The TB burden

Homeless men, some suffering from tuberculosis, wait for treatment at a street clinic in the old quarters of New Delhi. A file photograph.

PEOPLE with their faces covered with cloth, and coughing intermittently, stream into a government-run dispensary in South Delhi’s Kalkaji locality after 8 a.m. and form a long queue in front of a large window. Two men are seated at a table placed near the window, in a small room stacked with cardboard boxes containing medical kits.

This is a typical centre where the World Health Organisation (WHO)-recommended Directly Observed Treatment Short-course (DOTS) to tuberculosis (TB) is provided. It serves as the first point of contact for TB patients, and the facilities are free. The centre is staffed by one laboratory assistant and an adviser to ensure systematic follow-up. Depending on how seriously a patient is affected, treatment could take anywhere between six months and two years.

One of the staffers, who did not want to be named, said there were 135 patients coming for follow-up treatment at the centre. “We provide the patients tablets or any other medication mandated in their treatment regimen. Our main role is to ensure that they follow and complete their doses. This is critical because many of them tend to stop the doses once they start feeling better. We sometimes visit their homes to counsel them to continue the medication and complete the course,” the staffer said.

Often there are other reasons, such as procedural delays involving administration, for those in need of treatment not getting them on time or leaving it midway. Take for instance, Munna Saha. This 40-year-old victim of human immunodeficiency virus (HIV) and TB is a resident of Navjivan camp, a locality near the centre mostly comprising the underclass. Saha got his initial TB treatment at his native village in Bihar’s Chhapra district. His case was transferred from Chhapra to Patna for a brief while. For nine months he received treatment in Bihar. His case has now been transferred to Delhi. This is his second day at the DOTS Centre, During his previous visit, the centre referred him to a hospital. He also visited the All India Institute of Medical Sciences. Speaking in a muffled voice from behind his handkerchief mask, he said he did not know why he was being made to do the rounds of hospitals and was not given medicines.

His wife, Pratima, said: “They are asking us to go through these procedures, visit hospitals, but are not giving medicines.”

One of the staffers at the centre told the couple: “Your work won’t get done in a day. It will take some time.”

When this correspondent asked the staffer why the treatment to Saha was delayed, he said: “Saha got his case transferred from Patna to Delhi but came to the centre late. He had medicines for 15 days given to him by the doctor in Patna, although while undergoing a transfer he should be given medicines only for seven days. Also, he came to us only yesterday, and since he is now without medicines, he expects us to give them to him right away. We can’t do that because TB treatment involves a lot of follow-up. We will have to go to his house and check whether he actually lives there or not, then approve him and start the course for him.”

Meanwhile, another patient walks up and requests that his treatment be transferred to Varanasi: “I am going back home because I lost my job here and cannot stay any longer.” The staffer tries to convince him to stay back: “Only two months are remaining to complete your treatment.” The patient says he was forced to go because he was running out of savings.

As these two cases show, migration is a serious problem in health care. The Delhi State TB Officer, Dr Ashwani Khanna, identifies migration as a key “challenge”. He told Frontline that migration had a lot to do with patients’ inability or lack of interest in continuing or following up the treatment.

“Many of Delhi’s districts bordering Uttar Pradesh have high defaults, about 10 per cent, while in other parts it may be only 2-3 per cent. In the case of drug-resistant patients, the defaults are as high as 25 per cent,” he said. “The governments—both Central and State—have undertaken interventions to provide treatment despite many challenges. A new five-year plan on TB, beginning 2017, would address these and other challenges,” he said.

Extent of the epidemic

TB was back in the headlines in the second week of October after the WHO disclosed in a report that the global TB epidemic was substantially higher than previously estimated, solely because of an increase in the number of reported cases in India.

The numbers are quite alarming. As per the latest “interim estimates” recorded in the WHO’s “Global Tuberculosis Report, 2016”, India had about 28 lakh TB patients in 2015, much higher than the previously estimated figure of about 17 lakh for the same year. India also accounts for over a quarter of the TB cases reported worldwide. Predictably, much attention was drawn to the numbers. India, the TB capital of the world, had under-reported figures for 15 years and the sudden jump in estimates affected the global discourse about the actual extent of the epidemic.

To allay fears, Indian health officials pointed out that the report revealed the continuing trend of a drop in the number of deaths caused by the disease and the “TB incidence rate”, even if the overall numbers reflected a rise owing to improved notification of cases. The political leadership mentioned another aspect. Minister of State for Health and Family Welfare Anupriya Patel told Frontline : “We should not worry about these figures. This rise is not a real increase, this is an apparent increase. These figures show an increase because there has been a better data collection and analysis by the Government of India’s Revised National Tuberculosis Control Programme.”

But this focus on numbers has concealed the WHO report’s emphasis on addressing “social determinants” such as poverty, income inequality and undernutrition (considered a risk factor for TB), which are the reasons why TB remains among the top 10 killers in India.

The WHO report observes: “Societies that have experienced broad socio-economic development have seen a substantial reduction in TB incidence and mortality rates. Poverty alleviation has historically contributed the most to the reduction in TB rates in countries that now have a low TB burden.” It also cautions: “Economic growth alone is not a guarantee for a rapid decline in TB cases and deaths. Unequal wealth distribution, with large parts of the population left behind, leaves fertile ground for a sustained TB burden.”

The WHO’s observations have come at a time when international organisations of repute have disclosed some worrying facts about malnutrition and hunger in India. Two days before the WHO released its report, the Washington-based International Food Policy Research Institute (IFPRI) released the Global Hunger Index 2016. The hunger index calculated for 118 countries ranked India 97, below Bangladesh and Nepal , in hunger reduction. The report found that since 1992, undernourishment had not reduced sharply enough in India; from 22.2 per cent it has now declined to 15.2 per cent of the total population. In July, the WHO brought out its “report card on the world’s nutrition”, the Global Nutrition Report 2016. While acknowledging the Indian government’s “awakening to all forms of malnutrition”, which had the potential to be a “significant game changer for the world’s prospects of reaching the sustainable development goals”, it warned: “Like all the other countries, though, India must pay attention to its growing rate of overweight and, in particular, high rate of diabetes.”

The WHO’s TB report has listed diabetes as another “risk factor” for the disease after undernutrition. The WHO’s emphasis on addressing these “social determinants” is echoed by India’s civil society activists and experts. Dr Amit Sengupta, health expert and long-time campaigner on public health issues, told Frontline: “The high incidence of TB is a marker of a poor health system. The disease is an indicator of the capacity of the health system and broader determinants of health, including nutrition and housing.”

Pointing out that TB was also reported among the relatively well-off, he said a poor person was still more likely to be affected by the disease because of poor immunity levels. TB is caused by the bacillus Mycobacterium tuberculosis . It typically affects the lungs, but it can also affect other parts of the body. The disease spreads when those who are sick expel bacteria into the air by coughing.

The WHO bolsters the argument about links between poverty and TB thus: “Although poverty is a cause of TB, the disease is also a cause of poverty; this vicious circle plays out on individual, household and community levels. There is strong evidence of major direct social, medical and behavioural risk factors for TB, many of which are also closely linked to underlying poverty.”

The WHO’s TB report has mentioned another set of challenges that is not adequately addressed. It is concerned about India’s limited patient coverage, wide variability across States and localities on TB-specific support packages, weaknesses in administration and lack of formal links with non-governmental organisations.

Curiously, the Indian government broadly concurs with the WHO’s concerns. In his foreword to the government’s official annual publication TB India last year, Health and Family Welfare Minister Jagat Prakash Nadda wrote: “Tuberculosis is the oldest malady of human poverty and sufferings and remains a major public health problem despite notable socio-economic development, advances and availability of technology. It is a curable disease but still millions of people suffer every year and a number of them die from this infectious disease resulting in devastating social and economic impact.”

In an interview to Frontline , Anupriya Patel mentioned the government’s intention to make provisions to address malnutrition in the national plan that is being drafted for TB.

Clearly, the government has made the right noises about combating TB. But the challenges it faces on the ground are plenty, and the country’s health system appears far from ready to take on the task of combating the disease.