New Numbers On Tuberculosis Burden Must Galvanize India To Act

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Dr. Madhukar Pai

Last week, WHO released its 2016 Global TB Report. The news, unfortunately, is not good. The report shows that the TB burden is actually higher than previously estimated, mainly because of new data from India. In 2015, there were an estimated 10.4 million new TB cases worldwide. Six countries accounted for 60 per cent of the total burden, with India accounting for 27 per cent of the global cases, followed by Indonesia, China, Nigeria, Pakistan and South Africa.

An estimated 1.8 million people died from TB in 2015, of whom 0.4 million were co-infected with HIV. Gaps in testing for TB and reporting new cases remain major challenges, as they have in the past. Of the 10.4 million new cases, WHO estimated that only 6.1 million were detected and officially notified in 2015, leaving a huge gap of 4.3 million cases that are “missing” — either not diagnosed, or managed in large unregulated private sectors and not notified to TB programs.

Global TB elimination is an impossible goal without significant progress in this emerging superpower.

India continues to bear the brunt of the TB epidemic, with 2.8 of the 10.4 million new TB cases that occurred in 2015. TB is also a major killer of Indian people. The latest Global Burden of Disease estimates from Institute of Health Metrics and Evaluation, published earlier this month, show TB to be the sixth leading cause of deaths in India. In 2005, TB was the sixth leading cause of deaths in India, and ten years later, in 2015, it holds its place as a leading killer of people in India.

These new estimates from WHO and GBD are disappointing and underscores the need for greater investments in global TB control. In particular, India really needs to wake up to the enormity of the epidemic in the country, and put some serious money behind its under-funded TB program. Global TB elimination is an impossible goal without significant progress in this emerging superpower.

It is worth comparing China’s TB situation with that of India. China had 0.9 million TB cases in 2015, while India had over 2.8 million. The number of drug-resistant TB cases in China was 57,000, while India was estimated to have over 79,000. TB is no longer a major killer of people in China, and does not make the top 10 most important causes of death.

It is remarkable that China more than halved its TB prevalence over the last 20 years. Marked improvement in quality of TB treatment, driven by a major shift in treatment from hospitals to the China CDC public health centres (that implemented the DOTS strategy) was likely responsible for this effect, which has been demonstrated by repeated national TB prevalence surveys.

So, why does India struggle with a much higher TB burden? There are many reasons. For one, India has many social determinants that fuel the TB epidemic — poverty, malnutrition, smoking, and indoor air pollution. Secondly, India has under-funded TB control for a very long time. And much of the focus was only on the public TB program. It is only recently that the national TB program has seriously started to address the problem of TB in India’s large, dominant, private sector.

With new research, our understanding of the true burden of TB in India is improving. We are now aware that private sector manages over half of all TB in India, new research suggests that enormous quantities of TB drugs are sold in the Indian private market.

For a long time, India ignored TB patients managed in the private sector, and national prevalence and drug-resistance surveys were not periodically done (unlike China and other high TB burden countries). Furthermore, the Indian national TB program was (and still is) heavily reliant on insensitive diagnostic tools such as sputum microscopy. India is “fighting the TB war with 19th century cannons.” All of this meant that India has been under-diagnosing and under-reporting the burden of TB for a long time.

With new research, our understanding of the true burden of TB in India is improving. We are now aware that private sector manages over half of all TB in India, new research suggests that enormous quantities of TB drugs are sold in the Indian private market.

In addition, although India made TB notification mandatory in 2012, it has taken a few years for private sector notifications to accumulate. Now, thanks to several public-private partnership programs, significant increases are being noticed in case notifications from private sector.

Overall, the path forward for India is very clear — acknowledge the reality of a massive TB epidemic, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem. This will not happen without high-level political commitment.

Last week, on the same day of the WHO TB report release, The Lancet published a comment by the Indian Health Minister Mr Jagat Prakash Nadda and Dr Poonam Khetrapal Singh, head of India’s WHO Regional Office for South East Asia.

Overall, the path forward for India is very clear — acknowledge the reality of a massive TB epidemic, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem.

In their Comment, they acknowledged that TB is a bigger problem than imagined in India and other Asian countries, and suggested that TB should be made a top priority on national agendas. They also argue that political commitment should be translated into a comprehensive national TB control plan, and such a plan must be fully funded and implemented promptly by an empowered body that reports to the highest levels of government.

These statements by the Indian Health Minister is very impressive and progressive, as is the commitment from Dr Soumya Swaminathan, India’s Secretary of the Department of Health Research about India’s plans conduct prevalence surveys, develop innovative new tools for TB, address social determinants such as malnutrition, and create an India TB Research Consortium.

Hopefully, these leaders will deliver on the vision that they have articulated, and make TB a national priority in India. In fact, India has already started the process for creating the National Strategic Plan for TB Control in India (2017-2023). This plan must be ambitious, and fully funded by the Indian government. Otherwise, future TB reports will continue to bring bad news.

Madhukar Pai is the Director of McGill Global Health Programs, and the Associate Director of McGill International Tuberculosis Centre. (@paimadhu)


This article was originally published in The Huffington Post. See the original article here.

Photo Essay: Working at the Myungsung Christian Medical Center in Ethiopia

Angela Lee

My project was a practicum and a research project at Myungsung Christian Medical Center (MCM). MCM is a private, non-profit hospital, where I was under the supervision of a pediatric surgeon. I took part in both the clinics and the surgeries within the hospital, and I also participated in community outreach programs by MCM, such as the free of charge mobile clinics in rural communities. The research project was a retrospective study to calculate the backlog of defined pediatric surgeries at MCM, in order illustrate the gross lack of surgical accessibility in low and middle income countries in Africa.

Picture 1: Myungsung Christian Medical Center which is located in Addis Ababa, the capital of Ethiopia. The hospital consists of 2 wings: Shalom Wing and Grace Wing. The Shalom Wing is the original hospital complex. The Grace Wing was build in 2011, in order to accommodate more patients.

Picture 1: Myungsung Christian Medical Center which is located in Addis Ababa, the capital of Ethiopia. The hospital consists of 2 wings: Shalom Wing and Grace Wing. The Shalom Wing is the original hospital complex. The Grace Wing was build in 2011, in order to accommodate more patients.

Picture 2: The operating rooms at Myungsung Christian Medical Center and surgical team. Far left – Pediatric surgeon. Middle – 4th year medical student as first asssist. Right middle – Scrub nurse. Far right – Anesthesiologist. There are currently no medical residents affiliated with Myungsung Medical College as the medical program is only 4 years old. Therefore, it is not unusual to have the 4th year medical student as the first assist in non-complicated surgeries.

Picture 2: The operating rooms at Myungsung Christian Medical Center and surgical team. Far left – Pediatric surgeon. Middle – 4th year medical student as first asssist. Right middle – Scrub nurse. Far right – Anesthesiologist. There are currently no medical residents affiliated with Myungsung Medical College as the medical program is only 4 years old. Therefore, it is not unusual to have the 4th year medical student as the first assist in non-complicated surgeries.

Picture 3: Mobile clinic in Hawassa: Day 1. Patient triage and blood pressure readings. Volunteers with the help of interpreters take down the chief complaint and basic patient information. I was the designated team member to take blood pressure measurements on Day 1.

Picture 3: Mobile clinic in Hawassa: Day 1. Patient triage and blood pressure readings. Volunteers with the help of interpreters take down the chief complaint and basic patient information. I was the designated team member to take blood pressure measurements on Day 1.

Picture 4: Mobile clinic in Hawassa: Day 2. Dressing change of an infected ulcer under the supervision of Dr. Shin (center).

Picture 4: Mobile clinic in Hawassa: Day 2. Dressing change of an infected ulcer under the supervision of Dr. Shin (center).

Picture 5: Mobile clinic in Hawassa: Day 3 Ethiopian medical students teaching the children about hand washing and dental hygiene. More than 125 children participated in the teachings and activities.

Picture 5: Mobile clinic in Hawassa: Day 3 Ethiopian medical students teaching the children about hand washing and dental hygiene. More than 125 children participated in the teachings and activities.

Picture 6: Interventional angiography inauguration ceremony. Opening address by Reverend Kim (far left). I served as Korean to English translator (second from the left).

Picture 6: Interventional angiography inauguration ceremony. Opening address by Reverend Kim (far left). I served as Korean to English translator (second from the left).

 

Angela Lee was awarded the Medical Class of ’84 Student Bursary in Spring 2016. She is currently a 3rd year medical student who believes everyone has the right of access to quality health care. Angela chose to travel abroad because she wanted a better understanding of the social and medical struggles that both the people and the medical staff face in low resource settings.

Post-Travel Perspectives: Working for the Kigezi Health Foundation in Kabale, Uganda

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Neil Verma

I traveled to Uganda and joined the Kigezi Health Foundation primarily to expand my knowledge of global health disparities, community empowerment and rural medicine. Adequate nutrition remains a challenge for several families in the Kabale area with several diseases having clear associations with malnutrition. My work involved studying the impact of rabbit breeding in low-income families as a means to provide adequate nutrition and additional income. The ultimate goal remains to expand knowledge and resources to address public health issues and maximize population health.

My father and grandmother were born and raised in Kabale and these personal ties to Uganda have specifically drawn me to this community. My family’s experiences have provided me perspective on the impact of disease within this community while fostering my desire to provide medical service to the local population.

My experience with the KIHEFO reinforced my desire to engage in rural medicine and global health, addressing healthcare issues through improving the social determinants of health and community empowerment.

I had limited proficiency in Ruchiga–the local language–and a greater proficiency with the local language would undoubtedly help address the cultural and linguistic barriers and build rapport with patients. Local medical professionals are already faced with a demanding clinical workload, and learning the language and cultural practices partially alleviates the ethical responsibility of having the clinical staff host foreign medical trainees. Cultural attitudes towards medicine also have an impact on healthcare delivery in Uganda, particularly given that 80% of the population exclusively seek out traditional healers as their primary care providers. The KIHEFO has attempted to partner with traditional healers in order to encourage Ugandans to seek out modern medical services. The differences in particular disease treatment protocols and regimen add to the ethical conflict between my own perspective on healthcare and the approach in Kabale. To cope with these realities, I have relied on a network of former global health students and local professionals to better understand Ugandan healthcare along with their unique approach to addressing disease and suffering in a resource-limited setting.

My work with the KIHEFO will contribute to an academic relationship with McGill University and provide a mutually beneficial opportunity to expand knowledge and resources to address public health issues such as malnutrition and HIV prevention. Furthermore, an ongoing partnership between both parties will allow for expansion of available medical resources, services and additional opportunities for knowledge exchange and learning. The benefits of partnering with North American universities are already visible in the KIHEFO’s maternal clinic, which enjoys the use of a donated portable ultrasound machine. As services continue to grow, medical trainees and residents rotating through Kabale will provide additional training to local staff and counselling to community members in order to improve quality of care and maximize population health.

As a practicing physician, I will be able to use the knowledge gained working with the KIHEFO to advocate for policy changes locally and globally that also focus on the social determinants of health including food security and housing that will reduce health inequities. Learning the practice of rural medicine in Uganda allowed me to develop my awareness of the organization of healthcare in a resource-limited setting. It will give me the skills to strive to become a physician who remains conscious of the challenges of healthcare delivery and to provide the most efficient patient care.

As I have embraced the significance of public health to communities, I am optimistic that I will continue to engage in global rural medicine initiatives and devote myself to career and life as an advocate for global health.

My work with the KIHEFO presents challenges and learning opportunities that will improve my understanding of the disparities in global health, the value of community empowerment in healthcare and the challenges of rural medicine in a developing nation. These skills will serve as a foundation for my desire to pursue a career focusing on global health service and the development of global health policy.

Neil Verma was the recipient of the Ashworth Student Travel Award. Neil is a third-year medical student primarily interested in understanding the social, cultural and economic aspects of health and disease to improve global health.

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