Better Approaches to Fighting TB in India

Infectious disease specialist Ramnath Subbaraman documents the consequences of living in slums

During medical school at Yale, Ramnath Subbaraman spent a year in India caring for people with HIV. Their main cause of death, he learned, was not AIDS, but tuberculosis. “Even though TB kills more people globally than HIV, it gets far less global attention and support,” he said. He became an infectious disease physician and assistant professor of public health and community medicine at the School of Medicine, where he focuses on improving TB care in India and, not unrelated, documenting the health consequences of living in slums.

Promoting Safe Water

In Mumbai, about half of the population lives in slums, but not all slums are treated equally by the government, which provides basic services like water to some older, legally recognized shantytowns, but rarely to ones settled by recent migrants. Subbaraman sees that undocumented immigrants in the United States face similar forms of social exclusion: “People want low-wage labor that they can get from individuals who come from elsewhere, but they don't want to actually provide public benefits to them.” Subbaraman found that when slum residents have to get their water by illegally tapping into municipal pipes or paying high prices to private sellers, the little water they do get is prone to contamination. Piping water into all slums would have a profound effect on health throughout India.

Finding Lost Patients

Subbaraman found that, of the estimated 2.8 million people in India who contracted TB in 2013, only 45% accessed care and completed treatment. He and his team interviewed patients and health workers, and found that some patients who dropped out were daunted by the health-care system, which might call for TB tests to be done in one place and treatment in another, for example. Patients also felt stigmatized by health workers for having a contagious, poor-person’s disease. The workers, for their part, sometimes didn’t have the resources to manage the caseloads. Rather than blaming people with TB, Subbaraman recommended that the care system look within for solutions.

Putting Tech to the Test

TB is curable with antibiotics, but skipping doses brings a high chance of drug resistance, relapse, or death. To ensure people with TB are taking their medications, health organizations have embraced new devices such as digital pill boxes and ingestible sensors. The problem, said Subbaraman, is when “techno-optimism” by well-meaning funders leads to these ingenious gadgets being rolled out without enough data showing they actually work. He determined that one widely used technology, a pill pack that reveals a phone number to call each time a pill is popped out, underreported missed pills for many patients and overreported them for others. His goal isn’t to squash new ideas, but to test them objectively—a must when silver-bullet solutions are so attractive.


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