Tuberculosis burden in the tea gardens of Assam

Dr. Dharmakanta Kumbhakar

(The writer can be reached at drkdharmakanta@yahoo.com)

Tuberculosis (TB) is a major health problem in the tea gardens of Assam. Despite being curable, people continue to die in the tea gardens of Assam because of tuberculosis. There have been heart-breaking cases in which families have been wiped out because of tuberculosis. About 16 to 18% of the workers in every tea estate of Assam are affected by tuberculosis. There has been no control over the spread of infection and significant improvement in the situation over the years. Ignorance among the tea garden workers and lack of management support are to be blamed for this situation. Proper preventive measures have not been taken by the management of the tea gardens. The top management does not want 'too much development' for the labour community. The community that deserves maximum benefits remains at the rock bottom of the policy makers' priority list. The management of the tea plantations want to increase productivity and cut costs, and in the bargain, medical expenditure always gets the axe first.

Nothing has changed ever as far as the lifestyle of the tea garden workers is concerned. The estate executives continue to lead luxurious life, while the workers continue to live in poor conditions in the labour colonies, where diseases thrive. The labour colonies lack better housing, electrification, safe drinking water, scientific sanitation, proper drainage and better living conditions. The government does not have a tea garden-specific health report till date; even the rate of mortality continues to be alarming. The situation is becoming worse. The drug resistance TB is now becoming common in the tea gardens of Assam. Although the WHO-recommended Directly Observed Treatment, Short Course (DOTS) Programme, relaunched as the Revised National Tuberculosis Programme, has achieved success, leading to a slight decline in numbers, but HIV co-infection and multi drug resistance TB (MDR-TB) are adding a new dimension and keeping the numbers high in the tea gardens of Assam.

The failure of the immune system to control infection leads to active tuberculosis. Malnutrition reduces a person's immunity making him susceptible to tuberculosis. Similarly, fighting tuberculosis requires rich diets full of fats, vitamins, minerals and proteins. Anaemia and malnutrition continue to cripple the tea garden population of Assam making them most vulnerable to diseases like TB. Health-wise, malnutrition is common in the tea community. Nearly 95 % of the tea garden population of Assam is anaemic and malnourished. A study by the UNICEF and the Assam Medical College found that of the 14 meals in a week, only two are nutritional in a tea tribe family. Co-morbidities such as HIV, diabetes mellitus, smoking and consumption of alcohol which debilitate the immune system put individuals of the tea garden population of Assam at a greater risk of developing TB.

Tuberculosis is a social disease with medical aspects. Studies have pointed to the association of lower socio-economic status of the tea garden communities of Assam with the risk of developing TB. The socio-economic factors include many non-medical factors such as poor quality of life, poor housing, overcrowding, indoor air pollution, large families, early marriage, population explosion, under-nutrition, illiteracy, consumption of tobacco and liquor (as most of them do so), close contact to smear positive patients and lack of awareness of the cause of tuberculosis, etc. All these factors are interrelated and contribute to the occurrence and spread of TB in the tea gardens of Assam.

Overcrowding (higher population densities) and unhygienic living conditions in the tea garden labour colonies aid the spread of the infection, and ignorance among the tea garden population further fuels it. The tea garden workers live in one-bedroom houses with big families. Since tuberculosis is contagious, family members of a patient immediately become vulnerable. In addition, the level of awareness is low, so the patient is not isolated. The release of smoke from biomass fuels used by the garden people for domestic cooking also largely contributes to the infection.

The disease physically and economically devastates not just individuals but also families of the tea communities of Assam. Tuberculosis primarily affects the people of the tea gardens of Assam in their productive life years. Almost 80% of tea garden tuberculosis patients are aged between 15 and 54 and are key breadwinners for their families. In a study conducted by this writer amongst the tuberculosis patients of the tea garden community of Assam, 60.5% were male and 39.5% female with a male to female ratio of 1.53:1. The median age was 33 years. Tuberculosis was most prevalent in the age group of 16-30 years (41.6%), followed by 31-45 years (36.4%). The tuberculosis prevalence was 16.8% above 45 years age group and 5.2% below 16 years age group. Since tuberculosis hits the productive age group the most, absenteeism from work because of ailing health is high, putting stress on the meagre family income of the daily wage earners. It weakens those who are on treatment and there by affects their physical ability to work, earn a living and support the family. Many a time tuberculosis patients are stigmatized and ostracized by their family or employers. A patient of tuberculosis takes an average three to four months to recuperate, loosing that much more income. The loss is disastrous for those struggling against poverty. As most garden labours are poor, they usually don't take medicines regularly after diagnosed with tuberculosis and they are most likely to be defaulting in treatment. The vast majority (more than 90%) of the economic burden of tuberculosis in tea garden population of Assam is caused by the loss of life rather than morbidity. Tuberculosis kills more women in reproductive age group than all causes of maternal mortality combined in the tea garden population of Assam, and it creates more orphans than any other infectious diseases. The indirect impact of tuberculosis on children is considerable. Many a time children drop out from school to work and supplement the family income. The situation can be improved.

The tuberculosis burden in the tea gardens of Assam can be controlled. But, concrete steps both at the tea garden community level and the management level need to be taken for that. Early detection and complete treatment of tuberculosis cases, better health care system, proper health education and tuberculosis awareness, prevention of malnutrition, and better living conditions among the tea garden population are the keys to reduce the tuberculosis burden in the tea gardens of Assam.