GS Paper: GS2-13.Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

What’s the news?

• World Heart Day, observed globally on September 29, serves as a crucial reminder of the escalating threat posed by cardiovascular diseases (CVD) and the need to promote heart-healthy lifestyles.

Central idea

• World Heart Day, an annual event, initiated by the World Heart Federation in collaboration with the World Health Organization (WHO) in 2000, seeks to heighten awareness, engage communities, and advocate for universal access to CVD prevention, detection, and treatment. Tackling the silent epidemic of cardiovascular diseases in India demands a multi-pronged approach.

Public Awareness Efforts on CVD

• On World Heart Day, several English-language national dailies published full-page advertorials, which are advertisements designed to resemble written articles. These advertorials aimed to raise awareness about cardiovascular diseases (CVD) and promote heart-healthy lifestyles.
• The content of these advertorials seemed to provide information about CVD rather than directly promoting a product.
• Notably, there was limited involvement or a meaningful campaign by public health agencies like the Union Ministry of Health in raising awareness about CVD on this occasion.
• These advertorials were sponsored by the diagnostics, devices, and pharmaceutical industries, indicating a partnership between these industries and media outlets for public awareness efforts.
• Additionally, clinicians from high-end corporate tertiary care hospitals contributed by providing lifestyle modification advisories as part of the public awareness campaign

Alarming Data on Hypertension

• Data from the National Family Health Survey-5 (2019–2021) and the 2017-18 National NCD Monitoring Survey (NNMS) in India reveals concerning statistics about hypertension.
• The NFHS-5 data shows that 18.3 percent of the country’s population has hypertension, while the NNMS reports a higher rate of 28.5 percent among individuals aged 18-69.
• These percentages translate to significant numbers, given India’s large population.
• Both surveys highlight low levels of awareness, treatment, and control of hypertension.

Treatment Gaps and Disparities

• The NNMS data indicates that only 28 percent of those with hypertension were aware of it.
• Among those aware, 52 percent were receiving treatment, and a smaller percentage had their blood pressure under control.
• Disparities exist based on factors such as education, income, and geographic location, with better access to healthcare services in south India.
• Vulnerable groups, including males, illiterates, those with lower income, rural residents, smokers, and alcohol users, were less likely to be part of the treatment cascades.

Efforts in India

• India launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) in 2010, expanding its implementation.
• The program primarily focuses on screening and treatment.
• India is committed to the principles of primary healthcare and Universal Health Coverage (UHC), as outlined in the 2018 Astana Declaration.

Challenges

• Challenges include inadequate awareness, limited healthcare access in various regions, and disparities in healthcare access and outcomes. More resources are needed for primary healthcare.
• Contemporary approaches to managing CVD heavily emphasize risk factors, particularly lifestyle-related ones like diet, physical activity, smoking, and obesity.

• Epigenetic modifications may emerge as a consequence of a lifetime of disadvantage, structural inequalities, and discrimination, thereby influencing future generations.

• There is a challenge in retaining rural health workers.

The Need for a Holistic Approach

• Contemporary approaches to managing cardiovascular diseases (CVD) emphasize lifestyle risk factors.
• The WHO’s Commission on Social Determinants of Health highlights that these risk factors often result from systemic compromises rather than individual choices.
• The Commission emphasizes addressing socioeconomic factors that affect health across an individual’s lifespan and calls for equity and social justice in healthcare.

Conclusion

• As the WHO rightly asserts, Reducing health inequities is… an ethical imperative. Social injustice is killing people on a grand scale. World Heart Day serves as a stark reminder that the battle against CVD must continue with renewed vigor and a holistic perspective.

What’s the news?

• The recent case where a manufacturer of indigenous drugs filed a lawsuit against a medical practitioner over a social media thread has ignited discussions in medical circles.

Central idea

• The recent case prompts us to explore the broader questions surrounding the role of traditional medicine in our modern world, the principles of evidence-based medicine, and the steps governments should take to ensure the health of their populations.

The Evolution of Modern Medicine

• Early Medical Practices: In ancient civilizations, various cultures developed their own medical systems, often rooted in traditions and observations. These practices formed the foundation upon which modern medicine would later build.
• Scientific Renaissance: The Renaissance period in Europe marked a resurgence of interest in science and inquiry. This era laid the groundwork for the scientific approach that modern medicine would adopt.
• 19th Century Advancements: The 19th century witnessed significant strides in medical science and technology. Innovations such as the microscope, anesthesia, and surgical techniques transformed medical practices.
• Evidence-Based Medicine: Modern medicine became truly science-based in the late 19th century, when advances in technology allowed for a more accurate understanding of human physiology, health, and disease. The adoption of evidence-based approaches has become a hallmark of modern medical practice.
• Technological Marvels: The 20th century saw unprecedented developments in medical technology, including the advent of diagnostic imaging, organ transplantation, and the establishment of pharmaceutical research. These advancements revolutionized patient care.
• Global Collaboration: The latter half of the 20th century and the early 21st century have been characterized by increased global collaboration in healthcare. Medical knowledge, research, and innovations have transcended geographical boundaries, leading to improved healthcare outcomes worldwide.

The Global Nature of Modern Medicine

• Global Scientific Collaboration: Researchers worldwide work together to advance medical knowledge and develop innovative treatments.
• Access to Innovations: Patients globally benefit from medical breakthroughs, ensuring wider access to cutting-edge treatments and technologies.
• Healthcare Diplomacy: Many countries engage in healthcare diplomacy, offering aid and expertise to regions in need and fostering goodwill.
• International Healthcare Workforce: Healthcare professionals from diverse backgrounds contribute their expertise globally, addressing healthcare disparities.
• Cross-Cultural Integration: Modern medicine respects diverse healthcare approaches, integrating traditional medical systems and practices from different cultures.
• Pandemic Response: The COVID-19 pandemic highlighted global health interconnectedness, emphasizing collaborative efforts in vaccine development, information sharing, and medical aid distribution.

Traditional Medicine in the Modern World

• Traditional medicine, which includes systems like Ayurveda, Unani, and Siddha, continues to coexist alongside modern medicine. These traditional systems have a long history and cultural significance. However, their place in the modern world is subject to several challenges:

• Scientific Scrutiny: Traditional medicine often lacks the rigorous scientific validation that modern medicine adheres to. This can hinder its integration into the mainstream healthcare system.
• Safety and Quality Control: Ensuring the safety and quality of traditional medicines can be a concern. Contaminants, inconsistent formulations, and a lack of standardized production processes can lead to safety issues.
• Lack of Standardization: Traditional medicine formulations can vary widely from one source to another, making it difficult to assess their efficacy consistently.
• Cultural and Ethical Considerations: Traditional medicine is deeply rooted in cultural and traditional beliefs. Balancing cultural practices with modern medical standards can be complex, as some treatments may hold cultural significance but lack scientific validation.
• Education and Training: There is a need for comprehensive education and training programs to ensure that practitioners of traditional medicine are well-informed about modern medical standards and safety protocols.

Challenges in Evaluating Ayurvedic Medicines

• Complex Formulations: Ayurvedic medicines often consist of multiple herbs and ingredients, making it challenging to isolate and study the specific active components responsible for their effects.
• Diverse Combinations: Ayurvedic formulations can vary widely in their combinations of herbs and minerals. Understanding how these components interact and their individual contributions to treatment can be complex.
• Lack of Standardization: There is a lack of standardized protocols for the production and quality control of Ayurvedic medicines, affecting the consistency and safety of products.
• Integration with Modern Science: Bridging the gap between traditional Ayurvedic knowledge and modern scientific methods is essential. Developing research methods that respect Ayurvedic principles while adhering to contemporary scientific standards is a challenge.

The government’s role in promoting evidence-based medicine

• Regulation and Oversight: Governments should establish regulatory bodies to oversee traditional medicine practices, ensuring they meet safety and quality standards. This includes setting guidelines for the manufacturing, labeling, and marketing of traditional medicines.
• Research and Funding: New investigational methods and trial designs that can evaluate Ayurvedic therapies without undermining the classical basis of administering them must be worked out. The Ministry of AYUSH must facilitate this.
• Public Awareness: Governments can educate the public about the benefits and limitations of traditional medicine, promoting informed choices when seeking healthcare.
• Integration with Modern Healthcare: Promoting collaboration and integration between traditional and modern healthcare systems can provide patients with a more comprehensive range of treatment options.

Way forward: Maintaining an Open Mind

• Balanced Perspective: Maintain a balanced view when assessing traditional medicine alongside modern healthcare, considering both potential benefits and limitations.
• Open-mindedness: Embrace open-mindedness in exploring traditional practices for potential insights, fostering an environment of curiosity and exploration.
• Informal Verifications: Acknowledge the value of centuries of informal verifications in traditional medicine, recognizing that these practices have been refined through generations of use.
• Cultural Significance: Traditional medical systems are often deeply intertwined with cultural heritage and beliefs. Respecting and acknowledging this cultural significance is essential when considering their place in modern healthcare.
• Historical Insights: The reference to artemisinin, a Nobel-winning anti-malarial drug derived from a 1,600-year-old text of Traditional Chinese Medicine, underscores the potential for valuable discoveries when traditional knowledge is integrated with modern scientific methods.
• Collaboration: Encourage collaboration between traditional practitioners and modern scientists, promoting dialogue and cooperation for the advancement of healthcare.
• Evidence-based Approach: Subject traditional knowledge to rigorous scientific evaluation to ensure safety and efficacy, aligning with the principles of evidence-based medicine to validate its effectiveness.

Conclusion

• The coexistence of traditional and modern medicine systems is a testament to the diversity of human healthcare practices. It is crucial to embrace a nuanced approach that recognizes the strengths and limitations of each system, fostering an environment where science and tradition can collaborate for the betterment of public health.

Also read:

Homeopathy and associated issues

 

What’s the news?

• World Mental Health Day, observed on October 10, underscores the theme of ‘mental health as a universal human right.’

Central idea

• While the World Mental Health Day theme highlights the importance of mental health for all, it’s crucial to address the often-overlooked mental health challenges of India’s informal workers. This necessitates proactive policies aligning with the Sustainable Development Goals (SDGs).

The Global Perspective

• According to the International Labour Organization (ILO), approximately 15% of working-age adults globally live with a mental disorder.
• Decent work can positively influence mental health, but unemployment, unstable employment, workplace discrimination, and unsafe working environments pose significant risks to mental health.
• Informal workers, particularly those in low-paid and precarious jobs, often face psychosocial risks that compromise their mental well-being.

India’s Informal Workforce

• India’s informal workforce constitutes over 90% of the total working population. These workers endure unsafe conditions, work long hours, and have limited access to social and financial protections.
• Discrimination and gender disparities are prevalent, with over 95% of working women engaged in informal, low-paying, and precarious employment.
• The mental health of informal workers is further undermined by patriarchal structures and practices in their social and familial spaces.

Challenges faced by the informal workforce in India

• Lack of Formal Protections: Informal workers often lack legal and social protections. They work without employment contracts, job security, or access to benefits like health insurance and paid leave.
• Unsafe Working Conditions: Many informal workers labor in hazardous environments, increasing their risk of occupational health and safety issues.
• Long Working Hours: Informal workers frequently work long hours, often without clear boundaries between work and personal life, affecting their physical and mental well-being.
• Limited Access to Social Protections: These workers have limited access to social safety nets, making them vulnerable to economic shocks such as illness or job loss.
• Gender Disparities: Gender disparities are pronounced in the informal sector, with many women engaged in low-paying and precarious employment. Discrimination and patriarchal structures exacerbate these challenges.
• Precarious Employment: Informal work is characterized by its precarious nature, including irregular income, job insecurity, and uncertainty about future employment.
• Income Inequality: Informal workers often earn lower wages than their formal sector counterparts, contributing to income inequality.

Youth and Unemployment

• Youth unemployment is a pressing issue in India, significantly affecting mental health.
• Many young workers are forced into precarious and informal work due to desperation, accepting lower pay and poorer working conditions.
• Unemployment rates are particularly high among educated young women, reaching 42%.
• Given India’s demographic dividend, it is crucial to prioritize employment quality and long-term social security for this population.

Aging Workforce and Vulnerability

• India is expected to become an aging society in two decades, yet there is no clear social security plan for this growing demographic group.
• The Census of India 2011 reveals that 33 million elderly individuals continue working in informal sectors post-retirement.
• This vulnerable group lacks financial and health-care security, which can severely impact their physical and mental health.

Social Security and Mental Health

• Informal workers face mental distress due to accumulating debt and rising health-care costs: Informal workers often experience financial strain due to their precarious employment, leading to the accumulation of debt and increased healthcare expenses.
• Interconnectedness of Economic and Mental Health Factors: Mental health and well-being are interconnected with factors such as food security, access to livelihoods, and financial stability. These factors play a significant role in determining the mental health of informal workers.
• Post-COVID-19 Recovery Challenges: A study conducted among informal workers in Delhi, primarily migrants, reveals that the recovery post-COVID-19 remains uneven among different cohorts of informal workers. Many still report food insecurity, skipped meals, or reduced consumption, which can have detrimental effects on their mental health.
• Impact of Government Schemes: While some social security schemes have received increased funding, others, like the MNREGS, have seen reductions in funding. Adequate funding of employment guarantee programs can positively impact the mental health outcomes of informal workers.
• High Suicide Rates Among Daily Wage Earners: The National Crime Records Bureau (NCRB) reported that in 2021, 26% of people who died by suicide were daily wage earners. This statistic highlights the mental health challenges faced by this group and the need for better support and social security measures.
• Types of Social Security Measures: Social security measures can take various forms, including:
  1. Promotional: Aimed at augmenting income.
  2. Preventive: Intended to forestall economic distress.
  3. Protective: Designed to ensure relief from external shocks.
• The Code on Social Security 2020: It is necessary to revisit the Code on Social Security 2020, highlighting that it doesn’t explicitly state the goal of universalizing social security in India, particularly for informal workers.

Way Forward: Improving Mental Health Care

• Low Budgetary Allocation for Mental Health: India’s budgetary allocation for mental health currently stands at less than 1% of the total health budget. This allocation has predominantly focused on digital mental health programs.
• Importance of Community-Based Care: The World Mental Health Report 2022 emphasizes the need to strengthen community-based care as part of a comprehensive mental health approach.
• Human Rights-Oriented Care: To address mental health effectively, it is important to provide people-centered, recovery-oriented, and human rights-oriented care.
• Urgent Need for Proactive Policies: There is a pressing need for proactive policies that not only recognize the importance of mental health but also take concrete actions to improve mental health care in India.
• Basic Human Right to Good Health: Mental health is a basic human right, and it emphasizes the need to uphold this right by providing access to quality mental health care.

Alignment with Sustainable Development Goals (SDGs)

• SDG 3: Good Health and Well-Being: Improving mental health care aligns with SDG 3, which aims to ensure good health and well-being for all.
• SDG 8: Decent Work for All/Economic Growth: Addressing mental health issues among informal workers is crucial for advancing SDG 8, which focuses on decent work for all and economic growth.

Conclusion

• Proactive policies and comprehensive social security measures can uplift the mental well-being of this marginalized group, promoting a society where mental health is indeed a universal human right. Achieving this goal will contribute to the realization of the Sustainable Development Goals and ensure a healthier, more equitable future for all.

What’s the news?

• In June 2023, a study conducted by the Madras Diabetes Research Foundation in collaboration with the ICMR and the Union Health Ministry revealed alarming statistics about India’s diabetes crisis.

Central idea

• According to the study, 11.4% of India’s population, approximately 10.13 crore people, are living with diabetes. According to the WHO, a major reason for this is the consumption of unhealthy, ultra-processed foods and beverages. These statistics demand immediate attention and concrete actions to address the root causes of this public health crisis.

Key findings of the study

• Living with diabetes: 4% of India’s population, or 10.13 crore people, are living with diabetes.
• Pre-diabetic: 3% of the population, or an additional 13.6 crore people, are pre-diabetic.
• Obese Population: 6% of the population would be considered obese as per the BMI measure.

The consumption of ultra-processed foods: a significant contributor

• Contents of Ultra-Processed Foods:

• Ultra-processed foods encompass a wide range of products, including carbonated drinks, instant cereals, chips, fruit-flavored drinks, instant noodles, cookies, ice cream, bakery items, energy bars, sweetened yogurts, pizzas, processed meat products, and powdered infant formulas.
• These items are often characterized by their convenience and long shelf life.

• Increased Risk of Diabetes with Scientific Evidence:

• A concerning statistic reveals that a mere 10% increase in daily consumption of ultra-processed food is associated with a 15% higher risk of type-2 diabetes among adults.
• These foods are often high in sugar, fat, and salt, all of which contribute to insulin resistance and elevated blood sugar levels.

• Impact on Weight Gain:

• Ultra-processed foods are engineered to be hyper-palatable. They often contain combinations of sugars, fats, and artificial additives that stimulate the appetite and lead to overconsumption.
• This excessive calorie intake can result in weight gain, a known risk factor for type 2 diabetes.

• Structural Alteration:

• When food undergoes extensive processing, its original structure is often destroyed. Cosmetic additives, colors, and flavors are added to enhance taste and appeal.
• This altered structure and excessive processing can disrupt the body’s natural regulation of hunger and satiety, leading individuals to eat more and gain weight.

• Association with Cardiovascular Risks:

• The negative effects of ultra-processed foods extend beyond diabetes. Obesity and diabetes are key risk factors for heart disease and premature mortality.
• Research indicates that those who consume more than four servings of ultra-processed foods per day face a significantly higher risk of cardiovascular mortality compared to those who consume fewer than two servings per day.
• A similar trend is observed for all-cause mortality.

Exploitative marketing practices

• Shifting Focus to Low- and Middle-Income Countries:

• In many high-income countries, the sale of sugar-sweetened beverages has declined over the past two decades due to growing awareness of their health impacts.
• To compensate for this loss of sales, food companies have shifted their attention to low- and middle-income countries, where there may be less stringent regulations and a growing consumer base.

• Aggressive Marketing and Advertising:

• These companies invest substantial amounts of money in marketing and advertising ultra-processed food and beverages in countries like India.
• These aggressive marketing campaigns often target vulnerable populations, including children and the emerging middle class.
• Techniques like the use of cartoon characters, incentives, gifts, and celebrity endorsements are employed to make these products more appealing.

• Blaming Individuals vs. Addressing Systemic Issues:

• The food industry tends to place blame on individuals, suggesting that personal choices are responsible for unhealthy dietary habits.
• However, the environment created by aggressive marketing and the easy accessibility of ultra-processed foods play a significant role in shaping these choices.

• Impact on Public Health:

• The consequences of these marketing strategies are severe. They contribute to a deepening public health crisis, with diabetes being a ticking time bomb.
• Sugar-sweetened beverages, in particular, are highlighted as a major source of added sugar in diets, putting people at a higher risk of type 2 diabetes and other health issues.

The need for regulatory intervention

• Industry Opposition: The food industry resists marketing restrictions, citing economic concerns and portraying themselves as stakeholders.
• False Promises: Some industry initiatives, like ‘Eat Right,’ may appear health-focused but could divert attention from unhealthy product impacts.
• Impact on Regulation: Industry partnerships can hinder strong regulatory policies aimed at reducing ultra-processed food consumption.
• Role of Regulatory Authorities: Lackluster responses and industry dominance in regulatory bodies may impede effective public health regulations.
• Complementary Efforts: While exercise is essential, it should complement regulatory policies addressing marketing and warning labels on unhealthy foods.
• Balancing Interests: Governments must prioritize citizens’ health, striking a balance between industry interests and public well-being when implementing evidence-based, transparent regulations.

Strategy to safeguard: Mandatory Provisions

• To protect the public from the manipulative strategies of the food industry, the government must establish a legal framework or even an ordinance under Article 123 of the Constitution.
• This framework should focus on reducing or halting the consumption of ultra-processed foods and could include:

1. Defining ‘healthy food’
2. Implementing warning labels on unhealthy food
3. Imposing restrictions on the promotion and marketing tactics of unhealthy food and beverages
4. Raising public awareness about the risks associated with consuming such foods

Global Examples

• Several countries, including South Africa, Norway, and Mexico, have recently taken similar actions to regulate food labeling and marketing.
• The Indian government has the opportunity to demonstrate its commitment to public health by enacting similar laws.
• Much like the Infant Milk Substitutes, Feeding Bottles, and Infant Foods Act, which successfully regulated commercial baby food, this proposed legislation could make significant strides in curbing the consumption of unhealthy foods and beverages.

Conclusion

• India stands at a critical juncture in its battle against diabetes and a food industry that prioritizes profits over public health. The time has come for the government to implement robust regulations. By taking decisive action, India can protect the well-being of its citizens and set a precedent for responsible food regulation in the global context.

Also read:

Is India a Diabetes capital of the world?

What’s the news?

• TB, which affects over 25 lakh Indians every year and kills at least 1,000 every day, As India is on the cusp of a demographic shift, with the elderly population set to comprise a substantial portion of society, it is imperative to invest in the health of our elderly population and pay attention to their unique needs.

Central idea

• Advances in healthcare and increased life expectancy are propelling India’s demographic transition, with the elderly projected to constitute 12.5% of the population by 2030, up from 9% in 2011. This underscores the urgent need for age-responsive healthcare systems to address the complexities of TB care among the elderly, aligning opportunity with responsibility.

What is tuberculosis (TB)?

• TB is an infectious disease caused by the bacterium Mycobacterium tuberculosis.
• It primarily affects the lungs but can also affect other parts of the body, such as the kidneys, spine, and brain.
• TB is transmitted through the air when an infected individual coughs, sneezes, or speaks, releasing tiny droplets containing the bacteria. When inhaled by others, these droplets can lead to infection.

The Burden of TB among the Elderly

• Recent findings from India’s National TB Prevalence Survey in 2021 reveal a concerning trend: the prevalence of TB among individuals aged 55 and above stands at 588 per one lakh population, significantly higher than the national average of 316.
• This alarming disparity necessitates a dedicated focus on TB among the elderly and the formulation of age-specific TB guidelines.

Challenges faced by elderly TB patients

• Delayed Diagnosis: TB symptoms, including cough, fatigue, and weight loss, are often misinterpreted as signs of old age or other illnesses. Consequently, TB diagnoses among the elderly are frequently delayed or overlooked.
• Comorbidities: Many elderly TB patients have multiple comorbidities, especially diabetes, which complicates TB management. This leads to a higher pill count and an increased likelihood of side effects, affecting treatment adherence and outcomes.
• Access to Healthcare: Elderly individuals, particularly those in rural and hilly areas, struggle to access healthcare facilities due to mobility challenges. This can lead to delays in seeking medical care.
• Limited Information: Older individuals may have restricted access to reliable health information, as their social networks tend to shrink with age. This lack of information hampers their ability to recognize TB symptoms and seek timely medical attention.
• Economic Dependence: Most individuals over the age of 60 are retired and financially dependent on savings or family. While there are some social welfare schemes for the elderly, they often have limitations and may not provide adequate financial support.
• Stigma and Mental Health: TB-related stigma is a concern among the elderly, contributing to social isolation. Many elderly TB patients experience loneliness, anxiety, and a sense of purposelessness, negatively impacting their mental health.

Strategies to address these challenges and provide elder-friendly TB care

• Holistic Care Models: Transition from disease-specific care to holistic models that reduce the need for elderly patients to interact with multiple healthcare providers and facilities.
• Health Professional Training: Build the capacity of healthcare professionals at all levels to better understand TB in the elderly and manage multiple comorbidities effectively.
• Improved Case-Finding: Enhance case-finding mechanisms through effective sputum collection and transportation systems, mobile diagnostic vans, and active case-finding at geriatric OPDs and residential homes.
• Technical Protocols: Develop technical and operational protocols that guide the diagnosis and treatment of TB in the elderly, including sample extraction, comorbidity assessment, and drug dosage adjustments.
• Socio-Economic Support: Design and implement support protocols in consultation with elderly TB patients, including community care models, doorstep medicine delivery, peer support, counseling, and assistance with accessing social support schemes.
• Data Collection and Analysis: Ensure rigorous gender and age-disaggregated data collection and analysis to identify TB trends among the elderly, with a dedicated age category in all TB reports.
• Strengthen Collaboration: Foster collaboration within the healthcare system to build elderly-friendly care systems effectively.
• Research Agenda: Promote research focused on TB in the elderly, exploring state-specific trends, substance use, drug resistance, co-morbidity patterns, TB preventive therapy uptake, and intersectionality with other equity aspects.

Conclusion

• On this International Day of Older Persons, India must reaffirm its commitment to the well-being of its elderly citizens. By implementing age-responsive TB care models, strengthening healthcare systems, and conducting focused research, we can pave the way for a healthier, more inclusive future for our aging population.

Also read:

India’s diabetes epidemic is making its widespread TB problem worse