How Goa Is Fighting TB Among High-Risk Groups

Suresh, whose name has been changed to protect his identity, was diagnosed with tuberculosis (TB) in August after he vomited blood. He was then sent to the TB hospital in Margao, Goa. He will be in the hospital for six months for the duration of treatment where he is also given treatment for withdrawal symptoms, and addiction.

“My hands were shivering and I could not sleep when I arrived here. If I was out of hospital, I would not be able to manage a day without drinking,” he said. He said he was diagnosed with HIV about 20-25 years ago for which he said he was taking medicines on and off.

The Margao hospital which is perched on Monte Hill in south Goa was once a sanatorium, and built by the Portuguese rulers. It is a ramshackle hospital with wooden rooftops and flooring, large windows, and empty corridors, suited for infection control.

Mahesh Gaunekar, Goa state TB officer, said that in the past two to three years, they have been encouraging patients such as Suresh to get admitted in the hospital. As an alcoholic, Suresh has been classified among the vulnerable populations affected by tuberculosis who need in-patient care in this TB hospital for the duration of the treatment to have better outcomes. They also encourage admission for diabetic patients who need insulin injections, or migrant workers who struggle for housing and other needs. The idea is to ensure that medicines are taken properly, and that the patient feels supported.

The 66-bedded sanatorium had just 19 TB patients when IndiaSpend visited the hospital late August. Govind Desai, the South Goa district TB officer, said that they are not hard pressed for beds, and it makes sense for them to admit patients such as Suresh.

“So, that's why we prefer to keep vulnerable people. Especially when they're alcoholics, the moment we discharge them, they go and they give up on the treatment. So we try to keep them. At least while they're here, they continue their treatment,” said Desai.

Staffers of the sanatorium say that about half of the TB patients admitted have alcohol problems.

Staffers at Margao’s TB hospital say about half the admitted patients have alcohol problems.

Higher mortality

Goa has relatively fewer TB cases as compared to some other states in India, approximately 2,000 per year. In 2023, Goa reported 133 cases per 100,000 population, compared to the all India average of 179 per 100,000, as per the 2024 India TB report. In fact, South Goa won the bronze medal for reducing its TB incidence by 20% in 2021 in a subnational certification.

However, the TB mortality rate is higher than the all-India figure, as per the figures collated by Goa’s TB department. In 2022, the death rate was 8.3% as opposed to the all India figure of 3.9%. In 2023, the death rate climbed to 9.6%.

The Goa State TB department did an internal analysis of the 201 deaths in 2023. While the maximum number of deaths--30.3% (36)--were associated with type 2 diabetes, another 17.9% (36) of deaths were due to hepatorenal failure--that is, failure of the liver and kidneys--which were associated with alcohol consumption and alcoholic liver disease.

“We are not able to figure out the exact number of deaths due to alcohol consumption because most of our patients deny taking alcohol. Only if they go into withdrawal can we say for sure that they are taking alcohol in large quantities,” said Gaunekar.

Studies show that alcohol consumption impairs the immune system, which increases susceptibility to tuberculosis infection, as well as to reactivation of latent tuberculosis. As per the National Tuberculosis Elimination Programme, in 2023, 7.1% of TB patients in the country were identified as alcohol users. As per estimates, about 250,000 Indians are at the risk of contracting TB because of alcohol use disorders.

Alcoholism often goes hand in hand with living in unhygienic conditions, peer-to-peer infection, smoking tobacco, criminal background, or even imprisonment, said Shibu Balakrishnan, an expert in the nation’s TB programme.

Goa has one of the highest alcohol use in the country (independent of TB). As per the Magnitude of Substance Use Report, 2019 that was released by the Ministry of Social Justice and Empowerment, more than a quarter of Goa’s population currently uses alcohol, the fourth highest in the country.

The report used alcohol ‘quantum of work’ estimates that combine harmful use and dependence, which is understood as a category of consumption pattern in which the individual needs professional help. In Goa, the proportion of people with Alcohol ‘quantum of work’ was 8.4% (India average is 2.7%). Alcohol dependence in the state was found to be 3.4% (all-India India: 2.7%).

“Drinking alcohol is part of Goan culture,” said Mamta Borkar, a psychiatrist who works with alcoholics in both TB hospitals as well as other facilities in South Goa. “It is cheap and many consume alcohol on a regular basis or on weekends. We provide treatment for alcohol withdrawal state, memory disturbances, as well as detoxification treatment that is anti-craving. Relapse is very common.”

Suresh too was coming to the TB sanatorium for the second time. Last year, he had undergone TB treatment for six months, during which he underwent detoxification. But he had started drinking again soon after he left the sanatorium. “My friends do not leave me alone. If I drink alcohol even once, for someone’s birthday or some other occasion, I cannot stop.”

Another 30-year-old alcoholic patient, a migrant worker from Ganjam district in Odisha, was being treated in the sanatorium. He was in a similar situation as Suresh and was taking treatment for TB and detoxification for the second time in two years.

A flyer offering help for patients with alcohol problems is displayed at Margao’s TB hospital. Alcohol consumption impairs the immune system, increases susceptibility to TB infection and reactivation of latent TB, studies show.

Individualised care in sanatorium

In general, sanatorium-based individualised care is good for the patient, as long as there is no restriction on wage earning, family meetings as well as travel, said Balakrishnan.

Patients from all over Goa are kept in this sanatorium. “We have even admitted patients here who need close monitoring of diabetes, and who need insulin three times a day. Sometimes they may not be comfortable injecting themselves at home,” explained Desai.

IndiaSpend also met some migrant workers who preferred staying in the hospital for a long duration. The patients get a high protein diet of fish, eggs and milk, which helps in TB recovery.

“The patients need not only treatment but also good nutrition. This kind of care is good for successful TB treatment and for healthy recovery. This reduces the chances of TB-related sequelae (morbidity as a result of TB),” said Balakrishnan.

He added that state TB divisions are advised to have collaborative programmes with other programmes such as the National Programme for Prevention and Control of Non-Communicable Diseases that handle diabetes, cancer, mental health problems such as alcohol addiction, among others.

“TB programme is no longer about TB alone, but should go hand-in-hand with other programmes. For example, with alcoholics we need to manage social problems, behavioural issues and need deaddiction excerpts, for troubleshooting and providing support and rehabilitation to alcoholics. We need systems to support these patients,” said Balakrishnan.

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