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 study examined the socio-cultural consequences of acquiring TB on the patients and their families. A random sample of a hundred TB patients who received treatment at the Tuberculosis Chemotherapy Center, Madras, were chosen to determine the types of problems encountered in families stricken with pulmonary TB. The patients varied widely in marital status and by occupation. The problems encountered by the patients were broadly classified into three categories, sociological, financial and psychological. Of these, sociological problems such as disruption of family life, maladjustment, break-up of homes and loss of mental balance were the most commonly experienced problems and were more significant than occupational problems. It is suggested that unless the community and various Government and voluntary agencies act together to tackle the socio-cultural aspects impacting TB patients, along with the medical treatment, the patients will not achieve the desired benefits.

Effective strategies of health planning would begin by identifying and strengthening, through modern interpretation, the existing healthy habits, and practices of the community. After building an adequate rapport with the people through the sympathetic interpretation of their cultural heritage, the health planner should identify their deficiencies and tell them how to overcome them. Both the processes require considerable amount of education and persuasion. In this task, the local leadership and the local institutions can play an important role. Also, the Indian system of medicine and the system of nature cure should be fully encouraged and taken advantage of.

A study was conducted in southern Haiti, from Sept. 1969 through to March 1971, to determine the socio-cultural factors associated with the utilization of a TB out-patient clinic by the indigenous population. In the entire region of some 2200 miles, there was one western health facility for the treatment of TB. Dossiers of 832 patients, newly diagnosed with pulmonary TB and admitted to treatment between 1967 and 1970, were reviewed to determine their treatment utilization pattern on the recommended 2-year chemotherapy regimen. The data from these records were then anlaysed to investigate possible correlations between rural variables involved in patient utilization of the facility: a) the age distribution of the TB patients, b) the geographic distribution of their residences, c) proximity of these residences to main roads, d) withdrawal from treatment over varying time spans. Preliminary analysis revealed that this clinic was largely ineffective in combating the disease. A vigorous examination of its organization mechanism and patient files revealed that the attrition rate among the TB patients was 75.12 percent within the first 6 months of treatment. An in-depth analysis of the total cultural situation indicated that the clinic`s lack of knowledge about the local culture (the term TB meant symptoms not serious enough to merit a visit to the clinic in the local people's minds, the Haitians' concept that any person able to discharge their normally expected social functions was healthy and the clinic's operating time schedule which did not fit with the local people's way of life and activities) and consequent failure to operate within it was a major source of the problem. Suggested changes include: a) Shifting the clinic schedule to correspond with the daily flow of people in the rural areas, b) undertaking health education measures to teach the early signs of TB, the importance of early detection and the need for prolonged treatment, c) changing the term used in advertising the clinic and, d) using the newer combination drugs to reduce the treatment cost and enable patient to remain on treatment longer.

Existence of public medical facilities does not ensure their acceptance contrary to what was assumed by the NTP. Besides their limited research in the whole community, their case-holding is marred by defaulters. Defaulters are not necessarily the poor and the underprivileged, but are as likely to be those who indulge in medical consumerism out of consideration of status. To secure better case finding and case holding, involvement of private medical practitioners is suggested along with possible means of enlarging the "catchment area" of the DTC, like identifying special target referrals can be encouraged selectively, and emphasizing the superiority of routine diagnostic and curative activities of the DTC vis-a-vis private practitioners, so as to give a sociological "face lift" to the DTP, which will attract more of those patients who pay more, and get less, from private practitioners.

Early case identification and adherence to treatment regimens are two remaining barriers to successful TB control. In many nations, however, fewer than half of those with active disease receive a diagnosis and fewer than half of those beginning treatment, complete it. These twin problems derive from complex factors. People's confusion as to the implications of the TB symptoms, cost of transportation to clinic services, the social stigma that attaches to TB, the high cost of medication, organizational problems in providing adequate follow-up services and patients' perception of clinic facilities as inhospitable all contribute to the complexity. Socio-cultural factors such as the cultural understanding that people with symptoms apply to their disease, staff reluctance to adapt their work environments to patients' daily activities and the socio-political organisation of health delivery services have been emphasised. The importance of studies carried out on three specific subtopics: a) Perception and interpretation of chest symptoms, b) Influence of social stigma on help-seeking and adherence to therapy and, c) Adherence to treatment recommendations are discussed in detail.

A knowledge of the health culture of their patients must become a critical tool for health care providers if TB programmes are to be successful. Several anthropological procedures such as adopting focus group sessions are recommended to help uncover the health culture of TB patients. Thus, a comprehensive analysis of the health culture of groups at high risk for TB, as it interacts with the availability of effective chemotherapy will provide the needed groundwork to eliminate remaining barriers to successful, enduring TB control.

Doctors aboard a Canadian Coast Guard ship travelled to and surveyed the Inuit communities residing in the most isolated areas in Canada, the Eastern High Arctic, for pulmonary TB in 1962. The ship's four doctors surveyed 2,510 people, thoroughly examining half the number. Seventy-nine cases of TB were found. These patients were transported south to a Sanatorium for treatment and several measures were taken to minimize the patients' shock in being separated from their natural environment. Medical facilities and treatment became more accessible to the Inuits in the late sixties and early seventies.

The newsletter lists a series of recommendations following the SAARC Seminar held in Nepal, in 1993. Giving priority to support operational research studies on the above topic, stepping up the information, education, communication activities, encouraging community participation in early case detection, referral and follow-up examinations, including NGOs in future SAARC meetings are some recommendations to control the spread of TB.

Several case studies are presented in this paper to emphasize that the social and cultural dimensions of TB are of paramount importance from the management point of view. The conclusions drawn were: 1) The social stigma against TB was still dominant regardless of caste, social class, economic status, level of literacy and geographic location, 2) Maid servants appeared to be one of the most important transmitting agents of TB, 3) The perception of the patient towards his/her life and people (society) changed within moments of learning that they had contracted TB, 4) The physical recovery of the patient was faster than their psychological recovery. It is recommended that the NTCP take note of the behavioural dimensions of the TB patient from the management perspective.

This paper reviews current knowledge about the role that socio-economic and cultural factors play in determining gender differentials in TB and TB control. The studies reviewed suggest that socio-economic and cultural factors may be important in two ways: first, they may play a role in determining overall gender differences in rates of infection and progression to disease, and second, they may lead to gender differentials in barriers to detection and successful treatment of TB. Both have implications for successful TB control programmes. The literature reviewed in this paper suggests the following:

Gender differentials in social and economic roles and activities may lead to differential exposure to TB bacilli;

The general health/nutritional status of TB-infected persons affects their rate of progression to disease. In areas where women's health is worse than men's (especially in terms of nutrition and human immunodeficiency virus status), women's risk of disease may be increased; A number of studies suggest that responses to illness differ in women and men, and that barriers to early detection and treatment of TB vary (and are probably greater) for women than for men. Gender differences also exist in rates of compliance with treatment. The fear and stigma associated with TB seems to have a greater impact on women than on men, often placing them in an economically or socially precarious position. Because the health and welfare of children is closely linked to that of their mothers, TB in women can have serious repercussions for families and households.

The review points to the many gaps that exist in our knowledge and understanding of gender differentials in TB and TB control, and argues for increased efforts to identify and address gender differentials in the control of TB.

A study was undertaken to explore the knowledge, attitudes and perception of TB and their influence on the adherence to preventive therapy for TB. During 1997, 24 subjects were interviewed by using a semistructured questionnaire which included demographic details, background information on TB, knowledge and perception of TB and chemoprophylaxis. The persons were interviewed in the outpatient clinic in London at the start of the treatment and at monthly intervals thereafter. They were given INH daily for 6 months. The data was analysed descriptively and thematically. The outcome was assessed ? 6 months after the start of preventive treatment.

The sample was representative of age, ethnicity and previous BCG vaccination status. The study results revealed that 63% were aware of TB before starting chemoprophylaxis indicating a medium level of awareness. None mentioned health centre as the source of information. Knowledge of TB was gained outside the family. About 63% of them knew about transmission of the disease but few symptoms of active TB were recognized. Most (92%) were aware that TB was infectious. The perceived threat from TB was high (71% believed that TB was potentially fatal), although the estimated risk was low. Over half of the subjects (66.6%) suggested that TB was preventable. Knowledge of preventive therapy exceeded the general knowledge of TB, although the latter was associated with better adherence. Most denied knowledge of the risk of hepatitis from isoniazid. Defaulters failed to attend their first appointment, attributed more side effects to isoniazid and perceived a longer waiting time in clinic. The rate of non-attendance for appointment at the TB clinic was high.

The study has shown that there is an important lack of knowledge of the symptoms of TB. A better general knowledge of TB is more helpful than merely an understanding of the treatment regimen in promoting adherence. It recommends a single daily tablet, prior warning of dizziness and an open discussion of the problems of keeping to treatment for 6 months encouraging adherence to preventive treatment.

A study was undertaken to know the frequency of depression in hospitalized TB patients, its relation to various socio-cultural factors, duration and severity of the illness. Ninety-six proven male cases of pulmonary TB admitted in S.R.B.B.Y.A. Sadan, Bari, Udaipur from July-September 1975 were selected for the study. A structured psychiatric interview of these cases was done by a psychiatrist and the Hindi version of the Self-rating Depression Scale (S.D.S.) of Zung (1965) was administered. The raw scores obtained were converted into the S.D.S. index by a conversion chart as developed by Zung and his criteria were used for diagnosing the depression. Those patients who had a previous history of any psychiatric illness before developing pulmonary TB and patients developing psychiatric illness other than depression were excluded from the study. The minimum and maximum age limit was 21 and 59 years respectively. Of the 96 cases having pulmonary TB, 52 (54.17%) were found to be suffering from depression. The incidence of depression was higher in illiterates (65.4%) and farmers (84.7%). Depression was positively correlated with the duration and severity of pulmonary TB.

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.