When an adult Mullu Kurumba man, frail and lean, walked into the Gudalur Adivasi Hospital in the Nilgiris complaining of evening fever, chills, sweating, loss in weight and excessive cough, the young doctor at the clinic suspected a tuberculosis (TB) infection. Although subsequent laboratory investigations confirmed the disease, it was baffling to the health team that Mullu Kurumbas, one of the indigenous tribes in the Nilgiris, were now falling victims to the fatal disease - tuberculosis of the lungs.
According to the 2016 global report on tuberculosis by the World Health Organization, India accounts for the highest amount of TB cases in the world with 2.8 million new cases every year. With 217 new cases per lakh and approximately 1400 deaths every day, tuberculosis is indeed a ‘killer’ disease. Global statistics put the estimate to about 1.8 million deaths across the world annually, with 60% of them reported from India, Indonesia, China, Nigeria, Pakistan and South Africa.
What makes these numbers alarming? Mycobacterium tuberculosis, the causative agent of the disease, is increasingly becoming resistant to most of the anti-TB medicines, resulting in the evolution of multidrug-resistant TB (MDR-TB). An estimated 4,80,000 people developed MDR-TB across the world in 2015 alone and require a rigorous treatment of two years with expensive and toxic medicines, to recuperate.
With an aim to raise awareness about the burden of tuberculosis and to mobilize political and social commitment in efforts to end the disease, March 24th of every year is celebrated as ‘World Tuberculosis Day’. This day marks the discovery of the bacteria Mycobacterium tuberculosis, in 1882 by Robert Koch, a German microbiologist and physician, as the causative agent of TB.
The spread of Tuberculosis
Tuberculosis is an infectious bacterial disease characterized by the growth of nodules (tubercles) in the tissues, especially the lungs. While a third of the world’s population contain the bacteria, it does not cause any disease and is latent. Tuberculosis develops inside those individuals whose immunity to resist the disease is very low. Though most infections are seen in the lungs, TB can affect other vital organs like the brain too.
Tuberculosis spreads from one person to another through air, when one comes in contact with tiny droplets of cough or sneeze from the infected person. Factors like poor ventilation, overcrowded dwellings and workplaces, pollution and unhygienic neighbourhoods increase the likelihood of uninfected individuals being exposed to tuberculosis infection. Undernutrition among the poorer sections of the society further fuels a lack in immunity, resulting in increased risk of contracting the infection.
Tuberculosis and Poverty
Tuberculosis has been known historically as the ‘disease of the poor’. Socioeconomic inequalities, migration, rapid urbanization and population growth give rise to unequal distributions of key social determinants of the disease, including food insecurity and undernutrition, poor housing conditions and insufficient access to health care. TB patients who show signs of persistent cough often face social stigmatisation and economic barriers that delay their treatment and lack of social support to seek care when they fall sick.
In many cases, patients with TB find themselves in a downward spiral of poverty because of their inability to work and earn money. People tending to them will often need to give up work as well, resulting in a significant loss of earnings for the family. The cost of treatment, coupled with cost of travelling to clinics and additional nutritional needs, adds to economic woes. The social stigma surrounding the disease prevents recovered patients from getting back to their work due to fears surrounding TB.
Undernutrition, stemming from acute poverty, is identified as the main cause behind 55% of new cases of TB registered in India annually, according to a research published in the National Medical Journal of India. Apart from this, the effects of rampant alcoholism on chronic hunger also need a special attention. Chronic alcoholism tremendously reduces immunity and increases the chances of contracting TB infection.
About seventy years ago, when India became independent, the spread of tuberculosis was rampant with at least one person in every family affected, irrespective of their social status. It may be recollected that Kamala Nehru, wife of the first Prime Minister of India, Jawaharlal Nehru, died of TB. The government then launched its first national health programme focusing on TB, considering its severity. Today, there are about 25,308 Primary Health Centres (PHC) across the country that act as point of care delivery for patients with TB. Also called ‘DOTS (Directly Observed Treatment Short-course) centres’, they directly disburse medicines to patients and also treat the common side effects of the drugs.
The Revised National Tuberculosis Control Program (RNTCP) is a state-government run TB control programme of the Indian government. As per the National Strategic Plan 2012–17, this programme has a vision of achieving a ‘TB free India’, by providing universal access to TB control services. Under this programme, patients receive TB medicines free of cost and are provided quality tuberculosis diagnosis and treatment services across the country. This program, implemented in phases, has had a success rate of 46% in its latest phase.
The real warriors in the fight against the deadly tuberculosis are the health workers at PHCs.
“Attention needs to be paid on their public health skills and leadership competencies”, says Dr. Thelma Narayan, a member of the advisory committee of the Community Action for Health in the National Health Mission.
“It is a huge challenge to have the right human resources trained and to have a functional health system There is not much political attention on this aspect in the TB control programme”, she adds.
TB control is a global priority today and one of the ‘Sustainable Development Goals’, as identified by the United Nations, to be achieved by the year 2050. Most programmes aiming to control the spread of the disease largely focus on providing medicines and ignore the social determinants that play a major role. Poor diagnosis and rampant antibiotic abuse have given raise to multi-drug resistant bacterial strains, complicating treatment of the disease. The recently launched National Strategic Plan for Tuberculosis Elimination has now included universal testing for drug-resistant TB, to mitigate and identify such cases.
“We need a competent public health system which incorporates measures to build the skills of the health personnel to detect the cases, avoid over-diagnosis and prevent unnecessary treatment, all of which cause economic drain to both the government and the patient”, opines Dr. Narayan. In addition, health policies should be supported by development policies aimed to eliminate poverty, undernutrition, unemployment, alcoholism, and improve housing conditions.
While there are plenty of programmes that aim to tackle this deadly disease, the devil is definitely in the details of implementation. Perhaps, if all these measures are taken, we might not have to leave the frail Mullu Kurumba man behind, in this battle. As WHO puts it, we need to certainly ‘Unite to end TB’ and stick to the theme for the year – ‘leave no one behind’.