Transcript Tuberculosis in India

Tuberculosis in India:
A Critical Analysis
Lynette Menezes, MSW
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
Critical Analysis
• Factors that impact control of TB in India
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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
Epidemiological Process
• Two important factors
– crowded living conditions
– absence of native resistance
• Risk of infection
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closeness of contacts
infectiousness of the source
degree of sputum positivity
pattern of coughing
Historical Factors - 1
• Called rajyaroga (king of diseases).
• Recorded in sacred texts
• 1900 - 1947
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freedom struggle
no clear policy on TB control
tuberculosis Association of India (TAI)
world war II caused shortages
severe Bengal famine
Historical Factors - 2
• 1947-1950
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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
National Tuberculosis Program
• Goals & Objectives
– eliminate death and disability
– break the chain of transmission
• Implementation problems
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inadequate infrastructure
food and economic crisis
competing programs
political instability
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
NTP- Other Issues
• Patient factors linked to poverty
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reduction of symptoms
costs of treatment
lack of social support
lack of patient education
rude treatment
• Patient follow-up
– lack of personnel
– false addresses
Social Inequalities
• Poverty
– overcrowding
– inadequate nutrition
– lack of knowledge
• Gender differentials
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higher direct costs for women
higher rate of morbidity
less use of health services
social Stigma
Cultural Factors
• Attitudes and beliefs
– stigma
• isolation
• divorce
• ostracism
– beliefs regarding causation
• sex related
• physical and mental stress
• food/water
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
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inadequate food, clothing, books
inability to care for children
school absences and drop out
early employment to support family
Role of International
Organizations - 1960-1980
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Complacency
Belief in supremacy of medical model
Other health priorities
Focus on selective health care
• Reduced funding to TB programs
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
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