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Stop TB-Fight poverty : An Indian Perspective Introduction:
Stop TB, fight poverty is the theme for World TB day 2002. TB imposes a considerable economic toll on patients and their families. Because more than three-quarters of people with active TB are in the economically active age group (15 to 54), the economic and social costs to them and society are huge. They are income providers of the family. They are the parents of young children who need their economic and emotional support in order to thrive. They have elderly parents and relatives who depend on them. They are the citizens whose productivity and talents are essential to their countries’ development. The result of TB is that access to opportunities and choices- a key principle of human development –is blocked.
Ill health, malnutrition and high fertility are three main reasons why households become or remain poor. They cause poverty through diminishing productivity, reducing household income and increasing health expenditure. A more complete view of poverty includes deprivation not only from money income, but also human development, financial and physical security, expanding opportunities and especially participation in key aspects of social life.
Poor families have no buffer against loss of income-no savings and very limited access to borrowing. The way they cope with this economic adversity may provide short-term benefits –that is cash-but in long term makes them and their children destitute. The sale of assets such as land is a common response to large medical expenses.
Income poverty leads to ill health and ill health contributes to income poverty. A more complete view of poverty includes deprivations from not only money income, but also human development, financial and physical security. Poverty is also seen as a lack of basic human development indicated by poor health, malnutrition and educational development. Gender is in particular an important variable affecting both health and poverty. TB and Poverty
Links
The global experience with TB control has been able to define certain clear-cut linkages between TB and poverty:
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TB is more prevalent among low-income groups than among high-income groups.
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The cost of TB care, if borne by families alone can be unaffordable.
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TB is a chronic ill ness and requires care over a relatively long period-during which productivity is reduced, leading to interruption of education and work.
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Household income is severely reduced, family dysfunction increases, particularly if mothers are ill and poverty increases.
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Lower productivity and more poverty impede social and economic development and increase inequalities in society.
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Lower income people are higher risk-as TB spreads in crowded places-households, school, workplace, marketplace and commuting between them.
The real stakeholders in TB control
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A. The people: - the low-income groups are the most vulnerable people with limited resources to over come poverty-related TB risks viz:
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Barriers in access to primary health acre ans appropriate diagnosis and treatment for TB
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Emerging HIV/AIDS –TB co-infection
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Lack of knowledge about the disease
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Overcrowded living and transport conditions
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Urban congestion/pollution
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Poor nutrition
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B.Society: - as represented by politicians and policymakers, with power to reduce risks.
Poverty in India
Statistics as provided Government of India show that about 240 million people live below the poverty line. (The poverty line is really the line of destitution. At this line, people just enough money to provide them with food, converting to 2,200 calories and with nothing else. No roof, no clothes, no security, no minimal comforts, let alone schools, medicines and any fruits of industrial revolution.)
Poverty alleviation remains pronounced challenge before the Government. Though there ahs been a steady decline in poverty over the last two decades, the total number of poor people has remained more or less constant due to growth in population. The inter-regional disparities in poverty levels are quite alarming. According to National Sample Survey Organization (NSSO) the poverty situation ins several states in India is appalling: Orissa 47.15%, Bihar 42.6 %, Madhya Pardesh 37.4%, Sikkim 36.55% and Tripura 34.44%. In terms of numbers Uttar Pardesh has 53 million, Bihar 43 million, Madhya Pardesh 30 million, Maharashtra 22 million, West Bengal 21 million, Orissa 17 million and Andhra Pardesh 12 million people below the poverty line. (Economic Survey 200-2001)
Poverty alleviation programmes are still ineffective because they have not reached the poor.
Surveys by the NCAER (National Council of Applied Economic Research) reveal that almost 59% of all households, accounting for 526 million people, have an annual income of less than
Rs. 12500. This means a monthly household income of Rs.1000 or about Rs. 200 per head. This by any yardstick is abysmally low income.
Households with incomes between Rs.12500 and Rs.40, 000 per year account for 331 million people.
Only 4.1 percent, accounting for 37 million have an income of over Rs 40,000 a year.
(Life above poverty line: Rs 264 per month is all you need –Mohan
Guruswamy,
Courtesy www.tehelka.com)
Tuberculosis in India: (1)
General facts
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India carries a third of global TB burden. An estimated one in two of the adult population are infected with TB bacterium.
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The estimated incidence of all cases of TB is whopping 185 cases per 10,000 population.
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The TB epidemic continues to grow, every year, two million people develop active tuberculosis (more than any other country in the world).
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More people now die from tuberculosis than ever before -nearly 4,50000 every year. More than 1000 persons die of the disease each day.
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Only one in four people with tuberculosis is treated with DOTS. The current rate of DOTS expansion is still far too slow to reach the global targets by 2005. Failure to reach these targets will condemn millions of people to disease and death.
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Tuberculosis is inflicting enormous socio-economic costs. In India the estimated economic cost of TB is US $ 3 billion per year.
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India’s DOTS programme is mainly financed through a US$ 142 million low interest loan from World Bank with increasing costs already being met by national and state governments.
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The quantum of human cost of TB in the country is 4.56 –6.28 Disability-Adjusted Life Years
(DALYS). (The DALY combines a measurement of premature mortality and morbidity and reflects the 'burden of disease' in a population)
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The cost to the patient for successful treatment of TB averages US$ 100 to US$150, more than half of the annual income of a daily wage labourer. The estimated cost of MDR-TB to an Indian patient is approximately Rs 6500 a month (US$135).
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Research shows that 20% of rural patients and 40% of urban patients borrow money to pay for expenses due to TB.
Tuberculosis in India: (2)
Tuberculosis and Women’s
Health
Jackie Jackson Joint UK Coordinator of Institute for Indian mother and
Child (UK), in an article entitled Multiple disadvantages: India,
women’s health and tuberculosis, enlists the factors that make Indian
women more susceptible to TB. Poverty whom she describes as the main cause
of TB, affects 70% of women worldwide compared to 30% of men. Poverty
predisposes women to poor living conditions and nutrition and renders them
vulnerable to disease and infection. Research has shown that in their
reproductive years (15 –49 years), women are at greater risk of
developing the disease after infection than men at the same age. They may
also be exposed more to TB than their men folk due to their particular
duties and tasks. Besides these physical consideration the shame and
stigma of disease affects women more-to the point where women commonly
keep their diseased state a secret and unmarried girls fear that it will
affect their marriage chances.
As regards the pattern of early marriage in both the major communities of
the country, young brides are encouraged to begin a family early on. It
reduces women’s financial independence-which she would be able to use to
good effect were she to develop the disease.
Clearly tackling TB in India raises many questions about the
socio-economic and political structures within society. Can TB be tackled
in India without tackling behaviors in the society, such as the low status
of female, she asks? Certainly a husband or a father with TB puts an
enormous strain on the family whenever it threatens his wage earning
powers, however she warns that social cost to the family is much higher
when the disease affects mother. Her need to attend treatment programmes
takes her away from the children, the cost of treatment cuts into family
budget and a child is at a 3-10 times greater risk of dying within two
years if he/she loses their mother than those with both parents alive. She
suggests that TB programmes in future shall not use the medical model
instead tackle all factors operating on women with respect to disease side
by side. The multiple disadvantages for women in India that operate
through gender and associated factors will only be addressed by first
understanding their role in both infection, disease and treatment stages
and then formulating successful strategies to reduce their influence.
Therefore solutions that apply to both women and men should be
implemented. Tuberculosis in
India: (3)
TB and HIV
The Prime Minister of India in his speech at a meeting on National Program
for prevention and Control of HIV/AIDS on December 12th 1998, said,"
the health ministry puts the figure of HIV infections in the country as of
now at three million to four million. In some states, the infection rate
is one percent of the populations. Since we have these three to four
million infections today from a base of just a few infections in 1986,
imagine what the scene will be in another twelve years from the base now
of three to four million. I shudder even to contemplate the numbers."
As per National AIDS Control Organisation estimates the total number of
HIV infections in the country at the end of year 2000 stood at 3.86
million.
A document on Revised National TB Control Program (RNTCP) published on the
official web site of the National TB Control Program sums up the situation
rather crudely: "while the size of the HIV epidemic in India is
presently not known, it is clear that HIV will worsen the TB
epidemic". The document makes no further reference to the problem
The Draft National AIDS Control Policy has only to say this much for the
dual HIV-TB epidemic "with about 14 million TB cases existing in
India, HIV/AIDS also poses a twin challenge of HIV/TB co-infection. Nearly
60% of the AIDS cases are reported to be opportunistic TB infection cases.
Treatment of TB among the HIV-infected persons is a new challenge to the
National TB Control Programme, which has now adopted DOTS strategy for
control of TB infection. At the same time looking for HIV among TB
infected persons will also cause the problem of scaring away of a large
number of TB infected cases in the country from seeking treatment under
the DOTS strategy. There is no risk of any TB patient getting infected
with HIV unless he or she practices high risk behavior or gets infected
from transfusion of HIV-infected blood." The draft policy document
makes no further reference to meeting of two programs (National AIDS
Control Program and Revised National TB Control Program) to meet the twin
challenge.
There is no reliable data available to determine how the HIV prevalence
has affected the TB epidemic in India. There are only apprehensions and
estimates. Even the NACO or RNTCP have not come out with any studies to
document the linkage. The extent of collaboration (or lack of it) between
the two programmes is reflected in the documents of two programmes
available on their web sites.
On surface they appear to be two divergent lines, emanating from a common
point but distancing from each other as they travel to states, districts
and community health centers.
Why tackle Tuberculosis ?
Potential economic benefits for India
Effective TB control can help break the cycle of poverty and disease. It
cures people and returns them to active, productive life, which in turn
benefits their children and contributes to the economic and social
development of their country. As more people are cured, the cycle of
transmission is broken and fewer people are infected. Ultimately this
leads to fewer cases of active TB.
TB control is rated by the World Bank as one of the most cost-effective
health intervention because of its potential to avert a large percentage
of the global disease, its low cost for each year of healthy life saved,
the low cost per capita, and the potential impact on socially excluded and
poor people.
Ravindra Dholakia, Professor of Economics from Indian Institute of
Management, Ahmedabad in an article, Potential Benefits of DOTS Strategy
against TB in India, divides these into two broad categories:
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Pure social welfare increasing effects of DOTS,
which do not generate direct tangible economic benefits. These include
reduced suffering of TB patients, quicker and surer cure from the
disease, lives saved and disability reduced for dependents and
non-workers suffering from TB, poverty alleviation etc.
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Direct tangible economic benefits of DOTS which
include: reduction in prevalence of TB due to DOTS which improves the
efficiency and productivity of workers, TB deaths averted among
current and future workers and release of hospital beds currently
occupied by TB patients.
He postulates that that even if the Indian government
spends about US $0.74 billion per year to ensure the success of DOTS
strategy the investment would fetch a return of 16% p.a. in real terms.
Projected incremental costs to the government for successful DOTS
implementation throughout India are of the order of US $ 200 million per
year, compared to the tangible economic benefits of at least US $ 750 per
year, the article notes.
Conclusion
India carries a third of global TB burden. Every year two million people
develop active TB. TB accounts for nearly 4,50000 deaths every year and
more than 1000 persons die of the disease every day. TB is inflicting
enormous economic and social costs on the country. The estimated economic
cost of TB is US $ 3 billion per year.
In India 240 million people live below the poverty line. Poverty
alleviation remains a pronounced challenge before the government. Surveys
reveal that almost 59% of households accounting for 526 million people
have an annual abysmally low income of less than Rs 12500 (US $260)
Income poverty leads to ill health and ill health contributes to income
poverty. The cost to the Indian patient for successful treatment of TB
averages US $ 100 to US $150. Research shows that 20% of rural and 40%
urban patients borrow money to pay for expenses due to TB.
Indian women have to pay much higher social and personal costs if
suffering from TB. Besides poverty the shame and stigma associated with
the disease, early marriage and social pressures to start a family early
on and limited access to treatment facilities makes them more vulnerable
to disease more so during the reproductive age group of 15 – 45 years.
The nation has not risen adequately to meet the twin challenge of TB and
HIV/AIDS. The number of HIV positive persons has risen above 3.86 million.
Nearly 60% of AIDS cases are reported to be opportunistic TB infection.
This is going to add to the national load of 14 million TB cases.
Effective TB control can help break the cycle of poverty and disease. It
cures people and returns them to active, productive life, which in turn
benefits their children and contributes to the economic and social
development of their country. A cost-effective health intervention exists
for TB control and treatment: DOTS. Increasing public awareness about
proven, effective interventions like DOTS and providing greater access and
benefit to treatment for those with TB, will help put billions back into
the economy. Projected incremental costs to the government for successful
DOTS implementation throughout India are of the order of US $ 200 million
per year, compared to the tangible economic benefits of at least US $ 750
per year. The expenditure on health has declined in last decade and stood
at 1.11% of GDP in 1998-99. Indian government will have to increase its
expenditure on TB control.
The three aims associated with World TB Day 2002 theme viz DOTS expansion,
efforts to raise awareness among political leaders, decision makers and
opinion leaders and mobilization of TB sufferers for demanding greater
access to treatment are more relevant to India than any other country in
the world.
Suggested further reading
Ministerial Conference :
Tubeculosis and Sustainable Development
Web
Site : http://w3.whosea.org/cds/pdf/16march00.pdf
Potential Economic Benefitys of the DOTS Strategy in
India
Web
Site: http://www.who.int/gtb/publications/pebdots/
Tuberculosis and Poverty: A PPT Presentation
Web
Site : http://www.wpro.who.int/themes_focuses/theme1/focus3/
POWERPOINTSTB/IMPO-TB-Poverty-Aviva%20Ron.ppt
Tuberculosis in India : A Critical Analysis
Web
Site : http://apha.confex.com/apha/129am/techprogram/paper_27954.htm
Life above Poverty Line : Rupees 640 per month is
all that you need
Web
Site : http://www.tehelka.com/channels/currentaffairs/2001/oct/30/
ca103001lib1.htm
Multiple disadvantage : India, Women's Health and
Tuberculosis
Web Site: http://www.fons.org/tb3.htm
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