When she was eight months pregnant with her second child, 33-year-old Draupadi started getting sick with fever and violent coughs. A resident of Devdongar village in Rajnandgaon district of Chhattisgarh, she got herself tested for tuberculosis, but her sputum tests were negative. She delivered a baby boy in January, but was still not feeling any better.
In February, she was referred to the district hospital, where the doctors conducted an X-ray of her chest. She was diagnosed with TB. She weighed only 27 kgs then.
Luckily, just around that time, the state health department had rolled out a pilot project on poshan aahar or supplementary nutrition for TB patients in Rajnandgaon. Draupadi was given a packet of milk powder, two packets of groundnuts, and a packet of soya bean oil for a month.
Before she got this food basket, she would barely eat two meals a day. Now, she eats the peanuts after roasting them with a bit of oil, or just pops them into her mouth whenever she is hungry.
Draupadi enjoys milk the most.
She mixes the milk powder with a glass of water and has it once in the morning. “I do not even give it to my children,” she said.
First statewide programme
In Chhattisgarh, public health activists have been pushing for a nutrition programme for TB patients for nearly a decade. The state has one of the poorest rates of malnutrition in the country. Forty-three percent of its women and 39% of its men are undernourished with a body mass index less than 18.5, the minimum standard as per the National Family Health Survey conducted in 2005-'06.
In 2013, Kerala’s Wayanad district had started a supplementary nutrition programme for TB patients funded by the Integrated Tribal Development Project. Mumbai, too, is running a similar programme for patients with drug-resistant tuberculosis.
But Chhattisgarh is the first state to have allocated funds from its annual budget for providing nutritional supplements to TB patients. The first allocation was made in 2015.
The links between TB and undernutrition have been long known. In fact, in the 18th century, TB was called consumption because of the manner in which it seemed to devour the body. The only treatment available, before the advent of antibiotics, was access to clean air, healthy food and moderate exercise in a sanatorium away from the city.
While undernutrition weakens the body's immunity, making it more vulnerable to TB, the disease also makes undernutrition worse. The likelihood of death and relapse of the disease is also higher among undernourished people.
The World Health Organisation advocates counselling on nutrition as part of government-run TB programmes. But it stops short of advising supplementary nutrition for TB patients, citing lack of evidence.
This position has been slammed by many experts.
"To ask whether people suffering from a consumptive disease need food seems to me a little disingenuous," said Dr Salman Keshavjee, Associate Professor of Global Health and Social Medicine, Harvard Medical School. "Sometimes, we do something that is morally and logically sensible, because we know it helps people."
As an expert, he said he fully endorsed nutrition programmes for TB patients.
"It is hard to take a lot of pills on an empty stomach. It makes people nauseous," he said. "That alone should be a driver to advocate nutrition supplements."
A non-profit collective of doctors called the Jan Swasthya Sahyog runs a low-cost rural hospital in Ganiyari village in Bilaspur district in north Chhattisgarh. In 2013, the doctors here conducted a study that found strong links between undernutrition and deaths due to TB. Their research showed that a body mass index of 16 is associated with double the odds of death in men. This study became the talking point for the call for a statewide nutrition programme for TB patients.
With the announcement of the programme last year, Chhattisgarh government acknowledged the problem of undernutrition and its repercussions in the form of TB in poor communities. An allocation of Rs 12 crore was made.
In September 2015, the state health officials conducted a survey to find out people's food preferences. Most people expressed a desire for milk, eggs, along with groundnuts and oil.
The health department allocated Rs 600 per person per month. The State Health Resource Centre, which serves as an additional technical advisory body for the health department, was asked to pilot the project in two districts – Rajnandgaon and Bilaspur.
Currently, the food supplements are being given to about 200 patients in both the districts.
The aim of the pilot project is to determine the acceptability of the food baskets provided to the patients and find out effective ways of implementing the programme. It will also advise the state health department on tendering, procurement and distribution of these supplements.
More than 70% of the patients come to collect their food baskets each month, according to SHRC. Many of the patients told Scroll.in that they barely ate two meals a day. The food basket provides them about 800 calories worth of food, nearly a meal's worth.
No surprise then, the comprehensive treatment programme has helped patients gain weight and has improved their general well-being.
Among them is Rajendra Goad, 42, a resident of Rajnandgaon city, who used to work as a painter. He is barely five feet tall, and looks emaciated. He tottered out of his house, holding the walls for support and slumped down on the porch.
“I have been working since I was 15 or 16 years old,” he said. "I have always been thin."
Goad weighed only 25.8 kgs when he was diagnosed with TB in February. He was barely able to get out of bed since the past one year, let alone work.
“I went to a jholachap doctor (quack),” he said. "But the medicines did not work."
His wife is now the only earning member and earns about Rs 100 per day.
After he started getting the supplementary nutrition, his weight has increased to 33 kgs.
The distribution centre for the food is the district microscopy centre, where medicines are also handed out. The laboratory technicians and supervisors are then able to counsel patients about the treatment and follow up better.
“Earlier we used to tell patients drink milk every day,” said Sandeep Khirsagar, treatment supervisor at Khairagarh town. "But where do they get milk? They were so poor. Now with this scheme, we can at least try enforce some kind of nutrition."
Such is the impact of the programme that TB patients who are not getting the supplementary nutrition are upset.
“It has been tough for us to explain to the other patients that this will eventually become a programme for everyone. We are hoping it will be scaled up by September,” said Samir Garg of the State Health Resource Centre. Currently, SHRC is procuring food and managing its distribution. The scale-up of the programme all over the state would be a challenge, Garg admitted.
Not that nutrition supplements offer a magical solution. Four months in the programme, there have been 39 deaths among 398 patients. On a positive note though, the mean weight gain of patients who have taken food supplements for two months is an astonishing 1.8 kgs.
Draupadi has gained seven kgs since she started taking medicines along with the nutrition supplements.
Ramkishan, 38, a daily wage labourer, had chest pains and would cough all day. In February, he was diagnosed with TB. After he started taking the nutrition supplements, he has gained a little over a kg. He was 38.8 kgs and is now 40 kgs.
“On an empty stomach, I drink milk and then have groundnut roasted in oil,” he said, while picking up medicines and the food basket in the district microscopy centre at Khairagarh Civil Hospital.
Like medicine? “Yes, like medicine,” he said laughing.