Drug resistant (DR) tuberculosis (TB) in India is a public health problem that we have created for ourselves. While we knew about multi-drug resistant (MDR) TB, where the TB virus develops resistance to the two most commonly used drugs to treat it, isoniazid and rifampicin, a more advanced form of drug resistance called ‘extremely drug resistant TB’, aka the ‘totally drug resistant TB’, was discovered recently. Resistance to TB drugs has been a reality for over a decade and the phenomenon has taken a turn for the worse. We have, by our neglect, created a public health problem that should not exist.
Tuberculosis kills almost two people in India every minute. Public sector health authorities may deny it but DR TB is a bitter pill we must swallow. There are several factors that affect the growth and control of DR TB. Unless we take several steps simultaneously, we won’t be able to control what threatens to become India’s next big challenge in disease control.
All drug resistance is manmade. Desperate for treatment, TB patients consult one doctor after another. They are prescribed different treatments, which are often incorrect and make the body resistant to TB drugs. At times, costly drugs force patients to discontinue the treatment midway, leading to various forms of DR TB.
If you ask the government or the national TB programme, they will tell you that the private sector is the culprit. They will also tell you that the private sector is not ‘our’ problem. But TB is not controlled by any programmes or sectors. It affects all of us and so it is our problem. India leads the world in the number of TB cases and has the second-highest number of cases of MDR TB.
Tuberculosis is preventable and curable. Yet it is increasingly getting resistant to drugs. Patients in the private sector continue to be treated in inappropriate, non-standardised ways with anti-TB drugs of questionable quality. Various physicians flout the internationally recommended treatment. The public sector continues to blame the private sector but doesn’t take any action against it. The control programme is excellent. But people still die due to TB. Despite the recent notification, most of the patients are not notified to the national TB control programme and their treatment outcomes remain unknown. While notification is a step in the right direction by the ministry of health and family welfare, its implementation is not up to the mark. It’s important for the government to engage with the private sector players who are involved in providing treatment for TB and urge them to report every case of TB to local government authorities.
Further, the lack of regulation on access to over-the-counter drugs for TB and other diseases is also responsible for TB becoming drug resistant. The government needs to educate patients about the appropriate tests and the right treatment for TB. Unfortunately, a failure to do so has already cost us dearly, as thousands of TB patients have accepted incorrect treatment out of ignorance.
Also, drugs used to treat MDR TB are more expensive than the drugs used to treat TB. While a course of standard TB drugs costs
approximately R1,000, MDR TB drugs can cost more than R1 lakh. Therefore, the industry and government need to come together to develop ways in which the cost of these drugs can be brought down.
Moreover, the Revised National Tuberculosis Control Programme (RNTCP) provides treatment to TB patients on an alternate day basis. This increases the risk for patients to miss doses, which is another key factor that leads to the creation of drug-resistant strains of TB.
The time has come for the national programme to include all the major and minor players in the TB landscape in India. They must partner with all laboratories in an attempt to address the TB epidemic. One major recent achievement in this regard has been the ban on serological tests for TB. This decision has put an end to the manufacturing, sale, distribution and use of ineffective serodiagnostic tests for TB in India.
To reiterate, there is an urgent need for the authorities concerned to regulate the private sector so that patients get the right treatment and support to win the war against all forms of TB.
Zarir Udwadia is a chest physician at Hinduja Hospital, Mumbai
The views expressed by the author are personal