Using the data of the National TB Register, and reports from the Satakunta sanatorium, Finland, it was shown that the educational and occupational levels of new cases of TB among persons of more than 50 years of age remained comparatively unchanged in Satakunta during the period 1954-1969. In comparison with the total population of the same age in 1960, aged TB patients had a lower educational and occupational status. The level of housing of tuberculotic patients was found to be about the same as the total population in 1960. During the same period, the incidence of TB among those of 50 years and above did not change noticeably, whereas a complete change was observable with regard to the situation of younger age groups. In the current situation, with the influence of recent infection being practically excluded, it appears that the incidence of TB in old age cannot be influenced by purely social action, for example, by improving the level of housing. Instead, priority should be given to medical treatment.

A comparison of incidence rates and hospital utilization rates of the aged indicates that these two phenomena are almost parallel. This similarity lends support to the concept that patients have been hospitalized mainly for medical reasons. The occupational status of new cases of TB and discharged patients remained almost the same for a decade. This further indicates that social conditions were not decisive in the selection of patients for care. Not until after the mid-sixties did the aged attain the level of utilization of hospital services which could be anticipated on the basis of morbidity rates. A rough forecast is made of the estimated development in the near future: the number of persons of more than 50 years of age in 1980 would be about 80 percent of hospitalized patients.

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 problems as an integral part of the overall causation. India’s 5000 years of 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 with 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 wells 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 and 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. Today, 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 the health problem is essential for practicing modern medicine. A sound medical and public health programme must have a very sound infrastructure 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 the infrastructure, 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, and ill housed and illiterate?

It has been shown that most of the infectious TB cases in a rural community in south India are at least conscious of the symptoms of the disease; about three-fourths of them are worried about their sickness; and, about half of them actively seek treatment for their symptoms at rural medical institutions. The existing facilities deal with only a very small fraction of even these patients who are actively seeking treatment. India‘s NTP has been designed to mobilise the existing resources in order to offer suitable diagnostic and treatment services to those who already have a felt-need. India‘s health administrators have to initiate suitable administrative and organizational reorientation of existing services to satisfy these already existing felt needs. Simultaneous social and economic growth will help in developing the epidemiological strategy and the rise in living standard itself may have a significant impact in controlling TB.

The article provides a description of the health facilities including medical manpower available in India in the mid-60s. Given that the population was rising by 2.2% per annum, it was suggested that the social and sociological significance of the increase of TB morbidity be considered in relation to population growth. Since the Indian tubercle bacillus, while less virulent, varied from strain to strain considerably more than in the European countries, it was recommended that devising ways to combat TB be based on the specific needs of the country. Over Rs. 2,000 crores per annum was expected to be needed to combat TB in India. Therefore, it was more cost- effective to expend funds in the prevention and control of TB rather than used towards covering the cost of illness and premature death.

TB control was one of the priority items in the National Health Programmes incorporated in the successive Five-Year Plans covering 30 years. On reviewing the earlier history of TB Services in India, it was evident that, while the prevalence of TB was recognised in India from 2,500 B.C., the awareness of its existence as a major problem only occurred in the early part of this century. The establishment of the TAI in 1939 marked the first national voluntary effort and also when domiciliary treatment for TB patients was first offered. The break out of the Second World War and the aftermath of the partition of India in 1947 brought all nation-building efforts to a standstill. Subsequently, in 1948, the Indian Government set up a separate TB Section in the DGHS, encouraging rededication to providing TB services; at the same time antibiotics began to replace the use of pneumo-thorax treatment. By the mid-60s, the TB control programme in India covered wide-ranging activities such as Preventive Services, TB Clinics, Hospitals & Sanatoria, Rehabilitation, Research and Health Education. The emphasis was on providing preventive & clinical services and domiciliary, anti-microbial activity. A description of various other anti-TB measures taken by governmental, voluntary and international agencies completes the review.

Sociological investigations have revealed that more than half of all infectious cases in rural areas seek relief at various health institutions and that as many as 95 percent of them are conscious of the symptoms of the disease. These findings lead to the formulation of a felt-need oriented TB programme as an integral part of the services that are offered at the rural health institutions. Specialised TB institutions at the higher levels lend support to them by offering referral facilities. For a population of a million and a half, there is a DTC to give them administrative support. Such an integrated programme is not only very economical, but it also grows along with the GHS. Its orientation to felt need makes it more acceptable. It also has a potential for covering some 95 percent of the infectious cases in the community, thus indicating that it can have an impact on the incidence rates of the disease.

Much of the content of sociology directly concerns man’s adaptation to his changing environment and therefore, this field has important implications for public health practice. This paper reviews some major perspectives and some examples of research that illustrate how an appreciation of sociological variables can assist the public health practitioner.

The changes in the place of health programmes in the international development process, over time, has meant that the role of health has come full circle, today. The paper describes this changing role of health, from the classic imperative of the medical practitioner to heal the sick and comfort the afflicted through a period when the justification for spending money on health programmes had to be sought in their contribution to economic development to the current period, in the 70’s, when once again, health programmes can be justified without recourse to economic arguments. To support this view, several figures, presenting data on the comparative savings from BCG and standard TB treatment in Burma (in the 60s) and the prevalence of TB in the Indian labour force (in the early 60s) are illustrated to show how they might convince development economists to provide money for the TB health programme.

A City TB Programme (CTP) has been suggested that meets with most of the existing conditions in our big cities and is in accord with the principles underlying DTP and NTP.

Formulation of a nationally applicable, socially acceptable and epidemiologically effective NTP for India involved use of a wide range of principles of the discipline of community health. These principles can also be very profitably applied in the formulation of nationwide programmes to deal with other major community problems. Government commitment to strengthening rural health services in India by using multi-purpose health workers and by employing community health volunteers has further strengthened the case for adopting the approach developed for formulating the NTP on a much wider scale. This approach also gets further endorsement from the concept of primary health care contained in the Alma-Ata Declaration.

The purpose of the paper is to spotlight some of the problems of NTPs in developing countries and what to expect in the future. The paper presents a review of NTPs' problems with respect to whether they have achieved community-wide coverage, rural people's socio-cultural expectations concerning the health centers, integration of NTPs with GHS and certain management aspects. The conclusion is that a majority of these problems are managerial and attitudinal in nature. For instance, the wide variability in the quality of TB services provided at the periphery because of insufficient knowledge or awareness of some GPs, the lack of equitable sharing between hospitals (urban or rural), with health centers (urban or rural), the reluctance of well-qualified staff to accept rural postings, irregular supply of medicines and lack of staff supervision by senior officers have prevented NTPs from community-wide coverage. While all ingredients for physical integration with GHS are present, functional and attitudinal fusion, of the generalists with the specialists and of rural health centres with higher level institutions up to teaching medical colleges are still lacking. Managerial problems manifest in administration, operation and training are described and the need for political will or leadership is explained. Suggestions to overcome these problems include undertaking a number of operational studies to understand what has happened with regard to NTPs and why, improving training and/or supervision and making the GHS more quality-conscious and management-oriented.

The overview takes into consideration the historical, socio-economic, administrative and technical factors, which have played a prominent role in shaping India‘s NTP. It comprises an analysis of the current status, trend during the past ten years and discussion of some aspects that need further attention. Now, a majority of the constraints are administrative and not even operational, while the needed technical improvements are few. At the present stage of development, it would appear premature to say if the programme has succeeded or failed.

The article provides a detailed description of the urban TB programme established in 1986 in Bombay and covering the city. The existing health infrastructure was inadequate to deal with an estimated 1,50,000 cases of TB, of which 40,000 were infectious to others. The organizational structure of the city TB programme is explained and the duties of the city TB officer are listed. A review found that since 1986, about 70,000 newly diagnosed patients were put on treatment every year, of which, only about 205 were able to complete the treatment. While there was good public awareness and an excellent transport service, poverty among a majority of the city dwellers and constant rural-to-urban migration were major problems in TB control. Future plans to improve the TB programme are listed.

The medical practitioner has a major part to play in early diagnosis of pulmonary TB, thorough and systematic treatment of all detected cases till their disease is arrested, prevention of the spread of the disease by BCG vaccination to the uninfected, isoniazid chemoprophylaxis to all children below 5 years of age who are infected and to all adult contacts, health education of the people and finally in the rehabilitation of those who lose their jobs or require comparatively light work. He has to participate in this “Mahayagna” launched to eradicate TB from our land as speedily as possible.

The importance of GPs in various aspects of TB control is emphasised. The majority of patients who go to a State Clinic have typically been under care of a GP at one stage or another. In an urban clinic in Uttar Pradesh, an average of about 10-15% of patients are in the first stage, 20-30% in the second stage and 55-70% in the third stage of TB. These figures have held constant for the past 15 years. Given this scenario, it is considered that unless the co-operation between the clinic doctor and the GP improves, there could not be any improvement in these figures (which are similar to figures in the rural areas). The GP is equally important at the last stage of TB, when only he/ she can instill the necessary discipline in the patient to continue regular treatment. GPs can be useful in providing notification of TB, in regulating the sale and dispensation of anti-TB drugs, treating patients in domiciliary care, participating in mass radiography and contact exams. Several advantages that would accrue from a liaison between the clinic doctor and the GP are listed and it is suggested that registered Vaids and Hakims in rural areas be enlisted to help the Government.

The editorial emphasises the need for GPs to be provided with adequate knowledge and training (a responsibility to be shared by universities, medical colleges, the central and state governments and others involved in the anti-TB programme) so that erroneous diagnosis, leading delayed referral and, misuse of drugs, by GPs, may be prevented. Suggestions to accomplish this objective include replacing mere clinical teaching with community-oriented teaching in urban and rural practice fields, where the practice of the NTCP can be demonstrated, giving priority, especially to rural GPs to attend symposia and various types of orientation courses and holding State TB conferences in the District Centers with the participation of GPs and other specialists. The NTCP has no concrete plan to enlist the GPs’ aid. The GPs could assist significantly by training qualified and popular practitioners in rural areas to hold TB Clinics, to refer cases and to manage these clinics without fear of losing the cases. Provision of proper record keeping schedules, facilities for X-ray and sputum examinations, if these cannot be arranged at the clinic itself, would encourage GPs to participate collaboratively with clinics so that the clinics could manage the diagnosis and treatment while the management of the cases including default actions could be the GPs’ responsibility. The TAI, with the IMA, could jointly develop a strategy for the active involvement of GPs in the NTCP and forward it to the Health Directorate for implementation, with their co-operation.

The TRC, Madras, undertook a sample survey in rural (18,395 persons), urban (17,409 persons) and metropolitan areas (37,290 persons) to identify the chest symptomatics as defined in the NTP. The symptomatics were interviewed by medical social workers to obtain information about the action taken for relief, the type of health facilities utilised and the reason for the choice. Questions were also asked to find out the symptomatics' knowledge about TB. Based on an analysis of the results, more than 80% of the symptomatics were aware, over 75% had taken action, although most had no idea about its causation. Yet, more than 90% had contacted health facilities of which one-half were governmental.

The paper reviews current understanding of the behaviour and interactions of TB patients and private for-profit providers, as a precursor to devising interventions for field testing to win over the private practitioners and private voluntary organizations to the DOTS strategy. India is a vast and heterogeneous country. The location of the study sites are New Delhi, Agra, Jaipur, Lucknow, Morena, 24 Parganas, West Bengal, Wardha, Bombay, Pune, Tumkur, Madras, Bangalore, North-east which indicate that the available information is representative of the whole country. Even then specific local peculiarity cannot be excluded. The study period ranged from 1976 to 1996, most of them carried out in the 90s. In few instances, the evidence was supplemented by interviews with knowledgeable experts who had first hand information of the issues being discussed. The findings of the review report are as follows: The prevalence of TB is highest among male adults, belonging to low socio-economic strata and tribals. The general public was found to be reasonably aware of the symptoms of TB. Chest symptomatics are being found to be 5-10% of the general population. The process of health seeking behaviour of a TB patient is complex and may well last several years. Most persons in India requiring curative treatment without hospitalization choose private providers. People go to the nearest trusted health care providers who is usually a private for-profit providers. The poor and even in hilly areas choose them. Private practitioners are perceived more sympathetic, more conveniently located, more effective and more trusted for privacy than government run services as having condescending doctors, substandard drugs, inconvenient opening hours and long waiting times. However, once patients had switched from private to government run providers, they become far more appreciative of government-run services, drugs and staff. TB patient’s health seeking behaviour is dependent of their symptoms. About half of the TB patients seek help within a month, 50 to 80% from private for-profit providers. Diagnosis of TB is often delayed for weeks after first contact with a private provider. Almost 75% of smear positive patients found in the care of private doctors in mid-seventies were not being treated for TB. About half the patients continue treatment with the private providers who diagnosed the TB.

Most patients knew that they have TB even when the providers try to conceal this stigmatizing diagnosis. They knew that TB requires prolonged regular treatment. They start taking drugs, but loose interest after relief specially the low-income groups due to cost and inconvenience of taking drugs. With the passage of time, work and social commitments increasingly displace the chore of taking regular treatment. Even knowledge about consequence of irregular treatment did not prevent it. As their funds get depleted TB patients switch to government run services. The steady switching from private to government run services is not matched by switching from government-run to private providers. Except where DOTS is practiced, do not achieve consistent cure. With DOTS, 80% cure rate was demonstrated in pilot area while only 35% with standard regimen and 51.3% on SCC completed treatment in NTP. As implied by these events, long-duration patients accumulate in government-run services. Many TB patients believe that TB carries a social stigma. Ex-TB patients are less likely than average to find marriage partners in West Bengal. Unmarried girls with TB fear that they might never find a spouse, those married fears divorce. Women are typically less well placed than men to ensure their own cure.

Out of pocket costs for diagnosis and successful treatment in India are estimated at between 100 and 150 US Dollars per patient as per 1992-1995 rupees dollar rates. However, individual out of pocket expenditure on TB treatment dwarfs the substantial sums expended by the government on the NTCP. However, private expenditures on private TB treatment, which are estimated to exceed USD 150 million per year, are typically rewarded by palliation rather than cure of TB.

Over-diagnosis and over-prescription among private for-profit providers are predictable. X-ray was found the test of choice to rule out TB, with sputum examination done in only 10 to 20% of suspects. Treatment regimens prescribed were of 4 drugs intensive phase with six months duration and were probably adequate to achieve cure. Most of them prescribed anti-TB drugs and also gave expensive diet supplements and alcohol based tonics.

Private practitioners generally keep no patient records. Half of them admitted that they made no attempt to contact patients who defaulted from follow up visits. Only 5% stated that sputum negative smears were desired to call it a cured case. TB patients do not form an important part of the business; only 1% of patients seeking care at qualified allopathic provider while one-third had no patients. TB Specialists might consider TB as an importantpart of their business. Government services are normally free, but waiting time, wages lost and drug unavailability impose costs and inconveniences. Spot checks revealed that more than 50% of PHCs had one or more TB drugs not available. Only 15% of the patients knew that the treatment is free in government clinics. On the whole, government-run health care services in India have a poor image. The private for-profit health care sector plays a major health care / system in India. In 1989, there were about 2,42,650 qualified allopathic physicians as compared to 88,105 in the government services. The number of recognised hospitals in private sector grew from 2,764 in 1983 to 4488 in 1987. The profile of a typical rural private provider in Uttar Pradesh was a 38 year old male, with about 10-12 years of schooling, practicing a mixture of western and professional medicines. Only 7% were qualified, while 90% learn the skills from family members, or as compounders, pharmacist or as doctor’s assistants. Nearly all the rural practitioners sell medicines by margin added to the medications. About half of them were registered with some medical association.

Drug retailers in India consistently sell restricted drugs without requiring prescription. The legal and regulatory environment for health care in India is in a state of flux. On paper fairly well regulated but unregulated in practice. Consumer Protection Council (CPC) in India has taken an active role in pursuing cases of malpractice. However, CPC’s role has been questioned by the IMA and Supreme Court ruling.

Some important gaps in information persist. There is no reliable estimate of the number, density and distribution of specialist clinics where TB might form a more important part of the case load. Several options for interventions have been identified. Excluding TB drugs from private channels such as in Algeria and Chile. Mandatory referral of TB patients to government-run services such as in Oman. To run high quality and low costs to patients.

Involvement of private providers in the programme by modifying the prescribing behaviour by academic counseling. In any case complete regular treatment and standardized monitoring promise a greater improvement than changes in prescribing alone.