India: As the middle class rises, so does tuberculosis

NEW DELHI, India — When Fatima's doctor told her that she wasn't suffering from ordinary Delhi belly — her stomach cramps and diarrhea were caused by tuberculosis — her biggest fear wasn't the dreaded disease. With her marriage still impending, the 29-year-old, middle-class resident of Kolkata was afraid that her secret would get out, said Dr. Raja Dhar, a physician at the West Bengal city's posh Fortis Hospital.

“The first thing she told me was never to tell anyone that she had TB,” said Dhar, who explained that the young IT professional feared her impending marriage would be scuttled if people came to know of her infection — even though she was eventually cured.

Despite her shame, Fatima — whose name was changed for this article to preserve her anonymity — is in good company.

Although tuberculosis is still associated with poverty, malnutrition and crowded living conditions in India, the disease is endemic among rich and poor, Dhar said. Among the affluent, it has simply been lying in wait, only to emerge when the immune systems of the new rich are compromised by the same stress factors that are causing an increases in “lifestyle related” problems like type 2 diabetes and heart disease.

“In a country where tuberculosis is more or less endemic, you have latent TB present in the body that does not manifest because you have a good immune system,” Dhar said. “But if the immune system goes down, the time is ripe for the TB to actually flare up.”

According to the World Health Organization, the total number of TB sufferers has steadily declined in South and Southeast Asia over the past decade, but the region still accounts for a third of the world's total TB patients — with more than 3 million cases added every year, mostly from India. And just as the disease made a resurgence in America in the 1990s, thanks to immune system complications associated with HIV/AIDS, in at least one respect the problem is getting worse.

Working at an upscale, private Indian hospital for the past two years, Dhar said that around 70 percent of his TB patients are middle-class or affluent professionals — many of whom react with anger or disbelief when they hear his diagnosis. And looking back at hospital records and discussing the rate of incidence with doctors in other cities, he estimates that the number of wealthy people contracting TB has risen about 20 percent in recent years, even as the number of poor patients has dropped. Meanwhile, local press reports say the number of TB patients from higher income families have doubled in the last three years in Delhi hospitals.

Though TB is better known as the debilitating lung ailment, once called consumption, which affected writers like the Romantic era poet John Keats, India's affluent sufferers are mainly falling victim to lesser known versions of the disease that strike the stomach, heart or even bone. That makes sufferers even less likely to think they have TB, and also makes it harder for doctors to make the right diagnosis.

“More than the rate actually going up in affluent people, I think it may be just that people are realizing that TB is affecting everyone, not just the really poor,” said Dr. Madhukar Pai, a McGill University-based researcher who works with WHO's Stop TB Partnership program. “Awareness about TB may be higher, especially with rumors about Bollywood celebrities being affected.”

But even if TB has scaled the society columns, it still carries a powerful stigma. Not long ago, film star Amitabh Bachchan was compelled to issue a public denial when press reports circulated claiming that his daughter-in-law, Bollywood's Aishwarya Rai, was suffering from the same type of TB that Fatima hid from her parents and fiance.

That, too, makes a disease that should be easily cured more difficult to treat, according to Dhar. Most TB cases can be cured easily if the victim seeks medical treatment early in the disease's progression, and their doctors get the diagnosis right and prescribe the right treatment. But the more fear and shame associated with TB, the less likely that is to happen.

“There is a far greater taboo about people in the affluent class saying that they have TB,” Dhar said. “It's like having leprosy years ago.”

In that respect, some high-profile Bollywood victims — if any are willing to rise above ignorant perceptions about the disease – could be a huge boon, said McGill's Dr. Pai. Just as Hollywood stars and professional athletes helped reduce the fear and stigma surrounding HIV, a few rich and famous Indian TB patients could revolutionize the fight as new, drug-resistant strains of TB increase fear of the illness worldwide.

With a new molecular diagnostic test, called Xpert, available, India could eliminate its persistent problem with erroneous false-positives, provided it could roll out the new test to thousands of laboratories that today report as many as 1.5 million inaccurate results every year. And four new vaccines are in late-stage trials, setting the stage for a massive eradication campaign — if somebody will step up to the plate.

“Rich Indians have done almost nothing for TB in India,” Pai said. “No major philanthropic groups or donors or industries have taken on the TB challenge in India. Politicians and Bollywood stars and cricket celebrities have largely ignored the TB problem.”