India’s Evolving Tuberculosis Challenge

India is the undisputed global capital of TB with an estimated 2.2 million cases of active TB out of an annual incidence of 9 million cases globally and 40% of her population harbouring latent TB infection including an estimated 2.5 million HIV cases who can develop the most dreaded drug resistant disseminated TB at any time and succumb to it in no time.

India pioneered TB control among developing nations. A national TB control project was launched in 1962. With BCG vaccination as the main intervention, there was an air of expectancy that it would protect against TB. India is the undisputed global capital of TB with an estimated 2.2 million cases of active TB out of an annual incidence of 9 million cases globally and 40% of her population harbouring latent TB infection including an estimated 2.5 million HIV cases who can develop the most dreaded drug resistant disseminated TB at any time and succumb to it in no time. What is a matter of extreme concern is that TB accounts for majority of HIV deaths and there is a large pool of drug resistant cases that can potentially infect large numbers of people in the community each year if they are not insulated and rendered non-infectious by effective chemotherapy. India with a dubious distinction of harbouring a large pool of tuberculosis including HIV co-infection and an estimated 70,000 cases of multidrug resistant tuberculosis(MDR-TB) , many among them extensively drug resistant(XDR-TB) out of half million cases globally, can become an epicentre of TB explosion in the world if urgent measures are not instituted to make TB control really effective. In this regard, Revised National Tuberculosis Control Programme (RNTCP)that was initiated by the government to cover most of the country has met with partial success in the incidence, prevalence and cure rates of tuberculosis. There is still a substantial population in this country who have no access to quality TB diagnosis and treatment.

Rough Transcript:

Prabir Purkayastha: Hello and welcome to Newsclick. Today we have with us Dr. Amit Sengupta of the Jana Shashtra Abhiyan, a people’s health movement. Amit, India seems to have embarrassed itself quite severely in its performance at the World Lung Conference in Liverpool. What did it do and why has there been such a lot of criticism about that?

Amit: Well, if it wasn’t so sad in terms of what it means to people’s health, it was a rather amusing, India’s performance. It was led by the Director General of Health Services Jagdish Prasad. So this conference was really about discussing current threats to health related to lung diseases, tuberculosis was one of the focus of the conference and tuberculosis is by far the largest, at least in middle income and low income countries, by far the largest threat, in terms of lung infection. And the presentation, when India was supposed to present its progress in controlling tuberculosis, it started with a clip showing Amitabh Bachan explaining to people how he had contracted tuberculosis at some point in his life, spinal tuberculosis and how he got cured and that was projected as the major achievement that India had to report in terms of controlling tuberculosis. It glossed over the fact that India actually has done very badly in the last few years in being able to control tuberculosis in the country. And not just that, the Indian delegation there was confronted by activists who were present in the audience who protested and said that India should say some more about why they have not been successful in controlling tuberculosis to a significant extent and the Indian delegation head apparently dubbed them as people who are mentally disturbed. Now, this actually typifies the way in which health care is looked at in this country by successive governments and especially by this government.

Prabir: Coming back to what you said earlier, it’s a big killer in India, largest cause is tuberculosis, the WHO has released a study which seems to show that India has done or India has under reported significantly the number of infections on tuberculosis in India. Now what are the kind of figures and what does it show about India’s public health program?

Amit: The report basically points to the fact that there seems to be a jump in the number of new cases detected between 2014 and 2015 from 2.2 million to 2.8 million. The caveat that the report itself also points to is that these are at best guestimates and in fact what is planned is from next year there is going to be a survey done to try to get more accurate data. The Minister for Health Mr. Nadda is on record having said that actually the number of cases has not gone down but their surveillance mechanism is better, which may or may not be correct. The point that the report is making is that we have far more cases of tuberculosis in the country than what we are planning around and second that we have very poor surveillance mechanism in place for us to be able to accurately determine the number of cases which in the case of tuberculosis is actually very, very problematic because tuberculosis in public health we say, can mimic the symptoms of almost any disease.

Prabir: So India had a good public health surveillance program for a long time or is it that that program is weakened or is it only now that we are finding out the gaps in the program?

Amit: TB was identified even in colonial times as one of the big killers in India. The momentum of the program started in colonial times continued after independence. Right through the 60s, 70s we had a fairly well developed TB control program, doesn’t mean that it was effective in controlling TB entirely but at least we had the infrastructure in place. In the 90s and 2000s this has been replaced by what is called DOTS. DOTS is a program that the WHO advocates now – directly observed treatment. The logic behind the DOTS program has itself been criticized because what it means is that you don’t just give out the drugs, you have to come to a health provider and the health provider has to see you taking the medicines which at one level is very paternalistic, you think that people are not capable of taking their own medicines one, and second, it means the people who are the sickest, who are the most vulnerable would likely be left out of the program because they cannot come to the health center to take the medicines. That is one criticism against the DOTS program. Beyond that the data at least that is available seems to suggest that we are starting to control the problem of tuberculosis from average figures of about half a million people dying every year, the average has come down and plateau-ed at something like two hundred to two fifty thousand every year, still a very high figure. Just as an aside, if you look at TB deaths in India far, far more than HIV-AIDS ever was in India even when the numbers were much higher for HIV-AIDS infections. But what is interesting is that if you look at global funding, if you look at domestic funding, if you look at focus on control of infectious diseases lots of resources put in for HIV-AIDS , doesn’t mean that it shouldn’t have been but comparatively much less effort was put into tuberculosis. But there has always been this problem with tuberculosis except that we had started to believe that it was being controlled to an extent. But the latest WHO figures seem to suggest that that is not really the case. It can only be a conjecture as to what is the reason for these fairly alarming figures. One possibility is this is borne out by the data that we have, that there has now been a rise in the number of drug resistant cases and what are called XDR extreme drug resistant cases which are not responsive to any drug. India has the highest number of both multi-drug resistant and extremely drug resistant cases in the world. Now much of the so-called advance that we made in the TB program probably had nothing to do with what we actually did in terms of providing treatment etc but new drugs that were introduced in the nineties. So, Rifampicin, Ethambutol really came into the public system in the nineties. Before the nineties you had to use streptomycin which required an injection for three months which was a much larger drain on the public services in terms of the personnel required, logistics etc. Second, earlier the duration of the treatment was eighteen months. That was the full duration whereas now, with the new drugs it is six to nine months. So actually by the nineties treatment of TB relatively became much simpler for the public system to actually be able to deliver. And that would probably explain for a transient period the downturn in terms of the number of cases that were detected, the number of deaths due to tuberculosis etc. That honeymoon period seems to be now getting over, more people are getting resistant to the existing TB drugs and the system has not expanded to the extent that was required and that’s the most important point.

Prabir: Apart from them showing videos of Amitabh Bachan what else can the Government of India do with respect to controlling the spread of tuberculosis,controlling the pool of people who are already infected, reducing mortality etc?

Amit: TB has been classically known as the disease of the ghettos, so urban settlements; doesn’t mean you don’t get it in rural settings: you do in India, quite a lot. But typically in urban settlements, slums where you have congested spaces where people live, thereby able to infect each other and things like that. Now, if you look at planning today, urban planning today, the rich believe that they can sanitize themselves, that they can throw out the people so that they are invisible except when they come to their homes or offices to work, gated communities. Unfortunately infections don’t work on that logic and especially TB. So what we have done is that we have created pools of infection by ghettoizing further and further people living in conditions where the rich anyway don’t have a stake. They needn’t speak up for those conditions because they don’t even see them, forget live in such conditions. So there’s no one to speak up for these people. But these are the pools where diseases like TB will fester and will continue to fester so of course we need a much larger expansion of the public health system. But beyond that TB is finally a disease of living conditions and unless simultaneously you also address the issue of how to provide a kind of enabling living conditions which allows people to lead healthy lives especially free from tuberculosis. You will never be just by providing treatment facilities, however much expansive they are, you will never be able to control it.

Prabir: We will come back to you on this and other issues. This is all the time we have on Newsclick today. Do watch Newsclick for further episodes and also do subscribe to our you tube channel and our website.

DISCLAIMER: Please note that transcripts for Newsclick are typed from a recording of the program. Newsclick cannot guarantee their complete accuracy.