Although Robert Koch discovered the tubercle bacillus in 1882 and linked it with the diagnosis of pulmonary tuberculosis, we are still far away from controlling the disease. In India it remains a major health and community problem. It has been estimated that out of some eight million cases in the world more than one third are in India. This probably does not take into account extra pulmonary tuberculosis. If it did, the number would be higher. Although progress has been made in diagnosis, in India it is mostly on histological basis. First line anti TB drugs are freely available and are cheap. Inspite of this we are not able to significantly reduce the number of T.B. patients.
Isolating the Tubercle bacillus and growing it in culture is a slow and arduous process. Antibody tests are non specific and often erratic. The recently introduced PCR test has a high accuracy rate but is expensive and not possible to practice on community basis. Happily there is research going on and the bacteriophage and immuno fluorescence test should be available soon. But we look forward to some test that we can use at district level.
With the wide usage of anti tubercle drugs the problem of drug resistance (DR) and multiple drug resistance (MDR) has emerged. The use of drugs in the hands of all and sundry has resulted in the misuse and abuse of drugs. Although the WHO has recommended a standard protocol, some practitioners do not adhere to it. Patients have a tendency to stop treatment when major symptoms disappear. This has resulted in drug resistance and multiple drug resistance, which is today a major problem. Second line anti TB drugs are not so effective and are costly. We need to do more research in finding better drugs, that are reasonably priced. Extra pulmonary tuberculosis is not universal, and therefore reliable data is not available. Probably being non communicable, it has not caught the eye of world bodies. Tuberculosis is common in HIV positive patients. Treatment and progress will only be possible if both are treated simultaneously.
In the ultimate analysis tuberculosis is also a social problem. The Government will need to spend more on health care, improve housing and nutrition of children.
We also need a preventive vaccine. BCG is a live attenuated bovine vaccine which is useful only for preventing meningitis in children. As a general prophylactic it leaves much to be desired.
Dr. Kapoor has quite rightly chosen tuberculosis as a core subject of the 50th anniversary issue of the Bombay Hospital Journal. Not only does it accept tuberculosis as a major health problem, but it documents several areas of the body, where the disease was unknown. It also highlights the difficulties of diagnosis and treatment. The readers will no doubt gain from this extraordinary collection of case material.
Dr. BK Goyal
Chairman, Advisory Board