Shifting the paradigm in tuberculosis control: illustrations from India

Drawing on literature from India and key contributions from social science, this paper asks and attempts to answer the question 'who is to blame for t reatment failures in TB'? Some key lessons emerge: effective tuberculosis c ontrol cannot be achieved so long as the disease is considered in isolation from the social processes that maintain it, create the conditions facilita ting its spread and act as barriers to care. Insights into the economic and social burdens incurred with a diagnosis of TB are essential to understand why many patients, especially the most disadvantaged, are unable to comply with treatment regimens. TB and health care interventions need to be appro priate to the health service contexts in which they are applied, and sensit ive to the competing demands, needs and priorities of people's lives. The p aper argues for the need to reorient TB control programmes towards enabling patients to obtain care. The problem of access emerges as central to peopl e's ability to obtain and maintain appropriate therapy. Examples and charac teristics of successful non-governmental projects, from which policy makers , programmers and practitioners could learn, are outlined and contrasted wi th more rigid directly observed treatment approaches. We conclude that trea tment failures are not patient failures, and that TB control programmes nee d to address the social dimensions of TB, and adhere to the principles of g ood TB care, with the same commitment that is devoted to ensuring patients follow treatment guidelines. We suggest a paradigm shift away from a focus on diseased patients towards enabling health in the community.