... continued from Part I earlier

A number of challenges

The WHO's worldwide goal is to detect atleast 70 percent of all new active TB cases and successfully treat 85 percent of them by 2000.

Today, India, Indonesia and Pakistan together account for more than a third of all estimated incident cases. All of them today run DOTS programmes with fairly good success rates. But their real challenge is expanding these programmes for which they have a poor record. Only China and Bangladesh have managed a good mix of achieving high treatment success along with steady expansion. The South East Asian Region has much to do. Tackling, containing the spread and eliminating TB is not going to be an easy task.

For its part, the WHO is actively trying to evolve newer, simpler and more effective user-friendly diagnostic tools for TB detection. And as too many tablets in a dose are clumsy and unmanageable for millions of illiterate patients, efforts are on to come out with a single tablet of consistent quality. It will make drug distribution and management simpler and maybe, reduce treatment costs.

What is frightening is the sheer quantity of medicine required to fight the TB bacilli. Ideally, the best thing to happen would be the discovery of a vaccine for the multidrug resistant TB variant. But this may take decades of research. What is disturbing is the shrinking pipeline of new drugs and that the next effective drug could be many years away. So the only curative solution today is to expand and improve the DOTS programme.

It is not that there is not enough money, but there is little intent. There is too much verticalisation in public health to deal with individual diseases like TB. For e.g., we have disease control programmes for cancer. If you have lung cancer, you can walk into a clinic and start getting treated. But TB is often not diagnosed properly. The government largely sees TB as a disease programme and not a health programme.

Private health care too has not been brought under the mandate of TB contro. Therefore many patients end up paying huge amounts of money without getting cured.

HIV and TB are a deadly duo

In the last 20 years, the Human Immunodeficiency Virus (HIV) has emerged as an accelerator to TB. It helps TB to spread rapidly as the HIV patient's immune system is already weak. HIV's ability to fast forward the TB epidemic is throwing up frightening implications. The WHO warns that much of Asia may be sitting on a large TB drug resistant time bomb waiting to be activated by the growing number of HIV positive people.

TB is now the most important, life-threatening, opportunistic infection associated with HIV today. Consider: 56 percent of AIDS patients in India suffer from TB. In Myanmar, it is 80 per cent and in Nepal, it is 75 percent. A parallel epidemic of TB is likely to lead to its further spreading among the general, non-HIV infected population. If tuberculosis control services are not fortified, HIV could end up doubling or even tripling tuberculosis cases. Management of both these together is going to be almost impossible.

Poor TB control programmes can damage

TB has often been misdiagnosed and treated ineffectively either by unqualified doctors or by doctors who need training and updating of medical knowledge. The TB epidemic is also getting accelerated with poor and careless treatment. Often, the right combination of drugs is not prescribed. So doctors are as much to blame.

It is not enough to just treat a patient, but to ensure that he is completely cured. Otherwise, the treatment just gives the patient a superficial feeling of well being which takes him back to the community. Needless to say, he infects many others. Government hospitals and clinics are supposed to treat patients free but are often badly equipped to do any diagnostic tests and even do not have the required drugs. The scenario is ideal for the multidrug resistant TB to thrive.

Diagnosis is expensive, as one needs to check many people to find out the positive ones. The World Heath Organisation in a report released in the last week of October said that large amounts of money were being wasted on ill-conceived diagnostic tools for tuberculosis. It was failing to trace the disease in poor areas where they were most needed, it said.

The report pointed out that most of the nine million TB patients worldwide did not receive a laboratory confirmed diagnosis even though about $1 billion was spent on TB tests and evaluations. As much as $300 million was spent on drugs to treat TB worldwide but still 1.7 million fall prey to the disease annually as the infection is not being diagnosed. Cost control issues in programmes need to be in place, only then can corruption be controlled.

To makes matters worse, TB carries a strong negative stigma. This ends up with many avoiding medicine till it is too late or drop treatment as soon as they can. After all, the neighbours should not get to know. By neglecting treatment, they are rapidly joining the burgeoning group of chronic and drug resistant patients. Once this happens, it is like a death warrant as it is almost incurable.

Women are more vulnerable

Women are among the worst sufferers. A TB-affected mother is a real threat to the household as she is close to her children and has to perform household duties. In many cases, children whose mothers died of TB were found infected. Of the approximately six million women who are sick with TB at any given time, at least a third die undiagnosed or because of poor treatment. Among the reasons for this neglect is money, time, transportation and a social condition that treats women as second-class citizens especially in countries like India. TB deaths among women have major implications for child survival, economic productivity and family welfare. Those who care about empowering women and saving their lives must recognize the enormous impact that TB is having on women worldwide, and must act to effect change.

Women largely neglect medical help in the initial stages not wanting to neglect household responsibilities, which in India is seen as sacred, sometimes even more than their life. Male chauvinistic attitudes can infact deter TB treatment. Often, women do not have any access to money, living in households where men control the purse strings. Very often, women are viewed like property to do menial work in the household and bear children to keep the family line going. Women also try to suppress TB symptoms fearing stigma. Husbands could leave them or relatives and neighbours could reject them.

Revised National Tuberculosis Control Programme

The status report on the Revised National Tuberculosis Control Programme (RNTCP) says that the majority of the country is now covered by the programme making it the second largest such programme in the world. According to the government, each month, there are nearly one crore patient visits to health facilities covered by the RNTCP. Everyday, more than 15,000 are examined free and 3,500 are started on treatment. Everyday, more than 10,000 sputum slides are examined. Over 1,00,000 sputum tests are crosschecked every three months. 6,00,000 health workers have been trained and more than 11,500 lab microscopy centres are working, according to government figures.

On the other hand, the World Bank last year came down heavily on health programmes cutting out their funding as they detected corruption. The RNTCP was one of them. Many targets "achieved" were fake. Lab assistants would have fabricated registers with fake names of patients just to reach the target. When the World Bank stopped payments, they cited instances like one sputum sample of one patient multiplied into many samples with fake names and fake registers having these records so as to meet targets and siphon money.

Government programmes may thus claim success, but at the moment, there is nothing like success in TB control and treatment. There are large numbers of patients suffering from the disease and many of them dying. The constant challenge is to ensure quality of diagnosis, immediate treatment and monitoring. Only then, will the treatment success rates be high. (Concluded)