The occasion of World Tuberculosis Day (March 24) is a good time to take stock of progress in global TB control. Unfortunately, TB continues to be major public health threat, with an estimated 8.7 million new cases per year, and an estimated 1.4 million deaths attributed to the disease.
Early case detection and rapid treatment continues to remain the cornerstone of TB control strategy. With its incidence declining very slowly, it is now obvious that the disease cannot be eliminated by 2050.
TB lethal in India
India has the world’s highest burden of TB, which kills one person every two minutes in India and 750 people every day. The scourge imposes a big drain on the economy, as young, productive adults are the main affected category. Poor patients have to shell out a lot of money for TB treatment and suffer huge economic losses in the process. Global control is unattainable without enhanced control of tuberculosis in India.
The country has been in the news lately because of the international attention on the emergence of “totally drug-resistant” TB in Mumbai and the growing concern that routine control through DOTS (directly observed treatment, short-course) strategy may not be sufficient for reducing incidence.
Detection and follow-up
India’s Revised National TB Control Programme (RNTCP) has made great progress in the last decade, and free, quality-assured TB diagnosis and treatment are available to all patients who seek care in the public sector.
Over the past year, laudable political and administrative commitment has been demonstrated by major increases in the RNTCP budget, a ban of inaccurate, antibody-based serological tests for TB, a national order for mandatory notification of all TB cases, and initiation of a national Web-based case notification and tracking system.
The Government recently approved the National Strategic Plan for 2012-17, with the ambitious goal of universal access to quality TB diagnosis and treatment for all patients in India. This goal of universal access will mean increasing the capacity to manage and treat all forms of the disease (including drug-resistant TB), as well as substantially greater engagement of the private sector, which manages nearly half of all TB cases.
The Government is considering a simple National Standard Mechanism for universal access to quality-assured, free anti-TB drugs to all patients in the country, including those being treated in the private sector. Furthermore, the RNTCP has also shown enthusiasm for scaling up newer, WHO-endorsed molecular tests to enhance capacity for rapid detection of drug-resistance.
While these are positive developments, control of the disease in India is at a critical juncture.
The routine, basic DOTS programme has been scaled up and may have reached its limits because incidence is not declining. Therefore, innovative solutions are needed to go beyond current gains and address the challenges of private sector engagement and drug-resistance.
We know that TB case-finding has plateaued and many cases remain either undiagnosed or ineffectively treated. Delays in diagnosis or ineffective treatment lead to ongoing transmission, facilitating the spread of the disease. Patients often seek care in the informal and private sectors, and remain outside the reach of the RNTCP.
Private sector role
Patients pay a lot for inaccurate tests, and unsupervised, unsupported treatment, that is frequently far short of expected standards. Poor treatment practices lead to drug resistance, which endangers patients as well as the healthcare system. Without effective engagement of the private health sector, the new vision of complete TB control is unlikely to be achieved. Thus, there is an urgent need for new public-private partnership models to improve TB care in India.
The private sector can and should play a bigger role in supporting TB control efforts. Indian industry, celebrities, philanthropists and high net-worth individuals can, and should, make a bigger contribution to control a disease that causes an economic burden of $23.7 billion annually.
Indian celebrities and philanthropists have a track record for championing causes such as HIV/AIDS, polio and cancer prevention. Everyone in India remembers the big impact Amitabh Bachchan had on the pulse polio campaign. In sharp contrast, Indian celebrities have rarely stepped forward to champion the cause of tuberculosis control.
What India needs is at least one high-net-worth individual or celebrity to take up the fight against TB. Until that happens, it will always be a disease that happens to someone else and whose control does not need our collective efforts.
(The author is associate professor of epidemiology, McGill University, Montreal.)