As I speak to the emaciated bone forms, the golden rays of sunlight streaking across the well ventilated and very clean TB wards of the King George’s Medical University (KGMU) surprise me pleasantly and lift my sagging spirits. What I see here is very different from the generally filthy and unkempt general wards of government hospitals in India. Perhaps it is the dynamism of Professor (Dr) Surya Kant, who heads the Department of Pulmonary Medicine at King George's Medical University (KGMU), which ensures the best of care to the lowliest of the TB patients admitted in the hospital.
Sudhir (name changed), hailing from a nearby village and a father of 4 kids, is one of the several TB patients I meet. A suspected case of MDR TB, he is all bones and no flesh, and readily narrates his story despite difficulty in talking due to severe breathlessness. He had been an avid cigarette smoker till 2009 when he was first diagnosed with tuberculosis and put on medication (which included taking injections on alternate days for two months) for 6 months at his native place. He was supposedly cured, but after 6 months his cough returned and his sputum tested positive for TB. This continued on and off till eventually he came to KGMU, where his sputum was sent for culture examination in April, 2012 and the report was due to come in the first week of July (this underlines the absolute necessity of having better access to quick diagnostics like Gene Xpert). He was never advised by any doctor at the DOTS centre of his village to get his wife and children tested (whither contact tracing?). His suggestion is to have a TB awareness drive on the lines of the Pulse Polio Program, as people are generally very ill informed about the disease.
The Indian state of Uttar Pradesh (UP) has nearly 20% of the patients with active TB disease in India. Also, according to the drug surveillance reports, 17% of these TB patients could be drug-resistant. With drug susceptibility testing (DST) services available in only few cities and alarming levels of other risk factors such as high tobacco use, malnutrition, weak health systems, irrational use of drugs, and diabetes to name a few, UP, (and other states too) might be in for a serious battle ahead with TB and drug-resistant TB.
22 years old Yasmin (name changed), who has come all the way from Bareilly (300 km away from Lucknow) was admitted in the female ward one month ago, and has been diagnosed with DR TB (resistant to rifampycin), and will now be on medication for two years. Her pale and thin frame looks no more than 15. She has seven siblings and two of her brothers are former TB patients. She says, “I have been suffering from TB for last 6 or 7 years. The first time I was sick with fever and cough, I got treated by a private doctor—a full 8 months course along with injections. The weekly expenditure on medicines was about 500 rupees. Then I was okay, but after sometime the fever and cough recurred. I went to another private doctor. I was on medicines for almost a year but the cough would not go away. Then I took 6 months treatment in a government hospital. But I was not cured, so again went to the private sector. But it did not help much. The fever would go away but not the cough. I finally came to Dr Suryakant on the recommendation of some doctor in Bareilly.”
Dr Surya Kant while speaking to Citizen News Service (CNS) calls Mycobacterium tuberculosis a ‘Micro terrorist’ because “it is the only single causative organism in all flora and fauna that has the largest number of hosts. Although Robert Koch identified TB 130 years ago, we are still failing to control TB.”
He insists that, “In hospital settings, every precaution must be taken to ensure effective standard treatment. Proper and cross ventilation in wards, along with ample sunlight, should be ensured so that the same air is not getting circulated and air conditioning should not be done of the wards. Proper sputum disposal should be done, and every AFB sputum positive patient should be counselled to use a mask while talking or coughing. It is very is important to practice cough hygiene. The main challenge in early diagnosis of TB is the poor awareness regarding TB in the society. We have to educate the society about TB and health and use range of mass media campaigns including print media, electronic media among others more effectively.”
Of late the Government of India has taken a few progressive steps to boost the sagging image of its public healthcare system ridden with scams, more so in the field of TB control. The Planning Commission has more than doubled the allocation to fight TB from Rs 400 crore in 2011--2012 to Rs 710 crore in 2012--2013. RNTCP 3 (for 2012–17) aims to provide universal access to quality diagnosis and treatment for the entire Indian population. TB in India has been made a notifiable disease; serological tests (blood or antibody test) widely used in the private sector for diagnosing TB have been banned in line with the WHO suggestions; steps are also being taken to make DOTS care providers more accountable to ensure treatment adherence in patients and improve contact tracing. (DOTS providers at 36,000 odd DOTS centres in UP will have to record their act of dispensing medicines and taking sputum for examination on digital cameras. Only then will they be able to claim their salary at the month’s end).
‘The Integrated HIV Care for Tuberculosis Patients Living with HIV/AIDS Programme’ of The International Union Against Tuberculosis and Lung Disease (The Union) also promotes strengthening of the general health systems to deliver high-quality integrated TB and HIV care in order to ‘offer routine HIV testing and counselling for TB patients; offer HIV testing and counselling and TB screening to contacts of TB patients; increase TB screening among PLHs and ensure good TB treatment outcomes in persons confirmed to have TB; provide standardised antiretroviral treatment and regular patient follow-up to all eligible patients; improve recording and reporting of TB-HIV indicators.’
But in India, (and maybe elsewhere too) there is many a slip between the cup and the lip and it still remains to be seen how well the new strategies will be implemented to impact real situations. It is just not enough to have good intentions. One has to ensure proper and systematic practical implementation of sensible laws. As of July 2012, even reputed diagnostic centres in UP (and very likely elsewhere too) were using serological tests, despite their ban with immediate effect from 7th June 2012. Much more, than merely passing laws, will have to be done to regulate the private sector and improve quality implementation of the RNTCP. Mismanagement of TB not only subjects the patients to unnecessary or incorrect treatment; it also results in creating new infections and fuelling drug resistant strains of the disease in the community.
If governments are really keen on ‘Turning the tide” against TB and HIV, as envisaged by the forthcoming XIX International AIDS Conference (AIDS 2012) in Washington DC, they will have to show political commitment for collaborative TB-HIV activities, improve recording and reporting of TB-HIV indicators, strengthen supply management for consumables required by TB and HIV services, identify the best resource mix to sustain integrated TB-HIV interventions in resource-limited settings and implement patient and health systems-oriented operational research.
(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: firstname.lastname@example.org, website: http://www.citizen-news.org)