|Year : 2005 | Volume
| Issue : 4 | Page : 133-137
Tuberculosis control programme - societal participation
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160012., India
S K Jindal
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160012.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jindal S K. Tuberculosis control programme - societal participation. Lung India 2005;22:133-7
There is a surprising lack of societal awareness and participation in tuberculosis - control in spite of the fact that the disease is as much a social as a medical problem. Only 22 percent people had thought that tuberculosis was a significant problem. It is proposed that enhanced social participation shall help control the problem more effectively.
The more important aspect of societal participation lies in the involvement of various groups, voluntary associations and interaction social clubs in the actual implementation of tuberculosis control programme. We found the help of locally operative Sewa Bharati and Red Cross Society useful in drug distribution. Participation of these institutions for supervised drug administration under newer strategies such as DOTS, is especially meaningful. This is rather important in view of the enormous difficulties involved in drug supervision on ambulatory basis for a large number of patients distributed widely in the community. Help and participation of voluntary organizations is of critical importance for the success of this strategy.
| Introduction|| |
There is, perhaps no disease other than tuberculosis which has persistently threatened the society in a continuous simmering fashion since the time immemorial. The society has been painfully conscious of the problem from the period of ancient civilizations of Indo Aryans, Babylon and China  . It is a disease which has concerned the society even more than the concern to the patients themselves. The role of society has however changed from an attitude of fear, panic and punishment to that of sympathy, help and involvement. But what is required now when there is a resurgence of the disease, is an active participation of the society to contain the disease-onslaught. This is especially so in most of the third world countries where the burden of tuberculosis is enormous, but governmental resources are limited. It is rather alarming to note that 78% of the total cases of tuberculosis in the world are in the three regions namely South East Asia, Western Pacific and Africa. In many developing countries such as India, both the prevalence and the annual risk of tuberculosis infection have in fact increased in the last thirty years  . Further, in these countries, only 40-50% of new cases of tuberculosis are identified and put on treatment  . With additional onslaught of HIV infection, the threat has now assumed grave proportions.
Health care structure in the third world
Most of the third world countries, especially those of South East Asia such as India, Pakistan, Bangladesh, Sri Lanka, Nepal and Bhutan have a two fold system to provide health care. One, there is a vast governmental health-facility which comprises of different types of peripheral health institutions (PHI), supplemented with secondary and tertiary level referral hospitals in bigger cities. Secondly, there exists a parallel private and charitable service section managed by individuals and/or small groups. The private sector mostly works independently at local level without any central control or organized networking.
Tuberculosis management and control
The WHO Expert Committee on Tuberculosis  had formulated in the early 1970s that Tuberculosis Control Programmes (TCP) in the developing countries should be:
- integrated with general health services within the Ministry of Health;
- country wide;
- permanent, and
- adapted to the needs of the people with services being as close to the community as possible.
Further, it stressed that tuberculosis control should be integrated with the primary health care programme  . Several countries had adopted national programmes as per WHO recommendations. India, for example, had its own TCP in existence since the early 1960s. The National Tuberculosis Programme was administered through District Tuberculosis Centre (DTC) with each center under the charge of a district tuberculosis officer (DTO). Each DTC has got several types of centres and subcentres in the periphery, which are referred to as Microscopy Centres, X-ray Centres, Treatment Centres and Referring Centres depending upon the type and scale of facilities available, or provided at each center. Under the Revised National TB Control Programme (RNTCP), since 1993, directly observed therapy short course (DOTS) is now being used at most of those centers.
In spite of the existence of a free treatment programme, a large number of patients continue to be managed by the private sector. In India, about 50 percent of patients are likely to be treated in private and semiprivate clinics or hospitals spread all over the country. In a pilot study, it was estimated that of the 2506 persons visiting general dispensaries, who were questioned about the presence of chest symptoms, 1170 (46.7%) admitted having symptoms suggestive of pulmonary tuberculosis  . It was concluded that patients of tuberculosis do not bypass the city health institutions. In Pakistan, it was found that 80 percent of patients sought treatment from general practitioners  .
It is not only the private practitioners, but several big hospitals, medical colleges and institutions, both governmental and private which also are difficult to cover under the tuberculosis control programmes. A large number of patients who seek treatment from these places were therefore, deprived of treatment under TCP. An analysis of disease-pattern of new patients registered at the Chest Out-patient Clinic of this Institute had revealed that an average of 30.6 percent had pulmonary tuberculosis  . The figure is as high as 70 percent for the outpatient clinics of Departments of Tuberculosis and Chest Diseases of most medical college hospitals in the country which also were not covered under TCP. Ours is a tertiary care referral hospital in the Northern region of India. Analysis of the patients referred to the Chest Clinic had further revealed that an overwhelming 85% of tuberculosis patients were referred by the private practitioners. This only strengthens the observation that a very large number of patients were treated outside the purview of NTCP.
Fortunately, the RNTCP is designed to cater to the needs of patients seen in the private sector as well as the medical colleges. In spite of some of the difficulties, the strategy is proving successful.
| Pitfalls of Management|| |
There were tremendous logistic problems, administrative and economic difficulties involved in a nation-wide treatment programme such as the NTCP. It is almost impossible to include 100 percent of patients under TCP. Even under the programme conditions, treatment completion was rather poor. It was shown in a study from South India that only about 40% of patients took 80% or more of the prescribed drugs while a slightly larger group took less than 50% of chemotherapy  . The results were no better than would have been the case if no treatment whatsoever had been given  .
But there are several problems of management outside the programme condition as well. The one important issue is related to wide differences in prescriptions by different practitioners. There are innumerable errors committed in the choice of drugs, their dosage and duration ,, . The second issue concerns the presence of a drug confusion in view of the plethora of drug preparations available in the market. It was interesting to note that of 134 practitioners interviewed about their 'off hand' awareness, only about 60 and 40 percent could correctly recall the contents and dosages of combinations of 2 and 4 drugs respectively which were commonly used in their clinical practice  .
| Lack of Societal Participation|| |
There is a significant lack of involvement of the society in management and rehabilitation of patients of tuberculosis. We could find hardly any activity undertaken by the local non-governmental organizations (NGOs) and social-interaction clubs including the Rotary International (RI) and Lions Club in this direction. Some of the reasons for this type of indifferent attitude are given as under:
1. Lack of awareness
There is an almost total lack of appreciation of the gravity of the problem. Structured shortquestionnaire interviews on simple awareness of small samples of different sections of society of this region revealed that there was a significantly lesser perception of the problem of tuberculosis compared to that of cancer, hypertension, heart attack and AIDS (Acquired Immuno Deficiency Syndrome). There were only 22% who had thought that tuberculosis was a significant health problem (unpublished data). Acceptably, there is a wide variability in the knowledge, perception and attitudes of people of different areas of the country with diverse cultures, languages and socio-political environments. But considering the fact that this region has a much better literacy rate, the situation in other parts of the country is likely to be worse.
2. Societal distribution of tuberculosis patients
Prevalence and incidence of tuberculosis in India in the low income groups was nearly three to four times as common than in the middle and upper income groups respectively  . At Chandigarh, at the Chest Clinics of Government Medical College and the Postgraduate Medical Institute, more than 50 percent patients of all tuberculosis and over 70 percent of those with extensive disease belonged to low income groups amongst both urban and rural populations. Unfortunately, participation of the low income and rural groups in different societal activities is rather limited. Therefore, the issues involving these groups do not concern the various organizations as much as they should.
3. Medical bias
There is also a bias against tuberculosis in the medical community as well. There is no charisma associated with treatment of tuberculosis. On the other hand, there is lot of moral boosting publicity and glamour for medical personnel, as well as the hospitals, involved in sophisticated technologies and treatments. There are only a few doctors and fewer hospitals voluntarily opting to handle tuberculosis. In fact this is a major reason why patients requiring surgical forms of treatment for tuberculosis have great difficulty in finding a place for this purpose. There is a gross deficiency of thoracic and tuberculosis surgeons in the country.
The bias is also confounded by the attitude of the society, the media and the administration. Every one expects, respects and rewards only dramatic and rarer scientific (say medical) wonders from the medical community. Doctors therefore, have hardly an incentive to indulge in simpler and routine problems such as tuberculosis.
| Newer Strategies|| |
It is quite obvious that the solutions to the problem of such a magnitude are not just medical or scientific, but socio-economic and political  . The most critical point stressed in the revised strategy to control tuberculosis is the focus on treatment. Completion of treatment by individual patients requires to be ensured. As an example, ensuring treatment completion by an expanded use of directly observed therapy had been shown to result in a significant decrease in tuberculosis in New York City between 1992 and 1994 , .
| Directly Observed Treatment Short Course|| |
Several South East Asian countries including India have already adopted the WHO recommended strategy of Directly Observed Treatment Short Course (DOTS) for the effective tuberculosis control , . The strategy is essentially a 5-point programme with the following essential components.
- Political commitment
- Diagnosis by microscopy
- Adequate supply of short-course chemotherapy (SCC) drugs
- Directly observed treatment
The strategy has been identified by both WHO and the World Bank as one of the most cost effective of all health interventions. It has been not only shown to decrease the incidence of tuberculosis but also to result in a rapid fall in and prevent drug resistance. The strategy has been shown to succeed in the developed world as well as the developing countries in South East Asia.
| Societal Involvement|| |
There are two major thrust areas for societal involvement: i. Improving awareness, and ii. Implementation of treatment programme.
1. Improving Public Awareness
We have tried and tested a few methods in the last few years to create more public awareness and encourage their participation e.g..
- Articles in the lay press including newspapers
- Symposia and lectures
- Public exhibitions
A concerted effort on the part of people from different areas is required to keep the issue alive for any meaningful success.
2. Implementing treatment programmes
The most important step required in this direction is to involve the NGOs and other social groups in the actual implementation of TB Control Programme and DOTS strategy. Voluntary organizations should be involved as partners for an effective outcome  . There are several voluntary organizations operative in different parts of the country. The Tuberculosis Association of India (TAI) formed in February 1939 is perhaps the most active body involved in TB control all over the country. Tuberculosis societies are now being formed at district level for this very purpose. The Red Cross Society, Rotary and Rotaract International, Lions, Jay Cees and a few others run in a fashion akin to their parent international social clubs with diverse activities. There are several social, cultural and/or religious groups such as the Ramakrishan Ashram, Arya Samaj, Sewa Bharati, Singh Sabha and many others which also undertake activities for social welfare and uplift of the people. Excellent results, for example, were shown from a rural Tuberculosis Control Project run by an NGO - the Prasad Chikitsa Charitable Trust  .
We have tested taking help of Red Cross Society and Sewa Bharati for drug administration to the needy patients referred by us. A lot of doctors get free samples from drug companies promoting their products. These drugs were also donated to their pools. The system worked well as far as the role of the organizations was concerned. The major problem lay in the continued supply of drugs and holding on to the patients who came from distant places to seek treatment at this center. Treatment has to be ensured at the place of patient's stay. Under the RNTCP, the problems of drug supply and distribution are rather few.
| Problems of NGOs Involvement|| |
There are several important problems likely to be faced in the involvement of NGOs and other bodies. But none of the problem is insurmountable.
1. Financial misappropriation
It is often contended that the governmental money in the hands of non-governmental agencies is wasted and misappropriated. This is a malady which in no way is restricted. The only way to check the problem is to make the agency accountable and its functioning transparent. Given the voluntary and charitable character of these bodies, the corrupt practices are likely to be of smaller magnitude.
2. Inexperience in medical work
Members of most of the social organizations are neither trained nor experienced in the type of work they are likely to be involved. A preliminary training is therefore, required. The local official responsible for TB control can explain the essential components and provide training in the methodology at the time of initiation.
3. Misuse of drugs
Undeniably, some amount of misuse of drugs cannot be prevented. Further, some amount of drugs may find its way to the open market for sale. Such types of corrupt practices need to be watched and punished.
4. Record keeping
Voluntary workers are often poor record keepers. They do not like to be bound by books and rules. This is one aspect which needs to be explained and stressed in the initial training sessions. Record keeping is necessary in view of the type of the service desired from them in the interest of the patient.
5. "Pseudo doctor" phenomenon
There is always a great apprehension about some of these drug deliverers taking on the role of qualified physicians as "pseudo doctors" or quacks and start mistreating patients. Such kind of practice, is more likely in the villages and other remote areas where the level of education is low, people are poor and unable to afford to go to doctors. This is not entirely avoidable. But the risk is relatively insignificant and largely preventable in view of only a limited and fixed responsibility assigned to them.
| Conclusions|| |
Increased public awareness and involvement are essential for an effective fight against tuberculosis. Various voluntary organizations, social clubs and societies may be induced to actively participate in TB control. Their utilization in drug distribution and administration under supervision is likely to be most crucial for the success of TB Control Programme in general and DOTS strategy in particular.
| References|| |
|1.||Keers RY. Tuberculosis in antiquity. In: Pulmonary Tuberculosis - a journey down the centuries, London, Balliere Tindall 1978, 1-5. |
|2.||Chada VK. Global trends of tuberculosis - an epidemiological review. National TB Institute Bulletin 1997, 31:1-18. |
|3.||Centre for Disease Control. Estimate of future global tuberculosis morbidity and mortality. MMWR 1993; 42: 961-64. |
|4.||World Health Organization, 1974. WHO Expert Committee on Tuberculosis, 9th Report, Tech Rep Series, World Health Org 552. |
|5.||World Health Organization. Tuberculosis control as an integral part of primary health care. Geneva; WHO 1988. |
|6.||Gothi GD, Savic D, Baily GVJ, Samuel R. Cases of pulmonary tuberculosis among the outpatients attending general health institutions in an Indian City. Bull Wld Hlth Org 1970; 73:35-40. |
|7.||Marsh D, Hashim R, Hassany F, Hussain N, Iqbal Z, Irfanullah A, Islam N et al. Front line management of pulmonary tuberculosis: an analysis of tuberculosis and treatment practices in urban Sind, Pakistan. Tuberc & Lung Dis 1996; 77:86-92. |
|8.||Jindal SK, Bhaskar BV, Behera D. Respiratory disease pattern in a large referral hospital in India. Lung India 1989; 7:119-21. |
|9.||Datta M, Radhamani MP, Selvaraj R, Paramasiwan CN, Gopalan BN, Sudeendra CR, Prabhakar R. Critical assessment of smear positive pulmonary tuberculosis patients after chemotherapy under the district tuberculosis programme. Tubercle Lung Dis 1993; 74:180-86. |
|10.||Grzybowski S, Enarson DA. Drugs are not enough. Tubercle Lung Dis 1993; 74:145-46. |
|11.||Jagota P, Sreenivas TR, Parimala N. Improving treatment compliance by observing differences in treatment irregularity. Ind J Tuberc 1996; 43:75-80. |
|12.||Uplekar MW, Shepard DS. Treatment of tuberculosis by private general practitioners in India. Tubercle 1991; 72:284-90. |
|13.||Jindal SK. Anti tuberculosis treatment failure in clinical practice. Ind J Tuberc 1997; 44:121-24. |
|14.||Pamra SP, Mathur GP. Ind J Tuberc 1968; 15:81. |
|15.||Murray CJL, Dejonghe E, Chum HJ, Nyangulu DS, Salomao A, Styblo K. Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries. Lancet 1991; 338:1305-8. |
|16.||Frieden TR, Fujiwara PI, Hamburg MA, Ruggiero D, Henning KJ. Tuberculosis clinics. Am J Respir Crit Care Med 1994; 150:893-94. |
|17.||Frieden TR, Fujiwara PI, Washko RM, Hamburg ME. Tuberculosis in New York City - Turning the tide. Special article. N Eng J Med 1995; 333:229-33. |
|18.||World Health Organization. Guidelines for tuberculosis treatment in national tuberculosis programmes. Geneva; WHO, 1991. |
|19.||Jentgens H, Oberhoffer M, Rouillon A, Styblo K. Tuberculosis guide for high prevalence countries. 2nd Edn, Aachen; Miseroeor 1991. |
|20.||Nagpaul DR. Voluntary organizations or NGOs. Ind J Tuberc 1997; 44:1-2. |
|21.||Dholakia Y, Bannwart P, Wong JL, Patil J, Shelke G. A cohort analysis from a rural NGO tuberculosis control project. Ind J Tuberc 1997; 44:79-82. |