The purpose of this study was to show any changes that may have taken place in an institution when the primary function of the institution was changed. In 1968, researchers from the Faculty of Nursing, University of Western Ontario, Canada, began to study patient-satisfaction in the Sanatorium which was converted from an institution devoted to treating only TB to treating a larger category of diseases. A loosely-structured interview method was used as patients' responses to the researchers' questionnaire was poor. Informal talks were held with patients, staff and physicians. The people at the Sanatorium were candid and open in their reactions; hence the impressions gained were actual reflections. A redefinition of the objectives and procedures in the Sanatorium caused a complete reorganization of the social structure and changed basic perspectives on treatment policies, in turn, leading to the bringing in of a new administration. The nurses had the most difficult adjustments to make, being challenged by a new type of patient, a new administration and a substantially new approach to nursing. Patient-reactions were varied and based on whether they were old-timers, active cases or newcomers. As suggested by the title, this article illustrates how an institution dies efficiently by adopting the above method and by moving the entire operation to new settings. In a historical review, Angrist (1968) anticipates the death of mental hospitals and the passing on to community-based health clinics and home treatment. In summary, the institution is an integral part of society and has to operate as per its defined goal. Concerning TB, public perceptions have radically changed while for mental illness, there has not been enough change in perceptions to result in major structural change in treatment.

The article is an adaptation of a speech made by Dr. Mahler, Director-General of WHO on Sept. 8, 1976 in Kampala, Uganda and on 11th October in Karachi, Pakistan. The main focus of the speech is the need for a social revolution in public health to attain an acceptable level of health uniformly distributed throughout the world's population. The meaning of a social revolution in this context is to take a new approach to the solution of community health problems. Four key factors to adopt when taking this new approach are described in detail: 1) determination of social health goals, 2) identification of the health technologies that subserve the stated goals, 3) selection of sound and affordable health technologies and, 4) manifestation of the political will to determine health policies and appropriate health care systems. It is suggested that these four factors could also serve as a guide for collaboration between Member States, both within and between Regions and certain measures to meet the social challenge in implementation of the policies are offered.

This is an editorial with the view that TB and its control are manifestations of social and economic development. During the past eight years, active TB cases increased substantially in the US and other industrialized countries due to several social, economic and epidemiological factors. Available data suggest that two important steps are necessary for TB control: 1) to identify all persons with active disease and ensure their complete treatment and, 2) to identify high-risk persons with TB infection (such as HIV-infected persons) and provide them with complete preventive treatment. Four articles in the American Journal of Public Health (Nov. 1994, Vol. 84, No. 11), illustrated the challenges and priorities of modern TB control. Buskin et al (p. 1750), after reviewing risk factors for active TB among patients in King County, Washington, USA, suggested expanded outreach and services. Leonbardt et al (p. 1834) showed that with persistence, sensitivity and a mobile van, public health workers gained the trust and participation of patients and their social network which allowed 74% of infected contacts complete isoniazid preventive therapy. The need to provide services to underserved populations and, to improve the co-ordination and communication among health care workers, public health programs, clinics and other agencies in serving difficult-to-reach places were emphasised by Ciesie et al (p. 1729). Lastly, Dr. George Comstock (p. 1729), after a review of the past and prospective strategies for controlling TB, called for a renewed investigation of the epidemiology of TB, especially, to find answers to questions such as: Where does most transmission occur? How can risk of infection best be predicted? Following the collective recommendations of these studies and improving the social and economic environment globally would enhance successful anti-TB efforts.

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.

1The present paper describes certain economic aspects of TB in India, but does not attempt to combine them in a model. The estimated direct costs (beds, clinics, BCG campaign, drugs, private practitioners, after-care, social welfare etc. and research, training and administration) and indirect costs (disablement, premature death) of TB services of all kinds in India, based on known number of physical units multiplied by estimated average cost, have been calculated. These calculations demonstrated that the TB control programme which the NTP was proposing, was not substantially more expensive to the nation than existing TB services. It was concluded that a far higher government share would be economical and that district programmes utilising and promoting the development of basic, GHS would also be economical.