When vision and political will come together, the people stand to gain. Under the present dispensation, certain flagship programmes certainly display vision as well as political will. For instance, the Government initiatives such as Poshan Maah or National Nutrition Month, observed in September — an important tradition put in place since 2018 to further conversations on health and nutrition services in the country — can be considered a timely reaffirmation of the country’s priorities as citizens, especially the most vulnerable, navigate the stark impact of the pandemic on their lives and livelihoods. With our extensive work in the domain of nutrition and tuberculosis, we can really appreciate the centrality of such initiatives when it comes to creating positive disruption.
Thus, it has been highly encouraging to see health-nutrition being foregrounded by the Government within the national development narrative. This is also an occasion to understand why such focus must be sustained on a war-footing for some areas which are strongly linked with and fall under the ambit of undernutrition and infectious diseases. Tuberculosis or TB is an apt case study against this backdrop. Because the issue lies at the intersection of something both of us have strived hard to address over decades, we feel personally and professionally invested in any mitigation mechanism that can alleviate the people’s suffering.
According to India TB Report 2021, over 23 lakh new TB cases were reported in India and approximately 89,000 people succumbed to it in 2019. Now, let’s consider how malnutrition and TB essentially have a bidirectional relationship, which becomes more pronounced in the Indian context. In fact, undernutrition at the population level, according to the Health Ministry’s 2017 guidance document on nutrition, contributed to an estimated 55 per cent of annual TB incidence in India.
From our experiences, we have seen how undernutrition also compromises the body’s immunity and can lead to the progression of latent infection to active TB; this worsens undernutrition, which again, in turn, increases the severity of the disease creating a vicious cycle. The Government has been proactive in recognising this problem and initiating schemes such as the NPY which provides Rs 500 a month to TB patients as nutritional support. It is important to build on this success to drive a holistic discussion on nutrition and its integral role within the TB treatment narrative. What can be the contours of such a discussion and what are the critical points to consider?
Any strategy for nutrition and TB must factor in the importance of recording an individual’s BMI, which informs the trajectory of the treatment regimen. Data show how undernourishment doubles fatalities linked with TB. The undernourished elderly with a low BMI of less than 18.5 are also overwhelmingly affected by severe forms of TB. Patients with low BMI are ill-equipped to handle the stress of TB infection and anti-TB drugs. Therefore, it’s essential to work towards a model of consistent nutritional assessments and counselling that can be integrated within the TB treatment cycle; clearer understanding of nutritional details is crucial to the success of the rigorous drug regimen for the disease.
We must also understand how, in India, TB affects the poor disproportionately; the 2017 Health Ministry’s guidance document also notes a 4-fold higher prevalence in those with a low standard of living index compared to those with a higher standard of living. In this light, it may be useful to have local nutrition counsellors readily accessible to patients who can clarify for them beyond dietary supervision what holistic nutrition entails as part of TB treatment. The emphasis must be on ensuring nutritional evaluation before, during and even after the treatment regimen is complete. We must remember that below the desired BMI levels, efficacy of certain drugs may not be optimal, if not at all. To start with, we can try to incorporate initial BMI screening especially for more at-risk categories such as children and elderly at the point when patients are being screened for suspected TB.
There do exist modalities in some States to provide enhanced ration to patients through PDS linkages, and even supplementary nutrition through food baskets. A 2018 report by the Health Ministry on Patient Support Systems for TB Elimination has several recommendations in this regard that could be revisited and explored by the States for further implementation. Within the larger architecture of such recommendations, States can design targeted food baskets considering local preferences as well as infrastructure available for supply chain management. It will also be useful to have a prioritised beneficiary list comprising the most vulnerable sections of society so the nutritional resources can be allocated to those who need it the most.
Finally, the research community, which we are also a part of, does play a critical role in keeping the conversation on TB services alive. However, efforts to mitigate TB can only be amplified by increased intersectoral collaboration, considering the magnitude of the crisis. Multiple determinants of TB like poverty, malnutrition, urbanisation, indoor air pollution, sanitation, migration, etc, remain outside the purview of the health department. They may fall under different departments, but they share the commonality of being important factors in the TB narrative. For this reason, the TB programme’s initiative to create an inter-Ministerial committee is welcome. It is crucial to foster convergence between different departments to ensure TB-Mukt Bharat. Such unity of purpose can only help the Jan Andolan against TB and ensure the disease is eliminated by 2025.
(Dr C Padmapriyadarsini is Director, ICMR-National Institute for Research in Tuberculosis; Dr R Hemalatha is Director, ICMR-National Institute of Nutrition)
