Located in South Asia, India is the second-most populous country in the world, with more than 1.2 billion people. Tuberculosis (TB) is a major public health problem here. In India, nearly 2 million people—nearly 20 percent of the world’s TB patients—develop TB each year. Many of these people live in poor, urban communities. Approximately 300,000 people die from the disease every year.
These photographs focus on communities in northern Mumbai. With a population of 14 million people, Mumbai is the most populous city in India and the second-most populous city in the world. Despite being the richest city in India, Mumbai also has many slums, where cramped living conditions, poor nutrition, and lack of access to health care increase the chances of developing active TB.
There is a close link between poverty and TB. The overcrowding of Mumbai slums makes it easier for TB to pass from one person to another. People in the slums are often too poor to pay for proper health care, let alone the transportation to get to a hospital or clinic. TB creates an enormous economic burden for India: An estimated $300 million and 100 million work days are lost as a direct result of the disease.
The photographs of Mumbai show how TB affects people’s lives. In addition to the health and economic costs of the disease, there is a social stigma attached to TB that often isolates patients, who feel rejected by their friends and family. TB affects not just the individual patient, but also that patient’s family and community.
Many people in Mumbai live in poor and overcrowded neighborhoods, which presents many health problems. Here, the inhabitants of these buildings were asked to leave their homes in the slums, where they were squatting (living on land they didn’t own or rent), and to move to an apartment building, where they now have a title to their apartment. But the overcrowding in the building makes people susceptible to contracting TB, which is spread from person to person—through little droplets in the air when someone with active TB coughs or sneezes. Inhabitants’ poor nutrition and hygiene are also risk factors for getting TB. In addition, the elevators in these buildings usually are not maintained and do not work, making it difficult for very sick or elderly TB patients to get up and down the stairs to go to the health clinics and get their medicines to treat the disease.
Malnutrition and poor hygiene are also problems for people who live near or work at garbage dumping grounds. Here, workers at a local garbage dump try to put out a fire so they can continue scavenging for trash that they can collect and sell. According to local NGOs (non-governmental organizations), many of the workers in the dumping ground and the families who live nearby are infected with TB.
According to the World Bank, approximately 27 percent of the people living in India lived below the poverty level (which was set at $1.25 per day).* Because of this, many people live in unsanitary conditions and have to scavenge in dumps like these.
* World Bank, India Country Overview, September 2010
Men crowd in to a commuter train leading from the poor suburbs to downtown Mumbai. Crowding is one of the risk factors in concentrated urban environments, making it much easier for TB to be passed from one person to another. It is estimated that nearly one in three people in India are infected with the bacteria that cause TB. Most people who are infected have latent TB, meaning that they aren’t sick and don’t have any symptoms. However, 5 to 10 percent of people infected with TB go on to develop active TB, meaning that they are sick and show symptoms of the disease.
Poverty can have a profound effect on patients’ ability to receive quality treatment. The health services in the slums are incredibly inadequate; many doctors are not properly trained, and patients often resort to shopping for prescriptions or purchasing inappropriate medicines over the counter. For TB treatment to be successful, it’s important that patients take the right medicines at the right time and for the full duration of treatment. Here, people walk in front of a small pharmacy in Jari Mari, a poor slum in Mumbai.
Poverty can affect patients’ ability to complete their treatment. Here, Rhemat Shek lies on the floor of her mother’s home in Rafik Nagar, a neighborhood next to a garbage dump in Mumbai. Her son, Sana Jameer, and mother, Husna Bano, sit behind her. Rhemat and her husband came to Mumbai to be closer to a treatment center so she could receive medicine, but they say they may soon return home, interrupting Rhemat’s treatment, so her husband can continue to work. She is currently so weak that she is often unable to sit up for more than 10 minutes at a time.
Reshma Khavle, 16, has had TB for four months but is not getting any better. She sleeps on the floor in a small apartment that she shares with her grandmother and other family members. She rarely gets up and spends most of her time on the floor of the apartment. Weight loss, fatigue, poor appetite, fever, coughing, and night sweats are a few of the symptoms of TB.
A young girl walks through the Rafik Nagar slum, one of the areas in which Lok Seva Sangam, a local NGO, has set up free TB health clinics. People in the slums are often too poor to pay for proper health care, let alone the transportation to get them to the hospitals or clinics. Free health clinics located in the slums are crucial to successfully treating and slowing the spread of the disease.
A young man stands in Ashok Nagar, a slum neighborhood that is far from the city center. It can be very difficult and costly for TB patients who live in the faraway slums to get to a health clinic to receive their daily medicines. Transportation to a clinic may only cost 20 cents a day, but that can represent nearly 10 percent of a patient’s salary. Some patients will simply stop going to the health clinics in order to save the transportation money or to avoid missing work.
In countries where active TB is not a big problem, diagnoses of TB infections are made by a skin test. However, in places where many people are sick with active TB, doctors diagnose the disease when people show symptoms. Part of the diagnosis includes a chest x-ray to see if TB has penetrated the patient’s lungs. TB can be seen on an x-ray as white, irregular areas against a dark background. Here, a man receives a chest x-ray during the admission process at a hospital in Mumbai. However, a chest x-ray alone is not enough to confirm a diagnosis of active TB.
In addition to taking x-rays, health care workers will also take a sample of sputum (mucus from the lungs) to make an accurate diagnosis of active TB. There are two different tests: a smear test, in which the sputum is smeared on a slide and examined for TB bacilli, and a laboratory test, in which live cultures from sputum are grown in the lab. The smear test is relatively quick to do, but isn’t accurate enough to identify everyone with active TB—in fact, the test may miss more than 50 percent of cases. The laboratory test is much more accurate, however this test can take up to six weeks to complete. Both of these tests require lab equipment and trained staff. Because of the complexity of TB, it can sometimes be difficult to get an accurate diagnosis.
Here, Rajeshree Bamsode, a lab worker with a local NGO, stands in a small makeshift lab where she examines patient sputum samples to determine if they have active TB.
Boxes of TB medicine sit in a cabinet at a treatment center. Each box contains the entire six- to eight-month treatment regimen for one patient. Patients must take their medicine daily. If patients take their medication only intermittently or prematurely stop treatment, they can develop multidrug-resistant TB (MDR-TB), a strain of the disease that has high mortality rates and is much more difficult and costly to treat. While the typical six-month treatment for regular TB can cost $20, treatment for MDR-TB can cost tens of thousands of dollars and take several years.
A TB patient receives a daily injection at the Group of TB Hospitals in Mumbai. Having patients receive treatment in the presence of health care workers can ensure that patients take their full course of medicine and reduce the risk of creating more cases of MDR-TB. MDR-TB results from exposing the TB bacteria to the antibiotics meant to kill them, without completing a full course of treatment. Bacteria exposed to but not eliminated by antibiotics can evolve to resist the killing effects of the medicine.
A doctor visits a patient during his daily rounds at the Group of TB Hospitals in Mumbai. This patient is painfully thin and wasted from having the disease.
At the Group of TB Hospitals in Mumbai, a patient has a chest tube that was not working properly removed. The tube is meant to drain fluid that builds up in the lungs of TB patients and can suffocate them.
A patient at the Group of TB Hospitals in Mumbai lies on his bed as a crow perches next to him. Later that day, the patient was moved to a different bed where he could receive oxygen. He died early the next morning.
TB is among the top 10 causes of death in India. In 2009, the number of people who died (the mortality rate) from TB in India was 123 per 100,000. By contrast, in 2009, the mortality rate from TB in the United States was 0.16 per 100,000.*
Orderlies at the Group of TB Hospitals in Mumbai remove a recently deceased patient as another patient sits on his bed.
At the Group of TB Hospitals, the mother of a patient cries next to the body of her son. She found out her son had died when she arrived for her daily visit that morning.
Orderlies at the Group of TB Hospitals transport the body of a recently deceased patient to the hospital morgue.
Mohammad Ahmad Khan, age 4, has TB but has missed his last two appointments at the treatment center. One of the major struggles with TB is ensuring that patients take their medicine on time and finish the entire treatment. Poor or incomplete treatment of the disease can be worse than no treatment at all, as it can lead to the development of MDR-TB.
The predominant international TB control strategy is known as DOTS—Directly Observed Treatment Short course. DOTS focuses on five main points of action:
Ensuring government commitment to TB prevention
Conducting quality diagnoses based on sputum smear tests done on patients with symptoms of active TB
Observing patients to make sure that the right drugs are taken at the right time for the full duration of treatment
Having a regular supply of high-quality medicines
Regularly reporting and recording TB cases and treatment outcomes
Here, a girl waits in the doorway as patients receive their medicine at the Lomboni DOTS Center, run by a local NGO. Patients are required to come to the center three times a week and take the medicine in front of a community health worker.
People look in to a DOTS Center as they walk by in the late afternoon. In India, there is still a social stigma attached to having TB. Some people believe that TB is a disease of the poor and the weak, and they are ashamed if they are afflicted with it. For others, the stigma is due to misinformation and misunderstandings about TB—for example, that TB is not curable or that the treatment for TB can be deadly. Many patients are afraid that their neighbors will find out they have the disease. Single women fear that if people know they have TB, it will be impossible to marry. Parents worry about how their children might be treated.
Education is a key piece of successful TB prevention. TB education programs can teach patients about TB transmission and treatment and dispel myths about TB. Here, women in a tailoring workshop listen to an educational presentation on TB by members of Lok Seva Sangam, a local NGO that works on TB issues. Lok Seva Sangam travels all over the slums giving educational talks to different at-risk groups.
Men rest after a long day working in a tailoring shop. The men are migrants who come from all over India; they do not have the money to rent rooms. They work about 16 hours a day sewing clothing together and then sleep together in the workshop. Lok Seva Sangam, a local NGO working on TB, gives educational talks to workers like these, teaching them about the potential risks of living together in such a small, cramped space.
With quality treatment, TB patients can be cured. At the Padel Nagar DOTS center, Mohammad Haroon Khan takes his daily medicine, while Hanifa Hussain Sayed, a community health worker with a local NGO, watches.
Sandeep Tambe is currently taking TB medicine and is slowly beginning to feel better. He had been bedridden for awhile and his aunt, Rajeshshree Jadhar (at right), took care of him. If Sandeep continues to take his complete course of TB medicine, he can eventually make a full recovery from TB.