THE young woman sitting before me is wrapped in a black burqa. Only the dull pupils of her eyes are visible. She is breathless, weighs just 23 kilogrammes, is severely anaemic and her chest X-ray shows her lungs to be riddled with cavities. She has been coughing up bloody sputum laden with tuberculosis (TB) bacteria.
Six other members of her household of 25 persons suffered from TB. She is just one of the dozens of patients in the TB clinic with newly diagnosed tuberculosis, while many more men, women and children wait for tests or curative medicines. Such is the normal scene on a busy outpatient day.
But now there is a potential calamity: anti-TB treatment (ATT) is no longer available. The drugs have suddenly gone off the market, and despite appeals from physicians all over the country, chances of getting them back in the near future are remote.
TB is a global problem. Nearly two billion people worldwide are infected with the bacteria, and are at high risk of developing active disease. The 2014 World Health Organisation global report shows 9.6m people were ill with TB, of which 1.5m died. Pakistan bears the fifth highest disease incidence in the world, with 500,000 new cases detected in 2014 that were responsible for a colossal 48,000 deaths.
No age group is immune, but the most serious consequences occur in children and the elderly. Young women of childbearing age are most frequently hit. Often there are several persons affected within a family or household. As always, the poor and the marginalised bear the greatest burden of infectious diseases because of illiteracy, marginal food sustenance, overcrowded living conditions and non-existent healthcare.
With drugs to cure TB not available, thousands are poised to die.
Physicians will vouch that TB is the most prevalent infectious disease in their practice — be it in the lungs, or the glands, brain, bones, joints, intestine, kidneys, heart, spine, skin, eyes, etc. When a person with lung infection coughs, sneezes or laughs, the spray containing millions of bacteria disperses in the air; if ventilation is poor, others will inhale the spray and the bacteria will start the process of destruction in their organs.
For months, years or decades, the invading germs may remain latent and never be activated; however, in 10pc of infected individuals they reactivate and invade a vulnerable organ, causing fever, night sweats, poor appetite and weight loss. If the person has other conditions such as poorly controlled diabetes, AIDS, or is a smoker, TB will appear sooner and manifest itself more vigorously. Untreated, the disease will gradually destroy the affected organ.
TB is completely curable, provided the treatment is taken correctly. If the drugs are of inferior quality, taken erratically, incorrectly or with interruption, the bacteria mutate, converting sensitive TB into the dreaded multidrug resistant (MDR) TB. The second-line treatment of MDR TB extends over two years with injections and 20 to 30 pills every day. They are toxic, expensive and not always effective. MDR has risen to 5pc of all TB disease, and is a real threat among our population.
Ironically, the management of TB in hundreds of public hospitals and clinics across the country is better than that in the private domain; TB centres that fall under the aegis of the National TB Programme (NTP) are meeting international targets of diagnostics and treatment. NTP is financed through global funding, and it pursues a robust programme of TB care.
However, given the enormous burden of disease, NTP cannot reach the vast numbers of patients in towns and villages. Hence, most patients approach private care and must go through the ordeal of finding the right doctor, get correctly diagnosed and receive correct treatment. Errors of judgement or prematurely stopping treatment will convert ‘simple’ TB into a complex condition, resulting in death.
If the current situation of drug interruption continues any longer, thousands of TB patients will die untreated. Some will develop complications and die slow deaths; those who started treatment and had to disrupt it will develop MDR. Women and children will be the worst affected. The population will remain vulnerable, and Pakistan will earn more disrepute.
Where have the lifesaving drugs gone? After months of deafening silence from our decision-makers, it turns out that the Ministry of Health, the Drug Regulatory Authority of Pakistan and the ATT manufacturing pharmaceuticals are locked in an argument over pricing. Even as the quarrel continues, thousands more people are being added to the tuberculosis pool.
Perhaps the interlocutors are waiting for a explosion of TB, and eventually of MDR TB. At an international level, Pakistan might be branded as a TB pariah, as it has been on the polio front. There is still time to reverse the situation. Urgent action is required as the health of the nation hangs in the balance.
The writer is a specialist in infectious diseases.
Published in Dawn, June 14th, 2016