India's fight against TB undermined by chronic undernourishment

Nowadays when Tarsil Orao (50) wakes up in his little hut in a village near Bilaspur, Chhattisgarh, he does not reach out for a customary morning cup of tea. The cost of tea leaves, sugar, milk and fuel is more than his household can absorb on the meagre income he earns as a casual agriculture labourer. Come lunchtime, there is but one dish on the menu - cooked white rice. Vegetables and lentils are out of the household too. Now it is rice once a day, every day and twice only on days that the subsidised rice they get is still available. Children and adults alike eat the same.

Devsi and Dulairin’s house has two rope cots, some clothes hanging on a rope strung across the courtyard, some tattered baskets and odds and ends.  But barring a chulha with some cold ash in it, there is nothing else that relates to food in the house. No utensils, no spice jars, and no tins of stored grains are visible anywhere.  The story by now is repetitive. Food is not a given in their house, but something that they eat when available.  They have three children who are assured of at least a mid-meal every day in school, but for the rest, it is much like a game of chance.  

The people featured here, and several more that are not for lack of space, are victims of chronic hunger. Their underweight and under-nourished status bears testimony to the fact that with spiraling inflation and limited livelihood options, the quality of their diets has shrunk down the years.  

The figures speak.  As per a report published by Bloomberg, entitled ‘Early death assured in India where 900 million don’t eat enough’, “…rural Indians have seen their intake slide to 2,020 calories in 2010, from a high of 2,266 calories in 1973. A National Nutrition Monitoring Bureau study in nine states that make up the majority of India’s malnourished population showed a steeper decline, with average rural calorie counts falling to about 1,900 in 2005 from 2,340 in 1979. Daily protein intake dropped to 49 grams (1.5 ounces) from 63 grams. The global average is 77 grams, according to the UN’s Food and Agricultural Organization. The worldwide average daily caloric intake is about 2,800 calories a day.”

Severe under-nutrition

The same report says that India has set minimum daily intakes of about 2,100 calories a day for city residents, who are assumed to be less physically active. The level for rural-dwellers is pegged at 2,400 calories on the basis that tilling fields, harvesting crops and drawing water require greater exertion.

Given the daily deficits of calorie and nutrition intake, the fall-outs are predictable, vulnerability to diseases such as TB included. According to “Nutritional status of adult patients with pulmonary TB in rural central India and its association with mortality”, a study published on PLOS ONE, an open-access peer-reviewed science journal, under-nutrition is a known risk factor for TB and can adversely affect treatment outcomes. Authored by Anurag Mathur, Yogesh Jain, Madhuri Chatterjee and others, the study establishes a connection between nutritional status at the time of diagnosis and completion of therapy, and its association with deaths during TB treatment in a consecutive cohort of 1695 adult patients with pulmonary tuberculosis in rural India during 2004-2009.

It has data to prove that severe under-nutrition at diagnosis was associated with a 2 fold higher risk of death and that a majority of patients had evidence of chronic severe under-nutrition at diagnosis, which persisted even after successful treatment in a significant portion of them. 

Bakku Singh Baiga has been diagnosed with TB, weighs 30 kg and has a hemoglobin count of 3 gm/dl. His treatment at Jan Swasthya Sahyog, Ganiyari, Bilaspur District, Chhattisgarh, will be free.  But Dr Yogesh Jain, who founded the hospital 10 years ago along with a team, says, “Bakku Singh’s treatment will pose several problems as a person’s hunger status has an impact on how the disease can be tackled. It is a concern how he will tolerate medication, which by itself will put a strain on his life; he might be cured of TB but still succumb to what is not so obvious – chronic hunger.”

He continues, “TB as it manifests in rural areas, is completely different from the way it occurs in urban scenarios. Here it has nothing to do with congested living conditions or any other but actually relates directly to lack of food security and the fall outs thereof.  We have evidence of this, collected over five years as the first thing we do when patients come to us for treatment is to record their weight.  More often than not, we find them undernourished and challenged by hunger and with a BMI that is sometimes too low to be compatible with life. They are just unable to tolerate medication.  It is common knowledge that people who are assured of food security at least when they are under treatment have a better chance of making a quick recovery and chances of patients dropping out of medication are fewer.”  

While there is wide recognition that food security plays an important part in healthcare, it seems that the recognition has not translated into programme design.  Phase III of RNTCP has a vision of ‘Universal access - Reaching the un-reached’, which ambitiously declares that the programme has now adopted the new objective of aiming to achieve ‘Universal Access’ for quality diagnosis and treatment for all TB patients in the community.  But what about something as basic as food? Knowing the importance of food security during treatment is there any way that we can assure universal access for that too? Or is that considered too basic to figure in programme design?  (The writer has based the article on a research project)