It's India's worst scourge but no one has time or money for it
"If the number of victims which a disease claims is the measure of its significance, then all diseases, particularly the most dreaded infectious diseases, such as bubonic plague, Asiatic cholera etc must rank far behind tuberculosis."—Dr Robert Koch, who discovered the TB bacillus in 1882
OVER a thousand Indians will die of tuberculosis on March 24. Over a thousand Indians die of TB every day. One Indian dies of TB every minute. So, there's nothing extraordinary about March 24 really. Except that it's World TB Day. That annual, rare occasion to make headlines of these otherwise unwritten, unhyped deaths. Five lakh deaths every year by a disease that's eminently curable. Deaths by a killer that stalks us all.
Yes, every second Indian over 20 years of age is infected with the TB bacterium. It only takes a lowering of immunity and malnutrition for it to become a full-blown disease. It takes an inefficient public health system to make the disease our largest killer, in a world that's declared a global emergency on TB. But we find little time to talk about the fact that our country bears 28.4 per cent of the entire world's TB burden. That we, with a lesser population than China, have double its TB cases. And that we've been doing pathetically in combating this disease.
A collapsing public health system, political disinterest in a disease that gets no publicity and its sheer glamourless-ness in a mediacentric global society that has celebs shaking hands with AIDS patients, have all ganged up to push out TB from its priority in our public health agenda. The rich can afford to be treated of TB and keep quiet about it, the poor are left to suffer it. Hardly shocking then that in its review of the 22 countries that account for 80 per cent of the world's TB cases, the World Health Organisation (WHO), five days before World TB Day this year, listed India as one of the 16 countries unlikely to meet world TB control targets by 2000. Smaller neighbour Bangladesh found proud placement amongst the six countries that will.
Not that these shameful statistics mean much to those dying in unkempt wards of a disease that timely administration of drugs could have avoided. Their list of problems is personal and peculiar.
Abandoned by her in-laws because she was caught coughing blood, 18-year-old Sunita Sangwan still isn't sure of what ails her. Anxious not to be dumped at her mother's because she wasn't being useful around the house, she'd kept silent about the real symptoms of her disease. The local doctors she consulted at Panipat gave her cough syrups and advised hot-water gargles. Till she was found spitting blood. And discarded. Now weak and wheezing at the Chest Clinic and Hospital in Delhi's Nehru Nagar, Sunita barely manages to mumble: "The nurses here say I should have come for treatment earlier, but the doctors at Panipat didn't tell me it was so serious. I am uneducated, I was hiding my symptoms...the doctors should have known."
They often don't. A study conducted by Dr Mukund Uplekar on prescription practices in TB saw only four of 105 prescriptions conformed to standards set by the WHO and the National Tuberculosis Institute. The problem only begins there. Mal-practices are rampant. Expensive x-rays are thrust upon many who could be tested for TB through a simple sputum test. The quality and supply of drugs is erratic. When available, there's no checking to see that the patient is regular with his medicines.
Consequently, some two-thirds TB patients drop out of the treatment early, often becoming chronic sufferers and source of TB infection to others. More dangerously, very often they become incubators for a deadly, drug-resistant TB bacteria.
"I became ill three years ago and got medicines. They'd make me giddy and I'd vomit all the time. I gave up. Then, I was ill again. I went to another clinic. They gave me some more medicines. The doctor scolded me for being irregular. He was rude. I gave up again," says Jagdish Chander, an out-of-work car mechanic currently under treatment in a Delhi hospital. Looking much, much older than the 41-year-old he says he is, Jagdish is now a MDRTB (Multidrug Resistant TB) case.
That's the next threat. Though reliable and representative data on MDRTB in India is yet not available, a TB bacterium immune to the drugs administered because prescribed courses haven't been completed is already here. Add to that the fact that our 2.5 million HIV-positive infected are far more susceptible to TB, and we have a scary scenario at hand. Not to forget that each year—with or without the MDR and the HIV complications—two million people are anyway developing active TB.
So what's our strategy? The National Tuberculosis Programme (NTP) begun in 1962 did create infrastructure for TB control throughout India. But it obviously didn't achieve desired results. So a new strategy—DOTS (Directly Observed Treatment, Short-course) —was brought by WHO to India and renamed RNTCP (Revised National Tuberculosis Programme). Since 1993, RNTCP has been pilot tested in 20 sites all over the country. Globally 96 countries have adopted this new treatment strategy.
Very simply, DOTS means that instead of just giving the patient his share of medicines and hoping he'll consume it, the health worker who provides such medicines watches the patient actually swallow the drugs. The combination of drugs prescribed by DOTS—dubbed "more effective" by some, "too strong" by others—are more expensive than those given under the NTP.
The ministry of health and family welfare claims this new programme has nearly tripled the cure rate and doubled the proportion of cases which were being confirmed through the earlier programme in laboratories. The WHO puts the cure rate under DOTS for India at a whopping 82 per cent.
A huge success really but in a very small segment covering only 12 million people. In a country of nearly 1,000 million people. So is it the solution for our TB troubles?
"Anything implemented well will work. Give the programme to NGOs and they'll give you sure-shot success. But what's to guarantee that our health workers will suddenly become picture-perfect and monitor each patient's dosage consumption committedly. Also, in a country where TB clinics have to be renamed Chest Hospitals because of the stigma attached to the disease, it's somewhat unfair to expect people to visit distribution centres every alternate day," says Dr Sunil Kaul of URMUL Trust who worked with TB patients in Rajasthan's Bikaner district for seven years. Kaul says he has seen many finding it difficult to bring their ailing relatives to distribution centres because it clashes with their work hours. "The stigma, the societal problems, the ignorance has to be kept in mind before deciding on strategy."
"Sure," says Dr Thomas Frieden, Delhi-based WHO medical officer (TB), "but reversing the stigma will take some time. Cure can and should happen promptly. Both AIDS and the emergence of MDRTB show the urgency to cure." Quoting a study, Frieden says non-compliance in taking medicines has been known to be prevalent across gender, age, community, educational background.
So, it will take strict supervision in medicine consumption to cure TB. But others like Dr Mira Shiva, head of the public policy division at the Voluntary Health Association of India (VHAI), feel DOTS is part of technocratic Western models on health that are imposed on the people from above and make the country dependent on assistance from outside. "These models conveniently forget ideas developed indigenously, like the NTP, and ignore the problems that are peculiarly ours," she argues. "AIDS and TB are made to sound big but what about links of Kala Azaar with TB that kills thousands?" Shiva contends people can't be pushed to poverty, malnutrition, slums—all of which breed TB—and then be presented with an international-loan-based pharmaceutical solution. The VHAI, in fact, has come out with a report on the serious implications of the proposed RNTCP for India.
However, the programme finds advocates in 'pragmatic' experts like Dr J.L. Banavaliker, state TB control officer with the Municipal Corporation of Delhi. "We can debate everything to bits but finally the fact is: a well-managed DOTS pro-gramme brings far better results than NTP has been known to bring," he says.
Certainly. Well-managed health program-mes will cure as they're meant to. Any debate on health strategy will have every side lobbying for just that—a conscientious, committed execution of the many shifting policies that aim to keep our nation healthy. Says Dr D.R. Nagpaul, vice-chairman of the TB Association of India: "Health has never been a priority. We don't even give it 5 per cent of our GDP. Our ability to use these meagre resources is even more pathetic. Add to that the fact that age-old TB interests no one, with AIDS and dengue making headlines every other day."
No wonder really that no politician is happy to get the 'soft' health ministry. Let's rename it then. With TB killing so many every day, call it the Defence Ministry. And let's get on with the battle against TB. It's just killed another 1,000 Indians today.