China now has the second largest tuberculosis epidemic -second only to India- with more than 1.3 million new cases of tuberculosis every year. What makes the situation particularly serious, however, is that, according to the Chinese Center for Disease Control, China has the largest number of patients with Multiple Drug Resistant Tuberculosis (MDR-TB), and that Extremely Resistant Drug Tuberculosis (XDR-TB) is also widespread. These facts show the need to step up efforts to combat the disease.
In 1993, the World Health Organization (WHO) instituted a cost-effective treatment of tuberculosis called DOTS (a directly observed treatment of a short course of drugs) that was very effective in combating TB in low-income countries. However, over time, patients began developing resistance to the drugs used for treatment, causing MDR-TB to spread.
Less than one-quarter of those believed to have MDR-TB have been diagnosed, according to the WHO, which facilitates the spreading of this serious form of the disease. “We have managed by a combination of complacency and incompetence to allow this bacillus to mutate to a virtually untreatable form,” wrote Dr. Zarir Udwadia, an Indian world expert on tuberculosis and author of the book Principles of Respiratory Medicine.
Tuberculosis becomes resistant to drugs in patients who don’t complete the treatment. The current treatment for non-resistant tuberculosis is relatively cheap and consists of drugs called first-line drugs for TB. In MDR-TB the patient is resistant to at least the two most powerful anti-TB drugs. This form of the disease is much more costly to treat, and it is also much more toxic (it has more serious side effects), which explains patients’ reluctance to complete the treatment.
China has a large migrant worker population who leave the countryside to join the wage economy in China’s main towns and cities. Many of them practice unprotected sex and contract HIV/AIDS, which weakens their immune system and makes them more susceptible to tuberculosis. In addition, they live in circumstances that facilitate the transmission of the disease and impede their diagnosis and proper treatment.
Many of these migrant workers cannot afford the cost of treatment in the cities and have to return to their place of birth, because subsidized management of tuberculosis (and other kinds of social welfare benefits) is only allowed in those areas where they were registered at birth. Those migrants who were born in rural areas are not allowed to switch registration to become urban residents. Returning home for care is not the ideal solution because the rural health system doesn’t have the same quality as the one in the cities.
Although tuberculosis control has been part of the country’s public health program since the 1950s, it is only after the SARS epidemic in 2003 was effectively controlled that the Chinese government increased its efforts to revitalize its tuberculosis control program. In that regard, increased political commitment to public health as a result of the SARS epidemic benefited tuberculosis control.
In March 2004, the government revised the law on control of infectious diseases providing instructions on how to tackle, improve the reporting and implement interventions aimed at the control of those diseases. This law benefited tuberculosis control by improving the reporting of tuberculosis at health facilities across the country. As a result, tuberculosis must be reported to local public health authorities within 24 hours of detection.
In January 2004, the Ministry of Health implemented the world’s largest internet-based communicable-disease reporting system, which allows tuberculosis patients to be rapidly identified to ensure their proper treatment. In addition, the government started a massive effort to improve public health facilities.
Despite those efforts, however, more needs to be done in terms of training health workers to implement the DOTS, improving the recording and reporting systems and increasing awareness about the dangers of the disease. Also important is to control the increasing numbers of MDR-tuberculosis patients. According to the WHO, China has a third of the world’s number of cases of MDR-TB, even though the country has only 15 percent of the global burden of disease.
To lower the prevalence of tuberculosis, particularly in its resistant forms requires further improvement of the public health system. So far, considerable progress has been achieved. The estimated prevalence rate of tuberculosis per 100,000 people fell from 215 in 1990 to 59 in 2013, and its mortality rate declined steadily at an average rate of 8.6 percent between 1990 and 2010. China now has the opportunity and obligation to continue these remarkable achievements.
Dr. Cesar Chelala is an international public health consultant and a co-winner of an Overseas Press Club of America award.