Thursday, March 31, 2011

India: As the middle class rises, so does tuberculosis

Still a taboo disease associated with poverty, endemic TB knows no boundaries in India.

By Jason Overdorf
GlobalPost - March 31, 2011

NEW DELHI, India — When Fatima's doctor told her that she wasn't suffering from ordinary Delhi belly — her stomach cramps and diarrhea were caused by tuberculosis — her biggest fear wasn't the dreaded disease. With her marriage still impending, the 29-year-old, middle-class resident of Kolkata was afraid that her secret would get out, said Dr. Raja Dhar, a physician at the West Bengal city's posh Fortis Hospital.

“The first thing she told me was never to tell anyone that she had TB,” said Dhar, who explained that the young IT professional feared her impending marriage would be scuttled if people came to know of her infection — even though she was eventually cured.

Despite her shame, Fatima — whose name was changed for this article to preserve her anonymity — is in good company.

Although tuberculosis is still associated with poverty, malnutrition and crowded living conditions in India, the disease is endemic among rich and poor, Dhar said. Among the affluent, it has simply been lying in wait, only to emerge when the immune systems of the new rich are compromised by the same stress factors that are causing an increases in “lifestyle related” problems like type 2 diabetes and heart disease.

“In a country where tuberculosis is more or less endemic, you have latent TB present in the body that does not manifest because you have a good immune system,” Dhar said. “But if the immune system goes down, the time is ripe for the TB to actually flare up.”

According to the World Health Organization, the total number of TB sufferers has steadily declined in South and Southeast Asia over the past decade, but the region still accounts for a third of the world's total TB patients — with more than 3 million cases added every year, mostly from India. And just as the disease made a resurgence in America in the 1990s, thanks to immune system complications associated with HIV/AIDS, in at least one respect the problem is getting worse.

Working at an upscale, private Indian hospital for the past two years, Dhar said that around 70 percent of his TB patients are middle-class or affluent professionals — many of whom react with anger or disbelief when they hear his diagnosis. And looking back at hospital records and discussing the rate of incidence with doctors in other cities, he estimates that the number of wealthy people contracting TB has risen about 20 percent in recent years, even as the number of poor patients has dropped. Meanwhile, local press reports say the number of TB patients from higher income families have doubled in the last three years in Delhi hospitals.

Though TB is better known as the debilitating lung ailment, once called consumption, which affected writers like the Romantic era poet John Keats, India's affluent sufferers are mainly falling victim to lesser known versions of the disease that strike the stomach, heart or even bone. That makes sufferers even less likely to think they have TB, and also makes it harder for doctors to make the right diagnosis.

“More than the rate actually going up in affluent people, I think it may be just that people are realizing that TB is affecting everyone, not just the really poor,” said Dr. Madhukar Pai, a McGill University-based researcher who works with WHO's Stop TB Partnership program. “Awareness about TB may be higher, especially with rumors about Bollywood celebrities being affected.”

But even if TB has scaled the society columns, it still carries a powerful stigma. Not long ago, film star Amitabh Bachchan was compelled to issue a public denial when press reports circulated claiming that his daughter-in-law, Bollywood's Aishwarya Rai, was suffering from the same type of TB that Fatima hid from her parents and fiance.

That, too, makes a disease that should be easily cured more difficult to treat, according to Dhar. Most TB cases can be cured easily if the victim seeks medical treatment early in the disease's progression, and their doctors get the diagnosis right and prescribe the right treatment. But the more fear and shame associated with TB, the less likely that is to happen.

“There is a far greater taboo about people in the affluent class saying that they have TB,” Dhar said. “It's like having leprosy years ago.”

In that respect, some high-profile Bollywood victims — if any are willing to rise above ignorant perceptions about the disease – could be a huge boon, said McGill's Dr. Pai. Just as Hollywood stars and professional athletes helped reduce the fear and stigma surrounding HIV, a few rich and famous Indian TB patients could revolutionize the fight as new, drug-resistant strains of TB increase fear of the illness worldwide.

With a new molecular diagnostic test, called Xpert, available, India could eliminate its persistent problem with erroneous false-positives, provided it could roll out the new test to thousands of laboratories that today report as many as 1.5 million inaccurate results every year. And four new vaccines are in late-stage trials, setting the stage for a massive eradication campaign — if somebody will step up to the plate.

“Rich Indians have done almost nothing for TB in India,” Pai said. “No major philanthropic groups or donors or industries have taken on the TB challenge in India. Politicians and Bollywood stars and cricket celebrities have largely ignored the TB problem.”

Friday, March 11, 2011

What's to come of Free Tibet movement?

The Dalai Lama's decision to give up political role places the Tibetan freedom movement in precarious position.

By Jason Overdorf

NEW DELHI, India — Like his previous suggestion that he might pick his next incarnation before his own death, the Dalai Lama's move to withdraw from politics is a savvy move — this time to dilute the official powers of his office before China's pet monks can begin wrangling with Buddhist leaders in exile for the right to choose his successor.

But will the rough and tumble of parliamentary democracy also dilute international support for "Free Tibet"?

Observers say that the common people of the Tibetan exile community in India, at least, are nervous about the decision. But the Dalai Lama will likely retain his role as the symbolic head of the Tibetan exiles, and his sway over affairs will remain supreme if he chooses to wield it.

"He's trying to take less political responsibility and focus more on the spiritual dimension," said Srikanth Kondapalli, a professor in Chinese studies at Jawaharlal Nehru University. "But it doesn't mean that he will go away from the scene. Obviously the Tibetan community is highly religious, which means regardless of who is the prime minister, regardless who is the speaker of the parliament in exile, or the cabinet ministers, they will go ahead with the Dalai Lama."

That's true. But it also means that the Dalai Lama is the only leader who enjoys the complete trust and full support of the entire community. Democracy may bring a new kind of factionalism to Tibetan exile politics — where some groups reject the Dalai Lama's decision to settle for autonomy rather than independence and a radical fringe questions the resistance movement's commitment to nonviolence.

"There are factional, divisive politics within the Tibetan community," said Abanti Bhattacharya, a professor in the Asian studies department of Delhi University.

Moreover, exiled Tibetans are likely apprehensive because the move comes as alleged corruption scandals highlight the possible pitfalls of politics in the government-in-exile's host country, India. And it closely follows an ugly round of corruption allegations that implicated the third-highest Tibetan Buddhist religious leader, the Karmapa Lama — which reminded the exiles of their vulnerability, though the devout never gave the accusations much credence.

"As early as the 1960s, I have repeatedly stressed that Tibetans need a leader, elected freely by the Tibetan people, to whom I can devolve power," the Dalai Lama said in a speech Thursday to mark the 52nd anniversary of the 1959 Tibetan [3] uprising against the Chinese government in Llasa.

China quickly interpreted the statement as "a trick," as the religious leader has talked of stepping down in the past. But this time — to the dismay of many exiled Tibetans — he gave a specific date for his withdrawal from politics, saying he would propose the necessary amendments to the constitution of the parliament in exile on March 14.

"I'm sure the Tibetan people have been talking about the statement yesterday [announcing the Dalai Lama's retirement]," said Tsewang Rigzin, president of the Tibetan Youth Congress, an exile political party. "But at the same time we have to understand that his holiness has said many times that he's in semi-retirement and the current prime minister [of the government-in-exile] is his political boss. As far as we know His Holiness' vision is to have a truly democratic Tibetan society."

That line will make things difficult for China, forcing the Chinese government to talk with the elected government of Tibetan exiles, rather than their religious leader, if they are to hold any negotiations at all. And by devolving his political powers to elected representatives, the Dalai Lama is implicitly challenging the Chinese leadership to do the same thing at a time when it is already under international and internal pressures.

"[This means that] the future will be more complicated for the Chinese," said JNU's Kondapalli. "If you consider them as portions of China, a lot of portions of China are getting democratized, while the central government is not. For instance, Taiwan, Hong Kong, and now the Tibetans in a massive way. It will put a lot of pressure on the Chinese, especially after the Egyptian and Libyan developments."

At the same time, by diluting his political role and delegating more power to the elected government in exile, the Dalai Lama has acted to forestall a leadership crisis after his death. There is bound to be a contest between China's Tibetan representatives and the exiled monks to choose his next incarnation, which could end with the Chinese government effectively selecting the Tibetans' supreme religious leader. And regardless of who makes the selection, the present Dalai Lama's successor will be a small child, which would leave senior monks wrangling for influence.

"[Currently] the Dalai Lama has sweeping powers," said Kondapalli. "So it's better to amend the constitution and let the elected representatives deal with the day to day affairs, rather than [risk] a Chinese-appointed Dalai Lama running roughshod over everybody — because [otherwise] the sweeping powers will be there for the next Dalai Lama as well."