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LATEST NEWS UPDATES | Why tuberculosis is India's biggest public health problem-Ullekh NP

Why tuberculosis is India's biggest public health problem-Ullekh NP

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published Published on Jun 23, 2013   modified Modified on Jun 23, 2013
-The Economic Times


Anshu Prakash is worried about what he calls "mischievous propaganda" by "some people" who he thinks are misleading reporters. The joint secretary at the ministry of health and family welfare starts off by flatly denying that the joint monitoring mission (JMM) set up by the World Health Organization (WHO) and the government of India (GoI) discussed the impending danger of a TB drugs stock-out in August 2012.

"There was no such discussion. I am trying to help you, dear friend," he laughs in an on-the-record phone conversation. He vouches for the fact that Mario Raviglione, director of the Stop TB Department of the WHO, wasn't present at the August 31 meeting held at The Oberoi hotel in the capital. But when told that documents from the JMM meeting lists Raviglione as one of the participants, Prakash protests: "He is too senior to attend such meetings." Then he adds: "Not a word on procurement was discussed."

Official documents, however, tell a different story: they list "limited capacity to procure [drugs]" as one of the challenges in fighting TB, which is no longer a poor man's disease. One of five TB patients worldwide is an Indian. Prakash then goes on to blame junior WHO officials in the India office for "misleading reporters". After a brief argument, he concedes that he wasn't part of the health ministry in August last year. "I joined only on October 15. So I don't want to give you wrong information. I will check about the JMM meeting and get back."

Colourful Lies

WHO officials and at least two health ministry officials ET Magazine spoke to also say that the JMM meeting warned of a drug stock-out as early as August last year.

Raviglione, who confirms that he was in Delhi for the August 31 JMM meeting, says: "I was in Delhi to present and discuss the outcomes of the JMM. Among things, the reviewing team had identified the issue (of a likely TB drug stock-out) and recommendations were made to address it immediately. Later, our country office took care of following it up with the GoI ... it is the GoI's responsibility to follow up the measures suggested and the WHO's role is to provide support."

Two other members of the JMM that ET Magazine spoke to said on condition of anonymity that the issue had come up at the meeting. "It was then estimated that the current stock for children's TB drugs will last only until July next year," said one of the members.

Blessina Kumar, a TB prevention activist and vice-chairperson of Stop TB Partnership's coordinating board, says she had written several letters to the health secretary (K Desiraju) and the joint secretary (Prakash) since early this year, airing concerns about "the TB situation" in India. Kumar says she was referring to the imminent shortage of TB drugs in most parts of the country. According to its website, Stop TB Partnership operates through a secretariat hosted by the WHO in Geneva, Switzerland, and seven working groups whose role is to accelerate progress on access to TB diagnosis and treatment.

ET Magazine has reviewed these emailed letters. "The answer I was given was that since we are aware of it, this is not a problem," claims Kumar. Prakash didn't reply to emailed queries. In one of his replies to Kumar, Prakash wrote: "Thanks for highlighting important issues. These are very much on our agenda and priority."

Big Worry

India is home to 2.2 million tuberculosis patients, making it the largest number in a single country. According to other estimates, one person dies of the disease every two minutes in India. "This tally is when there is no drug stock-out. Imagine what the death toll could be following non-availability of drugs," declares Kumar.

According to Leena Menghaney, a New Delhi-based official at the French humanitarian-aid group Medecins Sans Frontieres, the stock-out of drugs is not uncommon in India. "Last year, there was a shortage of drugs for Kaala Azaar. And there was a scramble to get donations to buy medicines," she says adding that HIV/AIDS patients are the most empowered ones who immediately create a din over shortage of drugs.

In rural India, she says, TB patients aren't empowered enough to fight for their rights. Since 1993, GoI has been implementing the WHO-recommended DOTS (directly observed treatment, shortcourse) through the Revised National Tuberculosis Control Programme (RNTCP), which is run by the government and supported by the WHO, to test and treat TB free of charge.

"Treatment providers (doctors and others) in rural areas of many states are scared of reporting it out of a 'certain' fear of the top dogs at the centre," says another person who has worked with agencies that offer relief operations when drug stock-outs happen. He didn't elaborate. For its part, the government claims that the money allotted for procurement of drugs - for TB and others - are not "absorbed".

The government's claim, however, falls flat on the claim by Kumar that the issue of a likely TB drugs shortage wasn't discussed last August. "This is criminal negligence and amounts to genocide on the part of the government," accuses Kumar, herself a TB patient. She alleges that - as opposed to the government's claim that there was shortage only in paediatric TB drugs - there is a TB drug shortage even in cheap first-line drugs for traditional, easily curable TB in places such as Mumbai. She went on to say that most states are facing the brunt of a TB drug stock-out except in a few states such as Tamil Nadu and Kerala where procurement processes are far more effective.

ET Magazine, however, couldn't verify these statements.

A recent report in The Hindu had said that the WHO-GoI JMM had raised concerns about the "stock-out situation for paediatric drugs as well as prolongation pouches needed for patients who require to extend their treatment". Prakash initially called the report "false"; he later opted to "check and get back". For his part, Raviglione confirmed that The Hindu report was true.

Weak Defence of India

Raviglione, however, disagrees that India has had similar situations in the past as well. "India has had traditionally one of the best performing programmes in the world. There are, however, limitations like in any other place and they have been enumerated in the recent JMM of August 2012. We hope India will take on board all of them. I have not yet seen the report published."

In India, procurement of drugs is outsourced to private agencies that typically get a 4-5% cut on sales of drugs, including those for TB. "Yes, there is a lot of corruption involved in the procurement process and the MNCs are fed up with paying bribes," says a person close to the matter who asked not to be named.

"There is complete lethargy on the central government as well as among companies that procure drugs to be distributed for free in government-run primary health centres and in hospitals across the country," this person added. For his part, Prakash says that government's activities take some time. "There is a process involved in procuring them." He claims that paediatric TB drugs will be distributed by July. On Friday after inaugurating a private ward at the LRS Institute of Tuberculosis and Respiratory Diseases in New Delhi, Union health minister Ghulam Nabi Azad told reporters there is no shortage of TB drugs, and that the ministry had placed orders for new stock; this will arrive by the end of July.

Worst-case Scenario

Azad also pointed out that the increasing resistance to TB drugs was a big worry. Indeed, India has paid a huge price for ignoring drug-resistant TB - either multi-drug resistant (MDR) or total drug resistant (TDR) - until recently. Drug-resistant TB, according to medical experts, results from inadequate TB care and irrational use of drugs. For instance, 60-year-old Suman Goyal was "diagnosed" with TB by doctors in Kochi and was put under medication for over a month. Later, several tests done in Pune showed that she didn't have TB, only a bronchial infection; but by then she was already at the risk of developing resistance towards TB drugs.

By focusing merely on traditional TB and ignoring drug resistant ones, India's health authorities let the strains multiply and pose a major threat. TB expert and consulting chest physician at the Hinduja Hospital, Dr Zarir F Udwadia, wrote about the disease: "India emerges a global hot spot [even for MDR-TB] with the latest WHO anti-TB drug resistance report estimating that India with its 1.1 cases in 2006 represented 20% of the world's MDR-TB burden. These figures are a considerable underestimate because the majority of patients with MDR-TB are seen in the private sector and never notified."

TB is known to kill more than 3.5 lakh Indians annually - one death every two minutes - making it the country's biggest public health problem. "Yes, it is true that we were caught napping," admits a government official on condition of anonymity because he is not authorised to speak to the media. Clearly, officials such as Prakash are facing the heat as the epic scale of problem is compounded by the epic nature of denial from the health ministry.


The Economic Times, 23 June, 2013, http://economictimes.indiatimes.com/news/news-by-industry/healthcare/biotech/healthcare/why-tuberculosis-is-indias-biggest-public-health-problem/articleshow/20719726


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