1.2. In the beginning

1.2.2. Efforts of non governmental organisations

Unfortunately, no cure was found for years to come. Therapy implied isolation in sanatoria, artificial pneumothorax (AP) and thoracoplasty. The eventual death that followed TB, fuelled further taboos. People began to believe that avoidance was the only approach possible. Robert Philip of Scotland (1857-1939) was among the first to recognise that preventive aspects must form an important component of therapy and an organised effort was needed to tackle a contagious disease like TB. In 1887, he initiated a well-directed movement. He set up a dispensary for ambulatory care of TB and laid down a standard routine to be followed10. Philip’s efforts lead to "A national crusade against a national disease" and in 1898, the National Association for the Prevention of TB was born in Edinburgh. In 1900, the Central Bureau for the Campaign Against TB was born in Berlin, which was the forerunner of the International Union Against Tuberculosis (IUAT).11

After the First World War, from 1922, the IUAT started playing a prominent role. As governments alone could not effectively take steps, voluntary agencies began to assume responsibility for providing relief. The movement was more often lead by missionaries. Country after country followed suit in a systematic campaign of public education calling attention to the dangers of the spread of TB, the precautions necessary for its prevention and the possibilities of treatment.11

In India, the first open air sanatorium for treatment and isolation of TB patients was founded in 1906 in Tiluania, near Ajmer, followed by one in Almora after two years. Both were built by Christian Missionaries. In 1909, the first non-missionary sanatorium was built near Shimla. Upon the earlier work done by Dr Louis Hart from 1908, the United Mission Tuberculosis Sanatorium (UMTS) was built in 1912 at Madanapalle, south India. Dr Frimodt Moller became its Medical Superintendent. This institution and Dr Moller played a large role in India’s fight against TB through the training of TB workers, conducting TB surveys (1939) and introduction of BCG vaccination (1948). In addition, the first TB dispensary was opened in Bombay in 1917, followed by another in Madras. Soon anti-TB societies were formed in Lucknow and Ajmer. 6

On behalf of the government, Dr Lankaster conducted a tuberculin survey for several years and published the report in 1921. Due to the high incidence of TB infection, he recommended that the government should work closely with the non-governmental organisations (NGOs) and support their activities. Following this suggestion, India became a member of the IUAT in 1929. At that time, India was a conglomerate of provinces and states ruled by the British. The disease was threatening but funds were scarce. In 1937, Her Excellency Lady Linlithgow issued a public appeal for anti-TB funds on behalf of the government. As a result, nearly a crore of rupees was collected. 5% of this money was retained by the centre and the balance was distributed to the provinces and states. With the help of this 5% direct donation and the King George V Thanksgiving (Anti-TB) Fund, The TB Association of India (TAI) was formed in February, 1939. Her Excellency became the President of the TAI. Dr Frimodt Moller became its Medical Commissioner and Dr BK Sikand its Secretary. The provinces and states which received money also started their TB associations. The Bengal TB Association, however, had been functioning from 1929, and maintained dispensaries in Calcutta and Howrah. Its activities were strengthened by this funding. Drs AC Ukil and PK Sen were working in Calcutta in the All India Institute of Hygiene and Public Health12. In 1946 there were only 6000 beds available for the treatment of TB patients. The Bhore committee13 estimated that there were about two and a half million patients in need of treatment and half a million deaths annually. For a huge country like India, which included Pakistan and Bangladesh in those days, the sporadic efforts of NGOs were not adequate. The government had to intervene.

However, the issue of diagnosis, let alone treatment, remained unresolved. The diagnostic methods for TB, even as late as 1920s, were ordinary physical examination without X-rays. Wilhelm Conrad Roentgen (1845-1923) had discovered X-rays by the turn of the century. Yet, it took some time and many innovations, before the chest X-ray became technically adequate. Only by 1925, chest radiology could detect a deep-seated area of TB consolidation and thoracic surgeons began to demand X-rays. Even then, Mass Miniature Radiography (MMR) remained a dream until the work of Manoel de Abreu, a Brazilian physician. In 1936 with his efforts, the first X-ray apparatus of relevance in a collective thoracic survey was introduced in a German hospital of Rio de Janeiro. By 1945, the capability of the apparatus was enhanced to embody the MMR version. 14

As no drug or combination of drugs were effective against TB, the main line of treatment was good food, open air and dry climate. Till the advent of adequate chemotherapy, the treatment took a second place to diagnosis and prognosis. Even great physicians could only advocate vague platitudes like "attention should be paid to the bowels ...... adequate rest, .... etc". The Proceedings of the 1939 TB Conference was awash with physical examination, clinical observation, X-ray examination as a guide to treatment15. In 1939, the TAI recommended the Organised Home Treatment Scheme as the best compromise under the prevailing circumstances: the TB Clinic becomes the hub of all anti-TB activities around which such a limited TB programme works. 16

Meanwhile, the Second World War broke out. Fighting diseases took a back seat. However, after the War, even though India was being ruled by the British, it is to the credit of the government that they recognised TB as a major problem. They established a TB Division in the DGHS in 1946, with the Adviser in TB as its head. TB was also given a prominent place in the planning. Since the government was not only concerned with TB but with other diseases and health infrastructure, it constituted a committee under the chairmanship of Sir Joseph Bhore. Its secretary was Rao Bahadur KCKE Raja, who as the DGHS, played a dominant role in the TB field during his tenure. Published in 1946, the report presents a harrowing picture. As mentioned earlier there were about half a million deaths from TB and 2.5 million open cases of TB who were continually disseminating infection in the undivided Indian sub-continent. No surveys of sufficient magnitude have yet been undertaken to map out the distribution and intensity of TB infection in the country as a whole. Yet the information available suggests that, the incidence of disease is higher in urban and industrialised areas than in rural regions... existing facilities for an effective campaign .... are altogether meager.... The number of doctors with sufficient experience of TB work to qualify for posts in TB institutions does not probably exceed 70 or 80; fully trained TB health visitors (HVs) are in all probability only about 100... These figures help to indicate magnitude of the task that has to be achieved before satisfactory control can be established over the disease. 13

The Bhore committee placed organised domiciliary service at the forefront of the programme. It recommended setting up of a clinic for each district and the use of mobile clinics for rural areas. 13

BCG vaccine, named after the two scientists who developed it, stands for Bacillus Calmette Guerin. First introduced in 1921 in Paris, BCG vaccinations were administered in most countries in Europe14. Every one had pinned high hopes on BCG and the GOI followed suit. The BCG work started in India as a pilot project in two centres in 1948. In 1949, it was extended to schools in almost all states of India. Under the aegis of the International Tuberculosis Campaign, which had considerable experience in BCG work in many countries, it was introduced in India on a small scale in Madanapalle with Dr Frimodt Moller in the lead. India started the Mass BCG Campaign in 1951. There was a Central BCG Organisation with one BCG officer, one publicity officer and one statistical officer. A BCG Vaccine Production Centre in Guindy, Madras was set up in 1948. The WHO and UNICEF provided the necessary support. BCG work in India gained momentum. 17

The next issue was treatment. In the 1930s, sulfanilamide and penicillin came into the pharmacopoeia and revolutionised medical practice. Can drugs be found to combat TB? Fortunately, remedies were discovered rapidly. A breakthrough occurred in 1944 with the discovery of streptomycin (SM) by Dr SA Waksman. In 1946, Jorgen Lehmann found out that para-amino salicylic acid (PAS) had a demonstrable bacteriostatic activity against M.tuberculosis (M.tb). By 1950, Dr Domagk et al introduced thioacetazone (T). 18

The very notion that there can be effective drugs against the tubercle bacilli, was so revolutionary that researchers began to experiment on the effective dosages and combination of drugs to be used. The issue of affordability was also considered18. In the 1949 Annual TB Workers Conference, several papers were presented on the effects of PAS and SM on the patients and on the distribution of SM in India19. In 1951, Dr BK Sikand, the Director of the New Delhi TB Centre (NDTC) stated succintly in the paper: Some observations on the organised home treatment scheme in Delhi. He focussed on the organised scientific diagnosis, modern scientific treatment and economic relief to patients. He summed up his technique as "BCG syringe in the right hand and AP needle in the left"20. In 1952, Dr NN Sen presented a paper in the IX TB workers conference on the use of antibiotics and Dr E Nassau on the determination of sensitivity of the tubercle bacilli to SM and PAS21. Although Isoniazid (INH/H) was known to medical researchers from 1920 onwards its use as an antitubercular drug was established in 1952 by Drs Robitzek and Selikoff who revealed that INH is a miracle drug against TB and it continues as such till date.

In 1953, Frimodt Moller and others presented the paper The effect of SM and INH, single and combined, in the treatment of pulmonary TB in Indian patients in the conference. They stated: "The findings of the present investigation has impressed us by the remarkable results caused by the chemotherapy alone....some cases relapsed after treatment was withdrawn, so it can be concluded that chemotherapy may have to be kept up for more than 9 months"22. There were other studies of importance on treatment efficacy presented in the same conference.

In 1956, Drs Sikand and Pamra presented a paper on the "effect of SM, PAS and INH in 703 cases of pulmonary TB, diagnosed and treated during 1951-53". They found that the results of domiciliary treatment were encouraging enough to warrant a shift of emphasis from hospitals and sanatoria to clinics without waiting for any further trials. 23

These studies would, in time, revolutionise the management of TB all over the world. However, it soon became apparent that the tubercle bacilli could not be destroyed easily even with drugs. They had powerful survival techniques, besides developing resistance to drugs. Trials indicated that the newly available drugs, when used singly, were effective only for short periods. To be effective, treatment should be continued for at least 12-18 months. This brought with it several problems. How many patients will continue to take medicines for such a long duration? How to keep track? Further research was, therefore, needed to harness the potential of these newly discovered drugs. 18

In the mean time, the government had established in 1956, the Tuberculosis Chemotherapy Centre, later known as Tuberculosis Research Centre (TRC) in Madras (Chennai), under the auspices of the ICMR, Government of Madras, the WHO, and the British Medical Research Council (BMRC). This Centre was to provide information on the mass domiciliary applications of chemotherapy in the treatment of pulmonary TB. It demonstrated that the time honoured virtues of sanatorium treatment such as bed rest, well-balanced diet and good accommodation were remarkably unimportant provided adequate chemotherapy was prescribed and taken. Further, there was no evidence that close family contacts of patients treated at home, incurred an increased risk of contracting TB24. Therefore, it would be appropriate to treat infectious patients in their own homes.

Dr BK Sikand who had conducted several studies on the treatment and its organisational aspects would often stress: one thing is certain that no drug therapy can be employed to optimal advantage without frequent periodic review of the situation. Effective antibiotics have increased, and not lowered the responsibility of a correct diagnosis, especially when the treatment is to be continued for at least 12-18 months. The patient’s willingness to continue treatment for years is in proportion to the physicians conviction that it is necessary and his ability to transfer his belief to the patient. 23