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Earlier this week, the World Health Organization (WHO) said it was ready to assist the Indian government in reaching the target of eliminating tuberculosis by 2025.
This means it will help India reduce its annual count of new infections from 2.8 million to 140,000, or by an unprecedented 95%. Not only does India shoulder the highest TB burden in the world with over two million of the 10 million cases reported here, it also accounts for the maximum drug-resistant (DR) patients — nearly 130,000 people do not respond to first-line drugs.
To call the target ambitious would incorrectly imply that India has a shot at achieving this goal, if all resources were poured into the programme. The target is not ambitious. It is either pure rhetoric or, more disturbingly, completely lacking in understanding of ground realities.
Paucity of medicines
Even if the national TB programme were modernised overnight, budgets increased and human resources and diagnostic facilities made available, there is still one massive, glaring hole in the government’s strategy: there are no medicines.
According to the Health Ministry, over 100,000 patients are annually infected with DR-TB in India. In most cases, they need two drugs: delamanid and bedaquiline. Delamanid, a new class of drug to treat multidrug-resistant TB, received the Drug Controller General’s approval in August. However, it is not yet available to patients in India. Further, the government has, so far, not put forward a plan to rapidly scale up production of the drug.
Bedaquiline has been available in India since February 2016, with caveats. It came as a donation from USAID (United States Agency for International Development) on behalf of the American pharmaceutical company Janssen and was limited to patients living in a five-kilometre radius of six designated hospitals.
Earlier this year, an 18-year-old from Patna, with severe DR-TB and unable to access bedaquiline, successfully sued the government in the Delhi High Court to access the medicine. While the case opened doors for other DR-TB patients not meeting domicile requirements, the government hasn’t procured enough medicines to match the disease burden. As of now, India has 3,500 courses of bedaquiline and 400 courses of delaminid — both donations from USAID and Japanese pharmaceutical company Otsuka, respectively — to treat nearly 100,000 patients who are resistant to first-line medicines.
Onus on the government
This week, 69 organisations comprising affected communities wrote to Prime Minister Narendra Modi, marking the letter to officials involved in the Health Ministry’s TB programme. The letter notes “with alarm” that the slow progression of delamanid roll-out was an “unconscionable delay” on the part of the government. The patient community pointed out that delamanid has been available in the European Union and Japan for over three years.
In 2015, a Joint Monitoring Mission report pointed out that India’s TB targets were failing due to two key issues: the government’s inability to ensure early diagnosis and provide universal access to treatment to those diagnosed.
India’s response to its TB epidemic is now the world’s problem after WHO had to revise global TB estimates in 2016 to 10.4 million people infected — a jump of 500,000 from 2014 — after India informed WHO that it had been under-reporting TB cases from 2000 to 2015. While the Health Ministry is making the right noises about the urgency to respond to TB, patients and experts maintain that it is not putting its money where its mouth is. If the government is serious, it should ensure domestic production of delamanid and bedaquiline instead of running national programmes based on donations.