Social stigma weakening India’s fight against TB


New Delhi : India lags far behind developed countries in managing tuberculosis (TB) because of the social stigma attached to it and health workers are particularly vulnerable to the disease, says a new report.

Support TwoCircles

Titled “Worlds Apart – Tuberculosis in India and the United States”, the article by US-based doctor Vikram Paralkar has been published in the current online version of the New England Journal of Medicine.

Mumbai-born Paralkar says the “persistent burden of the disease in developing countries was once due to lack of scientific understanding and now due to lack of infrastructure”. Over one million TB cases are reported every year in India, as per official figures.

The article, which is based mostly on Paralkar’s personal experience of working in a remote village in India and Mumbai’s King Edwards Memorial Hospital, points out that even among India’s educated, tuberculosis carries a stigma.

Paralkar, who is currently a resident in internal medicine at the Temple University Hospital in Philadelphia, says life with TB in India seems “precarious”.

“…India has lagged far behind developed countries in the containment and management of the disease,” the writer says.

“Many people continue to slip through the net and into jostling crowds, with at the most a thin handkerchief to stifle their incessant coughs.”

He says: “Despite the laudable progress that has been made in India in the 60 years since its independence, it remains challenged in fundamental ways”.

“Social stigma often discourages people from seeking treatment for months and when they do seek it, treatment is administered on an outpatient basis, since isolating otherwise functional people is rarely feasible.”

He says the treatment of latent tuberculosis with nine months of single-drug therapy — the norm in the United States — is a concept found only in textbooks in India. “If it were implemented, nearly a 10th of the population would require treatment.”

Citing his stint in a rural health centre, he said: “I saw dedicated healthcare volunteers trek miles down narrow, muddy cattle paths to provide free Directly Observed Treatment (DOTS) to patients in remote areas.”

“Unfortunately, I also witnessed unscrupulous medical officers recording fictional patient names in their logbooks in order to meet government quotas,” he adds.

He says the rate of confirmed infection in the medical fraternity alone is startling.

Citing a finding at a medical school in northern India, he said researchers found an incidence of about 17 new cases of active TB per 1,000 medical residents per year as compared to about two cases in the general population. In the US, the rate is 0.05 per 1,000 in the general population.

“The prevalence of latent infection among healthcare workers at a rural medical school (in India) was more than 40 percent,” he said.

He said genotypic analysis of mycobacterium tuberculosis in patients admitted to two different wards in Delhi revealed clusters of genetically similar strains among patients who had had overlapping hospital stays at the same institution – making for compelling circumstantial evidence of nosocomial transmission.

Recalling his time at King Edward Memorial Hospital in Mumbai where he took training, Paralkar says: “Although they possessed a certain archaic grandeur, the wards housed patients in a communal space that was not designed for the containment of infectious diseases.”

He says patients suffering from TB were situated in the “farthest reaches” and stayed close to those who were being treated for AIDS or cancer.

Incidentally, the huge number of TB cases is also compounding the AIDS situation in India.

The writer says many of his classmates were “exposed to” the infectious disease. “Many more students probably underwent months of treatment without revealing their diagnoses. Even among India’s educated classes, tuberculosis carries a stigma,” he said.

The World Health Organization’s 2007 report on global tuberculosis control has said India’s Revised National Tuberculosis Control Programme has expanded DOTS “to the entire country, with 100 percent geographical coverage in March 2006”.

But Paralkar says: “Although these steps forward are worthy of celebration, we must remember that statistics are only as good as the village-level data on which they are based.”