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‘In India, anyone and everyone treats TB’: Dr Zarir Udwadia

Dr Zarir Udwadia tells DNA how migratory workers are falling between the gaps, the growing resistance to drugs, and the role of private practitioners.

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Dr Zarir Udwadia
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Dr Zarir Udwadia, consultant chest physician, PD Hinduja Hospital, has long been critical of the government for failing to take advantage of the latest available drugs. His out-patient department has hundreds of TB patients from across the state lining up for treatment every Monday. He tells DNA how migratory workers are falling between the gaps, the growing resistance to drugs, and the role of private practitioners.
 
Why are patients seeking private care?

If patients are happy with the quality of the treatment that they receive at the DOTS (Directly Observed Treatment Short-Course) centre then there would not be any need for them to come here. You need to hold on to the patients once they are enrolled and that doesn’t always happen. Patients are disillusioned with the quality of care that they get at the government centre, (so they) seek out private care - sometimes they seek out private care (even) before they seek out government care. The patient travels in this endless spiral from doctor to doctor, public to private, flitting back and forth between the systems.  
 
Who are the first healthcare practitioners that patients typically see?
Sometimes the first source of care is a homeopath, an Ayurved, or an Unani doctor. Sometimes the first source is a chemist. Also, in this country anyone and everyone treats TB. If there are guidelines properly laid down about who can prescribe and who cannot this would not be happening.
 
What are challenges posed by migration?
Migratory patterns are difficult to change. These people are the most marginalised. They don’t even have a proper proof of identity so they don’t get on to a DOTS programme. They fall between the gaps completely. They are shunned by the programme because the programme doesn’t want their figures to look bad.  
If the programme says that this particular patient enrolled but then dropped out because he migrated then it looks bad for this particular DOTS centre. Then they access different private practitioners, most of them of dubious quality.     
In rural parts of India, sometimes patients have to travel kilometres upon kilometres just to access the nearest DOTS centre. They are remote so they need to increase the manpower and they need to increase the number of DOTS centres.
 
What does migration do to adherence to the treatment?
It makes it dreadful, doesn’t it? They are not in the DOTS centre anymore and the private practitioner will start their own treatment. These are patients who will relapse and be irregular with their treatment and then end up MDR (multi-drug resistant) even if they started with a sensitive strain. They are given a fixed quota of drugs, they run out of drugs they will go to a different doctor who will give them different drugs. So it is a huge problem all over the world. We are finding delays of months before an MDR patient is correctly diagnosed and treated.
 

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