From the battlefield

This is Sergeant Kuruvilla, reporting from the battlefield in the war against Tuberculosis.

Thank you for your greetings on World Tuberculosis Day. It’s been more than a century since we’ve sighted the enemy, but alas there seems to be no end to the hoards of their armed regiments. 

At the front, Lieutenants Rifampicin and Isoniazid continue to do a commendable job inspite of the fact that the enemy has designed specific weapons against them called Drug Resistance. Lieutenants Pyrazinamide and Ethambutol continue to serve well, although there are reports of our own troops being injured by them unknowingly during combat.

I understand that new troops with extra fighting capabilities have been identified. It is very essential that they be deployed in our sector at the earliest. Lts. Isoniazid, Rifampicin, Pyrazinamide and Ethambutol have been in the field for quite long and the enemy knows their capabilities quite well. Sometimes, I wonder if the war is going beyond our grip. The new mercenaries of the enemy, MDRTB, XDRTB and TDRTB are ample evidence that we’ve not been diligent. We need the state-of-the-art technology radars available with usto detect these rouges and more potent weapons to fight them.

However, I need to point out issues which our own troops have been guilty of. Quite a few of our troops do not heed to the leadership of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol after some period of time. Instead, they put themselves susceptible to the machinations of the enemy tubercle bacilli. It is quite sad to see this happen.

Meanwhile, there are issues which need to be dealt by the social development wing of the nation. Social determinant issues such as malnutrition, overcrowding and poor livingconditions need to be addressed on a war footing.

Is it true that the enemy is advancing in at least some of our fronts? It is sad to know that even today, in the age of internet and smart phones, people have poor knowledge and attitude about the disease. It pains me to see people spit wherever they want, in spite of the fact that there is evidence of higher spread of the disease because of such practices. Of the last 10 patients, whom I diagnosed to have tuberculosis, more than half of them could not acknowledge and accept the fact that they had the disease. I believe that this is one of the major reasons that there is a delay indiagnosis.

There are quite a lot of the enemy who has infiltrated into our territory without our knowledge. Considering that the private and voluntary sector is the favoured point of contact for a large number of our population, we need to take them into confidence.

I’m encouraged that there is evidence that if standard epidemic control measures are put inplace, we would achieve control on the spread of the disease. We need to follow the basics of public health care. The eight essential components of ‘Primary Health Care’, outlined at the Alma Ata declaration give us enough guidelines to stifle the enemy.

With poor primary healthcare and emphasis on setting up tertiary care institutes all around the battle fronts, this objective is not going to be met. Priorities on tackling malnutrition, rural to urban migrations and overcrowding have to be given priority.

It is sad to note many of our fellow human-beings reap a profit off the victims of the enemy. The government needs to act.

Considering this year’s slogan, I’m sure that there need to be some major changes in our approach to treat tuberculosis. Reaching each of our patients would be a reality only if we allow active detection of cases. The World Health Organisation charter for treatment for tuberculosis has already accepted the superiority of daily drug therapy to intermittent therapy. In India, we need to slowly shift to daily treatment. There is presently no mechanism to ensure that patients remain cured after the completion of treatment. Relapse and re-infection remain hugely unaccounted for.

Unless, we areserious of my above mentioned issues, the slogan for this year – Reach the 3 million: Find, treat, cure TB’ will just be another catchy phrase and an issue to write articles on.  

I assure you of my team’s commitment to the control of the tubercle bacillus. 

Ominous signs

Today, in outpatient, I had a 30 year old lady walking in. Her history was quite shocking. 

Diagnosed to have tuberculosis without a sputum AFB more than a year back, she was on treatment for almost 10 months with a multitude of medicines including 90 injections of streptomycin. 

The problem was that she had not felt better throughout the course of her treatment. 

Below are 3 X-Rays she had with her. 

Feb 2014

Sept 2014

Feb 2015

I await for her sputum AFB. 

I'm not sure if I would do justice to her if I just refer her to a higher center nearby. 

Earlier in the day, I had another patient who was invariably depressed. The interesting thing was that this guy had absolutely no symptom suggestive of tuberculosis. However, he was on anti-tuberculous medications since the last 2 months. The reason - - - some doctor had done a Quantiferon TB Gold Test on him and it was positive. 

Just a glimpse of the scenario of tuberculosis control in the country. 

Of course, I would be glad to get feedback on the management of the patient . . .   

Tuberculosis . . . continuing to ravage . . . and helped on . . .

Over the last couple of weeks we've had reports of a new form of tuberculosis which the government refuted within a surprisingly short interval.

Today morning, in OPD, I had three new patients who were all partially treated tuberculosis. All very similar histories which found common ground in an article I read recently. I'm not very sure on whether their sputums will yield acid fast bacilli as almost all of them had been on some form of tuberculosis treatment. And none of them have had any trace of government medicines in them . . .

Well, tuberculosis is not an uncommon diagnosis in NJH. In fact, we are a tuberculosis unit which cater to one third of the district. Today and tomorrow, our Medical Officer is on a training course of diagnosis and management of Multidrug Resistant Tuberculosis. 

The patient I wanted to tell about is TT, a 17 year old young man admitted into our ward. We diagnosed TT to have miliary tuberculosis on the basis of his symptoms and Chest X-Ray. But TT was already on treatment for Tuberculosis from a private practitioner. He was put on a sub-optimal dosage of a combination therapy of Rifampicin, Ethambutol and Isoniazid. No Pyrazinamide . . . 

But, what interested me more was the number of other medicines which TT was on. I've tried to take a photograph of all the medicines put together. 4 of the medicines are multivitamins which totally cost about 30 rupees per day. Then, there is a cough syrup. One strip is Diethylcarbamazine . . . and then he has been on regular daily intravenous injection of Amoxyciline and clavulanic acid as well as on a combination of oral Ampicillin and Cloxacillin. 

It is unfortunate. There has much written on unethical and spurious medical prescriptions written by quite a lot of our fellow practitioners. It is not uncommon to see even well qualified and well known doctors write so lengthy prescriptions. Of course, there is a lot of money to be made. But, the ultimate question is about the cost poor people like TT or the other 3 patients whom I had seen in outpatient today pay? ? ? 

THE COSTLY DELAY - 1

You may have read this statement somewhere –

‘If you want to know the value of one year, just ask a student who failed a course.

If you want to know the value of one month, ask a mother who gave birth to a premature baby.

If you want to know the value of one hour, ask the lovers waiting to meet.

If you want to know the value of one minute, ask the person who just missed the bus.

If you want to know the value of one second, ask the person who just escaped death in a car accident.

And if you want to know the value of one-hundredth of a second, ask the athlete who won a silver medal in the Olympics.'

Couple of days back, I had two patients who would have done better if they had not delayed coming to us on time. I shall narrate the story of the first patient in this post and in a later post, the story of the second one.

LR is a 55 year old man from a nearby village, Rankikala. Since the last 1 month LR has been sick with vague symptoms. It started off with fever on and off in the evening. He went to the local practitioner (RMP) in our market village, Satbarwa who prescribed him some tablets. He improved for couple of days, after which the fever had come back. In addition, he developed something new – he had episodes of seizures of his right leg alone.

Satbarwa is famous for a Vaid (traditional healer) who is specialized in neurological ailments. I’m told that he uses the extract of garlic to make a concoction which is given as an intramuscular injection. I’ve had quite a lot of patients who vouch for this remedy in the treatment of neurological ailments. However, I’ve noticed that the recovery mainly occurs in patients who had ischemic strokes – which would have healed otherwise too. Since LR felt that having seizures is something related to the nerves, he straightaway went to the vaid at Satbarwa.

Unfortunately, nothing much happened. He still had a fever and cough was worsening. However, he felt that those symptoms are secondary and he needed to get treatment for his seizures. The seizures continued to occur. The Vaid decided that this needed further evaluation and send him to one of the physicians in Daltonganj. The doctor of Daltonganj also treated him for about 2 weeks – before LR decided that there was not much improvement.

LR came to NJH OPD couple of days back – He was frail and it was obvious that he had lost quite a lot weight recently. His pulse was feeble and Blood Pressure was just 80/50. His chart came to my table – as he entered my room, the diagnosis was obvious - Lung abscess. The stink from his breath was unbearable. It was difficult to fathom how one could miss the stink. And from his blood pressure and history of seizures  - possibilities narrowed down to either a disseminated malignancy or disseminated tuberculosis. Sputum AFB turned out positive for tuberculosis. I did an X-Ray which is put up here.

LR's Chest X-Ray

LR had spent almost 10,000 rupees by the time he came to us. He would have done better with a CT Scan Brain. But, he just did not have the money to make a trip to Ranchi leave alone the CT Scan. In addition to the Anti-Tuberculosis treatment, we have also started him on Steroids and Anti-seizure medications.

LR waits with his son for his anti-tuberculosis medicines

I’m confident that he will do well. However, things would have been easier had he turned to us early – which brings us to question on why people avoid coming to people like me in the first place. Money is obviously the major issue is institutions such as ours. However, he would not have had to spent this much if he had come to us straightaway. But, I did not understand why this does not happen, until I heard about ‘agents’ about whom I shall post soon.

My only prayer is that the delay would not turn out to too costly for LR whereby he may lose his life – unlike RD about whom I shall write in my next post (http://jeevankuruvilla.blogspot.com/2011/09/costly-delay-2.html).