413Bulletin of the World Health Organization | May 2007, 85 (5)
Public health classics
This section looks back to some ground-breaking contributions to public health, reproducing them in their original form and adding a commentary on their significance from a modern perspective. To complement the theme of this month’s issue, Mukund Uplekar & Mario C Raviglione review a paper by Halfdan Mahler on tuberculosis programmes in developing countries that was published in the Bulletin of the International Union against Tuberculosis and Lung Disease (1966;37:77-82). The paper is reproduced here in full.
The “vertical–horizontal” debates: time for the pendulum to rest (in peace)?Mukund Uplekara & Mario C Raviglionea
a Stop TB Department, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland. Correspondence to Mukund Uplekar (e-mail: [email protected]).doi: 10.2471/BLT.07.041756(Submitted: 28 February 2007 – Accepted: 2 March 2007)
“Historia magistra vitae” said Cicero: history is the teacher of life.1 It is an inevitable law of nature that unless there is a solid foundation of the past, no secure edifice of the future can be raised. Those who do not look at the past cannot devise means for the future; and unless the future is built on the past, it will be raised merely on stubble.2 The article on tuberculosis (TB) programmes in developing countries published in The Bulletin of the International Union against Tuberculosis and Lung Disease (1966; 37:77-82; reproduced here in full)3 four decades ago illustrates how past efforts to control TB could and should inform future interventions.
Dr Halfdan Mahler, WHO Director- General from 1973 to 1988, spent a decade in India beginning in the early 1960s and was instrumental in designing what became a blueprint for a national tuberculosis programme in a developing country. As WHO’s Director-Gen-eral he later promoted the concept of primary health care (PHC), eliciting extensive global support and initiating the health–for-all movement. Like the swing of a pendulum, both PHC and global TB control efforts subsequently suffered a decline.4 The pendulum has, however begun to swing in the opposite direction. TB programmes have been reinforced and the PHC concept is being revived by WHO’s new Director-General, Dr Margaret Chan (http://www.who.int/dg/speeches/2007/
eb120_opening/en/index.html). The challenges facing national TB pro-grammes today include TB/HIV co- infection, multidrug-resistant TB (MDR-TB), health sector reforms, effective community engagement and a need for new tools for diagnosis, treat-ment and prevention. These problems seem more complex, yet the fundamen-tal approaches discussed in Mahler’s article are still central to TB control and to addressing these current challenges. In addition to raising some pertinent ques-tions, this commentary draws four key messages from the article that deserve the attention of all concerned: policy-makers, programme managers, scientists and activists.
Sporadic efforts to control TB are wastefulA third of the world’s population is in-fected with TB, but the tools currently available cannot identify who will be responsible for producing millions of infectious cases of TB in the foreseeable future. The history of TB demonstrates that “Any sporadic effort in tuberculosis, however spectacular, will be wasteful; and it is wholly unrealistic to propose crash programmes with the objective of eliminating TB within a ten-year period”. This is perhaps the most im-portant message of Mahler’s article. Notwithstanding some new tools that
are emerging, this statement is as true today as it was four decades ago. TB control demands sustained and stead-fast efforts on the part of everyone concerned.
Programme management is distinct from patient managementNational TB programmes, as the article rightly suggests, ought to be a system with organizational and administra-tive features that allow pursuit of the optimal set of actions within the resources available to countries, cur-rently and in the near future, leading to specific and systematic reduction of the TB problem. It draws attention to the tendency to confuse the individual TB patient with the public health problem of TB and of identifying the operational conditions for a hospital, clinic or research project with those of the programme.
The recent outbreak of extensively drug-resistant TB (XDR-TB) in a hospi-tal in South Africa, and demonstration of its presence worldwide in diverse set-tings, raised an outcry and continues to receive media attention. Conversely, it is common to read accounts of spectacular demonstrations of managing TB in a small district or a project area by a vol-untary or a research organization. Both failures and successes need to be viewed
414 Bulletin of the World Health Organization | May 2007, 85 (5)
Special theme – Tuberculosis controlThe “vertical–horizontal” debates Mukund Uplekar & Mario C Raviglione
in the larger context, with an eye on scalability and appropriate lessons drawn to inform the national programme and to ensure that basic TB control is not derailed.
“The NTP does not emerge by simply pooling or multiplying sanatoria, clinics, research projects, rehabilitation centres, etc. … there is no escape from having as the primary objective, the sys-tematic reduction of the TB problem.” This calls for a strong national pro-gramme sustained over a period of de-cades, taking into consideration “what is technically desirable for a few and what is operationally feasible for the many”.
Understandably, the article repeat-edly draws attention to developing countries’ limited resources and the need to match actions to these available resources. With public health receiv-ing increasing attention and resources globally, the current situation is better. Also thanks to the “globalization of solidarity”5 and the pressure of activism, mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and UNITAID have been created. As a consequence, unprecedented funding is now available to poor countries to address specific public health problems of global concern. In this scenario, Dr Mahler’s advice to countries would very likely be about sustainability, ac-countability and performance.
Integrate, not disintegrateAs they come straight from someone who was both a TB stalwart and a “father” of PHC, Dr Mahler’s thoughts on strengthening general health services and integrating TB control are highly rel-evant to these current debates. Although it was penned years before the 1978 International Conference on Primary Health Care, in Alma-Ata, the article foreshadows the PHC concept that was to later occupy the centre stage in inter-national public health. PHC’s origins seemed to be rooted, as does its current
revival, in “an acute shortage of medical personnel in developing countries for all major public health priorities including tuberculosis”.
To address the then-prevailing hu-man resource crisis, the paper suggests that “the staff of multi-purpose health centres can be trained in a few weeks in standard techniques of diagnosis, treat-ment, and immunization” and declares that “all communicable disease campaigns have overwhelmingly demonstrated that only through falling back on strong basic health services in developing countries is it possible to achieve an effective consoli-dation of these campaigns”.
Does this mean that the national TB programmes should be fully integrated into general health services? While advo-cating that TB services indeed be thus inte-grated, Dr Mahler clarifies that integration, far from being a laissez-faire approach, requires “maximum involvement of all spe-cialized personnel such as programmers, organizers, tutors and assessors”.
Furthermore, he warns that “train-ing (of multi-purpose workers) is of no avail – yes, even potentially harmful, if the techniques are not employed within the supervisory framework of a programme having pre-determined efficiency forecasts and built-in control of actual achievements”. He addresses the doubts related to integration in conclud-ing that, “… a TB programme first and foremost needs specialists in epidemiol-ogy, operational research, programming, training and evaluation”. And finally, “no amount of lip-service to planning, training and evaluation will bring out the benefit … to the receiving end without a unifying central direction with adequate powers to enforce and, when necessary, modify the national programme”. It is unclear why, despite this clarity about the need for specialist attention, the TB programme within WHO experi-enced a rapid decline in PHC’s heyday. Dr Mahler, in 1966 at least, visualized a TB programme that maintained and monitored a supervisory structure to
ensure delivery of essential first-level TB care integrated into general health services. As for strengthening general health services, his expectation and that of WHO’s new Stop TB Strategy 6 has been that “the integrated TB programme … will grow organically together with the health services, each strengthening the other by adding to the confidence they inspire in public”. In the artificial dichotomy of vertical and horizontal approaches, the truth, like a pendulum, rests in-between.
What is effective?The article concludes by emphasiz-ing four conditions for implementing effective national TB programmes in developing countries, which again are as relevant today as they were in 1966. First, programmes should be planned based on a “systematic analysis of exist-ing epidemiological and socio-economic situation”. This highlights the need to look into social and economic deter-minants to understand what factors beyond TB programmes and health sys-tems sustain the TB epidemic at current levels. Second, “training and retraining of all specialized and multi-purpose health personnel” is essential, especially on managerial aspects in addition to technical basics. This remains a weak-ness to be adequately addressed in many settings. Third, there must be a built-in evaluation at all levels, including impact evaluation “to serve as the conscience of the programme”. Finally, the article stresses the need for “a unifying central direction with adequate powers” indi-cating true political commitment. The masterstroke the article offers is in de-scribing the two essential characteristics of TB programme managers: “emotional detachment to choose their programme priorities and the courage to stick to them under immense counter-pressures from vested interests”. Is this too tall an order in today’s world? O
References 1. M. Tulli Ceceronis. De oratore ad quintum fratrem liber secundus. Available
at: http://www.thelatinlibrary.com/cicero/oratore2.shtml 2. Ranade RD. Essays and reflections. Mumbai: Bharatiya Vidya Bhavan; 1964. 3. Mahler H. The tuberculosis programme in the developing countries. Bull Int
Un Tuberc 1966;37:77-82. 4. Raviglione MC, Pio A. Evolution of WHO policies for TB control, 1948-2001.
Lancet 2002;359:775-8.
5. Raviglione MC. Infectious diseases and globalization. Dolentium Hominum: Chiesa e Saluto nel Mondo 2007; 64.
6. Raviglione MC, Uplekar MW. WHO’s new Stop TB Strategy. Lancet 2006; 367:952-5.
415Bulletin of the World Health Organization | May 2007, 85 (5)
Special theme – Tuberculosis controlH
. MA
HL
ER
pers
on's
natu
ral r
esis
tanc
e fin
ally
succ
eede
d in
elim
inat
ing
the
baci
lli o
r whe
ther
the
baci
lli
surv
ived
in a
dor
man
t sta
te fr
om w
hich
they
can
be re
-act
ivat
ed. B
ut, w
e do
kno
w th
at th
ese
hund
reds
of
mill
ions
of
infe
cted
per
sons
are
bou
nd t
o pr
oduc
e m
illio
ns o
f in
fect
ious
so
urce
s of t
uber
culo
sis o
ver t
he n
ext d
ecad
es. A
ny sp
orad
ic e
ffor
t in
tube
rcul
osis
, how
ever
sp
ecta
cula
r, w
ill, b
ecau
se o
f th
is u
npal
atab
le e
pide
mio
logi
cal f
act,
be w
aste
ful;
and
it is
w
holly
unr
ealis
tic t
o pr
opos
e cr
ash
prog
ram
mes
with
the
obj
ectiv
e of
elim
inat
ing
tube
rcul
osis
with
in a
ten-
year
per
iod.
Th
ere
are
prob
ably
som
e 10
to 1
5 m
illio
n pe
rson
s in
the
deve
lopi
ng c
ount
ries w
ho to
day
are
capa
ble
of tr
ansm
ittin
g ba
cilli
to th
eir f
ello
w tr
avel
lers
. The
y ar
e no
t con
cent
rate
d in
the
tow
ns o
r in
any
prac
tical
ly id
entif
iabl
e are
as o
r gro
ups,
butr
athe
r ‘sp
lash
ed’ o
ver t
he w
hole
na
tiona
l te
rrito
ry.
Cal
cula
ting
from
a l
arge
num
ber
of s
ampl
e su
rvey
s in
dev
elop
ing
coun
tries
, at t
he m
ost o
ne q
uarte
r of t
he in
fect
ious
cas
es o
f tub
ercu
losi
s are
livi
ng in
urb
an,
and
at le
ast t
hree
qua
rters
in ru
ral a
reas
. Is
it th
en lo
gica
l to
conc
entra
te th
e fig
ht a
gain
st
tube
rcul
osis
on
the
quar
ter
livin
g in
the
tow
ns ?
Or
is it
not
rath
er o
bvio
us f
rom
a
com
mun
icab
le d
iseas
e po
int
of v
iew
tha
t th
e tu
berc
ulos
is p
rogr
amm
e m
ust
be o
n a
coun
try-w
ide
basi
s if i
t is t
o ha
ve a
sign
ifica
nt e
pide
mio
logi
cal i
mpa
ct?
Far
too
ofte
n, e
ven
tube
rcul
osis
wor
kers
ove
rlook
that
it is
ubi
quito
us M
AN
, with
his
pr
esen
t and
fut
ure suffering
caus
ed b
y tu
berc
le b
acill
i, w
ho r
epre
sent
s th
e real
pro
blem
th
at m
ust b
e the
focu
s of t
he tu
berc
ulos
is p
rogr
amm
e and
its p
riorit
ies.
Soci
olog
ical
surv
eys
in se
vera
l dev
elop
ing
coun
tries
hav
e sho
wn
that
mor
e tha
n 90
per
cent
of r
elia
bly
diag
nose
d ac
tive
case
s of
tube
rcul
osis
wer
e co
nsci
ous
of s
ympt
oms
sugg
estiv
e of
tube
rcul
osis
; tha
t m
ore
than
70
per c
ent o
f the
se s
pont
aneo
usly
exp
ress
ed w
orry
ove
r the
se s
ympt
oms;
and
th
at m
ore t
han
50 p
er ce
nt n
ot o
nly
wer
e con
scio
us an
d w
orrie
d, b
ut in
deed
had
take
n ac
tion
to s
earc
h fo
r alle
viat
ion
of th
eir s
uffe
ring
- mos
tly in
vai
n! Is
then
toda
y's s
ocia
l cha
lleng
e in
tube
rcul
osis
not t
o m
ake
effe
ctiv
e se
rvic
es a
vaila
ble
to a
ll th
ose
who
alre
ady
suffe
r and
w
ho a
re p
repa
red
to a
ccep
t hel
p? S
uch
a fe
lt-ne
ed o
rient
ed p
rogr
amm
e w
ill g
ive
max
imum
sti
mul
atio
n to
the
conf
iden
ce o
f the
gen
eral
pop
ulat
ion
in th
e tu
berc
ulos
is se
rvic
es b
ut a
t the
sa
me
time
this
prog
ram
me
will
be
by fa
r the
mos
t eco
nom
ical
and
will
take
car
e of
the
mos
t da
nger
ous c
ases
from
a c
omm
unic
able
dise
ase
poin
t of v
iew
. B
ut d
o th
e de
velo
ping
cou
ntrie
s the
n ha
ve th
e ne
cess
ary
reso
urce
s at t
heir
disp
osal
to fa
ce
tube
rcul
osis
effe
ctiv
ely
both
as a
n ep
idem
iolo
gica
l and
soci
al p
robl
em ?
Yes
, I b
elie
ve so
,if
they
hav
e th
e em
otio
nal d
etac
hmen
t to
choo
se th
eir p
rogr
amm
e pr
iorit
ies
ratio
nally
and
the
cour
age
to st
ick
to th
em u
nder
the
imm
ense
cou
nter
-pre
ssur
es fr
om v
este
d in
tere
sts.
I sho
uld
now
like
to a
naly
se b
riefly
thre
e ke
y va
riabl
es re
leva
nt to
ava
ilabl
e, re
sour
ces
nam
ely,
firs
t the
tech
nica
l too
ls, th
en th
e fin
anci
al re
sour
ces,
and
final
ly th
e pe
rson
nel.
Let
me
sta
rt w
ith
case
-fin
ding
. Ev
eryb
ody
liv
ing
in
a
give
n ep
idem
iolo
gica
l si
tuat
ion
is m
arke
d w
ith
a c
erta
in
ecol
ogic
al
prob
abili
ty
of
enco
unte
ring
tube
rcle
ba
cilli
; of
the
se b
acill
i be
ing
suc
cess
fully
tra
nsm
itted
; of
the
se s
ucce
ssfu
lly t
rans
-m
itted
bac
illi p
rodu
cing
dis
ease
; of
thi
s di
seas
e sp
onta
neou
sly
hea
ling
or
resu
lting
in
de
ath.
With
in t
his
rang
e o
f ris
ks t
here
is
a w
ell-m
eani
ng t
ende
ncy
to i
dent
ify a
pe
rson
as
a p
oten
tial
case
of
tube
rcul
osis
not
onl
y b
efor
e h
e b
ecom
es i
nfec
tious
78
H.
MA
HL
ER
Tub
ercu
losi
s U
nit,
WH
O, P
alai
s de
s N
atio
ns, G
enev
a, S
wit
zerl
and
‘It i
s ba
d pu
blic
hea
lth p
ract
ice
to tr
eat a
cas
e of
infe
ctio
us tu
berc
ulos
is a
t hom
e'.
If y
ou c
anno
t ac
hiev
e at
lea
st 9
5% t
reat
men
t su
cces
s, d
o no
t tr
eat;
`Em
phas
is
shou
ld b
e on
che
mop
roph
ylax
is b
ecau
se it
is e
pide
mio
logi
cally
too
late
to tr
eat t
he
activ
e ca
se o
f tub
ercu
losi
s’. T
hese
sta
tem
ents
are
cas
ually
pic
ked
from
the
vint
age
of a
dvic
e gi
ven
to d
evel
opin
g co
untr
ies
in r
ecen
t mon
ths.
H
ow is
it p
ossi
ble
to g
ive
such
mis
lead
ing
advi
ce?
Prob
ably
bec
ause
of
a la
ck o
f re
cogn
ition
tha
t a
natio
nal
tube
rcul
osis
pro
gram
me
in a
dev
elop
ing
coun
try
is a
hi
ghly
com
plex
sys
tem
in w
hich
org
aniz
atio
nal a
nd a
dmin
istr
ativ
e fe
atur
es a
re fa
r m
ore
impo
rtan
t tha
n, fo
r in
stan
ce, t
heth
erap
eutic
dif
fere
nce
betw
een
a tw
o- a
nd a
th
ree-
drug
regi
men
or
the
epid
emio
logi
cal d
iffe
renc
e be
twee
n a
bact
erio
logi
cally
pr
oven
and
an
X-r
ay s
uspe
ct c
ase.
Wha
t is
mor
e, t
uber
culo
sis
wor
kers
ten
d to
id
entif
y th
e op
erat
iona
l con
ditio
ns o
f a h
ospi
tal,
a cl
inic
, or a
rese
arch
pro
ject
with
th
ose
of a
nat
iona
l tub
ercu
losi
s pr
ogra
mm
e.
The
co
nseq
uenc
e of
co
nfus
ing
thes
e m
icro
syst
ems
with
th
e N
atio
nal
TB
Pr
ogra
mm
e is
hig
h-lig
hted
by
an a
naly
sis
of t
he t
uber
culo
sis
budg
et a
nd t
he
popu
latio
n ef
fect
ivel
y co
vere
d by
exi
stin
g tu
berc
ulos
is s
ervi
ces
in d
evel
opin
g co
untr
ies.
Oft
en m
ore
than
80
per c
ent o
f all
expe
nditu
re o
n tu
berc
ulos
is is
seen
to b
e co
nsum
ed b
y pe
rson
aliz
ed s
ervi
ces
cate
ring
for
les
s th
an 5
to
10 p
er c
ent
of t
he
tube
rcul
osis
pro
blem
, whe
reas
less
than
20
per c
ent o
f all
expe
nditu
re is
inve
sted
in
com
mun
ity se
rvic
es fo
r the
rem
aini
ng 9
0 to
95
per c
ent o
f the
tube
rcul
osis
pro
blem
. T
he n
atio
nal
tube
rcul
osis
pro
gram
me
does
not
emer
ge b
y si
mpl
y po
olin
g or
m
ultip
lyin
g sa
nato
ria,
clin
ics,
res
earc
h pr
ojec
ts,
reha
bilit
atio
n ce
ntre
s, B
CG
ca
mpa
igns
, et
c. T
he n
atio
nal
tube
rcul
osis
pro
gram
me
in a
dev
elop
ing
coun
try
shou
ld in
stea
d be
the
optim
al s
et o
f ac
tions
lead
ing
to th
e sp
ecif
ic a
nd s
yste
mat
ic
redu
ctio
n of
the
tube
rcul
osis
pro
blem
with
in th
e re
sour
ces
at th
e di
spos
al o
f th
ese
coun
trie
s to
day
and
tom
orro
w —
and
not
in
the
next
cen
tury
. T
his,
the
n, i
s th
e m
acro
syst
em o
f w
hich
I w
ould
pro
pose
to
atte
mpt
a s
hort
ana
lysi
s to
day,
sta
rtin
g w
ith t
he t
uber
culo
sis
prob
lem
, th
en p
roce
edin
g w
ithth
e av
aila
ble
reso
urce
s, a
nd
fina
lly m
ergi
ng th
ese
two
key
vari
able
s in
the
natio
nal p
rogr
amm
e.
The
ver
y re
ason
for o
ur fa
ilure
to a
ccel
erat
e th
e de
part
ure
of tu
berc
ulos
is m
ay to
a
larg
e ex
tent
be
due
to a
pec
ulia
r te
nden
cy t
o co
nfus
e th
e in
divi
dual
with
the
pr
oble
m.
It i
s ad
mitt
edly
muc
h ea
sier
to
star
t w
ith t
he c
oncr
ete
patie
nt-d
octo
r re
latio
nshi
p th
an w
ith th
e m
ore
abst
ract
pro
blem
-res
ourc
e re
latio
nshi
p, b
ut fo
r the
de
velo
ping
cou
ntri
es t
here
is
prob
ably
no
esca
pe f
rom
hav
ing
as t
he p
rimar
y ob
ject
ive
the
syst
emat
ic r
educ
tion
of th
e tu
berc
ulos
is p
robl
em.
Mor
e th
an h
alf
the
pop
ulat
ion
livin
g in
mos
t de
velo
ping
cou
ntri
es t
oday
hav
e al
read
y be
en in
fect
ed b
y tu
berc
le b
acill
i. W
e h
ave
no to
ols
to re
cogn
ize
whe
ther
a
77
Rep
rint
ed fr
om: B
ulle
tin o
f the
Inte
rnat
iona
l Uni
on a
gain
st T
uber
culo
sis a
nd L
ung
Dis
ease
196
6;37
:77-
82w
ith p
erm
issi
on o
f the
Inte
rnat
iona
l Uni
on A
gain
st T
uber
culo
sis a
nd L
ung
Dis
ease
(The
Uni
on).
7778
Rep
rint
ed fr
om: B
ullet
in o
f the
Inte
rnat
iona
l Uni
on a
gain
st Tu
berc
ulos
is an
d Lu
ng D
iseas
e 196
6;37
:77-
82
with
per
miss
ion
of th
e In
tern
atio
nal U
nion
Aga
inst
Tube
rcul
osis
and
Lung
Dise
ase
(The
Uni
on).
416 Bulletin of the World Health Organization | May 2007, 85 (5)
Special theme – Tuberculosis controlH
. MA
HL
ER
cent
cur
e, to
the
mos
t exp
ensi
ve c
ostin
g 50
dol
lars
and
giv
ing
95 to
100
per
cen
t cur
e. If
a
deve
lopi
ng c
ount
ry is
pre
pare
d to
com
mit
itsel
f to
an o
rgan
ized
com
mun
ity p
rogr
amm
e in
tu
berc
ulos
is, t
hen
the
choi
ce o
f reg
imen
is a
sim
ple
form
ula,
nam
ely,
rou
ghly
the
annu
al
drug
bud
get d
ivid
ed b
y th
e es
timat
ed n
umbe
r of n
ew c
ases
foun
d pe
r yea
r by
the
natio
nal
prog
ram
me.
It is
stra
nge t
hat s
till s
o fe
w c
ount
ries a
re p
repa
red
to a
dopt
this
sim
ple f
orm
ula
and
inst
ead
perm
it co
stly
ind
ivid
ualiz
ed d
rug
regi
men
s —
inc
ludi
ng s
uch
entir
ely
disp
ensa
ble
addi
tives
as
vita
min
s —
to s
tand
in th
e w
ay o
f a
chea
p, s
tand
ard,
com
bine
d pr
imar
y dr
ug tr
eatm
ent f
or a
ll ca
ses t
hat c
an b
e re
liabl
y di
agno
sed.
La
st b
ut n
ot l
east
let
us
not
over
look
the
pre
vent
ive
tool
s. Fo
r ob
viou
s fin
anci
al a
nd
man
pow
er re
ason
s, it
is im
poss
ible
to k
eep
the h
undr
eds o
f mill
ions
of i
nfec
ted
pers
ons u
nder
pe
riodi
cal d
iagn
ostic
follo
w-u
p or
und
er co
ver o
f dru
gs in
ord
er to
redu
ce th
e co
nseq
uenc
es
of u
navo
idab
le i
nfec
tion
that
tak
es p
lace
bef
ore
the
case
is
disc
over
ed i
n a
real
istic
ca
se-f
indi
ng p
rogr
amm
e. B
ut t
hrou
gh B
CG
im
mun
izat
ion
we
have
a 'tr
eatm
ent'
of t
he
baci
lli a
t th
e ve
ry m
omen
t th
ey a
re p
rodu
cing
a p
oten
tial
case
of
tube
rcul
osis
. Th
ere
prev
ails
an
alm
ost u
ncom
forta
ble
agre
emen
t tha
t BC
G v
acci
natio
n se
ems t
o of
fer t
he m
ost
impo
rtant
too
l fo
r re
duci
ng t
he f
utur
e su
ffer
ing
caus
ed b
y tu
berc
ulos
is i
n de
velo
ping
co
untri
es. T
his r
elat
ive
lack
of c
ontro
vers
y pr
obab
ly st
ems f
rom
the
com
forta
ble
fact
that
as
one B
CG
vac
cina
tion
give
s a re
mar
kabl
e pro
tect
ion
for a
dec
ade o
r mor
e at
the c
ost o
f a fe
w
cent
s, an
effe
ctiv
e B
CG
pro
gram
me
coul
d be
ope
rate
d w
ith so
me
5 to
15
per c
ent o
f pre
sent
ex
pend
iture
on
tube
rcul
osis
in d
evel
opin
g co
untri
es, a
nd d
oes n
ot, t
here
fore
, jeo
pard
ize
the
mai
nten
ance
of
such
ser
vice
s as
reh
abili
tatio
n or
che
st su
rger
y. H
owev
er,
in s
pite
of
its
appe
alin
g ef
ficac
y, c
heap
ness
and
eas
e of
app
licat
ion ,
BC
G v
acci
natio
n is
far
, far
fro
m
bein
g op
timal
ly u
sed
in d
evel
opin
g co
untri
es.
Turn
ing
from
the
tech
nica
l too
ls to
the
finan
cial
reso
urce
s, an
opt
imis
tic a
sses
smen
t of
natio
nal a
nd in
tern
atio
nal e
cono
mic
pro
spec
ts fo
r tub
ercu
losis
con
trol o
ver t
he n
ext d
ecad
e in
dica
tes
that
we
cann
ot r
ealis
tical
ly c
ount
on
mor
e th
an th
e eq
uiva
lent
of
5 to
10
cent
s ex
pend
iture
per
hea
d in
the
deve
lopi
ng c
ount
ries.
This
cor
resp
onds
to ro
ughl
y 5
to 1
0 pe
r ce
nt o
f the
tota
l hea
lth ex
pend
iture
per
hea
d be
ing
spen
t on
tube
rcul
osis
con
trol.
Now
, tak
ing
the
aver
age
mill
ion
popu
latio
n in
a d
evel
opin
g co
untry
, the
re w
ill b
e ea
ch y
ear i
n a
fully
de
velo
ped
tube
rcul
osis
pro
gram
me:
som
e 50
00 n
ew c
ases
to d
etec
t at a
cos
t of s
ome
10,0
00
dolla
rs, s
ome 7
000
case
s to
be k
ept u
nder
trea
tmen
t at a
cost
of so
me 3
5,00
0 do
llars
, and
som
e 10
0,00
0 EC
G v
acci
natio
ns to
be
done
at a
cos
t of 5
000
dolla
rs. T
his
tota
ls 5
0,00
0 do
llars
. A
dd t
o th
is am
ount
som
e 20
,000
dol
lars
in
extra
ove
rhea
d ex
pend
iture
for
tra
inin
g,
supe
rv isio
n an
d ev
alua
tion
and
the
tota
l com
es to
70,
000
dolla
rs o
r 7 c
ents
per
hea
d of
the
popu
latio
n. In
prin
cipl
e, th
en, t
here
are
no
econ
omic
obs
tacl
es to
an
effe
ctiv
e tu
berc
ulos
is
prog
ram
me
but i
t sho
uld
not b
e ov
erlo
oked
that
at
pres
ent
out o
f th
e ap
prox
imat
ely
5 ce
nts
spen
t tod
ay o
n tu
berc
ulos
is p
er h
ead
of p
opul
atio
n, s
ome
80 p
er c
ent a
re b
lock
ed b
y tra
ditio
nal s
ervi
ces,
such
as e
stabl
ishin
g an
d m
aint
aini
ng b
eds.
Let u
s ho
pe th
at a
t lea
st th
e ne
xt 5
add
ition
al c
ents
allo
cate
d to
tub
ercu
losi
s w
ill b
e dr
aine
d in
to t
he r
ight
prio
rity
chan
nels
. Th
ough
it i
s th
us p
ossi
ble
to a
chie
ve a
rat
iona
l — i
f no
t ha
ppy
— m
arria
ge b
etw
een
finan
cial
res
ourc
es a
nd t
echn
ical
kno
wle
dge
in a
ny d
evel
opin
g co
untry
, w
hat
abou
t av
aila
bilit
y of
per
sonn
el to
car
ry o
ut th
e pr
ogra
mm
e?
Ther
e is
an
acu
te s
horta
ge o
f m
edic
al p
erso
nnel
in
dev
elop
ing
cou
ntrie
s fo
r al
l m
ajor
pub
lic h
ealth
prio
ritie
s in
clud
ing
tube
rcul
osis
. W
hat
is m
ore,
in
the
free
80
TH
E T
UB
ER
CU
LO
SIS
PRO
GR
AM
ME
IN
TH
E D
EV
EL
OPI
NG
CO
UN
TR
IES
but a
lso a
lmos
t bef
ore
he b
ecom
es in
fect
ed. B
ut c
ase-
defin
ition
for t
he s
ake
of c
ase-
findi
ng
mus
t log
ical
ly b
e re
late
d to
cas
e-ac
tion.
Sin
ce th
e gr
eat m
ajor
ity o
f act
ive
case
s ha
ve o
ne
thin
g in
com
mon
, nam
ely
that
they
dev
elop
sym
ptom
s tha
t eve
ntua
lly m
otiv
ate t
hem
to se
ek
help
if
they
hav
e co
nfid
ence
in
the
heal
th s
ervi
ces,
it is
to t
his
grou
p th
at p
erm
anen
t di
agno
stic
faci
litie
s firs
t sho
uld
be m
ade
avai
labl
e. F
urth
erm
ore,
em
phas
is o
n th
e re
liabi
lity
of t
he d
iagn
osis
thro
ugh
givi
ng f
irst
prio
rity
to b
acte
riolo
gica
l ca
se-f
indi
ng s
ecur
es
optim
um u
se o
f sca
rce
treat
men
t res
ourc
es. T
he n
ext p
riorit
y w
ill b
e to
incl
ude
the
grou
p ha
ving
th
e ne
xt
high
est
prob
abili
tyof
su
ffer
ing
from
tu
berc
ulos
is,
nam
ely
the
sym
ptom
-mot
ivat
ed,
bact
erio
logi
cally
neg
ativ
e pe
rson
s, w
ith p
rogr
essi
ve p
ulm
onar
y pa
thol
ogy
as j
udge
d by
X-r
ay s
hado
ws.
It is
unl
ikel
y th
at t
he m
ajor
ity o
f de
velo
ping
co
untri
es c
an g
o be
yond
thes
e tw
o pr
iorit
ies o
n a
natio
nal s
cale
dur
ing
the
next
two
deca
des,
but t
hen
thes
e pr
iorit
ies w
ill n
ot o
nly
be in
con
sona
nce
with
the
felt-
need
of t
he p
opul
atio
n,
but a
lso
will
, as t
he h
ealth
ser
vice
s im
prov
e, le
ad to
ear
lier d
etec
tion
and
bette
r tre
atm
ent,
and
thus
to an
incr
easin
g fu
sion
of ep
idem
iolo
gica
l and
soci
olog
ical
obj
ectiv
es. B
y st
icki
ng to
th
ese
prio
ritie
s, a
genu
ine
case
of t
uber
culo
sis c
an b
e di
agno
sed
at th
e co
st o
f les
s tha
n fiv
e do
llars
in a
ny d
evel
opin
g co
untry
. Nev
erth
eles
s, th
ere
are
man
y de
velo
ping
cou
ntrie
s tha
t, lo
ng b
efor
e th
ey h
ave
thes
e pr
iorit
ies,
are
empl
oyin
g fu
nds
and
pers
onne
l on
spas
mod
ic
mas
s X-ra
y ef
forts
cov
erin
g an
insig
nific
ant p
art o
f the
pop
ulat
ion.
It is
som
etim
es fo
rgot
ten
that
mas
s che
st ra
diog
raph
y w
as in
trodu
ced
in th
e aff
luen
t cou
ntrie
s at a
tim
e whe
n th
e flo
w
of a
ttend
ers a
t che
st c
linic
s, ho
spita
ls, p
ract
ition
ers,
etc.
, was
ver
y ad
equa
tely
take
n ca
re o
f an
d, to
a la
rge
exte
nt, w
as b
egin
ning
to le
ssen
the
pres
sure
on
thes
e fa
cilit
ies.
It w
as in
tro-
duce
d at
a ti
me
whe
n th
ere
was
a re
lativ
e ab
unda
nce
of c
apac
ity a
nd sp
ecia
lized
man
pow
er
to ta
ke c
are
of th
e ad
ditio
nal c
ases
it d
isco
vere
d. T
o ap
proa
ch th
e pr
oble
m in
the
oppo
site
or
der
in th
e le
ss r
esou
rcef
ul c
ount
ries
is b
oth
bad
econ
omy
and,
in te
rms
of s
ocia
l and
ps
ycho
logi
cal a
ccep
tabi
lity,
inef
ficie
nt.
Wha
t the
n ar
e th
e po
ssib
ilitie
s for
mat
chin
g ra
tiona
l cas
e-fin
ding
with
effe
ctiv
e tre
atm
ent?
Th
e la
st W
HO
Exp
ert
Com
mitt
ee o
n Tu
berc
ulos
is r
ecom
men
ded
that
, as
ther
e w
as n
o ev
iden
ce t
hat
spec
ial
bene
fits
resu
lted
from
hos
pita
lizat
ion,
all
finan
cial
res
ourc
es a
nd
man
pow
er a
vaila
ble
for
tube
rcul
osis
con
trol
in t
he d
evel
opin
g co
untri
es s
houl
d be
co
ncen
trate
d on
org
aniz
ing
effic
ient
am
bula
tory
serv
ices
and
not
on
runn
ing
or c
onst
ruct
ing
new
bed
s. Th
en it
is s
aid,
— a
nd it
is f
or a
ny d
evel
opin
g co
untry
to c
hoos
e be
twee
n a
mod
ern,
sci
entif
ical
ly p
rove
d tre
atm
ent a
ppro
ach
cost
ing
a fe
w d
olla
rs p
er c
ase
treat
ed, o
r tra
ditio
nal p
ract
ice
dem
andi
ng p
rolo
nged
hos
pita
lizat
ion
cost
ing
hund
reds
of
dolla
rs p
er
case
. Th
ough
the
re i
s pr
etty
uni
vers
al a
gree
men
t th
at t
he b
ed o
r th
e di
et o
rth
e in
divi
dual
ized
atte
ntio
n ar
e no
t cr
itica
l fa
ctor
s in
cur
ing
tube
rcul
osis
, th
ere
is s
till
a pr
onou
nced
tend
ency
to d
eman
d in
stitu
tiona
l cap
tivity
bec
ause
of t
he a
llege
d hi
gh d
efau
lter
rate
enc
ount
ered
in th
e am
bula
tory
trea
tmen
t pro
gram
me.
Per
mit
me
to e
mph
asiz
e th
at th
e pa
tient
s ini
tially
trea
ted
in h
ospi
tals
per
se a
re n
o be
tter d
rug
take
rs th
an th
e pat
ient
s ini
tially
tre
ated
in an
effi
cien
tly o
rgan
ized
ambu
lato
ry p
rogr
amm
e. A
s a m
atte
r of f
act,
due t
o th
e lac
k of
int
egra
tion
in m
ost
coun
tries
of
exis
ting
tube
rcul
osis
bed
s in
to t
he a
mbu
lato
ry
com
mun
ity p
rogr
amm
e, th
e in
stitu
tiona
l pat
ient
s tre
ated
for a
wee
k in
a h
ospi
tal u
ltim
atel
y of
ten
fare
wor
se th
an th
e am
bula
tory
pat
ient
s. A
s fo
r the
cho
ice
betw
een
inst
itutio
nal a
nd
ambu
lato
ry tr
eatm
ent,
so fo
r the
cho
ice
betw
een
drug
regi
men
s. Th
e ch
oice
am
ong
the
first
-li
ne d
rugs
rang
es fr
om th
e ch
eape
st c
ombi
natio
n co
stin
g 3
dolla
rs a
nd g
ivin
g 80
to 9
0 pe
r
797980
417Bulletin of the World Health Organization | May 2007, 85 (5)
Special theme – Tuberculosis controlT
HE
TU
BE
RC
UL
OSI
S PR
OG
RA
MM
E I
N T
U D
EV
EL
OPI
NG
CO
UN
TR
IES
mar
ket
of s
uppl
y an
d de
man
d tu
berc
ulos
is do
es n
ot c
arry
suf
ficie
nt s
ocia
l or
eco
nom
ic
pres
tige
valu
e to
attr
act
eith
er t
he q
uant
ity o
r th
e qu
ality
of
doct
ors
any
tradi
tiona
l sp
ecia
lized
tube
rcul
osis
pro
gram
me
wou
ld re
quire
. For
tuna
tely
the
staf
f of a
mul
ti-pu
rpos
e he
alth
cen
tre c
an to
day
be tr
aine
d w
ithin
a fe
w w
eeks
in s
tand
ard
tech
niqu
es o
f dia
gnos
is,
treat
men
t and
imm
uniz
atio
n, b
ut th
is tr
aini
ng is
of n
o av
ail —
yes
, per
haps
even
pot
entia
lly
harm
ful
— i
f th
e te
chni
ques
are
not
em
ploy
ed w
ithin
the
sup
ervi
sory
fra
mew
ork
of a
pr
ogra
mm
e ha
ving
pre
-det
erm
ined
effi
cien
cy
fore
casts
and
bui
lt-in
con
trol
of a
ctua
l ac
hiev
emen
ts.
Ther
efor
e,
such
a
tube
rcul
osis
prog
ram
me,
fir
st
and
fore
mos
t ne
eds
spec
ialis
ts in
epi
dem
iolo
gy, o
pera
tiona
l res
earc
h, p
rogr
amm
ing,
trai
ning
and
eval
uatio
n. It
is
unfo
rtuna
te t
hat
tube
rcul
osis
spec
ialis
ts of
ten
belie
ve t
hat
to c
arry
out
the
se f
unct
ions
ef
fect
ivel
y do
es n
ot e
ntai
l an
y sp
ecia
l kn
owle
dge
beyo
nd t
he c
linic
al ‘
know
-how
’ of
di
agno
sis a
nd tr
eatm
ent.
The
basi
s for
a ra
tiona
l syn
thes
is o
f the
tube
rcul
osis
pro
blem
and
the
avai
labl
e re
sour
ces
in d
evel
opin
g co
untri
es t
oday
has
bee
n su
ccin
ctly
for
mul
ated
by
the
last
WH
O E
xper
t C
omm
ittee
on
Tube
rcul
osis
in fo
ur p
rinci
ples
: a.
Epid
emio
logi
cal c
onsi
dera
tions
requ
ire th
at a
nat
iona
l tub
ercu
losi
s pro
gram
me
mus
t be
on a
cou
ntry
-wid
e an
d pe
rman
ent b
asis
— n
ot sp
orad
ic o
r pat
chy.
b.
Soci
olog
ical
con
side
ratio
ns d
eman
d th
at th
e na
tiona
l tub
ercu
losi
s pro
gram
me
mus
t sat
isfy
the
exist
ing
felt-
need
s bef
ore
it pr
omot
es th
e aw
aren
ess o
f new
one
s. c.
Adm
inis
trativ
e co
nsid
erat
ions
mak
e it
man
dato
ry th
at th
e tu
berc
ulos
is se
rvic
es
be in
tegr
ated
into
the
gene
ral h
ealth
serv
ices
. d.
Econ
omic
con
side
ratio
ns re
quire
that
the
prog
ram
me
be su
ch th
at it
s app
licat
ion
on a
nat
iona
l sca
le is
with
in th
e re
sour
ces a
vaila
ble.
I b
elie
ve th
e fir
st tw
o pr
inci
ples
, nam
ely,
the
epid
emio
logi
cal a
nd s
ocio
logi
cal M
UST
S ar
e lo
gica
l inf
eren
ces f
rom
the
dyna
mic
s of t
uber
culo
sis a
s a c
omm
unic
able
dise
ase
prob
lem
w
ith it
s ubi
quito
us p
rese
nce
in ru
ral a
nd u
rban
are
as, a
s wel
l as a
soc
ial p
robl
em e
xpre
ssin
g its
elf
in t
he m
ajor
ity o
f ac
tive
case
s of
tub
ercu
losi
s be
seec
hing
the
hea
lth s
ervi
ces
for
alle
viat
ion
of th
eir s
uffe
ring.
Th
e la
st p
rinci
ple,
nam
ely,
the
stri
ctly
uns
entim
enta
l adj
ustm
ent o
f th
e pr
ogra
mm
e to
ec
onom
ic re
aliti
es sh
ould
, I b
elie
ve, b
e qui
te o
bvio
us fr
om w
hat I
just
said
abou
t the
fina
ncia
l re
sour
ces.
I ha
ve, s
o fa
r, no
t spe
cific
ally
ref
erre
d to
the
third
prin
cipl
e, n
amel
y, th
at a
dmin
istra
tive
cons
ider
atio
ns m
ake
it m
anda
tory
that
the
tube
rcul
osis
serv
ices
be
inte
grat
ed in
to th
e ge
nera
l he
alth
serv
ices
, and
sinc
e th
is c
once
pt is
fund
amen
tal t
o th
e su
cces
s of t
uber
culo
sis c
ontro
l in
dev
elop
ing
coun
tries
I sh
ould
like
to e
labo
rate
som
ewha
t on
this
.
Than
ks t
o a
sys
tem
atic
rese
arch
pro
gram
me
in a
few
of
the
dev
elop
ing
cou
ntrie
s w
e ha
ve, w
e ha
ve a
s ea
rlier
men
tione
d, t
ools
that
hav
e be
en s
impl
ified
and
sta
ndar
dize
d to
the
poi
nt w
here
mul
ti-pu
rpos
e h
ealth
wor
kers
, af
ter
som
e w
eeks
of
train
ing,
can
di
agno
se a
nd t
reat
inf
ectio
us t
uber
culo
sis
at
the
cos
t of
a f
ew d
olla
rs a
cas
e a
nd
imm
uniz
e th
e su
scep
tible
pop
ulat
ion
at
the
cos
t of
a f
ew c
ents
per
vac
cina
tion.
All
de
velo
ping
cou
ntrie
s a
re,
and
will
inc
reas
ingl
y b
e, e
ngag
ed i
n a
maj
or p
ublic
hea
lth
strug
gle
to p
rovi
de
basic
, co
mpr
ehen
sive
com
mun
ity
heal
th
ser
vice
s in
ur
ban,
an
d
parti
cula
rly i
n ru
ral,
area
s, T
he r
easo
n fo
r th
is i
s no
t on
ly t
he a
cute
sho
rtage
of
heal
th
pers
onne
l a
nd f
unds
, b
ut
also
th
at
rura
l p
eopl
e a
re
incr
easin
gly
res
istin
g t
he
neve
r-ce
asin
g ru
sh o
f s
hort-
lived
spe
cial
cam
paig
ns l
eavi
ng t
hem
with
out
a p
er-
man
ent
poin
t of
ref
eren
ce f
or t
heir
day
-to-d
ay h
ealth
pro
blem
s. A
ll, c
omm
unic
able
81
H. M
AH
LE
R
dise
ase
cam
paig
ns h
ave
over
whe
lmin
gly
dem
onst
rate
d th
at o
nly
thro
ugh
falli
ng b
ack
on
stron
g ba
sic h
ealth
ser
vice
s in
dev
elop
ing
coun
tries
is it
pos
sible
to a
chie
ve a
n ef
fect
ive
cons
olid
atio
n of
thes
e ca
mpa
igns
. The
inte
grat
ed tu
berc
ulos
is p
rogr
amm
e, th
ough
slo
w in
its
upt
ake,
will
gro
w o
rgan
ical
ly to
geth
er w
ith th
e he
alth
ser
vice
s, ea
ch s
treng
then
ing
the
othe
r by
addi
ng to
the
conf
iden
ce th
ey in
spire
in th
e pu
blic
. In
the
few
cou
ntrie
s tha
t hav
e st
arte
d to
put
inte
grat
ion
serio
usly
into
pra
ctic
e th
e re
war
d ha
s fa
r su
rpas
sed
expe
ctat
ions
. With
in o
ne to
two
year
s fro
m th
e be
ginn
ing
of in
tegr
ated
op
erat
ions
it w
as p
ossib
le to
ene
rgiz
e th
e ge
nera
l hea
lth se
rvic
es to
such
an
exte
nt th
at m
ore
than
hal
f of t
he to
tal l
oad
of in
fect
ious
tube
rcul
osis
was
bei
ng sy
stem
atic
ally
disc
over
ed; t
hat
treat
men
t effi
cien
cy w
as ra
ised
from
an
appa
lling
80
per c
ent d
rug
defa
ult t
o m
ore
than
60
per c
ent c
ompl
etin
g on
e fu
ll ye
ar o
f tre
atm
ent;
and
vacc
inat
ion
cove
rage
incr
ease
d fro
m 2
5 pe
r cen
t to
mor
e th
an 7
0 pe
r cen
t of a
ll el
igib
les.
Let
me
emph
asiz
eon
ce m
ore:
int
egra
tion
is no
t sy
nony
mou
s w
ith a
lai
ssez
-faire
ap
proa
ch. O
n th
e co
ntra
ry,i
t req
uire
s max
imum
invo
lvem
ent o
f all
spec
ializ
ed p
erso
nnel
as
pro
gram
mer
s, or
gani
zers
, tut
ors,
and
asse
ssor
s, bu
t not
as a
loof
per
fect
ioni
sts.
I sh
ould
lik
e to
end
my
com
men
ts by
em
phas
izin
g fo
ur c
ondi
tions
for
im
plem
entin
g ef
fect
ive
natio
nal t
uber
culo
sis p
rogr
amm
es in
dev
elop
ing
coun
tries
toda
y.
Firs
tly,
the
prog
ram
me
mus
t be
pla
nned
and
the
pla
n m
ust
refle
ct t
he o
ptim
al
com
prom
ise
betw
een
wha
t is
tech
nica
lly d
esira
ble
for
the
few
and
wha
t is
oper
atio
nally
fe
asib
le fo
r the
man
y. T
o ac
hiev
e thi
s, in
divi
dual
expe
rienc
e, in
tuiti
on an
d gu
essw
ork
mus
t be
repl
aced
with
a s
yste
mat
ic a
naly
sis o
f th
e ex
istin
g ep
idem
iolo
gica
l an
d so
cio-
econ
omic
sit
uatio
n su
pple
men
ted
whe
neve
r ne
cess
ary
with
ca
refu
lly
cond
ucte
d op
erat
iona
l in
vest
igat
ions
. Se
cond
ly, t
rain
ing
and
re-tr
aini
ng o
f all
spec
ializ
ed a
nd m
ulti-
purp
ose
heal
th p
erso
nnel
is
asi
ne q
ua n
on f
or t
he e
ffici
ency
of
the
prog
ram
me.
Thi
s tra
inin
g m
ust
parti
cula
rly b
e or
ient
ated
tow
ards
the
orga
niza
tiona
l and
adm
inis
trativ
e asp
ects
as n
o am
ount
of t
echn
ical
so
phis
ticat
ion
can
com
pens
ate
for o
pera
tiona
l def
icie
ncie
s. Th
irdly
, ev
alua
tion
mus
t be
bui
lt-in
at
all
leve
ls to
ser
ve a
s th
e co
nsci
ence
of
the
prog
ram
me.
Thi
s eva
luat
ion
mus
t ver
ify th
at th
e te
chni
cal a
nd o
pera
tiona
l com
mitm
ents
of
the
plan
act
ually
are
met
and
that
the
qual
ity a
nd q
uant
ity o
f the
out
-put
of e
ach
wor
ker i
s sa
tisfa
ctor
y. T
he p
rere
quis
ite f
or s
uch
a m
eani
ngfu
l ev
alua
tion
is s
trict
uni
form
ity o
f te
chni
ques
and
reco
rds c
ombi
ned
with
an
unbi
ased
ana
lysi
s. Fo
urth
ly, n
o am
ount
of l
ip-s
ervi
ce to
pla
nnin
g, tr
aini
ng a
nd e
valu
atio
n w
ill b
ring
out t
he
bene
fit o
f dru
gs a
nd v
acci
ne to
the
rece
ivin
g en
d w
ithou
t a u
nify
ing
cent
ral d
irect
ion
with
ad
equa
te p
ower
s to
enfo
rce
and,
whe
n ne
cess
ary,
mod
ify th
e na
tiona
l pro
gram
me.
82
8182