EDITORIALS

Economic & Political Weekly EPW january 21, 2012 vol xlviI no 3
9
T
he detection of 12 cases of total drug-resistant tuberculosis
(TDR-TB) in just one hospital in Mumbai at the end of last
year suggests a serious breakdown in public health inter-
ventions in preventing the spread of this highly contagious dis-
ease. According to the World Health Organisation (WHO), there
were three million cases of tuberculosis (TB) in India in 2010 with
more new cases every year than in any other country. Nearly 70%
of the patients are between 15 and 54 years and 3,30,000 die every
year due to TB. When translated into human costs these frighten-
ing gures suggest a huge productivity and social loss.
The detection of 12 drug-resistant cases in the P D Hinduja
Hospital in Mumbai means that these patients have shown resist-
ance to all the known anti-TB combination drugs. Given that the
infrastructure to detect drug sensitivity is woefully inadequate in
the country and that one TB patient can infect 14 persons in a
year, this is disastrous news for public health.
India is the second country after Iran to report this mutation of
the disease. While multidrug-resistant or MDR-TB is impervious
to the rst-line drugs that are combined to ght the infection,
XDR-TB or the extensively drug-resistant version does not respond
to either these drugs or the second-line ones. The reasons behind
this development are well known. It happens because patients
fail to go through the entire six-month course of medication at a
stretch. Apart from this, the doctors at the Hinduja hospital who
wrote about their study in the journal Clinical Infectious Diseases
point out that the public sector only provides second-line drugs to
1% of the patients who suffer from drug-resistant TB. It is private
practitioners who are responsible for mismanaging the treatment
that largely leads to the drug resistance. Out of the 106 private
doctors in one part of Mumbai whose prescriptions were exam-
ined by these doctors in another study, only ve had prescribed
the correct medicines to drug-resistant patients. The treatment
course can stretch up to two years for these patients.
In fact, the story of incomplete and irregular treatment is an oft
repeated one despite the governments focus on the directly observed
treatment scheme (DOTS) under the Revised National Tuberculosis
Control Programme (RNTCP). Under this scheme (12,000 TB centres
and nearly 4,00,000 workers), innovative measures such as stocking
the drugs with the local grocer, post ofce and even paan wallahs
have helped to a considerable extent. Even so, migrant workers,
truck drivers and daily wage labourers who cannot afford to lose a
single days work still nd it difcult to keep to a regular medication
regimen. But it is not the patient alone who is responsible for non-
compliance. Patients who are poor, undernourished, or homeless
cannot withstand these strong drugs and the callous attitude of
public health staff often contributes to their not adhering to the
regimen. Treatment of TB needs to go beyond medication and deal
with these root causes. Hence, it is not surprising that the relapse
rate is 35% in India as against the global 15%. There are two addi-
tional factors that constitute major obstacles in the battle against
TB. First, there is the pressure exerted by the pharmaceutical lobby,
especially through private practitioners, that leads to indiscrimi-
nate prescription of miracle antibiotics. This kind of irregular
consumption of antibiotics leads to drug resistance on a large scale.
Second, following the New Delhi metallo-beta-lactamase-1 (NDM-1)
controversy, there were insistent and urgent calls for a national
policy on antibiotics. A 13-member task force was constituted, and
its report specied mandatory conditions and regulations to be
followed by doctors and chemists while prescribing and selling
antibiotics. However, the government has not yet acted on this
draft report as it holds that implementing it is going to be difcult.
The new thinking in government circles is to focus on training
chemists in remote areas to prescribe antibiotics. Essentially, the
government is faced with the twin challenges of ensuring a
r ational use of antibiotics that will prevent the development of
resistant microorganisms and also guaranteeing proper access to
doctors and medicines in the rural areas. Yet, merely training
chemists to prescribe antibiotics cannot be a substitute for
strengthening and improving public health services, infrastruc-
ture and awareness drives. In the nal analysis, public health
c risis such as drug-resistant TB or other persistent diseases can
only be handled if a working public health system is in place. The
Hinduja hospital study and its implications need to be taken seri-
ously. India simply cannot afford to let lakhs of its citizens face
ago nising deaths in the prime of life. Especially, deaths that can
be so easily prevented.
Dealing with a Deadly Killer
India detects cases of total drug-resistant tuberculosis, but how should she deal with the problem?
From 50 Years Ago
Vol XiV, No 3, january 20, 1962
letters to the Editor
Trafc Congestion and
Laissez-Faire
Trafc congestion in Bombay is bad and it is
going to get worse. The problem arises because
trafc is run on a laissez-faire basis. It will not be
corrected until trafc planning is introduced. I
would like to suggest a simple planning scheme.
Any driver wishing to make a trip within
the Bombay limits shall be required to submit
an application to a Trafc Planning Bureau.
The application will specify the intended
origin and destination, and the preferred
time of departure. Applications should be
submitted at least 30 days in advance of the
day of the trip to allow time for processing.
The Trafc Bureau willreturn to each
applicant a card specifying the date, the time,
and the route that the driver will be permitted.
These cards can be attached to the outside of
the automobile where police along the way
can inspect them to ascertain that the driver
is travelling within the authorised route and
time limits. Users of taxis can apply for per-
mits to take taxis between specied points at
specied times
Lady Motorist
New York, January 5, 1962
(The motorist can still retain his freedom to
drive provided he parts with his freedom to
park his car anywhere he likes. This means
not only parking meters and parking lots,
municipal or commercial there can never be
enough of them but changes in building
regulations to compel builders of posh ats,
most of the tenants of which are car-owners,
to build garages or provide parking space
within the building compound Ed)