Tuberculosis in India A Critical Analysis by eqt50313

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									Tuberculosis in India:
  A Critical Analysis
    Lynette Menezes, MSW
  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
       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
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
  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
 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
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
     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
   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
   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
       Cultural Factors
• Attitudes and beliefs
  – stigma
     • isolation
     • divorce
     • ostracism
  – beliefs regarding causation
     • sex related
     • physical and mental stress
     • food/water
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
   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
    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
        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

								
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