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As India reels under the growing crisis of COVID-19, an unrelenting virus that threatens to destroy lives, it may be time to remember a long-standing and devastating foe — Tuberculosis or TB. Ironically, though the two diseases have numerous similarities, the one striking difference is that TB is curable but COVID-19’s cure is uncertain.
The media is filled with headlines about COVID-19 and the impending crisis. Lost somewhere in this fear are stories of thousands of TB patients who die each year. TB kills more than 1,400 Indians every day — a scary number even for the coronavirus. What’s more, TB doesn’t just destroy lives, it pushes millions into poverty and debt even when its more dangerous forms such as drug resistant (DR) TB remain curable.
So, why does this curable disease kill so many? A key reason is that lakhs of Indians even today lack awareness and access to accurate diagnosis, and the drugs required for fighting TB, much like the coronavirus.
This is most evident in the case of DR TB where patients often fail to access testing and medication. DR TB affects close to 2 lakh Indians annually. Some cannot afford tests and treatment while others are caught somewhere between an overburdened government system and a profit-driven private sector to access tests and treatment. Each year, this figure rises and mortality for DR TB grows. In short, we have de-prioritised public health so much that we are guilty of feeding this crisis by neglect and apathy.
Let's look at the facts. Even today, drug susceptibility remains inaccessible and unaffordable for most Indians. Despite government efforts, long waiting times in the public sector and exorbitant private sector pricing makes wide-scale testing impossible. As a result, numerous cases remain undetected and transmission is unabated. Considering India’s TB burden, these tests should be accessible and affordable if not widely available free of cost. Are they?
The challenges around treatment are severe. Currently, there is a stock out of Clofamzamine — an essential drug for treating DR TB — in India’s private sector, where millions seek care. Its unavailability complicates matters for thousands. The alternative to this drug is Linezolid — a drug with serious side-effects. In many cases, due to such side effects, patients give up on treatment.
Another case is the access to new anti-TB drugs Bedaquiline and Delamanid. While India has expanded access to Bedaquiline, it still remains available to only a fraction of those that need it. Despite the best intentions, World Health Organization recommendations, and growing evidence of effectiveness, insufficient procurement, delays coupled with a reluctance to share it with patients in the private sector have made this drug difficult to access.
As per recent reports, a similar problem exists in the form of depleting stocks of another new anti-TB drug, Delamanid. This is dangerous but particularly disturbing for the paediatric DR TB population, as Bedaquiline has not been approved for pediatric use and this is the only other new drug available to them.
The inability to resolve the access to diagnosis and drugs is possibly both a moral, and public health failure. We don’t have a cure for the coronavirus but we do have the ability to treat TB easily and still thousands die daily. Is this neglect, or apathy, or both?
As a nation, we should ask ourselves, where should the powerless and poor patient go whether affected by TB or coronavirus? The public sector is paternalistic to its own patients and often lukewarm to those seeking care in the private sector. The private sector, profit driven, has no inclination or power to solve these problems for patients. They only prescribe treatment — availability is not their concern. With insufficient access to and the resulting increased transmission of disease, who is responsible for India’s growing DR TB crisis?
We need to act immediately to resolve this situation. The government needs an independent body tasked with forecasting and procuring these tests and other essential TB drugs, and make them available to all patients in the public and private sector. A lack of availability of drugs for a disease like TB — that affects 30 lakh Indians each year — is not a lapse, it is a blunder.
We need political but also financial commitment to ensure availability and easy accessibility of these tests and drugs to all TB patients. We also need to hold the private sector accountable for producing essential tests and drugs in supply, and available at affordable prices. To do this, we must work more effectively with the private sector and create a relationship of mutual trust. The government should create, in each city, centres of excellence within the private sector which can responsibly administer these newer regimens and drugs. This is critical as the public sector is already overburdened and often short on human resources.
We cannot forget that at the heart of this crisis are patients who are vulnerable, often poor, with little agency. They are struggling to defeat TB and these tests and drugs are their legal right, but instead we reduce them to supplicating for access.
COVID-19 is a wake-up call to the entire health system and how it disregards the needs of those fighting diseases like TB. If we ignore even one patient, not only do we risk their lives, we risk the spread of TB and Corona. It’s time to fight COVID-19 and TB, just as it is time to invest in public health.
(The author is a public health consultant)
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