Tuberculosis (TB) is the single largest infectious disease in the world. India sees an estimated two million new cases a year and 1,000 deaths a day due to the disease. Within India, Mumbai has the most cases, and 15% of all deaths (nearly 9,000 people) in the city were caused by TB in 2010. This situation persists despite the fact that India has the highest number of anti-TB projects in the world.
Undeterred by these disheartening statistics, the Indian Government has for long chosen to focus on its ability to roll out the WHO-recommended TB testing and treatment program called Directed Observed Treatment Short course (DOTS). Since 1997, India’s Revised National TB Control Program (RNTCP), under the central government’s Ministry of Health, has been very successful in rolling out the DOTS program, and the country has achieved the international targets of 70% case detection and 85% cure rates. In spite of this success, there has been a recent increase in detected cases. TB spreads through the air: when a person with TB coughs, sneezes or spits, he sprays droplets containing TB bacteria, and people nearby breathing that in risk becoming infected. Because of the cramped and oftentimes unventilated living conditions in poor urban settlements, such as slums, the urban poor are at greater risk of infection than their richer counterparts, especially given their lower nutrition levels.
Totally Drug-resistant TB
Since early 2012, researchers have reported the emergence of what appears to be Totally Drug-Resistant TB (TDR-TB) for the first time in India and third time worldwide (after Iran in 2009 and Italy in 2007). There have so far been 12 detected cases in India, but Dr. Amita Athawale of Mumbai’s KEM Hospital, where TDR-TB cases are treated, has stated that this is “just the tip of the iceberg.” With 10 out of 12 cases in India coming from Mumbai, the city has been forced to confront the threat of TB, especially the virulent TDR-TB variety. Dr. Nora Engel, Assistant Professor of Global Health at Maastricht University in the Netherlands, researches TB in India and says: “Cities are particularly problematic because of the health risks associated with living in cities, especially if you are poor, due to density of housing and transport, pollution, stress, malnutrition, occupational hazards, asthma and lifestyle.” Dr. Engel also remarks that, “The situation is particularly worrisome in peri-urban and urban slums because there is often no community coherence and a multiplicity of [treatment] providers.” That together with a “lack of education, and above all migration, makes any effort to treat and intervene with regards to longer term diseases such as TB very difficult.”
While the Indian government first questioned and denied the existence of TDR-TB, or even that the rise of TB is a major concern, it has since made a dramatic U-turn, sharply increasing the budget for fighting TB, as well as looking into ways of strengthening the support services related to TB treatment and detection. Since the start of 2012, there is a renewed, large-scale effort to tackle TB in Mumbai.
TB Pilot in Mumbai
In Mumbai, the Brihanmumbai Municipal Corporation (BMC) and the Ministry of Health’s RNTCP efforts have worked separately to fight TB. However, with the latest scare, the two entities will be joining forces as part of a new big-budget pilot project to tackle urban TB. Within the project, public health department workers will undertake a large door-to-door survey to locate people with possible TB. It is important to note that Mumbai has been put in a special national health status category so that patients that have undergone two months of TB treatment but are not improving will get access to drug resistance testing. If they test positive, these patients will be given access to more expensive drugs for free. To carry out the increased quantity of testing and treatments, a number of additional private labs and hospitals will be involved in the TB program.
The increased effort to tackle TB in Mumbai will be financed by a huge rise in the healthcare budget. This will go hand-in-hand with a decentralized strategy of controlling TB. Mumbai was previously one single RNTCP district from a TB administration and control perspective. However, each of Mumbai’s 24 wards will become a RNTCP district, resulting in 24 new RNTCP districts, each with its own TB officer (a licensed medical practitioner) and one senior coordinating officer for the whole of Mumbai. Each of these new RNTCP districts will receive greatly needed, improved infrastructure, including additional TB drug stores and lab centers. While these improvements will help, hospitals also sorely need better equipment: at present some hospitals do not even have the necessary equipment to undertake surgeries necessary for the most severe cases of TB.
Health System Challenges
One reason for the increase in drug-resistant forms of TB is inconsistent follow-through of treatment. Many patients, who are not properly supervised, may discontinue the six-to-nine months required treatment when they feel better after just a couple of months. However, the TB is still present and active, thereby building up resistance to treatment drugs. The Indian government has preferred to turn a blind eye to TDR-TB patients, according to The Lancet, because of the high cost of treatment — US$4,000 — which is a considerable sum given that average per-capita spending on healthcare is US$45. In fact, one recent government proposal for treating TDR-TB is to send TDR-TB patients to a sanatorium outside of Mumbai. This proposal was stalled due to protests, including a concern over violation of basic human rights. Other experts argue that the best course of treatment would be to isolate TDR-TB patients within TB units at Mumbai hospitals. Generally speaking though, hospitals and other health centers have a bad record of controlling infections on their premises. This is especially true of government or public hospitals, which are where the urban poor would go for treatment. It is believed that this lack of control is actually contributing to an increase in drug resistance.
To be effective, the renewed TB effort of the RNTCP needs to better include the private sector. India has the largest private health sector in the world, and it is believed that over half of India’s TB patients go to more expensive private practitioners. Patients prefer private healthcare because of a lack of public facilities and treatment, as well as to avoid the long queues at government hospitals. This preference for private healthcare has several important implications. Firstly, patients seeking private sector treatment were until recently not allowed free medical drugs on the grounds that only public hospitals can provide them. Furthermore, even after allowing for private hospitals to access medicines, referring TDR-TB patients to a government hospital means that they have to go through a complete new screening for TB, which can take months. Patients may also have to repeat the same DOTS program they have already gone through under private healthcare, but this time under government hospital supervision. Meanwhile, patients are still carrying the TB infection and are likely to spread the disease.
Secondly, the lack of best practices, supervision, coordination and regulation within the private sector has serious implications for both individual and public health. Patients are given a range of different drugs for TB that often do not help. In fact, the substantial use of drugs that are not directly treating TB are instead helping it build its drug resistance. Dr. Engel states, “The development of multi-drug-resistant TB is symptomatic of the challenges facing current TB control in India, such as an unregulated private sector including practitioners, pharmacists and diagnostics labs. The over-the-counter use of TB drugs is huge, and socio-cultural issues of treatment adherence are not taken into account enough.”
To educate the public, the government is increasing its spending on awareness campaigns run by NGOs. For instance, Mumbai-based NGO Lok Seva Singam (LSS) conducts information, education and communication campaigns in poor areas of the city. These include everything from door-to-door campaigns to street theater, film screenings and group discussions. They found that a particularly effective strategy is to reach out to children in schools and teach them about TB together with their schoolteachers. What the children learn, they bring home to their families.
In another innovative initiative, BBC Media Action has started a multi-pronged campaign to increase awareness of TB symptoms and the need to get tested. Using the services of a newly created superhero, Bulgam Bhai, the campaign’s television advertisements show the superhero asking Indians whether they have been coughing for more than two weeks. The implications are that if a person has chronic cough for over two weeks, then she must have a sputum test to detect possible TB.
Some people argue that the campaigns to stop spitting on Mumbai’s streets that were so effective during the height of the H1N1 virus should be renewed. Chewing tobacco and consuming paan (a digestive that can include tobacco) has made spitting, which can carry TB bacteria, a huge problem across India. While spitting is officially banned in Mumbai’s public places, the small fines and lack of rule implementation greatly minimizes its effectiveness. Given the reluctance of officials to strictly implement rules, whether they regulate availability of drugs or simply spitting, Dr. Madhukar Pai, professor and TB researcher at McGill University in Canada, suggests India employ the services of its Bollywood superstars and industrial giants to front a campaign that could have substantial impact on people’s awareness and perception of TB — something that was proven with anti-polio campaigns.
What does the future hold?
While it is believed that severely limiting the availability of over-the-counter drugs could slow the incidence of drug resistance in India, the government has so far not seemed willing to do so. Some blame this reluctance on the fact that parts of rural India do not have access to a doctor to prescribe drugs, so instead, rural dwellers’ only option is to self-prescribe and get drugs in local shops. On the other hand, it seems the severity of the TDR-TB has at least jolted health authorities into action with respect to Mumbai. Dr. Engel believes that, “It is difficult to tell, as of now, what the impact will be [of the renewed TB effort], but there are some new technologies around which it is hoped will speed up testing. One question is whether the RNTCP/BMC will be able to deal with the increasing numbers of multi-drug resistant TB cases they might find, in terms of manpower, funding and capacity.”
Another important change that needs to happen is regarding the government’s lack of drug regulation. India’s powerful pharmaceutical industry has flooded the country with easily available drugs of questionable quality, which is already leading to staggering levels of drug resistance. A future scenario of increased drug resistance for what was until recently easily treatable ailments can become a very serious concern for the country and region as a whole.
Engel, N. (2011). Tuberculosis in India – A case of innovation and control, Maastricht (NL): Universitaire Pers Maastricht [Maastricht University Press]. [ISBN 978 94 6159 048 0]