March 24 is World TB Day, and a good time to take stock of progress in tuberculosis control, especially in India, the country with the largest number of TB cases.
India's rise in the field of science and technology has been grabbing headlines in the recent past. Last month, Science , the world's leading science journal, carried an entire section on science in India. It included an interview with Prime Minister Manmohan Singh, on his vision for India's future in R&D. India's efforts in the area of health, particularly polio, have been widely recognised. India, by any metric, is going through a phenomenal growth spurt and progress is visible in many areas — from economic development to success in communications and technology. Amid these positive developments, we should ask if India's progress is reflected in how tuberculosis is controlled. TB is one of India's oldest and perhaps most neglected public health challenges.
Drug-resistant form
India's Revised National Tuberculosis Control Programme (RNTCP) is widely appreciated for having made a big contribution by expanding basic diagnostic and treatment services to cover 100 per cent of the Indian population. A laudable but insufficient achievement in a country of 1.2 billion people. Why? Because despite these achievements, India has over two million new TB cases every year and TB kills nearly 1,000 people every day.
The emergence of drug resistant TB has made things worse. Three months ago, a team from the Hinduja hospital in Mumbai reported a few cases of “totally drug-resistant tuberculosis” — suggesting that this form of TB was incurable because of resistance to all the TB drugs tested. This report from Mumbai generated a firestorm of media and political response. How effectively can India handle drug-resistant tuberculosis? Not well, is the short answer. In 2010, only five per cent of patients who needed drug susceptibility testing actually got screened and only two per cent of the estimated 99,000 patients with multidrug resistant tuberculosis actually got appropriate drug treatment via the RNTCP.
The RNTCP has been consistently under-funded for many years, even though tuberculosis control is a very cost-effective strategy for improving the health status of India's population, with exceptional return on investment from a societal perspective. Indeed, India's health-care spending continues to remain one of the lowest in the world. What's more important to consider are the human and economic costs of not controlling TB, particularly drug resistant TB.
What about India's large private sector, which manages over half of all tuberculosis cases? Unfortunately, tuberculosis management practices in the unregulated private sector vary widely, often deviating from established standards. For example, inaccurate, blood-based, antibody tests are widely used, along with irrational drug regimens. Indeed, since antibiotics are easy available over-the-counter, antibiotic-resistance is a major threat for control of all infectious diseases. Also, there is virtually no reporting or notification of confirmed TB cases to the RNTCP by the Indian private sector. Thanks to reports of totally drug-resistant tuberculosis, efforts are now underway to make TB reporting mandatory.
Ultimately, the typical tuberculosis patient in India is caught between two suboptimal options — an under-funded public programme with limited capacity to deal with drug-resistant tuberculosis, and an unregulated private sector where mismanagement is likely. Not surprisingly, patients often move from one provider to another, and between private and public sectors. And while they do this, they continue to transmit the infection to those in their families and communities.
Way forward in control
To control tuberculosis and prevent drug resistance, political commitment and substantially greater resources are necessary. There is good news on both fronts. The RNTCP is beginning a new phase, the National Strategic Plan (NSP), for the period 2012-2017. The programme has already shown great commitment by setting the ambitious goal of universal access to quality diagnosis and treatment for all TB patients in the country. The RNTCP's vision just received the much-needed boost. The Planning Commission has raised allocation for the RNTCP to about Rs.710 crore for 2012-13, an 80 per cent increase over the last fiscal year's budget. While this is a welcome development, there is no doubt that even more resources will be required to reach the goal of universal access.
However, the government alone should not be expected to provide all the answers or resources. Indian industry, celebrities, philanthropists and high net-worth individuals can and should make a bigger contribution to control a disease that causes an economic burden of $23.7 billion annually. Indian celebrities and philanthropists have a track record for championing causes such as HIV/AIDS, polio and cancer prevention. Everyone in India remembers the big impact Amitabh Bachchan had on the pulse polio campaign. In sharp contrast, they have rarely stepped forward to champion the cause of tuberculosis control. For a brief while, A.R. Rahman served as the Global Ambassador for the international Stop TB Partnership. Sadly, his talents were under-utilised.
TB is one of India's greatest public health challenges but sadly it lacks support from the media, the rich and the famous. What India needs is a Rahul Dravid or Virat Kohli, a Vidya Balan or an Aishwarya Rai Bachchan, a Nilekani or a Tata to take up the fight against TB. Until that happens, TB will always be a disease that happens to someone else and one whose control does not need our collective efforts.
(Dr. Madhukar Pai is Associate Professor, Department of Epidemiology & Biostatistics at McGill University, Canada. Email: madhukar.pai@mcgill.ca)
