Tuberculosis in India
Joining the dots
India's new programme for controlling TB is working, but not yet fast enough for the millions affected
LALA is a young man but not a healthy one. Weight loss has pinched his face, giving it the shape of India; his silences end in coughs. Lala stopped taking medicine for tuberculosis (TB) because he started feeling better and ran out of money at roughly the same time. Now the disease is back and he can no longer afford treatment. He may be among the half-million Indians who will die this year from TB, which kills five times as many as malaria, striking mainly those in their prime.
These are avoidable tragedies. Tuberculosis is almost always curable, and the cure is not expensive. When death happens on an Indian scale it is because the health system is not working. Few Indians, knowing as they do that their state is riddled with cracks just the right size for people like Lala to fall through, are surprised when it does.
This is one failure that the Indian state has recently roused itself to correct. Since 1998 India has introduced on a large scale the internationally approved method for tackling TB. The revised national tuberculosis control programme (RNTCP) now covers 460m of India's billion people, and is expected to reach 800m by 2004. But continued success is not assured. The programme demands much from a public-health service that takes in a scant 1% of GDP and misspends much of that. TB control “is basically a management problem,” says Thomas Frieden, who helped India expand the programme and is now New York City's health commissioner.
Few places are harder to manage than India. The premise of TB control is that treatment cannot be left to patients and their doctors. Because there are lots of pills and people feel well before they are cured, they quit prematurely. TB sufferers can infect another 10-15 people in a year; in New York, officials can lock them up if they fail to take their medicine. The accepted remedy is DOTS (Directly Observed Treatment, Short Course), the invention of a Czech concentration-camp survivor. Its essence is the meticulous recording of each event in a patient's treatment, from diagnosis (usually by sputum test, not X-ray) to the administration of many pills and eventually to confirmation of cure. All this should cost the patient nothing.
If the system worked perfectly, TB would die out. In practice, the World Health Organisation sets two main targets: 70% of newly infectious cases should be detected, and 85% of those cured. That would halve the rate of infection in 8-14 years. Most districts in India are close to the cure target but fall short on detection. Since India has 30% of the world's cases, and TB travels, the rich world has a stake in India's success.
But how much can one expect from sprawling, chaotic India, where patients often live miles from roads and the public health system, notorious for absentee doctors and missing drugs, is a last resort, even for the poor? At least 80% of qualified doctors are in the private sector; their numbers are exceeded by 1.25m unqualified practitioners. None has much stake in DOTS, which takes away their customers.
Surprisingly, DOTS is surfing India's anarchy without falling over. Although few DOTS districts have hit both of the WHO's targets, they handily outperform non-DOTS ones, where treatment is at a doctor's whim and there is no mechanism for retrieving patients who quit. The mortality rate for infectious patients is less than 5% where DOTS has been introduced; elsewhere it is 29%. The RNTCP effort claims to have saved 210,000 lives so far.
This result is the progeny of an odd coupling: of the Victorian-vintage optimism underlying DOTS and the improvisational spirit that Indian conditions demand. The programme is, in a way, building a railway, with a station in every village for delivering treatment and picking up data.
The first link is between patient and observer, who can be anyone but a family member. Most often, observers are junior employees of the health service, such as anganwadi (child-health) workers. A second copy of each patient's record sits with a treatment supervisor, who has a motorcycle to track down defaulters. There should be no risk of missing drugs: each patient has a box containing all the drugs required for his cure, an Indian innovation. Word of success or failure comes back through quarterly reports on each district, which the world can scrutinise, if it cares, on the RNTCP website.
The system is not foolproof, though it is designed to be nearly so. Performance in a state or district depends largely on the zeal of the bureaucrat in charge. Rajasthan's health secretary dealt with recalcitrant professors at a medical college by threatening to suspend their licences. The state took a year to roll out DOTS to 44m people, close to a world speed record.
Now that it is no longer an experiment, RNTCP is facing the pressures of maturity. The goal of further expansion may start to compete with other priorities. The programme's main financier, the World Bank, has insisted that it devolve more responsibility to states, which may be necessary but could also weaken quality-control. The next big question will be how to deal with the private sector.
“RNTCP can control only half the problem, not the full problem, until it reaches the private sector,” argues M. M. Singh, head of India's Tuberculosis Association. Others think that people will use the public system once word spreads that it offers good, free care. Converting private doctors to DOTS, they say, is less important than getting the scheme to the half a billion people who still have no access to it.