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Tuberculosis, A Challenge To The Political Will Of Governments, Says Veteran Crusader

Tuberculosis is a global emergency. It challenges the ability and will of the governments everywhere to evolve the right policy mix to foster //the health of the vast masses of the disadvantaged people, says Dr.C.N.Deivanayagam of Chennai, an acknowledged expert and a rebel among Indian physicians.

There is no dearth of reports to show that Mycobacterium tuberculosis Hominis (MTB) (the scientific term for the dreaded TB) is spreading its tentacles across the globe. Both its virulence and reach are of terrifying proportions.

Tuberculosis is one of the world's leading infectious killers - second only to HIV/AIDS, admits the World Health Organisation (WHO). Each year about 1.6 million people die from this curable disease, it despairs.

The latest Global Tuberculosis Control Report of the WHO, released ahead of the TB day, does proclaim that the percentage of the world's population struck by TB had peaked in 2004 but has held steady in 2005.

However the WHO also admits that while percentage-wise the TB incidence is showing some decline, in absolute numbers, it is still forbiddingly high. But then that is because the population is outpacing the efforts to control the disease.

Similarly, the official website of the Directorate General of the Health Services of the Indian government, is gung-ho about the WHO-inspired Revised National Tuberculosis Control Program (RNTCP), and its key strategy of Directly Observed Treatment, Short-course (DOTS).

The figures reeled out by the Directorate General of the country - 600,000 health workers, more than 11,500 laboratory microscopy centers, covering the entire population of the country, 3,500 patients started on treatment every day, and consequently a success rate of 86 per cent in treatment, as against only 25 per cent earlier – are indeed impressive by any standards.

But Dr.Deivanayagam is not convinced. He believes that whoever designed th e DOTS of the WHO has failed to take into account the ground realities. He shrugs away all the numbers bandied out and says acidly, "From the way the program is structured, the abysmal poverty in which vast masses are sunk across the globe, the highly unhygienic conditions in which they are forced to live, the all too obvious lack of political will on the part of many governments to tackle such root causes and the consequent explosion in the numbers of the TB-patients, it is inconceivable that any dent has been made anywhere."

He notes that the very idea of making the TB patients visit the clinics thrice a week for treatment and collect medicines under the DOTS is almost outrageous. For how many can afford to trek to the nearest clinic that many times a week, who will pay them the transport fare and who will compensate them for the loss of the wages? he wonders. And any interruption in the administration of medicine could be fatal for the efficacy. But such is the way the entire regimen has been conceived, it is bound to fail, Deivanayagam asserts.

He still swears by the previous Self-Administered Therapy (SAT) where the patients are given medicine at one go for a month.

If the DOTS had been that effective, why the disaster looming large on almost every front, he challenges. The Directorate General concedes, " The TB burden in India is still staggering. Every year, 1.8 million persons develop the disease, of which about 800,000 are infectious; and, until recently, 370,000 died of it annually —1,000 every day."

Already the multi-drug resistant and extensively drug resistant strains of the TB have emerged, making a mockery of the official claims of success globally.

The HIV pandemic has been the latest addition to this witches' brew. TB and HIV are closely interlinked. In India there are an estimated over 5 million HIV-infected persons. And HIV breaks down the immune system. Without HIV, the lifetime r isk of developing TB in TB-infected people is 10%, compared to at least 50% in HIV co-infected. HIV is also the most powerful risk factor for progression from TB infection to TB disease.

Even more worrisome TB among children is on the rise. According to the latest figures, it is increasing even in such so-called progressive states like Tamil Nadu and Maharashtra.

There is of course this debate over the current paradigm of economic development where some sections advance much faster. So one has to be skeptical about labels like progressive, witness the horrid suicides in the cotton belt of Maharashtra. That apart in Tamil Nadu the official patronage of drinking is a matter of serious concern, says Deivanayagam.

Congested living, tremendous stress at the workplace and easy access to alcohol have meant more and more are hitting the bottle. And the infected father passes on the disease to his children.

What is the way out then? Of course concrete measures to reduce poverty and illiteracy, most urgently in the BIMARU region (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh), considered the most underdeveloped pocket.

Awareness level of TB should increase through sustained campaigns, at the same time access to treatment clinics and hospitals should also improve, not to speak of the availability of drugs.

And give back the choice to the patients. If they want the DOTS, that is fine. But if they want the SAT, ensure that one-size-fits-all approach has never worked anywhere, it is not going to in TB treatment either, the veteran crusader feels. And this is his message - empower the people, make them strong, they will resist TB infection and disease effectively. Hope the government will listen, some time.
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