TUBERCULOSIS MANAGEMENT AND ACADEMIC MEDICINE PRACTICE - FAILURES IN TODAY’S INDIA
O P KAPOOR
The contagious nature and widespread prevalence of tuberculosis puts each one of us at the risk of contracting it. An improperly treated lung tuberculosis patient can infect at least ten healthy persons in a year. This cycle of transmission continued for the past few decades in majority of developing countries. Hence, a third of the world’s population - nearly two billion people are tuberculosis infected. The South East Asia region had a prevalence rate of 94 per 100000 persons, and India has a fifth of the world’s tuberculosis patients. An epidemic of this proportion cannot be ignored.
As the international travel of us humans has increased enormously, so has that of mycobacteriae. Documented tuberculosis transmission on airplanes includes one in 1994 wherein a Korean lady who took a flight from Chicago to Honolulu infected four other nearby seated passengers. A few months later she died of tuberculosis. The clear message from this episode is that every nation is vulnerable to the poor treatment practices of other countries. Understandably, therefore, the WHO declared ‘tuberculosis as a global emergency’ in 1993. Infectious diseases have to be fought globally by every nation to protect its own people.
In the past three decades, HIV has hastened the pace of tuberculosis spread. Africa is reported to be the worst affected by the HIV-tuberculosis co-epidemic, and the crisis now also looms large on Asia that has the majority of the tuberculosis patients. Researchers predict that the number of tuberculosis patients attributable to HIV in Asia will rise from 2% in 1994 to 14% by 2000 AD.
We also face the nightmare of tuberculosis becoming impossible to cure in future. The inappropriate use of recommended drug therapy has resulted in drug resistant strains of mycobacteriae. The multi-drug resistant tuberculosis spread as easily as the regular tuberculosis, and the cost of its treatment increases by 50 or 100 fold. The current estimate of multi-drug resistant tuberculosis patients in the world is 50 million patients. The multi-drug resistant tuberculosis has the potential of returning humans to the era when the diagnosis of tuberculosis was a virtual death sentence.
India is a vast country with a complex socio-economic structure, a variety of languages and different diets. Patterns of disease too marginally differ that have been highlighted by me in the previous issues of the Bombay Hospital Journal. Some of the symptoms described by Indian patients are unique - for example ‘ghabrahat, ‘dhaat’ and ‘twisting of umbilicus’ that are expressed in their respective languages by patients hailing from Kerala, Rajasthan, Uttar Pradesh and other states. Careful interpretation of such symptoms by the physician at the primary care level is the key to diagnosis. And tuberculosis has many different ways of manifesting! For example, isolated tuberculosis has involved the lateral rectus muscle of eyeball, posterior pharyngeal wall, breast, thyroid, atlantoaxial joint, oesophagus, gall bladder, pancreas, spleen, rectum and other unusual sites. Case reports on tuberculosis from previous issues of the Bombay Hospital Journal are compiled together and re-published in this special issue. The obvious question to follow is that why are fewer than should be (or none) well-organized studies on tuberculosis published. India has failed in this aspect, to reveal the truth to the international community, its changing data on tuberculosis. I believe that the failures are of the currently evolved health care system.
The financial structure of modern healthcare in India has remarkable limitations. One of them is the threat to extinct the mission and spirit of academic medicine. The ‘non-specialized’ academic physician (holding the MD degree of internal medicine) can reliably generate tuberculosis data, as he is dependable for its accurate and evidence based diagnosis. The difficulties experienced in academic medicine practice are well known. Low fees for clinical services, lack of income generating procedures and identity diffusion amongst the super - and sub - specialities are some of them. Academic physicians are working harder for less money than ever before and are struggling. In metropolis cities, physicians attached to corporate hospitals work in an environment in which their overall contribution are viewed as a financial loss and therefore do not seem valued. Despite this gloom, academic physicians report high levels of satisfaction in their careers. This positive sense most likely reflects the great personal rewards in treating their patients.
Medicine is a scholarly profession and therefore requires scholars for its proper evolution. Whereas medical care inevitably has a business side, it is a profession founded on knowledge, wisdom and intellect. By virtue of inappropriate government policies, as well as prevailing market forces, the structure of medicine has changed so radically that its roots in scholarship are being sacrificed to the demands of business. There is no secret of the fact that the government has failed miserably for the health care of its population. The majority of patients are progressively changing towards private (or fees paid for) health care. Compounding this problem is the new world of private health care in which scholarship is no longer a guiding principle. Unless it is profitable it will be eliminated. Will then the specialists’ practitioners take over to treat tuberculosis - a disease with not as much income generating ability? If the true tuberculosis data of today is not being correctly gathered and reported by the surviving academic physicians, I wonder if it will ever be done by the high income specialists of the future.
A major audit of current medicine practice trends and its limitations in the context of evolving disease patterns is the need of this hour. Corrective steps can then follow. But who will take the responsibility of this exercise? I am frightened, as I see no attempt in this direction. Tuberculosis will continue to be ignored and it may not be far away for us to have more tuberculosis deaths than those from myocardial infarction or cancers.