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The ‘missing million’ tuberculosis patients hold the key

A majority of tuberculosis patients are poor, with poor nutrition and abysmal access to health services. They seek care in the public or private sectors but often oscillate between them and infect others.
By Soumya Swaminathan and Chapal Mehra
UPDATED ON FEB 12, 2015 11:09 PM IST

The 2013 Global Burden of Disease study shows that tuberculosis, though treatable, is the third leading cause of deaths in India, and kills over a half a million people each year. Why is it that despite continued efforts, tuberculosis deaths have decreased only by 20% since 1990?

India’s “missing” million tuberculosis patients could provide some insights. Most discussions miss the fact that there are close to 1 million “missing” tuberculosis patients. Missing means they are either undiagnosed or are grievously sick, infecting others and dying undocumented deaths. In other cases, they may be taking irregular or incomplete treatment, ending up with deadly drug resistant forms of the disease.

A majority of these patients are poor, with poor nutrition and abysmal access to health services. They seek care in the public or private sectors but often oscillate between them and infect others. Tuberculosis pushes these families further into poverty and causes deaths. An undiagnosed and infectious patient can infect anywhere between 10 and 15 people each year.

In 2012, when Mumbai first reported drug-resistant tuberculosis, it was a wake-up call which highlighted the inability of the public health infrastructure to cope with the challenge. Things have changed since then, with the Mumbai Mission for tuberculosis control addressing the problem by providing free, quality-assured rapid diagnostics and treatment and by incentivising private health care providers to follow uniform standards of care.

How can we address our tuberculosis crisis? Anyone who has symptoms should be able to get access to a rapid tuberculosis test, preferably with a drug-resistance test at the baseline. It means expanding access to care services and ensuring that all patients diagnosed in the private sector be notified to the tuberculosis programme.

We need to engage patients to continue treatment despite the long course and occasional side effects of drugs. The programme needs counsellors who can counsel patients as well as link them to available social sector schemes. Most tuberculosis patients are unable to work and need economic support during the treatment period. In some of the poorest districts of the country, we find low cure rates, because patients have migrated due to financial distress.

To address these challenges we need to make tuberculosis a national priority. We need to recognise that we are in the middle of a crisis. We need more resources otherwise, it will be hard to expand services especially for populations who are “hard to reach”, and often outside the formal health system. We need a national movement to eliminate tuberculosis – with the government, private health providers, corporates and the public joining hands.

(Soumya Swaminathan is director, National Institute for Research in Tuberculosis, Chennai.
Chapal Mehra is a public health specialist and writer based in New Delhi. The views expressed by the authors are personal.)

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