Fight the disease or the cause?

By G. Pramod Kumar

CHENNAI, MARCH 12. Tuberculosis becomes a controversial issue when it comes to the prescription for treatment. What is the pathological agent for TB? Is it the poverty bacillus or the TB bacillus?

The response to the crisis is diverse. For institutions like the World Bank, tackling the disease is a good investment, in which every $1 spent will fetch several times more in future, while for independent film-makers like Mr. Kjell-Ake Olsson from Sweden, it is yet another opportunity to expose the stark social realities behind bad health.

The World Bank and the World Health Organisation (WHO), which have unleashed a high-voltage global campaign against the disease, are single-minded in their pursuit: attack the disease. Their solution is a new package of drugs: DOTS (Directly Observed Treatment Short Course).

In DOTS, all people with the bacilli in the sputum are treated with four drugs under direct supervision. In the six- month schedule, the patients take four drugs for two months and then two for the next four months. During the first two months, the patients take the drugs from a `DOTS provider' and swallow them in his/her presence thrice a week. The sputum is tested after two months and if the bacilli are still found, the same treatment would continue for one more month.

For the next four months, the patients would collect the remaining two drugs from the DOTS provider once a week, but would continue to take them thrice a week.

According to Dr. Neil Hamlet, tuberculosis specialist, direct observation ensures treatment for the entire course with the right drugs, in the right dose and at right intervals. It is the ideal solution to the disease and the only option to prevent MDR TB. Using DOTS, the curability of TB even in HIV-positive persons is as effective as in HIV negative persons.

DOTS is projected as a community programme in which people volunteer as observers. ``TB control is very simple and does not need high technology,'' Dr. Hamlet adds. It addresses people with ``sputum positivity'' to cure their disease and also to prevent their spreading the infection. A sputum positive person can infect 10-15 persons every year.

The logic behind the programme is simple. There is a cure and TB programmes have been run for several decades, but the TB situation has only worsened and the reason is the lack of a system and lack of supervision.

According to the WHO in DOTS, twice as many patients successfully complete their treatment compared to those in the non-DOTS programme. DOTS is also said to be more cost-effective for the provider and also the household. DOTS has five components: political commitment, diagnosis by microscopy, adequate supply of drugs, directly observed treatment and accountability, adds Dr. Nair.

Critics do not object to the rationale behind the treatment, but object to the ``vertical'' programme that targets only the ``symptoms but not the disease'' and the insensitive logic that excludes the disease from its socio-economic and political settings. Mr. Olsson's compelling film TB or Not TB, addresses this issue. ``Instead of constructing a fence at the cliff, they are running ambulance services on the ground,'' says his film.

This argument reverberated at the ``tb.net 2000'' conference held in Kathmandu during the last week of February. ``Attempts to address the global TB epidemic through technical approaches are unlikely to succeed unless important socio- economic and behavioural determinants of the disease are also addressed,'' many participants said.

(Concluded)

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