The Central TB Division of the Union Health Ministry has warned the states and UTs about a possible delay in the distribution of drugs to combat TB.
India has set an ambitious target of 2025 to eradicate TB. (JP Davidson/Creative Commons)
German naturalist and professor of medicine Johann Lukas Schönlein coined the term “tuberculosis in 1834, long before Dr Robert Koch announced the discovery of Mycobacterium tuberculosis, the bacteria that causes tuberculosis (TB) on 24 March 1882.
Despite Schönlein naming it tuberculosis, the disease remained commonly known as “consumption”, with additional sobriquets such as “The White Plague,” and “The Captain of All These Men of Death”, the latter being attributed to English writer John Bunyan.
The deadly disease was mentioned in the writings of ancient Egyptians and Hippocrates of Kos. The most feared malady, then without remedy, was the greatest killer known to mankind, claiming one out of seven people in the United States and Europe.
Cut to present-day India, where tuberculosis kills about 2,20,000 people annually, despite the country making giant strides in science.
A century after Dr Koch’s discovery, 24 March was designated World TB Day, a day not to celebrate, but to educate and add strength to the mitigation initiatives. India has declared war on TB and rolled out its ambitious National TB Elimination Programme to eradicate the disease by 2025.
India’s is a race against time. South First looks at how far the country encompasses the spirit of the TB Day theme, “Yes, We Can End TB!”
As the world marks another TB Day on Sunday, a stark contrast between its theme and ground realities is evident in India. The slogan sounds like a sarcastic jab at lofty promises.
On Friday, 22 March, a collective of TB survivors, people living with HIV, and public health workers wrote a letter to Prime Minister Narendra Modi, reminding him of the “promise of a TB mukt Bharat” and the actual situation on the ground, where the required TB drugs have run out of stock.
Several states have exhausted important TB treatment drugs — 4FDC-1st line DSTB-IP (adult), Isoniazid, Refampicin, Pyrazinamide and Thambutol; 3FDC-1st line DSTB-CP (Adult) Isoniazid, Refampicin, and Ethambutol.
“We have received a letter from the Central TB Division of the Union Health Ministry warning about the possible delay in the supply of TB medicines. It asked us to procure them locally,” informed Dr Sivayogi, state head of the Tuberculosis Division in Karnataka.
Karnataka is also facing a drug shortage and has been struggling to procure the medications locally. The officials noted that the Centre has informed them that the procurement process has begun in Delhi and the drugs would be made available to the state soon.
A week ahead of World TB Day, Dr Rajendra P Joshi of the Central TB Division dispatched a letter to TB officers in all states, warning about a delay in supplies. The letter said that the national-level procurement of anti-B drugs has commenced but there could be a delay in the supply of certain drugs due to “unforeseen” circumstances.
The letter authorised the states and UTs to locally procure the drugs for three months or until central procurement is completed.
The temporary arrangement was made to ensure that patient care was not affected. The letter also mentioned flexibility in procurement regarding pack sizes and formulations and the possibility of reimbursing patients for drug costs under certain conditions.
Officials involved in TB eradication, however, were not impressed. They said the non-availability of drugs have become frequent,
“In the past year there have been many such circumstances. A few months ago, despite the shortage and non-availability of drugs, the Centre did not accept the shortage,” an official told South First on the condition of anonymity.
Meanwhile, the letter to the prime minister also said, “As a country with the highest burden of tuberculosis in the world, we are deeply disturbed that India is experiencing stockouts of critically required drugs to treat people with TB.”
Patients’ left in the lurch
Accredited Social Health Activists (ASHA) dealing with TB patients are worried about the repercussions of the shortage.
Speaking to South First, Narayani Gowda, a resident of Chamarajpet district said she has to visit the health centre at least four times to get medicines. “I have to leave my work and go. It will affect my livelihood so I have decided to not take the medication until it’s available,” she said.
Meanwhile, Sangappa Patil from Koppala, a farmer said his cough would be under control while on medication. “When I am sent back without medicines, I feel weak and lose weight,” he said. An ASHA have told his family that medicines and eating well would control the spread of TB.
Highlighting the predicament of patients, the letter to Modi said the non-availability of drugs meant the centres/officials asking patients to procure the medicines themselves. It might deprive them of the appropriate fixed-dose combinations. Also, the patients might be financially struggling and would not be able to afford the medicines, forcing them to skip the drugs.
The letter also raised apprehensions over the quality of the drugs the states would locally procure due to budgetary limitations.
“The relationship between TB and HIV is lethal. It’s akin to battling two monsters with a single shield. With this kind of disruption in supplying basic medication we will lose the gains of several decades,” an expert in infectious diseases told South First.
A TB officer in Karnataka, on condition of anonymity, further explained the problems.
“In many states, TB drugs are not easily available in pharmacies because of the government programme distributing free drugs to all patients, including those being treated in the private sector. Moreover, many states have not managed to procure locally as they are not geared towards procurement. Buying locally increases the price of the drugs and it is complicated,” he said.
He said the pharmas would manufacture additional medicines only after getting the orders.
“Price-controlled drugs are supplied to the government programme. Hence, most private chemists do not have a large stock of these medicines. Finding such drugs for many people suddenly is unrealistic and impossible,” Ganesh Acharya, an HIV/TB survivor, said. He was one of the signatories of the letter sent to the prime minister.
A recent global research published in The Lancet Infectious Diseases Journal spoke about India’s TB incidence dropping only marginally by 0.5 percent between 2015-2020 and failing to meet the World Health Organization END-TB milestone for 2020.
The government, in its ambitious stride, has vowed to eliminate TB by 2025, five years ahead of the global target.
However, experts and activists argued that without a radical overhaul in approach, the eradication of TB would remain a distant dream. The latest study estimated that the incidence of TB across all ages in India was 213 cases per one lakh population in 2020, well above the WHO’s milestone figures set for India, which is 171 per one lakh population.
It may be noted that the government in 2018, announced The Nikshay Poshan Yojana (NPY), to support TB patients with a monthly financial aid of ₹500 for their nutritional needs.
Despite this initiative, only about two-thirds of TB patients benefitted from the scheme in 2021, raising concerns about its effectiveness in addressing the nutritional challenges associated with TB treatment. Several states have claimed that the financial assistance has not come to patients, leaving them in a lurch.
“Though the amount won’t suffice for anything much, doctors advise us to eat meat, eggs, fruit and vegetables for better recovery, but it won’t be possible without financial assistance,” said a patient from Gulbarga.
Challenges in the Direct Benefit Transfer (DBT) process, such as the non-availability of bank accounts and unlinked accounts, have been significant hurdles for both health providers and patients.
Later, in 2022 September, as part of ‘Pradhan Mantri TB Mukt Bharat Abhiyaan’, a community support to TB patients, Nikshaya Mitra, which will not only provide financial assistance but provide mental support to TB patients. The support extended by donors in terms of ration, kits, nutrition supplements and others has helped the patients.
Speaking to South First, Prof Madhavi Bhargava, a Physician at Yenepoya Medical College in Mangaluru, who has worked with TB research and patient care said, “Nikshaya Mitra is a good initiative. However, it now depends on the availability of individual donors and CSR funds. It is not universal. The quantum in DBT and its regularity should also be reviewed.”
Between 2000 and 2009, Dr Anurag and Dr Bhargava’s single centre in rural Bilaspur, Chhattisgarh, diagnosed around 600 people with tuberculosis each year.
They also observed the impact of widespread undernutrition on the progression and severity of tuberculosis, a factor often overlooked in traditional treatment protocols.
Their RATIONS trial, a comprehensive study designed to assess the impact of nutritional supplementation on reducing TB incidence among household contacts of TB patients in Jharkhand, a region with high rates of undernutrition was much appreciated.
“While the RATIONS trial had shown much improvement, the assessment of Nikshaya is not done yet,” she added.
However, sources in the health ministry said that the concept of RATIONS, which the ICMR had promised to expand to other districts, has been in cold storage.
“While the theme of the World TB Day exudes optimism, the ground realities paint a different picture. It’s like promising a feast to a starving man without ensuring there’s food in the pantry,” Dr Kiran Kumar, a pulmonologist from Davangere, said.
He added that the absence of TB medications could disrupt treatment regimens, allowing the TB bacteria to survive and adapt, potentially leading to the development of drug-resistant TB strains. This form of TB would be more challenging to treat, requiring longer, more complex, and often more toxic treatment regimens, with lower success rates.
Calling it a “grand claim to eliminate TB by 2025,” Prasanna Saligram, Public Health Researcher, Sarvatrika Arogya Andolana from Karnataka said that the government was trying to eliminate TB patients with irregular supply of medicines.
“Six months ago, alarm bells were sounded about the shortage of TB drugs. But the government in its usual brazen style claimed there was no shortage. But now chickens have come home to roost with the Ministry of health scrambling around and asking the district health officials to buy TB medicines locally,” he said.
He argued that first, if there is a shortage in Delhi or Bengaluru, will the drugs be available in the pharmacies of Raichur? Second, for a government which claims to be so efficient, this is a colossal waste of money and highly inefficient, as anyone with common knowledge knows that it is always costlier to buy in retail rather than in bulk (and directly from manufacturers).
For the same money, one could buy more through bulk procurement.
(Edited by Majnu Babu).
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