Before the advent of western system of medicine in the eighteenth century, the practice of the empirical indigenous system of medicine of very high standard was in vogue in India. However, with growing industrialization in Europe allopathic system made spectacular progress of which Indian sub continent could not remain unaffected during British rule. As a result, indigenous systems of medicine declined and became more or less cult of the quacks. Only a small fraction of the educated Indians have a chance to acquire knowledge of western medicine and only a few could afford to avail these services while millions of Indians living all over the country had very little use of very advanced medical institutions based in big cities. Even after 14 years of political independence India continues to be the home of preventable epidemics as well as has high incidence of innumerable communicable diseases. Extreme poverty is perhaps the most important factor responsible for the poor state of health of the people in India. A plan for having better nutrition, better water supply, housing and better education will certainly result in great improvement in the national health. In the initial stage of social development all efforts should be directed to provide basic elementary medical and public health services to the entire population. The doctor going to work in an interior village in India must have a wide and varied knowledge of the preventive and curative aspects of medicine, all specialization rolled into one. The state must provide free medical care to all, particularly to the poor. In the concept of socialized medicine there is no place of top sided approach of having highly trained doctors who have nothing to offer to the public other than some useless mixtures. What is urgently needed is a social transformation of the practice of public health and medicine in India.

Health problems in India form only a small part of the large variety of pressing socio-economic problems that face the community. Pulmonary tuberculosis, among the health problems, is one of the many problems which need immediate attention. In the resources that are available for dealing with the different problems, the share which could be given to tuberculosis could not be big. If, due to some special reasons, a disproportionate slice of the resources is used up in applying advanced technological methods to satisfy a fraction of the total needs of the community, other problems may be accentuated. Logically a solution of the tuberculosis problem in India should form an integral part of a comprehensive overall social development plan for the community. If the tuberculosis control programme is according to the felt need, generated by the disease in the community, it would be in consonance with the other health and social programmes evolved for dealing with the other felt needs. Available information shows that it is possible to develop a minimal nation wide tuberculosis casefinding and treatment programme through the general health services. If the available resources in the future improve, then a corresponding qualitative and quantitative improvement in the working of the tuberculosis programme could be easily affected. It also appears reasonable to expect such a programme to produce an impact on the epidemiology of the disease.

In this paper an attempt is made to examine how the data from the history of medicine in India can help in formulating health programmes that deal with health problem as an integral part of the overall causation. India’s 5000 years old history provides an enormous perspective of the nature of man’s struggle against his environment starting from Indus Valley Civilization, the influence of Vedic Way of life of Buddhism, followed by frequent foreign invasions and general decline in the living standards of people. At the time of independence in 1947, India faced on one side, staggering problem of poverty, hunger, illiteracy, size in population and on the other side advantage of having ready made technological knowledge which could create effective weapons for dealing these problems. An Ecological Analysis of the History of Medicine in India shows an expansion of population due to availability of abundant resources which meant an increase in prosperity and social development. Public health facilities of the city of Mohenjodaro were superior to all other communities of the ancient orient. Almost all households had bathrooms, latrines, often water closets and carefully built well indicating the extent of health consciousness of ancient Indian people. During Ashokan period, there is existence of social medicine along the line of Buddhist Ideology. Emperor Ashoka states that “all over his dominions and adjoining territories, medical treatment is provided for men and animals”. However, the radical changes that followed after the introduction of British rule dealt a fatal blow to the practice of the Indian System of Medicine. A shift to practical western medicine during Nineteenth and Twentieth centuries led to neglect of Indian medicine and further decline.

These historical data help in providing a better understanding of the genesis of the present situation are also of immense importance for forecasting the pattern of health problems and health practices in the context of ecological changes that are expected to be brought about by other social development programmes, e.g., mechanisation of coal mining might influence the epidemiology of ankylostomiasis through better standard of living; conversely effective ankylostomiasis programme may bring prosperity by increasing the productivity of the coal miners. This is known as Positive Circular cumulative causation phenomenon-. To-day, Indian society stands on the threshold of far reaching social, cultural and economic changes. Utilization of the scientific knowledge generated by Industrial Revolution for dealing with health problem is essential for practicing modern medicine. A sound of medical and public health programme must have a very sound infracture of overall social, cultural and economic development. In a natural process of social evolution, medical and public health services cannot grow without such an infrastructure. Even if it were hypothetically possible to create artificially (at an astronomical cost) efficient medical and public health services without correspondingly developing in the infra structure, the social benefits accruing from such services will be of doubtful significance. What benefits will a hypothetical 'disease free' state bring to a population that is otherwise ill-fed, ill-clad, ill-housed and illiterate?

The purpose of the study was to establish the rate of emigration in a random selection of villages, with a view to forecast the likely loss of population in a follow up study on BCG vaccination in the area. The study was carried out in the total population belonging to 35 villages of Channapatna, Devanahalli, Magadi and Nelamangala taluks of Bangalore district in April 1960. Demographic characteristics such as birth and death rates, immigration rates and proportion of persons temporarily absent, were also studied. The head of the household if absent, any other responsible adult was interviewed on a house to house basis, regarding the composition of the family, according to the National TB Institute manual for census takers. Estimation of migration was to be based on the registered population of the current day, the population exactly one year ago and all relevant events during the intervening year.

The thirty five villages surveyed were found to have a population of 13,838 persons at the time of interview. This figure includes: (A) 13138 persons in the household at the time of census taking also belonged to it one year ago. (B) 470 persons born during the past year. (C) 230 persons immigrated during the past year. (D) 200 persons dead during the past year. (E) 307 persons emigrated during the past year & (F) 770 persons temporarily absent. The net increase in the population from April 1959 to April 1960 was, 193 persons or 14 per thousand.

It was estimated that not more than 5% of the population would be lost by emigration over a period of two years. About 1/3rd of the emigration is within the same taluk. Only a small portion of the emigrants are above 30 years of age. It is also found that a good proportion of women's migration is due to marriage. The study findings revealed that the hypothesis that large number of people leave the village every year, making BCG coverage impossible could hardly be upheld.

This study was undertaken in 34 villages and 4 town blocks where a few weeks earlier an epidemiological survey was carried out. All persons above 20 years whose photofluorograms were read as inactive, probably active, or active by at least one reader, were age sex matched with an equal number of X-ray normals, to form the experimental and control groups respectively. Thus, a total of 2,106 were eligible for social investigation. Interview sheets, with particulars of the name and location of village, household number, and individual number and the identifiable data of the interviewees were made available to the social investigators at random for contacting and interviewing them at their homes. The interviews were non- suggestive in nature and deep probing on the details of symptoms experienced by the respondent, which were fully recorded. About 79% of the experimental group and 83% of the control group were satisfactorily interviewed, which constituted the data further analysed. Of the numerous symptoms recorded, only that were associated with pulmonary tuberculosis were considered, of which cough occurring for one month or more, fever for a month or more, pain in the chest, haemoptysis and all combination of these four symptoms were analysed statistically.

Cough was found to be the most important single symptom. It was not only the most frequent symptom alone or in combination in the experimental group but was less frequent in the control group that 69% of sputum positive and 46% of radiological positive had cough while only 9% of the control group had it. Considerably fewer people had fever and pain in the chest. Pain in the chest appears to be non- specific, giving a ratio of only 2:l among the experimental and control groups while fever was in the ratio of 6:l and haemoptysis was ll:l. It was seen that 69% of the sputum positive cases, 52% of the X-ray active or probably active, 29% of the inactive and 15% of the normals (control group) had at least one of the above mentioned symptoms. In all the groups, the proportion of symptoms were higher among males than among females. In both males and females the prevalence of symptoms was higher in the middle age groups than among the younger or older groups. This age variation was more marked in the females. The findings of the study were analysed further along with the data obtained from a couple of minor investigations, conducted in the rest of the 28 villages which formed the total of the villages surveyed epidemiologically. This brought out further that 95% of bacteriologically positive cases are aware of symptoms, 72% experience 'worry awareness' and 52% form the action taking group. The above findings have been of considerable importance in planning further studies and in formulating the National Tuberculosis Programme.

Tuberculosis control by mass domiciliary chemotherapy is now being attempted on an increasingly large scale in the technically underdeveloped countries. The National TB Institute (NTI), Bangalore is an important centre for the development of such programmes and a study reported in this paper is an enquiry into the working of an urban tuberculosis programme which is operated under the auspices of the Institute. The excellent results of controlled clinical trials have lead to widespread belief that tuberculosis problem can be reduced significantly and rapidly by use of mass chemotherapy. However, the findings of such programmes elsewhere showed that by a long term continuous effort year after year, the removal of infectious cases can bring about a gradual reduction of the problem. Hence, it was necessary to study the treatment organisation of domiciliary chemotherapy on a large scale in respect of patients’ behaviour towards the programme during the treatment period. Three types of problems encountered in an urban tuberculosis programme are dealt in this paper: (1) problems related to the patients who are under treatment at the Lady Willingdon TB Demonstration & Training Centre (LWTDTC); (2) patients who prefer to take treatment from other institutions and (3) patients who come from outside the city. Study population consisted of 784 radiologically positive patients diagnosed at the LWTDTC from March 61 to May 61. All the outpatients were submitted to a tuberculin test and examination by a 70 mm photofluorogram. Those who were X-ray positive were given bacteriological examination of a spot sample of sputum by both smear and culture on their second visit scheduled on the third day. Of the 784 persons 318 (54%) were found to excrete tubercle bacilli. All patients suffering from active tuberculosis and sputum positive disease were put on a treatment regimen of 300 mg of isoniazid per day for a period of one year. During the course of the study a few of the sputum positive cases were given 10 gms of PAS in addition. The study population was interviewed by the Social Investigators of NTI: initially at the clinic immediately after their diagnosis, defaulters at their homes within four weeks of their defaulting and all patients after twelve months of treatment period. The coverage was 100%, 65% and 76% respectively.

The major problems identified and quantified were: Of the 784 patients under study, 84 (11%) did not even return to learn the results, 46 (6%) patients houses could not be traced, 138 (17%) resided outside the city, 48 (6%) emigrated during the treatment, 173 (22%) took treatment from outside sources, 156 (20%) took treatment regularly from the clinic and 139 (18%) also took treatment in the clinic but irregularly. Various reasons were given for defaults in drug collection, a sizable proportion of which could have been avoided through better organisation and administrative procedures and good initial motivation at the clinic. Default is a complex behaviour pattern and this study did not bring out any correlation between default and the economic, social, educational or other status of the patient. With changes in the system leading to a good treatment organization, it should be possible to have a higher percentage of regular patients than 20% as at present. About 64% sputum conversion among regular patients and estimated 25% among defaulters was observed.

The problem of tuberculosis in a developing country such as India must be considered in the overall social and economic context. Massive investment of money and resources to eradicate tuberculosis may interfere with other measures more important for the country's progress. But a limited investment in a suitably oriented tuberculosis programme could hasten the decline of the disease. Social planners thus face a special challenge in such countries. The problems are almost over whelming, while the resources available are extremely limited; scientists will have to formulate programmes which will ensure that these resources are utilised to give a maximal return from the investment. Thus, in considering tuberculosis as a problem of social planning in developing countries it will have to be dealt with at three different levels:

(a) Recognising the implications of factors other than a specific tuberculosis programme on the incidence of the disease; (b) devising methods that could offer the best possible returns from the available resources, both at any given point of time as well as at different time intervals; and (c) determining priority for allocating resources in a socially applicable tuberculosis programme. The National Tuberculosis Institute, Bangalore has used operational approach for formulating a nationally applicable and acceptable tuberculosis programme for India. The sequence of steps that led to the formulation of tuberculosis programme in India can as well be applied to develop a similar programme in any developing country.

It has been shown that most of the infectious tuberculosis cases in a rural community in south India are at least conscious of symptoms of the disease; about three fourths of them are worried about their symptoms and about half are seeking relief at rural medical institutions. It is well known that the existing facilities deal with only a very small fraction of even those patients who are actively seeking treatment. India's National Tuberculosis Programme has been designed to mobilise the existing resources in order to offer suitable diagnostic and treatment services to those who already have felt - need. India's health administrators have to initiate suitable administrative and organizational reorientation of the existing medical and health services to satisfy this already existing felt needs. The more provision of such services could very well motivate the remaining tuberculosis patients to seek the help from the medical institutions. This motivational force is expected to get reinforced as a result of progress in the field of education, mass communication, transport and industrial and agricultural production. Simultaneously, progress in the social and economic plans will offer the needed resources for strengthening the existing health services in terms of personnel, funds, equipments and supplies. Further more, social and economic development, by increasing awareness of the population, will ensure a more effective utilization of the existing services. Thus, social and economic growth will not only help in the development of an epidemiologically effective tuberculosis control programme, but the very rise in the standard of living itself might make a significant impact in controlling the disease in the country.