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Tackling TB: A Catch-22 for Health Authorities

March 7, 2013

TIME has an interesting report on the fight against TB in India. TB is rapidly evolving in India and around the world and the bacteria is muting into strains which are resistant to multiple drugs. This mutation makes the treatment difficult and lengthy as more drugs are to be combined to obtain a result. Drugs and treatment are however only part of the problem. TIME’s reportage does an excellent job at shedding lights on the multifaceted bottlenecks that any response against TB (and other infectious diseases) will face. If one wants to design a response to contain the epidemic, one has to identify where to start. When one considers however  the starting point of any TB responses, one gets the sense that tackling TB can turn into a Catch-22.

Scoop them into the system. If a country faces a growing epidemic of TB (like India), one of the priority is to get as many people as possible diagnosed for TB in time: this implies people visiting health facilities which are equipped with TB test and drugs. In many countries this scenario is far from reality: today in India there are for example only 57 doctors per 100,000 people in the public sector and this fall far short of what is needed. Long waiting time and mistrust towards government services have pushed people into either foregoing any sort of treatment all together or visiting private practitioners.  The problem with private doctors is that they ranges from qualified professionals to unskilled entrepreneurs who prescribe anything to sufferers in return for consultation fees. As a result, unqualified and unequipped hole-in-the-wall-providers are the first point of contact for many TB sufferers in India. Those sufferers remain outside the India TB response system.

Get the diagnosis right. When somebody goes to a clinic displaying the symptoms for TB one should receive the test to accurately diagnose the disease. The problem with TB is that the test takes weeks sometimes (during which time the person can infect others) and that many of the clinics (see hole-in-the-wall-providers) are not equipped with testing facilities. If one is given TB drugs but does not have TB, the bacterium is likely to win resistance against the drug: countries end up with strains of multi drugs resistant MDR and extra drug resistant XDR TB. That complicates the treatment and fuels the epidemic. If one wants therefore to contain TB infections, one of the priorities is to get the diagnosis right as soon as people enter in contact with the health system. If diagnosis is not done properly, many people are likely to be prescribed with the wrong treatment (treatment for normal TB instead of for MDR TB) and therefore they will fail to improve. So even if one goes to the health clinic and is enrolled on treatment chances are high that the treatment will not cure the person, if the diagnosis is wrong.

Until the End…Almost. People who have contracted MDR or XDR TB have to follow a lengthy and complicated treatment: many are not able to follow the treatment up to the end and they drop out. In India for example TB medication are for free but are to be collected three times per week at a clinic or hospital: day laborers cannot afford to leave their jobs so often.  From this perspective the priority is to ensure that once people are enrolled on treatment, particularly for MDR and XDR TB, they stick to their schedule and complete the treatment.

Catch-22. The problem with TB is that if one tries to tackle only one aspect of the problem one is bound to face a no-win situation. If one decides that the starting point is investment on more public health centres to get more people scooped in the TB system, one could find out that this response takes just too long and time is very scarce in the fight against TB. If one plans to provide private practitioners only with free TB drugs, one could fuel the resistance to second-line drugs for MDR TB because the diagnosis is not right. If one focuses only on increasing the precision of TB blood test across the health system one could end up with some providers turning to inexpensive but dangerously inaccurate TB blood test if they are not regulated. If one makes reduction of treatment attrition rate for MDR or XDR TB patients the priority, one could find out that rampant off-the-mill TB incidence gets worse as resources are channeled on treatment of drug resistant strains. You focus on only one aspect, you could end up with no improvements in containing TB cases.

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