A crumbling health system, slashed budgets and an overcrowded country — these factors make India the perfect playground for one of the world’s oldest diseases, tuberculosis.
In the past year, the global public health community, led by World Health Organization (WHO), has been looking at India with trepidation. In 2015 alone, 4.8 lakh Indians died of the airborne disease. In fact, India’s leading chest physician Dr. Zarir Udwadia called it “Ebola with wings” earlier this week during a TED Talk to mark World Tuberculosis Day, which fell on Friday, March 24.
Thousands without access
Two new TB drugs, Bedaquiline and Delamanid, being used in Europe and the United States for several years, are yet to be made available in India’s national health-care system. In January, an 18-year-old Patna girl took the government to court after she was refused Bedaquiline on the grounds that she was not a resident of Delhi. The drug is available only in six sites across the country and, according to Health Ministry’s annual TB report released on Friday, only 207 patients have access to the drug needed by at least 79,000 patients. Herein lies the crux of the matter, making India’s bureaucratic inertia the world’s problem: TB does not respect geographical boundaries and these patients continue to transmit drug-resistant forms of the disease due to the poor access to medicines. Not only does India shoulder the highest TB burden in the world with over 2 million of the 10 million cases reported here, it also accounts for the most drug-resistant patients — nearly 1.3 lakh people who do not respond to first-line drugs. “Transmission of drug-resistant TB will continue unabated unless patients get early diagnosis and the right treatment. India has to invest extensively and urgently if it has to expand the testing facilities and get the drugs to the patients. Currently, there is a mismatch between the urgency with which the government is talking and the resources we are committing,” says Chapal Mehra, a public health specialist on TB.
In a major embarrassment for the government, WHO had to revise global TB estimates last year after India informed that it had been under-reporting TB cases from 2000 to 2015. The global estimates were revised upwards to 10.4 million people infected with TB — a jump of 5,00,000 from 2014. In its annual TB report, the Health Ministry explained that “this apparent increase in the disease burden reflects the incorporation of more accurate data. With backward calculations, both tuberculosis incidence and mortality rates are decreasing from 2000 to 2015”.
The intent-action deficit
While the global spotlight for urgent action has sent the government back to the drawing board, experts maintain that it is not putting its money where its mouth is. The budget estimates in the annual TB report are in fact lower than that of 2014-15. As against ₹1,358 crore requested, the government approved ₹710 crore in 2014-15. In 2016, however, in the face of trenchant criticism, the budget requested actually went down to ₹1,000 crore and the approved budget was a measly ₹640 crore. “By no means is this enough to expand the programme. For the strategic plan to show impact, we must allocate enough resources,” says Mr. Mehra.
The government will soon be launching a new strategy, and Union Health Minister J.P. Nadda has announced that his Ministry will aim to “eliminate TB” by 2025. “Ensuring affordable and quality health care to the population is a priority for the government and we are committed to achieving zero TB deaths and therefore we need to re-strategise, think afresh and have to be aggressive in our approach to end TB by 2025,” he said on World Tuberculosis Day.
During the TED Talk, Dr. Udwadia, one of the first doctors to make Bedaquiline available in India, called tuberculosis patients “therapeutic destitutes”, adding, “Drug-resistant TB represents a collective indictment of all of us as a society. Of the tests too slow. The drugs too toxic. Of the government programme that’s underfunded and inefficient. Of the private practitioners who’ll dole out the drugs but not compassion. Of the public policy failure.”
For taking on government inertia, Dr. Udwadia was profiled by The New York Times in September 2016 in a report titled “Battling Drug-Resistant TB, and the Indian Government”.
The battle, for him, for patients and for caregivers is far from over.