TB In India: Is The Crisis "Silent" Or Is No One Listening?

It may seem trite but it's true that health is wealth. By this yardstick, we are a pretty poor nation considering that we are global leaders for a great number of diseases, including cancers, cardiovascular conditions and infectious diseases -- especially TB. 

Notwithstanding the recent discussions on the right to health, our governments continue to hold health as a domain of low priority with little political commitment and innovative thinking resulting in poor financial allocations - less than 2% of GDP.

A textbook case of this neglect is TB. India is home to over one-fourth of TB patients globally and has a growing population of drug-resistant TB cases that are hard to diagnose and harder to treat. Yet, ironically, we are credited with designing, implementing and launching one of the world's largest TB control programmes. A strange contradiction that belies our inability, lack of innovative thinking, and insufficient attention and resources to TB.

Our former Health Minister termed TB a national emergency. He was absolutely right. It is by all means an emergency. Yet even before the TB patient could hope, a new minister had taken his place. So, what measures can be recommended to our minister to respond to this crisis?

Let us start with the fundamentals. The ability to provide basic quality diagnosis and treatment unfailingly to TB patients whether in the public or private sector is a sacred duty of every government. Yet, we continue to fail in this effort. Our efforts to update diagnostics in the public sector and ensure access in the private sector remain well behind our needs. India needs to invest extensively in diagnostics, but seems in no hurry to do so. Procurement delays have lasted for as long as two years. Files languish with bureaucrats and grants are about to lapse. Meanwhile the TB patient continues to wait. Why should any patient have to pay for being diagnosed with TB? And if they do, why it should be prohibitively expensive? India's health establishment seems untroubled by these questions.

Similarly, drug pipelines for both basic and advanced anti-TB drugs are often leaky with no convincing explanations for the cause. Evidence of this was the large-scale drug shortages in 2013, which made headlines across India but with little remedial action. In such crisis, the hardest hit are the children with a perpetual shortage of paediatric drugs which the system generally fails to provide. It is imperative that action is taken to ensure India should not have another drug stock out. However, for that we would need accountability which seems to be missing.

Whilst TB is caused by an infectious microbe, susceptibility to this disease lies in several realms. Overcrowding, unsanitary conditions improper waste management, heavy air pollution and malnutrition contribute the seeding factors that establish this disease through a well-understood inflammation pathway. Unfortunately, the narrowness of the TB control programmes, restricted to biomedicine and technology, rarely address these factors despite historical evidence of their importance in combating TB. We will continue to fail in TB control until we secure inter-sectoral convergence as a means for disease control. As a start, recommendations for nutritional support for TB patients must be prioritised.

With no surveillance systems in place and gross shortages of good quality laboratories we are unable to recognise, prioritise and plan for the control and treatment of the various types of drug-resistant TB. Nor do we know the precise number of TB deaths simply because there exists no reliable system of certification. Finally, we remain in the dark as to how many TB cases really exist in India because two-thirds of patients access the private sector where the government has failed to implement disease notification.

The cruellest cut of all is the perpetual culture of denial that India's TB control officials are mired in. In 2012, the reporting of totally drug-resistant TB in Mumbai was met with hostility and denial. When officials refuse to recognise such a severe problem how can we expect a solution? A visible lack of urgency, concern and innovation seems to have gripped the system. Patients are made to run from pillar to post before the start of even basic treatment.

Nikshay, an information system established with much aplomb, failed to really take off. Finally there are three new drugs that are critical to treating drug-resistant TB. Each of these hold possibilities to improve TB treatment. Yet terrifyingly there seems to be no haste within the government to provide patients access. This bureaucratic lethargy has to be punished if India wants to fight TB.

Unlike the AIDS programme, the TB control programme has failed to mobilise and connect to people in an empathic manner. Its communication is stilted, often patronising. The gaps in human resources have stretched the extent and quality of the public health services.

There are multiple facets of the TB control problem in India that stretch well beyond treatment and diagnosis and have led to basic mistrust of the system and its capacity. It's time the government and our Health Minister did some soul searching and answered the question -- why don't they care enough about TB?