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Is DOTS the best TB treatment for India?

Although Directly Observable Treatment Short Course (DOTS) is a course of treatment for tuberculosis and costs the same as conventional therapy with regard to drugs, it involves additional infrastructure such as a testing lab and manpower for supervision

When the Union ministry of health and family welfare claims that the new Directly Observable Treatment Short Course (DOTS) is the best available treatment for tuberculosis in India it forgets to mention that the treatment covers only nine per cent of the 22 lakh patients in the country.

Running on funding of nearly a billion dollars from the World Bank, since 1998, DOTS has covered 221 districts. Treatment begins with a sputum test and patients found positive are prescribed medication for upto eight months.

For the first 12 doses, taken on alternate days, the patient is required to come to the DOTS centre to be `directly observed'. The rest is taken under the supervision of health workers.

DOTS treatment, however, does not cover non-pulmonary tuberculosis. It ignores people who test negative in a sputum test. So, if around 1 lakh patients received DOTS last year, according to the health ministry, the National Institute of Tuberculosis (NIT) found that more than 8 lakh non-DOTS patients had tuberculosis.

WHO figures are higher by almost another lakh each. Regarding the number of people who completed the treatment, the UN body records 83 per cent, one per cent more than the official figure.

Doctors at DOTS centres say that they have strict instructions on whom to treat. “Anyone who has received any drugs, even a small dose of Ampicillin, is to be denied DOTS,” says one doctor. “Only fresh sputum-positive cases are to be considered. I requested my higher-ups to extend treatment to a couple of patients who had taken other drugs but do not have multi-drug resistance. They refused.”

Furthermore, DOTS is extended only to those who can give proof of residence and can complete the course of treatment. The rest are given conventional therapy.

Though their treatment duration is longer than DOTS, two other treatments under the National Tuberculosis Control Programme -- standard regimen for a year, and short-course chemotherapy -- have shown encouraging results. However, while the NIT shows a treatment completion rate of 63 per cent for conventional therapy, the WHO says it is as low as 10 per cent, allegedly to ensure acceptability for DOTS.

Although World Bank funds for TB eradication will cease by September 2004, the Indian government has received an assurance of the continued flow of money from Stop TB, a global campaign involving philanthropic organisations and multinational pharma majors like Novartis, Lupin and Aventis, which also produce Rifampicin. This could explain both Stop TB and the government advocating DOTS in India.

“The West's attitude to health problems in India has been that of an intensive, supervision-based vertical programme at the cost of primary health,” claims Dr D Banerji who pioneered public health care in India.

Except for the smallpox eradication programme, nearly all the vertical programmes -- for malaria, filariasis, trachoma, cholera and leprosy -- have failed.

However, Dr L S Chauhan, director of DOTS, and Dr J P Narain, consultant with the WHO, say that the DOTS programme has been tested successfully in the US and other countries. “Precisely my point,” says Dr Ritupriya Mehrotra, associate professor at the Centre for Social Medicine, Jawaharlal Nehru University. “We have a different kind of tuberculosis which has a low multi-drug resistance and responds well to conventional, cheaper therapy.”

Although DOTS is a shorter course and costs the same as conventional therapy with regard to drugs, it involves additional infrastructure such as a testing lab and manpower for supervision.

While everyone involved admits that TB is a serious health problem, a change of medication alone may not be the solution. There is no guarantee that the person cured through DOTS will not fall ill again, as most patients are poor migrant workers who suffer from malnutrition.

“Tuberculosis was a problem in India even during colonial times, when it saw a decline in Europe,” says Ritupriya. “This sudden spurt of activity is a result of the West's fear psychosis. We have to get out of this colonial hangover and decide ourselves how to solve our problems.”

Source: The Week, December 8, 2002