Phnom Penh's Kantha Bopha children's hospital recently received a one-year-old

patient with a shocking health condition: a section of his spinal cord had

disintegrated, paralyzing him from the waist down.

A mother watches over her son at a Kantha Bopha Hospital. He has a severe form of tuberculosis.

A CT scan revealed

tuberculosis (TB) of the bone, probably transmitted to him by his mother before

he was born. Though doctors saved the boy's life by controlling the infection,

treatment came too late to prevent paralysis.

Although spinal damage

represents a severe form of TB disease among children, doctors at the Kingdom's

three leading children's hospitals say it is not unusual. During the past month

alone, Phnom Penh's two Kantha Bopha hospitals and the affiliated Jayavarman

Hospital in Siem Reap have received at least six similar cases in children

between the ages of one and 12.

"In most of them, it was a typical case

of missed diagnosis. Due to this, the infection spread to their bones over a

long period," says Dr Beat Richner, the Swiss doctor who established the first

of the specialist children's hospitals in 1992. In the majority of cases, he

says, primary infection begins in the lungs and, in the absence of diagnosis,

spreads to other organs causing serious complications.

Of the 35,000

children hospitalized at the Richner-run hospitals last year, almost half

suffered from one form of TB disease. These included pulmonary TB, meningitis,

the intestines, bones (mainly the spine) and tissue surrounding the

heart.

Among adults too, TB infection is widespread: the country has the

second highest infection rate in the world, just ahead of Zimbabwe, according to

World Health Organization figures.

More than half of the country's 11.2

million people are believed to have been exposed to TB, but the current

detection rate of 54 percent means many are still spreading the disease. Poor

sanitary conditions, high density dwellings and limited access to healthcare are

the major reasons for the spread of the disease.

"What makes the

situation here more alarming is that Zimbabwe's infection rate of 562 per

100,000 is attributed largely to a huge burden of HIV infection. Cambodia's rate

of 560 per 100,000 is not," says Dr Ikushi Onozaki, chief advisor of the

Japanese-funded National Tuberculosis Control Project (NTCP).

Dr Mao Tan

Eang, director of the National Center for Tuberculosis and Leprosy Control

(CENAT), a part of the Ministry of Health, says a major reason for the spread is

that detection rates in children and adults are low.

"However, detection

efforts have been intensified in our [revised] national TB program," he says.

"The target is to halve TB deaths by 2010 while maintaining a high cure rate,

and increase the detection rate to 70 percent by 2005." The government has

earmarked $25 million to raise the detection rate under the new five-year

policy.

Although Cambodia's infection rate is high, the actual number of

people who have TB disease is much less. Differentiating between the two is

important.

"TB is a complicated disease," says Dr Wim van Damme of

Medecins Sans Frontieres-Holland, Belgium and Switzerland (MSF). "You have to

make a clear distinction between TB infection and TB disease. The chance of [an

infected person] getting the disease is only about 10 percent."

Dr van

Damme says the likelihood of contracting the disease increases if a person

already has HIV/AIDS, diabetes, or suffers from malnutrition. This gives rise to

what health specialists refer to as 'co-infection'.

An HIV/AIDS patient

can have a co-infection, which means they contract both TB and HIV/AIDS. This is

because AIDS weakens their immune system and makes them more susceptible,

explains Dr Hor Bunleng, deputy director of the Ministry of Health's National

Center for HIV/AIDS, Dermatology and STD (NCHDS).

The need to tackle the

problem of co-infection has prompted the two major health programs to work

together on a program that will provide homecare treatment for both TB and

HIV/AIDS. The program, which is in the early stages of development, involves

both CENAT and the NCHDS, says Dr Bunleng.

"We would like to work

together with [CENAT] to come up with a joint strategy," he says.

CENAT

and MSF-France run the Directly Observed Treatment with Shortcourse (DOTS)

program, which provides medicine at home on a regular basis to ensure that TB

patients complete their treatment.

NCHDS also provides homecare treatment

in its home-based and community-based care program for HIV/AIDS

patients.

"We would like to integrate the DOTS and the home-based and

community-based care into one program," says Dr Bunleng. "We could mobilize

resources."

Both programs have seen some success. Cambodia's cure rate

for TB is 89 percent and the prevalence of HIV/AIDS among the 15-49 age group

has decreased from 3.1 to 2.8 percent.

"If you look at the target

HIV/AIDS groups, such as commercial sex workers, it is declining," says Dr

Bunleng. "It is a hope for Cambodia in terms of preventing HIV/AIDS."