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EIGHTEENTH
TUBERCULOSIS AND CHEST DISEASES
WORKERS’ CONFERENCE

DEVELOPMENTS IN THE ANTI-TUBERCULOSIS FIELD

DURING THE LAST FIFTEEN YEARS—

A BIRD’S EYE VIEW

by

Dr. P. V. Benjamin
Technical Adviser, Tuberculosis Association of India
and
Tuberculosis Adviser to the Government of India

JANUARY, 1962

BANGALORE

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It has been customary for me to give you a brief review of
anti-tuberculosis work in India every year in these conferences.
This time I would crave your indulgence for presenting a bird’s
eye view of the developments in the field during the last fifteen
years or so.
Bhore Committee Recommendations

The first concerted attempt to formulate a health policy for
India was made by the Health Survey and Development Com­
mittee, known as the Bhore Committee, in 1944-45. The re­
commendations made by this Committee in regard to tubercu­
losis were generally in line with anti-tuberculosis measures
adopted in western countries in those days, with certain modifi­
cations to suit Indian conditions. The number of beds available
at that time for tuberculous patients in India was about 6,000
and the number of clinics about 85. The recommendations
made by the Bhore Committee were briefly as follows:
1. Establishment of clinics and expansion of Domiciliary
Services: They visualised one clinic for every district town and
emphasised that Domiciliary Service should have a great part
to play in Tuberculosis Control. It may be mentioned the anti­
bacterial drugs had not been discovered then.

2. Establishment of Hospitals; They accepted the normal
criterion of providing one bed for annual death, but recom­
mended provision of about 217,500 beds distributed among
Primary Unit Hospitals, Secondary Unit Hospitals and District
Headquarters Hospitals. Since the provision of such a large
number of beds would take many years, they recommended in
the first five years, provision of 200 beds for every 10 million
population.

3.

Home for incurables: Their recommendations included

provision of homes for incurables, and suggested that non­
official organisations interested in social welfare should help in
this and that Government should undertake to meet a substan­
tial part of the expenditure through generous grants. The
Committee further recommended establishment of After Care
Colonies, provision of facilities for training tuberculosis work­
ers, undertaking tuberculosis surveys to obtain information
regarding the incidence of the disease and to provide a basis for
effective planning. An important recommendation made by
them was that there should be created a separate section for
Tuberculosis in the Directorate General of Health Services in the
Government of India with an expert staff to advise, coordinate
and expand anti-tuberculosis work in the whole country. They
also recommended encouragement of non-official effort through
the Tuberculosis Association of India and its branches to
supplement Government work.
Mudaliar Committee

A Committee under the Chairmanship of Dr. Lakshmanaswamy Mudaliar was appointed some time ago by the Gov­
ernment of India to review what has been achieved in the health
field and to recommend further measures needed in this regard.
While the report of this Committee is awaited it may be worth­
while reviewing anti-tuberculosis work in India after the Bhore
Committee’s report with special reference to the post-independ­
ence period.
Tuberculosis Adviser’s Section

P/- "T? 19

Two years after the Bhore Committee’s report, India
became independent and the National Government had to take
steps to implement that Committee's recommendations. The
events that followed independence made the tuberculosis
problem even more serious and difficult than what was pre­
valent at the time the Bhore Committee prepared its report.
One of the first steps taken by the National Government was
to act on that Committee’s recommendations in regard to the

creation of a separate Section for Tuberculosis in the Directo­
rate General of Health Services in the Union Government with
a senior officer as Adviser. This Section was created early in
1948. Soon after, this Section started making plans for a
comprehensive tuberculosis control scheme for the country.
About the same time the World Health Organisation was formed
and this body took keen interest in tuberculosis control espe­
cially in the under-developed countries of the world, including
India.
B. C. G. Vaccination

The newly created TB Section took up the question of
introduction of BCG Vaccination in India as a preventive measure
against tuberculosis. A pilot study for this purpose was started
in August, 1948. At the same time, the Government of India
took steps to set up a laboratory for the preparation of BCG
Vaccine at Guindy (Madras).
National Plans

A TB control programme which was prepared by an Expert
Committee (Technical Committee oftheTuberculosis Association
of India) and which was considered as practicable was included
in the national Five Year plans. The main items in this pro­
gramme were expansion of the BCG Vaccination on a nationwide
scale, establishment of clinics and expansion of domiciliary
services, establishment of at least one Training and Demonstra­
tion Centre in each State, provision of beds for isolation, reha­
bilitation centres and research. How these schemes were imple­
mented or what were the short-comings have already been
indicated in previous years, and 1 do not propose to repeat
them. References have also been frequently made to the National
TB Sample Survey. Therefore I propose to confine myself to
certain aspects of Research which has not been widely known or
appreciated.
Community Programme

A community TB control programme started in 1947 in
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Madanapalle was extended in 1951 to cover a population of about
60,000 people around that area. This programme included
case-finding by mobile X-ray and laboratory test, and provision
for isolating and treating cases discovered. The programme
was further expanded in 1958 to cover a population of about
200,000 with the emphasis on finding the results of domiciliary
treatment by self-administration of drugs with the minimum
supervision on a community basis. The first study has shown
that the tuberculosis mortality has been brought down from
about 150 to about 20 per 100,000 i.e. by one-seventh during
a period of ten years. While the death-rate did come down
there was hardly any change noticeable in the incidence of the
disease from year to year as noted by repeated examinations of
the population at least once in about 18 months. This study has
revealed that the development of active disease even in tuber­
culin positive cases takes an average of about four to five years.
A majority of new cases discovered are not in the young age
group (15 to 35 years) but in the group above 35 years. The
reason for this is not quite clear yet. During the investigation
it was noted that the virulence of tubercle bacilli varied in
India from that noted in bacilli isolated from patients in
western countries. This may be a possible explanation for the
slow development of the disease in an infected individual, but
this can be confirmed only after further research. However, it
may be mentioned that there are bacilli in Indian patients as
virulent as noted in patients in western countries also.
Moreover, once the disease develops, there does not seem to be
much difference in the type of the disease between those deve­
loped with varying degrees of virulence. The second study
referred to above in this large population group is still in
progress and it is too early to assess the results.
Applicability of Tuberculosis Control Programme

For many years it was obvious to those responsible for
tuberculosis control in the country that it would be impractical
to adopt in India those measures which were found satisfactory

4

in western countries. According to standards accepted by the
latter a minimum provision had to be made for at least one bed
for every annual death from tuberculosis, or one bed for every
thousand population. According to this India should have at
least 500,000 to one million beds. We have at present about
30.000 beds in the whole country and the annual rate of
increase, even after special efforts, is only about 300 to 400
during the last ten years. Therefore we were obliged to think
of some other method as an alternative to deal with the situ­
ation. The advent of effective drugs for tuberculosis made it
possible to consider the expediency of treating patients in their
homes, and in our opinion, this can be best carried out from
tuberculosis clinics serving as the base. This is the reason why
establishment of clinics was included as a priority item in the
national programmes. At present there are about 225 tuber­
culosis clinics in the country and the programme is to increase
this number to about 400 during the next five to ten years, there­
by providing one clinic for one to one and half million popu­
lation. Even so, we will be faced with numerous problems such
as finding out the cases and treating them effectively in their
homes. We have also to make sure whether domiciliary treat­
ment will be as good as institutional treatment.
Efficacy of Domiciliary Treatment

A research programme was therefore instituted for this
purpose in 1956 in Madras (Madras Chemotherapy Centre)
with the help of Government of India, Government of Madras,
World Health Organisation and British Medical Research
Council. The results of the investigations made in this Centre
are widely known, and do not need repetition. It may, however,
be mentioned that they have proved that domiciliary treatment
of tuberculosis with anti-bacterial drugs if properly supervised
is as good as treatment given in Sanatoria. Another important
finding of this project is that the development of disease among
the contacts of patients treated either in the sanatorium or
home is practically the same. Most of the contacts that

5
COMMUNITY HEALTH CELL
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developed tuberculosis did so during the first three months after
the treatment was started whether in sanatorium or in home,
indicating thereby that most of the infection had taken place
before starting the treatment. It also indicates that if effective
treatment is started after the diagnosis of the case, the contacts
do not run any increased risk even if the patient is treated in
the home. These studies have further shown that the best
form of treatment is a combined therapy with at least two
drugs l.N.H. and P.A.S.—if taken regularly and daily as these
are particularly suitable for domiciliary treatment and can be
taken by patients themselves.

Researches have, no doubt, shown that we can get good
results by drug therapy of patients in their homes. Yet there
are several practical problems to face in the application of this
weapon. One of the most important is the cost. I.N H. is
comparatively cheap, but P.A.S. costs about ten times more.
The cost of treating, say, 1,000 bacillary patients for one
year by l.N.H. & P.A.S. is about Rs. 150,000. Therefore
the cost of treating one million infective cases in India can well
be imagined. Few, if any, Governments in the economically
less favoured countries are prepared, or can easily afford to
provide the necessary finances for free treatment of the great
bulk of their infectious cases with such an expensive combi­
nation. Hence it is imperative to find a cheap companion-drug
to replace P.A.S. or even some new single drug which is cheap
and equally effective as l.N.H. and P.A.S. combined.
It is established that tuberculosis patients can be treated
in homes if a particular regime is followed. It is, however,
essential to emphasise the many difficulties to be overcome to
ensure extensive application of this programme to cover the
millions of patients in the country. Certain investigations are
being made to test the efficacy of this regime with partial
supervision by the investigating staff distributing the drugs once
in two weeks. At another centre investigation is being done
using the local health staff and social and other workers for

6

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drug distribution and check up. The investigating units with
mobile X-ray and laboratory outfit diagnose cases and provide
the drugs. In course of time it is hoped to find out the
effectiveness of these different approaches and if this system
works out satisfactorily the use of specialised staff can be
limited to diagnosis and general supervision and the non­
specialised staff can be used to extend the drug treatment to a
large number of patients.
Non-Specific Infections

During the extensive tuberculin testing associated with
B.C.G. Vaccination programme, it was noted that there is
widespread non-specific infection, which produces a low grade
tuberculin sensitivity, as different from the tuberculin sensitivity
associated with infection by microbacterium tuberculosis. At
the same time it has been indicated that there is a possibility
that the non-specific allergy found in a considerable proportion
of the population in India may denote some degree of immunity
against tuberculosis and thereby minimise the need for B.C.G.
Vaccination in these areas. It therefore seems that there is
urgent need to investigate the place, if any, of non-specific
allergy in the production of immunity against tuberculosis and
if so at what level. This is of great epidemiological importance.
Would B.C.G. Vaccination superimposed on those with non­
specific infections have a similar effect as noted by the B.C.G.
control trial carried out by the British Medical Research
Council in Great Britain or is it different? The objective of
this study is not to find out whether B.C.G. is effective or not;
but rather to find out the degree of effectiveness under the
epidemiological conditions in India.
An investigation pro­
gramme for this is being planned for.
I have indicated briefly what a stupendous and difficult
problem tuberculosis poses in India showing at the same time
that wc cannot control this disease in a foreseeable future if we
confine merely to methods used in the past by western
countries. 1 have also tried to spotlight some of the investiga-

7

tions that are intended to find out how best we can try to
control the disease in a comparatively short period by using
the means that are available or can be made available in the
near future. With modern discoveries, especially of potent
drugs, and with vaccine for prevention there is hope. We are
justified in saying that we have now the tools; the task is to
find out how best to use the tools and finish the job.

S

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