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Exclusive interview with Dr. Madhukar Pai, MD, PhD

Every year, the world observes World TB Day on March 24 to raise awareness of the continued tuberculosis epidemic, especially in the developing world, and efforts to fight it. March 24 is the date in 1882 when mycobacterium tuberculosis – the pathogenic bacteria which causes the disease – was discovered the Nobel Prize winning scientist Dr. Robert Koch.

To honour the 135th anniversary of Koch’s breakthrough on March 24, 2017, Health Issues India has had the opportunity to interview Madhukar Pai, MD, PhD, Professor of Epidemiology at McGill University in Montreal, Canada. Through his research, Dr. Pai has been extensively involved in efforts to combat TB worldwide. HII is thrilled to have his perspective on the effects of TB in India and on healthcare in India in general and the work that he does. Like our previous interviews with health leaders in India, Dr. Pai answered standard questions in three sections: on his views on health, his area of expertise (immunisation, prevention) and on his work. Each interviewee can, of course, refuse to answer any question but they can’t re-write the interview.

Section A

We would like to get your views on the status of health in India.

Health itself, sadly, does not seem to be a priority for India! This has to change first.

As I hinted above, I think the most vexing issue is the fact that India continues to under-invest in health. For decades, governmental expenditure on health has been one of the lowest in the world. It is currently at about 1·4% of the GDP, far behind many low income countries, and not even close to the 2.5% that has been suggested in the National Health Policy. We have a massive problem of malnutrition even today, and half the population lacks access to toilets.  These realities conflict with the economic growth story.

Despite the overall low investment in health, India has made impressive progress in some areas.

India has been polio-free for over five years, and this success has provided huge momentum to global efforts to eradicate polio. Indian drug manufacturers dominate the production of generic TB and HIV medications, accounting for more than 80% of the global market. The recent launch of a rotavirus vaccine produced in India has underscored the country’s potential for a leadership role in childhood immunization.

India has wonderful capacity for IT and tech. India has scores of talented, smart health professionals who are globally recognized.

I recently visited both South Africa and China. South Africa has done a wonderful job in dealing with TB and HIV, with serious scale-up of anti-retroviral therapies; TB innovations such as GeneXpert and bedaquiline; and a wonderful leadership role by their health minister on the international stage.

China has made mind boggling progress in health. Their Global Burden of Disease profile now resembles North American countries. TB is not even in their top 10 causes of death. China is also emerging as a heavyweight in medical research, biotechnology, genomics, and medical technologies.

Future citizens of India would wish that they had held their political leaders more accountable for providing basic, essential services, including universal health coverage.

I think the dramatic expansion of mobile telephony, ICT, and digital innovations are big societal trends and could have a big impact on health (as well as other aspects of life).

More than any new technology (or magic bullet!), I think the biggest impact will come from investing in health, strengthening primary care, and ensuring universal health coverage for the poor and vulnerable.

Section B

These next few questions are on tuberculosis and related fields in India.

TB kills more people today than HIV and malaria combined. In 2015, there were an estimated 10 million new TB cases worldwide and 1.8 million TB deaths. And India is the epicenter of this global epidemic!

India accounts for 27% of the world’s 10.4 million new TB cases, and 29% of the 1 million TB deaths globally. India also accounts for 16% of the estimated 480,000 new cases of multidrug-resistant TB. So, yes, we should all be worried about TB. It is, after all, an airborne infection that anyone can contract. Increasingly resistant patterns of TB have been reported, especially it seems, from Maharashtra.

Since the results of the national drug-resistance survey is not yet available, nobody knows the actual number of drug-resistant TB cases in India. WHO estimates that India had about 80,000 cases of drug-resistance TB during 2015.

But there are clear signs that severe forms of drug resistance have emerged, at least in some hot spots such as Mumbai. The most common form of drug-resistant TB in India is multi-drug resistant TB (MDR-TB), which refers to TB that is resistant to isoniazid and rifampicin, two of the most important first-line antibiotics. While MDR-TB is severe enough, hospitals in Mumbai have reported even worse forms of drug-resistance – what they called ‘totally drug-resistant tuberculosis’ (TDR-TB) – suggesting that this form of TB was incurable because of resistance to all the TB drugs tested.

Drug-resistance is a sign that quality of TB care is suboptimal. Indeed, several studies show complex care seeking pathways, long delays in diagnosis, under-use of microbiological tests widespread empirical management, and poor adherence to TB standards. Thus, poor quality of care, in both public and private sectors, increases the risk of drug-resistance and mortality. Persons with TB must take medications without stopping. Otherwise, TB bacteria can become resistant to the common, first-line drugs that are used. This usually happens when patients do not complete their full course of treatment; when doctors prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs. Drug-resistance can also emerge when the supply of drugs is not continuous; or when poor quality drugs are used.

It is worth comparing China’s TB situation with that of India. China had 0.9 million TB cases in 2015, while India had over 2.8 million. The number of drug-resistant TB cases in China was 57,000 while India was estimated to have over 79,000. TB is no longer a major killer of people in China and does not make the top 10 most important causes of death.

It is remarkable that China more than halved its TB prevalence over the last 20 years. Marked improvement in quality of TB treatment, driven by a major shift in treatment from hospitals to the China CDC public health centers (that implemented the DOTS strategy) was likely responsible for this effect, which has been demonstrated by repeated national TB prevalence surveys.

India needs to go beyond ‘coverage’ of TB services, and work hard to improve ‘quality’ of TB care, in both public and private sectors.

Enormous quantities of anti-TB drugs are used in the private sector, underscoring their importance and scale. India’s TB control program must begin to recognize the role of the private sector and start engaging with it more meaningfully.

Although implementation of the RNTCP resulted in an increase in patients seeking care in public facilities, several patients still initially seek care in the private and/or informal sector or get bounced between the private and public sectors. India is conducting pilot projects with Private Provider Interface Agencies in Mehsana, Mumbai and Patna and have shown that notifications from the private sector can be dramatically increased, with improvements in quality and patient outcomes.

So, lessons from these projects can be used to develop a comprehensive plan to engage with the private sector to improve quality of care, and better regulate this sector. The new NSP does a great job of outlining such a vision. I hope funding will follow.

We recently published the first simulated patient (mystery client) study to understand how pharmacies in three Indian cities treated patients presenting with TB symptoms or diagnoses and to determine whether these pharmacies were contributing to the inappropriate use of antibiotics.

We showed that pharmacies frequently dispensed antibiotics to simulated patients who presented with typical TB symptoms, and they rarely referred persons with classic TB symptoms to doctors (and this can delay the diagnosis of TB). However, none of the pharmacies dispensed first-line anti-tuberculosis drugs (which is good news).

The use of all antibiotics and steroids (which can be harmful to individuals who actually have TB), as well as the total number of medicines given, decreased sharply when the pharmacy staff decided to refer the patient to a doctor, which was far more commonly done when the patient presented with a lab test confirming TB, thus making the diagnosis apparent to the pharmacist. These findings can inform interventions to engage pharmacies in TB control and initiatives to improve protect antibiotics from misuse. With nearly 800,000 chemists in every corner of India, we absolutely must harness them for identifying people with suspected TB and get them linked to testing.

The Government of India announced its plan to eliminate tuberculosis (TB) by 2025 during the Union Budget address last month. The declaration is extraordinarily ambitious. Last month, the RNTCP also published a draft of a new National Strategic Plan (NSP) for TB Elimination 2017-2025.

This plan is very bold, progressive and comprehensive. There are clear plans to address gaps in the cascade of care. While I am excited to see the high-level political commitment and an ambitious NSP, my biggest concern is how India can go from rhetoric to real progress? Historically, India has promised a lot in this area, but not delivered because of poor investment and weak implementation. The best summary of this is in Sujatha Rao’s new book “Do we care?”.

The new NSP, if approved, funded, and fully implemented might be a game change in the fight against TB in India. It is extraordinarily ambitious and quite comprehensive. But the price tag is steep – The cost of implementing the new NSP is estimated at USD 2.5 billion, a steep increase over the current budget. Historically, despite being a highly cost-effective program, and despite having a high absorptive capacity, RNTCP has struggled to receive funding that is commensurate with the scale of India’s epidemic.

This simply cannot continue. India has to start backing its ambitions with dollars. Only then can India realize its potential to take the lead on TB elimination.

I am sure patients with pulmonary TB struggle to breathe in highly polluted cities, but I don’t have a clear answer on the type or magnitude of the effect. We know smoking and indoor air pollution are both associated with TB. But there is not a lot of evidence on how outdoor air pollution affects TB. I think this is a great area for research.

There is definitely great potential for mHealth and ICT tools to leap-frog some big traditional barriers. We are already seeing signs of this in the private sector pilot projects in India.

Section C

We would like to know about your work.

I was born and raised in India. After completing my residency training at the Christian Medical College in Vellore, India, I did my PhD in epidemiology at University of California at Berkeley (CA, USA), and a postdoc fellowship at University of California San Francisco (CA USA). In 2006, I joined McGill University as an Assistant Professor, where I received early tenure in 2011. In 2013, I became the Associate Director of the McGill International TB Centre, and in 2014, I became the Director of McGill Global Health Programs. In 2015, I was promoted to full Professor, with a Canada Research Chair in Epidemiology and Global Health. I worked on tuberculosis as a resident in Vellore, and then continued working on TB for my doctoral dissertation at Berkeley. I have continued that work since.

My research program is focused on improving the diagnosis and treatment of TB, especially in high-burden countries like India and South Africa.

We do a lot of work in the area of TB diagnostics, including validation of new tools, synthesis of evidence on diagnostics, supporting the development of policies and work to improve access to good TB tests. For example, in India, we partnered with the Clinton Foundation and the Bill & Melinda Gates Foundation to create the ‘Initiative for Promoting Affordable and Quality TB Tests’ (IPAQT). The Initiative aimed to make WHO-approved TB tests 30–50% more affordable than market prices so they could reach more patients. Thanks to this unique initiative, over 142 private laboratories are engaged, and nearly 500,000 patients have received WHO-approved TB tests.

We helped establish national and international standards for TB care and set benchmarks for quality TB care. Moreover, we developed a novel method for measuring TB care using simulated (mystery) patients. Insights from this work helped uncover that private providers in India underutilize TB tests, even when simulated patients present with typical TB symptoms; and highlighted a big gap between what doctors know about TB versus what they actually do in real practice. This approach is now being adopted by other countries.

Even as a kid, I wanted to be a doctor. So, working in health has been a passion for ever. I don’t think there is anything about my work that I hate.

I think each of us needs a strong purpose or passion in life. I found my purpose in global health, and I want to make a positive impact in the area of tuberculosis control.

Folks working in TB tend to be much less ambitious than folks working in other areas, notably HIV/AIDS. There is a mindset issue that needs to change.

For a kid who grew up in Tamil Nadu playing cricket in the sun, I am now a big ice hockey fan, and can skate on the ice! I continue to enjoy cricket though.

I enjoy watching movies, reading, and, of course, cricket and hockey.

I have a terrific, secure, tenured job at a leading university (McGill) which lets me pursue my global health work. I care a lot about India and work hard to give back. I visit India about 4 times a year for my TB work, and feel very connected to my roots. So, I think I have the best of both worlds.

Prof Madhukar Pai, MD, PhD is a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal. He is the Director of McGill Global Health Programs, and Associate Director of the McGill International TB Centre.

Madhu Pai did his medical training and community medicine residency in Vellore, India. He completed his PhD in epidemiology at UC Berkeley, and a postdoctoral fellowship at the UCSF. Madhu serves as a Consultant to the Bill & Melinda Gates Foundation. He serves on the STAG-TB committee of WHO, Geneva; Scientific Advisory Committee of FIND, Geneva; and Access Advisory Committee of TB Alliance, New York. He has previously served on the Coordinating Board of the Stop TB Partnership. He is on the editorial boards of Lancet Infectious Diseases, PLoS Medicine, eLife, PLoS ONE, International Journal of TB and Lung Disease, among others.

Madhu’s research is mainly focused on improving the diagnosis and treatment of tuberculosis, especially in high-burden countries like India and South Africa. His research is supported by grant funding from the Gates Foundation, Grand Challenges Canada, and Canadian Institutes of Health Research. He has more than 300 publications. He is recipient of the Union Scientific Prize, Chanchlani Global Health Research Award, and Haile T. Debas Prize. He is a member of the Royal Society of Canada.

Twitter handle: @paimadhu

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