Opinion |
Two silent epidemics, of tuberculosis (TB) and undernutrition, have been working together and devastating India for decades. The approach to tackling TB in India and globally has been primarily clinical. Not surprisingly, health systems, programmes and policy have focused primarily on controlling the TB bacteria.
What is overlooked, however, is that the latent TB bacteria themselves remain present in millions, especially in high-burden countries like India. Yet TB doesn’t manifest in all people who carry the bacteria. Why does this happen?
This is because the mere presence of the bacteria may not itself trigger active TB disease. But other ‘risk factors’ and ‘comorbidities’, among which feature undernutrition, can increase the probability of the latent bacteria manifesting themselves as TB disease.
In India, both TB and undernutrition exist on a massive scale. So when they work together, the results are devastating. COVID-19 brought India and the rest of the world to a standstill, dominating the headlines. In the mayhem, we forgot that India has a long-standing undernutrition problem that could be made worse by the pandemic. We also overlooked the possible impact it could have on TB.
Severity of disease
How do TB and undernutrition work together? Poverty and the resulting undernutrition increase the chances of active TB in someone who carries the bacteria, and also the severity of disease. It reduces patients’ speed of recovery, exacerbates side-effects from the medicine, and increases the likelihood of fatality.
Also read: Comment | The way to tackle malnutrition
So while treatment of TB in India may have increased substantially, it is unlikely we will be able to control the TB epidemic if we disregard the causal relation between undernutrition and TB. Despite India’s economic progress, even today, an increasing number of people remain undernourished and without food security, particularly children, women, tribal populations, and other economically marginalised populations. By some estimates, undernutrition accounts for almost 55% of India’s yearly tuberculosis cases.
When undernutrition is combined with other causes, the total incidence of diseases like TB can rise. As employment opportunities remain limited in India, and people migrate to other States for jobs, these challenges are bound to grow. Not just that, low nutritional levels can often lead to worsening of various side-effects that TB patients face. Survivors and patients have reported loss of eyesight, severe weakness in limbs leading to prolonged bed rest, constant fatigue and body ache as effects they experienced.
Role of governments
So what can we get governments to do? A few years ago, India launched the Nikshay Poshan Yojana (NPY), a nutritional support programme for TB patients who cannot afford sufficient nutritious food. This well-intentioned scheme is a case study in why good intentions are insufficient. The scheme’s design and conceptualisation were finalised without consulting survivors. Also, its implementation is fraught with challenges, including delays in or non-receipt of payments, and demand for excessive documentation. There is little doubt that the amount under NPY, Rs. 500, is insufficient and must be raised for all patients to at least Rs. 2,000. There is also a case for State-specific ration assistance schemes for patients whenever possible.
Why is this urgently needed? Even with government assistance, 50% of TB patients’ families suffer financially devastating expenditures as they struggle to satisfy their nutritional and other medical demands, driving them deeper into poverty and the disease trap. We must also recognise the rural, local and regional shortcomings of this scheme. In the end, if the objective of the NPY is that the most vulnerable benefit from it, we are failing. We need to guarantee that those affected by TB eat a well-balanced, tailored diet.
Also read: Comment | Nearly 18 lakh children in India severely malnourished: Centre
Eliminating TB
India has made bold claims about eliminating TB by 2025. While the COVID-19 pandemic has clearly dislodged this target, it is unlikely that we can control TB if we do not address undernutrition both as a preventative and as a curative tool. It is critical to ensure that the nutritional needs of India’s populations are met, and the road to that is food security. We need to focus on making our populations food secure and healthier, not just provide them with diagnosis and treatment. If we continue to neglect the nutritional needs of our populations, we may be creating a longer-term disaster than we can manage in the future.
Deepti Chavan is Fellow, Survivors Against TB; Chapal Mehra is a public health specialist.
