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| EDITORIAL |
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| Year : 2017 | Volume
: 4
| Issue : 1 | Page : 1-4 |
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The end tuberculosis strategy: Can India wave a magic wand?
Yatish Agarwal1, Rashmikant Dave2
1 Editor-in-Chief, Astrocyte; and Professor of Radiology at New Delhi's Safdarjung Hospital and Vardhman Mahavir Medical College, India
2 Honorary Executive Director, National Board of Examinations; and Executive Editor, Astrocyte
| Date of Web Publication | 6-Nov-2017 |
Correspondence Address:
Rashmikant Dave
Honorary Executive Director, National Board of Examinations; and Executive Editor, Astrocyte
Yatish Agarwal
Editor-in-Chief, Astrocyte; and Professor of Radiology at New Delhi's Safdarjung Hospital and Vardhman Mahavir Medical College
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2349-0977.217663
How to cite this article:
Agarwal Y, Dave R. The end tuberculosis strategy: Can India wave a magic wand?. Astrocyte 2017;4:1-4 |
Riding the death-horse throughout recorded human history, and probably for many thousands of years prior, tuberculosis the disease has held the human body, mind, and soul captive. Evoking a strange bag of human emotions: despair and horror, love and romance, duty and beneficence, if only to name a few! Given such graphic names as phthisis, consumption, kshya rog, the white death, the great white plague, the robber of youth, the Captain of all these men of Death, the graveyard cough, raja-yakshma, and the King's-Evil, if it has inspired poets, novelists, composers, painters, and artists for centuries and kept a tenacious hold on human creativity, its grip on global health has been no less horribly persistent and disturbing.
Of it, Robert Koch, in his address to the Berlin Physiological Society on 24th March 1882, had said: “If the importance of a disease for mankind is measured by the number of fatalities it causes, then tuberculosis must be considered much more important than those most feared infectious diseases, plague, cholera and the like. One in seven of all human beings dies from tuberculosis.”[1]
Some 135 years later, it derives no less an oblation. Claiming as it does more than 1.8 million lives 2 and ruining millions of homes each year. With one-third of the world population infected with the bacillus, and some 10.4 million people sick with the disease,[2] the global community has been strained to declare a war on it. The World Health Organization's call of “End TB Strategy” which envisions a world free of tuberculosis, zero deaths, disease and suffering due to tuberculosis by the year 2035 is a mission far nobler than it has ever espoused. The goal is to end the global tuberculosis epidemic, bringing about a 95% reduction by 2035 in number of TB deaths compared with 2015; a 90% reduction by 2035 in TB incidence rate compared with 2015; and zero TB-affected families facing catastrophic costs due to TB by 2035.[3]
A faraway dream
Noble as the mission is, and howsoever laudable its goals, the big challenge before us, is its doability. Despite the nature, cause and cure of the disease being no longer a mystery—unveiled as it has been through scientific discoveries fuelled by selfless sacrifices of such eminent men as Rene Laennec, Jean Antoine Villemin, Robert Koch, Wilhelm Konrad von Rontgen, Selman Waksman, Jörgen Lehmann, Gerhard Domagk, and many others—the challenges are far too many, and fault lines in the human social order far too stark. The biggest enemies are not far to see: poverty, hunger, malnutrition, overcrowded poor homes and illiteracy are still a part of the human order. Until that remains, nothing can quite work the magic of bringing tuberculosis to kneel. More than just a disease caused by a wily bacillus, tuberculosis is a yield of social evils. It harvests on the undernourished and gives them the wings to fly out of this world, freeing themselves of the misery and shame.
A worrisome situation
Most worryingly, and if the latest 2016 Global Tuberculosis Report of the World Health Organization is to be believed, the most vulnerable country to this global emergency of tuberculosis is India. The WHO report estimates that India had 2.8 million of new tuberculosis cases in 2015 compared with 2.2 million in 2014. The severity of the challenge is also seen in the staggering number of deaths – 4,80,000 – from this disease in the country last year, which is about a quarter of the 1.8 million tuberculosis deaths globally. A strong wake-up call for India to break the status quo on how tuberculosis and its drug-resistant forms are being diagnosed and treated, it requires a strong political will and commitment to tackle tuberculosis head-on and achieve the set global community targets by 2035.
The actual numbers could be even higher. The true burden of the disease in the country will be known only after the completion of 2017-2018 national TB prevalence survey.
The 2016 Global Tuberculosis Report strongly highlights the lacunae in testing for tuberculosis and reporting new cases. Globally, only 6.1 million of the estimated 10.4 million new cases every year have been detected and officially notified, leaving a huge gap of 4.3 million undetected cases. This problem is due to under-reporting of TB cases, where high numbers of unregulated private healthcare providers do not report tuberculosis cases. The situation is particularly worrisome in countries like India. Of the 2.8 million estimated cases in 2015 in India, the country diagnosed and notified only 1.7 million patients, leaving approximately 1.1 million presumptive patients to an unknown fate. The under-diagnosis is multi factorial, and a large number may simply be because of inaccessible healthcare.
Devising a pragmatic game plan
Clearly, if the battle has to be won, the country must embark on a multi-pronged pragmatic approach. If our policies must be driven by data and evidence, they must also be responsive to the needs and expectations of the community. The strategy must be based on finding all cases, treating them appropriately, reducing risk factors and preventing further transmission. For this, we need better and more efficient diagnostics, shorter treatment courses, and better preventive strategies.
Clearly, radical approaches are called for. The tuberculosis control program must do away with the strategy of waiting for patients to walk in to get tested and instead engage in detecting more cases, both drug-sensitive and drug-resistant. The emphasis must be on providing free, easily accessible healthcare, undertaking universal testing for drug-resistant tuberculosis, reaching out to tuberculosis patients seeking care from private doctors and targeting people belonging to high-risk populations. The other priority must be to provide anti-TB treatment — irrespective of where patients seek care from, public or private — and ensure that they complete the treatment.
Of the many risk factors for tuberculosis, the one that we need to pay most attention to is under nutrition. Malnutrition (low body weight) is thought to be responsible for 50 per cent of tuberculosis in India and also leads to higher death rate, because of impaired immune response. Reports from tribal areas of the country show that the average body weight of men and women with tuberculosis is 30-35 kg. Prevalence rates of tuberculosis are directly correlated with socio-economic status, with people in the lowest economic quintile having 3-4 times the rate of tuberculosis than those in the highest. Facilitating nutritional support to the people, and patients of tuberculosis, in particular, must weigh on policy makers' mind.
Poverty, illiteracy, unemployment, poor homes, hunger, and malnutrition are six of the deadliest foes any human order has to fight with. If the death-riding tuberculosis has to be vanquished, and the even bigger Frankenstein of multi- drug resistant (MDR) tuberculosis and extremely drug resistant (XDR) tuberculosis has to be tamed, the focus cannot remain impervious to these basic human necessities. Can India's people and political class rise to meet the challenges and wave the magic wand to fulfill the global community's noble call of ending the scourge of tuberculosis by 2035? Alas, it looks rather difficult …but then, who knows!
| References | |  |
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| 3. | World Health Organization. Tuberculosis. The End TB Strategy. . [Last accessed on 2017 Jun 11].  |
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