The geography of a city is a map to the lives of its inhabitants. The complex geography of Mumbai is a labyrinth that tells many stories the city's dwellers. While Mumbai is a dream for many it's also a difficult city to survive in. With millions living in makeshift slums, with poor ventilation, food or sanitation, maximum city is no stranger to infectious diseases and squalor.
So in 2012, when the first reports documenting the emergence of Total Drug-resistant TB (TDR-TB) emerged in Mumbai, many among the city's medical establishment were not surprised. For a decade, they had observed the expanding burden of drug resistance in Mumbai fuelled by inaccurate or delayed diagnosis and inappropriate treatment.
"The most remarkable aspect of this programme is the private sector engagement, where informal providers are used to bring patients to doctors that can provide accurate diagnosis and treatment."
TB was Mumbai's open secret. The growth in drug resistance was attributed to multiple factors --overcrowded living, poor nutrition, lack of sanitation and abysmal access to health services. The most cited reason was poor TB care in the vast and diverse private sector where millions first sought care. Here diagnosis was often incorrect and treatment inappropriate. In Mumbai's crowded slums, many of those diagnosing and treating TB were not even doctors. If the disease was diagnosed correctly, most patients were rarely put on the correct treatment. This was illustrated in a study of TB treatment in Mumbai slums which showed dozens of regimens and drug combinations being used to treat TB.
The discovery of TDR-TB brought home the realisation that Mumbai was in a TB crisis. Recognising this, the Mumbai administration called for a large meeting to brainstorm how Mumbai could effectively control TB. Doctors, health workers, communications specialists, privates sector representatives crowded in a single room one humid weekend to debate, discuss and determine Mumbai's future TB control strategy. The meeting was led by India's foremost TB specialist Zarir Udwadia who reported the first cases of TDR-TB.
The group came up with an ambitious multi-pronged strategy titled the Mumbai Mission for TB Control. The strategy focused on proactively finding new cases in slums, creating access to rapid TB diagnosis ( including testing everyone for drug resistance), improving access to correct treatment and extending these services and support to providers and patients in the private sector. It also focused on improved infection control, building empowered communities and immediate organisational strengthening within Mumbai.
There were sceptics, of course. They thought the plan was too expensive, ambitious and would stay in the realm of ideation. Meanwhile, the programme enlisted a strong coalition of partners including local NGOs, private sector representatives and agencies such as the WHO and the Gates Foundation. The municipal corporation contracted a public private interface agency whose job was to engage and work with informal healthcare providers to improve access and quality of diagnostics and treatment in city slims. A person with TB symptoms who went to these providers would be referred to a qualified provider, where they would be given a subsidised test and the option of free medicines. The city also engaged as a brand ambassador India's biggest superstar, Amitabh Bachchan, who had formerly battled TB himself.
Around 2015, after two years of work, the tide began to turn slowly in Mumbai's favour. The number of patients diagnosed through this programme increased from a few hundred to thousands. Public awareness increased, as did corporate and community participation; patients too started speaking up fearlessly about surviving TB. Today, though TB continues to be a serious problem, Mumbai is better prepared to address it. And though the contagion is far from over, there is a consensus among the city administration and the private sector that TB has to be prioritised.
"[I]f we delay developing and implementing such models we put millions of lives at risk and invite considerable human suffering."
Will the experiment transform Mumbai's TB problem? Time will tell. Nevertheless, the Mumbai example holds several lessons for urban TB control in India:
- The most remarkable aspect of this programme is the private sector engagement, where informal providers are used to bring patients to doctors that can provide accurate diagnosis and treatment.
- Similarly, the engagement of grassroots NGOs to bring community awareness on TB is critically important.
- To ensure that TB care was patient- and family-centric Mumbai provided trained counsellors to help patients and to aid them in understanding the critical importance of adhering to TB treatment. This resulted in creating a more conducive environment for patients at home, better infection control and also improved adherence.
- Recognising the importance of nutrition to drug resistant TB patients, the city also initiated a programme where they were provided with food aid.
Each intervention played a facilitating role in helping patients fight TB.
In India's large cities, with rampant poverty, poor nutrition and insufficient investment in public health systems, infectious diseases like TB represent significant challenges. Not everyone may agree with the Mumbai approach but it is time to learn from it how we improve access to health services and engage the private sector and communities for improving the health of populations. Many argue this approach is expensive. But here is the trade-off -- if we delay developing and implementing such models we risk creating more crises like Mumbai. If we procrastinate, we put millions of lives at risk and invite considerable human suffering. Perhaps we should consider this -- we don't really have a choice.