Missing the big picture in TB control

India’s TB control programmes turn a blind eye to historical experiences which reveal that in much of the advanced world today, the infection was controlled through enhanced nutrition, better housing design, socio-economic advancement opportunities and cleaner environments.

Hardly 20 per cent of our overall population utilises public health services.

The rampaging and terrifying face of tuberculosis in India today with a thousand deaths every day has a complex history. India’s

TB control efforts have for long suffered from not being able to see the wood for the trees or the big picture — a cardinal failure of control programmes where health-care professionals assume the role of sole resolvers of the disease. Not surprisingly, even today India’s TB control programme continues to clamour for more diagnostics, newer drugs, augmented human resources and the technological magic bullet to kill TB forever.

They turn a blind eye to historical experiences which reveal that in much of the advanced world today,

>TB was controlled through enhanced nutrition, better housing design, socio-economic advancement opportunities and cleaner environments.

A withering contrast is the way in which nutrition for TB patients is handled at the ministerial level in India — a game of handball between the Ministries of Health, Social Justice and Labour. While convergence in governance is utterly lacking even within health systems, scant attention is paid to more basic issues. A country that sends missions to Mars is unable to guarantee basic TB drugs to even its most vulnerable. Nowhere is this more evident than in the lack of availability of paediatric TB drugs even in large cities and the lethargic inclusion of new life-saving drugs for patients (many of them young) doomed to die from unresponsiveness to the existing drugs.

One of our greatest limitations in TB, however, has been a de-motivated workforce and poor care in the public health system. Ill-managed financial pipelines between the Centre and the States choke the receipt of funds at Ground Zero, where health workers struggle in slums, remote villages and hazardous health facilities. The cadres often get deprived of their salaries for months as funds fail to arrive.

Hardly 20 per cent of our overall population utilises public health services. Study after study attributes this to the poor quality of services at its facilities. The huge gaps in human resources and their poor skilling are not so much a resource issue but one of lack of inspirational leadership in the sector. Apart from remuneration, hardly any motivational incentives are offered to public health sector staff; nor are their services recognised when work is undertaken in difficult conditions. A de-motivated workforce cannot be a harbinger for effective TB control.

The overall decision-making pathways for the control programme (this is not restricted to TB) are ill-informed since the country has poor survey and surveillance mechanisms. Nikshay, touted and celebrated as a transformational health management information system for TB, is horribly slow in its development. It is an electronic registry at best, but hardly an epidemiological tool.

If the grounds of decision-making are so shaky and incomplete, then erroneous decisions are a natural consequence.

Ultimately, achieving a resolution of the big-issue gaps in TB requires both political will and vision — that seem to be lacking.

The decision to cut health budgets or to continue not to engage India’s vast private sector where millions seek care, will not reduce India’s TB burden; nor will constantly stalling the urgently needed nutritional support, new drugs and technologies for diagnosis that TB patients need. What we need is an entire transformation of the system and its entrenched red-tapism which is making us lose a battle against a critical infectious disease that is putting India’s growth and development at grave risk.

It is unlikely that our choices will bring a 40 per cent drop in TB prevalence that has been achieved by neighbouring China.

It seems the elephant, unlike the dragon, will continue to lumber on, loaded with 25 per cent of the world’s TB patients, several avatars of progressive drug resistant disease (an under-counted minimum of 1,10,000) and omnipresent social injustices and basic insecurities that fuel the fires of this deadly disease.

(The author is Director of the Foundation for Medical Research, Mumbai, and the Foundation for Research in Community Health, Pune. Her work focusses on levels and evolution of drug-resistant TB disease in India)