EDITORIAL : THE HINDU, INDIA

Wells of life – and death

“Does it take much to prevent such incidents?” the Supreme Court asked in November 2009 while considering the lethal risks posed by abandoned open borewells that had already taken several young lives. Doing some plain-speaking, it directed State governments to ensure that all abandoned borewells and tubewells were capped. Providing practical tips to cover them with wire mesh or lids, the court also wanted functioning wells fenced off. On the basis of this order, the Union government in February 2010 issued guidelines for the maintenance of borewells. All that was evidently in vain, judging from the number of accidents since then, including many in which children died after remaining traumatically trapped in the innards of the earth for days. The latest such heart-rending tragedy occurred in a Haryana village: the body of little Mahi, who fell into a 70-foot-deep borewell on June 20 while playing with her friends on her fourth birthday, was pulled out after some 80 hours of rescue efforts.

Borewells and tubewells are widely used for irrigation in Punjab and Haryana, mostly in rural areas, because of the falling water table. Where these were once narrow holes, they are now typically 18 to 24 inches in diameter. Rural India has become growingly dependent on groundwater. Almost all the government programmes seek to supply water to villages through tubewells. Poor recharge due to geological reasons and environmental degradation (where creeping urbanisation is a key cause) make many of them defunct. The typical short-cut solution is to dig more borewells. Most of them, illegal and unlicensed, are left uncapped once they fall into disuse. On a larger plane, excessive reliance on groundwater for drinking, irrigation and industrial uses in India represents a massive failure of state policy. A review sponsored by the Central Ministry of Water Resources four years ago estimated that 85 per cent of rural, 50 per cent of urban drinking and industrial needs, and 55 per cent of irrigation needs, were met out of groundwater. This points to a virtual withdrawal of the state from the water sector, despite the formation of the Central Ground Water Authority with a mandate to, among other things, interact with State governments and regulate extraction of sub-soil water. Incidents of borewell deaths will stop only when the government takes its goals seriously — of safety as well as better groundwater management — and starts taking measures in mission mode to ensure consistent water supply wherever needed. The best way to start is to team up with local bodies, starting with village panchayats.

A necessary ban

The recent decision by the Ministry of Health and Family Welfare to ban the manufacture, sale, distribution and use of serological (blood) test kits for diagnosing active tuberculosis — both pulmonary and extra-pulmonary — is significant. The blood test diagnoses active TB based on antibody response. The decision does not come as a surprise. In fact, the question was not whether the government would act but how soon it would ban it. In July last year, the World Health Organisation had for the first time issued an “explicit negative policy recommendation” against a practice used in TB care. India’s Revised National Tuberculosis Control Programme also endorsed WHO’s advice. It is unfortunate that the world health body had to step in to put an end to a test that has become widely available in many developing countries despite not being recommended by any regulatory agency. “A blood test for diagnosing active TB disease is bad practice,” the WHO stated in its July communiqué. The reason it came out strongly against the “diagnostic tool” is that the test produces very unreliable results. According to a 2008 WHO report, none of 19 commercially available rapid serological tests studied “performed well enough to replace [sputum] microscopy.” The organisation found that the tests provide “inconsistent and imprecise” results due to their inferior sensitivity and specificity. Unlike in the case of HIV and other diseases, detecting antibody response in people with active TB is difficult and hence unreliable as many factors can cause the response.

According to an August 2011 paper in PLoS Medicine, the blood test, if used in place of sputum microscopy for a year, will be able to diagnose 14,000 more active TB cases but will end up misdiagnosing more than 121,000 people as suffering from the disease (false positive cases). The antibody test is also prohibitively expensive. Every year in India, about 1.5 million serological tests are done at a cost of $15 million. As a result, a staggering number of people end up being wrongly diagnosed and unnecessarily medicated every year. The direct fallout of unnecessary medication is the increased chances of people developing acquired drug resistance, thus further complicating and compromising TB care. But imposing a ban is just the first step towards rooting out the malaise. Since implementing the ban will be a tall order, there is a need for increasing awareness level among the public. Simultaneously, the government should quickly complete the pilot testing of the WHO recommended Xpert MTB/RIF molecular test and make it widely available. Only the availability of a superior alternative can solve the problem.