TUBERCULOSIS in India

India’s  TB  Time  Bomb

                    

Dr. T. Rama Prasad    .......        March, 2020

          March 24, 2020 is 'World TB Day'.

          Robert Koch, a German scientist announced discovery of the bacillus that causes tuberculosis (TB) on March 24, 1882. He must be turning in his grave at our failure to contain TB even after such a long time after his discovery. A day may come when we may not have any drugs to treat MDR-TB & XDR-TB. Given the realities of the scenario, that situation might soon become a frightening reality.

     India is now facing a tuberculosis crisis in terms of morbidity, mortality, magnitude and drug resistance which no earlier generation ever had to face.  There are 2.8 million cases of which  half-a-million may be harbouring drug-resistant bacilli. And 50 crores may be carrying 'latent TB infection'.  Of late, one thousand persons have been dying every day in India due to TB.   And we have been losing 2,240 billion rupees due to TB each year.  Hence, it is imperative that policy makers, politicians in power and the public do some soul searching on the control of TB in India.   Now more than ever, comprehensive and novel methods are to be employed to control TB with the same sincerity and urgency we are witnessing to combat  COVID-19.

TB  Hatao

          If one goes through the 'India TB Report 2018 : Annual Status Report' (https://tbcindia.gov.in/showfile.php?lid=3314),  one gains the impression that there is a committed  political will and a strong programming strategy in place to reach the goal of ending TB in India by 2025,  in line with the 'National Health Policy, 2017'.   Every one concerned should work hard honestly to see that this new initiative would not end as a "TB Hatao" slogan. 

          And to have a critical insight into the conundrum of tuberculosis control in India, read the following.   And read it again in 2025  and on every World TB Day hereafter.

The  PRESENT

          According to the 'Global Report of 2017',  the estimated incidence of TB in India is 2.8 million,  accounting for a quarter of the world's TB cases.   Various new initiatives and policy changes have been made since 2017 for early detection,  better treatment,  more cooperation and positive outcome.   Government of India has set the highly ambitious goal of ending TB in India by 2025,  through 'National Strategic Plan (NSP) 2017 -25', in line with 'National Health Policy 2017'.   This is 5 years ahead of the target of 'Sustainable Development Goals',  and  10 years ahead of the 'End-TB target' of the World Health Organization (WHO). And, according to a recent publication in The Lancet Global Health,  only 57% reduction in incidence and 72% reduction in mortality may be achieved by 2035 with good control measures.  The study projects that eight million persons with TB can be saved over the next 30 years if tests are subsidised and patients are supported to complete the treatment which may cost an extra of 30,300 million rupees.

          In the present set up, with the expressed political will, various new initiatives to facilitate early detection and initiation of cost-free treatment through public health centres and as well through private medical sector are put in place.   Provision of new diagnostic tools like CBNAAT / GeneXpert,  Solid / Liquid Culture DST or Line Probe Assay, and new drugs like Bedaquiline and Delaminid are the additions.   More over, monetary support of Rs.500 per month to the patients during treatment and monetary incentive of Rs.1000 per case to doctors for notifying and giving drugs at the government's cost are being given.   And legally, TB is made a 'notifiable disease'  for better follow up and management.  In addition, pan-India engagement with private sector to close the enormous gaps across the patient-care-cascade in private medical care is initiated through NSP, WJCF, CHAI, CHRI, FIND India, GFATM, CTD, WHO, JEET, etc. to eliminate TB during 2017 - 25.

         We should hope and wish that this strategy would eliminate TB from India by 2025.  The proof of the success may be seen in 2025.   'The proof of the pudding is in the eating'.   Let's review in 2025.   To have a look at the flip side of the coin ('darshan' of the 'avatar' on the reverse), read the following.  And read it in 2025 and on every World TB Day hereafter.

From the PAST  to the  PRESENT

Half a century ago (1967), I entered the campus of a tuberculosis (TB) sanatorium as a medical officer.  It was a sprawling campus of more than 350 acres with serene atmosphere and salubrious climate where about 300 in-patients used to stay.  At that point of time, I thought that the “unfashionable”  TB and the sanatorium would be nonexistent after half a century, with the advent of new drugs. The half a century is now over.  While the sanatorium is fading away,  TB is killing more people than ever before in history  --  1,000 people everyday in India at present !  And, though poverty and TB have a mutually reinforcing relationship,  the wealthy are also affected by TB as the disease spreads through air,  and as even an aristocrat can’t have private air though he may have a private jet aeroplane. Dubbed as “Ebola with wings,”  it flies freely from place to place.  Kamala Nehru, Mohammed Ali Jinnah, Srinivasa Ramanujan, Lennec, Lady Roosevelt, John Keats, Shelly and a host of other celebrities succumbed to TB ! 

     DRUG RESISTANT  TUBERCULOSIS

In those days, words like ‘multi-drug-resistant tuberculosis (MDR-TB)’,  ‘extensively-drug-resistant tuberculosis (XDR-TB)’ and virtually incurable ‘totally-drug-resistant tuberculosis (TDR-TB)’ were not in our parlance.  And, 40 years ago,  I wrote in the columns of The Hindu (Apr. 28, 1977) that" … development of drug resistance, which is a result of inadequate and irregular treatment mostly, has far-reaching implications and if unchecked would make tuberculosis totally unmanageable by the present methods in course of time, whatever be the means. Irregular and inadequate treatment keeps the patient often alive, suffering and infective to disseminate drug-resistant organisms into the environment…. "   Now,  with my experience of half a century in this field, I find that there is less guarantee of a cure now than a few decades ago, notwithstanding the availability of more drugs, due to drug resistance. The ancient disease which is ‘unpopular’ and not ‘sexy’ among the present breed of doctors has become formidable through a metamorphosis due to our misuse of medicines.  There were tools, but we didn’t use them properly.  And so we landed in the medical quagmire.  And now it seems that TB has become insurmountable and invincible,  notwithstanding the introduction of new regimens which include molecules like Bedaquiline, Linezolid and Pretomanid.

GLOBAL  TUBERCULOSIS  REPORTS -- 2016 - 2019 

The magnitude of the problem is underlined by the ‘Global Tuberculosis Report’ released in October 2016.  It stated that India had underestimated TB data between 2000 and 2015.  The present estimates of the report indicate that India has the major burden of having 27 per cent of all the TB cases (10.4 million) in the world (China 14%, Russian Federation 9%), with 2.8 million new and relapse cases,  and more than 4,78,000 deaths (34 per cent of more than 1.5 million deaths worldwide) each year.  And the number of ‘multi-drug-resistant TB’ cases in India in 2018 is a shocking half million (1,30,000 in 2015), topping the world, and ticking the ‘India’s TB Time Bomb’.

Another recently published study (PLOS Medicine, October 25, 2016) found that only 45 per cent of the patients treated at government TB health facilities completed the course of treatment in 2013, and that 61 per cent of them had a relapse of the disease within one year of completion of the treatment                                                                                                                                              1                  (http://journals.plos.org/plosmedicine/article?id=10.1371%2Fjournal.pmed.1002149&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+plosmedicine%2FNewArticles+(PLOS+Medicine+-+New+Articles) !  The actual picture may be worse which may be known to some extent only after the completion of the “National TB Prevalence Survey” scheduled for 2017 – 2018.   No amount of spin and gloss can hide the bitter truth.

IMPERIAL COLLEGE, LONDON STUDY        
                                                                                                                                                                                                                   

A recent (August 25, 2016) study, published in The Lancet Infectious Diseases (www.thelancet.com), by the Imperial College of London, the Government of India’s Revised National TB Control Programme, the World Health Organization (WHO) and some other  organizations(http://www3.imperial.ac.uk/newsandeventspggrp/imperialcollege/newssummary/news_25-8-2016-11-33-10 )  revealed startling information about TB in India.  The study  reveals the disturbing fact that the true total TB burden of India could plausibly be closer to 2.6 to 6.8 million  --  that is 1.2 to 3 times more than the currently believed official estimates of 2.2 million !  It also indicates that over 2 million cases of TB cases were treated (2014) by India’s private sector alone which means that the ‘private bulk’ is of more than 80 per cent of the 2.2 million cases in India.

“WHO”  DISILLUSIONED

Some may think that I have been barking up the wrong tree, but the announcement by the World Health Organization (WHO) in October 2016 to seek a ‘Special United Nations General Assembly (UNGA)’ session on TB vindicates my critical comments.  The WHO seems to be frustrated by the lack of political will to control the deadly TB which has increased by 34 per cent  in India according to the ‘Global TB Report’. The 'Stop TB Partnership' and the WHO will discuss commitments from global heads of State ahead of the 'UN High-Level meeting' on TB in September 2018.  It is time for the alarm to be sounded, when governments cast a blind eye to blatant warning signs.  Some may say that lack of availability of the two new drugs - Bedaquiline and Delaminid - is the cause for increased incidence of drug-resistant TB;  it is like saying that people are dying as there are no ICU units in all the villages !

FAILING   PROGRAMME

Following a good deal of research in India in collaboration with international bodies, domiciliary treatment (treatment at home) came into vogue and we sang the dirge of the TB sanatoriums.  

Authorities publicized that people can easily get rid of TB with just six months treatment at home, fostering undue complacency among the public which did more harm than good.  Often, I ask  the patients, some doctors  and the public ... 'Is it true that TB problem is less, and that it is more easily curable now, compared to earlier decades ?' ... most of them say that it is true.  That is the level of complacency fostered.  Today,  people are more scared of ‘Swine flu’ and ‘Dengue fever’ than TB.  They just don’t know that TB has been killing 1,000 persons every day in India.  Even the 'tsunami' could kill only 1/20 th (18,000) of the annual toll taken by TB!  And imagine the stupendous economic loss to the country and the families due to the morbidity and mortality.  The magnitude of the problem does not attract anybody’s attention as TB disables and kills very slowly unlike Ebola or tsunami which grab national headlines.

Incorporating domiciliary treatment, the ‘National Tuberculosis Control Programme (NTCP)’ was established in 1962.  As it didn’t yield the expected results, the programme was modified as ‘Revised National Tuberculosis Control Programme (RNTCP)’ during 1993 to 1998.  Since 1997, 'thrice-weekly' regimen was being followed by the RNTCP.  As this regimen was thought to be associated with increased incidence of drug resistance and relapse, WHO recommended 'daily drug' regimen in 2010 to be adopted by the RNTCP.  And it took seven long years for our authorities to launch the change to the 'daily regimen' in November 2017 !  (http://pib.nic.in/newsite/PrintRelease.aspx?relid=173607).   Imagine the contribution to drug resistance and relapse by the TB control programme.   And, how "Directly Observed" is the "Directly Observed Treatment, Short-course (DOTS)" ?  And, the problems encountered in "Directly Observed" and the ground realities are well detailed in  http://www.thehindu.com/sci-tech/health/Improving-access-to-DOTS-is-crucial/article14580472.ece ... the detail gives the reason why it could not be "Directly Observed" here while it could be in Singapore ... of course, they have draconian methods to ensure regular intake of DOTS drugs strictly as per the protocol.

      The authorities which kept on painting a rosy picture had a zillion-volt shock when a report released on the eve of World TB Day (2012) by the World Health Organization (WHO) stated that ‘India presents a dismal picture having the highest number of MDR-TB cases in South East Asia’.  As a knee-jerk reaction, another “revision” of the RNTCP took place with the draft versions of the Joint Monitoring Mission(JMM) and the National Strategic Plan for tuberculosis Control (NSPTC) 2012 -2017 setting the road map for RNTCP for the next five years.  Thus, we are completely disillusioned with the TB control programme.  I don't place the blame entirely on doctors or other staff members of the 'Programme', as there are several factors beyond their control.  Many of them do what they are programmed to do according to the protocol and project a praiseworthy picture which they are expected to do (to please the bosses).  And, like all "good" officials, those concerned with TB have the challenge to try and minimise the implications of damaging data.  And the statistical data on health and disease in India don't enjoy a lot of authenticity and credibility. The whole world was mislead to believe that TB was controlled in India.  This is a prime example of the welfare schemes being far removed from the picture that organisers paint on paper.   Work culture, from top to the bottom, is a factor of paramount importance in translating theoretical projections into practical achievements.  People who visited workplaces in very successful countries know the difference.  The past and the present strategies to contain the dreaded scourge are theoretically excellent, but, but … (the pessimism is intended).

PUBLIC   PRIVATE   PARTNERSHIP                                                                                                           

Then is invented the catch-term “Public Private Partnership”.  Apart from four other objectives and improvements, the main thrust in the new strategy is to extend RNTCP services to patients diagnosed in the private sector as it is estimated that 60 to 80 per cent of the TB cases in the country are treated by private doctors.  It is now projected that ‘Public Private Partnership (PPP)’ would be a game-changer for the TB programme.

 Hence, another mantra is being chanted: 'Go where the patients go' (private practitioners).  But there are enormous gaps across the patient care cascade in the private sector.  To close the gaps and streamline the system the idea of pan-India engagement, coordination and motivation is mooted.  Thus, a consortium of various bodies and schemes are involved to rope in the private sector -- National Strategic Plan (NSG) to eliminate TB by 2025;  William J. Clinton Foundation (WJCF);  Clinton Health Access Initiative (CHAI);  Centre for Health Research & Innovation (CHRI);  Foundation for Innovative New Diagnostics (FIND India);  The Global Fund to Fight AIDS, TB & Malaria (GFATM);  Joint Effort for Elimination of Tuberculosis (JEET) to bring all these under one umbrella; Central TB Division (CTD) of Ministry of Health & Family Welfare;  State TB Office (STO);  WHO,  etc.  Eh ? What's this, too many cooks ?    ... spreading the risk of bearing responsibility makes one comfortable ... (pun intended) ... let's see whether the joint venture would tame the terrible TB.  And, in addition,  the 'offers' are there --  monetary support of Rs.500 per month to the patients during treatment and monetary incentive of Rs.1000 per case to doctors for notifying and giving drugs at the government's cost.  But where are the takers ?
                                 

For obvious reasons, there can be neither  interest, commitment nor capacity in the private sector to meet with the protocols and expected responsibility.  Because of this, the projected success of the revised and re-revised strategies may just be a chimera.  A programme which has failed over half a century can’t be expected to do wonders with a little more revision.  Why all this hoo-ha ... singing the same chorus in a different style ?

RITUALISTIC  EXHORTATIONS

        The annual rituals of conducting rallies, delivering sermons and hosting seminars on the World TB Day (March 24) have been going on mechanically.  Statistics rolled out in India must be viewed keeping in mind that the infrastructure is plagued by lack of well-structured and genuine reporting systems.  In the midst of all the brouhaha, one would leave the platform with a sense of déjà vu.  All the theatrical activity dissipates quickly, much like the fizzling out of the effervescence from a soda bottle.  Hackneyed  gestures and lackadaisical efforts are common.   One who follows up these acts would see the great farcical dimensions.  Grand pronouncements and rhetoric do not meet reality.  

STATISTICAL  FICTION

             On paper, everything seems to be genuine – planning, execution, accounting, results, democratic procedures, elections, technical jobs, professional dealings, and you name it. It may sound a triffle ironic, but the power honchos and the highly talented decision making bureaucratic brains are not necessarily the best or smartest people around.  Even the best planners in our set up run around in circles which is the easiest and conventional way.  We seem to have become experts in writing ‘statistical fiction’.  The much-touted achievements are part of this fiction.  Infrastructure is plagued by utter lack of well-structured and genuine reporting systems. Officials cook the books to please their bosses or to retain their seat.  None takes the statistics on health and disease in India without a pinch of salt.  If the statistical data are false,  it is natural that the results of the programmes based on them would be disappointing.

                                      “Lies, damned lies and statistics.”

                             --   Benzamin Disrael

‘TB’ for ‘Tuberculosis;  ‘TB’ for ‘Time Bomb’ ! 

WORLD  TB  DAY  …  March 24

What joy is it to celebrate the ‘World TB Day’ today when 1,000 persons are dying due to tuberculosis (TB) today in India as on any other day during the recent years ?  And, what pleasure is it to celebrate when doctors are threatened to be put in jail for not giving some information about their TB patients to the district officials ?  A notification made public on March 16, 2018 by the Union Health Ministry spelled out that doctors, chemists, hospital staff and druggists can be punished with jail term of six months to two years for not informing government authorities about their tuberculosis (TB) cases.   In India, TB was made a notifiable disease – like some diseases required by law to be reported to government authorities – in 2012, but not many cases were notified.  And, there was no provision until now to take penal action if cases were not reported.

            This is another joke in the infamous history of TB in India;  another knee-jerk reaction generated out of frustration, desperation and depression borne out of an empty feeling of not knowing what to do with the exploding drug resistance and the 'more than 1,000 deaths per day due to TB in India today'.  It’s like bolting the stable door after the horse has bolted !  

            In 2017, they thought that “Public Private Partnership” was the game-changer in the control of TB. And, in 2018, it is putting the doctors behind the bars and bringing the ‘National Strategic Plan’ to the fore, and  to 'Go where the patients go' !   Every year, on the occasion of ‘WORLD  TB  DAY’ they get novel ideas.  On paper, through legislation, we had already put an end to food adulteration, dowry evil, rape devils, crony capitalism, roaring corruption, booming bribery, and what not !  Did we not !  We don't take bribes, only "gifts" and "incentives" ...  we have to wait and see if the 'incentives' of Rs. 500 & Rs. 1000 would work in controlling TB. 

 And now we can relax as we seem to have solved the TB problem also by ensuring notification of the TB cases through legislation !!! With this draconian legislation, it is expected that most of the TB cases treated in the private sector (2 million -- more than half of the total number of the cases, according to the  study by Imperial College, London) would come into the official information net and thus followed up to the scientific completion of the treatment.  Reel is very different from real in our country.  The legislation may be ignored, or, if at all it is strictly implemented, the private sector doctors may just not treat the TB patients just as they don’t touch road accident victims or medico-legal cases, mostly.  By doing so, they don’t lose anything significantly.  Even otherwise, generally, the trend is to shun from treating TB patients for various reasons. Then who is going to handle this huge chunk of cases not cared for by the private sector ?  Government ?  There is no dearth of laws.  Only their implementation leaves much to be desired.   Responsibility is scattered and the punishment for violation of norms is too mild to be a deterrent.

            

Then, what is the effective solution?    

EFFECTIVE   SOLUTION

          Tuberculosis control is a quirky conundrum,  plagued by an abundance of problems and no clear solutions.   If the medical mess is about uncontrolled regimens of treatment,  burgeoning drug resistance and flagrant violation or ignorance of treatment guidelines,  it is also about bad infrastructure -- designed and executed poorly with absolutely no realistic foresight.   That is exactly why any revision after revision of the control programme is making health officials lose sleep.  

                 First,  let us have an idea about the problem.  The problem has been persistent, and increasing due to  (a) lack of a really effective vaccine to protect the population (TB would have become a thing of the past just as smallpox or polio if a very effective vaccine could be made – the BCG vaccine that is available does not totally protect against TB),  (b)  long duration of treatment (minimum 6 months) which most do not complete and end up as dangerous reservoirs of infection,  (c)inadequate and irregular treatment which results in drug resistance and keeps the reservoir of infection alive,  (d) spread of the disease by air through bacilli, coughed out by patients, which may remain infective for long periods – even months – and which may be carried by air to far away places to infect people everywhere,  (e)  low socio-economic living conditions which cannot be improved in the near future, and (f)  enormous segment of undiagnosed cases which spread the disease silently.  (g)  Irrational prescriptions by qualified doctors and by quacks which are common place in India.  (h)   irregular intake of drugs which is very common ... needless anti-TB treatment is also hazardous  

(i) huge presence of HIV and diabetes which favour development of TB   (j)   immense social stigma attached to TB and HIV which makes the people not to come out openly for treatment ... they silently spread the disease until they are stopped by death. 

If we take all these factors into consideration, it would be obvious that the most important plan to prevent and control TB is to detect all the cases of TB and treat them properly to make them all non-infective, if necessary, in a dictatorial way as is being done in Singapore or China.  To carry out this plan, the people at the helm of affairs should think outside the box of RNTCP and radically pursue a different course rather than just trying to prop up unsuccessfully again and again through revisions of the programme.  Antiquated disease control policies are legacy walls built by economic rules and regulations ... it requires a cerebral effort to bring down the walls of the traditional thinkers.

It is a gargantuan problem, but not an insurmountable one. The solution lies in the radical initiative of taking over the entire responsibility of detecting and treating TB throughout the country (which should include nutritional and economic assistance to the family members of the patient during the long period of treatment) responsibly, properly and exclusively by the government, as a vertical programme governed by an administratively and financially autonomous body, if necessary by creating a separate Ministry.  It is important to be autonomous,  as we all know too well how the game of governance – a game of handball between Ministries, Departments and Organisations – is played in our set up.   

                                                                                                        

It means that anyone outside the government facilities should not treat TB patients.  Once the diagnosis is made by a private practitioner, the patient has to be referred to the government agency for treatment.  The agency would be endowed with all the means, powers and teeth to ensure perfect treatment, and isolation, if necessary, to make sure that the patient would not transmit the disease to others.  It also means that TB drugs shall not be available in private medical shops (as in Brazil and Singapore).  This may seem to be utopian and quixotic but this is the only sure way to contain the insurmountable and invincible scourge.  Then the ready-made question springs up: "Where is the money for all this?"

Where are we getting the enormous money for space research and such things from?  That is from the government’s riches.  On March 31, 2018, India lost Rs. 270 crore due to the failure of a single satellite (GSAT-6A). About private riches, Indians have an estimated $462 billion, or about Rs.26 lakh crore, in tax havens abroad, according to Global Financial Integrity, a Washington-based think tank (October, 2014).

                Should we be proud of sending space vehicles to Moon and Mars or should we hang our heads down when 1,000 persons are dying every day due to TB in India as it is today?

    “O  miserable abundance,  beggarly riches."                                                                                 --John Donne

 (Dr. T. Rama Prasad is a former Medical Superintendent of the Ramalingam Tuberculosis Sanatorium  &  Perundurai Medical College and Research Centre, Perundurai.  His email ID is drtramaprasad@gmail.com)

                                                                                                                                                                                                                                                                                                                                                                                       

 

  

References:  

The following published articles were written by Dr. T. Rama Prasad.  (For more articles by this author, go to the title "About me and my Scribblings" on this blog / website.)

 1.      Drug Resistance in Tuberculosis  -  Journal of the Indian Medical 

        Association,  Vol.  64, pp. 264-267,  1975.

 2.    Childhood Tuberculosis - Part I - The Antiseptic, Vol. 76, pp. 449-504,1979

 3.    Childhood Tuberculosis - Part II - The Antiseptic, Vol. 76.  pp. 567-574, 1979

 4.    Short-course Chemotherapy - The recent Advances in the Treatment

        of Respiratory Tuberculosis - Current Medical Practice, Vol.24,

        pp. 41-46, 1980.

 5.    Drugs in the treatment of Tuberculosis - The Antiseptic, 

        Vol. 75,  p.678, 1978

 6.    Chemotherapy of Tuberculosis - The Antiseptic,  Vol. 76,  p.248,  1979.

 7.    Streptomycin in Tuberculosis - The Antiseptic,  Vol. 76,  p.516,  1979.

 8.    How effective is the TB control programme ?  (Special Article) -  

        The Hindu,  Vol.100,  No. 274,  p.8,  1977.

 9.    Five years Plans and TB Control Programme (Special Article) - 

        The Hindu,  Vol.101, No. 275, 

10.   National Tuberculosis Control Programme -  views presented,  

        on invitation  by theTuberculosis Association of India,  at the 32nd 

        National Conference on  Tuberculosis and Chest Diseases,  1977.

12.   Correlation between Geomagnetic Activity and Haemoptysis -

        paper  presented at the II Tamil Nadu State Conference on Tuberculosis 

        &  Chest Diseases,  1980.

THIS  IS  AN  ABRIDGED  TEXT  OF  MY    'SCRIBBLING'.     FULL  TEXT  WILL  BE  POSTED  LATER.        --  T. Rama Prasad

Dr. T. Rama Prasad

'PAY WHAT YOU CAN’ Clinic, Perundurai, Erode Dt., TN, India., 

Former Medical Superintendent (Special), RTS & IRT Perundurai Medical College and Research Centre, Perundurai.

Website: www.rama-scribbles.com & Blog: https://drtramaprasad.blogspot.com & Twitter: @DrRamaprasadt & Facebook: T Rama Prasad & E-mail: drtramaprasad@gmail.com & WhatsApp: +91 98427 20393.

 

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