TB is an intimidating word in the world of public health. Even though the disease is centuries old, it was only in 1882 that Dr Robert Koch discovered the TB bacillus—the agent that causes TB. Antibiotics were used against TB for the first time in 1944 after the discovery of streptomycin. But use of this drug alone led to antibiotic resistance that is still a major problem.
Although it is curable and preventable, TB still kills more people than any other infectious disease, surpassing HIV/AIDS in the number of deaths in 2015. In 2014 TB infected 9.6 million people and took 1.5 million lives, with 95% of these deaths taking place in low- and middle-income countries. A more worrisome situation in recent years has been the spread of drug resistant strains of TB throughout the world, primarily due to inappropriate treatment. MDR-TB (multi drug resistant TB) is any strain of TB that does not respond to isoniazid and rifampicin—the two key anti-TB drugs used in standard or first-line treatment. More rigorous treatment can cure MDR-TB, but the stronger second-line drugs are more costly and less available than first-line drugs. In 2014, the global burden of estimated cases of MDR-TB was 480,000—majority of them being in India, China, and Russia—and 190,000 succumbed to these drug-resistant strains. An estimated 9.7% of these MDR-TB cases are extensively-drug resistant TB, which has been reported so far in 105 countries. China, Russia and India together accounted for nearly 60% of the MDR-TB cases worldwide. India alone has around 70,000 new cases of MDR-TB every year.
More rigorous treatment can cure MDR-TB, but the stronger second-line drugs are more costly and less available than first-line drugs. The prolonged treatment of 24 months, and its debilitating side effects, makes the treatment more challenging, putting immense stress on the suffering patients. Suicide cases are not uncommon among the patients of MDR-TB. The stress of living with MDR-TB, the stigma attached to the disease, the dwindling family support, the long and arduous treatment regimen and the lurking doubt that the treatment may fail in spite of best efforts are some of the factors responsible for the increase in suicides among such patients. The Group of TB Hospital, Mumbai, which is perhaps Asia’s biggest TB hospital, has seen almost a dozen patients killing themselves in the past three years (till 2014) and over 40 suicide attempts made in the same period. The public health community is waking up to the often neglected, but highly important psychological aspect of MDR-TB treatment. Research studies have been conducted to provide evidence for the psychotic symptoms induced by the very drugs, like cycloserine, that are a mainstay of MDR-TB treatment.
The management of these adverse effects is a complicated task as discontinuation of treatment not only affects the efficacy of the treatment, but also helps in direct transmission of MDR-TB. Hence, health care providers are often advised to either change the dosage of the offending agent or introduce anti-depressants and other drugs to reduce the side effects. At a recent webinar hosted by CNS, Dr. Jamhoih Tonsing, Director (South East Asia), International Union against Tuberculosis and Lung Diseases (The Union) expressed the concern that the policy makers and TB experts need to consider issues beyond drugs and diagnostics. Importance should also be given to psychological and social support of the patients. She highlighted the importance of counselling through health workers as an effective strategy for maintaining the mental balance of the patients and helping them complete treatment.
Civil societies are trying to put MDR-TB on the agendas of governments, the world over, and one can only hope that the patients receive a better class of drugs along with the psycho-social support. In her memoir of depression-Shoot the Damn- Sally Brampton says—“Killing oneself is, anyway, a misnomer. We don't kill ourselves. We are simply defeated by the long, hard struggle to stay alive. When somebody dies after a long illness, people are apt to say, with a note of approval, that ‘he fought so hard’. And they are inclined to think, about a suicide, that no fight was involved, that somebody simply gave up. This is quite wrong.” People suffering from MDR-TB have to fight a long battle and any support rendered to them can be their ray of hope in the darkness which can help them to dispel the clouds of weariness and despair.
Dr Richa Sharma, Citizen News Service - CNS
April 7, 2016