Why TB is still with us
Challenge in notifying cases is the trust deficit between public and private healthcare systems.
It kills an estimated 4,80,000 Indians each year — more than 1,400 every day, almost one Indian per minute.
Having worked in community health for over two decades in Bihar and Madhya Pradesh, I am well aware of the power of the slogan. Especially of one so simple and telling: TB Harega, Desh Jeetega. And yet, this rang hollow as we marked another TB Day on March 24. The disease is far from being vanquished. It kills an estimated 4,80,000 Indians each year — more than 1,400 every day, almost one Indian per minute.
The startling fact is that this number creates little panic in the public. It doesn’t get any headline attention at a time when everything is a headline — when was the last time you heard a debate in Parliament or on prime time TV on TB? The toll hasn’t reached this figure overnight or in a month or even in a year. India has continued to account for one fourth of the global TB burden for more than a decade despite implementing the WHO-backed Directly Observed Treatment, Short-Course (DOTS) programme nationwide.
Indeed, India is the largest DOTS implementing country and the Revised National Tuberculosis Control Programme (RNTCP) under the leadership of Central Tuberculosis Division, a wing of the Union Ministry of Health and Family Welfare, has been praised internationally.
Recently, the government made three significant important policy decisions to improve disease surveillance: Making TB a notifiable disease (May 2012); including anti-TB drugs under Schedule-H1 (August 2013); and developing a case-based, web-based TB surveillance system.
So why is the disease still with us despite the above and the fact that its causative organism is known, effective drugs are available and key locations of the vulnerable population are well mapped? There are many reasons but let’s focus on one that doesn’t get discussed much: The public-private trust deficit.
Over 80 per cent of people with TB first knock on the doors of the private health sector where the standard of diagnosis and quality of TB care have always been contentious issues. As per norms, a private doctor or hospital has to inform the government about each TB case but this hardly happens. There is a deep trust deficit between the public and the private sector but it’s deeper when it comes to TB. It would be unfair to pass the entire blame for not notifying on private doctors. There is an undue expectation from private providers that they will follow the DOTS administration to ensure treatment adherence. There is no institutionalised mechanism to help them update their knowledge and skills about changing diagnostic algorithms, even the use of anti-TB drugs in appropriate doses for the correct duration.
A study by Zarir F. Udwadia and others to understand the prescribing practices of private practitioners in Mumbai found that the practitioners were never approached or oriented by the local TB programme. Only six of the 106 respondents wrote a prescription with a correct drug regimen. And the 106 doctors prescribed 63 different drug regimens. Wherever those barriers have been addressed, the notification has significantly improved. For example, in Patna, where private doctors have been engaged through a private-provider interface agency, notification has increased fourfold.
Although there have always been provisions for the involvement of NGOs and private practitioners in the government’s anti-TB programmes, the state and district-level programme managers themselves were never adequately oriented towards facilitating the partnership.
RNTCP has an “intermittent drug regimen” (three days of drugs a week). Outside RNTCP, the most common treatment method is the daily drug regimen. Healthcare providers, particularly in the private sector, have always had reservations in engaging with the RNTCP due to a lack of confidence in an intermittent regimen.
That’s changing. The treatment of TB with a daily regimen, under RNTCP, is being implemented for all HIV-infected TB patients across the country and for all TB patients in Kerala, Maharashtara, Bihar, Himachal Pradesh and Sikkim. It is likely to be made available across the country in the near future. This will likely to enhance notification from private sector.
One reason why notification is so important is because TB comes wrapped in silence and invisibility. Anyone, rich or poor, can get infected with the TB bacteria and already more than 40 per cent of the Indian population is said to harbour it. But over 90 per cent of such people (infected) may not fall ill because of TB or spread the disease. This will depend on their immune system, standard of nutrition, the condition of their overall health and their habitat. So, in cases where the patient is well-placed, the bacteria may remain alive inside the body for a lifetime without producing any symptoms. It is the poor and the marginalised who are the first victims.
That’s why the key to the fight against TB is how ministries other than the health ministry respond to the Sustainable Development Goals.
Prevention, care and support to TB-affected people will contribute to other SDGs and will help all, particularly the poor and the vulnerable who have to pay a catastrophic cost due to the disease — debt, loss of wages and death. At the rate of almost one a minute.
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