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.

There is evidence that man has suffered from TB for more than 5,000 years, and through crowded living conditions, debilitation, and malnutrition, TB became epidemic in western civilization and was a major cause of mortality. Identification of the tubercle bacillus as the causative agent in 1882 firmly established the infectious nature of the disease and the development of sanatoria soon followed. Before the advent of effective chemotherapeutic agents treatment involved rest, diet, and various surgical procedures, which were of little or no benefit to the patient. The discovery of dihydrostreptomycin, aminosalicylic acid, and isoniazid in the late 1940`s and early 1950`s meant that TB was now entirely curable in virtually all patients. Despite these effective chemotherapeutic and preventive agents, TB has receded to socio-economically disadvantaged urban and rural areas, where the incidence parallels that of developing countries. Conquest of the disease will require improved health care delivery to the indigent and dispossessed.

The Indian population probably predominates in the high-case-rate areas of Arizona and Newmexico and in the north-central and northwestern states. Trying to 'cure' TB from a purely medical standpoint is like trying to treat the symptom rather than the disease.

The paper stresses that taking preventive and socio-economic measures to combat TB would be more cost-effective than the treatment of a TB case, particularly, in a developing-country context. Therefore, it is suggested that the anti-tubercular chemotherapy treatment in a developing country should be scrutinised in comparison with socio-economic measures to control TB on several recommended lines.

The basic economic difficulties and some of the major problems of patients in the United States, created and intensified by TB, are discussed in this paper. Two major economic problems are listed. Provision for economic care ranges from little assistance in some communities to a minimum relief standard in others, with many intermediate variations. Concerning, emotional problems, those connected to the acceptance of diagnosis are of great significance. Several representative cases are described to illustrate the varying emotions patients experience. There is a growing interest to extend social services to address the above social problems and the social worker plays an important role in studying, evaluating and treating the social and economic problems of TB patients.

Deaths of resident white TB patients in Buffalo, New York, in 1949-1951 were found to be inversely correlated with socio-economic status as measured by economic quartile of residence. Data on the previous residences of these 493 patients were obtained; 84% were traced to 1946 or earlier and, 66% were traced to 1935 or earlier. The socio-economic distribution at the earliest address found did not differ significantly from the distribution at the time of death; this held true even for those traced to 1925-1935. It is concluded, within the limitation of the study method that no positive evidence was obtained that the excess of TB mortality in low socio-economic areas is due to downward socio-economic "drift" by the persons afflicted with the disease.

The problem of TB in a developing country such as India must be considered in the overall social and economic context. Massive investment of money and resources to eradicate TB may interfere with other measures more important for the country`s progress. But a limited investment in a suitably oriented TB programme could hasten the decline of the disease. Social planners thus face a special challenge in such countries. The problems are almost overwhelming, while the resources available are extremely limited; scientists will have to formulate programmes which will ensure that these resources are utilised to give a maximal return from the investment. Thus, in considering TB as a problem of social planning in developing countries it will have to be dealt with at three different levels:

(a) Recognising the implications of factors other than a specific TB programme on the incidence of the disease; (b) developing methods that could offer the best possible returns from the available resources, both at any given point of time as well as at different time intervals; and (c) determining priority for allocating resources in a socially applicable TB programme. The NTI, Bangalore has used operational approach for formulating a nationally applicable and acceptable TB programme for India. The sequence of steps that led to the formulation of TB programme in India can as well be applied to develop a similar programme in any developing country.

The new approach to the role of socio-economic factors in TB control demands that social planning in respect of TB has to be in consonance with the overall development of the community. A rational allocation of existing resources in the context of this process of social change can be achieved only through a comprehensive and integrated approach. One of the important principles of social planning is the tailoring of a programme to the felt-need of the community. The intervention becomes more readily acceptable, less costly and allows the due share to the other felt-needs of the community. The overall development of the community and providing basic facilities leads to the better public participation in the TB control programme. Improved nutrition status of the people specially by feeding young, will help in preventing the breakdown of the disease. Since TB is equally prevalent in rural and urban areas, planning of the whole area by involving the existing facilities and development of effective rural TB services will bring the services within reach of every person. Regular and continuous training and supervision of the general staff to carry out TB activities is one of the prerequisite. A continuous anti-TB drug supply for treating about 4 million cases per year for a very long period of 20-30 years can be achieved with the help of international assistance.

Even if the programme is fairly effective, it is visualised that the control programme and social planning should be on long term basis for several decades.

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 author presents a few selected topics for discussion expected to assist in the future formulation of strategies against the spread of TB. One such topic is demographic changes. In most developing countries, with constant age-specific rates, increasing population and a relative increase of the older age groups are expected to lead to an increase in the absolute number of TB cases, as illustrated with a simulation. The consequences of the fact that TB services are reflections of the health services which, in turn, reflect the general public services in the community and, that TB is closely related to the prevailing socio-economic conditions are discussed in detail. Also, it is suggested that the immediate and impressive successes of the reductionistic medicine led to an underestimation of the importance of the general living conditions in the generation of health.

The decline of mortality in the more developed nations has been related to two major influences, economic development and the introduction of medical measures. The contribution of medical measures has been a source of continuing controversy. Most previous studies employed either a birth cohort or calendar year arrangement of mortality data to address this controversy. The present study applies an age-period-cohort model to mortality from respiratory TB in England & Wales, Italy, and New Zealand, in an attempt to separate economic influences from that of medical measures. The results of the analysis indicate that while the overall contribution of medical measures is small, when examined by calendar year, specific birth cohorts both in Italy and England and Wales benefited substantially from these measures. The environmental conditions in New Zealand, however, were such that the introduction of medical measures barely affected declining mortality levels from respiratory TB.

The study examined the clinical profile of five hundred TB patients admitted to the Rajan Babu TB Hospital, Delhi and determined the clinical and socio-economic factors important in hospitalization, default and failure of therapy. An attempt was also made to judge the health awareness in these patients and from that the success or failure of the health education programme. It was found that the percentage of cases who had relapsed or who were drug failures was quite high in hospitalized patients. Socio-economic factors were solely or partially responsible for the patients seeking admission in almost 20% of the cases. These factors as well as lack of education and proper motivation were responsible for drug default and subsequent failure in a large number of cases. Health awareness was quite low even in patients who had stayed in the hospital for a prolonged period pointing towards a failure of health education.

The role of socio-economic factors for the risk of developing TB is unclear. Differences and similarities between cases and controls on various socio-economic factors were determined. Some 84 black TB patients on ambulatory treatment and 84 disease free controls living in the same urban area (South Africa) and matched for age and sex were studied. Variables measured were demographic details, general living conditions, household ownership of luxury items and, weekly consumption of four proteins (meat, fish, chicken & cheese). Three socio-economic indices were constructed from the above variables. No significant differences were found between cases and controls on most of the variables. Overall, significant differences were found on the pattern of language groups (chi-square; p= 0.031) employment groups (chi-square; p= 0.029) and meat (chi-square; p= 0.012) and chicken consumption (chi-square; p=0.034). A tendency was observed for more employed cases than controls to have a primary school education. However, no conclusive evidence was found on the association between socio-economic factors and risk of developing TB. The development of a more appropriate socio-economic measure for developing countries is a necessary step for further research.

A survey of the socio-economic status of nine villages in Sagalee Circle, Arunachal Pradesh, was carried out from 12-31 March, 1984, during a Mass Sputum Sample Survey, in order to determine the relationship between socio-economic status and TB. A total population of 1004 from 84 households was covered. The family structure in the ethnic group studied was that of a joint family and the custom of polygamy was practiced. Many areas surveyed were difficult to reach. The survey results revealed that the people were generally exposed to different types of common infections and diseases, preventable if the socio-economic status had been higher. However, the incidence of TB was less than the national level of 4%. Several recommendations are offered to assist future health planning and health promotion in the state.

The study examined the possible association between urban deprivation and TB in the elderly by comparing the TB notification rates in the Urban Priority Area (UPA, which includes the inner city and most of the poorer housing estates) and the rest of Leeds, UK, between 1986-1990. The results were analysed by chi-square test and revealed a greater than two-fold increase in notifications for TB in elderly subjects resident in areas of urban deprivation. The findings highlight concerns over continuing poverty and deprivation among Britain's elderly population.

Two hundred and ninety nine patients registered for treatment with the public health services-103 with rural PHC`s and 196 with urban TB clinics in Pune district were interviewed in order to understand social and operational determinants that influence treatment behaviour in lung TB. Detailed quantitative as well as qualitative information was elicited. The study showed that despite weak, if not missing, health educational inputs, patients' understanding of TB was satisfactory. Their preference for private doctors over public health services for TB, their frequent change of health providers for diagnosis as well as treatment, their poor treatment adherence despite knowledge of its ill-effects and their related actions perceived clearly as deleterious to their own good were influenced more by social, economic, and operational factors than by their self-destructive attitude and behaviour. The study concluded that it was the availability, affordability and acceptability of health facilities for TB-factors related primarily to the provider behaviour- that deserved greater and priority attention. Attempts at rectifying provider behaviour were likely to be more productive than those at disciplining patients.

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.

This study was undertaken to quantify the socio-economic impact of TB on patients and their families from the costs incurred by patients in rural and urban areas.

An interview schedule prepared from 17 focus group discussions was used to collect socio-economic demographic characteristics, employment, income particulars, expenditure on illness and effects on children from newly detected sputum-positive pulmonary TB patients. The direct and indirect costs included money spent on diagnosis, drugs, investigations, travel and loss of wages. Total costs were projected for the entire 6 months of treatment.

The results showed that the study population consisted of 304 patients (government health care 202, non governmental organization 77, private practitioner 25), 120 of whom were females. Mean direct cost was Rs.2052/-, indirect Rs.3934/-, and total cost was Rs.5986/- ($171 US). The mean number of work days lost was 83 and mean debts totaled Rs.2079/-. Both rural and urban female patients faced rejection by their families (15%). Eleven per cent of schoolchildren discontinued their studies; an additional 8% took up employment to support their family.

It was concluded that the total costs and particularly indirect costs due to TB, were relatively high. The average period of loss of wages was 3 months. Care giving activities of female patients decreased significantly, and a fifth of schoolchildren discontinued their studies.

A TB control project was undertaken in 1971 in South Western United States, in the reservation of the Navajo Indians (120,000 living in a vast, high, arid land). The specific problems in treating TB among the Navajo are described. The specific problem was that, despite efforts of medical personnel and available treatment facilities, only 25% of the active TB cases at home were taking their medications. The cause was found to be the inadequate number of trained personnel to do the necessary tasks to keep patients on medication. To achieve the project’s goal of increasing the percentage of patients at home, taking medication in one year, to 80%, job analyses were done to develop outlines of the duties, knowledge and skills required of TB workers, the case register clerks and the project Director, by interviewing the physicians, nurses and administrators working on the project. Subsequently, 4 weeks of training (carefully designed around the job requirements of the trainees) was given. An evaluation of the project indicated that 80% of active cases at home were on medication after a year and 96% in the fourth year. Only 4% of cases were lost to supervision, active cases in the hospital were down from 50% to 15%, hospital stay was down from 70 to 18 days, a quarter of active cases were on intermittent therapy, new case rates were down from 150 to 73 per 100,000. A subjective evaluation performed through the use of interviews and questionnaires revealed positive and negative feelings of the workers to different issues of TB work. The conclusions were that TB workers, recruited from the indigenous population and carefully trained, could greatly benefit a TB programme; such a project was best implemented by an objective-oriented approach focussing on the problem, cause, objective, solution and evaluation. These concepts could be successfully utilized in any TB programme, whether it be rural or urban, in a developed or developing nation.

This is a report of the "Health Sector Priorities Review" that the World Bank undertook with a number of collaborators, over two years. The core of this review is a series of studies on the public health significance of major clusters of diseases in the developing world and on the costs and effectiveness of currently available technologies for their prevention and case management. This analysis of TB, supported as a part of these studies, revealed the tremendous burden of TB and the existence of interventions of proven efficacy that were some of the most cost-effective in the international public health armamentarium.

To examine the problem of default in drug intake, a study of 320 patients with pulmonary TB and who were taking treatment at home from the domiciliary section of the TB Clinic in Indore, (Jan. 1969 - June 1970), was undertaken. Of 320 patients, 182 (56.2%) were defaulters. Sixty-six of these defaulters could not be studied for various reasons. Age and gender did not affect drug default while socio-economic factors such as caste, literacy status, social status and family system proved highly significant to default behaviour. Default was common in the joint family system, perhaps, due to lack of individual care when many members shared a common economy. Many defaults were due to family events, typically, births, deaths and marriages. Other important reasons for default were the patients’ feeling of having got well, toxicity of drug and carelessness, ignorance, financial difficulty and non-availability of drugs in TB Clinic. Suggestions to overcome the default problem include improving the general standard of living, eliminating poverty, illiteracy and backwardness, increasing patients’ awareness of the gravity of the disease and the need to take regular treatment, providing facilities for patients to continue domiciliary treatment under the supervision of the nearest medical center after initial check-up at the District TB Clinic, to avoid a long journey and expenses.

A prospective study was carried out to assess the impact of extra motivational efforts on the duration of unbroken drug-continuity in a cohort of 150 randomly selected TB patients undergoing anti-TB unsupervised domiciliary treatment at S.R.N. Hospital, M.L.N. Medical College, Alahabad. The contribution of extra-motivational efforts along with that of some other socio-economic characteristics of the patients, was obtained by the use of multiple regression analysis. It revealed that if monthly additional efforts of extra-motivation are made, devoting 15-20 minutes only in terms of explaining to the patient about the necessity and importance of regular and complete treatment, the average duration of unbroken treatment of a group of patients can be increased by as much as two months, a substantial gain from both curative as well as preventive aspects of any TB control programme.