This paper is designed to demonstrate that the sociological features of TB are paramount both historically and currently. Documented sources are shown to be abundant, accessible and highly consistent. There are 148 references, chiefly in English, but some in other languages. Three content areas are discussed; population, aetiology, and sanatorium care. A very close and long connection with statistical method is also documented. Population aspects are discussed with reference to the strong cultural, economic, and historical factors pointing towards social aetiology. The close connections with schizophrenia, alcoholism and emotional derangement are pointed out. Part of the psychiatric picture is ascribed to the peculiarities of sanatorium treatment.

The article is written in an era of hospitalization in the sixties, before domiciliary treatment was studied and recommended. The editor of the journal recommends that low resource countries should consider social aspects besides the economic ones for creation of hospital colonies for the treatment of TB. Without considering the local, social peculiarities of social and cultural heterogenecity, stigma, social competition and mortality, the efforts of segregation may represent greater hardships to an individual or to a family than the disease itself and a curtailed life. The editor quotes the plan approved by the Mexican National Security Administration which has included the social and other aspects besides economic ones. He recommended that social traits and local peculiarities to be kept in mind while formulating such plans. He further stresses that progress in the social sciences requires that, today, efforts for the control of TB be preceded in the underdeveloped area of the world by adequately integrated surveys of the whole situation in which the disease is transmitted. By temperament and by habit, administrators are fond of buildings and physical structures which demonstrate investment; but without basic objective knowledge of the people, of the spirit and structure of the society to which they belong, the buildings may remain deserted, and costly physical structures with all the niceties of modern science may be inadequate. That knowledge is today within our reach.

Health problems in India form only a small part of the large variety of pressing socio-economic problems that face the community. Pulmonary TB 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 TB 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 TB problem in India should form an integral part of a comprehensive overall social development plan for the community. If the TB 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 TB case finding and treatment programme through the GHS. If the available resources in the future improve, then a corresponding qualitative and quantitative improvement in the working of the TB programme could be easily affected. It also appears reasonable to expect such a programme to produce an impact on the epidemiology of the disease.

A prospective study of infection with TB among 680 contacts of 187 families in which there was at least one adult with active TB was carried out by the Dept. of Internal Medicine and Medical School of Texas. The family unit was defined as the one which occupied the same domicile (nuclear and extended). Three distinct groups: 1) Spanish-speaking Americans (SSA), 2) English-speaking whites (ESW), and, 3) English-speaking Negroes (ESN) appeared in the study population. The six characteristics chosen for study were, intimacy with source, severity of disease, age of contact, income, crowding and mode of living. The first three factors were independent of social factors. The analysis was done by scoring method. The findings of the study revealed a gross rate of 47% infection. A wide range of tubercular infection existed; 26.7%, 17.6% and 11.9% of all the contacts of the families of ESW, ESN and SSA were infected respectively. Similarly, no contacts of 27% of the families were infected. Infection in less than 6 years of age was nearly the same. For the three population groups, the rate of infection of 53% was highest among the SSW and lowest among the ESN, with a rate of 42.5%. It was found that the ESW had the stronger family structure and ESN the most unstable structure. The social factors of overcrowding and an impoverished mode of living has an important effect. Rates of infection are about 2-3 times higher when sputum is infectious and is positive on microscopy examination. The non-radiological factor being associated with higher infection rate is the outstanding feature of all studies and findings of this study are consistent with the other studies. Social characteristics seem to operate only as they contribute to the environmental factor in the transmission of tubercular infection

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.

A survey of the stations of the TB welfare service revealed that of 250 patients who received less than 6 month of in-patient treatment, at least 52.9.percent had negative sputum. In a study carried out during the year 1965-66, 92 patients admitted with positive sputum findings were dealt with ; during that period 60-100 beds on average were available for male patients with open pulmonary TB. In all these cases the diagnosis had been arrived at accidentally; the patients were or claimed to be asymptomatic. One quarter of these patients were homeless and most came from the fringe sections of the population and showed an anti social behaviour pattern.

The present study examined certain medical and social aspects of TB based on analysis of 630 cases selected from 1,480 patients having chronic pulmonary TB in Finland, in 1964. The findings of the studies were: Median age of the patients was 50.2 years for men and 45.2 years for women; the duration of roentgenologic history of TB was an average of 12.3 years and of the bacteriologic history, 10.1 years. About 15% of close contacts (family members) developed TB during the patients' illness. Resistance to M. TB was found among 80% of the cases examined for it. The disease was far advanced in 50% of the cases. Only 18% of the patients had no other diseases and the most common concurrent afflictions were vascular and psychiatric diseases. Two-thirds of the patients came from the two lowest social classes. In a fairly large number of cases, neglect of earlier therapy was encountered in the data. A comparison of data from the present study with the corresponding situation in Helsinki at the beginning of 1961 (which comprised of patients with positive sputa findings for a minimum of two years) showed that the age and sex distribution in both studies and the occurrence of resistance to first-line drugs were almost identical. It was concluded that at least half of the chronic pulmonary tuberculotics could be treated to bacilli-free state and that chronic cases could only be treated from the epidemiological point of view. When the age structure, disability due to the lungs being affected, psychic and additional somatic diseases were considered, little success could be expected from rehabilitating the patients for productive work.

To determine the level of awareness of symptoms of TB, a sociological study was carried out in a randomly selected population in Tumkur district in south India. The findings indicated that there was a considerable "felt-need" (50%) for a TB programme in the District. The problem of "Treatment Default" was found to have been exaggerated due to inadequate consideration of some basic factors such as inaccurate diagnosis, healed symptomatic TB cases actually taking treatment elsewhere, completing treatment in a longer span of time. On analyzing the causes for defaulting, two factors emerged. Greater consideration to the social, cultural and economic factors that influence the TB patient's motivation to take adequate treatment and, integrating the TB control programme with other development programmes such as education, population control, agricultural and industrial production, are suggested.

A degree of resentment against the problem of TB is necessary for the intensification of efforts on the part of the Government and the involvement of the whole community in these efforts. This can only be brought about when a state of awareness is created once again, as it was, following the last National Sample Survey. This is only possible by plotting the date of incidence and prevalence of the disease and, repeating this procedure over points in time to establish a trend. Placing a representative of the community as a multi-purpose worker at each Primary Health Care center, widening the scope of the DTP so as to involve as many practitioners as possible, improving the diagnostic and treatment facilities at the peripheral center in remote areas and, conducting periodic surveys to create awareness, are some suggested measures to solve the problem of TB.

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 study analysed the mortality rates (obtained from death certificates and census returns contained in the Decennial Supplement on Occupation and Mortality) in England and Wales during 1970-1972, by occupation and social class. Mortality rates were calculated in terms of the standardized mortality ratio (SMR):

(SMR =observed deaths X 100)
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                expected deaths

A major finding of the study was that mortality was inversely related to social class. This result may be explained in two ways. Either the incidence of TB was greater in the lower classes or, there was a significant difference in case fatality between the classes. Based on the available information, it was concluded that there were good reasons to suppose that both explanations were important.

A number of factors - cultural, social, political, economic and technical - have determined the nature of society's response to TB. Changes in these factors have brought about changes in society's response. For example, advances in the diagnosis and treatment of TB have greatly modified the earlier perception of TB as a social stigma. Social considerations related to isolation and prolonged sanatorium treatment have become much less relevant. In recent times, consideration of the social aspects of TB involves examining how the individual and the community react to the disease, the level of awareness of TB in the community etc. To break this vicious cycle, the expenditure in a well-conceived TB programme should be considered as an investment.

Treatment default is on two accounts, fault of the patient and, organizational lapses of the services. Inadequate staff and equipment, irregular drug supply etc. outweighs the lapses on the part of patients. Hence, a patient may be called a defaulter only after he/she does not utilise the optimal services provided. The TB social workers' role in India is to strengthen treatment, organization and whenever possible, provide treatment under supervision. Socio-etiological factors in India, example, rise in standard of living leading to better nutrition, less close contact, increase in the host resistance, genetic selection and attenuating virulence of bacilli could lead to the reduction in the problem of TB. Economics of TB should be evaluated as total suffering, that is, loss of work, cost of treatment, due to death and morbidity leading to a vicious cycle of poverty and sickness in the community.

The article emphasises the importance of identifying human factors which result in the under-utilization of TB services. Two areas, highly influenced by human factors, aside from the personal and sociological factors that determine the sickness behaviour of TB patients are: (1) the disease and its attributes, (2) the health care delivery system. Reviving the approach that TB is a serious and major disease and integrating TB services as components of primary health care, as done in the DTP, are important in TB control.

A case has been made out for developing some selected sociological parameters of assessing NTPs.

TB is primarily the problem of human suffering. The author, in 1967, presented some ways of measuring suffering. Eleven thousand, three hundred and fifteen persons from 2,135 rural Bangalore (Karnataka) families were questioned for the presence of TB symptoms two months preceding an interview. Four thousand, six hundred and ninety persons (41.4%) with symptoms were identified. Suffering was measured in terms of death, sick man-days, absence from work and loss of wages, hiring alternative labor, cost of treatment etc. Sick man-days were categorized as completely bed-ridden, partially bed-ridden and ambulatory days. The calculated rough specific mortality of 17.6% compared poorly with the overall crude mortality of 2.2%, without adjustment for age and sex. The overall economic penalty inflicted was about five times more for TB patients compared to other sick persons.

From a review of longitudinal surveys conducted in Singapore and Korea (1975) and in the Philippines (1981-1983), it was shown that the duration of symptoms (suffering man-days), before diagnosis in a fresh case, could be developed into a sociological parameter with cough, the most frequent symptom, being taken as the index symptom. For reliability, information on the duration of cough should be elicited in homes in the presence of the entire family by trained health workers. Specific mortality could also be used as a sociological yardstick. If information on TB deaths cannot be related to the entire community, the yardstick should be applied to patients placed on treatment by NTP. Effective NTPs should be able to bring down specific mortality fairly close to crude mortality. Finally, if the estimate of epidemiological prevalence of the bacteriologically confirmed cases in the community is available, it is desirable to calculate the proportion of the prevalence cases under the current treatment of NTP, from time to time.

The article examined the social dimensions of the NTCP and social issues inside and outside the health service system. The NTCP had initiated and advocated the use of symptoms as the basis for making the preliminary diagnosis, the use of people's felt-need as a basis for a passive case detection strategy through GHS and, provided home treatment instead of the earlier institutional therapy. The important social issues inside the health service system that affected the implementation of NTCP were: 1) Other communicable disease control programs did not use the social approach resulting in consumption of huge resources, 2) Precedence was given to family planning and malaria eradication. This was a frank distortion in the social nature of planning. The outside social issues identified in the paper were the problem of default due to poverty and uncontrolled interventions by the private sector.

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.

The aim of the sample survey conducted in January-February 1968 in the railway colonies of West Bengal was to determine the "Sociological Tuberculogenic Factors" that were responsible for the development and spread of TB in the population. The sample studied was found to be representative of the general population. The trend and behaviour of disease was dependent on the relevant standard of living (separate colonies were built for officers, upper subordinates and other categories with wide difference in social conditions), working conditions, habits and social evils such as alcohol consumption and "ganja" (illicit drug) smoking. The incidence of disease was more rampant amongst the low-paid categories and was inversely related to the group's income. Based on the findings, some suggestions were made to check the progress and spread of TB.

The methods of measuring the dynamics of behaviour of the tuberculous patient, the social consequence of a TB case in the family and neighbourhood or the economic burden of the disease to the nation is still in the embryonic stage. Negative reactions from family and associates could lead to the patient's denial of having TB, thus endangering the patient and the community. Since the NTP came into being, TB patients can expect a correct diagnosis and prompt treatment. As the patient's interest in treatment will decline when suffering is reduced, it is urged that the patient be motivated (preferably, at the start of the treatment regimen) to acquire a compulsive, obsessive, daily habit for drug consumption for at least a year. As the social security measures in the country are meagre, domiciliary treatment rather than institutionalization should be offered to reduce the extent of disruption to the economic and social life of the patient.

Another important area of concern is the measurement of suffering. With the revolutionary changes in the treatment of TB, the prior acute, physical suffering and mental agony of the TB patient has given way to a generalised form of distress. Using behavioural techniques such as group interviews of the patient amidst his/ her family and projective techniques will provide a thorough knowledge of the personality, values, expectations and social interactions of the TB patient. This knowledge could help explain why patients fail to avail diagnostic and treatment services offered to them and, enable the NTP to continue the felt-need oriented approach.

A medico-social study was conducted at the New Delhi TB Center to determine the factors involved in late diagnosis. A total of 400 new patients attending the Center from three different territories, were interviewed for information on the duration of symptoms and remedial action taken by them before reporting at the Center. The resulting data were then correlated with the clinical and bacteriological status of each patient to ascertain the consequences of late diagnosis for the patient. The results, based entirely on patients' narrations, indicated that patients' late visit to the Center was because of late diagnosis or referral. A concerted effort is necessary to promote awareness of TB among the general public and to ensure that GPs and General Health Institutions suspect TB early and diagnose or make referrals early.

This paper is based on the assumption that a tuberculous patient`s alcoholism is determined by specific characteristic feature of his personality, where an important role is played by his fear of death. The assumptions were corroborated by comparison between tuberculous alcoholics, on the one hand, and tuberculous patients, alcoholics and healthy subjects on the other hand.

The setting is Homeless and other fringe groups are a priority in the global strategies of TB prevention and control in big cities, as a consequence of their generally poor adherence to treatment and concurrent multiple social and health problems. The objective is to evaluate a social care and health follow-up programme targeting homeless TB patients in Ciutat Vella District, Barcelona, which covered 210 patients from 1987 to 1992. During directly observed treatment, primary health care and, if necessary, accommodation was provided. The design of the study is the differential TB incidence rate between Ciutat Vella and the other districts of Barcelona, the percentage of successfully completed treatments and the days of hospitalization saved by the programme were measured.

There was a significant decrease in the TB incidence rate among homeless patients in Ciutat Vella (from 32.4 per 105 inhabitants in 1987, to 19.8 per 105 in 1992, P=0.03), compared to an unchanged rate elsewhere (1.6 per 105 inhabitants in 1987, compared to 1.7 per 105 in 1992, P=0.34). A smaller than expected proportion, 19.6%, of patients failed to complete their treatment, and a decrease in the mean period of hospitalization for TB in the district hospital was recorded, falling from a mean 27.1 days in 1986 to a mean 15.7 days in 1992. The programme appears to be both effective and efficient, as it has enabled a large number of homeless patients to complete their treatment successfully, at the same time saving twice the amount of funds invested.

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 long term follow up study of symptom recurrence and action taking of TB patients of urban clinics in metropolitan cities may be of limited value. But such follow up studies based on a PHC, which is an important rural diagnostic and treatment unit in the TB programmes will be of a great value, because the center is responsible for comprehensive preventive and curative services to the community through family and household units. It is, therefore, important to know whether a TB patient, diagnosed and put on treatment by the centre, experiences recurrence of the symptom, for which he has sought relief at the centre and if so whether he goes in search of relief elsewhere.

A case is made for devoting serious attention to the human element in reducing the world-wide incidence of TB. Poor patient compliance remains the principal cause of treatment failure in both developing and developed nations. Contributory factors to treatment failure include the lack of effective communication between national TB services and private practitioners, physicians’ attitudes, behaviour and lack of understanding of cultural differences in patients’ attitudes to TB, its diagnosis and therapy. Other local factors affecting compliance, the relationship between education and TB control and human factors that impact anti-TB programmes at the national and international levels are discussed.

Non-adherence to treatment is an obstacle to the control of TB. Among many reasons mentioned for non-adherence, providers’ attitude, behaviour and knowledge and skill in dealing with TB patients has been cited as an important factor. Few studies also indicate that communication between patient and provider during interaction also plays an important role in the therapeutic process. Hence, this present study on patient-provider interaction was designed to describe some of the factors affecting adherence to TB treatment at LWTDTC, at urban district of Bangalore and its catchment area. The main objectives of the study were to find out the rate of adherence, application of present national control programme, patient perception of DOTS, retrospective elucidation of patient provider interaction and its influence on adherence to treatment. Treatment cards of a total of 602 smear positive patients treated with SCC regimen during Jan to Sept 1997 were analysed. From among them, 11 completed patients and 13 non-adherent patients were selected by systematic random sampling for subsequent interviewing. Further, 10 patients out of 153 patients who were under treatment from April to May 1998 and 15 patients receiving DOTS from 4 Treatment Units were selected by purposive sampling for the interviews. In addition, 23 health care providers (physicians, nurses, health visitors, laboratory technicians and health workers) were interviewed.

Most of the patients interviewed have sought the help of private health services prior to their diagnosis with the belief that their illness is not severe and attributed to cold, fever and viral infections. A majority of the patients were diagnosed within four weeks at the place of treatment. Only some had delay of more than 4 weeks. They were either referred by the initial provider (majority) or by self-motivation. Of the 602 patients, 449 (74.5%) did not complete the treatment. The non-adherence was more significant in the age group of 21-40 years. Defaulting was higher among males than females. The defaulting was early, as 64.3% defaulted within three months. None of the non-adherent patients reported having received a letter or being personally contacted by the staff. The patients put on DOTS had a separate box of anti-TB drugs for him/her and were given drugs in the intensive phase three times a week under direct observation and once a week in the continuation phase and two doses for self-administration. The results were that 74.2% of the patients put on DOTS were cured at the end of treatment. The providers have strong belief that DOTS is the answer to the problem of low adherence.

The most common reasons given for non-adherence by patients, providers and key informants, were lack of family support, providers behaviour, drug side effect, disappearance of symptoms, alcohol and smoking. Adherent patients attributed family support, self-motivation and providers’ assurance as motivating factors for completion of the treatment.

The available facilities for relief of TB patients (at different stages in the course of the illness, at diagnosis, treatment, rehabilitation and follow-up) in West Bengal and the duties of the medical social worker are described.