http://www.nytimes.com/2016/09/03/world/asia/zarir-udwadia-india-tuberculosis-tb.html 2016-09-05 10:05:14 Battling Drug-Resistant TB, and the Indian Government Dr. Zarir Udwadia shocked the world and fought with New Delhi after identifying an untreatable form of tuberculosis. Now he’s a sought-after international expert. === MUMBAI, I Until writing the letter in late 2011, Dr. Udwadia was perhaps best known as the pulmonologist to the elite in Mumbai, where his physician father had become known nationally for saving the life of a Bollywood superstar, Dr. Udwadia wrote about four of his clinic patients for whom none of the commonly used medicines worked to combat the disease, TB is so old that it has been discovered in the skeletons of Egyptian mummies, was India is of particular concern, having the most TB patients in the world — more than two million of the more than nine million active cases globally. India also has the most drug-resistant patients, about 100,000 with multidrug resistance, in which the two most powerful TB medicines do not work. Mumbai is especially problematic because of its overcrowded slums, with almost a third of TB patients in some neighborhoods having a resistant form of the disease. Drug-resistant disease is more expensive and even more difficult to defeat than the traditional form, requiring two years’ treatment with such a toxic course of medicines that many patients drop out. Even if they do complete the regimen, studies show there is only a 60 percent likelihood of a cure. In the media storm that followed Dr. Udwadia’s journal letter, government officials publicly denied the problem and accused him of wrongly setting off a panic. A Mumbai health official seized his patient samples for retesting. Dr. Udwadia clammed up for a few weeks but then re-emerged even more outspoken than before, vigorously defending his findings and denouncing the government for its complacency. The 55-year-old physician has been extremely vocal ever since, criticizing the government for failing to take advantage of a new generation of medicines to stamp out the disease. “With the new TB drugs approved by the F.D.A., nobody should be dying of TB,” he said in an interview this month in his small office, where, during his free clinic, he stood by an open window, examining the leather tanners, taxi drivers and maids, in saris, burqas and turbans, who were waiting in the long corridor outside. “They’re not available here because of government inertia, and it’s unconscionable,” he says, speaking with characteristic speed, enunciating every syllable for emphasis. J The tall, lean doctor with a halo of black hair refuses to wear a mask to protect himself, even though his wife says he does worry about contracting TB. “How can you connect to a patient that way?” he asks. Instead, he leaves open his window so there is good air circulation, which reduces the chances of infection. Where many international and Indian public health experts are cowed into speaking in diplomatic jargon for fear of losing government support for their programs, or even their jobs, Dr. Udwadia stands out as the most influential voice demanding better treatment for India’s TB patients and unabashedly criticizing the status quo. “He’s the conscience keeper and the pioneer,” says Chapal Mehra, a public health specialist who works for international agencies. “He stood his ground when the government tried to terrorize him, and forced us all to see the dirt.” Dr. Udwadia grew up in Mumbai, training in government hospitals, where TB was widespread, and at City Hospital in Edinburgh, where researchers first combined medicines for a cure. When he returned to India in 1991 to set up his medical practice, he had few patients, so he opened the free clinic to keep himself busy. It is now the busiest outpatient clinic at his hospital. Within a couple of years, India began seeing its first cases of drug-resistant TB. As more and more drug-resistant patients showed up at his clinic, he became expert in treating them with various combinations of medicines, as well as an influential voice about the dangers of ignoring the spread of those strains. A “They would never have created drug-resistance programs if it weren’t for him,” Mr. Mehra says. “And he continues to force the government and the fairly lazy medical community to do more.” Dr. Udwadia notes that the government TB programs still do not identify or treat the majority of drug-resistant patients. Two new TB drugs approved in Europe and the United States several years ago are still not available in India, he says. “It’s scandalous when there are so many desperate patients,” he says. “It’s conceivable, with the combination of those two drugs, that there should be no more drug-resistant TB in India.” Dr. Udwadia began using the first of the new TB drugs with his sickest patients soon after it was approved by the United States Food and Drug Administration in 2012. It is still not approved for widespread marketing in India, though the government TB program has promised to make it available next month to 600 patients with multidrug-resistant TB. Fifteen of his 20 patients who received the new TB drug recovered, which is significant, Dr. Udwadia says, because they were his sickest, having already failed to respond to almost every other treatment. Where he was not widely known before the controversy erupted over his journal letter, Dr. Udwadia is now a sought-after speaker. He communicates regularly with the physician who had been his hero for decades — But for him, he says, the best times are when a patient with drug resistance whom he has been treating for years is finally cured. When Mrs. Sheikh, a tiny woman wearing a salwar kameez, showed up for her recent checkup, Dr. Udwadia grinned and reached across the table to shake her hand, unable to contain his excitement as he reviewed her tests. They were negative for TB for the third successive year. Her lungs are so scarred from the disease that she becomes breathless after walking several steps, but she says she is grateful to be alive. She takes a two-day train ride from her hometown in northern India to Mumbai every six months for a checkup. “I know it sounds like a cliché, but these times are what I live for,” Dr. Udwadia says. “In India, all patients tell the doctor, ‘You saved my life,’ but with Rahima Sheikh, I know it’s really true.”