Real data

India may have a million more tuberculosis patients than we estimated

A new study indicated that there are 2.2 million tuberculosis patients being treated in the private sector alone.

India has a quarter of the world’s disease burden of tuberculosis. In 2014, the World Health Organisation estimated that there were 2.2 million cases of tuberculosis throughout the country. If that didn’t sound bad enough, a new statistical analysis suggests that there are 2.2 million tuberculosis patients seeking treatment at private healthcare facilities alone, in addition to the 1.6 million cases in government hospitals.

As an indicator of the number of cases of the disease, Nimalan Arinaminpathy, a researcher at the School of Public Health at Imperial College London, and his colleagues from various Indian institutions, analysed the sales of tuberculosis drugs in private healthcare facilities in 2014. They adjusted the data to account for possible over-prescription of drugs and other factors. What they found is that India is more likely to have had 3.8 million tuberculosis cases that year, an increase of a third from the WHO estimate.

“We've known for a while that it is critical to engage with the private sector, to control India's TB epidemic,” said Arinaminathy, the lead author of the paper that has been pubished in Lancet Infectious Diseases. “There are innovative new schemes being developed and piloted, such as efforts to engage with the private sector in Mumbai and Patna. However, our results show that the scale of the problem is even greater than has previously been recognised.”

Inadequate surveillance

Public health experts have repeatedly pointed out the gaps in reporting incidence of tuberculosis and possibility of underestimating the number of cases for the lack of a robust TB surveillance system. Previous estimates of tuberculosis cases in the private sector have relied on informed opinion, which is a reflection of the number of cases that fail to be reported to public health authorities.

In this study, Arinaminpathy and his team turned to data from the ground instead. Despite this, as Arinaminpathy cautions, the results serve to indicate that TB incidence is much higher than previously recognised but better surveillance will still be needed to pin down the true number.

"One of the things we have tried to do is try and divide them by state and we hope that will be a useful instrument for the government to target the states necessary for increase in notification," he added.

The huge gap in recording TB cases might also be due to the fact that many patients with TB symptoms do not approach doctors at the initial stages. “Patients from low-income communities especially, people from urban slums and rural areas, when they develop cough and its persistent, they seek advice from pharmacies,” said Srinath Satyanarayana, a PhD candidate at the McGill International TB Centre at Montreal.

Satyanarayana is the lead author of another study that shows how pharmacies in India contribute to delays in TB diagnosis.

Pharmacy first

Looking at previous analysis that showed that 25% of TB patients have their first contact with the healthcare system at pharmacies, Satyanarayana and his collaborators devised patient simulation study to check how the system works. They trained healthy people to enact symptoms of TB, visit the pharmacists and report the care received. A "simulated patient” would not carry a doctor’s prescription but simply would simply tell a pharmacists that he had a cough.

In some cases a pharmacist would ask about the duration of the cough and if there were other symptoms. The patient would then elaborate with symptoms typical of TB – a cough for more than two weeks, fever and weight loss.

“We found that in only about 13% of cases, [the pharmacist] asked them to go to healthcare providers without providing antibiotics and steroids,” said Satyanarayana. “The remaining 87% of the pharmacies gave them some medicine and in 40% of the cases these contained antibiotic.”

This practice of prescribing antibiotics not only delays a TB patients diagnosis and treatment, it also increases the chances of the disease spreading from the infected person. Secondly, the antibiotics given by the pharmacist will not help a person suffering from TB.

Moreover, unnecessary use of antibiotics only increases anti-microbial resistance, a immense and growing threat in India.

Plugging the gaps

The Revised National Tuberculosis Control Programme, the flagship programme in India for the control of the disease, and the Indian Pharmaceutical Association have out a policy document saying that pharmacists should be able to recognise people with TB symptoms and refer them to the nearest healthcare facility. But the new study shows that a very different reality on the ground.

The silver lining, however, is that in none of the cases did pharmacists give TB drugs without a prescription, a practice that would increase multi-drug resistance TB and make it more difficult to treat. Also, once simulated patients approached pharmacists with sputum tests that confirmed TB, the pharmacist immediately referred patients to hospitals without giving them antibiotics or steroids.

“What RNTCP should recognise is that pharmacies are an important source of healthcare for patients with TB,” said Satyanarayana. “Once they recognise that, they should have a formal mechanism in every district to identify all the pharmacies and inform them what their roles and responsibilities are, and how their practices can help TB control.”

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“My body instantly craves chai and samosa”

German expats talk about adapting to India, and the surprising similarities between the two cultures.

The cultural similarities between Germany and India are well known, especially with regards to the language. Linguists believe that Sanskrit and German share the same Indo-Germanic heritage of languages. A quick comparison indeed holds up theory - ratha in Sanskrit (chariot) is rad in German, aksha (axle) in Sanskrit is achse in German and so on. Germans have long held a fascination for Indology and Sanskrit. While Max Müller is still admired for his translation of ancient Indian scriptures, other German intellectuals such as Goethe, Herder and Schlegel were deeply influenced by Kalidasa. His poetry is said to have informed Goethe’s plays, and inspired Schlegel to eventually introduce formal Indology in Germany. Beyond the arts and academia, Indian influences even found their way into German fast food! Indians would recognise the famous German curry powder as a modification of the Indian masala mix. It’s most popular application is the currywurst - fried sausage covered in curried ketchup.

It is no wonder then that German travellers in India find a quite a lot in common between the two cultures, even today. Some, especially those who’ve settled here, even confess to Indian culture growing on them with time. Isabelle, like most travellers, first came to India to explore the country’s rich heritage. She returned the following year as an exchange student, and a couple of years later found herself working for an Indian consultancy firm. When asked what prompted her to stay on, Isabelle said, “I love the market dynamics here, working here is so much fun. Anywhere else would seem boring compared to India.” Having cofounded a company, she eventually realised her entrepreneurial dream here and now resides in Goa with her husband.

Isabelle says there are several aspects of life in India that remind her of home. “How we interact with our everyday life is similar in both Germany and India. Separate house slippers to wear at home, the celebration of food and festivals, the importance of friendship…” She feels Germany and India share the same spirit especially in terms of festivities. “We love food and we love celebrating food. There is an entire countdown to Christmas. Every day there is some dinner or get-together,” much like how Indians excitedly countdown to Navratri or Diwali. Franziska, who was born in India to German parents, adds that both the countries exhibit the same kind of passion for their favourite sport. “In India, they support cricket like anything while in Germany it would be football.”

Having lived in India for almost a decade, Isabelle has also noticed some broad similarities in the way children are brought up in the two countries. “We have a saying in South Germany ‘Schaffe Schaffe Hausle baue’ that loosely translates to ‘work, work, work and build a house’. I found that parents here have a similar outlook…to teach their children to work hard. They feel that they’ve fulfilled their duty only once the children have moved out or gotten married. Also, my mother never let me leave the house without a big breakfast. It’s the same here.” The importance given to the care of the family is one similarity that came up again and again in conversations with all German expats.

While most people wouldn’t draw parallels between German and Indian discipline (or lack thereof), Germans married to Indians have found a way to bridge the gap. Take for example, Ilka, who thinks that the famed differences of discipline between the two cultures actually works to her marital advantage. She sees the difference as Germans being highly planning-oriented; while Indians are more flexible in their approach. Ilka and her husband balance each other out in several ways. She says, like most Germans, she too tends to get stressed when her plans don’t work out, but her husband calms her down.

Consequently, Ilka feels India is “so full of life. The social life here is more happening; people smile at you, bond over food and are much more relaxed.” Isabelle, too, can attest to Indians’ friendliness. When asked about an Indian characteristic that makes her feel most at home, she quickly answers “humour.” “Whether it’s a taxi driver or someone I’m meeting professionally, I’ve learnt that it’s easy to lighten the mood here by just cracking a few jokes. Indians love to laugh,” she adds.

Indeed, these Germans-who-never-left as just diehard Indophiles are more Indian than you’d guess at first, having even developed some classic Indian skills with time. Ilka assures us that her husband can’t bargain as well as she does, and that she can even drape a saree on her own.

Isabelle, meanwhile, feels some amount of Indianness has seeped into her because “whenever its raining, my body instantly craves chai and samosa”.

Like the long-settled German expats in India, the German airline, Lufthansa, too has incorporated some quintessential aspects of Indian culture in its service. Recognising the centuries-old cultural affinity between the two countries, Lufthansa now provides a rich experience of Indian hospitality to all flyers on board its flights to and from India. You can expect a greeting of Namaste by an all-Indian crew, Indian food, and popular Indian in-flight entertainment options. And as the video shows, India’s culture and hospitality have been internalized by Lufthansa to the extent that they are More Indian Than You Think. To experience Lufthansa’s hospitality on your next trip abroad, click here.

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This article was produced by the Scroll marketing team on behalf of Lufthansa as part of their More Indian Than You Think initiative and not by the Scroll editorial team.