Insights into Editorial: Paradigm shift for TB control
Tuberculosis (TB) remains the biggest killer disease in India, outnumbering all other infectious diseases put together this despite our battle against it from 1962, when the National TB Programme (NTP) was launched.
All hope was pinned on mass BCG vaccination to prevent TB.
In 1978, the Expanded Programme on Immunisation (EPI) began, giving BCG to all babies soon after birth and achieving more than 90% coverage.
Yet, when evaluated in 1990, the NTP and the EPI had not reduced India’s TB burden.
In 1993, the Revised National TB Control Programme (RNTCP) was launched, offering free diagnosis and treatment for patients, rescuing them from otherwise sure death.
However, treatment is not prevention. Prevention is essential for control.
True to the spirit of World TB Day theme, there is a need to laud Tamil Nadu for deciding ‘It’s time to take bold and imaginative initiatives to create a TB control model’.
Tamil Nadu, an erstwhile global leader in TB research during the 1960s through the 1990s, will now become the global leader in TB control.
Landmark years in fight against TB:
In many ways, TB has never been more visible than before. The years 2018 and 2019 have been landmark years in the fight against TB, globally and in India, with the first ever High-Level Meeting on TB held at the United Nations last year.
In India, there is high political will and commitment to end TB, budgets are slowly increasing, new social support schemes have been announced and TB survivors are speaking up.
World TB Day is observed on March 24. The theme of World TB Day 2019 – ‘It’s time’ – puts the accent on the urgency to act on the commitments made by global leaders to:
- scale up access to prevention and treatment;
- build accountability;
- ensure sufficient and sustainable financing including for research;
- promote an end to stigma and discrimination, and
- promote an equitable, rights-based and people-centred TB response.
The World Health Organization (WHO) has launched a joint initiative “Find. Treat. All. #EndTB” with the Global Fund and Stop TB Partnership, with the aim of accelerating the TB response and ensuring access to care, in line with WHO’s overall drive towards Universal Health Coverage.
But as yet another World TB Day comes around on 24 March, it is important to keep reminding ourselves that we cannot win the fight against TB without ending stigma and discrimination.
Even as the government steps up investment in new tools and strengthens service delivery systems, we must make sure that stigma and discrimination are not left out of global, national and local plans to end TB.
And we cannot end stigma and discrimination if we do not improve public understanding of TB that it is curable, that pulmonary or lung TB spreads through air, that a person with TB becomes non-infectious soon after starting treatment and that extra-pulmonary TB (TB that affects parts of the body other than the lungs) is not infectious.
Impact of stigma and discrimination:
The impact of stigma extends beyond the shame, fear and guilt that a person with TB can feel.
As many TB survivors have told us over the years, stigma is often self-directed and internalised, drawing on social misconceptions of TB.
This is especially true of women with TB, who bear the brunt of criticism from their families and whose biggest fear is of infecting their children.
TB is a curable disease yet the impact of stigma can be long-lasting, often resulting in the breakdown of relationships. Stigma can be more devastating than the disease itself.
From the health system’s perspective, stigma is a powerful deterrent at every step along the care cascade the pathway from when someone develops symptoms of TB to until after they are declared cured.
Stigma can prevent someone with symptoms of TB from accessing services as we have seen that the fear of being diagnosed with TB often outweighs the anxiety associated with feeling ill or in poor health.
Stigma and discrimination also come together to inhibit someone with TB from continuing their treatment or seeking preventive therapy for their family.
As the Legal Environment Assessment report of TB recommends, adopting a rights-based, community-led, gender-sensitive and person-centred approach is central to reducing stigma and discrimination.
This means ensuring that all persons with TB receive respectful and high-quality treatment, including adequate information about TB and counselling.
For this, we need to sensitise healthcare providers to issues faced by those with TB and ensure they act in a non-discriminatory manner.
We must provide both treatment and legal literacy to people with TB, so that they understand their rights and can speak up if these are violated.
On March 13, 2018, the Prime Minister, who was inaugurating the End TB Summit, declared that India would end TB by 2025.
In September 2018, the first ever United Nations High Level Meeting on TB declared the urgent agenda “United to end TB an urgent global response to a global epidemic”.
Rhetoric and declarations cannot control TB. A strategy of simultaneously using all biomedical and socio-behavioural interventions can.
Four sub-themes under the “Unite to End TB” theme that WHO is promoting are:
- Together we will tackle TB by stamping out poverty.
- Together we will better test, treat, and cure.
- Together we will stop stigma and discrimination.
- Together we will drive research and innovation.
We must develop a robust system to ensure that they not only have a seat at the table but also have a say in decision-making that impacts the everyday lives of those living with TB.
It is the active involvement of these TB survivors and champions that can give an impetus to our collective efforts to improve public understanding of TB, reduce stigma, prevent discrimination and end TB in India.
Ending TB by 2025 is impossible but pulling the TB curve down by 2025 and sustaining the decline ever after is in the realm of reality.
The ultimate impact of this national strategic plan will be transformational improvements in the end TB efforts of India. It plans to take a “detect-treat-prevent-build approach” in its war against TB.