Going Dotty Over DOTS

A multi-drug resistant MDR patient has a 50 per cent chance of survival even after a two-year treatment that costs Rs 2.5-3 lakh and has such nasty side-effects that 10-12 per cent of the patients commit suicide. The 4 per cent figure, moreover, may be an understatement, for, according to a studydone jointly by the World Health Organisation WHO, Centers for Disease Control Atlanta, US and the International Union Against TB and Lung Diseases, 13 per cent of all TB patients in Delhi are multi-drug resistant.

8220;The five-year survival rate for a person with MDRTB is 50 per cent, which is exactly the same for a person with TB in 1900,8221; says V. Ramalingaswami, National Professor and former Director-General, Indian Council for Medical Research. In other words, multi-drug resistance has negated the progress of medical science in this century.

It8217;s a classic case of what Ramalingaswami calls 8220;the co-existence of good science and bad health.8221; A curable disease is assuming monstrous dimensions simply because the country8217;s health establishment hasn8217;t learnt the right lessons from its past failures. And nowhere is it more evident than in the way the Union Health Ministry is operationalising the Directly Observed Treatment Short-Course DOTS strategy, which, ironically, is the gift of Indianscientists to the world.

DOTS has grown out of two observations. One is that X-ray examinations don8217;t assure a good case detection rate. Hence the emphasis on the microscopic examination of the sputum of suspected patients sputum microscopy, a line of action first recommended by scientists of the National Tuberculosis Institute, Bangalore, in the 1950s, but which was accepted by our health establishment only after the WHO upheld it in 1993. The other logic behind DOTS is that 30 per cent of the patients don8217;t take medicines regularly, which accounts for the growing incidence of multi-drug resistance. DOTS, therefore, is the strategy that WHO has been promoting to the world, but even as New Delhi goes about implementing it at an elephantine pace, questions have arisen about its efficacy in the Indian context.

How can direct observation of 2.2 million patients of whom 800,000 report to the private sector work in a nation where primary health centres PHCs are mere statistics without medical supplies oreven the staff on duty? As Debabar Banerji, one of the country8217;s foremost public health analysts, puts it: 8220;Is it possible to have a healthy Revised National TB Control Programme RNTCP on the body of a sickly public health service?8221;

With just 22,962 PHCs serving 587,226 inhabited villages, even if in the distant future DOTS becomes a truly national programme 8212; which, according to Union Health Ministry estimates, will mean upgrading 10,000 laboratories with binocular microscopes, staffing them with paramedics who8217;ll conduct 100,000 sputum examinations daily, and training one million workers, of whom a lakh will have to be doctors, to supervise the treatment of 750,000 people at any given point of time it8217;ll be physically impossible for patients to report thrice a week for their allotted drugs.

In Delhi, for instance, a Voluntary Health Association of India VHAI study showed that the DOTS centre involved in the RNTCP pilot project was 3-4 km from the farthest points of its catchment8217; area.Patients, therefore, had to hire rickshaws that cost them Rs 12 one way. Which meant for the eight weeks of the intense phase8217; of DOTS, they had to spend Rs 24 a day, Rs 72 a week and Rs 576 in all on transportation alone. And since the majority of the patients were casual labourers who found employment at precisely the time when the therapy could be administered 9 a. m. to 12 noon, a visit to the DOTS centre three times a week meant the loss of a day8217;s livelihood for both the patients and their attendants. Even the most well-intentioned programme cannot succeed unless it takes into account odds like these.

India, according to WHO, won8217;t be able to implement DOTS nationwide before 2010. Flush with World Bank funding 142 million, to be precise, New Delhi flagged off the RNTCP on March 26, 1997, with the promise to cover 271 million people spread over 102 districts by the year 2000; today, 38 districts with a population of 100 million are covered by RNTCP. 8220;We8217;ll add another 39 districts this year,8221;promises G. R. Khatri, the country8217;s top TB control official. Even if he8217;s on course, a mere 27 per cent of the population will have access to a strategy that promises to bring the TB mortality rate down to 5 per 100,000, from 53 per 100,000 at present. 8220;It is not an easy programme to implement,8221; rationalises Deepak Gupta, Joint Secretary TB in the Union Ministry of Health. 8220;And if it doesn8217;t progress properly, the programme will result in greater drug resistance.8221;

The track record of the previous incarnations of the TB control programme, however, doesn8217;t give much cause for confidence. Till 1995, New Delhi had succeeded in launching the old National TB Programme, 33 years after it had been flagged off, only in 70 per cent of public health institutions in 391 of the 496 target districts; even its more recent version, the short-course chemotherapy SCC programme, is active in just 47 per cent of public health institutions in the 252 earmarked districts. An option could be to introduce sputummicroscopy in the SCC centres to improve case detection rates. But the RNTCP8217;s dependence on World Bank funding means DOTS takes precedence over everything else, negating the possibility of a multi-pronged strategy taking into account the many layers of Indian reality. And what if the World Bank loses in TB once it ceases to be seen as a health threat by the western world? That8217;s one possibility New Delhi must give some thought to as it goes through the motions of observing World TB Day.