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India’s syndemic of tuberculosis and COVID-19
  1. Rukmini Shrinivasan1,
  2. Saurabh Rane2,
  3. Madhukar Pai3
  1. 1Independent Data Journalist, Chennai, India
  2. 2Survivors Against Tuberculosis, Mumbai, India
  3. 3Department of Epidemiology and Biostatistics & McGill International TB Centre, McGill University, Montreal, Québec, Canada
  1. Correspondence to Dr Madhukar Pai; madhukar.pai{at}

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Before COVID-19 became a global pandemic, India was dealing with another, much older epidemic—tuberculosis (TB)—which affected 2.64 million Indians in 2019 and killed nearly 450 000 people in the country.1 That is over 1000 TB deaths every single day, well before COVID-19 entered the picture. In fact, no country has a higher TB burden than India, which accounts for a quarter of the 10 million global TB cases and 1.4 million TB deaths each year.1

Even before the pandemic, the cascade of TB care in India has been leaky,2 with long diagnostic delays,3 complex care pathways,4 poor quality of TB care in public as well as private health sectors2 5 and high TB case fatality.6 7

While the COVID-19 pandemic did not escalate in India until May 2020, by early November, India has reported over 8 million cases of COVID-19, with over 125 000 deaths. As the pandemic continues to escalate, the healthcare system is falling apart under the stress. India’s economy (GDP) contracted by 24% in the April–June period in 2020.8

While the public health system is collapsing under the stress of the growing COVID-19 caseload, the private healthcare system is becoming expensive and challenging to access.9 In both sectors, non-Covid-19 conditions are getting little attention.10 11

When India went into a stringent lockdown on March 25, anecdotal evidence suggested that citizens were having difficulty accessing routine health services.10 A large part of the health administrative machinery had to be diverted in identifying and containing COVID-19 cases, many hospitals were designated as ‘COVID-19 only’ and others restricted routine services for fear of an infected patient causing an outbreak.

Additionally, the complete closure of public and most private transport made travel to health facilities difficult, and horror stories of patients with …

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