The Growing Tuberculosis Threat: Can India control this drug-resistant threat?
October 12, 2012
ON THE MORNING OF 14 OCTOBER 2011, Zarir Udwadia, one of India’s foremost chest physicians, sent an email halfway around the world, to the Boston offices of the medical journal Clinical Infectious Diseases. The message was a brief one: just 15 sentences of precise, academic prose, submitted to the correspondence section of one of the most prominent journals in its field. The letter, jointly authored by Udwadia, microbiologist Camilla Rodrigues, and their research registrars, Rohit Amale and Kanchan Ajbani—all colleagues at Mumbai’s PD Hinduja Hospital—recounted their struggles to treat patients suffering from increasingly drug-resistant forms of tuberculosis. As the letter stated, “We describe the first patients from India with TDR Tuberculosis.”
This sentence, innocuous to untrained eyes, spawned the sort of reaction rarely seen in the measured world of the medical sciences. The letter was first published online on 21 December, and immediately caught the attention of the medical community: doctors, health officials and scientists put aside their post-Christmas ennui to debate the implications of this dramatic announcement. But this was just the calm before the storm.
Two weeks later, on 7 January 2012, Udwadia’s findings were splashed across the front page of the Mumbai edition of The Times of India, under the headline ‘New, deadlier form of TB hits India’. Correspondents for foreign newspapers immediately picked up the story, and soon the news was zipping through wire services and hitting front pages across the world.
Udwadia became something of a celebrity, at least in medical circles—he joked that his career “peaked in January”—as requests for reprints of his letter poured in from doctors and journalists. Health authorities also began to take note: within 10 days of the Times of India report, India’s Central TB Division, part of the Union health ministry, sent a three-member fact-finding team to Mumbai. A few months later, tuberculosis was declared a notifiable disease, a designation that requires private doctors to inform the health ministry of all tuberculosis patients they treat.
In March, Udwadia travelled to Geneva to discuss his findings at a meeting convened by the WHO with experts from around the world. Included in the agenda were various issues related to nomenclature that his results brought to the fore.
The TDR in “TDR Tuberculosis” stands for Totally Drug-Resistant; it denotes the existence of a strain of tuberculosis that is resistant to currently available first- and second-line drugs. There had been previous reports of what had been called TDR-TB—in 2003 from Italy and 2009 from Iran—before Udwadia and Rodrigues presented their own findings to the world. But this time, the use of the word “Totally”—with its sense of absolute incurability—sufficed to transport a short letter from the correspondence pages of a medical journal to front pages and television screens worldwide. Most people know that tuberculosis is an infectious disease, and that it passes through the air from person to person heedless of class and caste, particularly over periods of prolonged contact. Now, four doctors working in Mumbai, a city most often viewed in global culture through the prism of its ever-expanding slums, said they had isolated cases that weren’t responding to tested treatments for tuberculosis. Across the world, the headlines wrote themselves.
When follow-up reports began to appear, indicating that other doctors had seen similar cases, both in Mumbai and elsewhere, health officials in the city began to deliberate over how to respond. Their first reaction was to address the fear of contagion: in the week after Udwadia’s findings hit the newspapers, Mumbai health authorities sought to manage public anxiety over the spread of what was being reported as “TDR-TB”. They announced plans to locate and test the friends, families and neighbours of the 12 confirmed patients, and began to discuss plans for a quarantine facility for the affected patients—a move that was announced with certainty by several people affiliated with state health programmes. Yet within two weeks of the initial Times of India report, after health officials in Delhi began to examine Udwadia’s findings, a second and radically different reaction emerged. The official position seemed to change to one of sceptical attack: questions were raised about Udwadia’s conclusions, about the laboratory in which Rodrigues had conducted her tests and the type of tests they had employed, and about the motivations of the doctors, because they had presented their results to an international audience instead of going to the government first.
The argument emanating from Delhi was that Udwadia and colleagues had been irresponsible in their use of the term Totally Drug-Resistant—for the reasons listed above, but also because the very term “Total Drug Resistance” had not been agreed upon internationally, and had the potential to spark panic among the general population. Whereas Mumbai’s TB authorities and Maharashtra state health officials had initially discussed plans to curtail the spread of this dangerous new strain of TB, now the Union health ministry asserted that existing programmes and procedures were sufficient to handle these cases. The reasons for this shift in position have not been made clear, but several experts critical of the government’s reaction suggested that one motivation was to protect the country’s reputation—and its status as a desirable destination for international capital and tourism.
The debate about how to handle TDR-TB had quickly shifted to an argument about whether TDR-TB was real—and if it wasn’t, about what to call the strain Udwadia and his colleagues had observed. The government saw vindication for its position in a decision taken by the WHO after the publication of Udwadia’s letter—the WHO declared that it did not recognise the term “totally drug resistant”. Citing this, the Union Health Ministry stated that there was no such strain as TDR-TB, and added that there was no need for anything more than a slight modification to the current regime of TB control, but the nomenclatural battle has continued. Many medical experts, including Udwadia, argue that the widening spiral of drug-resistance is a stark indication that the procedures already in place are not sufficient to prevent the emergence of deadly new forms of TB or treat those patients suffering from drug-resistant strains—and that the rigidities of these existing programmes, and inefficiencies in their implementation, may in fact be a major cause of worsening drug-resistance.
While health officials may have attempted to discredit the news of a “totally drug-resistant” strain of tuberculosis as needlessly alarmist and based on faulty science, in an editorial published in the medical journal Thorax, Udwadia wrote that tuberculosis “remains India’s biggest public health problem. India bears a disproportionately large burden of the world’s TB, one a developing country can ill afford”. The WHO estimated that in 2010, India had a total of 3.1 million people infected with TB, of which 2.3 million were new cases of incidence from that year. In his editorial, Udwadia wrote that tuberculosis kills 300,000 every year. “That is one death every 2 minutes,” he added, “a grim statistic that has changed little over the decades.”
One of the biggest problems researchers and doctors face is that tuberculosis remains a problem of the downtrodden. Overwhelmingly, tuberculosis is a disease of the developing world, and in the developing world, a disease of the poor—one reason the disease garners little attention in both the local and international media. The poor are especially vulnerable to infection because they’re forced to live in overcrowded, substandard housing, often without proper sanitation and ventilation. Nutrition is a vital factor in staving off tuberculosis infection, so the conjunction of poverty and malnutrition further deepens the vulnerability of the poorest Indians, as do domestic migratory patterns, which often deposit poor migrants into the heart of communities teeming with tuberculosis…