India's flagship TB Program has achieved many firsts, providing hope to millions : Newsletter - Nov.-Dec. 2008
Eighteen-year-old Savita was forced to leave school after the eighth grade. Her father would rather have her stay home and help with the household chores. Savita’s mother was suffering from tuberculosis. Being the eldest, she had to take on the responsibility of “running the house” – which included helping her younger siblings go to school. As luck would have it, a few months later, Savita was also diagnosed with tuberculosis. Her sister Babita, 13, too contracted the disease. The family of five was almost pushed to the brink of poverty.
Had it not been for the sustained efforts of the country’s flagship tuberculosis program, families like that of Savita would have found it hard to survive. The economic and social cost of coping with the disease itself would have been enormous for families like hers.
Today Savita and Babita have come to the NDMC Polyclinic in Gole Market area in New Delhi to take their dose of medicine, being provided to them free of cost by the government. A nurse opens the box allocated to Savita and hands out her medicines which she takes promptly. She can now go about her daily chores hassle-free. “In the earlier TB control program, people were good with collecting medicines, but we could not ensure that they took them. Now these medicines are administered at the clinic and its several satellite centers, thus ensuring that patients take them,” said Dr Ravinder Verma, Medical Officer In-charge, NDMC Chest Clinic and HIV Center.
What is also critical to this program is adherence to treatment. It is important to prevent resistance to drugs and ensure total treatment because “treatment for multi-drug resistance TB is long, difficult and very expensive”, he added.
The NDMC Polyclinic in Gole Market, New Delhi which runs the DOTS Program
History of India’s TB program Going a little back into history, India had a National Tuberculosis Control Program (NTCP) in place since 1962. It was only in 1992, after a joint review of the program by the Swedish International Development Agency (SIDA), the World Health Organization (WHO), and the Government of India that a new approach to tuberculosis control, namely the Directly Observed Treatment – Short Course (DOTS), was introduced. The DOTS pilot tests showed promising results. The new approach was increasing cure rates and enhancing patient adherence to treatment. Finally, in early 1997 a Revised National Tuberculosis Control Program (RNTCP) was launched countrywide with a loan of US$ 142 million from the World Bank (1997-2005). In July 2006, the Bank gave a fresh credit of US$ 170 million.
At the time the revised TB program was launched, detection, accuracy and death rate from tuberculosis were hovering around 30 percent. The program had a long way to go. However, the DOTS strategy began to show amazing results.
“While the death rate declined eight to nine fold, the detection and accuracy levels increased by more than three folds. The sputum analysis test as opposed to x-rays itself increased the detection levels from 30 percent to 90 percent,” said Dr R. P. Vashisht, State TB Control Officer.
Since its inception, the program has initiated over 8.45 million patients on treatment, thus saving 1.52 million additional lives.
Flexibility is the way to go So what did this program undertake which was different from the earlier approach? Apart from ensuring greater compliance by administering drugs at the center, the sputum microscopy is a far more accurate method of diagnosis than x-rays done earlier. What is more, the entire program works in a decentralized mode and has a lot of flexibility. State TB Societies and District TB Societies were introduced. Decisions began to be taken at the local level. Diagnosis is now done in the village itself rather than at the district hospital. “For this we needed a huge infrastructure and a lot of funding. Hence, World Bank loan of a little over US$ 142 million (1997-2005) was sought,” Dr Vashisht said.
The flexibility under the revised TB Program has helped increase detection rates
Today, thanks to the huge infrastructure network created through the DOTS program, there is a microscopy center for every one lakh population. In difficult areas, anganwadi and health workers are authorized to collect the sputum samples which are then transported to the nearest lab.
With case detection rate at 70 per cent and treatment success rate at 84 percent nationwide, RNTCP has almost achieved the global targets of 70 percent case detection and 85 percent treatment success rate.
Delhi – a success story Take the example of Delhi which has made very good progress. There are 180 microscopic centers and 580 treatment centers in Delhi. The detection rate of TB cases is also the highest in Delhi. In 2007 the detection was 296 per lakh as against the national average of 130 per lakh in that year. “This is because the services are friendly, convenient and cost-effective,” said Dr Verma. This NDMC clinic also has an Integrated Counseling and Testing Center (ICTC) where TB patients can be tested for HIV. This collaboration is “very successful and provides a link with the AIDS program”, he added.
Delhi is also trying innovative ways of reaching out to its patients. Last year it entered into a collaboration with Bharat Petroleum to run a TB center in one of its prime petrol stations located in Delhi’s Race Course road. The idea was to create a friendly place where people could just walk in and get themselves tested. It also has a trained receptionist who administers medicines to the patients. The center is open all seven days from 9.00 a.m. to 5.00 p.m.
What is remarkable is that the whole system seems to be highly well-networked. Patients have many options to choose from. At the NDMC Polyclinic they can either take their medicines at the center or if that is not convenient, the clinic ties up with a community volunteer through a local NGO. It even goes to the extent of giving the patient an option to choose a person from his vicinity (not a relative) who is then trained and given the responsibility of ensuring that the patient takes the medicines. He has to maintain a chart given by the clinic and submit it regularly.
So what could be the motivation for such a large battery of dedicated workers in the program? Dr Vashisht feels the incentive could be the satisfaction of saving so many lives. “The average death rate from tuberculosis is only 5 percent as compared to 30 percent before the DOTS strategy was launched,” he added.
Today people are also quite aware. “Thanks to the program, more than 70 percent of the people, at least in Delhi, know that if you cough for more than three weeks, it could be tuberculosis,” Dr Vashisht added.
IEC campaigns such as these have helped create a high level of awareness amongst the people
Stigma and tuberculosis Doctors admit that while this level of awareness is helping allay several myths and misconceptions related to tuberculosis, it’s still a battle half won. “While stigma related to tuberculosis has reduced, we still have patients who face discrimination in society. What to speak of lay persons, it is even there among the medical staff. We still have doctors who refuse to drink anything at our clinic,” said Dr Verma.
However, the problem of stigma and discrimination goes beyond the impact on individuals and their families. It undermines public health efforts to fight the disease at a time “when 40 percent of India’s population is infected with the TB germ”, said Dr Vashisht – which means these germs lie dormant in an individual, but when the immune system does not work at an optimum level, they are likely to get tuberculosis. However, the RNTCP has set up a wide dissemination campaign which is also addressing the issue of stigma.
DOTS - A hope for millions Notwithstanding these challenges, this program continues to hold hopes for millions of people like Savita. Had it not been for India’s flagship tuberculosis program – one of the biggest TB programs in the world – families such as hers would have never been able to cope with this disease.
RSS