A case has been made out for developing some selected sociological parameters of assessing NTPs.

In recent years, we have been pleading, unsuccessfully so far, for the development of sociological tools so that we can measure the extent of the disease both epidemiologically as well as sociologically. And, also for using the sociological parameters for assessing the impact of NTP. It stands to reason that long before the epidemiological parameters show an impact, a reduction in suffering as well as altered pattern of action-taking may show a change in the disease as it goes down and away in a country.

TB is primarily the problem of human suffering. The author, in 1967, presented some ways of measuring suffering. Eleven thousand, three hundred and fifteen persons from 2,135 rural Bangalore (Karnataka) families were questioned for the presence of TB symptoms two months preceding an interview. Four thousand, six hundred and ninety persons (41.4%) with symptoms were identified. Suffering was measured in terms of death, sick man-days, absence from work and loss of wages, hiring alternative labor, cost of treatment etc. Sick man-days were categorized as completely bed-ridden, partially bed-ridden and ambulatory days. The calculated rough specific mortality of 17.6% compared poorly with the overall crude mortality of 2.2%, without adjustment for age and sex. The overall economic penalty inflicted was about five times more for TB patients compared to other sick persons.

From a review of longitudinal surveys conducted in Singapore and Korea (1975) and in the Philippines (1981-1983), it was shown that the duration of symptoms (suffering man-days), before diagnosis in a fresh case, could be developed into a sociological parameter with cough, the most frequent symptom, being taken as the index symptom. For reliability, information on the duration of cough should be elicited in homes in the presence of the entire family by trained health workers. Specific mortality could also be used as a sociological yardstick. If information on TB deaths cannot be related to the entire community, the yardstick should be applied to patients placed on treatment by NTP. Effective NTPs should be able to bring down specific mortality fairly close to crude mortality. Finally, if the estimate of epidemiological prevalence of the bacteriologically confirmed cases in the community is available, it is desirable to calculate the proportion of the prevalence cases under the current treatment of NTP, from time to time.

Selected data from the Philippines TB Survey (1981-1983) are presented to study the relationship between epidemiological and social aspects of TB, specifically, awareness of certain symptoms and prevalence of TB. Qualified sociological interrogators were drilled for several weeks prior to the survey in setting interview situations, non-suggestive questioning followed by a few leading questions, anatomy of the questionnaire and the standard way of handling it, testing for consistency both prior to use and during the survey. Individuals 20 years and above were asked if they had any suggestive symptoms, namely, cough, fever, chest and/ or back pain, or haemoptysis during 4 weeks prior to an interview. Of 9,090 such persons interviewed, 2,515 (28%) had one or more of the stated symptoms. Of those with symptoms, 3.6% had positive smear results compared with 0.5% among the asymptomatics. For culture positivity, the corresponding proportions were 4.2% and 0.9% and, for radiographic TB, 11.4% and 4.1% respectively. These differences were highly significant and applicable to all age groups. There appears to be a fairly close relationship between the epidemiological parameters and suffering awareness of symptoms produced by TB. This conclusion was supported by the finding that, when both symptomatics and asymptomatics were equally pressed to attend for the investigations, the presence of symptoms appeared to have increased the suspects' likelihood to attend for the investigations (P<0.0001).

Further, the data suggested that eliciting suggestive symptoms in a manner to reflect suffering awareness had a reasonably high degree of sensitivity and specificity; the highest level of sensitivity (74%) was reached with respect to smear-positive cases. Thus, using the symptom suffering as a useful sociological parameter is feasible. Concerning action-taking, on analysis, the pattern varied with age, gender, urban/rural habitat, nature and duration of symptoms, whether a symptom occurred alone or in combination, etiology of the symptom and social perception of what needs to be done for a particular kind of symptom and how an individual/ family should proceed if an action taken was unsuccessful. Nevertheless, the choice of action was related to the TB/ non-specific etiology of symptoms. Based on these findings, there appears to be a good case to develop an objective measurement of cough, of a selected duration and action taking as a sociological parameter of suffering to go along with the epidemiological measurement of TB in a community.

A City TB Programme (CTP) has been suggested that meets with most of the existing conditions in our big cities and is in accord with the principles underlying DTP and NTP.

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 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.

The editorial offers some considerations that should go into the making of a rational, National Drug Policy (NDP). Primacy must be given to the National Health Policy in the formulation of the NDP and the task of producing adequate quantities of essential/life-saving drugs, of good quality and at reasonable prices, must be placed as a challenge before the pharmaceutical industry under market-friendly controls. The production of non-essential/fancy formulations could be left to the demand-supply mechanism, at the same time, stressing rational prescribing practices as part of NDP.

This is an editorial on the Workshop organised by the DGHS, 11-12 September, 1991, to thoroughly review the NTP with respect to its overall achievements and shortfalls from expectations. Based on the deliberations, attended by representatives of various international agencies, several recommendations for action, to improve the NTP, were made. It was suggested that a Task Force be set up, with proper terms of reference and a suitable budget to oversee that the recommendations were implemented and that necessary corrective actions were taken, till the time of the next review.

The paper explains why the predominantly rural average Indian district received greater attention under the NTP than large cities. Also, why the DTP, as the basic unit of NTP, has not performed upto expectations on account of management weaknesses and not technological shortcomings. It has been shown why it is not necessary to think in terms of separate rural and urban TB services. The manner in which the existing TB services in most big cities can and should be made a part of DTP/NTP has been discussed. In metropolitan cities, where the operational environment is different, the principles of NTP can still be applied, after due operational and sociological studies, but it is preferable if such studies are made a part of overall health services systems research.

The editorial makes a case for encouraging the partnership of NGOs with the NTP to fight TB. The attitudes and perceptions of the Government, on one hand, and the NGOs, on the other, make this a complex proposition. Several reviews of the NTP’s performance over the last three decades concluded that the NTP’s achievements were below expectations despite notable progress made in some directions and that the programme was not likely to improve without better programme management and active participation in TB control activities by the people. Therefore, the Government, after the Surajkand deliberations in September 1991, accepted the recommendations of the TAI, one of which was the necessity to develop partnerships with NGOs. The changed facade of the NGOs, today, because of the large number of professionals that have joined them, adds to the benefits the NGOs would bring to a partnership. How the partnership should begin and the various mutual benefits for the Government and the NGOs in becoming partners are described.

Health has been defined as the state of perfect physical, social and mental well-being which is somewhat of an abstract definition. In this paper, economics of health is measured through economics of sickness. Because sickness is experienced, it can be measured and it inflicts physical, social and economic sufferings. In a community, economic prosperity is directly dependent on quantum of sickness and its prevention by health services. A sociological enquiry into the part played by disease in the socio-economic development of society was made by carrying out a study in two village population groups. The Social Investigators of NTI made deep, probing questions to elicit presence of symptoms, action taken by them, money spent on treatment and the loss of wages. In the first study, observation-participation technique was adopted. The investigators lived in the village for four months. In the second study, 20% households of those 22 villages which participated earlier in an epidemiological survey conducted by NTI, were interviewed.

Findings of the two studies are combined and presented. Illnesses were classified into major and minor on the basis of clinical severity and the duration of symptoms. In both the studies, 60% of all persons were asymptomatic during 2 months prior to the interview. About 18% had one minor illness, 13% had major illness and only 3% had one major and one minor illness. The quantum of multiple disease (3 or more) occurring in one person was less than 2%. Only 20% of living man-days were spent as sick man-days. The average annual loss on account of health reasons per family has been estimated to be Rs.90/- and Rs.15/- per capita. The overall economic loss due to sickness, direct and indirect amounted to 3% of the per capita income in the poorer groups of villages and 6% in the economically more favourably placed villages. The material available here strongly suggests that the sizes of households will not have much influence over the sickness in the community. Another significant feature of this study was the phenomenon of substitution within the family whenever the wage earner could not go to work. The evidence examined in this paper suggests that the actual economic loss is only 1/3rd of the calculated loss. It also suggests that the overall cost of sickness to the individuals and family is far less than what is normally calculated and is influenced by the money available in the household.

A socio-epidemiological study was undertaken by the NTI on out-patients attending the LWTDTC at Bangalore to understand the main reasons why people attended TB diagnosis and treatment centers so as to know why they default in treatment subsequently. During February-May 1966, a 50% random sample (comprising 2,653 persons of which 1% of the interviews were rejected) of the new out-patients attending the TB Center for diagnosis were interviewed by experienced social investigators before their X-ray examination. Eighty-three percent of the out-patients came from the city while only 17% came from the rural areas.

While a number of sociological characteristics such as profession, religion and literacy were found not to have any significant relationship with the patients' attendance, distance from patient's home to the city TB Center proved to be crucial. Further analysis of the data suggested that even in a city, a majority of the persons with symptoms first contacted, for treatment, the nearest health institution which typically happened to be a general health institution. This delayed early diagnosis or referral. Of those patients who subsequently attended the city TB Center, 37% had not received any treatment for TB from the general health institutions, 50% got non-specific treatment and only 13% got likely or definite TB treatment. Nineteen percent who did not have TB also got likely or definite TB treatment. It was clear that a very complex and multi-lateral relationship existed between the symptomatic patients, the institutions of general health and the established specialized services. Sociological or operational studies to examine this "complex" were suggested.

The study was carried out at LWTDTC, Bangalore to inquire into the epidemiological and sociological characteristics of patients attending a city TB clinic for the first time, to ascertain the reason for attendance and the nature of previous treatment if any. It was also to see whether there was a preference for seeking specialists and specialised services for alleviation of the symptoms experienced and whether there were any differences amongst the urban and rural attenders. A fifty percent random sample of 2,658 out-patients during 61 working days, formed the study population. They were interviewed by using a questionnaire based on the above mentioned objectives. 247 were not eligible due to incomplete record and below 5 years of age.

Majority of the out-patients were in 20-30 years of age and were wage earners. Nearly 80% were aware of their symptoms and contained 95% of the TB cases detected at the clinic. Most of them were having 2-3 symptoms. No difference in time of reporting was observed among urban or rural patients; 61% of the urban and 42% of the rural patients attended the clinic within 3 months from the onset of their symptoms. Distance is a major obstacle. Upon 4.8 km the number of new out-patients was large but the case yield was poor. As the distance increased the out-patients decreased but the case yield was more, suggesting a selective process influenced by distance. It was also found that 20% of the out- patients came of their own without any prior contact with any other source of treatment, 32% had previous contact with other health institutions, 31% were actually referred by them and 17% were advised by BCG workers. Further analysis showed that of the 1,642 patients who had previous contact with health institutions, 84% were at general health institutions, 10% at specialised TB clinics and 6% were others. Of the remaining eligible 2,403 patients, 83% were from urban and 17% from rural areas. Sputum was collected from 2,308 patients. Of them, 179 (7.8%) were found to be positive by direct microscopy or culture or both and 169 were positive by culture (91% confirmation by culture). 131 (80%) were sensitive to isoniazid and 32 were isoniazid resistant.

The data obtained suggests that attendance at a specialized TB centre is not necessarily a function of awareness of symptoms and of the knowledge that such specialised services exist. It also does not support the theory that people prefer specialized institutions in cities. It is also seen that urban and rural patients behave in almost the same way in that their first contact for symptoms suggestive of TB, is initially at the general medical services and they should be strengthened with adequate means for diagnosis and treatment of TB.

The author emphasises the need to take a holistic approach to health education. In India, changes in the curricula of medical colleges have not gone far enough to change the prevalent focus on disease and the attitudes and practices that go with it. Some pragmatic social scientists have recognized that health education is needed, not only for the general public, but for health administrators and teachers of TB and chest diseases too, in order to change their behaviour. Therefore, they suggest that to generate additional felt need among the people, health education is needed only when the existing felt needs of the people have been met and there is surplus capacity left to meet the extra needs. This, then, is the need-based cutting edge of health education.