Private medical practitioners are delivering a wide range of largely inadequate treatment and care to tuberculosis (TB) patients in India, according to a recently-released study. Carried out in Mumbai and Patna, the study involved 24 dummy patients going to allopathy and alternative medicine practitioners with four different types of TB presentations. Accurate management was provided only in 37% interactions or one in three patients.
The findings, published in the PLOS Medicine on Tuesday, are concerning as the first point of contact for nearly 50% to 70% patients with TB symptoms are private practitioners.
The study was carried out between November 2014 and August 2015. The dummy patients, called Standardised Patients, trained to portray four TB case scenarios, went to 730 private practitioners in Mumbai and 473 in Patna. Of the 2,602 interactions these patients had with the practitioners, correct management was observed only during 959 interactions as per national and international standards.
During the remaining 1,643 interactions, the patients came back with inaccurate prescriptions.
“There are two areas of concern. The diagnostic delay can contribute significantly to deterioration of the patient’s condition and lengthen the time during which the patient remains contagious. The findings suggest that there are systematic deficits in the management of TB in the private sector,” said Dr. Madhukar Pai, Director of McGill Global Health, and a co-author of the study.
“A similar study that we conducted in Nairobi and Kenya uncovered much higher rates of correct case management. So, there is something systematically wrong in India,” he said.
UN meet on TB
The revelations come at a time when TB has taken centre stage with the United Nations General Assembly’s first-ever high-level meeting on TB scheduled on Wednesday. India accounts for a quarter of the estimated 10.4 million new cases worldwide and the government has put the focus on the private sector’s engagement in controlling the spread of the infectious disease.
“The most worrisome cases are those where the doctor does not suspect TB at all, but then gives the patient fluoroquinolones and steroids. Fluoroquinolones can mask the symptoms of TB and further delay diagnosis, and steroids can exacerbate the condition”, said Dr. Pai.
The study, however, also debunks the belief that alternate medicine practitioners like Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) may be prescribing anti-TB drugs.
“No one is using TB drugs indiscriminately. AYUSH and informal providers are not using them at all,” said Dr. Jishnu Das, co-author of the study. Dr. Das said the good news is there are smaller groups of doctors in both cities who are performing at consistently high levels. “The key, therefore, will be to set up systems that allow us to identify these high-performing providers and see whether we can nudge patients towards them.”
Changes since 2015
Medicals experts, however, said much has changed on the ground over the last few years.
“The study was carried out between 2014 and 2015. In Mumbai, we started intensive sensitisation and training of private practitioners in April 2015 and there has been a lot of improvement in the standard of care for TB,” said Dr. Daksha Shah, Mumbai’s TB officer. Dr. Shah said findings of the study do not reflect the current scenario.