Unless urgent action is taken, more than 40 lakh people in India will die of tuberculosis in the next decade.

This highly infectious disease is on the march, threatening to overwhelm health services. And India has the world's highest incidence of TB.

Even in its normal form, tuberculosis is our No. 1 infectious - disease killer. Every year, according to official statistics, 2.2 million Indians contract TB and 500,000 die of the disease. But experts agree that these figures are grossly understated, and that innumerable cases go unreported. In fact, India has more TB patients than any other country in the world.

The economic cost of the disease is estimated at a staggering Rs. 12,000 crores annually. There are devastating social costs too. Around 300,000 children drop out of school every year because their parents have TB and the kids have to work to feed their families. Moreover, because of the stigma attached to TB, every year more than 100,000 women with the disease are thrown out of their homes or denied access to treatment.

TB is caused by a tenacious germ, Mycobacterium tuberculosis, that is as old as history; even cavemen were riddled with it. The germ thrives in poor social environments where over - crowding hampers ventilation and malnutrition lowers resistance. One victim can cough up billions of TB bacteria a day, so it is not surprising that most people are infected by inhaling droplets of sputum. Yet the body's natural defences are so effective that less than one person in ten infected with the bacterium develops the active disease.

Once activated inside the body, the germs multiply at a prodigious rate and spread via the lymphatic system. They may invade any organ, although 85 per cent of cases involve the lungs, resulting in pulmonary TB. The immune system reacts by breaking down healthy tissue into a soft, cheesy mass on which the tuberculosis bacteria feast, reducing it to liquid. In the lungs, this liquid finally breaks through a bronchial tube (respiratory passage) and is coughed up, leaving a ragged cavity.

Within a year when the symptoms namely weight loss, coughing, chest pain, night sweats, tiredness - become persistent, ten to 15 of a sufferer's contacts have probably become infected.

Untreated or incurable patients die a slow death coughing up more and more of their lungs and infecting family, friends and colleagues.

Theoretically, TB has been preventable and curable for four decades. Yet in 1993, faced with an upsurge even in developed countries such as the US, the world Health Organization (WHO) declared the TB pandemic a global emergency. The WHO estimates that between the years 2000 and 2020, nearly one billion people worldwide will be newly infected, 200 million people will get sick, and 35 million will die from TB unless immediate action is taken to curb its spread.

What has compounded the problem is MDR - TB. More than 50 million people worldwide are infected with it. Already frightening, these numbers could mushroom if the disease cannot be controlled.

What has gone wrong? Experts point to the following:

Poor patient compliance. Rekha Gowda, *27, the wife of a chickmagalur, Karnataka, farmer first developed TB in 1997. Although her doctor put her on a six - to eight month drug regimen, she stopped the treatment after four months because she felt better. The TB came back in six months, but this time too she didn't complete the full treatment, which would have effected a cure. In May 2001, by now resistant to standard drugs, she was given medication to treat MDR - TB. "She has to take the medicines regularly for nearly two years," says her chest physician, Dr H. V. Suryanarayana, of Bangalore's Bhagwan Mahaveer Jain Hospital. "I hope she doesn't stop too soon again."
Once major problem in controlling TB is that, like Rekha, a majority of people stops taking the drugs as soon as they feel better, generally after two months, "Only active TB germs are destroyed in the first few weeks of the treatment,"

A Major problem in controlling TB is that a majority of people stops taking the drugs after they feel better, generally after two months.

Says Dr. Sheela Rangan, programme consultant with the international humanitarian organization Medicines Sans Frontiers (Doctors Without Borders) that's helping Mumbai's municipal corporation combat TB. "Normally, to cure the disease, it takes at least six months of treatment."

Half - completed treatments kill off the weaker strains of the germ, leaving behind tougher, mutant strains, which then enter the infectious pool and require treatment that is 100 times more expensive, lasts four times longer - and often fails.

However, poor compliance is not always the patient's fault. Erratic drug supplies have also forced patients to discontinue treatment.

Poor prescription and non - standardized treatment regiments. Bad prescriptions by ill - informed and poorly trained doctors are as much to blame for MDR - TB as poor patient compliances.

"Not following the standard recommended treatment regiments and poor follow - up by doctors and other health providers are important reasons for the development of MDR - TB, " says Dr P.R. Narayanan of Chennai's Tuberculosis Research Centre. A study of 102 private practitioners in Dharavi, Mumbai's largest slum, showed that these doctors were prescribing 80 different TB treatment regiments, of which only four conformed to WHO guidelines.

"Doctors must follow the WHO's guidelines when treating TB, "says Dr Praveen Kumar Jain, consultant chest physician at Mumbai's Lilavati Hospital & Research Centre.

Inadequate state health facilities. According to the WHO, the most effective way of diagnosing pulmonary TB is through a sputum examination test, where TB germs are identified under a microscope. But until recently, government hospitals and clinics relied more on X rays for diagnosis. And although sputum diagnosis is increasingly becoming the norm, poorly trained staff and lab technicians make it difficult to implement an effective screening programme.

Moreover, there are few reliable facilities for testing drug sensitivity.

ALL IN ALL, health authorities have shown an appalling inability to administer an effective control programmed. While case findings have been satisfactory, methods of diagnosis have been poor, drug supply inconsistent, drug compliance barely monitored, and in many places government TB clinics have not even been fully functional.

HTV: a sinister partner. Once inhaled, the TB bacteria may lie dormant in the body for decades, shielded by a thick waxy cell wall. In fact, some experts believe that a third of all Indians harbour dormant TB germs, kept in check by their body's defences. If the immune system is lowered, however the germs leap into action.

Enter the AIDS virus. It's estimated that HIV, the virus that causes AID, will increase the incidence of TB by 15 percent. "HIV and TB don't go well together for the patient," says Dr Subhash K. Hira, director of the AIDS Research & Control Centre in Mumbai. "HIV activates dormant TB germs. An HIV - Positive person is 30 to 60 times more likely to develop TB than the average person harbouring the dormant germ."

In fact, TB is already exacting a devastating toll in India's HIV - positive community. "Almost 60 per cent of AIDS patients in India develop TB," DR Hira Says. "About 75 Per cent of all HIV - related deaths in India are, in fact, due to TB."
Moreover, one study revealed that at least 60 percent of HIV - positive patients had MDR - TB. At present, there are nearly four million Indian adults who are HIV - positive and, according to experts, this number could reach five million by next year. This means that the pool of people passing on MDR - TB could swell to an ocean in a few short years.

ALTHOUGH the Indian government started a nationwide programme to combat TB as early as 1962, it met with little success because of poor organization, faulty diagnosis and drug shortage. Here's what must be done:

Enforce treatment compliance. The WHO has found that there is a proven and cost - effective way: through what it calls the Directly Observed Treatment, Short - Courses (DOTS) strategy, where health workers watch each patient swallow the correct medication. Bangladesh, for example, improved its treatment success rates from 45 to about 80 per cent through strict adherence to this strategy. The Indian government started implementing DOTS in the mid 1990s and

There is now a proven and cost - effective TB - Control programme that has met with success.

Expects to cover 50 per cent of the population by the end of 2002, and 70 percent by 2004. Although treatment success rates have gone up, especially in cities, if DOTS is to succeed, a number of additional steps must be taken:

Ensure that drugs are readily available. Only when people have easy and timely access to medicines can they comply with treatment regiments. The government must ensure that drug shortages never occur.

Ensure participation by private medical practitioners. Since more that 50 percent of Indian patients, including the poor, prefer to visit private clinics rather than public dispensaries and hospitals, DOTS cannot succeed unless doctors in the private sector take part in it. "Almost all areas of Mumbai are now covered by DOTS, but we are still missing half the city's TB patients since they go to private doctors," points out Dr Sheela Rangan of Medicines Sans Frontieres. "We need to involve them in DOTS if we are to bring about significant change in the incidence of both normal and MDR - TB."

Accelerate the building of clinics and laboratories. In rural regions, such facilities are often non - existent. Even in areas where there are primary health centres, patients may have to walk for up to five hours to seek treatment. For the DOTS strategy to work, we must have additional clinics and laboratories.

Involve communities. TB is a social problem and can't be treated in isolation. Health authorities should encourage communities to form TB committees to meet the patients' needs for emotional support, health and nutritional information, skills training, housing and first aid. It is also essential to get rid of the stigma associated with TB.

The government must act now, while there is still time, Dr Rangan says. "We must check TB within the next few years. If we don't, our health facilities will be overwhelmed."

More women die each year of TB than of all maternal mortality causes combined.

Globally, TB is a leading killer of women

Every year, 300 000 children are forced to leave school because their parents have tuberculosis, and 100 000 women lose their status as mothers and wives because of the social stigma.