The rapid rate of development in science and technology in recent years, particularly, in mass communications has posed a great challenge to the Indian society. Welfare of the society can no longer be dependent on the totally inadequate and ill-defined "philanthropy" of charitable institutions and condescending moneyed men. Political changes must be accompanied with radical social changes, if social unrest is to be avoided. This requires a comprehensive social plan, of which medical and public health services form an important component. Medical social planning calls for a total change in the concepts in the teaching, research, and practice in the medical sciences. In the teaching of social medicine, more emphasis must be laid on the adequate utilisation of the already available knowledge for the good of the entire society. The main trend in medical research must be to get such basic knowledge about social medicine. Medical personnel inculcated with such a knowledge about social medicine will, in turn, determine the pattern of medical practice. Further, the administration in medical and public health services must get tuned to this social bias so as to extend the maximum aid to the newly oriented medical and para-medical personnel working in the various health services.

Before the advent of western system of medicine in the eighteenth century, the practice of the empirical indigenous system of medicine of very high standard was in vogue in India. However, with growing industrialization in Europe allopathic system made spectacular progress of which Indian sub continent could not remain unaffected during British rule. As a result, indigenous systems of medicine declined and became more or less cult of the quacks. Only a small fraction of the educated Indians have a chance to acquire knowledge of western medicine and only a few could afford to avail these services while millions of Indians living all over the country had very little use of very advanced medical institutions based in big cities. Even after 14 years of political independence India continues to be the home of preventable epidemics as well as has high incidence of innumerable communicable diseases. Extreme poverty is perhaps the most important factor responsible for the poor state of health of the people in India. A plan for having better nutrition, better water supply, housing and better education will certainly result in great improvement in the national health. In the initial stage of social development all efforts should be directed to provide basic elementary medical and public health services to the entire population. The doctor going to work in an interior village in India must have a wide and varied knowledge of the preventive and curative aspects of medicine, all specialization rolled into one. The state must provide free medical care to all, particularly to the poor. In the concept of socialized medicine there is no place of top sided approach of having highly trained doctors who have nothing to offer to the public other than some useless mixtures. What is urgently needed is a social transformation of the practice of public health and medicine in India.

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.

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.

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 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 oratorical piece provides a detailed description of the rich heritage of the work on TB in India which also contributed to dramatically changing the approaches to TB control, globally. The importance of integrating a social science approach in the epidemiological strategy was visualised at the very beginning of the establishment of the NTI in 1959 and this was the key concept in the formulation of the NTP. The social inputs in the NTP or, felt-need overlapping with epidemiologically assessed needs are described in detail. These inputs are, mainly, consideration of the awareness of suffering due to symptoms, giving priority to sputum-positive cases, integration of TB services with the GHS and, consideration of the need for improvement in people's access to health services. This revolutionary integration of social inputs in the TB programme by NTI resulted in the NTP taking a radically new approach to programme formulation and implementation. This led to the programme being more socially acceptable, cost-effective and epidemiologically effective. The problems encountered in implementing NTP during the last twenty-five years are detailed and some suggestions are offered to overcome them.

The purpose of the study was to establish the rate of emigration in a random selection of villages, with a view to forecast the likely loss of population in a follow-up study on BCG vaccination in the area. The study was carried out in the total population belonging to 35 villages of Channapatna, Devanahalli, Magadi and Nelamangala taluks of Bangalore district in April 1960. Demographic characteristics such as birth and death rates, immigration rates and proportion of persons temporarily absent, were also studied. The head of the household if absent, any other responsible adult was interviewed on a house-to-house basis, regarding the composition of the family, according to the NTI manual for census takers. Estimation of migration was to be based on the registered population of the current day, the population exactly one year ago and all relevant events during the intervening year.

The thirty five villages surveyed were found to have a population of 13,838 persons at the time of interview. This figure included: (A) 13138 persons in the household at the time of census taking also belonged to it one year ago. (B) 470 persons born during the past year. (C) 230 persons immigrated during the past year. (D) 200 persons dead during the past year. (E) 307 persons emigrated during the past year & (F) 770 persons temporarily absent. The net increase in the population from April 1959 to April 1960 was, 193 persons or 14 per thousand.

It was estimated that not more than 5% of the population would be lost by emigration over a period of two years. About 1/3rd of the emigration is within the same taluk. Only a small portion of the emigrants are above 30 years of age. It is also found that a good proportion of women's migration is due to marriage. The study findings revealed that the hypothesis that large number of people leave the village every year, making BCG coverage impossible could hardly be upheld.

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.

In this paper an attempt is made to examine how the data from the history of medicine in India can help in formulating health programmes that deal with health problems as an integral part of the overall causation. India’s 5000 years of history provides an enormous perspective of the nature of man’s struggle against his environment starting from Indus Valley Civilization, the influence of Vedic Way of life of Buddhism, followed by frequent foreign invasions and general decline in the living standards of people. At the time of independence in 1947, India faced on one side, staggering problem of poverty, hunger, illiteracy, size in population and, on the other side, advantage of having ready made technological knowledge which could create effective weapons for dealing with these problems. An ecological analysis of the history of medicine in India shows an expansion of population due to availability of abundant resources, which meant an increase in prosperity and social development. Public health facilities of the city of Mohenjodaro were superior to all other communities of the ancient orient. Almost all households had bathrooms, latrines, often water closets and carefully built wells indicating the extent of health consciousness of ancient Indian people. During Ashokan period, there is existence of social medicine along the line of Buddhist ideology. Emperor Ashoka states that “all over his dominions and adjoining territories, medical treatment is provided for men and animals”. However, the radical changes that followed after the introduction of British rule dealt a fatal blow to the practice of the Indian System of Medicine. A shift to practical western medicine during Nineteenth and Twentieth centuries led to neglect of Indian medicine and further decline.

These historical data help in providing a better understanding of the genesis of the present situation and are also of immense importance for forecasting the pattern of health problems and health practices in the context of ecological changes that are expected to be brought about by other social development programmes, e.g., mechanisation of coal mining might influence the epidemiology of ankylostomiasis through better standard of living; conversely, effective ankylostomiasis programme may bring prosperity by increasing the productivity of the coal miners. This is known as Positive Circular cumulative causation phenomenon. Today, Indian society stands on the threshold of far reaching social, cultural and economic changes. Utilization of the scientific knowledge generated by Industrial Revolution for dealing with the health problem is essential for practicing modern medicine. A sound medical and public health programme must have a very sound infrastructure of overall social, cultural and economic development. In a natural process of social evolution, medical and public health services cannot grow without such an infrastructure. Even if it were hypothetically possible to create artificially (at an astronomical cost) efficient medical and public health services without correspondingly developing the infrastructure, the social benefits accruing from such services will be of doubtful significance. What benefits will a hypothetical ‘disease free’ state bring to a population that is otherwise ill fed, ill clad, and ill housed and illiterate?

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.

Sociological investigations have revealed that more than half of all infectious cases in rural areas seek relief at various health institutions and that as many as 95 percent of them are conscious of the symptoms of the disease. These findings lead to the formulation of a felt-need oriented TB programme as an integral part of the services that are offered at the rural health institutions. Specialised TB institutions at the higher levels lend support to them by offering referral facilities. For a population of a million and a half, there is a DTC to give them administrative support. Such an integrated programme is not only very economical, but it also grows along with the GHS. Its orientation to felt need makes it more acceptable. It also has a potential for covering some 95 percent of the infectious cases in the community, thus indicating that it can have an impact on the incidence rates of the disease.

Formulation of a nationally applicable, socially acceptable and epidemiologically effective NTP for India involved use of a wide range of principles of the discipline of community health. These principles can also be very profitably applied in the formulation of nationwide programmes to deal with other major community problems. Government commitment to strengthening rural health services in India by using multi-purpose health workers and by employing community health volunteers has further strengthened the case for adopting the approach developed for formulating the NTP on a much wider scale. This approach also gets further endorsement from the concept of primary health care contained in the Alma-Ata Declaration.

It is now widely recognised that investment in health fields contributes to economic growth of countries by stimulating growth in ”human capital formation” and by preventing economic loss due to sickness, disability, premature death and cost of treatment. An integrated plan, in which investment in certain key areas in health field is made side by side with investment in similar areas in other social and economic fields, is essential for reversing the vicious circle of poverty and sickness in developing countries. Health economists will have to work in close collaboration with social planners in other fields in order to develop certain common units for measuring health and other social and economic problems and to identify those areas for investment in health fields which have considerable bearing on social and economic development.

This study was undertaken in 34 villages and 4 town blocks where a few weeks earlier an epidemiological survey was carried out. All persons above 20 years whose photofluorograms were read as inactive, probably active, or active by at least one reader, were age-sex matched with an equal number of X-ray normals, to form the experimental and control groups respectively. Thus, a total of 2,106 were eligible for social investigation. Interview sheets, with particulars of the name and location of village, household number and individual number and the identifiable data of the interviewees were made available to the Social Investigators at random for contacting and interviewing them at their homes. The interviews were non-suggestive in nature and deep-probing on the details of symptoms experienced by the respondent, which were fully recorded. About 79% of the experimental group and 83% of the control group were satisfactorily interviewed, which constituted the data further analysed. Of the numerous symptoms recorded, only that were associated with pulmonary TB were considered, of which cough occurring for one month or more, fever for a month or more, pain in the chest, haemoptysis and all combination of these four symptoms were analysed statistically.

Cough was found to be the most important single symptom. It was not only the most frequent symptom alone or in combination in the experimental group but was less frequent in the control group that 69% of sputum positive and 46% of radiological positive had cough while only 9% of the control group had it. Considerably fewer people had fever and pain in the chest. Pain in the chest appears to be non-specific, giving a ratio of only 2:1 among the experimental and control groups, while fever was in the ratio of 6:1 and haemoptysis was 11:1. It was seen that 69% of the sputum positive cases, 52% of the X-ray active or probably active, 29% of the inactive and 15% of the normals (control group) had at least one of the above mentioned symptoms. In all the groups, the proportion of symptoms was higher among males than among females. In both males and females the prevalence of symptoms was higher in the middle age groups than among the younger or older groups. This age variation was more marked in the females. The findings of the study were analysed further along with the data obtained from a couple of minor investigations conducted in the rest of the 28 villages which formed the total of the villages surveyed epidemiologically. This brought out further that 95% of bacteriologically positive cases are aware of symptoms, 72% experience 'worry awareness' and 52% form the action-taking group. The above findings have been of considerable importance in planning further studies and in formulating the NTP.

KEYWORDS: SOCIAL AWARENESS; INDIA.

The research study was an extension of a prior study (Anderson & Banerji, D., 1963) that undertook a one-year follow-up of 784 patients who were diagnosed at the clinic of the State TB Demonstration and Training Center, Bangalore. The study sought to determine, over a three-year period, how the pattern of drug collection among the above patients related to the findings about their bacteriological and sociological status.

This report contains a summary of the material and methods used in the clinic followed by detailed descriptions of the bacteriological follow-up of the patients, the significance of the radiological findings for the initial diagnosis and follow-up of patients and, the methods of sociological investigation. The results of the data analysis are also described in detail. The conclusion drawn from the research was that when TB patients, who actively sought medical help, were offered facilities for drug collection within a reasonable distance from their place of residence and when a "skeletal" organization was made available to supervise the treatment of these patients, it was very unlikely that the patients would continue to suffer from TB without availing themselves of the treatment facilities.

The panel discussion highlighted some basic administrative, organizational, technical and patient factors relevant to the problem of Treatment Default in the TB programme. In urban areas, the proper motivation of the patients, keeping of suitable records, prompt defaulter-action, adequate supply of drugs and the need to provide suitable facilities for patients coming from outside the clinic area, constituted the key administrative and organizational factors affecting treatment default. Regarding technical considerations, there was a need for a more precise definition of a case. It was pointed out that a large proportion of the patients were not really defaulters either because they were not cases of pulmonary TB at all or the patients took treatment from outside the clinic. Also, many so-called defaulters took the treatment after the expiry of the 12 months, while some were resistant to the treatment offered at the time of their first registration. In rural areas, the TB programme could only be strengthened with a concurrent strengthening of the over-all health administration.

A two-year follow-up study of treatment default among 193 patients with pulmonary TB, who were receiving domiciliary treatment in a Delhi urban clinic, revealed that the percentage of defaulting (that is, collecting drugs for less than 10 months) fell from 57% to 44% when the duration for calculating drug collection was raised from 12 to 24 months. The propensity to default appeared to be inversely related to the precision of diagnosis and the extent of lesions. While the default rate was 20.2% among those who were initially sputum positive, it was 100% among those sputum negative cases who had only minimal radiological lesions. This study, thus, questions the rationality of assessing the performance of a TB clinic on the basis of the ‘traditional’ definition of a defaulter. It has presented data to make a case for a more precise definition of a defaulter by offering a longer period for calculation of drug collection and by stressing the need for greater precision in diagnosis of cases who are put under treatment.