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India’s TB report must be seen in light of the country’s slide in Hunger Index

With a virtually unregulated private health system, an increase in notification of TB patients could be heartening for the government. But for the public health system, it is bad news.

Written by Shah Alam Khan |
Updated: October 26, 2019 1:44:32 pm
An end to TB is not possible till we end malnutrition, poverty and poor sanitation.

Over the last month or so, we saw some important documentation on India’s public health. The Annual India Tuberculosis (TB) report was released by the government on September 26. India is now home to about a quarter of the total global TB patients. The current government is committed to ending TB in India by 2025.

On October 2, Prime Minister Narendra Modi declared that rural India was open defecation free (ODF). On October 16, the Global Hunger Index (GHI) 2019 was also released; it put India at 102 in a list of 117 countries. Unfortunately, India’s ranking was below Nepal (73), Bangladesh (88) and Pakistan (94). Over the last century or so, it has been established beyond doubt that TB is more of a social disease owing its roots to poverty, malnutrition and poor sanitary conditions.

It is thus important to evaluate India’s TB report in the context of these two developments — India’s continuing downfall in the GHI and the declaration of our villages as ODF.

The TB report should reveal the progress on the government’s action plan on combating TB. Any evaluation of the report will be a reality check of the government’s resolve to end TB by 2025. As per the report, 21.5 lakh TB cases were reported in the country in 2018 — the highest number of TB cases registered in any country. The report says that with the introduction of Nikshay, the computer-based surveillance programme for TB patients, the reporting of TB cases has improved dramatically.

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The working of such a surveillance programme in an unequal country like India should, however, be taken with a pinch of salt. In a paper published in the BMJ Open in February, a qualitative analysis of the barriers to TB notification was evaluated. This study, conducted in a private tertiary hospital in South India, concluded that despite a national notification system — of Nikshay — other factors like patient confidentiality issues, poor knowledge of notification system, etc, prevented notification of TB patients in a hospital setting. These factors are social and without intervening at that level, it is hard to believe that the notification of TB cases can reach a significant number vis-à-vis ending TB by 2025.

The report also reveals that of the total notifications, 5.4 lakh cases were from the private sector, an increase of 40 per cent from last year. The report appears to mention this fact with a degree of pride. A closer look, however, should make us sit up and take note. Over the last decade or so, there has been a near-complete takeover of India’s health sector by the private players. Data shows that more than 80 per cent of healthcare is now being delivered by private health enterprises — something is evidently not right with the public health system.

With a virtually unregulated private health system, an increase in notification of TB patients could be heartening for the government. But for the public health system, it is bad news.


The GHI report is another stark reminder of what else is wrong in claiming that TB can be ended by 2025. A hungry India cannot be free of TB. Dietary deprivation is a direct indicator of inequality. Unequal societies cannot be made free of disease and infirmity. In an important study on nutrition and TB published this month in the BMC Pulmonary Medicine journal from Ethiopia, the researchers clearly show that the proportion of malnutrition in TB patients was nearly 60 per cent. The authors conclude that even a very distal reason for malnutrition in the community became a proximal causefor TB.

Finally, we are told that rural India is now ODF. The truth of this statement awaits documented validation through well-planned studies. However, TB and sanitation have a direct causal relationship. The Integrated Disease Surveillance Programme run by the National Centre for Disease Control maintains a web portal that details the outbreak of epidemics. Since 2009, all outbreak are reported on a weekly basis.

We evaluated the validity of the claims of the Swachh Bharat Abhiyan (SAB) through the data on this website. It was seen that there was no statistically significant reduction in the occurrence of vector-borne epidemics in the country, two years after the launch of SAB.


An end to TB is not possible till we end malnutrition, poverty and poor sanitation. We need a paradigm shift in the response to TB. This should include a more sensitive approach on gender and towards the underprivileged.

This article first appeared in the print edition on October 26, 2019 under the title ‘A health warning’. The writer is professor of orthopaedics, AIIMS, New Delhi. Views are personal.

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First published on: 26-10-2019 at 04:10:30 am
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