Key
words: DOTS, TB problem, homeopathy, private-practitioner, cost-effective.
In India,
DOTS is reported to be one of the fastest expansions of the strategy than anywhere in the
world.1 By
the end of 2004, 942 million population had been covered and by the end of 2005 entire
country was expected to be covered under RNTCP.1
With the
expansion of DOTS, TB scenario has started changing in India. Patients from middle and low
socio-economic class are shifting from private practitioners to DOTS centres. It is
favourable in India to have full co-operation of NGOs,
Medical colleges, private doctors (IMA) against TB. However, the drawback is regarding
case management practices.1, 2
India has more new TB cases annually than
any other country. Some epidemiologists forecast
a rise of 20% in the incidence in the next 20 yrs, for India, and 58.6% over a 15 yrs
period for the world, at large.3 However, nearly one-third of the world
population is asymptomatically infected by M.Tuberculosis,4 WHO
has not yet found the sufficient evidence of TB epidemic declining nationally.5
Following the rapid
implementation of DOTS, India has reached 57% case detection countrywide in 2004, and 70%
within DOTS areas. A surveillance report of CDC has
indicated a relative increase of extra-pulmonary TB cases in US from 16% in 1992 to 20% in
2000.6 DOTS is dealing with the
Pulmonary cases while extra-pulmonary tuberculosis (EPTB) is coming out of the shadows
which is far difficult to treat because it presents with a diagnostic dilemma.7-8 Such patients are left untreated
for a long time. Even its primary infection site remains undetected. Response of TB in
some other conditions such as tuberculomas to anti-tuberculosis treatment has
not been well defined as yet.9 No natural barrier has yet been
found which can prevent movement of TB bacilli from extra-pulmonary sites to pulmonary
region. Though the treatment of EPTB is easy with any effective regimen because it is a
paucibacillary disease8, yet lots of measures such as
early diagnosis will have to be developed for tackling the increased threat of EPTB. And
above all, such patients can not be investigated at the time of terminating the
treatment. However, these suppressed bacilli may become active later.
Despite new
advances in understanding the biology of TB bacilli we are lacking in the development of
newer drugs in last 30 yrs,4 while there is need for development
of new drug and new effective vaccines urgently.
A report of
NDTB centre, New Delhi found that about 36% patients are not satisfied with DOTS policy of
stopping treatment without x-ray at the end of treatment.7 And this way some cavitary lesions may remain
untreated that may eventually cause the reoccurrence of active TB. While there is very
high incidence of cavitary lesions in India, which is one of the causes of poor impact of
TB control programme.7
Although
there is no doubt regarding the effectiveness of DOTS yet it will be
difficult to check the spread of tuberculosis since DOTS has no provision for drug
resistant strains (MDR and XDR TB) and, moreover, it is providing no preventive procedures
to check the recurrence of the disease.10 There are lots of things
regarding its final outcome that are apprehending the mind of policy makers and
researchers. Christopher Dye et al have well predicted in their report “reaching the
targets for TB control” in 1998, if the targets are achieved by 2010, three-quarters
of worldwide tuberculosis burden would not be averted in the next 23 years.11 While WHO has already shifted its target from
2005 to 2015.
Political
will, operational and managerial problems are the same as they were responsible for the
failure of NTP previously. TB News of
healthinitiative.org has shown their fundamental apprehension whether DOTS services are
reaching the poor, vulnerable and underprivileged. The constraints under which RNTCP is
working in India are far bigger than those listed above. A few reports have appeared in
the media from time to time about misappropriation of RNTCP funds.
WHO has
launched DOTS as a marker of more serious efforts to tuberculosis control. “Promoting awareness of TB and DOTS in traditional healers,
particularly in remote areas” is one of the challenges for which WHO has made some
planned activities, for India, such as ‘Mobilize community-based self-help groups and
NGOs to assess needs, promote early diagnosis and provide patient support.5
Discussion:
If we can design an Automatic Transaction
of Medicine (ATM) machine, which would prove to be far better, in many senses, than health
workers in the current settings of DOTS centres.
Unfortunately,
proper use of traditional healers and general practitioners has been greatly ignored in
this scenario. A large number of private practitioners from different systems of medicine,
estimated to be around 8 million, provide care to the patients in the country but nearly
3000 private practitioners are officially providing RNTCP services.12 Private practitioners from different fraternity
can be convinced to provide DOTS services to their patients. And they would prove to be better than ordinary health workers if they
are allowed to provide their medicines along with DOTS services. Patients taking ATT may
need some medical help for his minor ailments and he or she can get medical aid
immediately in the same settings. The compliance is decreased if other symptoms are not
taken care of at DOTS centres, leading to revisiting private practitioners and hence cost.
Nearly 0.27
million homeopaths are providing most economical health care services in India. They could
be engaged for the purpose of providing DOTS. They would prove to be better than ordinary
health workers in all aspects. I can presume one more benefit of improved doctor-patient
relationship in such settings.
But we see
there is a great ignorance of homeopaths in any national health programmes. Why it is so?
- Mechanism
of action of homeopathic drugs is still not clear. But there are too many used
conventional drugs which don’t have clear mechanism. There are many areas of
chemistry, physics and other sciences that are not well understood. It is always not
possible to know everything about a subject prior to using it effectively. Researches are
made for same purpose.
- Some
persons believe that the homeopathic results are simply because of the
placebo effects. But every trial is compared with a placebo first. So they should not
oppose its use if it is not putting an extra burden on TB control budget.
- Homeopathy
is supposed to work for the self limiting functional disturbances. While it
is a fully developed health science based on fixed principals and has a holistic approach
of ill person. Its basic principals and fundamentals were developed by the modern doctors
who were in the search of some thing more useful but less harmful for the already
suffering persons.
- Conventional
doctors are not happy in sharing the positive results. But as clinicians they want to use
whatever thing may help their patients. (Every hospital in India has a temple in their
premises).
Homeopathy could also work as an adjuvant.
This was the most accepted view of most doctors of conventional medical science who had
studied my published and unpublished treated TB cases. They thought that there was
something extra other than ATT that had been used in such cases. Because, they had never
seen or even imagined results similar to my work of TB ever before, they were willing to
use homeopathy in their TB patients.
Conclusion:
Clinics of motivated general practitioners
of any fraternity could be used as DOTS centres. Failure of DOTS is being predicted from
many places due to many reasons; in this situation it would not be unethical to take the
help from every alternative system of medicine. For the case of homeopathy, it is rather
known as complementary medicine in many countries.
Whatever could be the modus operandi,
results are encouraging even in TB treatment. Homeopathy is safe and cost effective. It is
effective too, can be judged from my published case reports.13,14,15 Homeopathy could also
be used as a supportive therapy in the same settings of DOTS.
References:
1 Prahlad Kumar, Journey of
tuberculosis control movement in India: NTP to RNTCP, Indian J tuberc 2005; 52:63-71.
2 Ganapati Mudur, News,
Private doctors in India prescribe wrong tuberculosis drugs, BMJ 1998;317:904.
3 Chakraborty A K,
Epidemiology of tuberculosis: Current status in India, Indian Journal of Medical Research,
Oct 2004.
4 Chopra,Puneet, Meena L
S, and Singh Yogendra. New drug targets for Mycobacterium tuberculosis. Indian Journal of
Medical Research. Jan 2003.
5 WHO Report 2006, Global Tuberculosis control,
Country profile, India
6 Centre for Disease
Control and Prevention. Surveillance Report. Reported Tuberculosis in US, 200. Atlanta,
GA:CDC, 2000.
7 M.M.Singh, Fifty
Eighth National Conference on Tuberculosis and Chest Diseases: A brief review, Indian J
Tuberc 2004;51:99-101
8 Editorial,
Extra-Pulmonary Tuberculosis: Coming Out of the Shadows, Indian J Tuberc 2004; 51: 189-190
9 H.S. Lee, J.Y. Oh,
J.H. Lee, C.G. Yoo, C-T. Lee, Y.W. Kim, S.K. Han, Y-S. Shim and J-J. Yim; Response of pulmonary tuberculomas to
anti-tuberculous treatment; Eur Respir J 2004; 23:452-455.
10 Goyal K.K, Does World needs Integrated Medicine to combat
Tuberculosis?, http://www.stoptb.org/material/news/press/KGoyal.010312.htm
11 Christopher Dye, Geoffrey P Garnett, Karen Sleeman,
Brian G Williams Prospects for worldwide tuberculosis control under the WHO DOTS strategy,
Lancet 1998; 352: 1886-1891
12 Central TB Division,
Directorate General of Health Services Ministry of Health & family Welfare, New Delhi.
TB India 2003; 16-46.
13 Goyal K K, case report Pulmonary Tuberculosis, Simile
(A newsletter of the Faculty of Homeopathy, London) April 1994; 2/4: 14-16
14 Goyal K K, case report Collapsed lung with
Empyema, Simile (A newsletter of the Faculty of Homeopathy, London) April 1996;
9-12
15 Goyal K K, Two Cases of Pulmonary TB treated with
Homeopathy, Homeopathy (2002) 91; 43-46
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