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Falling through the cracks in the state healthcare system

Falling through the cracks in the state healthcare system
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First Published: Tue, Jul 13 2010. 12 30 AM IST

Poor and vulnerable: A six-year-old boy, infected with TB, sleeps in his mother’s arms in Gujarat. Eradicating infectious diseases remains a challenge in developing countries such as India. Abhijit Bh
Poor and vulnerable: A six-year-old boy, infected with TB, sleeps in his mother’s arms in Gujarat. Eradicating infectious diseases remains a challenge in developing countries such as India. Abhijit Bh
Updated: Tue, Jul 13 2010. 11 26 AM IST
Mumbai: The anti-retroviral treatment centre (ART) for HIV patients at the government-run King Edward Memorial Hospital (KEM) in the city is at some distance from the main reception area.
In early May, it turned away a 30-year-old widow infected by her husband, who had been undergoing treatment at the centre for the past four years, after it was discovered that she had a secondary infection in the form of drug-resistant tuberculosis (TB). The centre is not equipped to provide the medication required to deal with this turn in the complexity of the infection.
The patient, who did not want to be identified, will now have to rely on the help of a non-governmental organization to take her treatment forward.
“I am not alone. Many people get turned away from government ART centres either because they can no longer survive only on first-line treatment or because they have developed some co-infection. They are not even adequately diagnosed for their problems,” she says, as she makes her way down the dingy flight of steps that lead back to the hospital reception.
Poor and vulnerable: A six-year-old boy, infected with TB, sleeps in his mother’s arms in Gujarat. Eradicating infectious diseases remains a challenge in developing countries such as India. Abhijit Bhatlekar/Mint
There are 2.3 million people living with HIV in India. HIV prevalence among TB patients is around 5%. According to the World Health Organization (WHO), among the 1.5 million TB cases reported in 2008, an estimated 73,720 were HIV-infected.
In an era where communicable diseases, such as avian influenza, SARS and swine flu have become a serious challenge to policy planners, the ability to treat complex secondary infections poses different questions. While government-sponsored hospitals do not possess the wherewithal, the options available in private medical care are prohibitively expensive.
Some non-profit groups have started repositioning themselves in these circumstances.
Recently, the Mumbai office of Médecins sans Frontières (MSF, doctors without borders), an international medical aid agency, transferred all those HIV-positive patients who need the first line of treatment to government ART centres.
The agency now wants to focus on people who either need second-line treatment, are co-infected with TB or hepatitis or have a different strain of HIV infection that is not treated by the government.
“There is an accessibility issue when it comes to second-line treatment. The main place where MSF works is to cover the gaps of the government. The access to second line in the government set up is not very sufficient,” says Tiago Dalmolin, field co-ordinator, MSF Mumbai.
The worrying aspect of communicable diseases is not so much the numbers as the damage it does to the productivity of the workforce once it reaches a critical mass.
According to data compiled by WHO, only three infectious diseases figure in the top 10 causes of mortality. Diarrheal diseases (sixth), tuberculosis (seventh) and HIV/AIDS (eighth) together account for 11% of mortality—compared with 45% caused by non-communicable diseases.
If not dealt with swiftly, this could pose a serious challenge to an already overloaded health service and will require substantial fiscal support from the government. Many diseases, such as TB and malaria, can be cured if detected and treated in time.
Others, such as HIV/AIDS and polio, are incurable. While developed countries have achieved success in either significantly reducing or eradicating many infectious diseases, this remains a challenge in developing countries such as India.
Another challenge for HIV-positive patients in India is that those who begin treatment in the private sector are not taken in by the public sector. The side effects of first-line ART medicines are not addressed at the government centres either.
“TB without HIV wasn’t so urgent. But now, with co-infection, we will lose everything,” says Blessina Kumar of the organization Rahein —Health and Development Consultancy Services. “The HIV work will get undone...if it is not urgently handled.”
Field workers also believe that India’s official numbers for multi drug-resistant (MDR) and extensively drug-resistant forms of TB are under-reported—one of the reasons being inadequate diagnosis.
“Normal TB diagnosis is with smear sputum. But in HIV-positive people, and particularly in children, the sensitivity is not so good, So you get a false negative. We need to do smear and culture analysis. Also, one of our concerns is MDR TB. Public healthcare only relies on smears even in HIV-positive people and if these people want to get a culture test done, then they have to pay for it... and that is very expensive,” adds Dalmolin of MSF Mumbai.
Kumar says the government should not only redesign its national TB programme but also push large pharmaceutical companies to come up with new drugs. “We can’t have a drug that is 40 years old.”
This is the last of a five-part India Agenda series on health.
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First Published: Tue, Jul 13 2010. 12 30 AM IST