India loses 5 lakh to lethal TB

Tuberculosis has killed many more Indians in a year than decades of insurgencies and incidents of sectarian violence. Of the 1.4 crore people in the world who had TB in 2015, 30 lakh  were Indians. Across the globe, 18 lakh patients died of TB in 2015, and almost five lakh of them died in India. A staggering number of Indians — over 400 million — are estimated to be infected with TB.

An airborne disease, TB knows no borders. Its impact on India’s economy, an engine of global financial growth, affects wallets worldwide. The TB patients miss three to four months of work and often even more. Not being able to work for such long periods leaves a person’s family impoverished and the economy limping.

Yet the Union government has failed to grapple with the urgency and magnitude of the crisis. In February 2017, Finance Minister Arun Jaitley announced the audacious goal of eliminating TB by 2025.

Jaitley did not offer any hints about how this incredible feat is to be accomplished. Bewilderingly, along with his grand proclamations of ending TB, Jaitley’s revised budget estimates for 2017-18 show a $2 million decrease in funding for India’s TB programme compared with 2016.

Within three decades of its conception, the Revised National Tuberculosis Control Programme (RNTCP) has become one of the world’s largest public TB programmes. It aspires to provide free TB treatment to all. To do so, it has established a network of laboratories and clinics throughout the country as well as a robust community health worker programme to provide rapid testing and standardised treatment for TB.

Nonetheless, it has fallen short of its self-stated goals of a 90% success rate for public notification of each TB diagnosis and a 90% treatment success rate. Only 59% of people were notified of their TB diagnosis in 2015, and 74% were treated successfully.

The failure to meet these lofty goals is partly because many are treated in the private sector, outside the RNTCP’s parameters but also because of the programme’s inadequate funding and resources.

According to the World Health Organisation (WHO), India had a budget of $280 million for TB in 2016; funds from international sources such as the Bill and Melinda Gates Foundation and the Global Fund made up for 62% of it. By contrast, South Africa — with less than 1/20th of India’s population — spent $480 million on TB, with only 8% of it from international sources.

The RNTCP is familiar with unfunded mandates, and despite the stretching of every rupee, bills rack up quickly in TB programmes. Take the programme’s intention of modernising the country’s TB testing, for instance.

Diagnosing TB using microscopy is a common technique that dates to the 1880s. Unfortunately, microscopy requires specialised labour and is prone to error. Incubating sputum in the laboratory is more sensitive but takes weeks.

In contrast, novel diagnostics to detect the TB bacteria’s DNA within sputum offer considerable promise. For instance, a modern test named the Xpert MTB/RIF can identify TB within hours from the time a person produces a specimen, and with sensitivity superior to microscopy. This test offers the simplicity and portability of a K-Cup coffee maker and can be operated by health workers with minimal training.

Tests like the Xpert MTB/RIF could theoretically decentralise and accelerate TB diagnostics and help turn the tide of the epidemic. But each test cartridge costs roughly $10.

Even if testing is extremely targeted to, say, the three million Indians most at risk, that’s $30 million. What if we have to test 10 people to diagnose one case? That would be $300 million, exceeding the entirety of the 2016 TB budget.

India’s problems extend far beyond paltry TB funding. The national health budget for 2017-18 is approximately $7.5 billion. While this might seem an unfathomable fortune to millions of people who make two dollars on a good day, it’s peanuts. No, it’s more like the discarded husk of a peanut.

Consider other comparable economies with large TB burdens. Despite a population that is a sixth of India’s, Brazil’s total health budget is $110 billion. China budgeted approximately $200 billion for health in 2016.

India’s under-funded healthcare system struggles to provide preventive care to Indians who need it most. Affluent people prefer and can afford private institutions. The poor are more likely to avoid preventive care, be malnourished and endure poor living conditions. Unsurprisingly, they are also more likely to get sick.


Healthcare expenditure

Illness saps their productivity and healthcare expenditure drains their savings, reinforcing a cyclic and generational poverty. Indeed, children are among the most malnourished and stunted in the world. This physical and cognitive stunting decreases lifetime productivity and wages.

To eradicate TB, finding active cases is necessary along with rapid initiation of TB treatment and ensuring the completion of therapy. Additionally, contacts of TB patients must be located, tested and treated if necessary. Enlarging India’s corps of community health workers will be important for these activities.

The private sector must be trained, motivated and assisted to provide the standard of care or to refer TB patients to RNTCP services. Public-private partnerships, already piloted by academic and programmatic alliances, have helped increase awareness and expand access to diagnosis and treatment.

They need to be regionally individualised and scaled up. It is also vital for investments in healthcare to be matched with increases in social welfare spending such as in the midday meal scheme and maternal health programmes.

Millions of Indians have died of TB, and millions more have seen the disease stifle their hopes of a better tomorrow. It is time for the government to cough up the money needed to end the suffering.