prompt identification and treatment as well as monitoring and contact screening. Only when PNG clinics can provide all this should care be transferred. It seems extremely unlikely that this will occur by the planned date of February 2012.

Australia enjoys one of the lowest rates of TB in the world. King and colleagues, also in this issue, argue that this can in part be attributed to premigration screening, which they say benefits applicants, by earlier detection of their disease, and the Australian population, by avoiding exposure to people with active TB. Their argument of substantial cost savings with this approach is compelling.

While it is impossible to completely protect Australia from TB coming to our shores, the two strategies of continuing to treat PNG residents and conducting premigration screening appear to be effective at reducing this risk and should be supported.