Failing to notify TB cases can land doctors in jail. But will this help India eliminate the disease?

Doctors, pharmacists, chemists and laboratory staff will face jail time if they fail to notify tuberculosis cases to the Ministry of Health and Family Welfare, according to a notification issued by the ministry on March 16. The government aims to eliminate tuberculosis by 2025. To do so, it plans to identify infected patients and also screen people who have been in contact with them for symptoms of the disease.

Tuberculosis kills 4,80,000 Indians every year, the notification states. And there are more than a million “missing cases” in a year – most of which are either undiagnosed or inadequately diagnosed or treated in the private sector.

The notification says any clinical establishment – doctors, laboratories, pharmacists, chemists and druggists – that fails to notify tuberculosis patients will be booked under Sections 269 and 270 of the Indian Penal Code. Section 269 pertains to a “negligent act likely to spread infection of disease danger­ous to life”, and carries a jail term of up to six months or a fine or both. Section 270 refers to a “malignant act likely to spread infection of disease dangerous to life”, and invites imprisonment that may extend to two years or a fine or both.

Hidden cases

The government had made tuberculosis a notifiable disease – which meant that doctors, hospitals and laboratories were required to inform the government when they detected a case – in 2012. Despite this order, notification of tuberculosis cases from the private sector has remained low and the majority of notified cases are from the public sector. A report published by the ministry’s Central TB Division said that 68 lakh cases were notified from public health providers in 2012 but only seven lakh cases from the private sector.

A study published in the medical journal Lancet, which looked at drug sales data in India, estimated that 22 lakh tuberculosis patients sought treatment from the private sector in 2014.

Public health experts, too, say a significant number of tuberculosis patients in the country seek private treatment, making it difficult to ascertain the real burden of the disease. “Unless the private sector’s TB cases are taken into account, we will not know the prevalence and incidence of TB cases in the country,” said Dr Om Shrivastav, a senior infectious diseases consultant in Mumbai.

As Dr Zarir Udwadia, consultant chest physician at the PD Hinduja Hospital in Mumbai, put it, “We do not even know the number of enemies we have to fight.”

Only by understanding the actual burden of the disease can the government and the medical community come up with a strategy to eliminate tuberculosis, doctors agreed.

Grey areas

While doctors welcomed efforts to get a more accurate count of tuberculosis cases in the country, some feared the government’s new move would drive many patients to “underground clinics” to receive treatment discreetly. “Most TB patients are worried about sharing their details with the government,” said Shrivastav.

According to Dr Yatin Dholakia from the Maharashtra State Anti-TB Association, the move to penalise doctors may not necessarily work. “The Maharashtra government is already mulling a Bill for tuberculosis control, which has a provision to send caution notices to doctors and remove their names from the medical council registry if they fail to notify TB patients,” Dholakia said.

Like Shrivastav and Dholakia, many doctors are worried about the implementation of a notification that puts the medical provider in an uncomfortable position.

As a doctor who treats tuberculosis patients in Aurangabad pointed out, “I have to take the consent of the patient before informing the nodal agency. And if the patient does not give me the consent, I cannot inform the government. In that case, I will be liable for penal action.”

Some doctors feel criminal liability may, in fact, act as a deterrent to treating tuberculosis patients altogether.

However, the notification states that patients can also “self-notify” to the government.

Shrivastav said there were many grey areas to consider before penalising doctors. “We have to ensure the data of the patient is not misused and they are not discriminated against,” he said.

Manjiri Gharat, vice-president of the Indian Pharmaceutical Association, said there would be resistance from patients to the notification before adding, “We have to go beyond individual patients and by notifying all TB cases to the government, we will be in a better position to control the spread of TB infection.”