Mumbai’s XXtreme TB is neither new nor sudden

Mumbai has been in a state of panic for the last two weeks after doctors at Hinduja Hospital reported the first cases from India of Extremely Drug Resistant TB (XXDR), which is immune to all first-line and second-line drugs used in the disease’s treatment. The panic stems from the idea that we are facing a new kind of bacteria and the possibility that it may spread among a large section of people in the city.

It’s worth pointing out, therefore, that the earliest reported case of XXDR TB was way back in 2003 in Italy, according to a 2007 article in medical journal, Eurosurvelliance. In this article, GB Migliori, director, WHO Collaborating Centre for TB and Lung Diseases, discussed the cases of two patients who initially had a less severe form of TB but it developed into XXDR TB due to mismanagement of the disease at the earlier stage. One of them underwent treatment for five years, while the other was treated for almost eight years. Drug susceptibility tests (DST) were performed on both patients, which indicated that the TB was resistant to all known anti-TB activity, wrote Migliori. “Both (women) died in 2003, before 50 years of age, after a long, unsuccessful treatment with all available drugs without achieving bacteriological conversion.”

In 2003, the only known forms of the disease were the primary TB and multi-drug resistant TB (MDR TB). When the bacteria developed resistance to the first line of drugs for primary TB, patients with MDR TB would then be treated with second-line drugs.

However, doctors started noticing that some MDR TB patients too were showing resistance to some of the second-line drugs. “In 2006, WHO officials met in Geneva to define XDR TB (extensively drug-resistant TB). In the same meeting, XXDR TB too was discussed, and the term was accepted unofficially,” said Migliori.

According to Migliori, it is difficult to identify XXDR TB, since the patient has to be tested against all available drugs. This is expensive and “the test results are open to interpretation. Moreover, there are few labs in the world who can conduct such tests,” he said. What this implies is that over the years many XXDR cases may not have been documented; so it may be fallacious to think that there has been a sudden emergence or spike in XXDR TB.

Doctors in India agree. “DST (drug susceptibility testing) for all the drugs is costly and not effective for treatment. So the testing is done only for the primary drugs. DST for other drugs is also dubious right now. The same test carried out by different labs yields different results, and the technology is non-standardised,” said SK Jindal, chairman of the Expert Advisory Committee on Management of Tuberculosis.

Only three labs in India are accredited to carry out DST for all available TB drugs, which is needed to confirm XXDR TB. Other labs can only diagnose MDR TB and XDR TB.

Bacteria strains are rarely tested for sensitivity against all drugs, said experts. “We can only classify a strain as XXDR if we can get it tested from an accredited lab, of which there are very few in India. Moreover, these labs only accept samples from patients who are being treated via the Revised National Tuberculosis Control programme, and not from private parties,” said KC Mohanty, HOD, Chest Medicine, KJ Somaiya Hospital.

While Hinduja tested and found 12 XXDR TB cases, Jindal concedes that there may be several others which have gone unreported. With the government now moving to accredit more laboratories to carry out DST for all drugs, you can expect more XXDR cases to surface.

So, then, are we in the middle of an XXDR TB outbreak? “No,” says Jindal, “TB is not as virulent as the H1N1 virus (swine flu). It spreads mostly when there is close contact with the patient. And XXDR TB is no different.”

[This article originally appeared in DNA]


Flower sellers of Matunga

Visiting Matunga to see the Ganesha murtis is an annual ritual for me. I love clicking photographs of the beautifully decorated pandals. This time though I also turned my lenses on stalls that sell garlands in Matunga. Matunga, as some of you may know, is the temple district of Mumbai. Here’s one of the photographs. The rest on Zooomr.

This guy was hesitant to face the camera, let alone smile. A comment from his colleague however had him in splits

This guy was hesitant to face the camera, let alone smile. A comment from his colleague however had him in splits --R Krishna

For argument’s sake

Recently, I had a discussion with one of my colleagues about arguments. He was of the opinion that when you are arguing, after a while it’s just better to stop talking and listen to what the person has to say. He told me that some of his friends did not agree with his point of view, and felt that it is important that he hold forth his views.

I was reminded of a sentence I read in Paul Theroux’s book, The Elephanta Suite — ‘In India, you really couldn’t say anything that hadn’t been said before.’

And that’s my reply to all those in favour of arguments. ‘Dravid’s a loser’ has been said before, and so has, ‘Dravid is Mr Cool’. There is no end to it. Arguments are always at the risk of becoming an excercise in exerting your ego. After a point of time, it’s not the topic and the truth that lies at the heart of the argument that matters — defending you stand becomes the most important thing.

Am I giving a sermon sitting on top of a white elephant? Absolutely not. As my friends and relatives will assert most incessantly (no point arguing that) I am the worst offender in this respect. I enjoy arguments (until I realise it has turned into an ego slug-fest), but I have realised that there’s no deep meaning in it. Just plain time-pass.

Is the iPhone your best bet?

The soon to be launched iPhone 3G is coming to India. But will you be getting the best deal? What about options?

Apple has developed a (good) habit of turning seemingly ordinary
concepts into gadgets that border on science fiction. iPod and the more
recent iPhone will more than testify for this.

iPhone led a new
genre of cell-phones with an intuitive touch interface. Many gizmo
freaks however were disappointed when the iPhone did not launch in
India. But this time ‘round, things look better with two of India’s
biggest telecom players announcing that iPhone 3G will indeed be
available for cell-phone users.

What seems to be catching many
people’s eyes — perhaps more than the iPhone 3G’s new design — is the
price. At $199 (Rs8,000) the iPhone looks cheap. But the iPhone may not
be available at this price in India. Even in the US, the data-plans
offered by telecom companies such as AT&T will be more expensive
for the iPhone 3G than for other phones.

To cut a long story
short, the iPhone 3G costs around $450 to $500. Telecom companies like
AT&T will subsidise the cost initially, but will more than make up
for it in the data plan (cost for talking, SMSing, and browsing the

Sources within Vodafone India could not confirm the pricing of the
iPhone 3G or the plans that would be offered along with it, adding that
the pricing model in India may well differ from the one in the US. Surprisingly, existing iPhone users are not too kicked about the launch.

“I would have considered going in for the official version with
Vodafone had I not bought one last November,” says Suyash Barve.
According to Barve, the new version doesn’t offer anything additional
features that are significant, at least in India.

Other users like Ritesh Rai, CEO, Genesis Modern Trade are actually
planning to give up their iPhone. “Once it launches there will be a
whole lot of people who will be carrying the iPhone around. There will
no longer be a novelty factor attached to it,” says Rai.

When the
iPhone launched in January 2007, there was nothing that came close to
its design, touch interface, and audio-video playback. But this time
other companies have caught on and launching worthy competitors of
their own, dubbed the iPhone killers.

HTC’s Touch Diamond has
already hit the Indian market (with Airtel for approximately Rs27,000).
Apart from a sleek design, it features a 3D interface that should make
the Touch Diamond stand out from the crowd. The other goodies are
top-of-the-line as well – it has built-in global positioning system,
Wi-Fi connectivity, and 3G-connectivity. The Touch Diamond runs on
Windows Mobile 6.1 Professional.

After the Touch Diamond the
most anticipated iPhone killer is Sony Ericsson’s Xperia X1 – the name
itself oozes with style. It was rumoured that Sony Ericsson may
postpone the launch to 2009, but recent reports confirm that the Xperia
X1 will be available by late 2008. Xperia X1 will feature a 3-inch
touch-screen display. And for those who type a lot (SMS/email), there’s
a slide-out QWERTY keyboard where the keys are arranged exactly like
your PC’s keyboard.

And can Nokia be left far behind? The
Finnish behemoth till date has not been too keen to develop
touch-screen models, but will now enter the fray with the Nokia Tube.
Nokia has not yet revealed too many details and the phone is due in
late 2008.

Other models to look out for are the LG Dare, which launched last
week, Blackberry Thunder, and the Samsung i900 Omnia, which features a
heavy-duty 5MP camera.

Of course, none of them as of now turn as many heads as the ‘bitten
apple’. iPhone’s brand value will remain high for some time to come.
But while you spending your moolah, you
might as well have a look at the options coming your way.

The Krishna Rao Commission

I’ll do it.” The words escaped my mouth before I could think things through. Sometimes your mouth says yes to something your heart had always wanted to do, before your brain had had a chance to process it. My heart had always wanted to visit the small towns and villages of India — to see the ‘real’ India.

The task I had taken up involved visiting and collecting data from three tribal areas of Maharashtra for a Planning Commission survey to measure the efficacy of income generation schemes for Tribals. One of the districts I had to visit was Nandurbar — a place which I never knew existed until then.

“Volvo hai?”

“Nandurbar? No, only semi-deluxe bus,” the man said. The semi-deluxe bus turned out to be an AC bus with a non-functional AC. But to maintain the temperature perhaps, there were a few windows that wouldn’t budge, letting in wind, dust, and rain.
A light drizzle greeted me when I reached Nandurbar early in the morning. The bus dropped me near the main bus-stand, and I proceeded to check into a nearby hotel, which came highly recommended.

The room was just the way I expected: damp, stuffy, dull, and the mug in the bathroom had paint stains. There were many big black ants loitering about, about which I dutifully complained to the manager. “It has rained, sir. That’s why they have come out,” said the manager in a tone that suggested ‘Why bother? They won’t cause no harm’.

The local tribal office was small but pleasant. On the day I arrived, two officials escorted me from the hotel to the office. I was ushered into one of the bigger cabins, where a formal welcome speech was made, and a bouquet of flowers was presented to me. I was introduced as Krishna Rao, the man from New Delhi — a fact I did not bother to correct, because in government offices, the word ‘navi dilli’ worked like a charm.

Field inspectors were appointed to assist me during the survey. This took a huge load off my mind, as it meant they would take me on their motorbikes to the villages I wanted to visit. “I will introduce you to the tehsildar if you want,” said one of the field inspectors, and turned the bike before I could respond.

At the tehsildar’s office: “Sir, meet this person… he’s come from New Delhi and is a member of the Krishna Rao Commission.” My mouth opened in protest, but I stopped just in time — I had to maintain the façade to get my work done quickly.
Riding pillion with various field inspectors on the motorbike gave me a 180-degree view all along. Nandurbar, and its adjoining areas, Sakri, Shirpur and Navapur have a rugged, untamed beauty. I was on a high when I visited the villages at the base of the Satpura mountain range. Beyond the Satpura is the Narmada, and further North are the Vindhyas – the heart of India is mystical, and I had just touched its southern tip.

The Tribals love their mountains and stay as close to them as possible. This, however, has isolated them. Even for people who wanted to help, travelling in such areas is no cake walk. In fact, many of the villages cannot be accessed by roads.

In one of the villages we visited, almost everyone was illiterate. The whole village came out to see what the man from New Delhi wanted. I was interviewing one lady: “Age?” I asked. “Around 24,” she replied. “Do you have children?” “Yes, I have two.” “What’s their age?” “One is 12 and the other, I think, 10.” I turned to the field inspector in disbelief, “If she is 24 and her child is 12, wouldn’t it mean she delivered her first baby when she was 12-years-old?” The inspector questioned the lady, “That’s not possible!” An old woman in the crowd started laughing, “Please explain to me… in what way is it impossible?”