Ambulatory chemotherapy in a developing country: Clinical and epidemiological studies

In October 1955, at the request of the Government of India the World Health Organization (WHO) sponsored the visit to India of 3 representatives of the British Medical Research Council to advise on studies designed to provide information on the mass domiciliary application of chemotherapy in the treatment of pulmonary tuberculosis. This was a problem of great importance, since India, which at that time had only 23,000 tuberculosis beds, has been estimated to have at least 2½ million active cases of tuberculosis (BENJAMIN, 1946), and a national sample survey conducted by the Indian Council of Medical Research indicates that there are at least 1½ million infectious cases in the country (Indian Council of Medical Research. 1959). The Indian authorities were, however, disturbed by the possibility that chemotherapy at home might prove inadequate treatment and that a high proportion of patients might become chronic excretors of drug-resistant organisms. This could represent a serious public health risk if domiciliary chemotherapy were widespread. In the course of discussions it was agreed that it would be premature, with the knowledge then available, to begin with the mass domiciliary application of chemotherapy, even in a limited area. It was decided to investigate scientifically 2 major problems. The first and most important need was for an investigation of the efficacy of treatment at home as compared with treatment in sanatorium, including a study of the risks to which treatment of patients at home might expose their contacts. Secondly, because chemotherapy with isoniazid alone was being used on an increasing scale in India, it was important to investigate closely the efficacy of isoniazid when used alone, compared with standard combined chemotherapy, as well as the epidemiological consequences of an increase in the number of patients in the community excreting isoniazid-resistant organisms. Following negotiations with the Madras State authorities, a centre was established in Madras City (population 1,750,000), under the auspices of the Indian Council of Medical Research, the Madras State Government, WHO and the British Medical Research Council. The latter’s Tuberculosis Research Unit is responsible for the scientific direction of the studies and has worked closely with the Council’s Unit for Research in Drug Sensitivity in Tuberculosis and Statistical Research Unit