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Archive for June 2017

Catching the ‘blood seeds’

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The place: A village in Northern Karnataka, India, some years ago…

It was a typical Indian village marked by labyrinthine rough-hewn paths, lime-washed houses with tiled roofs, a central temple and little shops with shampoos, snacks and fairness creams in affordable pouches, hanging from strings. The little shops also offered mobile recharges. Swachchh Bharat was yet to be rolled out so toilets were conspicuous by their absence.

I met him in the Dalit quarter of the village. I don’t know if he is still alive but his image is vividly etched in my memory like a portrait cut in stone. He was an unemployed carpenter, too unwell to work, as he was suffering from TB. He sat outside his house on a dirty stone slab. An open sewer flowed past his house, leaving behind stench and hordes of flies. Knees drawn up tightly, unmindful that his trouser buttons had come undone, his eyes were restless, but his body drooped with fatigue. His skin had an unhealthy pallor to it.  Given to excessive drinking, he was also suffering from withdrawal and depression as the local liquor shack owner had denied him alcohol because of his inability to pay. He had not taken his medication for days but the bigger problem he was grappling with was his inability to access alcohol.

The story playing out in his one-room, windowless dwelling behind him was even more dramatic. Deserted by his wife and children, it was his aged mother who cared for him. She was blowing life into some twigs she had collected, to cook a meagre evening meal for her son. This was from food materials she had borrowed from neighbours. She was unable to buy food as there was no money in the house. The house had not been cleaned for days and litter lay all around. She told me tearfully that her son had no wish to live and was refusing medication for his TB.

To sum up this story, a patient was about to give up on medication; he was not only in danger of losing his own life, he was capable of spreading his infection to his mother and several others around him. The causes for his present state of  despondency and lack of will to live were many. But he was being treated only for TB.

There had been no attempt on the part of the system to address his depression, alcohol dependence or lack of will to live. Doing this would not only have helped him, it would have spared the others who came in contact with him. It would have prevented the ‘blood seeds’ from falling to the ground.

1=10=100=1000=10000

The Hindu epics are full of sub-plots and stories. Among them are the stories of rakshasas (demons) who shed rakta-bijas, or blood seeds. These rakshasas had the ability to reproduce several replicas of themselves out of every drop of blood that spilled out of them when the heroes attempted to vanquish them. The stories also talk of how ways were found to catch the drops of blood before they fell to the ground so as to prevent more rakshasas from being born.

Contrast this with TB. Each patient is said to be capable of infecting at least 10 others, before s/he becomes non-infectious. That makes for a mathematical nightmare if one were to consider the number of people among us who are in the infectious phase. The reference to rakshasas here is NOT to the patients but to TB and the ‘blood seeds’ reference is to the bacilli residing in them.

TB control – looking at it symptomatically

Given this situation, what do we do? We go at TB symptomatically. We ‘treat’ TB. We spend millions of dollars on diagnostics and medication and preventive vaccinations. I need to quickly say, this is NECESSARY. Curative services for TB are an imperative. But how do we kill the rakta bijas? What is prevention in the context of TB? It is not, and I repeat, it is NOT only vaccines. It is much, much more.

It is about creating an environment that is hostile to the spread of TB. The presence of TB in a society is an indication that that society has failed to achieve any or all development goals. It is undoubtedly an indication that hunger, housing, sanitation, employment, poverty and other indicators of development are wanting. There are enough examples to prove that low-burden countries have all these basic amenities in place. And this means that TB did not find willing hosts to live with in these countries.

At ‘Time to end TB – a new path to defeating the world’s oldest epidemic’ a meeting held on 20&21 June 2017, at the Wilton Park, West Sussex, United Kingdom, several rounds of deliberations were held on multi-sectoral collaborations and ways to enable the achievement of the SDGs. These deliberations, were they to find action, would have a direct bearing on TB control.

The eradication of hunger, while not directly related to TB, would result in healthier people with stronger immune systems; the creation of better housing would result in lesser transmissions of TB; good sanitation, assured employment and a more predictable way of life would sure result in healthier people, less vulnerable of contracting TB.

It would then mean that the ‘blood seeds’ are caught before they fall to the ground and we would have defeated the numbers – finally.

Bharathi Ghanashyam

 

 

Written by JournalistsAgainstTB

June 25, 2017 at 2:43 pm

The draconian world of TB

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The world of TB is a very intimidating and indeed a draconian one – and it’s not solely because it is a killer disease. Consider the reasons why:

The world of TB and the world of a child who is not doing well in school are much the same. When the child does well, the credit is shared by the entire family and school community that the child was connected with; when a TB patient goes on to complete treatment and gets well, the credit is for everyone to share.

When a child gets poor grades or a TB patient does not complete treatment and fails to get well, the onus shifts – the child is a non-performer, a laggard, an under-achiever etc. A TB patient is a defaulter, a drop-out & a living, walking, breathing nuisance to society waiting to breathe out the malicious bacilli into the lives of all those who came in contact with him/her.

The truth in fact is far from what people believe. A child performs badly not because s/he does not want to do well; the child under-performs because the system failed her/him in some way. A TB patient did not complete treatment and remained sick, or worse still died, not because s/he did not want to get well and was on a suicide mission – the patient did not get well because the system failed her/him in some way.

The TB sector in India (and probably in other parts of the world too) is oxymoronic in nature. We have the money; we have the expertise; we have the drugs; we have the infrastructure – and yet, we have TB figures on the rise and alarmingly so. We also have alphabets being added to it in profusion – DR, MDR, XDR and probably TDR. Why is this situation so? Is every TB patient on a suicide mission? Is there an insidious hand at work to kill the world with unchecked bacilli?

Let’s redefine the defaulter

What or who is a defaulter? The dictionary defines a defaulter as someone who ‘fails to fulfill a duty, obligation, or undertaking’. This definition begs a question. When a TB patient seeks treatment and has entrusted her/himself to a medical system, who gave the undertaking? What was the undertaking given for? The answer is obvious. The health system gave the patient a sacred undertaking and took on the duty of making her/him well. And then failed. So who is the defaulter? The patient or the system? It doesn’t take much intelligence to arrive at a logical answer. Undoubtedly, it is the system which has defaulted. It is the system which is the defaulter. If this be true then let’s shift the argument a bit.

When the system defaults

Does a bank ask a defaulter why s/he defaulted on a loan? It is understood that a person who borrowed money in trust will keep her/his obligation to pay it back. Then why must the patient be sympathetic of the system that failed her/him? Why must a patient accept the treatment (other than medical) that is currently being meted out?

Consider some facts – TB is a disease of the poor. Myth or fact? A bit of both. But it is accepted that it affects the poor disproportionately. And kills very often. Let’s look into the world of a TB patient and what s/he has to go through on the route to recovery.

First off – loss of identity – from the moment s/he is diagnosed, their identity is subsumed by a box. They become a number on a box, which is visited thrice a week when the medication has to be dispensed. I have sat for days in DOTS centres and observed that the healthcare professional relies on the number on the box rather than the patient who stands in the room.

Second – stigma and censure. Arrive at the DOTS centre and be censured for getting the disease; don’t turn up and get censured for being careless and being a threat to the community. Be treated at arm’s distance by the healthcare professionals, despite the training they have received on how to take care of themselves.

Third – side-effects and suffering. Complain at your own risk, because no one’s going to listen. You’re going to be told this is to be expected and it won’t help to make a fuss. Bear it; you’ll settle in a while. But DON’T give up treatment because then you’re going to become drug-resistant and become a threat to all around you.

Medically illiterate, baffled at what’s happening to them, fearful of the erudite healthcare professionals who are so much more equipped to know what the patient wants or needs, and a feeling of utter despondency and inadequacy – this is the portrait of a TB patient under treatment. In the face of all this, what options does a patient have, but to run away, or ‘drop-out’?

There is presently a lot of buzz around patient-centred care. The buzz is welcome as it might just bring about the vital shift from the healthcare-setting-centred model that is currently in use. We might just see the onus shifting from the patient to the healthcare setting and the definition of defaulter shifting. The patient might just manage to come into the centre.

It is a definite sign that people, be they in healthcare settings, the level of policy makers or the patients, want change. That’s why the narrative is changing and there can only be good news around the corner. There is hope at last and we just might be sitting at the threshold of something positive.

Bharathi Ghanashyam

 

 

Written by JournalistsAgainstTB

June 23, 2017 at 3:00 pm

Posted in TB and Media

The media is but a mirror

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I watch or read the news for an hour every day and often feel indignant as I witness slanging matches peppered with violent and abusive language on different media platforms – almost inevitably on issues that do not impact the lives of the multitudes of my country.  And I continue to hope that someday the media will debate the real issues that challenge India – hunger, poverty, homelessness and disease. These issues don’t challenge just a small percentage; they impact millions like Rameshiya and Dulari and their families…

For Rameshiya and Dulari (who live in a remote village in Chattisgarh)* and who I met a few years ago, while on a field trip, it was normal to wonder where their next meal was coming from. From the public distribution system (PDS), they got some amount of raw rice at highly subsidised rates. And as long as this rice lasted, they ate. But they ate just rice, morning, noon and night.  If they were lucky they got to eat some vegetables from their backyard a few times a week and some dal (lentils) about twice a MONTH.

As I sat with Rameshiya who looked way older than her (estimated) 45 years and asked her what she and her family ate everyday, she looked away and I instinctively sensed that pride prevented her from telling me.  Her son (19), told me that they ate rice.  I urged him to go on.  He repeated that they ate rice.  On prompting again, he said that’s all they ate and if they were lucky, they ate a little chutney with that.  And then he went on to say that they didn’t have a choice of how much they wanted to eat.  They had to share whatever there was, regardless of whether each portion was a mere handful.

Both families had members who were suffering from TB and were being treated. It was debatable whether they would complete their treatment considering that they were hungry more often than not and might not have been able to withstand the side-effects. They would then be branded ‘defaulters’ who were on the rampage spreading DR – TB in the country.

All this, while our politicians, with alarming frequency and lack of responsibility flaunt non-issues, polarize the country on religious lines, and insidiously get communities to focus on the wrong issues.  It’s enough now! Let’s get back on track. There’s proof that poverty and under-nutrition are unchecked issues and need urgent attention; there’s proof that without addressing these, progress is unattainable. We can’t afford delays – here’s the proof as beautifully captured by Chapal Mehra:

http://www.huffingtonpost.in/chapal-mehra/india-cannot-eliminate-tb-by-2025-without-also-tackling-poverty_a_22116851/

Let’s move away from green and saffron and cows and other trivia and look at the real issues. The media is a mirror and cannot then help but reflect the debates and the commitment on the part of the powers that be. And let’s  force ACTION!

*Information was collected a few years ago.

Bharathi Ghanashyam

 

 

Written by JournalistsAgainstTB

June 10, 2017 at 11:59 am

Posted in TB and Media

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