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The migratory mutant: How patterns in the labour market are helping TB spread

The first of a three-part series takes a closer look at Multi-Drug Resistant tuberculosis, and how migratory patterns in the labour market are helping the bacteria spread into Maharashtra’s hinterland.

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There’s green, lots of it, and patches of yellow, in hilly Melghat as September nears its end. The monsoon has brought the trees alive and the jowar is ready for harvest; all it needs is a last shower.

In this rain-fed area—power is patchy and irrigation almost nonexistent— this is the only time of the year that farming is viable. And so, close to 80% of Meghat’s population, all landless labourers, is back home from their jobs as labourers in other regions and cities to harvest the crop. They bring with them some money, a few baubles for the family, and muscle for the harvest. And more often than not, nestled deep in their bosoms, deadly strains of tuberculosis that no known drugs can beat.

Soon though, they will again migrate to cities like Akola, Nagpur, even Mumbai, in search of work, often in orange plantations. Men will jump onto the empty trucks that contractors bring with them to transport cheap labour to construction sites as far as 700 kms away. Only along the way will they find out where they headed, or for how long. They ask no questions.

They are not dissimilar to thousands of migrant labourers across the world who will move across locations, even borders, in search of work as rural farming becomes increasingly precarious, often transporting deadly diseases during their travels. It is how SARS became a pandemic a few years ago and how the Zika virus reached European shores from Brazil.


Also Read: TB is curable, but not for much longer: Dr N Mistry

TB travails

 “Once the crop is harvested the men will go to Mumbai, Pune or Amravati. Most of the times the children go along as well,” says Mina Maoskar, an ASHA (Accredited Social Health Activist) worker
in the village Dharanmahu in Melghat’s Dharni area. Schooling is not a priority of course, livelihood is. Typically it is these rural ASHA workers who oversee the DOTS (Directly Observed Treatment
Short Course) treatment programme, which means they are responsible for ensuring TB patients take their medicines everyday.

In Mumbai, the workers from Melghat will live in the desperate slums of Dharavi, Deonar or Bhiwandi. Unable to afford decent accomodation, they will crowd 4-5 to a rented room—usually without any ventilation or bathrooms – ideal conditions for the TB bacteria to find a host. That the victim is often undernourished only makes it easier for the bacteria. Every time someone infected with TB coughs, they release the bacteria into the air.

Those with low immunity around them will be the most at risk. It could be anyone—a customer they are serving, a resident doctor treating them in congested rooms, or the anorexic girl they are driving around in a taxi. The TB bacteria is indiscriminate, it only explores new lungs, from young children to senior citizens.

And as newer drugs play a game of seek and destroy, it adapts, mutates, and forms newer forms of resistance against its killers. So, when the migrant workers grow too weak to work, they will return home, turning their backs to the city’s attractions. They will go back to places like Melghat, where the bacteria finds fresh victims. This means that India today has 2.2 million cases— close to a quarter of the 9.6 million worldwide – more than any other country. In India, 22 lakh people are infected with the bacteria annually; 10 per cent succumb to it, data from the government’s annual TB report for 2015 shows.

The worst part? TB is curable.

Urban origins

There are dozens of MDR-TB cases in the Amravati area, under which Melghat falls. With CBNAAT machines—which can detect which drugs a TB infection is resistant to—now available in all districts of Maharashtra , officials at the district level are able to test patient samples for drug resistant strains of TB in a matter of minutes instead of the weeks earlier.

The results provide compelling evidence of how common MDR-TB and extremely drug resistant (XDR) TB are in the countryside. And it almost always shows that the patient has ties to Maharashtra’s TB hotbed—Mumbai.


“All the cases of multi-drug resistant (MDR) TB are migrants who have returned from Mumbai. Some of them are even showing signs of being resistant to all known drugs,” says PT Khadse,
district TB coordinator for Amravati under which Melghat falls. 

Officials in Latur too are grappling with the influx of TB thanks to the drought migration that the region has been witnessing. “We have three cases of XDR-TB, out of which two returned to Latur after falling ill in Mumbai. There are 63 patients with MDR-TB and most of them have either worked in Mumbai or contracted TB from those returning from the city,” said Suryavanshi DR, a DOTS PLUS and TB-HIV supervisor.

In a city like Mumbai, there are at least seven different strains of the bacteria in the air, waiting to travel to the hinterland. The migrant workers are the perfect vehicles. Crossing boundaries of cities
and states, the bacteria is only growing stronger with both medicine and government failing to catch up. As governments, NGOs and doctors struggle, the TB bacteria ventures further into the country, virtually unchallenged, taking advantage of weak defenses. 

Children are the most at risk. Most villages in Melghat have a population of anywhere between 700 to 1,500 and nutrition levels are abysmal. “There are Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM) cases in my village. Around seven children here are malnourished,” says Maoskar, who is a daily spectator to children wasting away, their lungs vulnerable to the disease each time they travel with their parents to cities like Mumbai. 

Discipline gap

Unfortunately, TB patients in India are nowhere as serious about the disease’s treatment as the bacteria is about its own survival. Migrant workers typically buy over-the-counter drugs to treat their cough-like symptoms instead of going to a hospital. They then return to work at construction sites, hotels, or double up as autorickshaw and taxi drivers, continuing with their public interactions, and creating more opportunities for the infection to spread. 

“We have several patients who are aware of their MDR-TB status but they will refuse to cover their mouth while coughing. Many refuse to stick to the long treatment,” complains Praful Awaghad, a counsellor with the non-profit organisation Mamta. The NGO works with the government’s Revised National Tuberculosis Control Programme (RNTCP) programme in Amravati as a part of Project Axshya, a global initiative of several NGOs and civil society to reduce TB deaths.

Once they are back in the village, their treatment is further compromised by the lack of something as basic as roads and transportation to the nearest government health centre.

In Melghat, the distance between two villages is at least 10 kms, the nearest sub-district hospital over 40 kms away. For a poor patient with weak lungs, that is often
too long a walk.

“One must remember that walking 10 kms on a mountainous terrain is very different from covering the same distance on a plain road,” points out Dr MS Jawahar, who retired as a scientist from the National Institute of Tuberculosis Research in Chennai.

That means that most patients will not take the effort to continue medication if the government DOTS centre is far away. Heavy rains, summer days, or a busy harvest season add to reasons for is continuing treatment. This means the patient’s nearest family members are the most at risk, fueling a new cycle of infection. 

Ravi Pathre from Maoskar’s village has one more month to go before he completes his six-month long treatment course for TB but he has to return to Amravati for work. “I will ensure that I complete my course,” he assures Khadse who has come to check on him in Melghat.

Some workers request their DOTS providers to give them an advance supply of the free medicines. Some like Maoskar will relent, breaking the rules, whcih are sometimes overlooked when following them could cost a life.

“In rural areas, TB is a disease that is destroying families and communities,” says Dr Anurag Bhargava of Jan Swasthya Sahyog (JSS) that runs low-cost health programmes in Chhattisgarh.

“Migration is a big problem,” Khadse explains. “We have to track the migrant worker and coordinate with officials in different districts. Their treatment can be continued in any DOTS centre near to them but they have to take the effort to go there,” he adds.

Sewri TB hospital, Asia’s largest facility for TB treatment has scores of such patients. By this time, if they are alive, their bacteria has already grown resistant to first- and second-line drugs. “By the time patients come here they stop responding to drugs and we run out of treatment options,” says Dr Lalitkumar Anande, chest surgeon at Sewri TB Hospital.

Most migrant workers will not bother with their treatment once the initial symptoms subside. Holi is when most migrant workers will return to their villages, but in a few days, they will come back to  the city, only to fall ill again.

Lives are lost, but everyone moves on. The migration must go on. They must return to the blighted city again, and again, and again. There are mouths to feed at home.

(The second part of this weekly series will explore why poor patients across villages are giving up free-life saving TB drugs. The author is a recipient of the 2016 REACH Lilly MDR-TB Partnership National Media Fellowship for Reporting on TB.)

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