Improve living and working conditions to wipe out TB

This article is about TB, but equally, it is not about TB. Despite the fact that India has the highest burden of tuberculosis in the world, this piece does not advocate for more money for the programme, nor does it make the usual arguments about how preventable it is and how it can be cured if detected on time, etc.

What this piece attempts to do however is raise questions. Can India, on its way to super power status, claim with any conviction that it has addressed quality of life for all, regardless of their economic status or caste and creed? TB, the presence or absence of it in a society, is a great way to measure this.

Rene’ Jules Dubos, a microbiologist, pathologist and environmentalist who spent a large part of his life studying microbial diseases, wrote in his book, The White Plague: Tuberculosis, Man, and Society, “Tuberculosis is a social disease, and presents problems that transcend the conventional medical approach.”

While trying to comprehend what he might have meant, I recalled a remark by a geography teacher I once met, who lived in a jungle and worked in a tribal school.
 He had said, “The presence of even one tiger in a jungle indicates that the eco-system, or the food chain of that jungle is intact. For a tiger to survive in a jungle, every other species has to be thriving and plentiful - flora, fauna and small game.”

When I apply that logic to TB, and relate it to Dubos’ observation, it makes sense. While the tiger analogy indicates the health of a forest, the rampant presence of TB in a society, as it is in India, denotes the opposite and indicates that something is indeed very wrong with that society.

The world follows some standard indicators to determine the state (healthy or otherwise), of people living in it. Maternal and infant health, nutritional status, life expectancy etc are just some of these. When measured, each of these give specific results - how many mothers died after childbirth, or how many children did not survive for long after birth etc.

Measuring and interpreting the incidence of TB, however, can also point to a much wider canvas and actually hold a mirror to the kind of society we live in. For now, the image in the mirror for India is not pretty at all, and in the context of TB, it is even worse. Here’s why.

TB is an airborne, droplet infection. But everybody who inhales the infected droplets does not fall ill with TB. It is only the immune-compromised who do. The term immune-compromised simply means those whose immune systems have lost the ability to fight illness.

Lack of nutrition, unhealthy living and working conditions such as poorly-ventilated houses and hazardous occupations, the presence of already debilitating diseases and lack of access to timely health care can reduce the ability of the body to fight disease, thus making it easy for TB to attack.

Basic indicators

India’s numbers for malnutrition, infant and maternal mortality and several other basic indicators are high. They don’t need repetition here as they have been quoted so often. Combined with poverty, poor living and working conditions and lack of nutrition, these then become contributing factors for the spread of TB.

The high numbers for TB in India are sure indicators that a large section of India’s population lives with deprivation of all kinds. This reduces their immunity, thereby keeping TB alive and thriving among them. The circle is then perpetuated because they in turn spread the disease to others around them and the chain thereafter is endless.

India’s TB programme is largely dependent on curative services through the Revised National Tuberculosis Control Programme (RNTCP). If India is to do its bit to end TB by 2030, a goal spelt out by the Stop TB Partnership that world leaders have agreed to, this alone will prove inadequate. Much more needs to be done.

Examples from developed nations are available, which show that TB can be eradicated through the improvement of living and working conditions.

In his paper Ethics, Tuberculosis and Globalisation, Michael J Selgelid points out that even prior to the discovery of the TB bacterium and curative medication,TB mortality in countries such as England was already declining early in the 19th century.

He also quotes Thomas McKeown (1988), who he says, has argued that TB's decline in wealthier nations is best explained by the improvement in living conditions—and, in particular, the improvement of nutrition—associated with industrialisation.

Creating an environment hostile to the spread of TB means having the basics in place and providing quality of life for everyone at all times. This costs money. It means finding the linkages and ensuring they are addressed. It means respecting human rights. It means ensuring TB control is not entirely dependent on the pill as prevention is the key to eradication.

There is potential for this to happen, if we were only to see the linkages. Can the freshly unveiled Start up India policy for instance, spell progress even for the most micro-enterprise which shows promise?

The day all the little known innovators, whether they are making better bhel-puri or dosas, or running auto-rickshaws that provide sightseeing services too or the farmer who is attempting to go organic but doesn’t know where his markets are, have the knowledge to use the benefits of the policy, India will really kick-start progress.

Can Swacch Bharat really clean up India? If all this works, does TB have a choice but to go away? After all, well-fed people living in secure conditions are not ideal pr-ey for TB. The mirror will then show a very pretty picture. And the tiger will thrive.