April 7, 2010 - Eighteen-year-old Savita was forced to leave school after the eighth grade when her mother began suffering from tuberculosis (TB). Savita, being the eldest, had to assist with household chores and help her younger brothers and sisters go to school. Unfortunately, Savita and her thirteen year old sister Babita soon contracted the disease. The family was pushed to the brink of poverty.
Fortunately, a government testing and treatment centre for TB was nearby. Both girls now visit the NDMC Polyclinic in the Gole Market area in New Delhi to take their medication, provided to them free of cost by the government.
Tuberculosis is a leading cause of illness and death in adults
India has one of the most severe burdens of tuberculosis in the world, accounting for one-fifth of the global incidence. TB is India’s leading cause of adult illness and death from a communicable disease. Most of those infected are 15- to 59-year-old adults, the most economically productive segment of society.
In 1993, the Indian Government began to treat tuberculosis patients with the World Health Organization-recommended Directly Observed Treatment Short-course (DOTS). Left on their own, many TB patients fail to take the entire regimen of medication, contributing to the spread of drug-resistant TB for which treatment is long, difficult and expensive. Under DOTS, healthcare workers observe patients as they take their medicine.
More than one billion people covered by DOTS Strategy
In 1997 the Government formally launched the DOTS strategy nationwide. The first World Bank credit (1997- 2005) allowed rapid expansion of the DOTS strategy throughout the country. By providing free services through public or pnon-public institutions, the project ensured that the diagnosis and treatment of TB was available to all citizens regardless of their economic status. Full nationwide coverage of the DOTS strategy was achieved in March 2006, covering over one billion people.
“In the earlier TB control program, patients were good with collecting medicines, but we could not ensure that they took them. Now these medicines are administered at the clinic and its several satellite centers, thus ensuring that patients actually do take their medicines,” said Dr. Ravinder Verma, Medical Officer In-charge, at a government Chest Clinic and HIV Center in New Delhi.
Detection and cure rates increased dramatically
The results have been dramatic. Diagnosis is far more accurate. While x-rays were used to detect the disease earlier, the sputum analysis test has increased detection levels from 30% to 70% at the national level, achieving global targets. Between 1997 and 2008, more than 9.5 million people suffering from TB were diagnosed and placed on treatment, thus saving more than 1.7 million additional lives.
Cure rates for those placed on treatment have also increased dramatically - tripling from 25% in 1997 to 86% in 2009, exceeding the global target. As a result, deaths from the disease were cut sevenfold - from 29% in 1997 to 4% in 2008.
Another key reason for the success is that the entire DOTS program is decentralized. Diagnosis is done in the villages rather than in district hospitals. Quality-assured diagnostic facilities are available through more than 12,000 microscopy centers.
Moreover, more than 300,000 local health workers or trained community volunteers ensure that patients adhere to their drug regimen. Associations of medical professionals are promoting international standards for TB care. Also participating are over 250 medical colleges and some 2,500 NGOs.
Doctors admit that while this level of awareness is helping allay several myths and misconceptions related to tuberculosis, it’s still a battle half won. “While stigma related to tuberculosis has reduced, we still have patients who face discrimination in society. What to speak of lay persons, it is even there among the medical staff. We still have doctors who refuse to drink anything at our clinic,” said Dr. Verma.
However, the problem of stigma and discrimination goes beyond the impact on individuals and their families. It undermines public health efforts to fight the disease at a time “when 40 percent of India’s population is infected with the TB germ”, said Dr. Vashisht – which means these germs lie dormant in an individual, but when the immune system does not work at an optimum level, they are likely to get tuberculosis. However, the RNTCP has set up a wide dissemination campaign which is also addressing the issue of stigma.
Hope for Millions
Notwithstanding these challenges, this program continues to hold hopes for millions of people like Savita. Had it not been for India’s flagship tuberculosis program – one of the biggest TB programs in the world – families such as hers would have never been able to cope with this disease.
The World Bank has helped scale up the Revised National TB Control Program nationwide. The first World Bank credit for $142 million ran from 1997 to 2006. The second credit, from 2006 to 2011, is ongoing and provides $170 million. The World Bank has contributed to several innovations in the TB control program over the years, including the establishment of a strong cross-referral system between the TB and the HIV/AIDS programs, the pioneering of the public-private mix for diagnosis and treatment of TB, and the initial expansion of laboratory capacity to address the increasing problem of multi-drug resistant TB.