India’s Tuberculosis Challenge

World Tuberculosis Day is observed on March 24 every year to raise public awareness about TB. The Press India talked to Prachi Shukla, Country Director, World Health Partners, on the current challenges that India is encountering in its fight against TB and the way forward.

TPI: As India aims to eliminate TB by 2025, do you think the pandemic has reversed most of the gains made till now towards elimination of TB?  

PS: The global pandemic did put a break on all efforts made so far in ending TB. However, it has also shown a way as to how any epidemic or disease that takes a toll on people’s life must be treated. The uncertain times of Covid beginning from 2020 thus far comes with a lot of learnings. The way world tackled the grim situation is how we need to handle TB- with full force.

TPI: Do you think grassroot participation, particularly of PRIs and community leaders, as part of TB response is still lacking in India?

PS: We are way past the discussion phase, addressing TB epidemic requires comprehensive approach rather than a restricted one. It is time to hold hands and accelerate efforts from all sectors, be it government, private, development sector and the community.

TPI: Artificial Intelligence (AI) is increasingly being applied to diverse challenges in healthcare. How impactful AI could be in TB diagnosis and treatment in the coming years?

PS: Newer technologies have shown great impact in medical diagnostics, Artificial Intelligence (AI) is one such which has immense potential of diagnosing TB. The problem India faces is access, scarcity of trained human resources and quality diagnostic centres at town or below town level. AI based solutions have the power to overcome these challenges and provides timely diagnosis. WHP is also doing AI based chest X-ray in rural areas and the results achieved so far shows huge potential in not just diagnosis but in addressing multiple challenges across the cascade of TB care. AI algorithm can be designed to conduct caseload estimation at the district level using a variety of risk and transmission factors which will help identify missing cases and the prioritisation of TB patients for health workers through stratification of the risk of drop-off from treatment.

TPI: TB is among the leading causes of death among women in the country. What needs to be done to develop a more gender-responsive approach to TB in India?

PS: To achieve TB elimination goals, exhaustive and inclusive collaborations are imperative to reach more vulnerable populations and increase the depth of TB service availability. TB affects over 10 lakh women and girls and more than 3 lakh children every year in our country. Hence it is vital to ensure women and children not only have equitable access to healthcare but also actively seek and complete appropriate TB regimen. There is a need to have a multi-pronged approach to combat negative community perceptions and reduce the social construction of stigma. These days social media platforms reach the unreached; robust awareness and literacy campaigns; regular counselling of women and girls and advocacy at all levels is required.

TPI: The connection between mental health and TB, particularly comorbidities like alcohol use and tuberculosis etc, has not been of much focus till now. How can mental health be integrated in the overall TB care cascade?

PS: The Covid era has forced all of us to comprehend and address the TB-mental illness nexus as it has become more pronounced now than ever before. A person’s physical health is also dependent on its mental health. From the point of diagnosis until they recover, a TB patient is under a lot of stress- loss of job, prolonged ill-health, rejection by community/family members and much more looms large over his/her head. All of this compounded with stigma and substance abuse such as drugs, alcohol are responsible for mental issues which leads to poor adherence, higher drop-out rates, drug resistance and poor treatment outcomes.

To bring attention to the need, we must have holistic solutions that integrate with the health systems, complement and supplement their objectives and not verticalize. Empowering people through social media campaigns, regular capacity building, mandatory screening and counselling sessions, creation of peer support groups, mentors, and community champions. All of this combined with easy access and availability of services and support will enhance the patient experience and improve quality of life.

The programming model of World Health Partners departs from traditional approaches since the attempt is to meet the ‘here and now’ needs. An important aspect of this approach is to use existing resources more efficiently in order to achieve mass provisioning of standardised care. Social relationships and people skills of private providers, are combined with the medical and diagnostic resources of the public sector to deliver well-rounded services to both urban and rural communities. Evidence-based management and monitoring systems combine with advances in telecommunication, diagnostic and medical technologies to enable efficient implementation.

TPI: TB related stigma acts as a strong barrier to uptake of services and treatment adherence, yet concerted action towards stigma mitigation is wanting? What could be the new strategies for this?

 PS: TB patients and their family members are constantly inundated with questions on how, when, where of the disease that inflicts mental strain which is even greater than the physical pain. Stigma is a strong barrier in health seeking behaviour and occurs due to low awareness, societal ignorance and misconceptions and mistaken norms about the disease. We need to draw lessons from other successful disease programs and build mass awareness and campaign drives to ensure every individual is reached. Myths and misconceptions need to be dispelled through targeted campaigns that focus singularly on stigma as the centre point.

TPI: Briefly share how World Health Partners is focussing on designing innovative, equitable and accessible solutions for TB care?

PS: World Health Partners (WHP), a non-profit Indian organization, is currently implementing four TB-related projects in Gujarat, Jharkhand, Bihar, Punjab and Odisha.

WHP’s operational strategy uses an innovative combination of medical benchmarks, technologies and real-time metrics to deliver TB care services to poor and neglected communities.

WHP TB project’s crucially hinges on integrated components consisting of sensitization of providers about importance of early diagnosis and case notification, and strengthening it with training on the standards of diagnosis and treatment. The program ensures the clients (TB patients) receive standardized services on a subsidized or no-cost basis. Additionally, the program seeks to bring about the desired behaviour change among providers to ensure appropriate TB case management at all levels. A multi-layered patient tracking mechanism ensures completion of treatment and a well- rounded communication campaign is used to raise awareness and disseminate information in the community. Simple technologies are optimised to create a local point for the rural and underserved to access health care, newer technologies and digital tools such as computer-aided algorithms, artificial intelligence (AI) for chest radiograph, digital adherence technologies, integrated processes and electronic medical records bring high levels of efficiency to the doctors and paramedical personnel. Routine tasks are supported by digital systems which free up the personnel to carry out many other critical tasks related to patient centred care.

Lately, WHP has been focused on addressing comorbidities and mental health issues that severely impact the treatment outcome. A technology supported call centre through missed call screens and counsels patients to improve quality of life and treatment adherence.

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