Put in more money to tackle tuberculosis: Dr Mario Raviglione, the director of World Health Organization's Global Tuberculosis Programme

1.)  India has recorded the highest number of tuberculosis cases including Multi-drug-resistant (MDR-TB) cases in the world, in spite of being less populous than China. Why is the disease burden in India highest in the world?
It is estimated in the WHO global TB report in 2013 that India has 22 lakh tuberculosis cases, of which up to 3% are estimated to be multi-drug resistant. India has notified only 16,000 MDR-TB cases till date. The number of “missed” TB cases in India is about one million. We believe large parts are probably “hidden” in the private sector that does not report cases to the Indian government. In spite of being less populous than China, India has more than double TB cases than China.  In China, despite of the largest population in the world, the incidence of TB is lesser than India. This is because China is a richer economy and it started a good TB control programme with the help of a loan from the World Bank, way back in the early 1990s. India only started an effective TB control programme years later, in the late nineties and therefore it has not yet quite recovered the way China has from the TB scourge.  

2.)  Even after two decades of starting the TB control programme, what is the reason behind India not sharing results of a National tuberculosis survey documenting the MDR-TB burden and the prevalence of the disease with WHO?
India has yet to initiate survey at the national level to document drug resistance and TB disease prevalence. A drug resistant TB survey is about to start in early 2014. India has conducted surveys in some states but not on a national base. It is good to have state or city wise surveys for precise calculations but a national survey provides a comprehensive picture of the TB situation, may it be on drug resistance or general prevalence of the disease. However, the cost of a national survey in India with 22 lakh estimated cases of TB to track, is immense.

China has half of the number of TB cases as compared to India and is richer. Thus, it has pulled off national surveys in both drug resistant TB trends and general prevalence. For example, China has met all three of the 2015 millennium development goal targets for reductions in TB disease burden, with reductions in prevalence and mortality after documenting nationwide TB prevalence surveys in 1990, 2000 and 2010. However, India is yet planning nationwide surveys, results of which will be published eventually after the survey is complete.

3.) What changes in the systems need to be brought about in India so that TB can be controlled effectively?
One fourth of all TB cases in the world are based in India. In 2011 – 2012, there has been a tremendous increase in detection of cases in India. In spite of this, India still tops the list of the highest number of missing cases in the whole world. Private practitioners in India don’t necessarily report cases. In terms of drug resistance, India has notified 16,000 MDR-TB cases in 2012. Up to three times over cases were reported in 2012 as compared to 2011. However, it is estimated that 75% or close to 50,000 MDR-TB cases in India have yet not been detected or are lying hidden as the private sector does not report them. Until last year, there was no mandatory notification for a private doctor to inform the government of a TB case. However, now that the private doctors are mandated to report cases by the Indian government, enforcement of the law will be the way to address the issue of missing cases.

4.)  Is it advisable that TB drug regimens are not available with private chemists or doctors? Will that help in gaining control over drug resistance?
In India, if you go to a pharmacy and buy the drugs, the chemist may sell you a drug even without you presenting him a doctor’s prescription. This is a huge issue and should be regulated. Regulation of drugs entails that you really need a doctor to prescribe it.  Brazil is a very good example of a country where you cannot find TB drugs in any pharmacy. If I am a private doctor in Brazil, I have to refer my TB patient to a public TB clinic, where the patient gets drugs for free.  In India, it’s going to be difficult to adopt the Brazilian model as India is a different democracy. If you say you want to remove drugs from private sector, they will say it’s not liberal. But if you cannot regulate use of drugs, you will always have the problem of missing TB cases. Besides, there is a big risk of misuse of drugs and creation of MDR-TB by those who don’t follow the international standards.

5.) How are the targets for elimination of Tuberculosis looking, globally as well as in India, especially when some activists had mentioned that it may take over 150 years more to get rid of TB?
That’s a difficult one. Elimination means that the incidence of TB should be beneath one infectious case per million. Global average incidence rate of TB is 120 patients in a population of 100,000. In India, up to 250 people per lakh population get infected with TB, while in China the incidence is between 50 – 60 people having TB per one lakh population. It’s difficult to eliminate TB. Even when you think you have the last case, someone in the family or neighbourhood may have been exposed, infected and would have then developed active disease six months down the line. We are dealing with a disease that has infected two billion people around the world already. Two billion infected people comprise of one third of the global human population. This is a pool from which new cases will continue to emerge unless we can use prophylaxis or preventive treatment in an effective way.

6.) But WHO is not an enforcement authority, so if India has a mind of its own, how will it ever live up to global standards of good practices and compliance for achieving elimination of TB?
World Health Assembly member states have called upon WHO to develop a new strategy and new targets to tackle TB in the post 2015 scenario. This strategy will be presented in front of the World Health Assembly in May next year, and member states, including India, will have to ratify it. Once they accept it, you don’t expect that everything will change the next day itself. However, you hope that countries like India will say, now that we have accepted the recommendations, we will have to intensify our programme and put in more finances to strengthen it. It all boils down to political will and commitment at the end of the day.