Defeat TB now and forever [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • JANUARY 1982 DEFEAT TB NOW AND FOREVER Cover: German physician Robert Koch first identified the bacillus that causes tuberculosis in March 1882. il , Design by Peter I2'i Davies. 1,,,_ IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Vied ma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Persian. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WH 0, Av. Appia, 1211 Geneva 27, Switzerland. Contents Defeat TB — Now and Forever by Halfdan Mahler 3 Robert Koch by Paul Steinbruck 4 Tuberculosis in profile 8 Worldwide control — is it possible? by Jerzy Leowski and Antonio Pio . . . 11 Training course in Japan by Jose C. Abcede 16 Success among the Eskimos by Stefan Grzybowski 18 Controlling TB in Africa by S.J. Nkinda 22 How treatment has evolved by H. Stott 24 The Captain of all these Men of Death 29 News Page 30 The tell-tale shadow on a tuberculous lung is reveal- ed by X-ray. Inset: the bacilli of tuberculosis as Koch saw them under the microscope. ( Photos WHO) Defeat TB now and forever by Dr Halfdan Mahler Director-General of the World Health Organization Robert Koch's brilliant discovery of the bacillus of tuberculosis, in 1882, was the first step up the long road towards the elimination of this ancient scourge as a major public health hazard. Yet why is it today, on the Centenary of his discovery, that the number of tuberculosis cases in the world is actually increasing? For more than 30 years, highly effective drugs and vaccine have been available, making TB a preventable and curable disease. Technologically sound strategies to prevent, detect and cure TB were gradually perfected. But progress has been agonizingly slow. In the majority of developing countries, there has been little or no improvement in the epidemiological situation. Between four and five mil- lion highly infectious cases emerge each year, and TB brings death to at least three million persons annually. Even in countries with highly developed health care, it remains a serious risk for disadvantaged groups. The Centenary of Koch's discovery should be dedicated to appraising our TB control strategies: we should coura- geously admit the many mistakes of the past and make a new commitment to eliminate TB as a major health problem, at the latest by the year 2000. This goal is fully attainable, but to attain it requires a better understanding of the true causes of the genesis and spread of the disease. We now know that a combination of socio-economic as well as biological factors give rise to TB—undernutrition, inadequate housing, poor hygiene, lack of water, the debilitating effects of acute infections and diarrhoea, and lack of awareness of the real causes of ill health. Concomitant measures are therefore required in all these areas so that the human body can make the most of its own defence mechanisms. It is in this context that specific preventive and therapeutic measures can be effective. Does this diminish in any way the glory of Koch? Not at all. The fruits of health research, like all other research, are rarely the work of one person alone. Each relies on the work of predecessors and contributes to the work of suc- cessors. Koch made an outstanding contribution to the understanding of the specific relationship between a microbiological entity and a disease entity; this had repercussions far be- yond the field of tuberculosis. Succeed- ing generations revealed in turn the broader medical and socio-economic epidemiology of the disease. The chal- lenge for the control of tuberculosis today lies in the proper understanding and application of this combined knowledge. Here is one more illustration that health can only be attained through a combination of diverse measures in the health and other related sectors. These measures have to be applied within communities to deal with the full range of problems whose combined effects ravage the health of people. With the possible exception of smallpox eradica- tion (which had unique features—the exception that proved the rule), at- tempts to deal with single communi- cable diseases in ways that were at best parallel and at worst divergent have proved to be ineffective. There is no escape from the need to deal in a concerted manner with those factors that in the final analysis are common to most of these diseases. This is the rationale for primary health care ac- cessible to all in a spirit of social equity, and for health systems based on primary health care. Such health sys- tems are the cornerstone of the Strategy for attaining health for all by the year 2000 that was adopted by wHo's 156 Member States in the World Health Assembly in May 1981. In adopting this Strategy, the Health Assembly called it a partnership be- tween governments, WHO and people in all walks of life, and referred to non- governmental organizations as part of the people. The role of voluntary organizations continues to be extreme- ly important in the prevention and control of tuberculosis. The Interna- tional Union Against Tuberculosis and its national affiliates have been in the front lines of this fight and will play a vital role in the years to come. As we commemorate the anniversary of Koch's discovery—a milestone along the long road still lying ahead—wHo is proud to join with IUAT in declaring: "Defeat TB—now and forever." ■ 3 Robert Koch, 1843-1910. Facing page: The first big breakthrough in mankind's struggle to control tuberculosis was reported in this Berlin weekly journal on 10 April 1882. Inset: Koch (nearest camera) dissecting a tuberculous cow at Kimberley, South Africa, in 1896. ( Photos WHO) Robert Koch The German doctor and microbiologist, whose discovery 100 years ago we now celebrate, lived from 1843 to 1910. His recognition of the tubercle bacillus as the cause of tuberculosis won him the Nobel Prize for Medicine in 1905 by Paul Steinbruck n 24 March 1982, we celebrate the centenary of the discovery of the tubercle bacillus by Robert Koch. In a lecture entitled "The aetiology of tuberculosis", he announced his discov- ery before a small circle of scientists in the Institute of Hygiene at Berlin University. But his paper did not confine itself to the fact that a hitherto unknown bacterium had been found. Even that fact would have been enough to make Koch's name imme- morial. The precision and completeness of the investigation, its comprehensive aim, the convincing nature of the experiments and of the conclusions drawn from them—all of these were unique and un- precedented. Robert Koch had completed this study in not longer than six to eight months. Paul Ehrlich, then still a young medical assistant, has described how the lecture seemed to him. He wrote: "At this memorable session, Koch appeared before the public with an announcement which marked a turning-point in the story of a most virulent human infectious disease, and which paved the way towards a new era of research and disease control. In clear, simple words Koch explained the aetiology of tuberculosis with convincing force, presenting many of his microscope slides and other pieces of evidence. Everyone who was present at this lecture was deeply affected, and I must say that this evening has remained in my own memory as my greatest scientific experience." At that date, Koch was already well- known in the scientific community. In addition to his tasks as a general prac- titioner and county health officer in Wollstein (now Wolsztyn, Poland), he had described the aetiology and pathogenesis of anthrax (in 1876), cultured its germs and determined the conditions under which its spores develop and spread. He had put forward effective proposals for preventing the transmission of this disease. He had carried out basic studies into diseases resulting from wounds. And through systematic research into the methodology of culturing and identifying micro- organisms and their properties, he had created the methods and tools which subsequently led him to his great discoveries. The pure cultivation of germs so that they could be isolated and identified under the microscope will remain one of his special achievements. This fulfilled the three most important conditions for fully isolating the germ of an infectious disease that his teacher Jakob Henle had pos- tulated back in 1840, at Gottingen. Henle had said that the germ must be identified in the affected organism; that the germ must be isolated from the affected organism and grown in pure cultivations so that its morphological and functional properties could be studied; and that from the pure culture the disease must be reproduced in experimental animals, out of which the germ must then be recovered. For more than 16 years, Koch had worked as a general practitioner and had seen such acute infectious diseases as cholera and anthrax recurring in epidemics and killing many people and animals. Tuberculosis was a widespread disease in all countries of Europe at that time, claiming thousands upon thousands of victims among children and adults alike. In Prussia, tuberculosis mortality amounted to more than 300 cases per 100,000 inhab- itants in 1882, and Prussia did not differ much from other European countries. Between one-third and a half of deaths in productive middle-age groups could be attributed to this disease. At the end of his memorable lecture, Koch declared: "I have carried out my investigations in the interests of public health care and because I hope they will bring about the greatest benefits for public health." In those days there were contradictory theories about the nature of tuberculosis or, as it was then called, phthisis or consumption. Rene Laennec and later on Joseph Grancher had considered it to be a 4 tie Berliner Elinische Wochenschrift erscheint jeden gontag in der Starke eon wenigstens 14 Bogen gr. 4. Preis •ierteljahrlich 6 Mark. Bestellungon LIM:1MM alle BochhAndlungen nod Post-Anstalten an. Einsendangen wolle man portofrei an die RedactioD (W. Koniggrktserstraese 125.) odor an die Verlaga- 6achhandlnngg •on August Hirechwald in Berlin (N.W. Unter den Linden 68.) adressiren. BERLINER KLINISCITE WOCHENSCHRIFT. Organ fur practische Aerzte. Mit Berucksichtigung der preussischen Medicinalverwaltung und Medicinalgesetzgebung Redacteur: Professor Dr. C. A. Ewald. mach amtlichen Mittheilungen. Verlag von August Ilirschwald in Berk Montag, den 10. April 1882. 15. Neunzehnter Jahrgang. Inhalt: I. Koch: Die Aetiologie der Tuberculose. — II. Muller: Ueber einen Fall von Wanderleber. — III. K fis ter : Veber antiseptische Pulververbande (Schluss). — IV. Verhandlungen arztlicher Gesellschaften (Berliner medicinische Gesellschaft). — V. Feuilleton (Maximaldosentabelle der Pharmacopoea Germanica, ed. II — Tagesgeschichtliche Notizen). — VI. Amtliche Mittheilungen. — Inserate. I. Die Aetiologie der Tuberculose. (Hach einem in der physiologischen Gesellschaft zu Berlin am 24. Marz cr. gehaltenen Vortrage.) Von Dr. Robert Koch, Regierungsrath im Kaiserl. Gesundheitsamt. Die von Villemin gemachte Entdeckung, dass die Tuber- culis-^ Thiere iibertragbar ist, hat bekanntlich vielfache Be- ber anch anscheinend wohlbegrundeten Widerspruch so dass es bis vor wenigen Jahren unentschieden sste, ob die Tuberculose eine Infectionskrankheit sei t. Seitdem haben aber die zuerst von Co hnheim o mon sen, seater von Baumgarten ausgeffihrten in die vord'ere Augenkammer, ferner die Inhalations- ' Tappeiner and Anderen die Uebertragbarkeit -cegen jeden Zweifel sicher gestelit und e. s 'n Platz unter den Iofectionskrank' al der Opfer, welche eine Kra t 'ire Bedeutuog zu gelten hat, amentlich aber die gefurchtetste. Cholera u. s. w. weit hinter der Tuber Statistik lehrt, dass '/, slier Menschen nd dass, wenn our die mittleren productiv. tracht kommen, die ehr dahinrafft. Di rund genug, ihr kbeit zu widm ep Verhaltnisse, von zur Perlsucht en heitspflege it u den A' nkhei• nod die zum Zwecke der Isolirung und Zucbtung des Tuberkel- Virus angesteliten Versuche konnten bis jetzt nicht als geiungen angesehen werden, so dass Cohn heim in der soeben erschieneneu neuesten Auflage seiner Vorlesungen Ober allgemeine Patholog;e „den directen Nachweis des tuberculosen Virus als ein bis heute noch ungelostes Problem" bezeichnen musste. Bei meinen Uutersuchungen Ober die Tnberculose habe ich mich anfangs auch der bekannten Methoden bedient, ohne dr mit eine AufklArung Ober das Wesen der Krankheit zu erlav- v. Aber durch einige gelegentliche Beobachtnngen wurde ich veranlasst, diese Methoden zu verlassen und andere Wege ei zuscblagen, die schliesslich anch zu positiven Resultaten ft-dater). Das Ziel der Untersuchung musste zunachst ad den Nat.' weis von irgend welchen, dem KOrper fremdartigen, parasitic Gebilden gerichtet sein, die moglicherweise als Krank ursache gedeutet werden konnten. Dieser Nachweis { ch io der That durch ein bestimmtes Farbnngsverfahrei in alien tuberculOs veranderten Orgen the in nicht bekannte Bacterien zuTflnden 4'''ihren, den Weg, auf welcher' h te, zu schildern land is esselben Obergehen. cte werden in der bekanntei ne Bacterien iiblichen Weise Deckglas ausgebreitet, getr g in Alkohol in Schnitte tte gelangen in eine Far ung. 200 Ccm. destillirten conce ❑ trirten alcoholischen D umgeschtittelt und erhalten di -11 einen Zusatz von 0,2 C lag darf selbst nub, n. Die zu fArben nden. Dnrch Er bade kann di ie Deckglas n LOsung Tuberculose ein Drit, - che Gesundheit: eit einer ellen day 's I a rife ge a Ge ten to gehort, dheits- iologie, so er- e Tuber- bleibee Farbl eq Above: Koch 's microscope. His study of the bacillus 111 took him less than eight months. Left: A grizzled mullah in Afghanistan, suffering from a cough and fever, patiently lines up for diagnosis and treatment. Right: Scene at a health centre in India. Tuber- culosis attacks both young and old. Photos WHO, WHOM. Riboud, and WHO P. Almasy ) single-cause, non-infectious disease but with many different manifestations. Rudolf Virchow took an opposite view with his theory of two causes, but he also advocated its neoplastic origin—that is, as a new and abnormal growth within the body. Though the infectious nature of tuberculosis had been proved by several investigators, these observations had made no headway amid the rivalry between the hereditary and the neoplastic theories. This situation changed almost immediately after Koch's discovery. The disease could now be recognised under the microscope by determining the tubercle bacillus in the patient's excretions, and it could be confir- med by culture and animal experiment. Many diseases that had not until then been related to tuberculosis could be identified as specific tuberculous pulmonary or extrapulmonary lesions. Koch published his findings in a mono- graph in 1884: "On the aetiology of tuberculosis." Its conclusions still corres- pond in most points to the knowledge existing 100 years later. When Koch announced to the Tenth International Medical Congress in Berlin, in 1890, that he had found a remedy by which "the process of disease can be completely stopped without harming the organs in any other way", he raised a storm of enthusiasm and expectation. But he was mistaken in regarding tuberculin—a sterile liquid containing substances extracted from the tubercle bacillus—as a remedy for tuberculosis. The disease cannot be cured by it. A corresponding feeling of disillusion followed the hopes that had been raised so high. Nevertheless, tuberculin has become an indispensable diagnostic substance for recognising tuberculous infection in hu- mans and animals. And his research work became the basis on which Calmette and Guerin built up their anti-tuberculosis vaccine, BCG. Koch gave his opinion several times on the problem of combating the disease, one occasion being his Nobel Prize lecture in 1905. He recommended "prevention of infection by isolation of the patient in hospitals or behind screens at home; disinfection of the patient's excretions; nursing in organized dispensaries; in- formation and health education of the population and particularly of the patients and their families; and obligatory registra- tion of all cases as a basis for collecting statistical data". He regarded the dispen- saries "as one of the most important, if not the most important, tool in the fight against tuberculosis". Discovery of the tubercle bacillus coin- cided with efforts of the working class to improve their socio-economic conditions and with the initial steps towards social medicine in the closing decades of the nineteenth century. Hesitant attempts to cure tuberculosis were already starting, but were often based on rather mystic ideas; now the setting up of special sanatoria received generous assistance from benefac- tors, associations within the community, social insurance (which was just coming into being), and even governments— although Koch had estimated that their future contribution to the control of tuberculosis would be very low. In 1887, Sir Robert Phillip, stimulated by Koch's proposals and objectives, establish- ed the first anti-tuberculosis dispensary in Edinburgh. In Belgium, France and Ger- many, dispensaries and tuberculosis care services developed, and spread rapidly to other countries. National and international tuberculosis associations sprang up, and made it their task to exchange views on the problems of the disease and its control. In 1898 and 1899, congresses attended by specialists from many countries took place in Paris and Berlin. Many other international conferences followed the founding of the International Union Against Tuberculosis in 1901. Koch's work was not only confined to tuberculosis. He became an excellent hy- gienist, an organizer and teacher of health officers in the German public health services. He applied his knowledge, ex- perience and unflagging capacity for work to investigating epidemic diseases in Africa, Asia and elsewhere. The last third of the 19th century was a period of ever-growing dynamics in the social and technical fields, in which science and medicine participated. So the merits of a scientist do not only consist in adding to the store of fundamental knowledge. His discoveries also stimulate further progress by raising new questions, making new and promising methods accessible, encourag- ing new services of disease control and, not least, fostering the training of specialists who in turn will add further to our knowledge. Scientists all over the world have con- tinued Koch's work and have gone on to become great men of science. Isaac Newton once said of himself: "If I looked further than others did, I did so only because I stood on the shoulders of giants." Such a giant Robert Koch was for the study and understanding of tuberculosis. ■ 7 Tuberculosis in profile The toll Three million people still die from tuberculosis every year. Four to five million new cases of acute, highly contagious pulmonary tuberculosis emerge each year, plus an equal number of new cases of less serious or less contagious forms, which are nevertheless dangerous (including those found in children or adoles- cents, and extra-pulmonary forms). Without treatment, new bacillary cases remain contagious for about two years before either death inter- venes or a more or less precarious cure occurs spontaneously. This makes a total at any given time throughout the world of at least ten million distri- butors of the bacillus, who spread infection all around them. This is the situation of tuberculosis in today's world. Most of the victims live in developing countries, where the majority of cases are never diagnosed at all, still less correctly treated. The name Its earliest medical name was phthisis, derived from the Greek verb phthinein, to waste away. In the nineteenth, and even in the early twentieth century, it was generally known as consumption. But as long ago as the seventeenth century the Dutchman Franciscus Silvius of Ley- den first used the term "tubercle" to describe nodular lesions found in the lungs of people who had died of the wasting disease. Johann Schonlein, in 1839, appears to be the first person to have used the name tuberculosis. Our weapons against TB At least ten drugs are effective against it. Of these, six are considered to be essential: isoniazid, rifampicin, streptomycin, pyrazinamide, etham- butol and thiacetazone. Each of these drugs has its own particular action and directs itself against several types of the numerous bacilli populations harboured by each patient. The cost of treatment varies from us $15 to more than $250, according to the drugs used. Regimens which include rifampicin are the most expen- sive, but they enable the duration of treatment to be cut from one year to only six months. What is essential is that the patient should be absolutely regular in following treatment. BCG vaccine, first discovered in 1921, protects children against tuber- culosis. It costs between two and five US cents per dose, and when freeze- dried remains stable for one month at room temperature even in hot tropical climates. Milestones Traces of tuberculosis lesions have been found on 3000-year-old Egyp- tian mummies. The Greek physician Hippocrates (460-370 B.c.)—"the father of medi- cine"—was the first to describe the disease. 1865: Jean-Antoine Villemin, a French military veterinary surgeon, showed, as a result of experiments conducted in Paris, that tuberculosis could be transmitted to animals by inoculation. 1882: German physician Robert Koch announced his discovery of the tubercle bacillus on 24 March, and on 10 April published his memorable article entitled "Aetiology of Tuber- culosis". 1890: Koch produced tuberculin, an extract of dead tubercle bacilli, used as a diagnostic test of tuber- culous infection. The large-scale use of the tuberculin test made it possible to measure the extent of infection throughout the world. 1895: Roentgen discovered, in Vienna, the X-rays which allow an examination of the chest. For the first time, there were radiological images available which showed the extent of the lesions in patients and, occasion- ally, in people who had no symptoms. However, it is bacteriological exam- ination for the tubercle bacillus which results in actual confirmation of the diagnosis. 1905: Award of the Nobel Prize for Medicine to Robert Koch. 1921: French scientists A. Cal- mette and C. Guerin discovered BCG, an attenuated form of the bovine bacillus, as vaccination against tuber- culosis. BCG stands for Bacillus- Calmette-Guerin. 1944: Selman A. Waksman and his colleagues, in the USA, discovered streptomycin, the first antiobiotic effective against tuberculosis. Waks- man received the Nobel Prize for Medicine in 1952. 1946-1952: New drugs appeared, namely para-aminosalicylic acid (PAS) and isoniazid (INH). These drugs are highly effective and very cheap. 1948-1951: The first mass vaccina- tion campaign was carried out by the Scandinavian Red Cross Societies, with the support of UNICEF. From 1951, WHO took over and helped governments progressively to under- take their own BCG programmes. 1956-1960: Many studies showed that domiciliary treatment is as effec- tive as sanatorium treatment, and that Koch believed—wrongly—that tuberculin offered a remedy for the disease. But it is still used for diagnosing tuberculous infection, as here during an anti-TB campaign in a Nairobi school. ( Photo WHO/D. Henrioud) successful treatment of adults de- pends not on bed rest, leave from work, good diet or fresh air, but on the regular ingestion of drugs for a sufficient period of time. Henceforth, the fight against tuberculosis no longer depended on the number of hospital beds available. 1964: A twice-weekly chemother- apy treatment was introduced, in place of the daily regimen. This made complete, direct supervision of treat- ment much easier. 1966: Rifampicin proved to be an excellent drug against tuberculosis. 1972: Wallace Fox and his colleag- ues from the British Medical Research Council, in collaboration with several centres in East Africa, showed that the addition of rifampicin, or of pyrazinamide—a drug which was originally abandoned but had since been re-adopted—to regimens con- taining isoniazid made it possible to reduce the duration of treatment. ■ 0.• • • * • • ft • • I! 111, '.• O. •It • • 40, '4 • o• • • *It • • • • * • • • Worldwide control — is it possible? We alreacy possess all the necessary weapons to wipe out tuberculosis. All we need to cefeat the disease, now and forever, are the financial resources anc the political will by Jerzy Leowski and Antonio Pio espite the excellent weapons that we possess to combat tuberculosis, the disease remains a worldwide public health problem. It is true that tuberculosis is on the wane in developed countries, but in many developing coun- tries it still ranks amongst the most deadly diseases and shows no signs of receding. Why has tuberculosis been brought under control in some parts of the world and not in others? How long will it take to control it everywhere, or is it merely a pipe- dream to believe that it can be controlled throughout the world? wilo has given a clearcut answer to this question. Yes, tuberculosis can be defeated, everywhere. To bring this about, a com- prehensive national tuberculosis pro- gramme must be implemented, and it must meet four conditions. It must be country- wide, that is to say, services must be available to rural as well as urban popula- tions. It must be planned on a long-term basis, since new cases will develop from the pool of infected people for two or three generations to come. It must be adapted to the expressed demands of the population; only accessible and effective services will gain public confidence. And it must be integrated into the community health structure so as to meet all the above requirements. BCG vaccination From a health point of view, there are two fundamental components of a national tuberculosis programme: firstly, im- munization of children, and secondly, case- finding and treatment of cases. BCG vaccination must be continued and expanded on a mass scale in countries Breaking the chain of infection from one person to another is particularly difficult in teeming urban slums. Facing page: A moment's pain for the baby; all in a day's work for this Turkish doctor, who had already inoculated no fewer than 70,000 babies against TB. (Photos WHO/UNICEF/B. Wolff and A. Duran) where tuberculosis is still a serious pro- blem. This policy therefore applies in practically all the developing countries. Although such factors as different epi- demiological, ecological, and immunologi- cal conditions may influence the protective effect of BCG, as shown by contradictory results of controlled trials, there is evidence that BCG plays a valuable role in preventing severe forms of childhood tuberculosis, for instance meningitis and miliary tuber- culosis (a form which spreads throughout the body). Where infant TB is a problem, the widest possible coverage with BCG vaccina- tion should be ensured as early in life as possible. This is why BCG has been included as one of the six vaccines of wHo's Expanded Programme on Immunization (EPI). The other five vaccines protect against diphtheria, measles, poliomyelitis, pertussis (whooping cough) and tetanus. In countries with a low tuberculosis prevalence, BCG policies should be adapted to the changing situation, and primary vaccination can usually be postponed until the children leave school. At whatever age BCG is administered, great attention must be paid to the quality of the vaccine, its handling during the transport and its storage. Health agents need to be trained to vaccinate correctly. Proper evaluation of the coverage and monitoring of the effectiveness of BCG vaccination programmes are also essential. When theory is to be put into practice, things are not always simple. Let us look at some of the difficulties encountered in the Yemen by the wHo Expanded Programme on Immunization (EPI). Yemen lies in the south-west part of the Arabian peninsula. In ancient days it was known as Arabia Felix (happy) because it is well-watered and forms the greenest part of the peninsula, in sharp contrast with the arid land which extends north and east towards Saudi Arabia and the great Nefoud desert. The legendary Queen of Sheba is reputed to have reigned over Yemen. 11 Worldwide control—is it possible? Left: A technician prepares culture media at the Tuberculosis Chemotherapy Centre in Nairobi. Right: For some unfortunate people, diagnosis and treatment come too late. The woman shown here being examined by doctors from the TB Control and Training Institute in Dacca died shortly afterwards. ( Photos WHO/D. Henrioud and WHO/ E. Schwab) In 1977, EPI was initiated in Yemen as a long-term integrated component of the established health services. A recent report published by wHo's Weekly Epidemiologi- cal Record describes some of the problems that emerged. The report states: "The challenge facing EPI in Yemen is to overcome the constraints posed by: a formidable mountain and desert terrain; an under-developed transport and commun- ication network; a highly dispersed population of 5.8 million, approximately 85 per cent of whom live in villages with fewer than 500 inhabitants; a health services infrastructure which, though rap- idly expanding, does not yet reach most of the districts in which the great majority of the population resides; a chronic shortage of trained manpower at every level, neces- sitating a heavy reliance on expatriates, many of whom are not Arabic-speaking; and a public which until recently has never had experience with health services and has consequently not yet been accustomed to the very idea of immunization." Parents not aware A survey taken in the capital, Sana'a, to find out why immunization rates were low showed that the principal reasons given by parents for not bringing their children to be vaccinated initially were that the children were not sick "and therefore did not need injections", or that they considered them too young for injections. The main reasons given for not returning to complete the series were that parents were unaware of the importance of three doses, or that they were "too busy". The case-finding and treatment com- ponent of the programme must be developed as an entity. Its aim is to break the chain of transmission of infection by identifying the sources of infection and neutralising them with adequate chemo- therapy. The transmission of infection in a community is maintained essentially by patients whose sputum contains so many tubercle bacilli that they can be detected by direct sputum smear examination under a microscope. 12 Sputum examination by direct micro- scopy for patients with persistent respira- tory symptoms, notably a cough, should become a routine procedure in all health institutions, including isolated primary health care centres. Adequate chemothera- peutic treatment must be administered free to all those who excrete tubercle bacilli. When in the patients' sputum a direct smear examination does not reveal any tubercle bacillus, they may be given the possibility of bacteriological culture of sputum and other examinations, including a chest X-ray. But it must always be remembered that, unless the presence of tubercle bacilli can be demonstrated, the diagnosis of this disease is never conclusive. In most countries and areas where TB is frequent, it has been established that from two to five per cent of all new adult out- patients are people with respiratory symp- toms who are eligible for sputum examina- tion. Of these, around five per cent may be found by direct smear microscopy to have the disease. Ambulatory treatment It has been proved beyond doubt that treatment in a hospital or sanatorium offers no medical advantage over ambula- tory care, and that the most effective and cheapest way of treating patients is by out- patient treatment. It is absolutely useless to squander limited resources on sending cases to hospital. On the other hand, the success of treatment depends fundamen- tally on the regularity of drug-taking, and this calls for adequate supervision during the whole period of treatment. Until recently, the standard duration of TB chemotherapy was 12 months. Research has now shown the effectiveness of six- month regimens, known as short-course chemotherapy. To be fully effective, these regimens need an efficient delivery treat- ment system. Because of the higher cost of short-course chemotherapy, it is even more important that the treatment be entirely supervised and the results continuously evaluated. 13 What everbody should know about tuberculosis The infection is mainly transmitted by exposure to bacilli spread into the air from one patient with pulmonary tuberculosis. Coughing, sneezing, and even talking, by a patient fills the air with droplets of moisture contain- ing the bacilli. Fortunately, infection does not often lead to disease, but the risk persists throughout life. Before 1946, the only measure to protect the community from infec- tion was to isolate patients in sanatoria. Since then powerful drugs have become available to render patients non-infectious in a short time and to cure them completely. Thus, the best for the individual is also the best for the community: early diagnosis of patients with tuberculosis and their effective treatment. The simplest and most pertinent way of diagnosing tuberculosis is by microscopic examination of the pa- tient's sputum. The usual symptoms of pulmonary tuberculosis are persis- tent coughing, loss of weight and fever. Treatment requires a regular drug intake, daily or twice a week, for 12 months. Recently short-course treatment regimens (6 months or 9 months) have also been developed and introduced in a number of countries. BCG vaccination is the recom- mended measure to prevent tuber- culosis in children. It is applied to infants a few days after birth, or when they are 2-3 months old, simul- taneously with other vaccines. wilo's Expert Committee on Tuber- culosis, in the introduction to its ninth report, describes major problems. It says: "Shortages of financial, material and physical resources and a shortage and maldistribution of trained manpower are aggravated by a lack of managerial skill. The health infrastructures of many coun- tries have deficiencies that remain uncor- rected. These often lead to an increasing feeling of dissatisfaction because of inabil- ity to apply, on an adequate scale, the potent weapons against tuberculosis. In some countries, a major constraint has been a reluctance to change traditional and outmoded orientations. Determined lead- ership is needed to effect the necessary changes and to apply more effectively the potent measures available for tuberculosis control." Since these words were written in 1974 the situation has not substantially changed. The main hurdles which hamper the new approach to tuberculosis control are the weaknesses in the organization of control activities, particularly in rural areas. So the importance attached to the organizational aspects of the programme Schoolchildren being examined for BCG scar in Malaysia. Those without a scar will receive vaccination against TB. Facing page: International cooperation in Nairobi: A Kenyan and aforeign doctor study the culture they have made. ( Photos WHO/J. Abcede and WHO/ D. Henrioud) can hardly be over-emphasised. The avail- able standard technology is simple enough to be applied even by rapidly trained primary health workers. The key organiza- tional problems are: the establishment of microscope centres with regular super- vision and supply of reagents, the need for referral, recording and reporting systems, arranging the regular follow-up of patients under treatment and the tracing of patients who default, and maintaining a regular supply of drugs. The fact is that, today, we possess all the necessary weapons to wipe out tuber- culosis. The key elements that are required to defeat the disease, now and forever, in poor countries, are the financial resources and the political will to make it possible. ■ 14 / Training course in Japan The earliest participants were invitec to stucy their own country's problems anc to seek their own solutions. As a result, the training course is now more rational, more public-health-oriented anc more community-mindec by Jose C. Abcede he more integration, the more generalisation of tuberculosis ser- vices we have, the more we need TB specialists—not in a technical way but to provide the brains for the tuber- culosis control programme of a nation. "If you have too many hands, you need strong brains to get the hands to work rationally." In these words, Dr Yoshikuni Azuma described the Japan/wno International Tuberculosis Training Course which he has directed for the past 11 years. Physicians from all over the world have been going to Japan every year for four months of training in TB control since 1963. Already 287 doctors from 37 countries have completed the course held at the Research Institute for Tuberculosis, which is run by the Japan Anti-Tuberculosis Association. The course is financed by the Japanese Government through the Japan Interna- tional Cooperation Agency (ncA). From 1967, it became a joint Japan/wno training course. The main objective was to give training to key organizers of national TB programmes in modern methods of tuber- culosis control, and to prepare them for the promotion of the programme in a rational, realistic and efficient manner. The following aspects have been em- phasized: how to "think epidemiologic- ally", how to protect healthy populations from the disease, how to stop the con- tinuous spread of TB infection, and how to plan, organize and assess a programme with cost-benefit considerations in mind. After more than 10 years' service with vsmo in TB control (Tuberculosis Research Office, Headquarters and South-East Asia region), Dr Azuma came back to the institute in 1969 to be engaged mainly in international training courses here. He said that in the early years there was a strong clinical bias. Later, there was a steady shift towards epidemiological and programme- oriented aspects, as well as towards new training methods. In order to encourage participants to develop their own rational and critical thinking, increasing weight is placed on group discussions, practice and workshops in analytical studies of TB problems and national TB programmes. There are no passive lectures. International staff Teaching staff are from Japan's Ministry of Health and Welfare, the Research Institute and the Japan Anti-Tuberculosis Association. Consultants and other teach- ing staff from overseas countries are provided by wno and lend an international character to the faculty. The problems that beset many national TB control programmes have been des- cribed in the biennial report (1979-1981) of Dr Hiroshi Nakajima, wno Regional Director for the Western Pacific. Dr Nakajima said that the decline of tuber- culosis "would have been more rapid if control measures had been properly implemented". In a number of countries, he said, the technical and management aspects of the programme "need to be strengthened to improve and maintain the quality of services". In Tokyo, I mentioned Dr Nakajima's report to Dr Azuma. He replied that the Institute was very much aware of the problem. He expressed strong support for integrating TB control into the general health services. "We asked participants to study their own country's problems and to seek their own way of solving them", Dr Azuma explained. He added: "We cultivate the facility for planning scientifically." The course is now more rational, more public- 16 Dr Annik Rouillon, Executive Director of the International Union Against Tuberculosis ( IUAT) addresses the 1981 training course at the Research Institute for Tuberculosis in Tokyo. ( Photo WHO/J. Abcede) health-oriented and more community- minded. A more significant change has been in the background of the participants. Many non-TB specialists have been sent by their governments to this Tokyo course. In 1981, the first non-medical statistician took the training course. Thirty-seven countries That same 1981 group was, in fact the biggest so far, with 26 participants. And since 1963, health officials from the follow- ing countries have benefited from the course: Afghanistan, Bangladesh, Brazil, Bolivia, Burma, China, Colombia, Egypt, Ethiopia, Hong Kong, India, Indonesia, Iran, Iraq, Japan, Kenya, Republic of Korea, Laos, Liberia, Malaysia, Nepal, Nigeria, Pakistan, Papua New Guinea, Peru, Philippines, Singapore, Sri Lanka, Sudan, Tanzania, Thailand, Turkey, Uganda, Viet Nam, Samoa, Yemen and Zambia. Observation visits to various medical institutions and hospitals, as well as to cultural centres, have been part of the programme. This has contributed to a greater understanding and appreciation of Japan. However, the participants are also afforded the opportunity to observe tuber- culosis control activities in countries which have quite similar conditions or whose experience is at least relevant to their own environment. In Japan, the Research Institute and JATA have unique roles in the government's TB control programme. Asked whether he would recommend setting up tuberculosis institutes in other countries, Dr Azuma said such institutes could function as brains trusts for national TB programmes. In some countries the TB services within the minis- tries of health could serve as the nucleus of the institute. Dr Azuma cited the example of the National Institute for Tuberculosis in the Philippines, which he said could be "a great force" in that government's TB control programme After completing the Japan programme, the participants spend one or two weeks each in the Republic of Korea, Malaysia or the Philippines, where they observe or practise supervision operations in periph- eral TB programmes. This second part of the training course has been financed by WHO. The seed is sown Dr Azuma sees a growing role for this group training course, which he likened to a seeding process. Increased emphasis on the planning and management of control programmes, community participation and the primary health care approach should be kept up, he said. The 1981 training course was his last one. He has now retired, though he will be assisting the course when he is available. To succeed him, the Japan Anti- Tuberculosis Association has appointed Dr H. T. Lin. For many years, Dr Lin was team leader of the wHo Regional Tuber- culosis Advisory Team in the Western Pacific. He is thoroughly familiar with the problems of tuberculosis in developing countries. Explaining that increased em- phasis will be placed on the primary health care approach to tuberculosis control, Dr Lin underlined that the decline of tuberculosis will represent a signal contri- bution to wHo's goal of Health for All by the year 2000. ■ 17 uccess among the Eskimos diti7g044Nt Case-finding and treatment programmes in the Far North have proved capable of sub- stantially reducing the TB problem in 10 to 20 years: there is no need to wait for long-term improvement in socio-economic conditions. L skimos came to North America from Siberia several thousand years ago and settled in Alaska, Arctic regions of Canada and in Greenland. They are very intelligent, resourceful and hardy people, and because of these qualities they survived under the most rigorous climatic conditions, eking out a precarious living by fishing and hunting. Although sporadic contact with "white" explorers dates back a few hundred years, a more intimate contact between many groups of Eskimos and white people is more recent, having taken place in many areas as late as the 1940s and 1950s. White people brought with them their religion, their culture and their technology as well as their alcohol and their diseases. These diseases, although often quite benign in white people, proved to be great killers of Eskimos; measles, for instance, decimated many settlements. Tuberculosis was brought into the North at varying times, but mostly during the earlier part of this century, and Eskimos showed very little resistance to this infec- tion. In the Canadian North there are settlements containing cemeteries in which most of the graves date back to the 1930s and 1940s and contain victims young and old—of Koch's bacillus. As late as the 1960s, more than 100 cases of active tuberculosis were evacuated to tuberculosis hospitals in southern Canada Left: Out on a hunting foray, a young Eskimo looks down at the settlement of Igloolik. Right: Inuits from the Thule area of Greenland wait for X-ray examination of their lungs. ( Photos L. Sirman © and C.M. Smidt, Central Hospital, Naestved, Denmark C)) by Stefan Grzybowski 4 • Above: Local schools become temporary clinics during case-finding visits by doctors in Greenland. Left: The anti-TB programme had to succeed. Life is harsh enough in the Arctic wastes without a debilitating disease taking its toll. ( Photos C. M. Smidt, Central Hospital, Naestved, Denmark © and L. Sirman C).) from one single Eskimo settlement of some 400 population. It is estimated that, around 1950, among every 100 Eskimos there were two cases of smear-positive tuberculosis, one of whom died; and that one out of four children became infected by tubercle bacilli every year. Intensive anti-tuberculosis programmes were introduced in the mid-1950s in Alaska and Greenland, and several years later in Canada. These programmes in all three countries included very intensive case- finding activities; in many areas every Eskimo was examined twice a year for the disease. Thorough treatment of all active cases consisted in those early days of chemotherapy given in the sanatoria sit- uated in the distant, more densely populated areas; many Eskimos spent two years or more in these institutions. Eskimos from Greenland were evacuated to Den- mark, while those in Canadian Arctic were sent to sanatoria in southern Canada. These case-finding and treatment pro- grammes were very similar in all three countries. The preventive programmes, on the other hand, were quite different. Green- land relied mainly on BCG vaccination, and Alaska mainly on chemo-prophylaxis, while in Canada both measures were used. In all three countries there was a very rapid decline of the tuberculosis problem. Mortality dropped more than 100 times, and the incidence rate of active cases fell by between 10 and 40 times over the next 10 to 20 years. Risk of tuberculous infection also diminished some 70 times. There are three main lessons which can be learned from this successful fight against tuberculosis in Eskimos. Firstly, present technology makes it possible to reduce the tuberculosis problem very substantially over a relatively short period (10 to 20 years); we no longer have to wait for socio-economic improvement, which usu- ally occurs more slowly. Secondly, a good case-finding pro- gramme followed by thorough treatment constitutes the most important anti- tuberculosis activity. Both forms of preven- tive programme, using BCG vaccination or chemo-prophylaxis while helpful—con- tribute somewhat less towards a successful outcome. While the anti-tuberculosis pro- grammes among the Eskimo communities cost millions of dollars, it is possible to obtain similar results by much cheaper measures, for instance by relying on sputum examination instead of costly X- rays, and on ambulatory instead of hospital treatment. Thirdly, close cooperation on the part of the whole population is essential for the success of the programme. The philosophy that "you need us and we need you", voiced by many Eskimos, has led to good compliance of the population with all aspects of the anti-tuberculosis pro- gramme. ■ 21 Controlling TB in Africa Once the Ministries of Health have drawn up a centrally co-ordinated primary health care programme, the community itself can create and maintain its own health rather than relying on visiting health workers by S. J. Nkinda Ln the history of the fight against tuberculosis, three important land-marks stand out. First there is the discovery of the tubercle bacillus by Robert Koch whose centenary we celebrate this year. Second, the development of effective chemotherapeutic agents, with the potent drug isoniazid coming into use in 1952. Third, the development by who of the concept of a National Tuberculosis Programme, which was presented in the 8th Report of the Expert Committee on Tuberculosis in 1964 and further elab- orated in the 9th Report in 1974. To a large extent tuberculosis control has become a widely applied community activ- ity, rather than the clinical speciality it was in the past. This is largely because control techniques and procedures have been simplified and standardised in such a way that auxiliaries and paramedical staff can apply them at any health facility, including a health post. The modified control tech- nologies were tested for a period of ten years before the who Expert Committee on Tuberculosis reaffirmed their efficacy, applicability and acceptability to govern- ments in 1974. Treatment essential The control measures consist of a preventive component—namely BCG vaccination—and a curative compo- nent—namely a case-finding/treatment programme. Case-finding which is not followed by treatment is not only a waste of time and resources; it can also be harmful, since it undermines the confidence of the public in the health care delivery system. BCG vaccination, given to a non-infected population and using a potent strain and correct technique, is highly effective in preventing tuberculous disease in children. Recent findings from BCG trials in Southern India suggesting a lack of protection are still under close scrutiny and who policy at present remains unchanged. Direct vaccination (that is, without prior tuberculin testing) using syringe and needle is recommended at birth and at the age of school entry. The application of mass BCG vaccination was accepted by many de- veloping countries where it was carried out in uracEF-assisted campaigns. Similarly, many countries agreed to integrate BCG vaccination into the general health services and combine it with other immunizations such as those under who's Expanded Programme of Immunization. In Tanzania, for example, vaccinations are given in all hospitals, health centres and some dispensaries. Only about 50 per cent of children are delivered in health facilities and can therefore be vaccinated at birth. Vaccination at the age of school entry is, for practical purposes, negligible. Mobile Maternal and Child Health teams extend vaccinations to peripheral areas which have no static services. In Africa, in general, data on coverage are lacking, but reduction in the incidence of tuberculous meningitis, miliary tuberculosis, and tuber- culosis in children is partly attributed to BCG vaccination. Passive case-finding, whereby patients with chest symptoms present themselves to health facilities, is the approach recommen- ded. For control purposes, the main disseminators of infection are patients with pulmonary tuberculosis whose sputum, when stained and observed under a micro- scope, shows the presence of bacilli. Of these patients, 80 per cent are found to have persistent cough, and the majority of them are discovered as self-reporting patients rather than through active case-finding by mass miniature radiography. In a review of the methods of case- finding in terms of sensitivity, specificity, acceptability, feasibility, efficacy and cost, Dr T. Shimao reaffirmed the recommenda- tions of the 9th Report that direct smear microscopy should be the method of choice in developing countries. Mass miniature radiology has not been used to a large extent in developing countries, and is not recommended because it is very expensive and gives a very low yield of cases. Rural microscopy The recommended approach for case- finding can be applied at hospital, health centre and dispensary levels in the health care systems of developing countries. In Tanzania, the majority of the diagnoses are still made in hospitals. While new micro- scopes have been distributed to almost all of the 220 rural health centres in the country, microscopy has yet to function in all of them because workers are still undergoing training. The major role of the 2,290 rural dispensaries and of health posts will be to recognise suspects and collect sputum specimens or refer them to nearby microscopy centres, to examine people in contact with positive cases, and to increase awareness within the community about respiratory symptoms. Microscopic diag- nosis of tuberculosis will be carried out only on a small scale in these facilities. The achievement of case-finding in many developing countries has so far been unsatisfactory. In Africa, not more than 30 per cent of existing smear-positive cases are detected. On the basis of a risk of infection of about two per cent per year in Tanzania, the incidence of smear-positive cases per year is 100 in every 100,000, but prelimi- nary statistics show that, on the average, 22 smear-positive case detection rates were only 41 in 100,000 in 1980. wHo's recommendations on drug treat- ment are: to use drugs of proven efficacy, to administer them in adequate, regular dosages, and to give them on an out-patient basis. The treatment should be free of charge to patients; it should be permanent- ly available throughout the country and integrated into the general health services. It should be supported by a reliable supply system and it should be accepted by the community. The staff providing it should be efficient, sympathetic and capable of establishing good relations with the pa- tients. Whenever possible, fully supervised chemotherapy should be introduced as this will encourage patients to take their drugs regularly. The work of many investigators provided the data which formed the basis of these recommendations. Bed rest and institutional (sanatorium) treatment were shown not to be important factors for cure. Controlled trials with the routine regimens consisting of streptomycin, isoniazid and thiacetazone were found to be highly acceptable and applicable in community treatment in Africa. The cornerstone of successful chemotherapy is adequate and regular drug-taking. The application of the recommended regimens in high-prevalence countries has, to a large extent, produced disappointing results. Not more than 50 per cent of diagnosed smear-positive cases are cured. And in Tanzania, in 1970 to 1971, out of 549 positive patients only 38 per cent attended clinics for one year. Case-finding plus chemotherapy is the most potent weapon for tuberculosis con- trol. It has been estimated that this component accounted for a seven to eight per cent reduction per year in the risk of infection in developed countries. However, the trend of the risk of tuberculosis infection has remained virtually constant, or has been reduced only slightly, by the control measures in the last 20 to 30 years in many developing countries. The main reasons seem to be inadequate coverage of facilities for diagnosis, patients stopping attending for treatment, irregular drug- taking (i.e. gross interruptions in self- medication), inadequate regimens and migration. It is clear that developing countries must make fundamental changes in the delivery of health care by adopting and implement- ing primary health care. The success of the new simple but effective tuberculosis tech- nology developed by wHo and the International Union Against Tuberculosis requires self-reliance and community par- ticipation, and the political determination to introduce primary health care. Minis- Mass radiography was once popular, but is not recommended today. It proved to be a costly and inefficient case-finding method. ( Photo WHO/D. Henrioud) tries of Health need to prepare a centrally co-ordinated but administratively decen- tralised programme, under which the major problems in chemotherapy, namely irregularity in drug-taking and loss of patients from observation, can be over- come. The house of the patient is identified by the primary health workers, and com- munity leaders can be asked to help to motivate the patient or they can even be active supervisors of the treatment. Pri- mary health care is "...a health approach which integrates at the community level all elements necessary to make an impact on the health status of the people." Tanzania's new National Tuberculosis and Leprosy Programme is trying to make people aware of the health problems facing them. They are also being made responsible for participating actively in selecting ways of dealing with the problems, in the light of the resources at their disposal. The villagers should, for example, select the trainee who will work among them as their community health worker. This helps to ensure that health tasks they have decided upon are carried out according to their plan. And in turn, this means that the community can create and maintain its own health rather than relying on the services of visiting health workers. ■ 23 I. efore the discovery of the tubercle ° bacillus by Robert Koch in 1882, s tuberculosis was treated empiri- cally that is, on a basis of observation and experiment, rather than theory. Since classical times many people considered that it must in some way be infectious, but during the early part of the nineteenth century this concept was super- seded by the prevailing "diathesis" theory which postulated a permanent condition of the body rendering it liable to certain diseases. People with the "tuberculosis diathesis" were considered to be at special risk if they were subjected to bad sanita- tion, miasmas and foul airs, and to protect against these it was necessary to pay careful attention to personal hygiene, have plenty of fresh air and wear warm clothing (particularly flannel!). In the treatment of the disease, the older methods of bleeding and purging had been gradually abandoned and emphasis was placed on a nutritious diet (including cod liver oil), a change of climate, and personal hygiene—in which baths played an impor- tant part. For the distressing cough, opium was prescribed, and sometimes it was recommended that leeches should be placed over the trachea. A more specific treatment was the insertion of setons (pieces of tape drawn through folds of skin) in the chest wall over the diseased areas of the lung. Mercury compounds were often given by mouth. Indeed, attempts to treat the disease by drugs (chemotherapy) had been made since the earliest times; arsenic, iodine, mercury, silver and gold all had their vogue. Prior to 1882, the transmissibility of tuberculosis had been demonstrated in laboratory experiments by several workers, notably Villemin. Robert Koch not only identified the tubercle bacillus but demon- strated the infectivity of sputum, thus showing clearly that tuberculosis was an infectious disease. Even so, it was not until the twentieth century that the full signifi- cance of their discoveries became recog- nised. Only then was it accepted that the vast majority of tuberculous infections were spread from person-to-person through the sputum by the air-borne route, and that patients who contracted the disease did so usually only after repeated exposure to highly infectious cases. As a result, the importance of relieving overcrowding at work and in the home, including separate sleeping arrangements for the patient, and the routine medical surveillance of close contacts, especially children, was recognised. By following these measures strictly, it was possible for tuberculosis patients to live with their families without infecting them. Indeed, it was demonstrated in one model commu- How treatment has evolved Great benefits have stemmed from the shift from hospital care to ambulatory care, and from pro- longed daily treatment to intermittent and short- course treatment. The value of both these innova- tions was first cemonstrated in developing countries by H. Stott 24 A home visitor from the TB Control and Training Institute in Dacca calls on an elderly patient. (Photo WHO/E. Schwab) nity for tuberculosis patients that their children were at less risk of becoming infected than children in the general population. Following Koch's discovery in 1882 and the discovery of X-rays by Röntgen in 1895, two methods of early diagnosis of pulmonary tuberculosis became available, namely bacteriological examination of the sputum to identify the tubercle bacilli and X-ray of the chest. At the same time, treatment of the disease became more rationalised; sanatoria opened their doors, where patients were isolated and treated with rest followed by strictly controlled graduated activities. Artificial pneumothorax (the introduc- tion of air into the pleural cavity through a needle in the chest wall) was first in- troduced by Carlo Forlanini as a method of collapsing, and thereby resting, the dis- eased part of the lung by reducing its volume and movements. It was a long treatment requiring repeated refills of air for up to five years and, until the early 1950s, it remained the most effective method of halting the disease. In some patients (usually those in whom an artifi- cial pneumothorax had failed), the more radical surgical procedure of thoracoplasty was undertaken in which the lung was collapsed after removal of the overlying ribs. Treatment with a gold compound, "sanocrysin", was particularly fashionable for a period after 1924. It was easy to give, requiring only occasional injections, but was hazardous and there was little ev- idence, if any, of its value. Its use declined rapidly in the 1930s. With the introduction of effective drugs against tuberculosis, streptomycin in 1945, P-aminosalicylic acid (PAS) in 1946 and particularly isoniazid in 1952, the treat- ment of the disease was revolutionised. In a series of carefully controlled investiga- tions, particularly collaborative ones, the principles of chemotherapy were elu- cidated and very soon the great majority of patients were being successfully treated, and many of them cured, with these drugs. But important conditions had to be ad- hered to if treatment was to be successful, namely that a combination of two or more drugs had to be prescribed so as to avoid patients developing resistance, and the drugs had to be taken daily and regularly for long periods, usually being prescribed for 18 months or more. The introduction of chemotherapy op- ened up new fields in the surgery of pulmonary tuberculosis, since by prevent- 25

ing the spread of infection from the diseased lung during operation it largely avoided the hazards which had previously made surgery a risky procedure. For a period, resections of the diseased parts of the lungs were widely undertaken, but as the practice of chemotherapy became more sophisticated, and its potential more widely recognised, operative intervention became much less frequent. It is now only rarely practised. The remarkable success of chemother- apy called into question the value of certain time-honoured practices such as sana- torium treatment, bed rest, fresh air and a nutritious diet, which had previously been considered vital. The classical study to identify the part played by these factors in patients treated with chemotherapy was undertaken in Madras, India, comparing treatment at home with treatment in a sanatorium. It showed conclusively that sanatorium treatment was unnecessary if adequate and effective chemotherapy was prescribed and conscientiously taken daily for one year. Further, the treatment of patients in their homes provided no special risk to their families because of the great rapidity with which chemotherapy reduced the infectivity of patients, even within a few days of starting treatment. The study also showed that certain common practices in the treatment of the disease, rest, a good nutritious diet, good accommodation in airy surroundings and isolation of patients, were not necessary in the chemotherapy era. Many subsequent investigations have confirmed these conclusions, and the treatment of patients with pulmonary tuberculosis on a domiciliary basis is now standard practice. This was a turning point not only for developing but for technically advanced countries too, and has many obvious advantages, more particularly in the low cost of treatment and the stability of the family unit. Treating patients in their homes presents one major problem: how to ensure that they continue to self-administer their chemotherapy regularly for long periods even though, for most of the time, they may feel perfectly fit. If this is attained, a cure can be virtually guaranteed for every patient. In practice this is not achieved, usually because patients stop taking their drugs altogether or they take them ir- regularly. Irregularity may be difficult to detect and is often concealed from the medical attendant, with the result that resistance to the drugs often occurs and they cease to be of benefit to the patient, whose condition deteriorates. Above: Bed rest in a sanatorium used to be considered vital to TB treatment. A major study in Madras, India, showed that chemotherapy was just as successful at home. Below: In an Asian country , patients collect their pharmaceutical supplies at the roadside from the mobile unit 'sjeep. (Photos WHO and WHOIAbcede) Left: It can be tedious, waiting to give a sputum sample at the health centre. ( Photo WHO' P. Almasy) Because patients tend to stop self- administering their drugs once they are feeling better, new drugs which need only be taken over a six-month period (instead of one year) represent a great advance in chemotherapy. ( Photo WHO/P. Almasy) Supervising the administration of drugs on a daily basis for long periods is impractical in most circumstances, par- ticularly in developing countries, but it becomes more feasible if the drugs are given at longer intervals, say, twice-weekly, or even less often. Principally for this reason several twice-weekly drug regimens, usu- ally administered for one year, have become standard practice in certain urban communities and for patients who are notoriously irregular in the self- administration of their drugs (alcoholics or vagrants, for instance). These intermittent regimens are not suitable in circumstances where patients have to travel long dis- tances, as frequently occurs in developing countries, for the supervised administra- tion of their drugs. But the scope for supervised intermittent chemotherapy has been increased thanks to the introduction of the very potent drug rifampicin, a highly effective regimen which only needs to be given once-weekly for one year. Because patients tend to default and become irregular in self-administering their drugs once they are feeling better, another approach is to shorten the total duration of treatment. Since rifampicin came on the scene, the development of several highly effective and potent daily regimens which need to be given for only six months represents a great advance in chemother- apy; so too do effective short-course regimens in which the drugs are given intermittently, twice or three times a week. These have led to a reduction in the number of doses which the patient is required to take from 375 doses for the one-year daily regimens to 190 for the six-month daily regimens, and to only 64 doses for the one- year supervised once-weekly regimen. In the technically advanced countries, there is reliable evidence that the tuber- culosis problem has been decreasing since the turn of the century; a drop in mortality of about four-fold occurred in the first four decades of the century. This remarkable decrease can be attributed to the rise in general standards of housing and living conditions, and to more specific anti- tuberculosis measures, including steps to protect contacts by isolating the patient and the general education of family members. After the introduction of chemotherapy in the late 1940s, there was a greater and more rapid improvement in the tuber- culosis position, so that by 1980 the mortality from tuberculosis in developed countries had decreased approximately fifty-fold over the previous three to four decades. These spectacular results have been possible through chemotherapy com- bined with intensive case-finding efforts, backed by an abundance of technical and financial resources. But the disease will still occur, although at a decreasing rate, in these countries for many years to come. Special problems such as refugees and immigrants from countries with a high prevalence of tuberculosis and other high- risk groups will continue to require par- ticular attention, although they are unlikely to have a significant detrimental effect on the overall tuberculosis picture. Unfortunately little is known about the picture in developing countries because vital statistics are lacking. It has been estimated that four to five million highly infectious cases occur each year, with an equal number of less infectious cases. In contrast to the rapid improvement in developed countries, in most developing countries the position has remained cons- tant for many years or, in a minority, has been declining only very slowly, despite the availability of simple and reliable diag- nostic tools and relatively inexpensive and effective preventive and curative methods. The failure to utilise these satisfactorily can mainly be ascribed to the prevailing shortage of financial, material and physical resources. The 33rd World Health Assem- bly in 1980 noted with concern that tuberculosis remained one of the most important health problems in developing countries, and that the implementation of tuberculosis control measures was inade- quate. In consequence, the Director- General of wHo called on all Member States "...to strengthen tuberculosis con- trol activities, to promote programme evaluation, epidemiological surveillance of the tuberculosis problem and health ser- vices research on diagnostic, curative and preventive measures." In tackling these problems in developing countries it is obvious that assistance will be required from the technically advanced ones. As the Report of the Joint IUAT/WHO Group on Tuberculosis Control (1981) has pointed out, simplified and effective tuber- culosis control methods tested and evolved in developing countries have since been adopted by technically advanced countries to their own advantage. Great benefits have therefore been realised throughout the world because of the shift from hospital care to ambulatory care, and from pro- longed daily treatment to intermittent and short-course treatment. The value of both innovations was first demonstrated in developing countries. It follows that it is in the interest of technically advanced coun- tries to support a continuing programme of research in tuberculosis, so as to establish international solidarity in the global fight against this disease. ■ 28 Anton Chekhov Simon Bolivar "Antonia" by Amedeo Modigliani Frederic Chopin The Captain of all these Men of Death 6,. j round 1660, the preacher John Bunyan wrote in one of 4 his moral fables: "The Captain of all these Men of Death that came against him to take him away, was the Consumption, for it was that that brought him down to the Grave." All through recorded history, men, women and children have been brought early to their graves by phthisis, consumption, tuberculosis—this wasting disease caused by the bacillus that Robert Koch detected through his micro- scope in 1882. In early times, descriptions of symptoms were often too vague for us to be sure that TB was indeed the cause of death. But during Europe's era of Romanticism in the arts, the pallid and doomed composer, artist or writer was virtually a vogue figure. The English poet John Keats, who died in 1821, aged only 26, was typical of these. Among his best-known lines are these: "... For many a time I have been half in love with easeful death... Now more than ever seems it rich to die, To cease upon the midnight with no pain." Some other famous victims of tuberculosis include: French painter Antoine Watteau, 1684-1721, German composer Carl Maria von Weber, 1786-1826, the South American Liberator, Simon Bolivar, 1783-1830, Polish composer Frederic Chopin, 1810-1849, American philosopher Henry David Thoreau, 1817-1862, Russian writer Anton Chekhov, 1860-1904, and Italian painter Amedeo Modigliani, 1884-1920. Millions upon millions of victims around the globe never lived long enough to achieve fame. This is why we now invoke the slogan, in this Koch Centenary year: Defeat TB—now and forever. Breast is Best The International Federation of National Red Cross and Red Crescent Societies, Geneva, has designed a sticker, reproduced here in life-size, to signify its support of breast-feeding and the recently-adopted Internation- al Code of Marketing of Breast-milk Substitutes. The design is not copyrighted, says Mr David Chalfan, editor of the societies' publication, Panorama, in order to encourage its use "any place and in any way compatible with gett- ing its message across". •0• 000 000 000 0• 00 000 0• 4100 000 000000 000 00 000000 0. 0• ton moo lie • * 0• 0•• 00 000 000 050 000 000 00 000 00• 000 000 5• 00 *00 00• 000000 000 000 000 000 000 000 00• 000 000 000000 ••• ••• 000 110 00 .0 000 00 00 00 000 Solar Fridges for Vaccine Storage To Face Large-Scale Field Tests A method of harnessing solar power, first developed for the U.S. space programme, will be field-tested on a large scale in thirteen nations to determine its effectiveness to fuel refrigerators for vaccine storage and ice- making. The trial is backed by the World Health Organization which is carrying out an Expanded Pro- gramme on Immunization aimed at protecting children against measles, polio, tuberculosis, diphtheria, whooping cough (pertussis) and tetanus by 1990. Financed by the U.S. Center for Disease Control and the National Aeronautic and Space Adminis- tration, the trial begins in the next few months. To be tested are refrigerators in which electricity is generated by photovoltaic panels exposed to the sun. This type of refrigerator, which makes from one to two kilograms of ice in 24 hours, is on the market in many developed countries, and is used both domestically and commercially. Starting in Colombia, the Dominican Republic, Ecuador, Gambia, Guatemala, Guyana, Haiti, India, Indonesia, Ivory Coast, Maldives, Mali, and Peru, the trial is part of a planned series Electricity is generated by photovoltaic panels. Model of fridge to be tested in field trial. (Photo WHO/UN) of field tests scheduled to take place, after laboratory testing, over the next two years. Through systematic monitor- ing of the performance of dif- ferent solar-powered cooling methods, WHO is seeking a solu- tion to a major problem faced by health officials responsible for immunization programmes—that of transport and storage of vaccines. Each year over 85 million child- ren are born in the developing world. Of that number, an esti- mated five million die every year, and another five million are dis- abled as a result of the six childhood diseases. Despite the availability of vaccines, less than 20 per cent of children in de- veloping countries are being immunized. In order to retain their potency, vaccines must be kept at tem- peratures below 8°C (46° F) at all points of a "cold chain", that is, from the time of manufacture to the time of use. Otherwise, the vaccines spoil. To transport vaccines, there are "cold boxes", and other types of carriers, designed in Sweden by the National Bacteriological Lab- oratory, Stockholm, and now manufactured in a number of developing countries, among them Colombia, Indonesia and the Philippines. Heavily insulated with polyurethane foam, and cooled by ice packs, they are capable of keeping vaccines cold—even in steamy climates where the temperature may regis- ter a high of 43°C (109° F). And there are guidelines for packaging vaccines and for shipping them internationally, drawn up by WHO and UNICEF. Now, more than ever before, countries are strengthening their cold chain systems. Foremost among the reasons that lead WHO to tap the sun as a source of energy is the lack, or irregular supply, of electricity, particularly in rural areas of trop- ical countries. Another reason is the high price, and increasing scarcity, of kerosene and liquid propane gas which are used to fuel refrigerators. Added to all that, domestic kerosene in a number of countries has been shown to be of a quality more suitable for industrial use than for wick burners which power refrigerators. Much has already been done to build and maintain the cold chain from producer to user. Another development in vaccine storage, for instance, is the "ice-lining" refrigerator, with the capacity to maintain temperatures on only eight hours' supply of electricity daily. In addition, national per- sonnel are being trained in handling and distribution of vac- cines, as well as in skills to maintain and repair equipment. "Solar-powered refrigerators could turn out to be a viable option in the future", WHO offi- cials say. "Although more dif- ficult to install, solar-powered refrigerators are simpler to op- erate and easier to maintain. In addition, there is the question of costs." The price of a conventional refrigerator, and the costs of operating it for ten years, are estimated at US $1,750. The solar fridge now costs more, approxim- ately $5,000, but the price is likely to drop to under $2,000 by 1984. As there are no fuel costs, a solar refrigerator over the long haul could be less expensive to op- erate than a conventional model. Plague Cases Down, Deaths Up in 1980 The number of cases of human plague reported from around the world decreased by 376 between 1979 and 1980, but deaths in- creased by 26. According to WHO's Weekly Epidemiological Record, there were a total of 505 cases and 56 deaths in 1980 as against 881 and 30 the year before. Among the details: The highest number of cases, 283, and deaths, 29, in 1980 were reported from Asia. Those figures represent a decline from the 387 cases, but a rise from the 16 deaths of the year before. While Viet Nam accounted for most, 180, of the Asian cases in 1980, the numbers dropped from the 306 of the previous year. The country also reported a decline in deaths, from 8 to 5. Two other countries reported, Burma with 73 cases and 4 deaths, and China with 30 and 20 respectively. The Americas reported the second highest total, 142 cases during 1980 in four countries—a sixfold increase over the 23 cases of 1979. The number of deaths also increased from 2 to 7. The sharp rise followed outbreaks in Brazil, which were, the report says, "most marked in the north- eastern States of Ceara Bahia, and Pernambuco". Brazil repor- ted 98 cases but no deaths. Bolivia reported 26 cases and 2 deaths, and the United States 18 and 5 respectively. Most of the U.S. cases, 13, occurred between May and September in six coun- ties of New Mexico, but cases were also reported from Califor- nia and Nevada. African cases declined from 471 to 80 over the two years, but deaths increased from 12 to 20. Four countries reported in 1980: Angola for the first time since 1975, with 21 cases and 4 deaths; Kenya, 5 and 2; Moz- ambique 10 and 5, and Tanzania 44 and 19 respectively. Clear Writing, an Aid to Development Clear writing can advance the cause of development particular- ly in rural areas of the Third World. Such is the conclusion of a study by the University of Nairo- bi, and the theme of a manual published by Volunteers in Tech- nical Assistance, a U.S. private, non-profit organization. But with a single exception, all rural papers in Kenya, Tanzania and Zambia are edited by non- 30 WORLD HEALTH for readers everywhere 1982 Subscription Rates One year Two years Three years US$ 15.— 27.— 36.— Sw. fr. 25.- 45.- 60.— ORDER FORM Please enter my subscription to "World Health" as follows: One year ❑ Two years ❑ Three years ❑ I enclose cheque/international postal order in the amount of • Name: Street • City: Country: World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. World Health is also distributed through the network of international bookstores and subscription agencies. For payment in national currencies, please contact your usual bookseller. journalists, according to a study sponsored by the U.N. Educa- tional, Scientific and Cultural Organization and carried out by Prof. Peter Mwaura, director of the University's School of Jour- nalism. "Writing for a rural readership requires special sen- sitivities and skills", he says. The study recommends that the grass-roots press be run by a new breed of journalists who are trained not only to report clearly, "in terms which the villagers can understand", but who are also educated in local ways, and thus appreciative of the problems of rural dwellers. These qualifications are needed to interpret and explain changes to them, thereby fa- cilitating development. Because of the widening cul- tural and economic gap between industrial centres and the coun- tryside, newspapers in cities have, in large measure, failed to reach rural audiences, the study says, in calling for the re- structuring of the grass-roots press to do the job. Titled "Plain Talk: Clear Com- munication for International De- velopment", the manual is aimed mainly at multi- and bi-lateral development agencies. Its pub- lication has been deemed suf- ficiently newsworthy for the pages of Development Forum, a U.N. monthly devoted to promot- ing development. "The path to international de- velopment is littered with projects that have failed because planners used language and pictures that others could not understand", it states. According to author Mr David Jarmul, "writing for development projects should be as easy to understand as possible. After all, it is hard enough to understand a new concept, or how a com- plicated machinery works. Dif- ficult language just makes it harder." • In the next issue World Health Day 1982, which falls on 7 April, will be devoted to the aged, with the slogan "Add Life to Years". Representing an increasing proportion of our planet's po- pulation, old people have plenty to contribute to the community; they also have special needs. The February- March issue of World Health examines their social standing and their aspirations in dif- ferent parts of the world. Briefs Aging. While the total population in Asia is projected to increase by 52 per cent by the year 2000, the number in the 60-plus age group is expected to rise by 102 per cent. These population projections were presented at the first Asian regional meeting preparatory to the U.N. World Assembly on Aging, which is scheduled for Vienna this year, from 26 July to 6 August. On the Agenda are two major issues—developmental, such as the effect of aging populations on economic and social programmes, and humanitarian, such as health, housing, social welfare, and income security of the aging. So preoccupied are most Asian nations with other problems that there is little awareness of their changing demographic make-up. The U.N. Economic and Social Commission for Asia and the Pacific says that, thus far, little attention is paid to the needs of the aging. Canada Joins. Canadian scientists took part in the work of the International Agency for Research on Cancer, Lyons, France, for years, even though their country was not a member. Last October however, Canada joined up to formalize a long-standing working relationship, and to become the agency's twelfth member. The eleven others are: Australia, Belgium, Federal Republic of Germany, France, Italy, Japan, the Netherlands, the Soviet Union, Sweden, the United Kingdom and the United States. Chimpanzees, Monkeys. WHO has been urged to step up development of an international programme in primates, aimed chiefly at protecting the primate populations of all species, particularly the chimpanzee and monkey, and at deciding upon the numbers needed for medical research. None of the species identified as endangered or rare by the International Union for Conservation of Nature and Natural Resources, Switzerland, experts from ten countries say, should be taken from the wild for biomedical research. Financing of the programme is now being sought. Danger in Diving. An international medical guide for divers should be drawn up and made standard equipment on board all ships from which divers work, a joint ILO/WHO committee on the health of seafarers recommends. Diving is a dangerous profession, it says, pointing out that the casualty rate of divers exceeds that for seafarers or fishermen. People. Appointed as Director, WHO's International Agency for Research on Cancer, in Lyons, Dr Lorenzo Tomatis (Italy), effective from January. A staff member since 1967, he was formerly Director, Division of Environmental Carcinogenesis. He succeeds Dr John Higginson (U.S.) who was appointed in 1965 as the agency's first director. Smoke Without Glamour. As a measure to deglamourize the image of a smoker, President Fidel Castro is quoted by Reuters as saying: "My contribution will be not to smoke in public." He made the statement while launching, last October, an anti- tobacco campaign in Cuba. Vaccines: Never on Some Days. Air shipments of vaccines, the most delicate of biological products, should be planned so as to ensure arrival on Mondays, Tuesdays, Wednesdays or Thursdays. This is one of a series of recommendations on international shipment drawn up by WHO and UNICEF. If shipments arrive close to non-work days, that is Friday, Saturday or Sunday, then risks of delays, and consequently of vaccine spoilage, are higher. (For related story, see opposite page.) Authors of the Month Dr Halfdan MAHLER is the Director-General of the World Health Organization. Professor Paul STEINBRUCK is a specialist at the Medical Academy for Further Education in the German Democratic Republic. Dr Antonio Pio is the Chief of the Tuberculosis and Respiratory In- fections unit at WHO headquarters in Geneva, and Dr Jerzy LEOWSKI is the Medical Officer in the same unit. Mr Jose C. ABCEDE is the Public Information Officer for the West- ern Pacific Region of wilt), based in Manila. Professor Stefan GRZYBOWSKI is Professor of Medicine at the University of British Columbia, Vancouver, Canada. Dr S. J. NKINDA is the Senior Medical Officer with the Tanza- nian Ministry of Health, based in Dar-es-Salaam. Dr H. STOTT is a tuberculosis epidemiologist with the British Medical Research Council in London. Pr in te d i n S w it ze rl an d Im u ri m e ri es P e n n ie s S. A . La u sa n ne MF Home-visiting by community health workers, as here in India, h e ps detect early cases of tuberculosis. (Photo WHO/A. S. Kochar)