Tuberculosis

Tuberculosis is the commonest killer of young people in rural Bilaspur, and it is not unusual to find more than one patient in the same family. This happens partly because family members of patients suffer much closer contact than do other people and also because people in the same family generally share the same level of undernutrition. A recent survey of the scientific literature as well as our own experience tell us that undernutrition is a much more frequent cause of immunological suppression than even HIV-AIDS which is a pity since undernutrition can be prevented much more easily than HIV infection and, of course, undernutrition is so eminently treatable.

As a group, 80% of our patients are undernourished, and 60% do not have enough food at home round the year. Eighty percent of our adult female patients weigh < 40 kg and 20% of them weigh < 30 kg. Ninety percent of our adult male patients weigh < 50 kg and 40% of them weigh < 40 kg. 40% are in debt, often due to the cost of treatment, sometimes to the tune of tens of thousands of rupees.

Poverty interacts with tuberculosis in a vicious cycle: it makes you more likely to come down with tuberculosis and then it makes it that much more difficult to seek treatment and continue that to completion. Due to decreased host resistance consequent to malnutrition, the poor often have more extensive disease. Moreover, they tolerate anti-tubercular drugs poorly and are more likely to die despite treatment.

Issues in Treatment

We have been arguing for changes to the management of tuberculosis for several years. The following changes have been made in the public health system's practices in treating tuberculosis.

The World Health organisation accepts and recommends daily frequency of drug treatment in tuberculosis for all types of tuberculosis as the preferred frequency rather than intermittent frequency in the last 3 years. We had reviewed the literature and our own experience and had found intermittent treatment regimens inferior to daily treatment regimens.

The need for supplemental food in treatment of tuberculosis has also been recognised. The World Food Programme is now going to make provision of food for patients with tuberculosis and HIV in selected states.

The need for treatment provision for multi drug resistant tuberculosis in the public health system has been accepted. While the numbers are small, the state has agreed to it.

Further Changes Are Needed

We feel that sputum microscopy is a robust, simple and reliable tool which is underutilized for the diagnosis of tuberculosis of the lungs. By examining multiple sputum samples, we diagnose 60% of our patients with tuberculosis of the lungs without an X-ray. The value of sputum microscopy can be significantly enhanced by using simple concentration tools such as the Ammonium sulphate-Sodium hydroxide technique.

To avoid treatment failure or relapse among TB patients, one needs to give more prolonged treatment with daily rather than intermittent regimens. We need to study this in greater detail.

We feel that the socio-economic predicament of the patient needs to be looked into more closely to find out objective predictors of defaulting behaviour. Patients at high risk of default must be counselled more thoroughly than others and also followed-up more assiduously. This has helped us to reduce defaults if not eliminate it altogether. In anti-tuberculosis drugs, there is a desperate need for standard formulations, bio-availability related information, assurance of quality, and price control.

Preliminary results from nearly 60 isolates suggest that even initial resistance individually to streptomycin, ethambutol and the fluoroquinolones is more than 10%. Acquired resistance levels are far higher.

We need to educate doctors about standard treatment guidelines for tuberculosis. Few formally qualified doctors (MBBS or MD) in Bilaspur prescribe anti-tuberculosis drugs in the right dose or combination for the right duration.

Case Studies

A Family with TB

The gentleman to the left of the picture was the first person in his family to fall prey to tuberculosis. He completed treatment successfully, thanks to a generous grant from the Sir Ratan Tata Trust that allowed us to take a comprehensive look at the social and medical factors that lead poor rural patients with tuberculosis to stop treatment prematurely despite medicines being made available at government clinics free of cost. After he recovered, his father and sister came down with the disease. Their skeletal features tell us clearly why tuberculosis was once known as 'consumption' or 'kshaya roga'. Fortunately, his father and sister were diagnosed in time and they too went on to make an uneventful recovery.

A Migrant Worker

A patient diagnosed with pulmonary tuberculosis working at a construction site near Aundh in Pune developed symptoms of pulmonary tuberculosis and in fact was diagnosed to be so when she accessed care at a public health facility in Aundh. She was due to be started on treatment there, but she returned to her mother's house about 75 km from Ganiyari. She came to us for the sake of treatment. Numerous offers of referral to the RNTCP in Chhattisgarh, or to the Doctors in Aundh were to no avail, because the patient had faith in us because her sister who had previously fallen very ill to tuberculosis had been treated here successfully. She kept up her appointments regularly and only after she completed her 6 months of therapy, did she leave again for Pune.

This case illustrates the predicament of migrant workers who develop serious medical problems but then either cannot negotiate the processes of seeking care at the local public health facility or seek care back home because of the ease of communication in one's own language and faith in their familiar health care providers.