In Digital India, TB still makes public health care cough blood

It is perhaps prudent to mute national pride celebrations until tuberculosis in the country comes down.

 |  5-minute read |   06-10-2015
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The general mood in India over the past weeks has been pretty upbeat. With reports of Prime Minister Modi "conquering" the Silicon Valley, and with Satya Nadella and Sundar Pichai making it big on the global stage, we can't stop gushing about how "India's time has finally come".

But some Indians, for instance public health professionals, are not in a rush to celebrate. We are unfortunately too up close with the ground reality to be upbeat over media-hyped "achievements". While I am certainly not pessimistic about India's potential, I always think cautiously about the realisation of that potential, especially being aware of some of its embarrassing public health failures. One such failure is our tryst with an ancient malady - tuberculosis (TB).

As high as 40 per cent of Indians carry TB inside their bodies. In 2013, about nine million people in the world developed TB, and 2.1 million were Indians. TB has not only been annoyingly perseverant in infecting us (famously including Amitabh Bachchan), but more importantly, as we will see, it stands as a testament to the stubborn persistence of our major longstanding problems.

Some of our most serious national issues are widespread poverty; corruption and mismanagement; a problem-ridden health system; weak political will for social development; and poor sanitation and hygiene. Interestingly, our high tuberculosis rates are strongly associated with all of these. Poverty, through poor nutrition and poor living conditions, intensifies TB. Mismanagement and corruption in the public sector broadly, and the national TB programme specifically, undermine treatment of patients. The health system - the most important agency for TB control - suffers from a host of problems including neglect by successive governments, lack of human resources, and poor quality of services. Weak political will robs India of socially progressive policies and generous funding in education and health. Finally, the legendary neglect of sanitation and hygiene by citizens and local administrations augments the spread of TB bacteria.

The extraordinary aspect about TB is that it can be eliminated only when all, rather than some, of these problems are taken care of. For example, even if we somehow minimise corruption and improve sanitation, TB rates will still be high if we do little about poverty and the fragile health system. With these multiple strong associations, one can assert that the best (and the most convenient) proxy measure of India's holistic progress today is not how many foreign firms are investing in India, or how many CEOs of international companies are Indian, or how much the GDP is growing; it is the levels of tuberculosis. And for now we are faring very poorly.

There's more to TB's uniqueness - it is a highly sociopolitical disease. The six months to two years of treatment periods put to test the robustness of health systems and strength of political will for public health; the time-tested methods of prevention, though easy and simple, demand action more at the civic level than the individual level; and the rapid wasting of the patient's body and high death rates make it more palpably lethal in popular imagination than other ailments.

The 1980s' TB epidemic in New York City revealed how politics and tuberculosis are intertwined. Many experts blamed the waning political commitment over the '70s and '80s leading to underfunding of public health activities. They coined the phrase "U-shaped curve of concern" for this phenomenon where political will and funding bring down a disease, but resurgence immediately occurs if these are withdrawn prematurely. In India now, with the national government withdrawing funding from many public health programmes, this curve of concern is a serious cause for concern.

There are more reasons to use the "TB-meter" as the perfect indicator for India's development and "greatness". The ailment's history clearly demonstrates how the West was able to tame it through sociopolitical progress - it became a menace in Europe and USA with the disorganised urbanisation and overcrowding of the Industrial Revolution, then started steadily declining with political reforms and social endeavours emphasising sanitation and better standards of living, and then briefly rose around the World Wars when general living conditions declined.

Presently too, if we look at country-wise lists of causes of health loss, only countries with low human development indices (like Burundi, Swaziland, Uganda and India) have TB among the top 10. The incidence rate of TB is 171 per 100,000 persons for India and only 3 for the USA, for example.

Thus, it is perhaps prudent to mute national pride celebrations until TB in the country comes down. Not because bringing down TB will magically set things right, but because only when things are alright with India will its TB naturally nosedive. India achieving very low TB levels will mean a whole host of highly positive developments - district and state governments showing strong commitment to citizen welfare and generously funding health systems; poverty, income inequality and corruption being minimal; and cities and villages having high levels of sanitation and hygiene. It will be the ultimate proof of our much-aspired "development". Undoubtedly, TB rates need to be taken very seriously by policymakers and citizens.

Few of today's proud Indian youth will be aware of the Pyaasa song "Jinhe naaz hai Hind par woh kahaan hain. (Whither are those who feel so proud about India?)" asked poet Sahir on seeing the common Indian's optimism waning just ten years into independence. That song, well, also had a subtle reference to TB - "woh berooh kamro mein khaasi ki thhan thhan". Today, 58 years later, as the same thhan thhan still reverberates in millions of Indian homes daily, Sahir's reality check assumes epic significance and offers serious food for thought regarding India and its perceived greatness.

Writer

Kiran Kumbhar Kiran Kumbhar @kiranskumbhar

Indian physician-writer. Harvard health policy expert.

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