A sanatorium in Goa becomes a refuge for migrant workers recuperating from tuberculosis
Menaka Rao
Margao TB Hospital in Goa. Menaka Rao/The Migration Story
GOA: For over a year, Tushar*, a migrant worker from Odisha, has been an inmate at the TB (tuberculosis) Hospital at Monte Hill in Margao, Goa. In March last year, a barely conscious Tushar was picked up from a train by the Goa police and taken to the Goa Medical College where he was diagnosed with TB.
“He had TB of the spine. In fact, he had lost one of his ribs to the disease, and had to undergo surgery,” said Dr Govind Desai, South Goa TB officer. Tushar was eventually moved to the sanatorium in Monte Hill to recover.
A labourer engaged in handling heavy goods in Surat for nearly a decade, Tushar had been unwell for about six months as the intermittent fever he suffered went undiagnosed. “The doctor my employer sent me to gave me paracetamol each time,” said Tushar who is in his 40s.
Daunted by his sickness, he decided to leave Surat for Goa where he had worked in a fish market between 2002-2005. “I had about Rs 3,500 in my pocket. I told my friends I will go to Goa and die,” remembered Tushar, who has not been in touch with his family in Odisha’s Sundargarh district for more than 14 years. He chose the relative familiarity of Goa for a future he considered bleak.
The TB Hospital in Monte Hill, has been Tushar’s home for over a year now as he makes a slow recovery.
The sanatorium houses many migrant workers like Tushar who suffer from TB, and also alcoholics and diabetes patients. It is not unusual for TB patients to have a long stay at the sanatorium, at times even years, noted Dr Manish Gaunekar, Goa State TB officer.
Sanatoriums, a relic of the colonial era, might have outlived their purpose as antibiotics for TB negated the need for in-patient treatment/admission for recuperation, rest and care for patients. However, the TB Hospital in Monte Hill, now has an extended purpose as it becomes a refuge for migrant workers who are diagnosed with the disease and are willing to stay at the sanatorium for treatment. Here they receive treatment, nutritious diet and specialised care over prolonged stays while they recover far away from home.
“Over the past three years, we have facilitated extended stay for patients who do not have family support in the state, particularly migrant workers, and also those who are alcoholic, since there is the likelihood that they may not adhere to treatment. In order to ensure they take their medication regularly, and have better outcomes, we try and convince patients to be admitted for longer durations,” said Dr Gaunekar.
While better outcomes, meaning better cure rates, in TB prevention and treatment are the driving reason for suggesting longer sanatorium stay to vulnerable patients, the facility particularly aids patients who are migrant workers and in desperate need for comprehensive care including nutritious food, medicines, and attention to comorbidities such as diabetes. For the migrant workers though, a stay at the sanatorium comes with significant financial and labour loss, which makes prioritizing health a complex choice.
Goa and tuberculosis
Goa has a relatively lower incidence of TB compared to other states in India -- 134 cases per one lakh population as against the all India figure of 172 cases per lakh population. In 2023, Goa recorded 2091 TB cases. The country had an estimated 28.20 lakh cases in 2022, accounting for 27% of the disease burden in the world. An estimated 3.41 lakh people died of TB in 2022 in the country. The disease affects those with reduced immunity, either because they have health conditions such as HIV, diabetes or silicosis, substance abuse disorders or if their health is compromised due to socio-economic circumstances such as poverty or poor housing.
The living and working conditions of migrant workers, and their lack of access to nutritious diet dents their immunity, making them susceptible to diseases such as TB, noted experts. “Migrant workers often have no choice but to engage in work that is dangerous and difficult, and in unhygienic conditions,” said Santosh Poonia, director, India Labour Line, Aajeevika Bureau, an organization that works to protect the rights and wellbeing of migrant workers.
“To save money for their families, migrant workers often end up living in accommodations with poor ventilation, and do not eat well,” he added.
Goa receives migrant workers largely from Karnataka, Jharkhand, Chhattisgarh, Bihar, and Odisha among other states, said Feliza Goes, project coordinator for Pravasi Bandhu — Caritas Goa, an organization working with migrant laborers in the state. “They are mostly employed in construction, fisheries, and in the industrial belt. Goa is expensive, and migrant workers spend at least Rs 3,000-5,000 for cramped rooms which they share with others,” she said.
The immense financial constraints mean migrant workers with TB often do not opt for treatment at a sanatorium. “Many leave for their hometowns after the diagnosis or choose not to stay in the sanatorium as it means loss of wages,” said Dr Desai. Getting them to opt for residential treatment, the TB officer observed, is at times difficult. “We try to convince them to stay. But if they are adamant, we make them sign a consent form citing ‘leave against medical advice.’ Our field staff tracks them on the ground to ensure treatment,” he added.
However, a good number of migrant workers are lost to follow up, said experts working with migrants as well as the TB programme.
“The national TB programme [the National TB Elimination Programme] has a mechanism to transfer a migrant patient from their city of work to the health centre in their hometown. But it does not always happen,” said Dr Shibu Balakrishnan, an expert engaged with the TB programme. He noted that even the ill workers who stay back in the city of work are difficult to track. “Their workplace changes all the time,” he added.
Prevailing prejudices against migrant workers across the country, including Goa, exacerbate their plight in the event of illness. In the State, non-Goans are charged for healthcare services at government hospitals. The measure deters migrant laborers from going to hospitals, said Goes. “Healthcare for diseases other than TB, malaria and infectious and vector borne diseases, is chargeable. Migrant workers often do not have the Pradhan Mantri Jan Arogya Yojana card which provides health insurance,” added Goes.
Considering the roadblocks migrant workers face in accessing affordable healthcare, Goes noted the sanatorium at Monte Hill is an exception as it prioritizes their care.
Sanatorium for recuperation
An inside view of the Margao TB Hospital. Menaka Rao/The Migration Story
Sanatoriums were particularly popular in Europe and the US in the early 19th century. The first sanatorium in India was built by Christian missionaries in Rajasthan in 1906, and many others came into existence subsequently and provided patients a healthy balance of treatment, diet, rest and exercise. Even with the advent of antibiotics for TB, patients were being treated in sanatoriums. In 1956, the Indian Council of Medical Research along with the World Health Organization and others conducted a landmark trial in erstwhile Madras which showed that the outcomes of patients who get sanatorium care were comparable to those recuperating at home. The trial helped change policy and most TB patients were then allowed to receive treatment at home. The national TB programme, which was subsequently established, focussed on ‘ambulatory’ care — taking medicines at home.
Consequently, sanatoriums were converted to hospitals, either general or specifically catering to TB and pulmonary diseases. Currently, only patients receiving treatment for drug resistant tuberculosis are admitted briefly (multi-drug resistant tuberculosis refers to tuberculosis where the patient is resistant to the most effective TB drugs; it requires treatment for at least two years) , or those with complications and requiring lung surgery are admitted to hospitals, said doctors.
“The first two months of treatment are challenging for a tuberculosis patient. In-patient treatment is necessary especially for those who are socially unstable, severely undernourished, and unable to get care at home,” said Dr Anurag Bhargava, professor of medicine at Yenepoya Medical College, Mangaluru, who researches on tuberculosis and its biosocial indicators, particularly malnutrition.
When labourers diagnosed with TB return to work during treatment, chances of the disease worsening and turning drug resistant are high, said Dr Pavitra Mohan, co-founder of Basic Health Services, an organization engaged in improving the health of labourers.
“Sanatorium care, if provided as an option for labourers, can ensure better nutrition and rest, help reduce lung damage, and is likely to improve overall recovery,” he added
Recovery, the priority
Almost all the 20 patients at the 66-bedded facility in the Goa sanatorium are migrant workers, said Tripti Shirodkar, staff nurse at the TB Hospital in Monte Hill, still referred to as a sanatorium by healthcare professionals. “If they are from Goa, we often do not admit them at the hospital for more than two months. They have a home to go to which is not far away; but that is not the case with migrant workers, so we keep them for at least six months,” said Shirodkar.
In fact, a criterion for long-term admission at the hospital is malnutrition. “Many of the patients have a body mass index lower than 20 which is a risk factor for poor outcome,” said Dr Desai.
Nursing staff at the TB hospital observed that an important factor which persuades unwell migrant workers to opt for a long-term stay at the hospital is the access to nutritious and high protein diet of fish curry, egg and milk every day.
Dr Bhargava and his team conducted a trial in Jharkhand among TB patients which found that nutritional supplementation was associated with decreased mortality.
Access to nutritious food and shelter was definitely factors that led Ameya*, a migrant worker who had a job in a bar, to opt for TB treatment at the sanatorium. The 42-year-old from Mumbai had arrived in Goa to work as a driver. “Almost as soon as I was here, I lost my original documents, including my driving license and Aadhaar card. I could no longer get a job as a driver, and ended up working in a bar and sleeping on the road. I was picked up by the authorities and put in a shelter home, and then I was tested positive for TB,” said Ameya who has been in Goa for over two years.
Steep rents make finding an accommodation difficult for migrant workers in the State and some end up sleeping on the streets, explained campaigner Goes.
Ameya has been in the hospital for nearly six months. “I did not have a job. It made sense for me to be admitted here during treatment,” he added.
The facility hosts not only TB patients, but also a migrant worker from Karnataka who suffered a paralytic attack which rendered him immobile. He was found on the streets four years ago by the police, said Dr Desai. “We shifted him here around 2020 just before the pandemic. He needs nursing care and treatment for minor illnesses,” added Dr Desai, noting that efforts to find a shelter home for the patient has not yet been successful.
About half of the TB patients admitted in the hospital are alcoholics, said the nurses. “They need admission as their immunity is low and are not able to maintain a diet which TB patients require,” said Suchitra Masurkar, a nurse at the Monte Hill facility.
Krishna*, a migrant worker from Bengaluru, was diagnosed with TB last year. Admitted in the sanatorium for six months, he also underwent a de addiction programme, but suffered a relapse both for TB and addiction, and is back at the hospital. “I was diagnosed with TB again. It has been a month and 20 days since I have abstained from alcohol. If I was not here, I would have started drinking by now,” he said.
Tushar (name changed) suffers from spine TB, and was paralysed from waist down last year. Now he can walk with crutches. At Margao TB Hospital, August 2024.
The hospital caters to the needs of vulnerable patients, largely migrant workers, who apart from TB are battling addiction issues or require a physiotherapist, as Tushar does. When Tushar came into the sanatorium he was paralyzed chest down. After being bed-ridden for a year, he can now move around with the aid of a walker. Dr Desai is convinced Tushar will be able to walk without support in due course and discharged from the facility.
For Tushar, however, the sanatorium and the care it offers has been a life changer. “I got a new life here. If I was anywhere else, I would have been khallas [dead],” he said.
(Names of all TB patients have been changed on request to protect privacy).
Menaka Rao is a Delhi-based independent journalist who reports on public health and law.
Edited by P Anima
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