In the past, there was a belief that every ill had a pill and the pill killed the germs that made you ill. That germ could be a bacteria, virus or a parasite. Factors such as genetic and metabolic causes, hormonal imbalance and altered neuro-chemical transmitters causing illnesses were less known then. But there was fairly good knowledge of how good air and nutrition reduced consumption illnesses such as tuberculosis (TB).
History and a perspective
This is why sanatoriums/sanatoria were set up in mountain terrain, with fresh air, pure water and good food, in the quest for a cure for TB. There were no drugs for TB till the discovery of streptomycin in 1943. With improved wages, better living standards and the accompanying higher purchasing power for food, the TB mortality rate came down from 300 people per 1,00,000 population to 60 in England and Wales. TB disappeared from socio-economically developed countries long before the advent of chemotherapy. After the Second World War, in 1946 G.B. Leyton reported a 92% reduction in the incidence of TB among British soldiers who were fed an additional Red Cross diet of 1,000 calories plus 30 grams of protein when compared to Russian soldiers who were fed only a camp diet. This historical importance of good nutrition was ignored by the modern therapist who tried to control TB initially with streptomycin injection, isoniazid and para-aminosalisylic acid. In the ecstasy of finding antibiotics killing the germs, the social determinants of disease were ignored.
Not patient-centric
With more drug arsenals such as rifampicin, ethambutol, pyrazinamide, the fight against TB bacteria continued, which became multidrug resistant. Sharper bullets were fired into the frail body of patients. It was bacteria targeted, not patient-centric. The regimes and the mode of delivery of drugs were changed to plug the loopholes of alleged “non-compliance of illiterate and irresponsible patients”. Blister packs of a multi-drug regime were provided at the doorstep, and the directly observed treatment/therapy (DOT) mechanism set up. There was little done to try to understand where patients lived, what work they did for a living, how much they could afford to buy food, and how much they ate.
Many of the poor discontinued blister-packaged free drugs thinking that these were “hot and strong” drugs not suited for the hunger pains they experienced every night. They coughed up virulent bacteria from their emaciated body to infect many around them. It is no wonder that TB was never brought under control.
Let me narrate this example. I was defending a project proposal to provide nutritional supplementation of additional rice, dhal and cooking oil for TB patients in the tribal areas of Bastar-Chhattisgarh as part of the National Rural Health Mission (NRHM) plan in 2009-10. But it was rejected twice by the central technical team as ‘an intervention without proven benefit’.
Nutrition status and TB risk
“The nutrition of the individual, is the most vital factor in the prevention in tuberculous disease,” said Dr. J.B. McDougall of the World Health Organization (WHO), in1949. And, Dr. René J. Dubos in the Journal of the American Medical Association, in 1960, said, “It is most unlikely that drugs alone, or drugs supplemented by vaccination, can control TB in the underprivileged countries of the world as long as their nutritional status has not been raised to a reasonable level.”
The fact is that 90% of Indians exposed to TB remain dormant if their nutritional status and thereby the immune system, is good. When the infected person is immunocompromised, TB as a disease manifests itself in 10% of the infected. India has around 2.8 million active cases. It is a disease of the poor. And the poor are three times less likely to go for treatment and four times less likely to complete their treatment for TB, according to WHO, in 2002. Scientists like Rudolph Virchow (before 1902), Sir William Osler (before 1919) and Dr. Dubos (from 1960) have been saying the same thing.
The work and the findings of a team at the Jan Swasthya Sahayog hospital at Ganiyari, Bilaspur in Chhattisgarh (led by Dr. Anurag and Madhavi Bhargava, Yogesh Jain, Biswaroop and Madhuri Chatterjee, Raman Kataria, Gajanand) established the association of poor nutritional status with a higher risk of TB. In the period 2004-09, among the 1,695 pulmonary TB patients they treated, men had an average body weight of 42.1 kg and a body mass index (BMI) of 16. For women, the average body weight was 34.1 kg and a BMI of 15. With these levels of undernutrition, there was a two to four-fold rise in the mortality associated with TB.
In 2014, research led by Dr. Anurag Bhargava (professor of medicine) showed that undernutrition in the adult population was the major driver of India’s TB epidemic. Subsequently, the central TB division of the Ministry of Health came up with a “Guidance Document – Nutritional Care and Support for Patients with Tuberculosis in India” after a national workshop held in February 2016 at Yenapoya Medical College, Mangaluru, Karnataka. The 2019 Global TB report identified malnutrition as the single-most associated risk factor for the development of TB, accounting for more cases than four other risks, i.e., smoking, the harmful use of alcohol, diabetes and HIV.
Beginning with the JSS, a number of organisations began providing eggs, milk powder, dhal, Bengal gram, groundnuts and cooking oil to diagnosed patients along with anti-TB drugs. Chhattisgarh also initiated the supply of groundnut, moong dhal and soya oil, and from April 2018, under the Nikshay Poshan Yojana of the National Health Mission, all States began extending cash support of ₹500 per month to TB patients to buy food; this amount needs to be raised. Without simultaneous nutrition education and counselling support, this cash transfer will not have the desired outcome.
‘Syndemics’
According to Dr. Bhargava, “undernutrition and TB” are “syndemics”, and the intake of adequate balanced food, especially by the poor, can work as a vaccine to prevent TB. This vaccine is “polyvalent, acting against many gastrointestinal and respiratory tract infections; orally active, that can be produced in the country without patent rights; dispensed over the counter, without prescription and without any side-effects; safe for children, pregnant and lactating women, and of guaranteed compliance because it brings satisfaction and happiness”.
Also read | Why people with diabetes are at a high risk of tuberculosis
The food vaccine is a guaranteed right for life under the Constitution for all citizens, more so for TB patients. Thus, the goals of reducing the incidence of TB in India and of reducing TB mortality cannot be reached without addressing undernutrition.
Dr. K.R. Antony is a paediatrician at Kochi, Kerala and former Director of the State Health Resource Centre (SHRC) Chhattisgarh
