Smt. Mohsina Kidwai, Union Minister for Health FW & others at
the inaugural function,
Silver Jubilee 1985
It is but natural that sometime...one has to seek
an answer to the question, how far it has been possible to fulfill
the purpose for which an institution was created... .The greatest
contribution of the NTI has been to work out the modalities of an
applicable programme... . What was possible for the NTI in 20 years
of its existence was to generate and disseminate valuable information...
However, what the NTI could not ensure, was to see that the users
(i.e., the health agencies responsible for delivering health care)
used the knowledge! In other words, the Institute had no means to
effectively organise and supervise the use of the knowledge generated
and distributed by it, simply because it was not the objective with
which it was set up!
In What has NTI achieved?
NTI NL 1979, 16, 104
Scientific session, Silver Jubilee 1985
4.1 The Tumkur district baseline studies
The great benefits sprouting from any work based on a
long term vision takes time to germinate. Such work embodies well considered
alternatives and the most pragmatic have better chances of being included.
It would be necessary to engage in TB work along with sister concerns
at the pace the community sets. Except that, the TB programme would set
the direction, activate the community and accelerate the pace so that
the vision articulated by the great minds designing and running the programme
takes hold. In time, the programme will take roots in the community to
slowly become the communitys own. There will be time to deliberate
on the many possible ways for progression, understand the implications
involved, consequences thereon and even plan for corrective measures.
Best of all, hasty actions will be avoided. There will be an additional
advantage: there will be plans for evaluation as an ongoing process.
There are many advantages in preferring such a view over
the short term view, especially when planning for a nationally applicable
control strategy. For e.g., time after time, anxious TB workers bring
forth the TB detection camp idea. There are so many TB patients in the
community waiting to be identified. Should one wait for the patients to
turn up at the GHS to seek relief from the symptoms they are suffering?
Why not organise TB detection camps fairly regularly to catch them early?
The idea is not without its own appeal and even tacit
approval from the zealous. However, it is necessary to consider a few
critical issues: the obduracy of TB as a disease; organising TB detection
camps on countrywide basis; simple ways to utilise the available infrastructure
without interfering in other programmes; good attendant diagnostic facilities;
sustainable follow up system for treating patients thus detected; infrastructure
to attend to the problems encountered in case holding; the perennial resource
crunch, administrative bottlenecks... If we recollect the deficiencies
and poor coverages of the mass BCG campaign approach, the camp idea buckles.
It would naturally give way to the slow, reliable and ever widening approaches
recommended under the NTP. The TB detection camp idea may have its rationale
or urgencies but studies conducted revealed the other way. In Maharashtra
73 shibirs were conducted from 1969 to 1976 to improve case finding while
in Karnataka from 1975 to 1976, a study of 25 camps were conducted91.
It was found that these efforts may even boomerang and cause harm if adequate
ongoing facilities were not provided. In 1989, Jagota and others conducted
a study of camps for examining sputum of chest symptomatics attending
out-patients of PHIs92. They found that only 16.3% of the referred symptomatics
whose sputum samples were collected earlier actually turned up. More than
two-third of the cases were missed as referrals did not turn up on the
camp day. These findings do not undermine the educative value of camps.
They can be conducted once in a while to help MOs at PHIs to select chest
symptomatics but not as part of the NTP methodology92.
Another interesting example of incisive analysis can
be found in the paper, validity of case finding tools in a NTP by Dr VH
Balasangameshwara and Chakraborty93. For case finding in the DTP, the
recommended method is sputum smear microscopy of patients with chest symptomatics
attending health institutions on their own. There is a slight variation
in the procedure of initial screening of out-patient attendance followed
at the DTC and at the PHIs. At the DTC, patients with chest symptoms are
first subjected to MMR (chest) and those with any abnormality are examined
by smear microscopy. At the PHIs, all patients with chest symptoms are
subjected to smear microscopy. PHIs do not have X-ray facility. The question
is how much do these differences in the screening tools, matter in case
finding? After thoroughly examining the data available from field surveys
and from the DTP records, the authors opined: Examined in the context
of statistical reliability of tests, the methodology of prior X-ray screening
by the DTC for case finding TB appears to be well founded. In contrast
to the DTC, the need for X-ray screening at PHIs does not arise, as the
procedure of patients being subjected to screening for the presence of
chest symptoms has in itself a very high specificity of 97%..... X-ray
and smear microscopy should not be used indiscriminately as case finding
tools in mass active case finding programmes. Their predictive values
of positivity are likely to be very low at the current case prevalence
rates in the community, which are in the range of 2-8 per thousand93.
Suffice it to say that the NTP has well chiseled, long
term considerations. It has to cater to the entire nation. Therefore,
it has to take into account several related aspects. For e.g., TB is not
a short term disease. It is not also concentrated in a few identifiable
pockets. The disease now is chronic, slow or indolent, fibrotic, not so
fatal and prevalent more among the elderly87. Described as the shooting
star phenomenon, patients continuously show up from the vast pool of the
infected as if from out of the blue. Repeat surveys show that fresh cases
of the second survey come up mostly from the X-ray normals and some from
the X-ray abnormals of the second survey. There is considerable auto-healing
and deaths that almost matches with the number of patients breaking down
into disease annually. Experts hold the view that environmental and socio-economic
conditions play such a key role that it is perhaps difficult to fight
TB by programme alone94. The programme must take all these and other key
factors like available infrastructure support and peoples perspectives
in its reckoning. Further, any programme however well researched is likely
to develop operational difficulties while functioning. There must be an
in-built ongoing mechanism for modifying it to find durable solutions.
There must also be periodic scrutiny and evaluation so that the programme
stays fine tuned. This underscores the importance of the enduring views
steadfastly nurtured by the NTI in all aspects of its work including training