Right step to a cure

The fact that the not-so-rich too consult private doctors highlights the importance of the role of the latter in health care. One instance is the success of the DOTS programme spearheaded by the Chennai-based Advocacy for Control of Tuberculosis, writes GOUTAM GHOSH.

YOU cannot deny that the DOTS (Directly Observed Therapy, Short course) has its obvious advantages but you cannot wish away its problems either. Finding out which way the balance tilts, depends on how you look at it, and how much you have at stake. If you are implementing the system, you will tend to attach greater weight to the positive aspects of the Revised National Tuberculosis Control Programme (RNTCP) of 1993. No harm, provided your sub- system works. But for success, the whole system should thrive, not just your part of it.

After seven years of RNTCP, one cannot wish away the fact that it has not worked as remarkably as was anticipated. The problem with impact reports is, as Jimmy Volmnik et. al. point out, "Many of these studies may have been written up because they were successful..." (Jimmy Volmnik, Patricia Matchaba, Paul Garner, "Directly observed therapy and treatment adherence," Lancet, Vol. 355, April 15, 2000, P. 1345-50).

Broadly there are two feasible suppliers of DOTS in the revised system. The one, the public health sector comprising the public health centres, Government hospitals and smaller units, and the other, the private sector, encompassing a wide range of private doctors, general and multispeciality clinics, in addition to corporate and other hospitals. The initial focus was on the Government-supported health care delivery system.

Given that the identification of a tuberculosis case in the DOTS strategy depends on the patient or his relatives who must report to a health centre for a check-up - the first step in the process of medical intervention is passive - there is no way the public sector alone can meet the RNTCP goal of treating 170 lakh TB- afflicted people within a feasible period of time. Whatever the period identified, the number is likely to explode unless every additional patient is taken care of and a section of the already piled up stock of patients is treated at each point in time. As a rule most people avoid public health centres. They go to private doctors.

He identifies possible cases of tuberculosis, and prescribes treatment. Thus the success of DOTS, despite its severe lacunae, depends critically on the role the private health providers play.

After seven years, the Government seems to have woken up to reality and has taken the first few hesitant steps by tacitly admitting the role that non-Government organisations (NGOs) can play and by giving them the bare support needed to implement the system. The Chennai-based Advocacy for Control of Tuberculosis (ACT) is one such organisation that has been reaching out to tuberculosis patients and making sure the patients take the prescribed drugs.

The operating system of ACT is simple. It reaches out to the private practitioners and convinces them of the DOTS strategy. The Tuberculosis Research Centre, Chennai, conducts a refresher course to inform the motivated doctors about the importance of the sputum smear tests and how to identify tuberculosis cases. These doctors then direct the suspected cases to ACT which liaise with clinical laboratories where the sputum smear tests are done. Once a case is identified, the patient is asked to find someone other than any of his family members who will see that the of patient takes his medicines regularly. This person - the DOTS provider (DP) - is then trained by ACT to record details of the patient taking the medicines. The Corporation of Chennai gives the drugs and each box has to be accounted for. The ACT monitors the process closely through surprise checks to see if the patient or his DP is sticking to the schedule. After the treatment period, the patient goes through a screening test to make sure he is cured.Of the 173 patients on record since January 1998, 87 patients had completed treatment and 62 were cured - a 71 per cent success rate that is more convincing than the 90 per cent plus rates claimed by other centres in India. ACT has been able to attract a committed set of women volunteers who, despite their urban orientation, seem completely at ease with patients, especially the poor. But once the number reaching the ACT for medical intervention increases, there is a possibility, however remote, that the average level of commitment of a larger lot of social workers could decline.

Dr. P. R. Narayanan, Director, Tuberculosis Research Centre, Chennai (which is credited by the World Health Organisation to have been a centre where DOTS originated) said, "Patient is the king". His welfare should be at the top of the priority list. Given the ACT's success story, though in a small way, many prospective NGOs would step in for a share of the pie. As the history of NGOs has shown, not all are equally committed to a cause, which implies ipso facto a misallocation of resources over time. NGOs tend to spend a significant part of their resources on administrative expenses, and what filters down to the target groups is a small fraction of the endowment.

Only a few NGOs are unlikely to suffer from a resource crunch in the near future, and therefore there is every reason to believe that such exceptional NGOs' commitment may not be eroded in the short run. Needless to say, NGOs as a lot must be wary of unproductive expenditures because every rupee saved is a rupee more for the treatment. That would espouse the TRC chief's belief - that the patient is the king.

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Faith works

Pammathukulam is far from Red Hills lake, north of Chennai. The hut we looked for was tucked in a cluster and we found Kumaraiah (75) sitting between two cages housing his parrots. It was evening, but he could see well and was bubbling with energy. Seven months ago, he had struggled hard to fight the tuberculosis that had afflicted him. The treatment had worked and he seemed to be in good health now. He was so enthusiastic that he refused to ask a youth to go in search of his DOTS Provider, picked up his walking stick and shuffled out of his hut into the darkness to look for his benefactor. For six months, Machchakalai, an elderly man had given Kumaraiah his drugs thrice a week without fail.

Kumaraiah's wife could barely walk after her hysterectomy, but she joined the curious group that wished to know how it all happened - how Kumaraiah was identified as a tuberculosis patient, how he managed to take the drugs which could induce severe and visible side effects, like vomiting, headache, stomach ache, and some toxic effects on the liver. A private doctor had told Kumaraiah to test for tuberculosis. Machchakalai, the sympathetic and natural leader, had agreed to give Kumaraiah the drugs. Back soon after his search for Machchakalai, Kumaraiah joined his wife and the group to tell us how he would cycle to bus depots far away with his parrots which told gullible customers their fortune. He earned Rs. 200 a day, but blew up a large part of it on drink - mostly the local brew.

Machchakalai interrupted to say he wanted to save Kumaraiah's life. That, he insisted, was his duty as a human being towards another in distress. There was no rhetoric here, only a simple statement of belief put in practice. The DP's role was recognised formally by the two women representatives of the Advocacy for Control of Tuberculosis (ACT) who handed over a gift-wrapped timepiece to Machchakalai. This token incentive that was strictly a subtle sixth to the World Health Organisation's five-point strategy was probably intended to motivate the DP to take up more such cases if identified in his area. Kumaraiah turned the clock over and over again before giving it to the beaming DP. The gift of life to Kumaraiah probably meant there was no need for any tokens in recognition of his compliance to the medication regime.

Beyond the southern fringes of the metropolis is the fishing hamlet of Neelangkarai. The thatched sit-out in front of Sami's hut was a welcome relief after a walk on the sand that hot afternoon. Sami, a fisherman, was now cured of tuberculosis. He was better off than many of his fellow fishermen. The fishing community is well-knit, and one stands by another in need. That is why his DP never hesitated to see that Sami took his medicines regularly. When I visited the place, the DP had gone to work. Sami said he was cured, but his wife seemed too emaciated to be healthy. She surely had to be screened for tuberculous bacilli.

Sami said he had been referred to ACT by his family physician whom he pays Rs. 30 for every consultation. This shows that private doctors can make a difference in the prevalence of the disease. As a consultant chest physician from a corporate hospital put it, 60 per cent of the cases approached the private practitioners for treatment. This could be true in metropolises, and less so in the rural belts, but nevertheless it is a point that needs to be noted.

At a slum in Mylapore, Kuppan, a painter, and others welcomed the social workers with a broad smile of recognition. Kuppan was lazing on the road but sprang up the moment he saw the group. He vouched that he had been taking his medicines regularly. His DP, Senthamarai, a housewife, promptly brought the carton of medicines to show the group that not a single dose had been skipped. Kuppan gets to work for just five days a month, so he has not enough money just to pay for the expensive medicines he needs. He could have gone to the nearest Chennai Corporation outlet for his drugs, but he chose ACT instead.

The young representatives of ACT had to walk through the two-feet wide lanes between rows of huts to reach Kannan's house. We found him on the other side. He looked emaciated. His DP is his brother, Ganesan, an autorickshaw mechanic, who takes care of him in every way, despite his fairly large family. Kannan is a bachelor, and is jobless.

The day-long tour that covered eight patients and their DPs showed that private initiative can work. The one-to-one system seems better suited than one caretaker for many. That 87 patients had been taken care of through an NGO shows that with vested interest swept away, an NGO with a group of motivated, young people, burning with the desire to do something for the poor, can clip the cost of intervention to make a difference in the lives of those it touches.

On the other end of the spectrum, the DOTS clinic at the Anna Peripheral Hospital in Anna Nagar opened around 8-40 a.m. There was a long line of patients waiting outside Room 13 by the time Dr. Ashok Kumar and Ms. Kalaichelvi of the Institute for Thoracic Medicine walked in. The record keeping was tedious and time- consuming which meant there was less time devoted to patients.

For three patients, the process of recording and recording on the RNTCP card and then again in Corporation of Chennai drug register as well as in another register, then pulling out the relevant drugs from the carton, replacing them on the pile; next the patient taking the medicines lasted 37 minutes.

It should be obvious that for feasibility, the staff strength at each centre should increase at least 50-fold for a eight-hour shift of non-stop work if the system were to handle 2000 patients each drug-day.

There is no doubt therefore that for a feasible solution, one-DP- to-one-patient should be the norm if DOTS is to see at least a little success. The question of long term strategy would even then remain.

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