Tuberculosis Control and Directly Observed Therapy from the Public Health/Human Rights Perspective
The 1980s and 1990s have seen a resurgence of interest in tuberculosis. Increasing cases world-wide led to the World Health Organization (WHO) declaring a global emergency in April 1993.1,2 Despite the availability of tools for controlling TB, programmes have been unable to sustain high cure rates.3 As a consequence of this, and the increasing problems of drug resistance, the international community, through the WHO, has developed and launched the directly observed therapy short course (DOTS) strategy.4,5 This strategy is described as: government commitment to a national TB programme; case detection through ‘passive’ case finding (sputum smear microscopy for pulmonary tuberculosis suspects presenting at a health facility); short course chemotherapy for all smear-positive pulmonary TB cases [under direct observation for, at least, the initial phase of treatment [DOT]; regular, uninterrupted supply of all essential TB drugs; and a monitoring system for programme supervision and evaluation.4-6
The DOTS strategy has achieved excellent results in New York, other parts of the US,7-10 and in China.11 However, from other parts of the world voices have been raised asking if DOTS is the most effective way to control tuberculosis,12,13 if DOTS can and should be perceived as a panacea,14 and if the DOTS strategy is ethical.15,16
The control of infectious diseases like tuberculosis lies within the broad framework of public health. A currently accepted definition of public health is ‘providing the conditions in which people can be healthy.’17 Although public health contains within it many perspectives and disciplines, it is the biomedical perspective, the realm of medicine based on knowledge and practice from the natural sciences, which currently dominates thinking and approaches to health care and control of disease. Increasingly, it is being appreciated that biomedicine can benefit from working with other disciplines and perspectives. This interdisciplinarity encourages change and flexibility in approaches to health care and disease control.