As PM Modi's TB Deadline Looms, Govt Must Know That Not Counting Isn't an Option

Not detecting TB cases means worse outcomes for the patient, more cases among first degree contacts and in the long run, rising incidence of drug-resistant TB.

That food is India’s Achilles Heel in tuberculosis control has been reiterated by the brilliantly intuitive Indian Council of Medical Research-backed study on how food baskets can prevent secondary infections in family members of TB patients. But for India the bigger challenge in TB has been keeping count – the patient needs to be identified and put on treatment first before measures are instituted to safeguard their families. Food baskets, the study also showed, can reduce TB mortality too.

Only a fraction of actual TB cases are reported – this despite the 2012 notification making non reporting a punishable offence – and many more probably continue to evade the formal system, often seeking succour in quackery. India’s decision earlier this year to maintain its own count of TB making it the first country to move away from World Health Organisation numbers could add another level of complexity, potentially breeding complacency.

Meanwhile, evocative though it is, the idea of food as a vaccine for tuberculosis is not a comforting one in a country that has the highest burden of the disease in the world and ranks 107 out of 121 countries in the Global Hunger Index, with levels of hunger being termed “serious”. The Union government has labelled the GHI as an attempt to “taint” India. Now one can only hope that with the Prime Minister Narendra Modi’s promised deadline of 2025 to eliminate TB looming large, the findings of The Lancet’s study on the efficacy of food baskets as a means to reduce secondary TB infections among family members will find a place in the basket of government interventions against the disease.

The study is further proof that undernutrition is one of the key drivers of India’s TB epidemic. The infection is so common among Indians that a skin test widely used for detection of the bacterium is not the test of choice in India. That is because the test gives a positive result for exposure and in India it is estimated that 40% people carry the infection while only 10% develop the disease. The difference between a carrier and a patient is their immunity – linked to a large part to nutrition – levels.

TB diagnosis of course has made several strides in recent years to keep pace with the emerging challenge of drug resistance.

Systemic challenges

But systemic issues plague India’s TB war and some of those are hidden in the last few pages of the India TB report 2023 released in March this year by PM Modi.

It is estimated that about 80% TB patients seek treatment from the private sector. However data published in the government report show that only 30% of TB notifications happen from the private sector. This despite the fact that the disease was made notifiable in 2012 and subsequently not notifying it became a punishable offence. A TB patient that is not notified is one that misses out on the nutrition stipend they are eligible for and is also one that is out of the web of health workers who ensure patient adherence to the minimum six month course of anti tubercular drugs.

There are also challenges beyond what the TB report captures. A particularly daunting one remains access to healthcare services which, contrary to perception, is not just a function of availability. The organised healthcare system for reasons that have been dealt with at length in various academic papers intimidates and in-dignifies India’s poor.

That is why their “doctor” of choice is often a quack – euphemistically referred to often as the “informal” sector. Post the introduction of the National Rural Health Mission and Ayushman Bharat, it is the Indian cities that are fertile hunting grounds for quacks, much more than rural India. The cities, thanks to the crowded and unsanitary living conditions for migrant workers, are also breeding grounds for tuberculosis.

Unfortunately for many of India’s urban poor quacks remain the first ports of call and “family doctors” in any health event – so much so that on occasions when they have reached the DOTS Centre, peer pressure, coupled with the unpalatable drug reactions make many drop out and seek remedy in quackery. Money is not always the motivation – quacks can and do charge a fairly high price for their services.

Keeping count

India sparred with the WHO over the country’s COVID19 death count and neither side budged from their perspective positions. In the aftermath of that long and occasionally acrimonious exchange, India unveiled in March this year a new modelling system to count TB cases — the first country in the world to do so. The model has dramatically spruced up India’s report card, with TB incidence down to 196 per 100,000 population instead of the 210 estimated by WHO and total TB deaths in 2021 down from WHO’s 4.94 lakh to 3.20 lakh.

The TB mortality rate — according to the Indian model — stands at 23 per 1,00,000 people against the 35 that WHO had estimated in 2022. WHO estimates.

The biggest disparity though is in the number of missing cases during 2020-2021 when a slew of factors including lockdown and diversion of TB control manpower on pandemic duties caused. WHO estimates India missed out on diagnosing 41 lakh cases. India estimates that it missed about 4 lakh cases each in 2020 and 2021. The total number of TB notifications in 2022 stood at 24.2 lakh cases — the highest ever but only marginally above the count for 2019, the last pre-pandemic year, when it stood at 23.9 lakh.

The decision to change goalposts in a challenge as recalcitrant as TB immediately after the biggest disruption since the inception of the TB control programme could be catastrophic. To project India’s “progress” in terms of the new domestic calculation vis à vis
the earlier international one is like comparing apples and oranges. What’s more, it would perpetuate a sense of complacency and take away from the efforts of the last few decades.

India may be spared the ignominy of being the country with the worst TB incidence but that sheen would come at a cost.

Whether India incorporates the findings of the ICMR backed study on food packets for contacts or not, the first step in the control of any disease and in its eventual elimination is to acknowledge the gravity of the problem and not attempt to trivialise it.

Abantika Ghosh is a former journalist and author of Billions Under Lockdown: The Inside Story of India’s Fight Against COVID-19. She is currently working with Chase India. She tweets @abantika77.