Opinion Vikram Patel on TB among the vulnerable: When food is a vaccine  

Why did I find this study remarkable? Apart from conducting the research in one of India’s least developed states and amongst its most disadvantaged peoples, the studies were conducted during the first year of the pandemic when most of the country was locked-down for extended periods. Despite these challenges, the studies were conducted with a high level of fidelity to the research protocol, a testimony to the commitment and motivation of the field research teams.

The parent study observed that a 5 per cent gain in weight in the initial months of food supplementation was associated with a 60 per cent reduced risk of dying. But even more remarkable was the finding of the second study: Providing food to the family members of the infected individual was associated with a 50 per cent reduction in the occurrence of lab-confirmed TB infection in these household members. Stunning findings and, not surprisingly, these two papers were published in the Lancet, the world’s most impactful medical journal, and its equally prestigious sister journal, the Lancet Global Health.

In sum, these two studies confirm something that historical and clinical evidence has suspected for a very long time. The largest declines in TB incidence and mortality in the Western world, where TB today is vanishingly rare compared to India, occurred in the first half of the 20th century, before TB antibiotics had been discovered.

The reason was a massive reduction in poverty in those countries contributing to more hygienic living conditions and secure and nourishing food supplies. Despite this observation, with the advent of medications for TB, the treatment of this disease pivoted to these new drugs and attending to social determinants was largely discarded as being irrelevant to the business of healthcare. This is why RATIONS is so very important: These two landmark papers demonstrate, convincingly, that food supplementation is not just an effective treatment for people with TB, but is also an effective vaccine for their family members.

Of course, if food supplementation can be so effective for TB by acting through strengthening the body’s immune system, then one might expect that such benefits may be seen across all infectious diseases and, perhaps, a range of other health conditions. More generally, attending to a wider array of the social determinants of disease through the health care system may offer better outcomes for all diseases associated with deprivation and disadvantage. In my own discipline of psychiatry, for example, it has been clearly demonstrated that income support to poor families contributes to reduced suicide mortality, addressing intimate partner violence contributes to reduced risk of depression in women, and housing support for people with schizophrenia contributes to recovery and reduced mortality due to co-existing medical conditions.

This body of evidence has a singular implication: Healthcare must go beyond its narrow fixation on biomedical interventions if we are to achieve better outcomes both for our patients and for population health. Indeed, the word “universal” in universal health coverage, a goal that governments around the world have embraced, must imply not only addressing the full range of health problems but also all the social determinants that are associated with them. Integrating social welfare services within primary and secondary care facilities offers one strategy to achieve this goal and, in so doing, the public sector will become greatly strengthened and the first choice for the majority of India’s people.

It is heartening to note that the government launched the Nikshay Poshan Yojana in 2018 to offer food supplementation or cash transfers to buy food for TB patients. The RATIONS studies should give renewed impetus to enhance the impact of the scheme by ensuring that food supplementation is delivered simultaneously with medication and to expand the coverage of this benefit to all household members of the patient. Doing so will greatly improve the chances of the government achieving its ambitious target of eradicating TB by 2025.

Apart from these enormously important implications for informing how health care for the poor should be delivered, there is one other aspect of the RATIONS studies, which deserves to be highlighted. In a country striving to be a leader in science but whose state medical institutions have, with a few exceptions, failed to deliver world-class research that is also relevant to the health of India’s teeming masses of the poor and disadvantaged, it is notable that RATIONS was led by scientists working in a medical school affiliated with a university founded by the Islamic Academy of Education, a not-for-profit trust.

The funding for the study came from the Indian Council of Medical Research, in effect financed by India’s tax-payers, and the co-investigators were drawn from the Ministry of Health and Family Welfare and ICMR’s TB research institute. This is a marvellous exemplar of how partnerships between the state and civil society institutions can generate path-breaking science. Such partnerships must be fostered and accelerated in the future, not least under the aegis of the proposed National Research Foundation.

Ultimately, generating high-quality medical research that offers solutions to realise better health for India’s peoples, and especially her poorest, is an extremely important mission for the government, and the robust network of civil society organisations offer a unique opportunity for the state to leverage to build both a healthier country and a scientifically advanced one.

The writer is Pershing Square Professor of Global Health at Harvard Medical School and co-chair of the Lancet Citizens Commission on Reimagining India’s healthcare system