Introduction

COVID-19 has disrupted life across India as we know it. Controlling the pandemic has impacted other health services and comorbidities of which tuberculosis (TB) is the most significant. With similar clinical symptoms, TB and COVID-19 present a deadly mix for India’s health system. TB, though curable, remains India’s severest heath crisis killing over 1200 Indians every day. TB services have been widely disrupted leading to delays in diagnosis, treatment, access, increased suffering, and mental health problems in those affected. The author examines the impact, implications, and possibilities that exist for addressing these twin epidemics. The lived experience and narratives of TB-affected individuals are examined. Systemic challenges are documented. And, alternatives and ways ahead to address these epidemics together are explored—as India and the world comes to terms with living with COVID-19.

The Emergence of COVID-19 and Its Impact on Health Care and Populations

Toward the end of 2019, news from China revealed that infection with a novel coronavirus was resulting in pneumonia cases in Wuhan city [1]. While unexpected and unnoticed, it spread alarmingly resulting in an epidemic throughout China. As the world came to grips with its lack of understanding and knowledge about the virus, new cases began emerging globally and soon an ever smaller, connected, and globalized world became even smaller and more vulnerable as it grappled with an emerging global public health crisis. Recognizing the growing pandemic in February 2020, the World Health Organization (WHO) designated the disease as COVID-19 which stands for coronavirus disease 2019 [2]. The virus that causes COVID-19 was designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Several months later, the world is reeling under this unprecedented pandemic, and science and understanding of COVID-19 are still evolving. Interim guidance has been issued by the WHO and by the United States Centers for Disease Control (CDC), but the world is only slightly better prepared to face this pandemic [3, 4]. Our understanding of transmission has improved, but COVID-19 remains largely incurable. It was initially thought that certain drugs such as Remdisiver may be effective in addressing some of COVID-19’s complications and reducing mortality. This, however, was disproved by the recent results of the Solidarity Therapeutics Trial [5].

Globally, about 37 million confirmed cases of COVID-19 have been reported [6]. This number is believed to be an under-estimate. Based on sero-prevalence surveys in the United States and Europe, this figure may be much higher if we account for potential false positives and false negatives. In countries across the world, the overall prevalence is expected to be much higher as the number of cases is a function of the testing done [7].

The world and countries like India are reeling under the growing COVID-19 crisis as it threatens to destroy lives, economies, and even global trade [8, 9]. Countries have been forced to look inwards. But while the impact on global trade, and hence on long-term global incomes, is yet to be adequately understood, the outcomes of the disease seem devastating. The World Bank estimates a baseline forecast envisioning a 5.2% contraction in global GDP in 2020. This indicates the deepest global recession in decades, despite the efforts of governments to counter the downturn with fiscal and monetary policy support [10].

Impact on the Health System and the Population

COVID has dislodged the entire health system in low- and middle-income countries (LMICs). Its impact has been felt more severely and acutely in LMICs as in these countries health system infrastructure is weak, overburdened, and fraught with limitations. Alongside, several health crises have been persisting resiliently in countries like India and other LMICs.

Clearly, the health system has been caught largely unprepared for this crisis [11]. Its impact has been significant across the system in both the public and private sectors [12]. The crisis has exposed the inability of the health systems in the LMICs to cope with an epidemic of this magnitude [13]. What has also emerged is the inability of these countries to simultaneously address pre-existing health challenges and programs on an ongoing basis. Hospitals, health centers, and clinics in many cases, already overburdened around the world, have been further impacted by the increasing influx of COVID-19 patients—dislodging all others.

The pandemic has unleashed one of the most complex global health crises in recent history which has exposed the lack of health system preparedness. This lack of preparedness is visible at multiple levels where it has systemic [14], organizational, human resource, and capacity-related challenges [15]. At a deeper level, these are political and represent, in several LMICs, a neglect of investment in population health [16] and a lack of democratic accountability.

There are also clinical and research challenges, and the capacity to address these is limited. At a fundamental level, there are deeper ethical and moral challenges. And, strategies for managing population health are less prevention-led and more treatment-led [17, 18]. This is evident in the large-scale neglect of the social determinants of health in countries like India where there is a lack of health system preparedness and poor infrastructure [19,20,21]. There has been an apathy to address the more fundamental population health problems. Thus, there are short-, intermediate-, and longer-term challenges which have been exacerbated by the crisis.

A single strategy seems unworkable to respond to this crisis. Clearly, different strategies and evidence-based perspectives are needed. These need to be from multiple disciplines including health research, public health, epidemiology, sociology, behavioral sciences, management, and economics. What is sorely lacking is the capacity of the health system. Managing the COVID-19 crisis is about integrating it intrinsically into healthcare governance [22]. We need to redefine our health planning, funding, and manpower strategies. COVID-19 has compelled us to re-examine our health system and also re-evaluate health services. We also need to ensure the accountability of the health system [23].

Challenges due to COVID-19 exists at the level of population health [24]. We are currently witnessing the short- to medium-term impacts of COVID-19. We have yet to adequately understand the long-term implications of its residual impact on cured populations [25]. There is also the immediate task of simultaneously addressing other health concerns of the population.

As health systems have put in efforts into managing this pandemic globally, they have diverted focus, personnel, critical resources, and points of access from several other prevention, health promotion, and treatment services [26]. This is combined with the perennial shortage of health workers in most LMICs and with panic, fear, and risk perception among populations. The outcome is that large numbers of people do not access healthcare [27, 28]. Most efforts are targeted to the pandemic and so many do not seek health care for their problems [29]. Essential service are not being used [30]. The capacity of the health system and, in particular, of government facilities has become a political wrangle among stakeholders because of the lack of hospital beds and intensive care units (ICUs) in India [31]. In some instances, the state has strengthened services with equipment and staff [32]. This, however, has not been a uniform phenomenon in all countries. The fear of COVID-19 has caused collateral damage. In the private sector, procedures such as coronary stents, knee replacements and others are not being conducted [33].

Insufficient healthcare infrastructure and human resources and rising case load of infections along with serious supply chain disruptions has resulted in fatigue, frustration, and anger in the health workforce and the clients [34]. It has also created an atmosphere of fear among patients and healthcare workers. This has led to stigmatization, compromised ability to provide in-patient care, and declining safety standards during the pandemic [35]. Another serious gap is the lack of reliable and adequate information. The lack of scientific facts and information on disease progression, and how we expect the disease to spread, has impacted country-level responses [36, 37]. This in turn has led to inappropriate community-level and individual-level responses and behaviors. The outcome is that this virus is defeating even the best prepared scientifically advanced nations resulting in an inadequate response of the health system at national and global levels. There has also been a significant negative impact on other health programs [38].

In India, the public sector and its resources are being pre-dominantly re-directed toward COVID efforts. Evidence of this is visible in the shortage of beds, doctors, and health workers. Perhaps the most impacted are the ongoing programs including immunization, women’s health, cancer, and tropical diseases among others.

Immunization has been gravely impacted in India [39]. An almost unending lockdown ensured that the immunization programs in several regions were interrupted and continue to be so. It is the apprehension of many that around 80 million children globally and a substantial number in India are at risk of contracting diphtheria, polio, and measles. The numbers in India are yet to be modelled. The re-location of health workers for COVID-19 care in countries like India has led to immunization services being neglected and, in some cases, virtually stopped. Fear of infection has prevented people from pro-actively seeking immunization for their children. Where the impact of lockdowns is less severe, health workers are being re-directed to handle the pandemic by contact tracing, testing, and quarantining. It is unmanageable for them to also implement immunization programs [40].

Many cancer centers have reduced their services after initial reports from China that indicated that COVID-19 outcomes were worse among patients with cancer. In some cases, like the Tata Memorial Centre (India’s largest cancer center), even though operations were scaled down they continued to provide care. This, however, is not the case across the country [41, 42]. It is unclear whether this is due to increased susceptibility of cancer patients to COVID-19 or because they are more likely to be in contact with COVID patients due to their frequent hospital visits. These issues need to be evaluated.

Women’s health has possibly been most compromised during the pandemic [43]. There are a combination of factors—social determinants, women’s lack of agency, their inability to seek care, and a gender-unfriendly health system, particularly in rural India. Consequently, the incidence of caesarean sections is reported to have declined.

The private sector, which has been engaged in the COVID-19 response in India, has had both challenges and successes. The private sector is witnessing a loss of business, and this trend is expected to continue in the foreseeable future [44]. A significant section of its services has been redirected towards COVID-19 care. The anticipated losses and severe impact on cash flows are being turned into a possible revenue generation stream. There have been some reports of unethical practices in a bid to make up the losses. There is evidence that huge bills, often under unclear and misleading cost, are generated.

TB and COVID-19 in India

The COVID crisis is receiving significant media attention. Its impact has devastated our population, our economy, our freedom, and our minds. We are made to be believe that COVID-19 is our severest crisis [45]. Forgotten in this hyperbole is that numerous other diseases continue to devastate India’s population. Of these, the most persistent and significant is tuberculosis [26].

Despite an extensive national program and a vast private sector, India continues to bear the highest burden of TB in the world, accounting for an estimated 2.8 million cases every year and killing more than 400,000 persons annually [46]. There is also a high burden of drug resistant TB (DR-TB).

The Impact of COVID-19 on TB in India

The TB program and has been badly hit during the COVID-19 pandemic [47]. On-the-ground investigations and reports reveal that both diagnosis and treatment have been affected. Drug-sensitive and drug-resistant TB patients were  unable to access medicines. Until India ordered bidirectional screening for TB and COVID, diagnosis was suffering badly. This has put both diseases in jeopardy and has likely increased the transmission of infection. The lack of transportation has restricted patients’ ability to access health centers to receive medical services and medicines.

Diagnosis

TB-affected individuals, especially those suffering from pulmonary TB, were not visiting laboratories and hospitals because they were  frightened of getting COVID-19. Moreover, those advised crucial drug susceptibility testing (DST) were  either not getting it done or, in several cases, it is not happening easily. Patients were  also unable to collect their test reports. This is deeply problematic as TB notifications for new cases was  falling consistently [48]. By some estimates, there are close to one million missing TB patients in India. This number will rise in all likelihood and become a challenge for case detection and initiation of early treatment [49].

Economics and TB

With the loss of jobs in an already slowing economy, patients and their families are getting desperate because of insufficient nutrition. Due to the lockdowns, consistent migration and losses in the informal economy, and food insecurity, nutritional levels are bound to fall which is likely to increase hunger. This will have a long-term impact on immunity levels. A proposition to consider here is the activation of TB disease in otherwise latent cases who would not have otherwise added to India’s TB cases. There have also been numerous instances of the non-receipt of direct benefit transfers (DBT) under the Nikshay Poshan Yojana, a nutritional support scheme which gives a monthly sum of Rs. 500 to TB affected individuals to meet their nutrition and food requirements [50]. Poor nutrition forces those from economically weaker sections of society back into poverty and debt and puts them at risk of increased mortality due to TB [51]. A loss in income will also in all likelihood impact healthy behaviors like early care-seeking and diagnosis and will, thereby, increase the transmission of infection.

Treatment

The COVID-19 pandemic and lockdowns along with their impact on the health system and economy have also had a significant impact on TB treatment. At a macro-level, health system resources have been re-organized and re-directed towards COVID-19 care leading to shortfalls in TB care. Increasingly, there have been reports of non-availability of drugs in both the public and private sectors [52]. Also, access to new drugs such as Bedaquiline and Delamind is bound to reduce during this time leading to increased challenges for the treatment of multidrug resistant (MDR) TB [53]. Also, without supportive supervision and other forms of monitoring and support, treatment will be affected. The worst affected are drug-resistant TB patients who are on regimens of injections. Injections have to be administered by health workers who are either unavailable or not easy to reach because of limited transport facilities [54]. The lack of access to health services has also brought up issues related to the management of adverse drug reactions and comorbidities.

Workforce Challenges

A large section of the TB workforce has been re-directed toward COVID-19 care. This has caused significant delays in active case finding at the community level, and so decrease in diagnosis, notifications, and treatment. There have been numerous reports from the ground indicating that patients on treatment are finding it challenging to contact their healthcare providers, reach hospitals, and health workers to get treatment, support for adherence, side-effect management, and a host of other issues [55]. As many health workers in remote areas, such as accredited social health activist (ASHA) workers, are re-directed to COVID-19 work, patients that require medicines and follow-ups for TB have no recourse.

Mental Health

India has not been addressing mental health problems that are common in TB patients [56]. People with mental health problems are at an increased risk of exposure to TB infection due to homelessness, smoking, poor nutrition, and comorbidities such as HIV [57]. Also, several anti-TB medicines like Cycloserine for drug-resistant TB cause mental health problems such as anxiety and psychosis. COVID-19 is exacerbating these problems [58]. Depressed patients are three times more likely to stop or give up on treatment due to side-effects than others. They are also more likely to delay seeking treatment. The result is drug resistance, increased transmission, and poor treatment outcomes.

Stigma

COVID-19 and TB symptoms are very similar. Both diseases are highly stigmatized. In TB, this stigma has been long-standing [59]. Stigma in TB manifests in two ways: (1) self-stigma which is a discrediting attribute that an individual acquires when going through a traumatic life-experience: This reduces the individual’s status and capacity in his own eyes and (2) social stigma which is more obvious and direct: TB patients face isolation, discrimination, and rejection within families and communities. Stigma also causes anxiety and fear of perceived or actual job loss, divorce or abandonment, and mistreatment within the family. Cultural ideas about TB associate it with socially unacceptable lifestyles and behaviors with particular reference to sexual behaviors, ‘dirtiness and promiscuity,’ alcohol, smoking, and ‘sins’ [60].

Gender disparities in TB are striking. While TB affects twice as many men as women, the brunt of social stigma disproportionately impacts women. There exist rampant incorrect notions about TB-related to fertility in women which leads to an increased and a severe form of stigma for women ranging from neglect to complete isolation. Examples of divorce, inability to marry a potential suitor, and challenges with in-laws are well documented. Since the health system is not responsive, many patients discontinued treatment.

Lack of Effective Communications

Throughout this crisis, a critical challenge has been the lack of reliable and effective public information and communication that engages credibly with the people and gives them helpful information. This is particularly true for TB-affected individuals and communities who have not been able to obtain reliable and accessible information on where to seek diagnosis and treatment, how to manage side-affects, and access government services or how to protect themselves from COVID-19. Instead, there has been confusion on the facts and most importantly on government support. This has affected patient morale and has also seen a fall in a number of patients seeking diagnosis and treatment, adherence monitoring, self-reporting, and managing of side-affects. One only needs to see the thousands of images of helplessness, hunger, and anger everywhere to realize this is not limited to TB patients alone. 

Lack of Integrating Gender and Sexuality in Care

Experiences globally and in India show that women are more hesitant to report their symptoms, have poorer access to health care, shoulder a heavier burden of running the household, and are at higher risk of malnutrition than men [61]. Moreover, trans individuals, non-binaries, and persons with non-heteronormative sexual orientation are less likely to report their condition as they face discrimination and abuse by healthcare authorities and are often given poor quality care or denied access to it altogether. These conditions are exacerbated for those seeking care for TB and living with HIV [62]. Members of the lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) communities report a higher incidence of HIV and other risk factors. As India and other countries struggle with COVID-19, the gendered aspect of the disease has been almost entirely ignored. The experience with TB in times of COVID-19 is unlikely to be different.

Addressing TB and COVID-19 Together

Addressing TB is determined by social, economic, cultural, religious, caste, and political factors. In this pandemic, charting a new course needs an understanding by decision-makers of these factors in the context of both diseases. The factors for TB have a strong bearing on COVID-19 infections as well. Hence, the two must work in tandem to navigate these complexities and competing priorities.

TB and COVID-19 are both airborne. Such airborne spread of TB and COVID-19 infection to others is most likely to occur with close contacts such as family members, friends, or those in school or at work. Overall, half of the untreated TB patients die of the disease, while others enter periods of re-mission and re-lapse that may last for decades. Current approaches to the pandemic do not even factor in the fact that India’s extensive TB burden combined with COVID-19 is a dangerous mix that can devastate large sections of the population.

Furthermore, as has been reported, that many more TB cases and now COVID-19 survivors have, in some cases, reduced breathing capacity due to scar tissue in their lungs and so have compromised lung capacity [63, 64]. Hence, issues arising post-cure also need to be considered. Some suggestions on how to address TB and COVID-19 jointly are provided here.

Prioritize Case Detection

Fever and cough are symptoms of both TB and COVID-19. This commonality can be leveraged to encourage simultaneous screening and provision of diagnostic services for TB and COVID-19 in both the public and private health sectors. The government has announced bidirectional screening for TB and COVID-19. However, its implementation remains unclear and efforts made in this regard are undocumented [65]. It is important that TB programs must expand their capacity and continue using the Xpert MTB/rifampin (RIF) TB test since this test is critical for early detection of drug-resistant TB. There is an urgent need for case finding for TB and COVID-19. This is important in high density as also high burden areas. Case finding is the first step which is followed by isolation and treatment of cases.

Address Treatment Challenges

India needs to address treatment challenges for ongoing and new patients both in the public and private sectors. All TB patients should be provided with at least 2 to 3 months’ supply of medications to minimize frequency of consultations at TB facilities. The TB program must carefully track and forecast supplies to avoid stock-outs [66]. India’s pharma industry has been gravely affected by the lockdown limiting the supply of essential medicines. India could explore setting up alternative medicine delivery networks such as courier services. It is critical for TB programs to switch to oral regimens recommended by the WHO. Access to new and novel adherence technologies and new drugs for TB must be increased in both the public and the private sectors.

Deploy Overarching Communication Plans

Even today, the most common fears among TB-affected individuals are around how they can self-protect, locate testing facilities, and obtain economic support. These insecurity and fear have been fed by an absence of communications from the state. There is an urgent need to prepare an overarching communication plan that helps with the delivery of the above-mentioned interventions. It should be planned and executed in a phase-wise manner. For starters, a comprehensive people-centered, focused information campaign that covers every aspect of these diseases from prevention, to where and how to access government support, testing, economic and food support, and health care in context of both TB and COVID, should be rolled out. There is a need to set up a communication strategy group in every district so that every query can be answered. False news should be stopped. It is important to engage with the media actively to provide information and answer queries about services available. In the absence of this, the authorities may end up feeding fear, stigma, and poor health-seeking behavior that will increase vulnerability. The need is to empower communities with information to help resolve their basic health, social, and economic concerns.

Initiate and Create Accessible Remote Treatment Support

With the fear of infection in clinical environments, on-site referrals for routine care should be replaced by remote support. This is particularly relevant for TB and COVID-19 patients in their quarantine site at home or in dedicated quarantine locations. This has created a dramatic impetus to find innovative ways to support patients remotely and effectively.

Create and Emphasize Community-Based Care

Capacity for community-based care is essential [65]. As community-based groups, including TB survivors, are generally closer to patients than TB program staff, they could be engaged to provide peer support via WhatsApp, social media, and mobile phones during the COVID-19 pandemic. This can be supplemented by technology based support by health workers in difficult terrains where access remains difficult and infrastructure is weak.

Engage Private Health Services

The private health sector in India includes a range of service providers such as quacks especially in rural areas and qualified allopathic doctors who are mostly found in urban areas. This private sector is the largest provider of curative care in India. According to the National Family Health Survey-4, over 60% of all Indians seek care from the private sector at some point or another. In the case of TB, this number remains reasonably high even though the government provides free treatment and diagnosis. There are numerous reasons for this of which ease of access and perceived quality of care are the leading ones. Clearly, TB in India cannot be ended unless the private sector is effectively engaged. This means that the government needs to employ new and innovative strategies to engage and work with the private sector, mobilizing both the public and private health sectors, as well as community-based groups in a collective COVID-19 and TB response.

Strengthen Coverage and Timeliness of Direct Benefit Transfers to Patients and Providers

Direct benefit transfer (DBT) plays a crucial role in mitigating challenges pertaining to nutrition and travel support for patients and incentivizing private providers to notify and facilitate treatment completion [65]. Again, this is another instance where the program could benefit immediately through payments on a regular basis for Nikshay Poshan Yojana (NPY). Tribal and private provider schemes turnaround time (TAT) for NPY should be deployed soon. There is also a need to aggressively pursue procurement of digital signature certificates (DSCs), train staff via e-training and fast-track delivery of tokens in lockdowns to deploy DSCs.

Make Response Gender-Sensitive

Even today, there are numerous reports of gender discrimination because of hesitancy to seek care and widespread stigma in TB. It is, therefore, important to provide gender-sensitive care. An important first step is to initiate an inclusive public conversation about what TB, COVID-19, and other disease mean to genders and communities. One of the ways the government can develop a narrative around gender and health is through public awareness campaigns. Next, it must integrate these concepts into training programs. The government must provide gender-sensitivity training to all health personnel. This is crucial because unless the conceptual frameworks change in the minds of those who provide care, it is meaningless.

Concluding Comments

As the world and India are grappling with the COVID-19 crisis, TB must not be forgotten. TB kills more than 1200 Indians every day. It is so widespread that it does not just destroy lives, it also pushes millions into poverty and debt. This happens even when its more dangerous forms such as drug resistant (DR-TB) remain curable. We need to ensure that we have strategies that work for both TB and COVID-19. This crisis presents an opportunity to improve access to health services and develop innovative tools, strategies, and community-based interventions that have been ignored for too long. Access to healthcare is critical for COVID-19 and also for TB as it ensures early diagnosis and treatment.