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Mumbai is a crucible of bacterial opportunism. Perched on India's west coast, it is one of the fastest-growing cities in the world, with Greater Mumbai's population already at some 18 million. As more and more people pour into Mumbai, its edges have become a shifting horizon of rising and falling slums housing the migrant workers who make the city tick. In Ambujwadi, a cluster of some 8,000 people in north Mumbai, residents live like they do in most slums: in stiflingly close quarters, without running water or clean food. It's just the kind of crowded, hardscrabble place where M. tuberculosis thrives and where drug resistance is increasing.
Since 2006, India's government has provided free TB medication nationwide, but to get it, patients need to go to a clinic, hospital or government drug provider three times a week. For day laborers, that means less money and less food. In India's urban slums, as many as a third of TB patients stop taking their drugs before the standard six-month treatment is complete, according to Operation ASHA. New TB patients are prescribed six months of a combination of four medications, with two months of intensive treatment followed by four months of continuing care. Following the regimen is crucial. If patients don't respond to that treatment, or if they test positive for drug resistance, they are given other, more powerful second-line drugs, which can be highly toxic and are part of a grueling two-year program. If a patient stops that, the bacterium gets stronger still.
On one sweltering June morning, health worker Shilpa Kamble winds her way through Ambujwadi's labyrinthine dirt lanes, past goats picking over garbage and open-air stalls hawking cookies and Coke. She stops outside a piece of cloth that serves as the front door of a lean-to home. In Mumbai and other parts of the country, the government has teamed up with NGOs like Navnirman Samaj Vikas Kendra, where Kamble works, to keep track of patients and to make sure they stick to their drug regimens. Inside the hot, airless hovel, a man named Nasim Mohammed rests on a dirt floor. He weakly props himself up to talk to Kamble, wiping away the fluid that seeps from his eyes. Mohammed has been taking government TB drugs for five months, but he isn't getting better. "He doesn't move around much," says his wife Hasibunissa Shekh. "He sleeps most of the time." Neighbors have been helping feed the couple since Mohammed has been too weak to work, but both husband and wife are alarmingly thin. Now they're waiting for the test results to find out whether Mohammed's TB is drug-resistant. That will take weeks; in the meantime, Shekh and anybody else Mohammed comes into close contact with could become infected.
When doctors at Hinduja first reported TDR cases in late 2011, the central government groused at them for being alarmist. But eventually New Delhi nearly doubled the budget of the national TB program. Now 529 of the nation's 662 health districts are, at least on paper, equipped to treat drug-resistant cases, and last summer the government said the whole country would be covered by March. Says Dr. Minni Khetarpal, Mumbai's deputy health executive officer: "After a year, I am confident the numbers will go down."
If You Build It, Will They Come?
At least in Mumbai there are options. Between the newly robust network of government clinics, NGOs, hospitals and labs, there is a reasonable chance that sufferers will get scooped into the system. But in rural areas in other words, most of India that possibility is worryingly remote. In Patna, the capital of Bihar state, which has one of India's highest TB rates, 30 spartan beds are lined up in a new drug-resistant-TB ward. This is one of three facilities in Bihar where patients go to start government treatment for drug-resistant TB. Anil Kumar, a shy 18-year-old, sits on one of the beds with his father hovering over him. Kumar has been diagnosed with MDR TB. He was only tested after his sister, who had floated from private doctor to private doctor for years, finally died. Ajay Kumar Singh, the doctor on duty, says the boy almost certainly contracted the drug-resistant strain from his sister, and for that, he's lucky. "His diagnosis was made at her sacrifice," Singh says.
Thousands of families might not know to do the same. Finding a way to bring patients into the system is tricky in a place where mistrust of government services runs deep. Once bedeviled by insurgents, bandits and some of the worst infrastructure in the country, Bihar is still trying to shake its reputation as the nation's basket case. Things have improved, but years of official neglect are hard to undo in far-flung villages that are waiting to catch up with a shinier India. "There's [not enough] staff in the local hospital," says Mohammed Ishaque, a villager whose wife has TB. "They just tell patients to go to private doctors."