1. Tuberculosis in India: A Critical Analysis Lynette Menezes, MSW

2. Incidence and Prevalence Global –Leading cause of death world wide –One third of the world infected –6 million cases globally India –Leading cause of mortality – 1000 deaths daily –Estimated incidence 185 per 100,000 new cases –Absence of recent national epidemiologic data

3. Critical Analysis Factors that impact control of TB in India –Epidemiological processes –Political and economic history –NTP implementation –Social inequalities –Cultural attitudes and beliefs –Socio-economic impact on families –Revised National Tuberculosis Control Program –Role of Multinational Organizations

4. Epidemiological Process Two important factors –crowded living conditions –absence of native resistance Risk of infection –closeness of contacts –infectiousness of the source –degree of sputum positivity –pattern of coughing

5. Historical Factors - 1 Called rajyaroga (king of diseases). Recorded in sacred texts 1900 - 1947 –freedom struggle –no clear policy on TB control –tuberculosis Association of India (TAI) –world war II caused shortages –severe Bengal famine

6. Historical Factors - 2 1947-1950 –gained independence –influx of 10 –15 million refugees –80% below poverty threshold –< 5% of 2.5 million received treatment –Constitution, Art 47 – relates to health provision 1956-1965 –Balance of payments of crisis –58 million vaccinated - effective ?? –Largest prospective BCG study

7. National Tuberculosis Program Goals & Objectives –eliminate death and disability –break the chain of transmission Implementation problems –inadequate infrastructure –food and economic crisis –competing programs –political instability

8. NTP- Structural Factors Urban-rural disparity –inadequate rural infrastructure health personnel drugs sputum microscopy facilities Interstate disparity –no extra inputs into resource poor states Private sector - 75% health expenditure –No clear TB policy and monitoring

9. NTP- Other Issues Patient factors linked to poverty –reduction of symptoms –costs of treatment –lack of social support –lack of patient education –rude treatment Patient follow-up –lack of personnel –false addresses

10. Social Inequalities Poverty –overcrowding –inadequate nutrition –lack of knowledge Gender differentials –higher direct costs for women –higher rate of morbidity –less use of health services –social Stigma

11. Cultural Factors Attitudes and beliefs –stigma isolation divorce ostracism –beliefs regarding causation sex related physical and mental stress food/water

12. Socio-economic Impact Human Costs –4.56 - 6.28 million DALYS Economic costs –loss of work days –medical and non-medical Other costs –impact on children inadequate food, clothing, books inability to care for children school absences and drop out early employment to support family

13. Role of International Organizations - 1960-1980 Complacency Belief in supremacy of medical model Other health priorities Focus on selective health care Reduced funding to TB programs

14. RNTCP Problems Multi drug resistance –HIV/AIDS infection DOTS –impractical in rural conditions –patients cultural beliefs –human rights Inadequate infrastructure –Lack of motivated personnel No control over private providers Absence of strong national policy Inadequate funds

15. Recommendations Interdisciplinary perspective Update epidemiological data Need for ethnographic research –focus on gender and class differentials Revise current DOT strategy Increase funding for TB intervention Investigate policies of international funding organizations