How drug-resistant tuberculosis is bringing life to a halt in India

At a government-run tuberculosis (TB) hospital in Mumbai’s Malad suburb, 29-year-old Usha and her mother wait patiently for their turn to get medicines. Uma, who is 50, was diagnosed with Drug-Resistant Tuberculosis (DR-TB) a week ago at a private clinic. She wears a weary look on her face.

"I have been coming to this hospital for three days for these medicines, leaving my work aside—with no doctor in sight. My mother's condition has worsened over a week, with a persistent cough and fever due to delayed treatment," Usha says. 

At another government-run hospital in the nearby suburb of Kandivali, frail-looking,  40-year-old Ashok—the sole breadwinner of his family of three—waits. Diagnosed with TB nearly seven years ago, he now fears a relapse. “I was coughing heavily and unable to breathe when I was first diagnosed. I completed my treatment and recovered, but recently, I have begun experiencing chest pains again and fear that a relapse is imminent."  

In 2018, the Government of India launched the Nikshay Poshan Yojana to provide monthly monetary assistance of Rs. 500 to TB patients for adequate nutrition through centralised Direct Benefit Transfers (DBT). The amount of the aid was raised to Rs. 1,000 earlier this year. At the time of the scheme’s launch, Ashok—the resident of a small tenement in Mumbai—didn’t reap any of its benefits because he was unaware about the Yojana. And though he received timely medication from the government hospital, managing his nutrition as per the doctor’s advice was challenging, as both his wife and son depended on him.  He believes that the government should provide sufficient financial assistance and rations to patients suffering from the disease.  

Globally, India leads in DR-TB with 1,35,000 cases of MDR/RR TB annually due to a lack of rapid diagnoses in low-resource settings, posing a significant constraint on DR-TB treatment.

Many vulnerable socio-economic populations in India, especially informal and migrant workers, are unable to afford the luxury of rest and proper nutrition without remaining reliant on daily wage work. This is despite schemes like the Nikshay Poshan Yojana, as patients in need remain unaware about their provision. 

A silent crisis

The United Nations defines TB as a bacterial infection primarily affecting the lungs, but it can also affect the brain and spine. It is caused by the Mycobacterium tuberculosis bacteria. The World Health Organization states that India has the highest number of TB cases worldwide; the country reported 26.07 lakh tuberculosis cases in 2024, with Uttar Pradesh reporting the highest cases at 6,81,779, followed by Maharashtra at 2.25 lakh cases. Mumbai contributed 60,051 cases to the state's numbers in 2024.

The death rate from multidrug-resistant TB (MDR-TB), specifically, hovers around 20% in India—higher than the global average of 17%. These figures depict dire on-ground realities; for context, the National Tuberculosis Elimination Programme (NTEP) aimed to eradicate TB by 2025, five years ahead of the Sustainable Development Goals (SDGs) target of 2030.

‍

The different types of DR-TB are mono-resistant, poly-resistant, MDR-TB, and extensively drug-resistant TB (XDR-TB). Around 3.2% of new DR-TB cases are MDR-TB/rifampicin-resistant—they resist first-line drugs, or the first round of drugs that is administered when the bacteria still responds to medication. When the bacteria resists this first round, like in the case of DR-TB, the infection is fought with a different combination of medicines: second-line drugs, which can be more toxic, more expensive and less effective. 

Globally, India leads in DR-TB with 1,35,000 cases of MDR/RR TB annually due to a lack of rapid diagnoses in low-resource settings, posing a significant constraint on DR-TB treatment. As a result, it is estimated that around 56% of MDR-TB cases remain undiagnosed in India.  

The WHO guidelines recommend using rapid molecular tests like GeneXpert to diagnose DR-TB instantly, offering detection in less than two hours, compared to conventional culture-based methods, taking several days or weeks. However, these services are scarce in the rural hinterlands of India, especially the Northern states.  

Only one in three DR-TB patients worldwide receive high-quality care, the WHO notes. In India, which contributes over 27% of global cases, DR-TB presents a significant public health problem, as patients often require changes in their treatment plans, usually linked to poor treatment adherence in peripheral and resource-limited zones. Drug-resistant tuberculosis cases increased by 36% in Mumbai between 2015 and 2017. 

In 2022, the WHO recommended using a shorter six-month regimen called BPalM, consisting of four drugs, to treat DR-TB—compared to the standard 18-24 month regimen—as it has a global success rate of 85%. This positive statistic comes with better treatment outcomes, reduced mortality rates and less infectiousness in recovery. BPalM is also significantly more cost-effective—and the reduced treatment costs ensures more access to patients.

However, India has adopted this regimen conditionally, and private practitioners don't have access to prevent its misuse. In Mumbai, a hotspot for drug-resistant TB, only 144 patients have been given the BPalM regimen this year on a pilot basis.  

Also read: Antibiotic overuse is turning your gut against you

DR-TB’s persistence, and nutrition’s role in fighting it

There are several types of TB. It can be inactive (latent TB): the infected individual does not have symptoms and cannot spread the infection, which is suppressed by treatment. It can be active: the infected individual can spread the infection through droplets in the air.

Active TB can be treated and even cured, but it is a particular kind of active TB that scares doctors and patients alike: the forms that are drug-resistant, meaning one or more anti-TB drugs administered to the patient show no effect on the bacteria. It fights back. 

Dr. Indu Bubna, a Mumbai-based pulmonologist with over 20 years of experience, says, "DR-TB is a form of TB that does not respond to the primary anti-TB drugs, particularly isoniazid, and rifampicin because of incomplete or incorrect treatment. DR-TB is more toxic and requires lengthier treatment." According to Dr Bubna, the challenge emerges when a patient is diagnosed with XDR-TB (extensive drug-resistant TB)—a more severe form of DR TB—making the case more complex with the failure of second-line drugs.  

Though India is widely considered the ‘pharmacy of the world’, TB patients in the country suffer due to the lack of medicines.

"In India, before visiting a government Directly Observed Treatment (DOT) centre, patients tend to self-medicate, delaying diagnosis. Often, treatment is started based on X-rays without the appropriate tests because of strained finances," Dr Bubna adds. Drug shortages during the patient's treatment can also cause interruption, making the disease more resistant.  

TB is known as the "disease of poverty" because the chances of contracting it are furthered by factors such as malnourishment as well as the lack of air and sunlight in cramped residences. An airborne disease, it is caused only by inhaling infectious droplets from the air. TB is not caused by any changes in diet, or anything in the water, but these are still really important factors in the context of the disease. Malnutrition renders the immune system weak; a malnourished person is more at risk to get infected by TB—in fact, it increases the risk by 13.8% per unit decrease in the body mass index (BMI). The body’s ability to respond to treatment is severely affected, as poor nutrition can prolong recovery. Moreover, some people develop resistance to TB over time, and this can be due to the lack of access to proper nutrition and prescribed, timely dosages. 

Malnourishment is also a risk factor in converting latent TB to active TB, and this weakness in immunity also makes patients less likely to recover once they do contract the disease. 

Dr Bubna points out that the incidence of TB is now increasing in the middle and higher income sections of India’s population as a result of one specific reason: these sections follow rigid, traditional diet regimens that are often lacking in nutrition. "TB is not just about malnourishment—it also manifests in patients who don't eat food on time and travel in overcrowded spaces. Furthermore, people with HIV, diabetes and those who indulge in drug abuse are also vulnerable," says Dr Bubna.

Malnutrition renders the immune system weak; a malnourished person is more at risk to get infected by TB—in fact, it increases the risk by 13.8% per unit decrease in the body mass index (BMI).

The prevalence of TB can be linked clearly to a lack of access to nutrition as well as a flawed approach to nutrition. Dr. Bubna explains, “While the Public Distribution System (PDS) and mid-day meal programs provide calories and iron-fortified staples like rice and atta, these diets often lack adequate protein and key micronutrients. Protein is especially important because it helps rebuild tissues, strengthen muscles, and restore immune function. Micronutrients such as zinc, vitamin D, vitamin A, and B-complex vitamins are also vital for immune defense and healing, but these are often missing in the diets of TB patients.” The gap lies in the difference between calorie sufficiency and nutrient adequacy: patients often get food that satiates hunger, but does not provide the quality of nutrition required for faster recovery and reduced relapse risk.

"In India, most people lack either vitamins B12 and D, or protein,” Dr. Bubna points out. This is also reflected in the burden of disease that India carries: we account for around 27% of TB cases across the world. A well-balanced diet rich in proteins and vitamins, like iron, zinc, B12, and D3, is essential for patients battling DR-TB. Addressing TB care's social and nutritional loop is essential for its elimination. 

According to government data, over Rs. 3,200 crore have been disbursed to 1.13 crore TB patients under the Nikshay Poshan Yojana; the government has committed another Rs. 1,040 crores as a 60:40 divide between the centre and states, under the same programme.

The unaffordability of nutrition is a concern for several patients in India. Even with low prices, a healthy diet remains out of reach for nearly 74% of Indians, according to a UN agency report. "Doctor sensitivity also plays a crucial role in wholesome counselling. Without that, the prescription is never complete. Every TB patient should have a protein and iron-rich diet, comprising green leafy vegetables, one fruit, paneer, soya, and several proteins, because they have a high risk of relapse and mortality for DR-TB." 

Also read: The warning about antibiotics we should have heeded

The realities of testing, monitoring and privilege

To improve diagnostic services, says Dr. Bubna, governments must decentralise testing, improve sample transport, and integrate private labs into the national network—changes that are underway in Mumbai. However, India’s more remote centres lack even basic tests like the Line Probe Assay (LPA), a quick molecular test that presents results within 24–48 hours. 

Screening and testing for TB early and accurately is extremely crucial to treatment and recovery from this infection, and there are multiple provisions in place for this. In 2012, the Government of India made TB notification mandatory for both public and private sector healthcare providers. In 2017, the Government of India announced a National Strategic Plan (NSP) to eliminate TB, and set aside a budget specifically for testing. The very next year, the Ministry of Health and Family Welfare issued another order stating that doctors, pharmacists, chemists, and laboratory staff could face jail time if they fail to notify TB cases.

Despite these stringent rules, India contributes approximately 25% of “missing” TB cases globally, as the WHO estimates that approximately 1 million TB cases in India are not recorded annually. A detailed report from IndiaSpend reveals that while the NSP aimed to spend funds on diagnostic equipment, testing kits, and increasing testing in the private sector, they only spent “2.1% of  [their] budget (Rs 4.34 billion) on diagnostics up to 2023-24.” While the 100-day campaign to eradicate TB introduced by the centre in 2024 did amp up testing and diagnosis in several states, the overall practice remains uneven in the country. In some places, testing facilities are either defunct or non-existing, like in Haryana—where the only state-level laboratory closed due to lack of support staff—or districts in Bihar, where none existed until 2020. As a result, it is estimated that around 56% of MDR-TB cases remain undiagnosed in India.

Even delayed results of testing pose a threat for this precarious disease. Public health activist and TB survivor Ganesh Acharya draws attention to how delays in test results, even for basic investigations like X-rays, can have negative consequences. "Referrals by doctors at government-run hospitals require a 15-day window to provide services like CT and MRI, making the initial stage more painful for patients with significant out-of-pocket expenditures. Ideally, test results should be available in two hours through the Cartridge-Based Nucleic Acid Amplification Test (CBNAAT).” CBNAAT is a rapid molecular diagnostic test used to detect TB, which promises quicker results because it’s a fully automated test that analyses DNA from sputum samples. “However, the lack of resources and the staff makes the provision challenging.” Acharya adds. 

Despite these stringent rules, India contributes approximately 25% of “missing” TB cases globally, as the WHO estimates that approximately 1 million TB cases in India are not recorded annually.

According to Firoz Shaikh, the general district supervisor for Mumbai's TB department, "The testing facilities for the GeneXpert test—a type of CBNAAT test—are available for free in government hospitals like the Sewri Hospital, Topiwala Hospital, and Shatabdi Hospital in Mumbai." Yet, a glaring concern is that the government department only contacts patients seeking private treatment to complete their treatment on time—a provision largely missing for patients in government-run hospitals, according to Shaikh. 

"Usually, patients from higher income groups don't register on the Nikshay portal for the government's DBT transfers. Sometimes, patients receive Rs 1000 monthly for their treatment, but there are times when the amount is released later. To resolve this, patients can download the Nikshay Mitra application and complain using the toll-free number." Shaikh adds that the Nikshay schemes have been relatively successful in Maharashtra compared to other states in India. "The patients respond regularly to avail these schemes in Maharashtra as the diagnosis rate is higher."  

Public health activist Acharya rues the lack of accountability within the public sector. “The Nikshay Poshan Yojana is a centralised Direct Benefit Transfer (DBT) scheme; I don't understand the reasoning behind delays in payments. Furthermore, I have heard of cases where individuals have received only Rs 500 (half of what they ought to have received).”  These gaps are glaring, especially when we consider that a trial held in the states of Odisha and Jharkhand found that adequate food packages given to patients significantly improved their health outcomes.

Challenges in testing and monitoring only add to the financial and emotional burden caused by drug shortages. Though India is widely considered the ‘pharmacy of the world’, TB patients in the country suffer due to the lack of medicines. For instance, essential treatment drugs are unavailable for months in states like Uttar Pradesh. In 2023, a Times of India report found that Pilibhit in Uttar Pradesh was facing a drug shortage, unable to provide for approximately 1,200 frontline TB patients, including 124 MDR-TB patients.  

"Skipping a dose on even one day is a big mistake for a TB patient, but there is nothing one can do when the government machinery runs out of medicine. This is a very negative aspect of the program, as it fails to address the systematic gaps for essential medicines," says Acharya.  

What can be done better? 

Dr. Bubna steers the conversation back to patients: understanding the importance of nutrition at home and within families is essential. Immediate digital awareness, volunteers—such as those under the Nikshay Mitra scheme, where people adopt TB patients to aid them with nutrition support until their recovery—as well as the integration of community kitchen services for those without houses or migrant DR-TB patients, the presence of counsellors at clinics—all represent crucial, effective interventions that make patients cognizant of the role nutrition plays in their ailment. 

"In rural areas, anganwadis and caregivers can work together to ensure food security, with the availability of fortified food rich in iron, folic acid, and vitamins. If supported with proper nutrition like probiotics and proteins, the side effects of drug doses can be mitigated." 

Mehra adds that schemes like the Nikshay Poshan Yojana have made a significant difference but are inadequate in a country where a high-protein diet is costly.

According to Acharya, urban areas like Mumbai’s Govandi suffer more due to a lack of basic provisions such as sanitation and proper ventilation. "The fight is not just about a 100-day awareness campaign. It has to be systematic, with measures like food, sanitation, and open spaces. Political will has to be informed by survivor consultations."  

According to Chapal Mehra, a public health practitioner and founder of the forum Survivors Against TB, "Nutritional provisions play an essential role in health security. Those affected by TB tend to belong to the lower-middle class and middle class, and often, the person who is affected is also the primary breadwinner of their family.”   

Mehra adds that schemes like the Nikshay Poshan Yojana have made a significant difference but are inadequate in a country where a high-protein diet is costly. "What can one get for Rs 1,000? We can't say that the government is not trying, but it's not enough, and the amount under the Yojana should be increased to Rs 2,000 for basic provisions."  

With inputs from Sijal Sagarika

Also read: Meet the minds investigating bugs lurking in poultry

‍

{{quiz}}