TB: what to do?
Without a local healthcare system, tuberculosis will continue to ravage rural India. Kirk Leech reports on his time in Gujarat.
Recent outbreaks of tuberculosis (TB) in the UK have brought attention to the problem of TB in the developing world – where it never went away.
Much of the debate has focused on the fact that most people in the developing world have, as an article in New Scientist magazine put it in July 2001, ‘bog-standard TB’, which can be treated with drugs that cost only $10 for a six-month course (1). The article welcomes the fact that leading drug companies are now to supply cheap TB drugs to the developing world at between 60 and 90 percent of their market price. But while this is a welcome move, it does not really deal with the problem of TB in the developing world.
The drugs in question are ‘second-line’ antibiotics, which are already about as cheap as they will get. Taking these drugs is quite a complicated procedure, which often involves taking a combination of 10 or more drugs at the correct time of day, and not on a belly starved of food or water. The problem in countries like India, which has one of the fastest growing TB rates in the world, is that many people do not finish their course of drugs, largely because they cannot afford to do so. This allows for the development of drug-resistant strains of TB.
The World Health Organisation (WHO) has responded to this problem with a scheme called DOTS – ‘direct observed treatment short course’. Nurses or health workers will supervise those taking the drugs to ensure they complete the course. But while you could imagine this working in New York or London, it is more difficult to see it in India, where over 70 percent of the population still live in isolated rural areas.
From the time I spent living and researching in rural India, in an area where treatment of TB comes down to one small clinic, I would say that dealing with TB involves more than drugs, or complicated schemes to ensure compliance with treatment programmes. What rural India really needs is a local healthcare system – and without it, the disease is likely to keep spreading.
By a conservative estimate, four to five individuals per thousand have TB in India. This is at least one hundred times the prevalence of TB in the USA or Europe (2). India is home to 16 percent of the world’s population, and has about 33 percent of TB cases worldwide. Out of every 7.5million cases of TB, it is likely that one million individuals will not be saved (3).
Himmatbhai Baria was a member of a scheduled tribe, a farmer and a father. He arrived by bus in the village of Mangrol in Gujarat, India, and his son took him to the clinic run by ARCH-Vahini, a medical and social welfare NGO working in the poorest and most rural parts of Gujarat. His son went to register him at the clinic’s window, and by the time he got there his father died, both lungs shot by disease.
It had taken Himmatbhai and his son three hours to travel the 80km from his village to Mangrol, changing buses three times – all to get to ARCH-Vahini’s small clinic, which is the only chance that the poorest and most powerless people in this area have of getting relief from diseases like TB and malaria.
One family had walked over 150km from a village deep in the interior to get to the clinic to receive treatment for their sick son. Their two-year-old child had TB of the spine and had consequently lost the use of both legs. If early diagnosis had been possible, the child’s legs – and, as it may turn out, his life – could have been saved. During his time at the clinic, the boy was given treatment, even though the doctors are not confident that the family will continue the treatment back in their village, or that they will return for further medication. The child is not likely to see the monsoon season.
There is a social stigma attached to TB, as there is to leprosy. TB is infectious, horrible and a disease of poverty. The mycobacteria that cause the disease start in the lungs and later spread to other parts of the body. When the person coughs, the contents of his diseased lungs come out forcefully as a fine spray, which travels about three feet from the mouth before slowly settling down.
The initial symptoms are chest pain and sometimes fever – problems that may not appear serious at first, and are often suspected as TB only when the patient has been sick for a few weeks. You can see how high chances of re-infection are in tribal villages, where people do not want others to know they have the disease, and where continuing with the medication is a rarity, given the costs of the medication and the difficulties involved in travelling to a health centre.
ARCH provides TB drugs for free. No government facility in the area does the same. Under-funded state doctors will give a prescription, but this has to be to be paid for, at a cost well out of many people’s reach. Through donations, ARCH has been able to sustain treatment with the same TB drugs – in contrast to government clinics, where the supply is erratic and irregular. Because of the lack of funding to enable them to buy the necessary drugs, government clinics may start people on one drug course, and then be forced to switch to another drug or a combination of drugs. Starting and restarting drug courses, allows for TB bacilli to build up a resistance to the drugs, and for new strains of TB to emerge.
ARCH’s work mirrors many of the problems facing government clinics. Microbes responsible for TB are developing resistance to two or more of the currently prescribed drugs. Low levels of compliance with the treatment compounds the problem. Because of the stigma associated with TB, people will often not admit they have the disease back in their villages. They may take the antibiotics in the clinic but stop when they return home. And because, in the rural areas where ARCH is situated, the health service is pretty much non-existent, there is little back-up for the organisation’s work.
ARCH has tried different means to deal with the problem of non-compliance. Meetings are held with TB patients explaining to them – with the help of charts and models of the lungs – what happens with TB, its causes, how it spreads, and why full treatment is necessary. ARCH has attempted to move the clinics closer to the villages, has begun to charge a deposit that people only get back if they finish the course, and has even resorted to charging people who continually fail to finish the course.
Despite all this, in Mangrol only about 50 percent of adults treated for TB finish the course (4). The World Health Organisation’s DOTS scheme is, according to ARCH, wishful thinking – even though the scheme has been expanded in India, it covers only about 20 percent of the country.
However many innovative schemes are dreamt up to deal with non-compliance with TB treatment, none can tackle the more fundamental problem – the lack of a local healthcare system. Without a system that can diagnose and treat far more people than is possible for an organisation like ARCH, TB will remain the kind of threat it is difficult even to imagine in the UK.
Kirk Leech is a contributor to Ethical Tourism: Who Benefits?, Hodder & Stoughton, 2002. Buy this book from Amazon (UK)
(1) New Scientist, 7 July 2001
(2) Quoted in ‘Using Body Mass Index to assist Tuberculosis Detection in Rural India: A comprehensive Review of the Global Tuberculosis Detection strategy’, Thesis submitted to New York Medical College 2001, by Ashish Patel
(3) Geneva World Health Organisation 2000.Presented at Ministerial Conference on Tuberculosis and Sustainable Development, Amsterdam, Netherlands, quoted in ‘Using Body Mass Index to assist Tuberculosis Detection in Rural India: A comprehensive Review of the Global Tuberculosis Detection strategy’, Thesis submitted to New York Medical College 2001, by Ashish Patel
(4) ‘Using Body Mass Index to assist Tuberculosis Detection in Rural India: A comprehensive Review of the Global Tuberculosis Detection strategy’, Thesis submitted to New York Medical College 2001, by Ashish Patel
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