Attention to gender issues in tuberculosis control.

Although a seventy per cent excess of male over female TB cases are reported globally each year, the reasons for this difference are unclear. Generally, women in poor countries confront more barriers than men in accessing health care services. Yet, research is lacking to explain the impact of gender inequalities in access to care on reported sex ratios for TB. A review of the limited available literature and field visits to TB programmes offered insights and suggested a framework to study gender differentials in TB. This paper considers the role of gender at various steps in effective TB care. A research strategy to study and account for gender differences in TB control is proposed.

Private health care.

During the last decade there has been considerable international mobilisation around shrinking the role of States in health care. The World Bank reports that, in many low and middle-income countries, private sources of finance comprise the largest share of total national health expenditures. Private sector health care is ubiquitous, reaches throughout the population, preferred by the people and is significant from both economic as well as health perspective. Resources are limited, governments are weak, and a new approach is needed. This paper provides a broad overview and raises key issues with regard to private health care. The focus is on provision of health care by private medical providers. On the background of the world's common health problems and interventions available to tackle them, the place of private health care in the overall context is first discussed. The concept of privatisation within the various forms of health care systems is then explained. The paper then describes the genesis and key elements of rapidly enhancing role of the private sector in health care and points to the paucity of literature from low and middle-income countries. Common concerns about private health care are outlined. Two illustrative examples--tuberculosis, the top infectious killer among the poor and coronary heart disease, the top non-infectious killer among the rich--are presented to understand the current and possible role of private sector in provision of health care. Highlighting the need to distinguish between health care as a public good or a market commodity, the paper leaves it to the reader to draw conclusions.

Clinical and electrophysiological evaluation of nerve function impairment following cessation of multidrug therapy in leprosy.

Seventeen multibacillary (MB) and 15 paucibacillary (PB) cases of leprosy who had had regular and adequate multidrug therapy (MDT) were examined clinically and electrophysiologically at periodic intervals for 1 year following cessation of MDT. All the major nerves were assessed for nerve function impairment (NFI). Overall, two MB (13.3%) and three PB (20%) cases showed signs of deterioration clinically and/or electrophysiologically. The nerve conduction (NC) follow-up studies revealed no significant improvement in the sensory conduction in both the MB and PB groups of nerves, whilst motor conduction showed a significant improvement at the first 6-monthly follow-up among the MB group of nerves. At the study onset, sensory impairment (MB = 62%, PB = 25%) predominated over motor in terms of both severity and frequency. The lower extremity was more frequently and severely affected than the upper in both groups of patients. As an individual test, NC measurement proved to be more sensitive in detecting NFI, but the combination of physical palpatation for nerve thickening and graded nylon test (GNT) was closely comparable to measurement of nerve conduction.

Higher incidence of viable Mycobacterium leprae within the nerve as compared to skin among multibacillary leprosy patients released from multidrug therapy.

As identified by a significant growth in the footpads of immunosuppressed mice, the incidence of viable bacteria in a group of 26 multibacillary (BL-LL) patients released from multidrug (MDT) treatment was found to be two times more in the nerves (46%) as compared to skin (23%). Evidently there was a positive correlation between the overall bacterial load and the incidence of viable organisms. Bacterial growth was also observed in two out of five cases where neither the skin nor the nerve homogenate had shown any presence of acid-fast bacilli. Histopathology of biopsies, skin as well as nerve, including those having viable bacteria did not show any features of active disease.

Primary resistance to single and multiple drugs in leprosy--a mouse footpad study.

Skin biopsy homogenates obtained from three cases of lepromatous leprosy with no prior history of antileprosy treatment were tested in the mouse footpad for the sensitivity of Mycobacterium leprae to multiple drugs. One of the inocula was sensitive to all the three drugs tested using the highest concentration each of DDS 0.01 g%, RFP 0.03 g% and CLF 0.01 g%. The 2nd inocula showed growth in the presence of 0.01 g% DDS only. While the 3rd inocula (Pt. KU) tested resistant to all the three drugs in the first, i.e. man to mouse, as well as in the second passage, i.e. mouse to mouse.

Immunohistological localization of mycobacterial antigens within the peripheral nerves of treated leprosy patients and their significance to nerve damage in leprosy.

The presence and distribution of Mycobacterium leprae-specific and cross-reacting antigens within the peripheral nerves of multidrug-treated patients with leprosy was investigated to gain a better understanding of the mechanism of nerve damage and the effect of multidrug therapy (MDT) on it. There was no specific qualitative difference in the type of antigens in the leprosy spectrum. However, our results indicate that there may be differential handling of antigens by the macrophages as compared to Schwann cells. This could play a key role in the pathogenesis of the disease. Multidrug treatment is effective in arresting the progression of the disease process as well as in reducing the viable bacterial load, both in borderline lepromatous and lepromatous (MB) and borderline tuberculoid and tuberculoid (PB) cases. However, the presence of M. leprae antigens in all the multidrug-treated MB nerve lesions and 87% of PB nerve lesions suggest that the antigens persist for a prolonged period. Hence, the risk of immunological reaction and antigen-associated silent nerve damage may continue even after majority of M. leprae were killed. The findings give further support to the view that most of the nerve damage is due to bacterial antigens.

Private doctors and tuberculosis control in India.

Over three quarters of the 8 million registered doctors in India are engaged in private medical practice. In urban and rural areas alike people prefer private doctors to public health services for their health care needs. A majority of patients and those with suspected tuberculosis also report first to private doctors. Nevertheless private doctors seem to be alienated from national efforts towards control of tuberculosis, there being no well-defined role for them in the National Tuberculosis Programme. This study of private doctors practising in the low income areas of a metropolis of India reports on the knowledge of private doctors about diagnosis and treatment of tuberculosis and their awareness and perceptions about the public health services available for tuberculosis control. The study reveals gaps and weaknesses in the private doctors' reported practice of managing lung tuberculosis, the most important and persistent problem of public health concern in India. The need for organized efforts towards involving private doctors in disease control programmes wherein their curative functions could contribute significantly is stressed.

Persistence of Mycobacterium leprae in the peripheral nerve as compared to the skin of multidrug-treated leprosy patients.

Skin and nerve biopsies obtained from 18 multibacillary (MB) and 16 paucibacillary (PB) cases of leprosy who had been fully treated by the WHO regimen were assessed for bacterial load using different staining techniques. In addition skin and nerve homogenates of 10 MB cases were tested for 'persistor' Mycobacterium leprae using immunosuppressed mice. While significant amounts of integral bacilli and BCG cross-reactive antigen of M. leprae were detected both in skin and nerve tissues of all the MB cases (100%), 56% of skin and 62% of nerve biopsies of PB cases also showed the presence of BCG cross-reactive antigen. Detection of 'persistor' M. leprae in 2/10 skin biopsies (20%) and 3/10 nerve biopsies (30%) of MB cases was thought to be unexpectedly high after 2 years of MDT.

Treatment of tuberculosis by private general practitioners in India.

Early detection and optimal treatment constitute the most important measures in the control of tuberculosis. This study of prescriptions for tuberculosis recommended by 102 private doctors, practising in the slums of Bombay, shows a lack of awareness among doctors who treat tuberculosis patients in their own clinics about the standard drug regimens for treatment of tuberculosis recommended by national and international agencies. While there are a few standard, efficient, recommended regimens, 100 private doctors prescribed 80 different regimens, most of which were both inappropriate and expensive. The study highlights the need for effective communication between those implementing national tuberculosis programmes and the practising private doctors, continuing education of these doctors for updating their knowledge and their active participation in at least those national disease programme for which their curative functions could contribute significantly to control of a disease.

The private GP and leprosy: a study.

In urban and rural areas alike, people in India tend to prefer private medical care to the existing government health services. Nevertheless, the large private health care sector has hitherto been virtually alienated from activities of public health importance including priority disease control programmes. This study of 106 private general practitioners (GPs), practising in low socioeconomic areas of Bombay, shows a gross lack of knowledge and awareness among private doctors about leprosy and also about the National Leprosy Control Programme. The possible reasons are discussed. Effective involvement of GPs in the National Leprosy Control Programme should facilitate both integration and better implementation of leprosy control activities. The study also highlights some areas for future interventions at both primary and secondary health care levels and the need for a strategy, based on larger studies, to train and make private doctors participate in controlling diseases of major public health concern like leprosy.

Private doctors and public health: The case of leprosy in Bombay, India.

People in India tend to prefer private medical care to the existing government health services. Nevertheless, the large private health care sector has hitherto been virtually alienated from activities of public health importance including priority disease control programmes. This study of 106private general practitioners (GPs), practising in the slums of Bombay, shows a gross lack of knowledge and awareness about leprosy and also about the National Leprosy Control Programme. Active involvementof GPs in the National Programme should facilitate both the integration and better implementation of leprosy control activities. The study also highlights some areas for intervention at both the primary and secondary health care levels and the need for a strategy to train and make private doctors help control diseases which are of major public health concern.

Sympmed I: computer program for primary health care.

Sympmed I is an experimental computer program that identifies and offers treatment to outpatients whose symptoms can be effectively and safely treated. To verify the safety of using such a package an evaluation of Sympmed I was carried out. The patients' symptoms were entered into the computer by a junior doctor and then by a non-medical person, an engineer. The prescriptions offered by the program were compared with those given by a general practitioner after examining the patient. It was found that 390 of 500 (78%) patients in the first group and 276 of 400 (69%) patients in the second group were offered prescriptions comparable to the ones given by the general practitioner, and the rest were advised to see a doctor. In no case was a patient offered treatment when he or she needed to see a doctor. The results of the evaluation confirm that most problems seen by first level medical personnel in developing countries are simple, repetitive, and treatable at home or by a paramedical worker with a few safe, essential drugs, thus avoiding unnecessary visits to a doctor.

Clinical and histopathological observations on pure neuritic leprosy.

Pure neuritic leprosy is a well accepted clinical entity. In the absence of skin lesions there is a greater possibility of missing the diagnosis of leprosy due particularly to a wide variety of pure neural manifestations that may mimic other peripheral neuropathies. Histopathological studies of pure neuritic leprosy have received less attention for ethical reasons and limitations of surgery. Classification of pure neuritic leprosy poses problems since the histological spectrum (e.g. Ridley-Jopling scale) is based chiefly on the skin picture. Review of the past literature shows conflicting reports about comparability of the skin and nerve pictures. This paper presents clinical and histopathological observations on twelve patients of pure neuritic leprosy, the interesting observations being that all the patients showed lepromin positivity and a narrower histological spectrum, ranging from TT to BB only.

Dapsone dependent nodular panniculitis.

A patient recorded to be suffering from tuberculoid leprosy since 1973 and on regular Dapsone monotherapy for about nine years developed asymmetrical, erythematous, subcutaneous, nodular swellings restricted chiefly to the extensor aspects of lower limbs two months after discontinuation of Dapsone therapy. During the course of Dapsone treatment, the patient had developed similar swellings twice previously each time when he stopped the drug for about a month. The swellings disappeared on commencement of Dapsone Treatment. This has been reconfirmed under our supervision. The biopsy of one of the lesions revealed panniculitis with vasculitis. The original diagnosis of leprosy was probably invalid.