"India's DOTS programme, specially designed to prevent people from skipping or giving up treatment of tuberculosis, lost track of more than 35,000 patients last year, government figures released today have revealed" - The Telegraph, 24 March.

"India boasts of having the most successful TB programme covering the entire population, but statistics reveal a different story. The World Health Organization says one fourth of drug resistant TB cases in the world are found in India, indicating a rapid slow down in the programme ..." - NDTV, 25 March.

"Nearly 70,000 people suffering from multi-drug resistant tuberculosis (MDR-TB) in India require quality second-line treatment, experts at the World Health Organization say. India needs quality second-line drugs to treat these patients ..." - The Hindu.

These recent reports in prominent publications chillingly portray the dismal condition of tuberculosis control in India. The news reports clearly highlight how the much-hyped TB control programme has actually been far less of a success than was previously assumed. The news couldn't have been worse at a time when the whole world is expecting better TB diagnosis in a country which contributes to the maximum number of infections in the world.

Tuberculosis, one of the biggest health threats in India, kills two people every three minutes. Overcrowded living conditions combined with appalling sanitation result in the spread of this contagious disease. The situation is worse in the economically weaker sections because of the lack of proper medical facilities. With just 33 per cent of the population having access to safe sanitation, and a whopping 900 million living on less than Rs.80 a day, it is no wonder that this disease manages to create havoc in a small time frame, killing over 1000 people every day.

The latest World Health Organization (WHO) report states that three million people develop tuberculosis in the Southeast Asian region every year, India reporting 22 per cent of these. TB is still a grave health threat in India, leading to 2.2 million new cases every year, out of which 1 million are infectious smear positive pulmonary cases. Tragically, the cases in India account for one-fifth of the global cases of TB. In fact, a recent study suggests that missed diagnosis of TB in India and China is spurring a global spread of the disease.

THE DOTS strategy

The government has been aware of the issue for quite some time. Its Directly Observed Treatment, Short Course (DOTS) strategy, recommended by the WHO, is a systematic one, based on political and administrative commitment, good quality diagnoses, uninterrupted supply of short-course chemotherapy drugs, standardised intermittent drug regimens administered under direct supervision, and systematic monitoring and evaluation. The government took the decision to launch and implement DOTS in India because the previous programs had not been successful in combating TB.

DOTS aims to ensure that every tuberculosis patient completes the full six-month course of treatment, typically involving four drugs. While modern anti-TB treatment can cure virtually all patients, it is imperative that in every case, the treatment be continued for a minimum of six months. If the complete treatment is not followed, serious complications that include relapse or development of drug resistant TB may occur. Thus, the need to monitor patients continually, until they complete the full course and recover.

DOTS was launched formally as the Revised National TB Control programme in India in 1997 after pilot testing from 1993-1996. Since then, according to the website of TBC India (Central TB Division), DOTS has been widely advocated and successfully applied. The success stories shown on the programme web site emphasise the wide participation by ordinary people "to make DOTS services available and accessible even in the most remote corners of India."

India now has the second largest DOTS programme in the world and it is already expanding faster than any other country's program, adding more than 100,000 new patients to its treatment every month. But despite such a large program, a number of questions still remain. Why has India's rate of detection of new cases fallen to 3 per cent from an average of 6 per cent in the preceding five years? How did the default of 35,000 patients go unchecked? Why is the relapse rate around 35 per cent, which is much higher than the globally accepted rate of 15 per cent?

The DOTS program's main aim was to ensure that every tuberculosis patient completes the full six-month course of treatment typically involving four drugs. A number of people, however, do not undertake the full program, but drop out before it is complete. Such patients might develop drug resistant TB, a far more deadly form of the disease, and end up worse off than they were when they began their treatment. Worse, even a single such defaulter can create a significantly large pool of infected people. The new strain of drug resistant TB is totally due to the negligence of patients, and as such, very preventable by simply ensuring that each patient completes the course as expected.

Not really accessible

That, however, can happen only if DOTS services are easily accessible. Currently, there are 12,000 centres for TB and around 400,000 DOTS workers. These numbers, however, do not tell the full story. Since TB is mainly a poor man's disease in India, many patients are unable to spend money traveling to the nearest centre. In some places, this cost is prohibitive, particularly since the travel may be needed several times a week. In fact, it has been found that a sick patient may have to travel four times to the center before getting treatment. It is no wonder, then that many of the poorest default after a few visits! Many even prefer the local quacks over the actual medical practitioners.

A TB Report Card released by Global Health Advocates on the occasion of World TB Day has called for further increases in the number of microscopy centres for diagnosis and also an increase in the number of DOTS providers so that people have to travel less distance for diagnosis and treatment.

Bobby John, president of Global Health Advocates, an international advocacy organization noted, "When a patient defaults, there's not enough incentive for the DOTS provider to seek out the person who's not continuing treatment." This clearly proves that a new strategy to provide incentives like extra commission to DOTS observers who bring back any defaulter, may help. Another option is to provide free meal to all those coming in for treatment at the centers.

Just as importantly, patients need to be informed about the seriousness of this disease and the complications arising from lack of complete treatment. This challenge needs to be tackled head on if the programme hopes to convert the worrisome statistics on TB to exemplary ones. Else, India will begin to lead the world in drug resistant strains of the disease too, a distinction to be earnestly avoided.