Trajectory of a killer disease

Vidya Krishnan been on the health beat for many years and meticulously documented weaknesses in global and Indian health policy, which have turned it into an unacknowledged pandemic

This book starts with anecdotes involving vampires, beheading corpses, and sweetening sour wine. All these esoteric activities have a bearing on the subject. Bram Stoker’s Dracula was inspired by stories of epidemics when people were buried alive.

Before tuberculosis (TB) was well-understood it was thought to be a “vampiric” disease. Infected families burned and beheaded the corpses of early sufferers under the belief that “undead” family members were sucking the vital force out of the still-living.

Vidya Krishnan then settles down into a solidly researched narrative of the trajectory of this killer disease. She’s been on the health beat for many years and meticulously documented weaknesses in global and Indian health policy, which have turned it into an unacknowledged pandemic.

TB has been around since the days of the pharaohs, and is held responsible for one-seventh of all deaths in history. The World Health Organization (WHO) estimates roughly one-fourth of the world’s population may have latent TB —that is, they are all potential carriers.

The disease is treatable. But treatment is long and painful and some drugs have awful side-effects. Many TB strains are drug-resistant (DR). There are currently just two drugs to treat the worst drug-resistant TB (DR-TB). In 2019, 1.2 million people died from TB and 31 per cent were Indians. India is an epicentre of DR-TB. Poor health policies have exacerbated concerns about its spread. The government states it’s in Mission Mode to eradicate TB by 2025. But experts reckon this won’t happen until 2040 at least.

The early chapters detail advances in 19th century medical science when an understanding developed of hygiene, antiseptics, and germ theory. Ignaz Semmelweis found a correlation between the unwashed hands of surgeons, and high mortality rates. Tragically, he failed to convince his fraternity that washing hands was useful.

The chemist Louis Pasteur was working to prevent wine turning sour and discovered heating to exactly determined temperatures for exact time periods (killing only the offending bacteria) worked. Pasteurisation later proved to be a great tool in the battle against disease. The surgeon, Joseph Lister started to popularise sterilisation.

In 1882, Robert Koch isolated the TB bacillus (also cholera and anthrax) and “consumption” as it was called, formally became tuberculosis. Koch also figured out a cure, which didn’t cure but worked as a diagnostic. (Arthur Conan Doyle was the first doctor to publicly express doubts about the efficacy of Koch’s tuberculin).

As germ theory caught on, public campaigns against spitting, in favour of shaving, shorter skirts (trailing skirts which touched the floor picked up germs), helped cut infection rates. But TB treatment didn’t take off till after World War II when the new wonder drugs, antibiotics, promised cure. That hope was derailed in the 1980s, when HIV appeared — the combination of HIV-TB proved absolutely lethal.

There are two drugs —delamanid (patented by Otsuka), and bedaquiline (Johnson & Johnson) which work with DR TB. Neither is easily available in India, despite the fact that J&J manufactures delamanid here. According to this book, 9,400 Indians out of 147,000 known DR-TB cases had access to these drugs circa 2020. That is only after a seminal court case by a dying TB patient, Shreya Tripathi, forced the government to ease access.

India being a TB epicentre is also attributable to other poor policy decisions (like bad town planning). It is while dealing with the causes and outcomes of India’s poor policy choices that the book moves beyond being a dispassionate account of a deadly disease and morphs into a passionate, angry indictment of global healthcare and patent policy.

The worst known TB infection rates are in Mumbai chawls and low-income high rises. The Natwar Parekh Complex for example, was built to house 70,000 relocated slum-dwellers in 59 high-rise buildings. Each flat is 225 square feet; most house families of 6-8; the buildings are situated three metres from each other (private buildings in Mumbai have mandatory 16 metre separation). Doctors For You, an NGO which has worked in NP Complex for over a decade, did a “trigger map” of TB overlaid on the geography. Every building has a huge number of cases, and there are larger clusters on the lower floors where there’s a lack of sunlight. Mumbai in general, is a TB hotspot because the city was planned to aid richer inhabitants in segregating their help, and lower income groups like mill workers. Vast numbers live in overcrowded, insanitary conditions. The author asserts, quite credibly, there is also a caste angle to this segregation.

There are long expositions on patent laws, and on the TRIPs patent regime, and examples of big pharma’s milking of patents. This latter pushes drug costs up by massive multiples.  India could have tried in many ways to improve access to TB drugs, which are manufactured here. The author suggests compulsory licensing, for example. Instead the establishment is in denial — DR-TB patients must “prove” they need the new drugs. It has fired experts and expelled foreign-funded organisations working in this space. In all, this is a train wreck in slow motion.