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December 1999 Insights Issue #32New possibilities for TB control?The WHO policy package for tuberculosis control, known as Directly Observed Treatment, Shortcourse (chemotherapy) - or DOTS, presents interesting questions about the role of research in policy. This is because the precise relationship between research evidence and the development of the policy has never been clearly established. Nor are there clear mechanisms for new research to feed into the strategy. Yet the policy rapidly became accepted as the international gold standard for TB treatment, and was widely lauded as the final word on TB control. Findings from an Indian research project resonate strongly with others that suggest it is high time to reopen the debate on this TB control policy. Despite the range of activities being promoted in the strategy, direct observation of treatment became the policy's focus (the acronym denoting the policy - DOTS - is based on this element). Why this is so has not been clearly documented. Another problematic aspect of this policy is the rigidity with which it is sometimes applied by national programmes. The lack of transparency in the policy process, focus on direct observation, and inflexibility in application have led to a number of problems in at least one setting in India, and raises questions about the future effectiveness of the strategy in the absence of adaptation. Research conducted in New Delhi in 1997 by the Lala Ram Swarup Institute of TB and Allied Diseases, together with researchers at the London School of Hygiene and Tropical Medicine, highlighted problems arising from overly rigid application of DOTS. The study revealed that the emphasis on achieving 85 percent cure rates through a focus on patient supervision has meant that patients are pre-selected for inclusion into the new programme. These likely 'defaulters' are also more likely to be the most socially vulnerable patients. Evidence from the Delhi study shows that, of 2161 patients seeking care at TB clinics, only 879 were given DOTS: the remaining patients were given unsupervised standard therapy. Some of these patients opted out of DOTS but others were refused DOTS by the TB health visitors. Patients opting out of DOTS gave these reasons:
TB health visitors apply various criteria for deciding whether or not to include patients for DOTS. The exclusion criteria include:
According to the health visitors, the current programme makes it very difficult to meet the needs of patients who cannot fulfil these criteria. Thus these health workers use their best judgement to select those patients who will comply with DOTS. Sadly those denied treatment, however, are among the most poor and marginalised. Increasingly tuberculosis researchers are calling for a reconsideration of imposing DOTS as a fixed and universal blueprint for TB control. These researchers stress the importance of:
In light of these findings we, like Bayer and colleagues (1998), 'view our findings as providing an opportunity to reopen the discussion of TB policy, which may, in the mid-1990s have moved to premature closure'.
Contributor(s): Jessica Ogden and John Porter Source(s): Funded by: DFID, New Delhi Health and Population Field Office Date: 13 December 1999 Further information: John Porter Search Eldis for sources on Health and Population issues
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