Stephen Lewis is an outspoken and often impassioned Canadian diplomat and former United Nations official with a lot of experience in tracking health crises in Africa. Now he has turned his attention to tuberculosis in India, where he made a fact-finding trip in early October. He was shocked and disheartened by what he saw and heard.
India’s goal of eliminating TB by 2025 “is aspirational mythology,” Lewis wrote in a report released Oct. 27. “India faces a tuberculosis crisis of monumental proportions.”
In a week of meetings in Delhi and Mumbai with Indian government health officials, visits to public and private hospitals and talks with doctors, lawyers and representatives of independent American foundations and other nongovernmental organizations, Lewis was accompanied by senior staff from the United States Centers for Disease Control and Prevention. He acknowledged, however, that in this short initial visit he could only “scratch the surface” but he absorbed considerable context.
“First, the health sector in India has been starved for resources for twenty years,” he wrote in his report. “This pulverizing under-investment compromises every effort to come to grips with tuberculosis. The health systems are so fragile, so overburdened, that it’s simply not going to be possible to subdue TB in the way the government pretends.”
Lewis noted that in 2016 health was allocated 1.3 percent of GDP. Even with an increase this year to 2.5 percent, this was too little for the overwhelmed health sector.
“Not enough attention is paid to that simple economic reality,” Lewis wrote. “It’s as though endlessly repeating the mantra of good intentions is enough. It’s not. You can’t embrace success when the foundations of the public health system are perilously frayed with neglect.”
One percent a year for 20 years, he added, “is a gross rebuke to the health of the nation.”
India, with about 1.3 billion people — the next census is not due until 2021 — falls well behind China in health budgeting and outcomes. This week the Chinese president, Xi Jinping, announced his intent to put more government effort and money into filling persistent gaps in services.
Worldwide, India accounts for 27 percent of new cases of tuberculosis, or about 2.8 million, and 29 percent of the deaths, some 900,000. “It’s a plague that haunts the nation,” Lewis wrote.
In an exclusive interview with PassBlue on the eve of the publication of his report, Lewis said that India had some success in dealing with tuberculosis cases that respond to traditionally used medications and treatment regimens. A national strategic plan exists to defeat tuberculosis over the next seven years; GeneXpert machines to test for the disease are appearing in the country; and two new drugs, Bedaquiline and Delaminid, are scheduled for broader use in cases of drug resistance.
But Lewis also said that India’s health systems — public and, increasingly, private — are not prepared for the spread of multidrug resistance and what is known as exceptional drug resistance (MDR and XDR). “I want, with all my heart, to believe that this picture of achievement is real,” he wrote in his report. “But I am seized with incredulity.”
South African experience and analyses have determined that the two multidrug-resistant forms of TB are not necessarily advanced stages of an existing lower-grade infection, but can be transmitted directly to infect people at higher, more serious levels.
“So the phenomenon of having the most drug-resistant concentration in the world in India is very frightening, because it’s such a massive population,” Lewis said. “It can be transmitted through the air like normal TB, and there are very large numbers.
Tuberculosis is a bacteria commonly spread from person-to-person through sneezing or coughing. The airborne bacteria most often affects the lungs but it can also affect other parts of the body. Lewis said that “latent” tuberculosis is lying in wait in a third of the national population.
“Drug resistant TB is out of control,” he wrote in his report.
As for Lewis and his association with the UN: from 1984 to 1988 he was Canada’s ambassador to the UN after serving as a labor mediator and broadcaster in Canada. From 1995 to 1999, he was deputy executive director of Unicef, and from 2001 until 2006, he worked as the UN special envoy for HIV/AIDS in Africa under Secretary-General Kofi Annan. In an interview [with me] during that period, he said how much that role had made him focus on women’s rights as well as HIV-AIDS because of the vulnerability of millions of African women without power over their lives and reproductive health choices.
In 2007, Lewis and Paula Donovan, a former Unicef and Unifem official with extensive experience in Africa, who had also been on the UN special envoy’s team, created AIDS-Free World, a nongovernmental organization that has grown into a human-rights advocacy group. It covers such issues as sexual violence, gender discrimination and the criminalization of HIV. Most recently, the group has garnered international attention by investigating and reporting on sexual abuse and exploitation in and around UN peacekeeping missions.
On his trip to India, Lewis was joined by another colleague from AIDS-Free World, Georgia White, a research and policy associate. A few months earlier, they traveled to Nunavut, a semiautonomous territory stretching across most of the Canadian Arctic, created in 1999 for the Inuit, the indigenous people of the region. In Nunavut, Lewis and White were also studying the high levels of tuberculosis, which Lewis wrote about in a separate report. (A third TB-related trip in planned for South Africa in early 2018.)
“Both in Nunavut and India, they talked about those factors of overcrowding in housing and poverty and nutrition and all of the things that lead to the spread of diseases,” Lewis said in the interview with PassBlue after the India trip. “That was a commonality,” he said, despite the hugely different populations and cultures of the two places.
What was different was the urgency, or lack of it, he found in India among health officials.
“The social determinants of health lie in tatters: homelessness, overcrowding, poor nutrition, food insecurity and excruciating poverty, taken together, constitute a death knell for public health,” he wrote in his India report. In it, he described meetings with children lying three-to-four in beds in a pediatric hospital that did not separate those with tuberculosis from those with other illnesses.
He wrote in detail about the story of Shreya, a teenage girl who was denied treatment with Bedaquiline for any number of specious excuses and ploys, until Anand Grover, director of the Lawyers Collective in India, took her case to court — and won. Grover is a practicing advocate before the Supreme Court of India and adjunct professor at Georgetown Law in Washington, D.C. Shreya was saved not by the health care system but by a court.
The doctor who had kept Shreya alive was Zarir Udwadia, who first wrote, in the British medical journal The Lancet in 2012, that India could be facing totally resistant strains of tuberculosis. But that did not make him a hero in Indian medical circles.
“When I raised Udwadia’s name in conversation with very senior officials of the Ministry of Health . . . the reaction ranged from derisive smirks to dismissive contempt,” Lewis wrote.
In the interview with PassBlue, Lewis spoke of the paradoxes of India and ironies in an Indian leadership that always sees the country on the cusp of global greatness. Yet in social policies, the current Hindu nationalist government of Narendra Modi has been no different than the relatively secular Indian National Congress party that it replaced. “There is this great resistance to admit what’s gone wrong.”
“India has Amartya Sen, a Nobel winner, who talks so thoughtfully about the public sector and about the importance of health, education, nutrition, et cetera, and it has Tamil Nadu and certain other states where there were very progressive policies,” Lewis said. “But on balance, neither the Congress Party or Modi over the last couple of decades has cared much about health or education or water or nutrition — these very important so-called soft sectors, without which you can’t have a secure society.”“