Comeback of a killer

“While these statistics may not be cent per cent accurate, their potential to create disaster is unquestionable,” says Dr Z.F. Udwadia, consultant physician at Hinduja Hospital, Mumbai.

Despite TB being a disease whose cause is known and cure is available, death rates keep rising. In the early part of the century, the practice was to keep TB patients in sanatoriums. But research has proved that it was not very effective.

India has the dubious distinction of having been hit by TB in epidemic form for centuries. “It is supposed to be on the declinenow. But increasing population means an increase in the number of TB patients which makes it worse in terms of numbers,” says Udwadia.

So far, the country has been living with the false hope that a BCG shot is the answer to the problem. Dr Peter Davis, Director of the Cardio Thoracic Centre, Liverpool says that the BCG vaccine is “not very effective”. “BCG protects only three in four vaccinated children, so it is only 75 per cent effective,” says Davis.

Specialists have attributed the rise in TB cases to the ignorance of general practitioners regarding the disease. Says Dr J.C. Kothari, a TB specialist and consultant physician at Bombay Hospital & Bhatia Hospital in Mumbai: “General practitioners have varying standards, there is no updating of knowledge, little formal training in community health and few doctors have knowledge of the National TB programme”.

An overwhelming 90 per cent of the general practitioners, says Dr Kothari, have insufficient knowledge of the disease and continue toprescribe anti-biotics. This tends to make the TB bacterium drug-resistant. “India has one doctor for every thousand people — much in excess of the WHO guidelines of one doctor for every three thousand people. But 50 per cent of these are non-allopathic doctors, while there is an unknown percentage of quacks,” he explains.

This despite the National TB Programme which has been around for three and a half decades. Many reasons are attributed to the failure to bring about an improvement on the TB scene, the main one being geographical constraints. “The country is so vast that some places are inaccessible to the nearest TB control centres,” explains Dr Udwadia. This is compounded by the paltry national budget allocation for TB. “While the TB programme is given Rs 40 crore, we need Rs 400 crore which exceeds the total health budget,” he adds.

Another stumbling block to effective treatment is the attitude of patients. Ignorance topped by secrecy and fear of ostracism keeps them away from propertreatment. “In many cases, after a few weeks of treatment, the patient begins to feel better and then he stops medication,” says Dr Udwadia.

Another reason could be that people in the lower income groups cannot afford the medicines. They are literally in a Catch 22 situation: While private practitioners charge exorbitant fees, the public health care system in the country is not anything to write home about.

The challenge has grown tremendously of late with the emergence of a strain of MultiDrug-Resistant TB (MDRTB). The western world is actually witnessing a resurgence of TB mainly due to this new strain. “Treatment for multidrug-resistant TB is so expensive that very few can afford to get themselves treated,” says Udwadia. It took three and a half years and Rs 5,00,000 for one of his patients to get rid of the disease.

Dr Davis who also happens to have edited Clinical Tuberculosis, the standard international TB text book, says, “The only way TB can be cured totally is when a person is afflictedthe first time”. The only method that has yielded satisfactory results is what is known as Directly Observed Therapy Short-course (DOTS), which is now the main plank of the Revised National Tuberculosis Control Programme (RNTCP). A contribution of Indian research scientists in the ’50s and ’60s, DOTS has been implemented the world over with astounding results.

“During a joint review of the National Tuberculosis Programme in 1992, by WHO and Government of India, we came to the conclusion that the NTP did not meet expectations,” says Dr Frieden explaining why the RNTCP was adopted. Multidrug-resitant TB is basically a manifestation of the poor TB control, he asserts.

“The RNTCP has adopted a fresh approach. It shifts the responsibility for cure from the patient to the doctors, the health system,” says Frieden. Under DOTS, the doctor or medical officer has to ensure that the patient consumes the medicines in front of him. “The doctor administers the medicine wherever the patient finds it comfortable– at home, office or in the clinic,” says Dr Davis. While the costs may be high, more lives could be saved under this programme than through the NTP. Pilot projects have been in place in 13 States since 1993. The results have been encouraging. Eight out of 10 patients diagnosed in the programme since 1993 were cured, which is twice as much that of the previous programme. “Around 40,000 patients have been treated through this method and the success rate is 80 per cent,” says Dr Frieden. In Lucknow, he says, there was 98 per cent cure through DOTS.

Now DOTS covers 1.8 crore people. By the end of 1998, the programme hopes to to cover 14 crore in a phased manner.

A major thrust area for the programme will be providing intensive training for medical practitioners. The programme at the Central, State and even district levels will be closely monitored by specially trained medical officers who will in turn be required to send reports to the TB Centre at Delhi every three months.

“When I was fresh frommedical college, I was sure that by the time I was old, TB would have been eradicated from India. Today, I can only hope that by the time I die, we will able to bring the disease down to manageable levels,” says Dr Kothari.