It has been shown that most of the infectious TB 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 NTP 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 organizationl reorientation of the existing medical and health services to satisfy this already existing felt needs. The provision of such services could very well motivate the remaining TB 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 & 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 TB control programme, but the very rise in the standard of living itself might make a significant impact in controlling the disease in the country.

In India, TB appears to have been prevalent from the Vedic civilization, about 1000 B.C. The Indian medical treatises traceable to the period, contained directions for diagnosis based on symptoms, therapies based on herbs, metals, minerals and, the general management of daily life. In 1946, the country's needs were assessed by the Bhore Committee and subsequently by the Mudaliar Committee. At this time, the TB problem as a public health problem, was ignored. With independence, in the late forties, there was a realisation that large areas of the country were devoid of basic health services. The development plans of this period were extensive, appropriate and inter-related. As a result, the NTP and other health programmes were established. The NTP was formulated in 1961 by the NTI which was established for this purpose. The programme, based on a large number of studies, was to serve the community by providing diagnostic and treatment facilities throughout the country, through GHS. Currently, in the mid-seventies, due to several socio-political challenges faced by the country, the achievements of the NTP are far from expectations.

The present study attempts to understand the nature of the social and operational constraints affecting TB control and identify ways to remedy them. Such constraints, which are by their very nature intricate, demand prolonged, in-depth, field-based, qualitative and quantitative investigation, for their appreciation. The design of the present study allowed such an exhaustive inquiry and the composition of the study team facilitated it. The study had a ‘rural’ and an ‘urban’ component, and ‘users of health services’ and ‘providers of health services’ as sub-components. Distinctively, the investigation encompassed the lay people, the patients of TB, the public health care providers and the private health sector – all within the set-up of a district which is the peripheral administrative unit of the NTP. The study was conducted between 1991 and 1994 in Pune district of Maharashtra, at the time when TB was being rediscovered as a problem requiring urgent attention and action. Pune is one of the better developed districts of the most progressive state of Maharashtra in India. While this limits the generalizability of the study findings, there is little reason to believe that the constraints faced by the programme and its beneficiaries in areas with lower levels of development and poorer infrastructure, will be less.

This was a presentation made to the President and Chair of the TB Workers' Conference in British India, 1939. The presenter traced the history of the organized control of TB in many countries with reference to State legislation and, described the variations in laws passed and their impact on different aspects of the anti-TB efforts. The latter part of the presentation was focussed on legislation and TB in India. Defects in certain existing provincial laws were explained as also the negative impact of some of them on the patient and his/her family. It was considered premature to consider any comprehensive and useful TB legislation in India at the time before correcting existing provincial laws and recommendations were made to enforce laws concerning certain factors which promoted the spread of TB.

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?

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.

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.

TB is a good example around which a discussion of change can take place. The health technology of TB already exists and is widely understood. Economic and effective methods of prevention and treatment have been evolved, widely tested, and made available world-wide. The question is how to get this to the right people in the right way.

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.

Change is continuous and its ripples deep spreading in society far, wide and long, influenced as well as maintained by the factors that trigger the change. A society therefore needs sentinels to monitor the social changes and try influencing the socio-political thinking of those in power in order not to let events overtake people. Otherwise, the resulting adhocism is seldom capable of dealing with the national situations properly. The emergence of a large middle class in India is one such situation.

The editorial comments refer to the 1989 Ranbaxy-Robert Koch Oration given by Dr. William Fox, titled "TB in India - Past, Present and Future". Dr. Fox highlighted most of the major aspects of TB in India, being familiar with the TB scene in India for over 35 years. Emphasis was placed on the need to improve research, training and evaluation aspects of NTP and on improving programme administration and management based on these findings. However, Fox's recommendation to establish a long term National TB Standing Committee with various powers is considered to reveal his unfamiliarity with various aspects of the Indian administrative and political climate and the social upsurges prevalent at the time. The editorial suggests an alternative way to manage the TB programme, while supporting Dr. Fox's views, in general.

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.

This is an editorial on the Workshop organised by the DGHS, 11-12 September, 1991, to thoroughly review the NTP with respect to its overall achievements and shortfalls from expectations. Based on the deliberations, attended by representatives of various international agencies, several recommendations for action, to improve the NTP, were made. It was suggested that a Task Force be set up, with proper terms of reference and a suitable budget to oversee that the recommendations were implemented and that necessary corrective actions were taken, till the time of the next review.

The guest editorial considers that the NTP, while a well-designed one, has been deficient in implementation of the programme, that the blame for this deficiency should go to the general conditions under which the programme has to function and not the programme itself. Therefore, those who wish to improve the functioning of the NTP should direct their attention to improving the GHS. Regarding the TB control programme in urban areas of India, three trends that have emerged are described. Given these trends, it is considered that only a consensual approach based on mutual understanding towards achieving a common goal could bring about the desired change in the programme. A set of interventions to improve the programme are included.

The paper explains why the predominantly rural average Indian district received greater attention under the NTP than large cities. Also, why the DTP, as the basic unit of NTP, has not performed upto expectations on account of management weaknesses and not technological shortcomings. It has been shown why it is not necessary to think in terms of separate rural and urban TB services. The manner in which the existing TB services in most big cities can and should be made a part of DTP/NTP has been discussed. In metropolitan cities, where the operational environment is different, the principles of NTP can still be applied, after due operational and sociological studies, but it is preferable if such studies are made a part of overall health services systems research.

Since NTP is integrated with GHS, any improvement in GHS is bound to improve NTP. Similarly, if GHS suffers from any inadequacy, it gets reflected in NTP. In other words, NTP will sink or sail with GHS. Thus, to achieve the objective of Health for All by 2000 A.D. through primary health care, the existing infrastructure for GHS should be strengthened as per the recommendations and utilised effectively. This becomes all the more compelling in view of the AIDS epidemic which is knocking at the doors of India.

The paper presents a comprehensive analysis of the sociological research on TB conducted in India between 1956-1998. Human suffering; health seeking behaviour, factors affecting and improving treatment compliance are the important sociological aspects of TB that have been investigated. The genesis of DOTS has been traced to the long-standing efforts to try different strategies to overcome the problems associated with treatment completion for e.g., development of supervised, intermittent and SCC regimens. Following are the salient conclusions given in this paper:

In the early 60s, the visionary approach of researchers to focus on the sociological and epidemiological aspects of TB ensured that the NTP, from its inception, was socially relevant and epidemiologically effective.
The level of knowledge of TB does not necessarily lead to patients seeking relief or taking treatment regularly. It is the physical suffering which is found to be associated with the action taking. Cough is found to be one of the most important chest symptoms of TB as it prompts patients to take action for relief.

Organizational and administrative factors such as insufficient facilities for management of TB, inadequate and irregular supply of anti-TB drugs, long distance to travel for seeking relief, drug intake or drug collection act as barriers and prevent patients to be adherent for treatment. Training of health providers is essential so that they give accurate advice to patients concerning treatment and manage the TB activities. Certain other actions to improve treatment adherence include decentralization of TB services while ensuring regular supervision of programme activities.

Increased research efforts in sociological aspects of TB are needed for successful implementation of DOTS programme. There is a need to explore the feasibility of including diverse groups such as private practitioners, social & leprosy workers and dais (birth attendants), as DOTS supervisor. We can also investigate the utilization of other agencies like STD booths and pan shops. The barriers to the expansion of DOTS programme should be removed.

NTP reaches people through PHCs and sub centres. A study was conducted to find out the perception of illness and utilisation of health facilities by the community. This study was conducted in a random sample of 48 villages selected according to Probability Proportioned to Size within 5 kms. of the selected PHIs in Kolar district using a multi stage sampling technique. Information on socio-economic status, availability of health services and their utilisation was collected. 13,323 individuals were interviewed. 706 were ill in a period of two months prior to survey. 71.3% had taken allopathic system of treatment. 69.1% had approached government hospital or PHC. 34 patients reported to have TB. All had attended either DTC or PHC.

The study indicated that morbidity was perceived much early and also followed by an action. Data indicates a high percentage of preferring allopathic system in general and from peripheral health centres and other government hospitals in particular. Data indicates that in spite of overall backwardness of the study area and very limited economic resources people have utilised the PHC to the maximum. The reason could be either high acceptance of PHC or inevitability. But, there is an evidence of higher utilisation of family welfare and MCH services. The data shows all TB patients have had exposure to standard regimens, all of them have approached either PHC or DTC for treatment. This confirms the felt need oriented concept of NTP. Also high level of morbidity among children below 4 years of age and action taken indicate an enhanced level of demand for health services.

A socio-epidemiological study was undertaken by the NTI on out-patients attending the LWTDTC at Bangalore to understand the main reasons why people attended TB diagnosis and treatment centers so as to know why they default in treatment subsequently. During February-May 1966, a 50% random sample (comprising 2,653 persons of which 1% of the interviews were rejected) of the new out-patients attending the TB Center for diagnosis were interviewed by experienced social investigators before their X-ray examination. Eighty-three percent of the out-patients came from the city while only 17% came from the rural areas.

While a number of sociological characteristics such as profession, religion and literacy were found not to have any significant relationship with the patients' attendance, distance from patient's home to the city TB Center proved to be crucial. Further analysis of the data suggested that even in a city, a majority of the persons with symptoms first contacted, for treatment, the nearest health institution which typically happened to be a general health institution. This delayed early diagnosis or referral. Of those patients who subsequently attended the city TB Center, 37% had not received any treatment for TB from the general health institutions, 50% got non-specific treatment and only 13% got likely or definite TB treatment. Nineteen percent who did not have TB also got likely or definite TB treatment. It was clear that a very complex and multi-lateral relationship existed between the symptomatic patients, the institutions of general health and the established specialized services. Sociological or operational studies to examine this "complex" were suggested.