Why has the incidence of tuberculosis in India remained around 170 per 100,000 people for the last 20 years despite DOTS, the directly observed treatment strategy, being in place?
Answer: DOTS is a passive system that kicks in only after a person takes the initiative and gets tested for the disease. Despite the high prevalence and mortality rate, researchers are yet to figure out a system that works proactively, identifying all people with active TB and treating them. The compulsion to identify and treat people with active pulmonary TB as early as possible arises from the fact these patients stop infecting others only at the end of two months of treatment. The reason for the overall failure to identify an efficient and effective system for tracking down people with tuberculosis boils down to a grievous lack of public health research originating from India. India has the greatest total disease burden in the world, and is plagued by both communicable and non-communicable diseases. Yet the total number of research reports and journal papers on public health is small. This, despite the fact that public health research plays a pivotal role in understanding disease distribution in the population and reducing the burden through effective intervention strategies.
A paper recently published online in The Lancet (“Research to achieve health care for all in India,” by Lalit Dandona et al.) reported that though the proportion of health papers published from India increased from 0.4 per cent of the global total in 1988 to 1.8 per cent in 2008, the papers on public health constituted a measly 5 per cent of the total health research papers published. While there has rightly been increasing representation of diabetes and cardiovascular disease in recent times, many of the leading causes of the disease burden such as lower respiratory infections and mental illness continue to be under-represented. The skew in the focus of health research reflects funding priorities. For instance, HIV/AIDS is better covered than chronic diseases and injuries that have much greater weightage in India's disease burden. Of what use are public health programmes and policies if the evaluation research to understand their effectiveness and deficiencies is weak? It is time these shortcomings were addressed by the national health policy, which promises to strengthen public health research. Increasing funding for evaluation research in addition to research on high burden diseases and the health system must be taken up as a life-saving priority. Now is the time for the government to put its money and political will where its mouth is.
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