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Caught in crossfire: Martyred foot soldiers of India’s war against TB

Maitri Porecha | Updated on March 20, 2020 Published on March 20, 2020

Numbers tell a story: Last year, India reported 23.9 lakh tuberculosis cases, of which over 60,000 were multi-drug resistant   -  ISTOCK.COM

As the world struggles to blunt a new deadly virus, the foot soldiers in the battle to eradicate an old foe — tuberculosis — remain its most vulnerable too. The high rate of infection and deaths among workers — sweepers, ward attendants, cooks, security personnel, among others at the country’s sanatoriums — leaves their families scarred for life. A special report on the eve of TB Day, marked across the world on March 24

In the heart of Mumbai, close to the Sewri Creek where migratory pink flamingos land every winter, nestles the Group of TB Hospitals, more popularly known as GTB Hospital or Sewri TB Hospital.

Chhaya Thakur knows the place all too well. It was where her husband, who died of suspected tuberculosis (TB), worked. This was also where her father-in-law worked, and was diagnosed with TB; her brother-in-law, another of its employees, died of TB. And this is where she too works, worrying if she will be struck by the disease.

Cycle of decay: Chhaya Thakur took her husband Hemant’s job at the GTB Hospital after he died of tuberculosis   -  MAITRI PORECHA

 

With 1,200 beds and 1,374 employees, it is Asia’s largest TB facility. Internal records — hitherto maintained in a decrepit hospital logbook and now analysed and digitalised for the first time, by this correspondent over a six-month long investigation — reveal that up to 132 employees were infected with TB over the last 20 years.

Seventy — nearly half of them — died, a case of fifty percent mortality amongst those infected. BLink found that, on an average, up to three workers died of TB each year at the hospital. Even until 2018, records show one death to six deaths a year, mostly from lung TB.

With a current annual budget of ₹33,441 crore, the Municipal Corporation of Greater Mumbai (MCGM) is India’s richest civic body. But it has turned a blind eye to the welfare of its foot soldiers. While health experts feared that staffers such as nurses and cleaners in TB hospitals in the country were often infected, the situation proved particularly dire at GTB Hospital, where little has been done over the years to improve working conditions.

Among the dead employees were sweepers, ward attendants, cooks, a barber, a gardener, lift men, security guards, messengers, an electrician, a telephone operator, nurses and a doctor. The high rate of infection and deaths has scarred workers and their families for life. Some now live with the repercussions that come with TB treatment, including hearing loss, infertility and psychiatric ailments.

BLink’s probe shows that afflicted staffers were often admitted multiple times to the hospital before they finally succumbed. Of 132 staffers, 13 were admitted twice, 16 thrice and five four times. One staffer was admitted as many as five times in four years from 2000.

“The casualties could be much higher,” says a hospital clerk seeking anonymity. “These are only the records of workers who chose to get admitted to GTB Hospital for treatment. We don’t have any records of workers who recovered or died seeking treatment elsewhere.”

In 2017, Prime Minister Narendra Modi announced that India would eliminate TB by 2025. TB is mostly curable but patients have to be on strong medication for long periods. The problem is of multi-drug resistant (MDR) TB. This is when patients stop responding to the four basic drugs in use and need tailormade regimens, including drugs such as Bedaquiline and Delamanid that are useful in treating drug resistance.

Last year, India reported 23.9 lakh TB cases. Of the reported cases, 66,561 were MDR-TB.

“An additional 3 lakh TB patients are still missing and the national programme has been unable to track them. India recorded 60,000 TB deaths last year, while the World Health Organization (WHO) has estimated 4.4 lakh deaths in India,” says Vikas Sheel, joint secretary, ministry of health and family welfare.

The Central government, however, has no data for health workers who contracted TB on the job. Eliminating TB by 2025 is a far cry, especially when the vulnerability of those at the forefront of the battle has been whitewashed.

Health experts are particularly worried about MDR-TB. There are two ways of contracting it. The first is when patients stop their medications before they are cured. The second is direct transmission from other MDR-TB patients through infected saliva. Hospital workers risk directly contracting MDR-TB in the wards.

 

Chhaya’s story

Vinod Thakur, a sweeper at GTB hospital, was diagnosed with TB 20 years ago. Between April 10, 2000, and May 2, 2001, he was admitted to the hospital thrice. He died in the very ward he had served for many years.

Six months after Vinod’s death, his elder brother Hemant, also a sweeper at the hospital, succumbed to TB. Their father was a GTB employee who had contracted TB and recovered from it. When he was left immobile by a road accident, Hemant was given his job at the hospital.

Hemant has been dead nearly 20 years, but his wife Chhaya can never forget the sufferings he underwent. “I clutched him in these very arms when he breathed his last. And just like that he was gone,” she says. “The burden of treatment was too much for him to bear. He was suicidal. One day, when he was feeling slightly better, he caught a local train and wandered off. My father-in-law got him readmitted after locating him, but he kept asking me to take him home.”

Hemant died before his diagnosis could be confirmed. Back in the day, laboratory reports took months to arrive, and the complicated disease resistance patterns of TB were not fully known. “We were awaiting his sputum culture reports. The lab test had cost us ₹7,000. Hemant never lived to know his diagnosis,” Chhaya says.

She was three months’ pregnant when her husband fell ill. Unable to cope with the trauma of the illness, she aborted the foetus. “I had no other choice. I was working as a housemaid to sustain the family. I had to report to the ward at 4 am daily for his routine blood tests. What could I have done?” she asks.

Despite the dangers of the job, Chhaya took Hemant’s place at the hospital after his death. “I agreed because there was no other stable source of income. My child went to school and we did not have money for food.”

Three months into the job, she was asked to transport the corpse of a young woman who had died of TB, along with a smaller package, to the neighbouring KEM Hospital for a post-mortem.

“When the package was opened, my heart sank. It was the dead woman’s seven-month-old foetus. I started feeling short of breath. For the next 15 days I was bedridden. A doctor diagnosed me with high blood pressure and asthma. Since then I have been asthmatic,” she rues.

Chhaya has cleaned and packed bodies for autopsies, including those of men, in the absence of male attendants. “Once there was a convict’s body that no one was ready to touch. I went ahead and packed it. At times, the patient passes stool before death, or vomits blood... we have to clean all that up. If the deceased was infected with HIV, we need to clean the body, remove the clothing and put the body in a plastic bag. We staple it from head to toe, so that even a nail is not exposed,” she adds.

But there is little concern for the safety of the cleaners and other workers, she says. “If any of the employees gets admitted to the hospital because of TB, the administration should pay more attention towards them, and their nutrition. They should be allotted a separate room and given clean linen. But the top people in the civic body have no idea about how many staffers are infected and how many of them die,” she holds.

Chhaya’s son Ankit is is a student of Commerce in a Mumbai college. “I sweep corridors of the TB hospital to ensure a good future for my child, but I will never ever allow him to work here,” she stresses.

And despite a tragic past, Chhaya finds hope in the darkest nooks of the hospital. She keeps the patients and her fellow co-workers in good spirits with witty one-liners and laughs when asked about psychologist or other experts counselling staffers.

“Despite all the trauma we face, no one counsels or talks to us. I mostly try and keep my co-workers in good spirits. I love cracking jokes,” she says jovially.

Patients abandoned by their families, now inhabiting the female ward for years together, have become her friends.

She recalls how an elderly Parsi woman, Roshan, who breathed her last at the hospital in October, 2019, became extremely fond of her. Roshan was long cured of TB but stayed on for six years as no one from her family showed up to take her back home.

“After Roshan died, I could not focus on my work for nearly a week. I was very distracted. Her memories kept coming to mind. I cleaned her filth and served her food, and she would teasingly call me ‘chaawli.’ We were very close,” Chhaya says.

She is also friendly with Neha, a young TB patient from the eastern suburbs of Mankhurd. A few months ago, Neha was discharged after she had been cured of TB. “And then, a few days later, she came back to us with injuries. Her husband had thrashed her so badly that her arm was twisted, and her leg fractured. She is bed ridden now. Whenever I meet her, she says she wants to eat chicken."

There was a time when patients at the hospital were served protein-rich non-vegetarian food, which helped boost their immunity. “In the 1990s and earlier, the hospital served chicken, mutton and fish, both for the patients and employees. But now, none of that is available in the hospital kitchens,” she says.

No nutrition for workers

The 1,000-odd patients eat ‘sattvik’ — or vegetarian — meals supplied by the International Society for Krishna Consciousness (Iskcon). The civic body spends close to ₹110 per day per patient for two meals.

The employees, however, no longer get nutritional support. Back in 2013, they were provided with breakfast to pump up their nutrition intake before they started the day’s work in highly infectious wards. A caterer was hired for this. Since October last year, the breakfast for staffers has been discontinued.

Priyanka Kore, head of Bhumika Mahila Mandal, the self-help group that had been awarded the breakfast contract, says it was paid ₹13 per meal. After serving the civic body a final notice in October 2019 for ₹10-15 lakh dues, the mandal discontinued the supply of the meagre meal of boiled black gram or thick porridge or upma made of semolina.

Provision of food for workers has always been erratic, staffers say. In 2013, their daily milk quota was reduced to 50 ml from the earlier 150 ml. The boiled gram or egg was largely found to be unpalatable; workers either carried them back home, or refused to take them.

Dr Lalit Anande, medical superintendent at GTB Hospital, confirmed earlier this month that meals for staffers had not resumed. But the hospital is in talks with the municipal corporation to rectify this, he says.

“We are envisioning spending a minimum of ₹40 per day towards each worker’s nutrition. But we are yet undecided on whether to provide that money upfront to the worker or provide in-house catering. One size does not fit all. Workers who are sick and cannot avail themselves of the food being served in the hospital would rather take the cash,” Anande says.

Meanwhile, a sole dietician, in charge of charting out diet plans for 1,000 patients and an equal number of staffers, sits in a corner office, across the hospital kitchen. Namrata Rajput is pouring over dinner preparations as workers load vessels of dal, chappati, vegetables and rice to be served to patients in the wards. Rajput says that while patients’ lunch and dinner are taken care of by Iskcon, it is the workers’ food that is neglected.

“In the bid to cater to lowest tender — ₹ 13 per meal — we compromised on the quality of food for the staffers,” she says.

She refers to a list drawn out by the municipal body’s ‘Diet Subcommittee’, which specifies items that can be served to the workers. “Simple items such as split black gram or urad dal are not on the list. So I cannot prescribe serving Idlis in breakfast as we do not have the permission to procure urad dal under civic rules. Similarly, it does not include something as basic as rice flakes or poha. Also, there is no provision for non-vegetarian food for workers,” says Rajput.

Study on TB in workers

In 2017, doctors in the hospital culminated a five-year long study among health care workers. It screened staffers from 2011 to 2015 to understand pattern of TB occurrence and deaths in the hospital. All employees were subjected to a routine medical exam, sputum tests, chest X-rays, and if they were positive for TB, tests were conducted to determine drug-resistance.

Road to recovery: The drug-resistance ward at GTB Hospital, Asia’s largest TB facility   -  MAITRI PORECHA

 

It observed 841 staffers and found that 65 were infected. The study revealed that the maximum number of TB cases, up to 10.9 per cent (50 of 459 screened) were among the workers, up to 6.7 per cent cases (2 of 30) were doctors, 3.4 per cent cases were among para-medical staff such as nurses and technicians (10 of 293) and up to 5 per cent cases (3 of 60) were in the administration section.

Up to 20.3 per cent cases related to staffers who had worked in the hospital for periods ranging between 10 and 19 years.

The germ afflicted people irrespective of literacy levels, the study found. TB was found in five per cent of the 624 staffers who had studied till the secondary school level, 6.4 per cent of the 94 who had studied up to the primary levels and 29 per cent of the 17 who had not gone to school.

Doctors then analysed the 65 TB cases and found that 38 of them (up to 58.5 per cent) were multi-drug resistant. Of the multi-drug resistant cases, only 26.3 per cent of the workers could be cured while 57.9 per cent were on advanced treatments. The remaining 15.8 per cent workers could not be saved.

Red alert

A study underlines the spread of TB in Mumbai’s GTB Hospital

For five years, doctors in the GTB Hospital carried out a study on the spread of TB among its staffers. They screened employees from 2011 to 2015 to understand the pattern of TB occurrence and deaths among healthcare workers in the hospital.

Staffers were subjected to routine medical examinations, sputum tests and chest X-rays; and if they showed positive for TB, tests to determine drug-resistance were carried out.

The report, released in 2017, covered 841 staffers. It revealed that the maximum number of TB cases (10.9 per cent) were among the labour (largely cleaners and sweepers), up to 6.7 per cent cases were of doctors, 3.4 per cent among para-medical staff (nurses and technicians) and up to 5 per cent among those in the administration.

Father’s gift

The history of GTB Hospital goes back to the pre-British era. Design plans, from as early as 1935, suggest that the 45-acre land parcel, which now forms the GTB Hospital campus, was donated to the British by an Indian philanthropist, Premchand, to construct a hospital in the memory of his son Ramesh, for the sole purpose of treating TB patients. It was then a forested area on the outskirts of Mumbai, with proximity to the cemeteries. With rapid urbanisation, the hospital is now in the city’s heart.

When the Second World War broke out, the hospital premises were taken over by the British Navy for housing troops. “The premises were later handed over to the municipal corporation in 1946 for the purpose of treating TB patients. In 1948, Mahatma Gandhi’s eldest son Harilal Gandhi was infected with TB and died here in one of the hospital’s hallowed wards. With 1,200 beds, it is Asia’s largest TB hospital,” explains Dr Anande.

But the hospital that admits 15,000 TB patients every year has long been in a state of neglect. In 2015, the then superintendent, Dr Rajendra Nanavare, made a presentation to the WHO on how the municipal corporation aspired to turn GTB hospital into a “Centre of Excellence and Research for TB”.

It proposed to establish the hospital as a standalone teaching institute for developing experts in TB, and also undertake research activities on its biological and clinical aspects. “The centre of excellence entails having all faculties such as ear-nose-throat, ophthalmology, neurology, orthopaedics, gynaecology, dentistry and so on under one roof. For instance, a TB patient can deliver a baby here or if a TB patient requires an intervention related to teeth, the dental department can take care of it,” says Anande.

On the top floor, a 15,000-sq-ft space was to be made available for agencies such as the Indian Council of Medical Research, the Bhabha Atomic Research Centre and the Indian Institute of Technology for PhD-level research projects, he adds.

But five years down the line, these plans have been relegated to the backburner, and doctors blame the civic body for not taking this forward. The hospital building is undergoing structural repairs, and the clinic dedicated for its workers is being used to accommodate patients. Meanwhile, Anande is struggling to provide workers with adequate vitamin supplements to ensure that staffers who have not been infected remain healthy. “I need at least a ₹40 crore budget to stock up antioxidant supplements in the hospital pharmacy. Currently the municipal corporation sanctions not more than ₹2 crore,” he says.

Workers’ woes

It is well past the monsoon season, but on a gloomy October afternoon, it is raining non-stop in Mumbai as Karamveer, a ward boy from the hospital, leads the way up the treacherous moss-laden steps leading to the top of a hillock. Here, up to 48 sweeper families reside in slums. The civic body has warned them that their houses may get washed away in heavy monsoons.

Bitter pill: Karamveer, seen here with wife Sushila, was one of four GTB Hospital workers diagnosed with TB in 2017   -  MAITRI PORECHA

Karamveer’s hut is perched at the top of the hillock. After applying for the job of a Class IV worker advertised in the newspapers, he was employed as a ward boy in the hospital. Karamveer, who had migrated from Delhi to Mumbai for work, did not know what he was signing up for.

He and his wife Sushila both ended up contracting TB. The hospital database reveals that Karamveer was one of four workers diagnosed with TB in 2017. He was admitted to the hospital on January 4, 2017. Two employees who were admitted in the following months — staff nurse Poornima Bhimsen Gaikwad and ward boy Pradeep Dalvi -- died in March and May, respectively. Karamveer has been declared infection-free but is in the last leg of his multi-drug-resistant TB regimen.

“I am not transmitting TB infection currently, but am still on drugs and slowly recovering from the disease. There is constant pain and tingling in my limbs because I am diabetic,” he says.

Karamveer is also stuck in a loan trap for money that he says he never borrowed. Despite having a job, he took ₹2 lakh on loan from a money lender to run the household. But the problem was not the money that he borrowed. A few years ago, he had signed up as a guarantor for a co-worker who had taken a loan of ₹6 lakh from the municipal bank. “And then my co-worker refused to join work. He would sleep or lounge around outside his hut all day. As a guarantor, I am compelled to fend off his loans. The bank automatically cuts my salary and diverts it towards repayment of a loan,” Karamveer explains.

A shy Sushila opens up after Karamveer leaves. Seated cross-legged in the tiny 100 sqft room that also doubles as a kitchen, she appears frail, having recovered just recently from TB.

Of their three children — Mohit (12), Rachana (10) and 18-month-old Saurabh — the youngest was born when Karamveer was infected with TB.

The couple was not familiar with family planning methods, she says, blushing at the mention of condoms. “We did get a pack of condoms once, but our children discovered it and tried blowing balloons with them. It was very embarrassing,” she says.

While Sushila does not want to get pregnant again, her neighbour Ujwala Amjuri underwent an in-vitro fertilisation (IVF) procedure last year and delivered twins. First infected with TB in 2005, Ujwala’s husband Balaji (45) had been battling various complications from TB infection for the past 15 years.

Looking for life: Ujwala Amjuri with her husband, Balaji, and their twins; Balaji has been battling various complications arising from TB infection for the past 15 years   -  MAITRI PORECHA

 

He went on to develop extensively drug-resistant (XDR) TB, which meant very few drugs could work for him, giving him only a 30 per cent chance of survival.

By 2013, Balaji had taken three years of leave, and was forced to join work despite his XDR-TB status. “He swept wards, disposed garbage, washed patients’ spittoons and their infectious clothes. All this because the civic body’s leave policies did not allow him any respite,” Ujwala rues.

Now cured of the disease, Balaji is dealing with the attendant mental trauma. “He is still taking psychiatric treatment at the neighbouring KEM Hospital. He uses sleeping pills at night and becomes cranky if he misses his daily medication,” she says.

His most productive years were snatched by illness, and he now wants early voluntary retirement. Ujwala wanted to have children to brighten up their home. Despite spending close to ₹3 lakh on Balaji’s treatment, she borrowed money from her brother for her IVF treatment. And it worked.

“The babies arrived like rays of sunshine after a long bout of dark days,” she says.

Red tape

In 2015, Dr Nanavare had also presented to the WHO a 12-point infection control programme which claimed that the hospital provided its workers with a nutritious diet and adequate TB leave. But a proposal to provide leave to the workers till they are fully cured is stuck in red tape in the top echelons of the civic body.

According to the Municipal Service Regulations of 1989, a municipal worker suffering from a disease such as cancer or TB can be granted one year’s paid leave only after the employee has exhausted the regular leave they are entitled to.

“In 2010, we realised that many complicated forms of TB were emerging, including extreme drug-resistance, in which the treatment may get extended to two years or more. Therefore, the hospital sent a new proposal to the civic body to grant TB leave for up to two years,” Anande says.

The MCGM, however, sanctioned TB leave only for three to nine months. Even workers with multi-drug-resistance TB were not allowed long leave, says Anande.

“Many workers are directly contracting multi-drug resistance which takes multiple years to treat but are allotted a maximum of nine months of leave, never upto two years,” said Anande.

At times, workers suffer loss of pay while bearing heavy treatment costs.

Balaji Amjuri fell prey to TB multiple times over 15 years, each time his drug resistance worsened. First it was multi-drug resistance, which then progressed to extensive drug-resistance. For patients like them a leave up to nine months would fall woefully short.

In October 2019, Anande initiated a fresh proposal calling for TB leave for workers till they were completely cured. “This proposal is in its final stage and will be ready within a month. We will then see what decision the civic body takes,” he says.

Meanwhile, the staffers continue to suffer. Ward boy Pradip Tukaram Tawde lost his hearing in 2018 after being put on toxic injectable TB drugs. Another worker, Mawanji Narayan Kachre (44), combated TB for over three years from 2013.

Tawde pulls out a blank piece of paper and scribbles on it with a pen. He writes that he is fearful the germ, which has already taken away his hearing, will infect him again.

Tawde’s colleague Jayawant Vishnu Brij (53) is sitting beside him. Four years ago, the disease hit Brij. He has worked in the hospital for 30 years now. Having completed his tenth grade in a rural school in Ratnagiri district in Maharashtra, he dreamed of bagging a job in the urbane locales of Mumbai, oblivious of what the future had in store for him. “I did not want to farm. But in the process I got TB,” says Brij.

“First I felt the weakness in my legs. It gradually crept up through my whole body. Because we work in the patient wards, we know what it is like,” Brij says.

He had directly contracted multi-drug resistant TB strain, but he did not know this because the hospital lacked an advanced GeneXpert testing facility which allows a person to know if he or she has developed MDR-TB.

Brij was kept on basic drugs for two months. “But the drugs simply didn’t work. That’s when I was diagnosed as multi-drug resistant and was put on more potent medicines,” he says.

His friend, Mawanji Narayan Kachre (44), who suffered from TB for over five years while sweeping floors and tending to patients in the ward, has a similar story to relate. A resident of Titwala, on the fringes of the city, he travels four hours each day to get to work.

Sewri TB Hospital is one of five specialised hospitals of the municipal corporation. Workers there cannot be transferred to other medical colleges or hospitals run by the corporation. Working for hours at a stretch in the TB ward, without an option of taking a break or a transfer, took its toll on Mawanji in 2008.

“From sweeping and mopping the floors to serving patients their meals, to discarding the infected sputum and then cleaning their urine and excreta, ward attendants do everything,” he says.

One day, while on his way to work, he suddenly started feeling weak in his limbs. Within a week, he had developed a fever, and lost his appetite.

For six months, after the tests confirmed that he was TB positive, he was subjected to the basic drugs. “But they did not suit me,” he says.

Six months of the toxic pills did not kill the germ. He had, meanwhile, exhausted his leave, and stopped receiving a salary from the corporation. Finally, in 2013, after undergoing multiple rounds of treatment, he started feeling better.

Mawanji says he has seen despairing patients turn suicidal — as many as 24 patients committed suicide over the past eight years, according to figures released by the hospital. There have been at least 40 suicide attempts.

“They just could not take it anymore. The medication doses were heavy. They would overturn plates of food that we served. Every four to six months, I saw people trying to kill themselves. Once, a patient stabbed himself in the neck with a fruit knife,” he says.

In 2016, he requested that he be shifted out of the wards and now works in the clerical department. The hospital tries to accommodate requests from infected workers who want to move away from clinical settings. However, there is no official policy for transfers to less-risky settings, and not all transfer requests are met.

Mawanji, however, continues to fret. “I am scared. What if the disease relapses in a worse form,” he wonders aloud.

Ministry of Health and Family Welfare has now made it mandatory for all patients to receive GeneXpert testing to avoid misdiagnoses, but it still takes a few weeks before patients get access to the testing facilities, doctors at the hospital say.

A doctor’s death

Hospital records reveal that Arvind Solanki, a sweeper, was admitted to the hospital on August 19, 2003. He suffered from TB for two years and died after being readmitted on August 14, 2005. His widow, Pramila Solanki, an ayah in the hospital, recounts her ordeal.

In the same boat: Ayah Pramila Solanki’s husband died of tuberculosis in 2005   -  MAITRI PORECHA

 

“After Arvind died, the hospital authorities gave me ₹2500 for lakdi (wood for cremation). For one year after his death, I worked as a maid in the homes of various doctors at the hospital. I washed utensils, mopped floors, tended to an elderly mother of a doctor as an ayah, in order to earn, so my three kids could go to school. And then I landed up a job under what is called ‘pity case’ at this hospital,” she says.

Dr Suresh Waje’s signature appears in multiple patient records of the infected workers’ register. Dr Waje, a civic doctor, had been treating TB patients and staffers in the civic body health system for 20 years. In 2015, he was diagnosed with extremely drug-resistant TB and died in the multi-drug resistant ward of the GTB Hospital. He was 44.

Medical anthropologist and clinician Jennifer Furin at the US-based Harvard Medical School says that people who work in TB care are seldom taken care of.

“These are people who work very hard but receive no recognition. When things go wrong the government points a finger at them, when really they don’t have the tools that they need. I think it is really a pity what happens to all people who work in TB settings,” says Furin. “When my mother realised that I was to be a TB doctor, she wept in sadness,” Furin reminisces.

But those most affected in TB hospitals, she points out, are the cleaners. “We know from studies and unpublished observations that people who spend most time in the TB wards are the cleaners. We lose so many workers to this disease and they are such a valuable resource but they are not seen that way. Most of them are not given proper personal protective devices. If there are not enough N95 masks, they are first given to the doctors, but it is the worker who spends the most time with the patients,” She says.

Workers who are not adequately trained have a tendency to reuse an N95 mask, ideally to be worn just once, for over a week or a month. “Ideally N95 mask has to be changed daily, but these are the short cuts we take,” Furin says.

Then there are workers like Pramila who do not wear an N95 mask. She finds them too uncomfortable, she says. Furin explains that masks can be uncomfortable if they are not ‘fit-tested’ and staff trained on how to use them.

Furin believes that India could decrease the transmission in healthcare settings through rapid diagnosis tests. “This is to diagnose them quickly and to know if patients have Rifampacin-resistant TB so that they could be initiated on drugs such as Bedaquiline or Linezolid upfront,” she says.

As of now, there is a restricted supply of Bedaquiline and Delamanid. From time to time, there is a shortage of other drugs such as Clofazamine. “India’s refusal to make life-saving drugs available universally also puts healthcare workers at a risk,” Furin observes.

In South Africa, she explains, patients undergo a GeneXpert test at the very onset. “But India has not put this in the political will and they still want us to believe we have got five years to eliminate TB. India is being very dishonest with itself, with its citizens and with the global community on what it needs to do to tackle the TB problem,” she says.

There is need for immediate action, she holds. “You need to have a frank discussion. It does not mean pointing fingers, but it means we are in the middle of a problem and here is where we want to go, how do we get there. But we cannot do that if we pretend that everything is fine.”

Child care

Dr Zarir Udwadia, a leading Mumbai-based TB doctor in the PD Hinduja Hospital, Mahim, says that when workers get directly infected with multi-drug resistant TB, the most vexing issue is of how to contain its spread in the immediate family of the patient.

“If a mother has MDR-TB and her children are exposed to it for months, I really can’t say anything to them, except wear a mask. Wearing a mask reduces transmission by 50 per cent even if it is a simple paper mask. But we don’t know what treatment we should offer, for children are excessively vulnerable. We have no data about what to do with children in the MDR context,” Dr Udwadia says.

Another problem that the government needs to tackle is the stigma attached to TB. Recently, the central government brought out a policy against discrimination of persons with TB at the workplaces, but Dr Anande wonders if a policy is enough.

“We must have a law in place along the lines of HIV against stigmatising people living with TB. They must be assured that they will be taken back on their jobs after they complete treatment,” Anande says

Law, societal changes, drugs, tests, adequate nutrition — the list of dos is a long one. Meanwhile, an army of healthcare workers continues to battle TB — and succumb to it.

(This report was supported by the Thakur Family Foundation. The foundation has not exercised any editorial control over the contents of the report)

Published on March 20, 2020

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