India: Battling TB in India’s slums

May 9, 2013


Sohrat Parveen and her mother Shahnaz Begum (head covered) at a TB clinic run by Operation Asha, an NGO providing TB services in a Delhi slum. Sohrat Parveen puts her finger on a device that verifies her fingerprints before she is administered her medication. Operation Asha has developed this innovative new software that records both the patient’s and the counselor’s fingerprint each time a drug is administered to ensure that patients consume the drugs in strict accordance with the mandated regimen.

World Bank - Vinita Ranade

For weeks, 12-year-old Sohrat Parveen suffered agonizing pains every time she ate a meal. But she was too scared to tell her mother. Then, one day, her mother got the truth out of her.

“Sohrat was thin and weak and had no appetite,” recalls Shahnaz Begum, mother of eight, whose ten-member family lives, eats and sleeps in a one-room tenement in a crowded Delhi slum. Rounds of doctors’ visits followed, each expense digging deeper into the family’s small earnings from a tiny shop nearby. Still, the child got no relief.

Finally, at Safdarjung Hospital – one of the largest public hospitals in the city – a battery of tests and scans revealed the cause of the problem; Sohrat had tuberculosis (TB), and the bacteria had invaded her stomach.

One in every five TB cases is in India

While the family was devastated, the doctors were not surprised. TB, which has been around since the time of the pharaohs, remains one of the world’s most infectious diseases and one of the biggest killers in India today. In the pre-antibiotic era it claimed a number of famous lives, including that of Kamala Nehru, wife of India’s first prime minister, and Mohammed Ali Jinnah, the first prime minister of Pakistan.

Today, India accounts for about a fifth of world’s TB burden, with an estimated 2.2 million new cases and some 300,000 people dying from the disease every year. Of these, an estimated one million cases go unreported every year, each one potentially infecting 10 to 12 others.

In recent years, a dangerous new variant has emerged – the deadly multi-drug resistant strain or MDR-TB – that is much harder to diagnose and treat. And an even more virulent strain, extensively drug resistant (XDR-TB), which does not respond to most known drugs has been reported in some parts of the country. India’s high incidence of diabetes complicates the problem, as diabetics are far more prone to catch the infection as well as to suffer from its recurrence.

The cure for TB is both long and difficult. It involves nine months of medication – often with unpleasant side effects – for the drug-sensitive strain, and an even more exacting two year-long treatment with a much stronger cocktail of drugs, at a cost of Rs. 1 lakh ($2,000) per case, for the drug-resistant variety.

Rapid urbanization can fuel TB’s spread

India’s massive wave of urbanization intensifies the chances for the infection to spread. TB bacteria proliferate in dank, dark slums such as the one where Sohrat lives. Their warrens of narrow lanes and haphazard jumble of homes, shops, and workshops are packed so tightly together that little light and air can filter through. And, these dense labyrinths are spreading rapidly across the country as legions of people flock to towns and cities in search of a better life.

Well-to-do people are not immune. Posh neighborhoods stand cheek-by-jowl with densely packed pockets of poverty in almost every Indian city, and airborne bacteria know no boundaries.

"TB anywhere is TB everywhere" says Dr. Peter Small, program officer with the Gates Foundation. "Unlike HIV/AIDS from which people can protect themselves, TB is a threat to everyone who breathes, rich and poor.”

Greater attention and resources needed

Clearly, greater attention and resources are needed to control the spread of the infection. India today spends the least among the high TB burden nations, allocating just $115 per case, while China, for example, spends about $300 per case, Brazil $750 and South Africa $1,000.

Moreover, few private health practitioners know the correct drug regimen to treat the disease. They often prescribe expensive diagnostic tests that fall far short of national and international standards – leading to tens of thousands of misdiagnoses every year, and fueling the spread of the drug-resistant strain.

" All too often, patients are misdiagnosed and wrongly treated by private providers who then dump them, broke and drug-resistant, onto the public health system "

Dr. Peter Small

Program officer with the Gates Foundation

New opportunities

Nonetheless, there is cause for optimism. India has recently endorsed an ambitious national strategic plan for TB control which is not only candid about the challenges it faces but also articulates innovative solutions for each of them. Importantly, the government of India has pledged increased funding to further expand basic TB services 2012-17, and scale up services for MDR TB nationwide.

Progress is now being made on every front. India has recently banned inaccurate serological tests long prevalent in the private sector. A new molecular test with quick results and near-100% accuracy is now available; it is, however, very expensive, little known by the public, and not widely accessible.

New methods to engage the host of private health care providers – a diverse and widely dispersed set of doctors, quasi-doctors, labs, and clinics that provide most of the health care in the country – are being explored. Municipalities in Mumbai, where extensively-drug resistant TB (XDR-TB) was reported in 2011, are piloting strategies that offer incentives to private medical personnel to report cases to the national TB control program and improve the care they provide.

The government is also putting IT technology to good use and has established an online reporting system. In the slum where Sohrat lives, Operation Asha (an NGO improving TB care for slum populations) is pioneering the use of biometrics – fingerprints – to monitor the administration of drugs to TB patients. This is critical as missing a dose or interrupting treatment can be extremely dangerous, for those who default can develop the drug-resistant strain.

Next 10 years will be critical

“We are now at a critical juncture,” says Small from the Gates Foundation. “While the scale up of the DOTS program was one of the greatest public health interventions in history, the next 10 years will increasingly define the characteristics of a modern large-scale TB control program.” If successful, India can once again emerge as the global leader in TB control – although the disease may well take another 50 years to eliminate.

“India already has experience to improve TB detection, reduce the time between infection and diagnosis, and effectively engage with private providers to improve the care they provide,” says Patrick Mullen, health specialist with the World Bank. “Most of the elements are there – these now needs to be brought to scale up to push back the epidemic.”

In the Delhi slum

At Delhi’s Indirapur slum, Sohrat has just returned from school. At a tiny TB treatment center, she swallows the clutch of drugs supplied free of charge by the government, under the watchful eye of an Operation Asha counselor.

Today, the clinic is full of TB patients: newly-married housewife Suman, middle-aged factory worker Salim, 16-year-old schoolgirl Shobha, widowed factory-worker Asha, and teenager Yusuf who contracted the disease when he came from his village home to look after his brother who was admitted to the local TB hospital for treatment. The disease, most certainly, knows no boundaries. India’s battle against TB must continue.