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.

This was a presentation made to the President and Chair of the TB Workers' Conference in British India, 1939. The presenter traced the history of the organized control of TB in many countries with reference to State legislation and, described the variations in laws passed and their impact on different aspects of the anti-TB efforts. The latter part of the presentation was focussed on legislation and TB in India. Defects in certain existing provincial laws were explained as also the negative impact of some of them on the patient and his/her family. It was considered premature to consider any comprehensive and useful TB legislation in India at the time before correcting existing provincial laws and recommendations were made to enforce laws concerning certain factors which promoted the spread of TB.

It has been shown that most of the infectious TB cases in a rural community in south India are at least conscious of the symptoms of the disease; about three-fourths of them are worried about their sickness; and, about half of them actively seek treatment for their symptoms at rural medical institutions. The existing facilities deal with only a very small fraction of even these 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 a felt-need. India‘s health administrators have to initiate suitable administrative and organizational reorientation of existing services to satisfy these already existing felt needs. Simultaneous social and economic growth will help in developing the epidemiological strategy and the rise in living standard itself may have a significant impact in controlling 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.

The editorial describes briefly, the history of hospitalization for pulmonary TB, noting that this history, in the two succeeding centuries, had been chequered, as it was influenced by successive scientific advances. Currently, even the near revolution of modern chemotherapy has not made hospitalization obsolete. In the developing world, this may not happen for a long time, because admission criteria other than medical could have equal weight. Those who will not accept that hospitalization for TB may have become irrelevant were ignoring economic reality and sensible practicality. It is urged, therefore, that hospitalization for TB be confined to managing emergencies, as a part of general emergency services. In developing countries, all the beds thus released could be handed over to the GHS as contribution to newly emerging primary and secondary health services.

The overview takes into consideration the historical, socio-economic, administrative and technical factors, which have played a prominent role in shaping India‘s NTP. It comprises an analysis of the current status, trend during the past ten years and discussion of some aspects that need further attention. Now, a majority of the constraints are administrative and not even operational, while the needed technical improvements are few. At the present stage of development, it would appear premature to say if the programme has succeeded or failed.

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.

The editorial comments refer to the 1989 Ranbaxy-Robert Koch Oration given by Dr. William Fox, titled "TB in India - Past, Present and Future". Dr. Fox highlighted most of the major aspects of TB in India, being familiar with the TB scene in India for over 35 years. Emphasis was placed on the need to improve research, training and evaluation aspects of NTP and on improving programme administration and management based on these findings. However, Fox's recommendation to establish a long term National TB Standing Committee with various powers is considered to reveal his unfamiliarity with various aspects of the Indian administrative and political climate and the social upsurges prevalent at the time. The editorial suggests an alternative way to manage the TB programme, while supporting Dr. Fox's views, in general.