Tuberculosis in India: A Critical Analysis

1. Tuberculosis in India: A Critical Analysis Lynette Menezes, MSW

2. Incidence and Prevalence • Global • Leading cause of death world wide • One third of the world infected • 6 million cases globally • India • Leading cause of mortality – 1000 deaths daily • Estimated incidence 185 per 100,000 new cases • Absence of recent national epidemiologic data

3. Critical Analysis • Factors that impact control of TB in India • Epidemiological processes • Political and economic history • NTP implementation • Social inequalities • Cultural attitudes and beliefs • Socio-economic impact on families • Revised National Tuberculosis Control Program • Role of Multinational Organizations

4. Epidemiological Process • Two important factors • crowded living conditions • absence of native resistance • Risk of infection • closeness of contacts • infectiousness of the source • degree of sputum positivity • pattern of coughing

5. Historical Factors - 1 • Called rajyaroga (king of diseases). • Recorded in sacred texts • 1900 - 1947 • freedom struggle • no clear policy on TB control • tuberculosis Association of India (TAI) • world war II caused shortages • severe Bengal famine

6. Historical Factors - 2 • 1947-1950 • gained independence • influx of 10 –15 million refugees • 80% below poverty threshold • < 5% of 2.5 million received treatment • Constitution, Art 47 – relates to health provision • 1956-1965 • Balance of payments of crisis • 58 million vaccinated - effective ?? • Largest prospective BCG study

7. National Tuberculosis Program • Goals & Objectives • eliminate death and disability • break the chain of transmission • Implementation problems • inadequate infrastructure • food and economic crisis • competing programs • political instability

8. NTP- Structural Factors • Urban-rural disparity • inadequate rural infrastructure • health personnel • drugs • sputum microscopy facilities • Interstate disparity • no extra inputs into resource poor states • Private sector - 75% health expenditure • No clear TB policy and monitoring

9. NTP- Other Issues • Patient factors linked to poverty • reduction of symptoms • costs of treatment • lack of social support • lack of patient education • rude treatment • Patient follow-up • lack of personnel • false addresses

10. Social Inequalities • Poverty • overcrowding • inadequate nutrition • lack of knowledge • Gender differentials • higher direct costs for women • higher rate of morbidity • less use of health services • social Stigma

11. Cultural Factors • Attitudes and beliefs • stigma • isolation • divorce • ostracism • beliefs regarding causation • sex related • physical and mental stress • food/water

12. Socio-economic Impact • Human Costs • 4.56 - 6.28 million DALYS • Economic costs • loss of work days • medical and non-medical • Other costs • impact on children • inadequate food, clothing, books • inability to care for children • school absences and drop out • early employment to support family

13. Role of International Organizations - 1960-1980 • Complacency • Belief in supremacy of medical model • Other health priorities • Focus on selective health care • Reduced funding to TB programs

14. RNTCP Problems • Multi drug resistance • HIV/AIDS infection • DOTS • impractical in rural conditions • patients cultural beliefs • human rights • Inadequate infrastructure • Lack of motivated personnel • No control over private providers • Absence of strong national policy • Inadequate funds

15. Recommendations • Interdisciplinary perspective • Update epidemiological data • Need for ethnographic research • focus on gender and class differentials • Revise current DOT strategy • Increase funding for TB intervention • Investigate policies of international funding organizations