Not just drugs, ancillary approach needed for TB-free India

A recent Lancet Commission report on tuberculosis (TB) calls for greater investments to ensure everyone has access to high quality care no matter where they seek it, reaching those at a higher risk and ensuring accelerated research to develop new tools and strategies apart from other action items.

While this broadly captures the logical steps required to eliminate TB, our research in Mumbai over the years has attempted to look at TB more from a patient’s perspective and as a consequence of their environment.

Anyone can be affected by TB, but it is five times more likely to impact the poor, and though it’s completely curable, the treatment longevity can push economically weaker families into further deprivation.

The stigma associated with TB adds to the risk of being unemployed, pushing them further into financial hardship. Poverty, coupled with environmental conditions, including low hygiene conditions, crowded and poorly ventilated homes and work-places, provide an environment conducive to the spread of TB.

These challenges put the spotlight on the long-term measures that need to be implemented to break the disease cycle.

The Papworth experiment in Britain and the Farmer experience in Peru exemplified how TB was not just a medical condition and how its decline can be achieved by significantly improving living conditions, including housing, nutrition, social environment and financial security.

WHO’s housing and health guidelines has TB infection on top of the list of risks attributed to unhealthy housing. A case in point is Mumbai, which is one of the most densely populated cities in the world with nearly 12.4 million people and still growing.

For instance, vulnerable housing in Mumbai experiences one air exchange every 12 hours compared to the minimum desirable of 6 per hour, significantly increasing the risk of infection. Unsurprisingly, Mumbai has emerged as a ‘hotspot’ with a large concentration of TB cases.

Though there is scope for greater research in this field, another factor that contributes to weakened immune responses is poor nutrition, which is prevalent across Mumbai and the country. 

And while the decision by the TB programme to provide an incentive for all TB patients is welcome, assuring nutrition to patients through a mere Rs 500 every month, is at best a token gesture.

Nutrition requires more financial support, which will ensure that the patient does not become vulnerable to TB by slipping into the cycle of poverty and under-nutrition. 

Admittedly, we need to put a robust documentation system that creates a repository of evidence-based stories that bring out the direct impact that nutrition (and other social and ecological factors) has on treatment outcomes. 

While the focus of the government’s National Strategic Plan is to bring every TB patient into national TB programme’s fold, a collective approach by various departments like urban development, sanitation, social welfare and perhaps even food, can help in evolving long-term solutions to improve living conditions of the urban poor, as well as ensure food and nutrition security. 

From our research, we understand that the disease imposes additionally on the patient, the difficult task of navigation of a complex and fragmented health system. 

Low awareness, knowledge-action gaps and stigma associated with TB continue to be the biggest challenges in tackling the problem.

If the patient happens to be drug- resistant in an urban metropolis, they may travel from 86 km to 650 km between the first onset of symptoms to the completion of treatment. 

This includes unsuccessfully ‘shopping’ for providers that are unable to provide them relief from their symptoms (due to misdiagnosis or incorrect prescriptions) before they finally turn to the public sector for care. 

They face challenges of travel in the public sector too, as they move between locations for different aspects of care.

To address this challenge, a pilot private sector engagement programme in Mumbai was started in 2014, which involved creating a network of sensitised service providers in the private sector to strengthen their capacity to serve patients better. 

By engaging a host of private providers including chemists, diagnostic labs, and formal and informal providers, the initiative even with its limited reach in the community, has shown reasonable success in shortening the care seeking pathway.

Author is director, the Foundation for Medical Research, Mumbai