Its a dangerous killer because it prowls with stealth. And its fatal signals could be as innocuous as a cough, a mild fever or gradual loss of weight. But thats no cause to take tuberculosis, Indias single-largest infectious killer, lightly. For, the prediction is that in the next decade it would have killed 15 million Indians-or half of Mumbais population.
TB, hitherto known as "poor mans disease", is, ironically enough, draining the economy-more than Rs 8,000 crore annually. And only after the problem assumed such irreparable proportions has the government sat up and taken note of it. Today, the Revised National TB Control Programme (RNTCP), first introduced in 1993, is the second-largest in the world after China. The most important part of this programme is the directly observed treatment short-course or dots, used to treat more than 225,000 patients in India.
dots is important because it tackles the disease at its most untamed and lethal level, that of drug resistance. The killer bugs return was facilitated by the abuse of an entire array of TB drugs which made it multi-drug resistant (MDR), thus rendering the disease almost incurable. In order not to mess things up further, dots was implemented. Its strategy basically consists of ensuring proper intake of medicines by making every patient swallow anti-TB drugs thrice a week over a six-month period under the supervision of a health worker. Supervised treatment ensures that the patient completes his treatment and gets completely cured. In contrast, a patient who follows an irregular regimen of anti-TB drugs runs the risk of conferring MDR to the TB bacteria infecting him and worse, passing it on to the others.
In 1997, the Indian government received a $142 million "soft" loan from the World Bank to extend RNTCP to one-third of the country and prepare the remaining two-thirds for the programmes eventual implementation.
This February, the programme was reviewed for the first time by a team of health experts from the who, the Centers for Disease Control, the World Bank and some British and Danish development agencies.
And their discovery, that RNTCP works, is sure happy news. Its saved more than 40,000 lives, prevented more than 450,000 TB infections and relieved the economy of a medical burden of $300 million. dots, as a strategy to control TB, is twice as likely to cure patients and seven times more likely to prevent deaths from infectious TB as the older treatment regimes.
But then comes the downside: although the programme claims an 80 per cent cure rate, it covers only 14 per cent of the population at present. Particularly in the cities, where about 60 per cent of the population resorts to private health care, the key to expanding the programme lies in moving beyond the government-run outlets and reaching out to private physicians as well.
Availability of TB drugs is another problem, says Dr Vijay Panjabi, president of the 150,000-strong Indian Medical Association and a member of the dots programme. Says he: "These drugs are supposed to be supplied free under the dots programme. But they dont want to give these free drugs to private practitioners."
Not a particularly good situation, considering that two million Indians develop TB every year and nearly half-a-million die of it. A single person with untreated TB can infect 10 to 15 others, by coughing, singing or talking. The spread of aids complicates this further, increasing TB cases by at least 200,000 each year.
Thomas R. Frieden, TB medical officer for the Southeast Asia regional office of who, however, is against a hasty expansion of dots. He cautions: "If this programme is implemented poorly, its worse than not implementing it at all. If it grows too fast, you compromise quality. It could give rise to drug resistance, reducing the chances of curing TB, not only in this generation but also in the next."
MDR TB is probably the biggest danger facing any control programme. Not merely that, it threatens to bring TB from the antibiotic era into a post-antibiotic era with incurable forms of the disease spreading fast. MDR TB is caused by strains of tuberculosis bacteria resistant to the two most effective anti-TB drugs available-isoniazid and rifampicin. Whereas regular TB can be cured in six months, its MDR variety requires, at least, 18 to 24 months of treatment, with medicines that are 100 times more expensive. A routine case of TB can be cured for less than Rs 900. A single case of MDR can cost more than Rs 2 lakh.
Frieden blames it on drugs being prescribed by private physicians often in wrong combinations and with no one to ensure that the medication is being taken correctly.
Says Dr P.R. Narayanan, director of the Tuberculosis Research Centre in Chennai: "Once they see that the dots programme is working, TB patients will rethink the myth that the government system is not good enough."
That there are many differences between the private sector and the government health worker is undeniable. But what is even more obvious is the need for the differences to be resolved on both sides if dots is to succeed. This fact has hit home and the government has finalised a plan for non-governmental involvement in RNTCP. Five schemes are available to ngos in areas covered by the TB programme-as health educators, treatment supervisors and monitoring agencies to ensure that TB hospitals are following recommended policies; as microscopy and dots centers; and as TB service providers in areas with a population of about five lakh.
The government has ambitious plans to cover half the population by 2002, with the World Bank loan. The total additional cost of implementing RNTCP countrywide would be about Rs 210 crore a year. This means that the cost of combating TB is only about Rs 2 per person per year, almost equal to that of the malaria control programme, even though TB claims 20 times more lives than malaria. Besides, the returns are enormous. Studies in southeast Asia indicate that each dollar spent on dots will yield a return of $55 over 20 years.
Says Dr Arata Kochi, director of whos Stop TB Initiative: "Where dots is not used, patients are seven times more likely to die. Thats the first thing I would have in my residential area."
A thousand Indians will have succumbed to TB at the end of this day. One every minute. But the fight against TB has made a small beginning. With government commitment, private sector participation and public pressure, half of Mumbai might still be saved.
