A Perspective for Discussion of India's National Tuberculosis Programme
Item
- Title
- A Perspective for Discussion of India's National Tuberculosis Programme
- Creator
- Debabar Banerji
- Date
- December 27, 1984
- extracted text
-
December 2 7/
w
1934
A PERSPECTIVE _JFOR DISCUSSION OF INDIANS
N ATI ON AL”TU BERCU LOS''lS’~ PROGRA14ME
Debabar P-anerji
Professor
Centre of Social Medicine & Community Health
Jawaharlal Nehru. University
New Delhi-110067
introduction
I have been engaged in writing on health service
This
development in India for quite some time,
has enabled me to bring together some of the main
ideas which I have developed in the course of my
work of over three decades.
I am preparing this
note because India's National Tuberculosis
Programme (NTP) provides a very good example of
an aspect of health service development in India,
I am hoping that this perspective is given due
consideration in any discussion of NTP.
Incidentally, study and analysis of the
approach to NTP also raises very interesting and
fundamental questions 2•Why was this approach
adopted in the case of tuberculosis?
Why was this
approach not adopted in the case of Community
Health Workers'* Scheme, Multipurpose Workers’ Scheme
or health service research for rural health develop
ment? Why was this approach not adopted in the
formulation of the National Family Planning Programme,
the National Malaria Control/Eradication Programmes,
the National Leprosy Control Programme, the National
Programme for Control of Blindness, the National
Filaria Control Programme, and so on?
Two fundamental considerations emerge from
the instance of the NTP.
Fir.\t, it i.- the per pie
who •provide the primary motive force for social
revolution or social transformation. There are
three types of persons who are directly or indirectly
related to this dynamic movement of the people.
There arc tho'-e who oppose the social revolution with
-
2
all their might*
Ironically, there are other
persons who are well-meaning ana have radical creden
tials, but because of their inability to think clearly
they create more confusion and in this way obstruct
the march of the people.
Finally, there are those
who have the humility to understand the primacy of
the people and who are prepared to make their modest
contribution in facilitating that march.
.
My feeling
is that while discussing issues
that concern health of the people we have to under
stand the momentum of the movement among people
themselves and try to find out how to minimise the
hurdles that are put on their way and how to contri
bute to the march through our own inputs.
The second fundamental consideration arises
from the first.
It concerns the technological,
epidemiological, social and political competence of
those who venture to formulate people oriented health
programmes under the conditions that exist in a
country like India.
This note will first
fir: t deal
de al ith some of the
positive gains made by the people of India in terms
of developing a public health approach to the problem
of tuberculosis in the country
T is will be
followed -rith a brief account of the way a group
of interdisciplinary scholars have got together to
formulate a nationally applicable, socially accept
able and epidemiologicalIv effective tuberculosis
programme for India.
Then there will be analysis
3
of the factors which have come in the way of imple
mentation of the NTP and how pressure from the people
is at work in overcoming those hurdleso
Some Positive Aspects of Tuberculosis Works in Indias
clS in 1951 an. effort was made
Why is it that as early as
to develop epidemiological approach to the problem
of tuberculosis in India? Admittedly, the approach
was very modest, but considering the situation
prevailing at that time, it is remarkable that tuber
culosis workers even dared to deal with tuberculosis
as a public health problem by launching the Mass FOG
C amp ai gn.
that
India could launch the National Sample Survey of
Tuberculosis in the country which, despite its many
obvious shortcomings, can still be considered as a
Why is it,
acc.in in the early fifties,
classic epidemiological study carried out anywhere
in third world countries? Why should India have
undertaken the classic study of comparison of home
treatment and sanitorium treatment of tuberculosis
cases by establishing the Tuberculosis Chemotherapy
Centre at Madras in the mid-fifties? Why is it that
some of the pioneer tuberculosis workers in India
had already started providing domiciliary care to
tuberculosis patients well before the findings of
the Madras study became available?
Finally, perhaps as a culmination of the
dynamics of the movements referred to above, why is
it that as early as in 1959 the Government of India
4
established National Tuberculosis Institute
(NTI)
giving it the specific mandate to make an inter
disciplinary approach to formulate a nationally
applicable, socially acceptable and epidemiclogically
effective NTP for India?
Then, why should NTP
become a part of the Prime Mini-ters Twenty Point
Programme?
The Work of /Jome socially Sens i tivc ^Community
Physicians in the Field of Tuberculosiss
Perhaps one of the very significant features of
tuberculosis work in India has been that throughout
the past several decades there have been many dedi
cated and committed tuberculosis workers who had
been ceaselessly trying to deal with tuberculosis
as a public health problem.
It is- th!" momentum c i
work of the pioneers which led people in NTI to adopt
the approach of “going to the people and learning
from them” in formulatin'- India's National Tuber
culosis Programme.
This in fact was a major landmark
in health service development.
It etc -ec vividly
how those who have a vested interest in perpetuating
the old order had been making people the scapegoat
to explain away their inability to develop a tuber
culosis programme in the country.
Adding insult to
injury, they had been using their biased concepts
about the people to create a market for the sale of
mass-radiogra..hy units in the country.
Providing a sociological foundation to the
formulation of the NTP not only added a very vital
social dimension to understanding the epidemiology
5
of the discas-e in the country, but it also was
instrumental in formulating a people oriented
technology to deal with the problem o '■ tuberculosis
under the then existing condition. end also r-'vif ' nc;
a direction for development of the procra-ane
rr ...
and more re- urees -?re. made, avail able; to it „
The last portion of the previous scntcnc- i.:
being underlined to emphasise that conceptually
is a dynamic entity and it does not accept any limi
tations as such; its advantage*• is that it ensures most
effective use of whatever resources that could be
made available at a given time.
I would stress once
again it does not in any way impose resource limita
tions as a permanent constraint.
Data about people also showed us where to
provide tuberculosis services.
People told us that
they will like to have tuberculosis services as an
integral part of the general health service system,
and not as a vertical programme.
Apart from the very challenging task involved
in working out the. details of a people-oriented
tuberculosis programme for the countr/ as a whole,
socially concerned tuberculosis workers had also to
contend with very complex questions concerning defi
nition of a case of a tuberculosis, place of radiology
in the diagnosis of tuberculosis efficacy of different
combination of chemotherapeutic agents, the problem
of drug resistance and the problem of treatment
default.
6
Each one of the above problems was used by
the vested interests, who wanted to thwart the
efforts of the people to have a tuberculosis
programme- for themselves.
It goes to the credit
of tuberculosis workers in India that they had had
the epidemiological and social competence to
withstand these efforts.
Their success is reflected
in the fact that NTP is not simply accepted as the
national programme for I-• i : , 'it I . has also been
accepted virtually everywhere in the world. As a
result of its acceptance in India, there has been
an astonishing demystification of tuberculosis work.
Tub;rc"l
as a medical speciality has got considerably devalued.
Sanatorium construction, which was
once such a massive component of the programme, has
now tapered off.
r.-T Control Programme ( LC)
contrasts sharply with NTP in terms of clinical,
epidemiological, administrative as well as sociologi
The N-at:i
cal inputs.
1 Lc
Significantly,
the call for strengthen
ing NLCP came from the political leadership - from
the then Prime Minister herself.
But the response
of the scientists was patently inadequate and
unscientific - e.g. “essentiality of verticality
xJSi*ulti-drug therapy” and “immunomodulcs” for
developing a vaccine. What was the response of
socially sensitive community physicians to such
recommendations? Indeed, how did they respond to
the ICSSR-ICMR Report on Health For All by 2000 AR?
7
Obs tructions in the Implementation cf NTP;
Obstructions were expected, because NTP was designed
as an integral part of the general health services
of the country and it was anticipated that because of
the power structure and the class character of the
medical and social science establishment, there would
be considerable opposition to the implementation of
the NTP. How many of the physicians in the country
are familar with NTP? How many of the social
scientists in India are familiar with the social
science studies in relation to the NTP? For that
matter, how many professors of sociology or of tuber
culosis or of preventive and social medicine in India
are familiar with NTP? What is the political economy
of such a crass ignorance?
There is also the question of default.
Hut
who is the prime defaulter? Those who are still
allowing millions and millions of cases, who are
knocking at the doors of the various health institutions, to be dismissed with a bottle of cough
mixture are the £rch defaulter6. Big defaulters are
also those who deprive people of facilities for
dignosis and treatment because of
o administrative
Ironically, these defaulters are not taken
note of by crusading social scientists and tuber
culosis workers and voluntary social workers who
rush forward to heap abuses on the people for not
neglect.
taking the treatment prescribed by ill-informed
physicians .
8
The muddle headed thinkinc among obviously
well-meaning social physicians also gets revealed
when they fail to understand NTP in its wider pers
pective and get preoccupied with the minutaeso
People have taught us that their needs for
dignosis and treatment are not met by the establishmento
The causes for not meeting that need are quite 1
apparent.
It is this failure to meet people's need
which should become- the prime instrument for belabour
ing the system. It is conceded immediately that oner,
the needs are met, one keeps on the pressure by
insisting on better and better services for the
people. However, if this basic weakness of not
meeting the pre-existing needs of the people is
ignored and a case is made for better and better
treatment for those who happen to get their needs
met, we would unwittingly be doing damage to the
people at large by putting the cart before the horse.
We will go on demanding cakes for the few while vast
masses are being denied even bread. This is one of
the major failings of those who are concerned about
the people but who have not acquired the. epidemiologi
cal competence to see the entire problem in its
perspective.
Recent Developments:
The launching of the Multipurpose Workers’ Scheme and
the Community Health Workers1 Scheme, strengthening
of the staff at the sub-centre level and inclusion
of NTP in the Twenty Point Programme present yet
•
•
I •
9
another facet of the victory of the pee; > 1 <■ in /re ; ting
their rights from their oppressors
"igni fi ntl-,
the oppressors have hit bac'- once a ga i n by b r i r. g i n c.
the cart before the horse.,
Presumably erc<
C r c < ur-<
ur ( c
by the drug industry, they arc shc>’ing ccncc-r:. ."o?the tuberculosis patients in the country not ??y
widening the base, but by talking of multi-drug
therapy, which includes rifap.icin.
L
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