Strategies for tuberculosis control from experiences in Manila : the role of public-private collaboration and of intermittent therapy

It is estimated that 8.5 million new tuberculosis cases occurred in the year 2001 and that 1.8 million people died of TB. Operational research to improve the use of existing tools is vital. Studies in Manila, Philippines were carried out to exami ne TB illness experience and help seeking of TB patients. Apart from patient interviews, focus group discussions with non-affected urban poor residents and group discussions with public health care providers were carried out. The TB illness burden was found to be substantial; ill-defined suffering, such as emotional and social distress as well as social stigma, was common. Non-affected urban poor residents expressed ambivalence towards TB patients: fear of getting infected contrasted with feelings of concern and support. Interaction with the health care providers was found to be problematic. Misconceptions have the potential to increase the burden of TB. Giving health information, interpersonal skills and other aspects of clinical care need to be improved. The patient interviews also inquired about case finding. Only 29% of the respondents had gone first to a health centre after onset of TB-related symptoms, and 53% had initially consulted a private doctor. Two-thirds of the patients (66%) had received a prescription for drugs, and 29% had purchased and taken anti-TB drugs for at least three weeks before they came to a public health centre. The health seeking delay after symptom onset was relatively short – 64% of the respondents said they went to a health facility within one month. With these findings as a background, we examined the TB-related practices of the private practitioners and approaches to public-private collaboration and assessed the feasibility, acceptability and effectiveness of thrice-weekly therapy in comparison to daily therapy. Forty-five private practitioners of Malabon who treat adult TB patients were interviewed in their clinics. For diagnosis, most private practitioners relied on clinical presentation and result of an X-ray and 96% used X-ray as a tool to monitor treatment. Sixty percent of the respondents prescribed in accordance to international guidelines a regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol. However, over-dosage was common and length of treatment not always correct. For re-treatment cases, none prescribed the recommended retreatment regimen. The private practitioners perceived the main reasons for patient non-adherence to be the patients' lack of finances to buy drugs and patients' perceived well-being after a certain period of treatment. Patients' lack of money was seen as the main obstacle to treatment adherence. The only case holding mechanism mentioned was occasional visits of the TB patients to the clinic. Our findings of the private practitioner's unsatisfactory quality of care and of the limitations of the public sector indicate the need for collaboration between public and private sectors. The private practitioners were therefore asked about their felt needs for additional knowledge on clinical management of tuberculosis and their views on the public TB programme and collaboration with the public health sector. And discussions with personnel of the public health centres inquired about collaboration with private practitioners. The private practitioners' most frequently mentioned needs for updated clinical knowledge were about appropriate use of sputum microscopy, how to tell patients that household contacts need a check-up, and motivating the patients to adhere to treatment. There was considerable interest to receive and follow the national TB guidelines. The main perceived problems they identified with the public TB programme were insufficient drug supply, poor quality of the TB drugs, and lack of health education. Two suggestions on how to establish public-private collaboration (mandatory referral of poor TB patients to the public TB programme and allowing private practitioners to use the governmental TB drugs) were generally welcome, but they expressed reservation concerning feasibility of the latter suggestion. The personnel of the public health centres were positive about mandatory referral of poor TB patients to the public TB programme but sceptical about allowing private practitioners to use the governmental TB drugs. Our findings suggest steps to facilitate public-private collaboration. The public programme needs to be strengthened and collaboration prioritised. Public-private collaboration has great potential to make TB care that is based on the principles of DOTS, the internationally recommended treatment strategy, accessible to more people with TB. While our studies on the private practitioners and public-private collaboration aimed to see DOTS being used more widely, the randomised controlled trial that compared thrice weekly with daily therapy aimed to make the main tool of DOTS, namely short-course chemotherapy, more efficient and patient- as well as providerfriendly. Intermittent regimens (twice weekly and thrice weekly regimens) are recommended, but the evidence base regarding their effectiveness in comparison to daily therapy is not very strong. We carried out a randomised controlled trial: thriceweekly therapy was randomly assigned to 10 of the 20 health centres of a municipality in Manila. All TB patients of the other 10 health centres received daily therapy. Patients were interviewed three times. Drug susceptibility tests were performed. A total of 806 patients (451 under thrice-weekly and 355 under daily therapy) were interviewed shortly after treatment start. 18.5% were re-treatment cases. Multidrug-resistant TB was found among 2% of the new and 26% of the previously treated patients. Under thrice-weekly therapy, directly observed therapy in the health centres was more common than when treatment was daily. Thrice-weekly therapy was more popular among patients and health personnel and resulted in savings of about 40% of the cost of drugs. There were also some disadvantages of thrice-weekly therapy compared to daily therapy: gastro-intestinal disturbances were reported more frequently. And sputum conversion rate assessed after two months of treatment was lower (74% vs. 81%; p = 0.03). Treatment outcome was similar, but treatment failure and default due to side effects was more common among those treated thrice weekly (p = 0.08 and p = 0.04, respectively). In a multivariate model, adverse treatment outcome (failure and relapse) was not associated with mode of treatment (p = 0.7). In the light of the potential benefits of intermittent therapy, its equivalence to daily therapy should be established more firmly and if confirmed, fully thrice-weekly therapy should be used more widely. Our research indicated approaches of how to improve TB control in terms of more appropriate practices in the private sector, better access to proper TB care, and more efficient and patient-friendly use of treatment. Resources and commitment for further operational research and for pilot projects are needed to further test and implement outlined approaches to public-private collaboration and to clarify the role of intermittent therapy

Un étrange étranger

Lorsque Thomas Mulock arrive dans les Hautes Terres d’écosse au début de l’été 1849, il découvre une région meurtrie par plusieurs années consécutives de récoltes désastreuses dont la survie économique ne dépend que du Central Board, la structure mise en place en février 1847 pour venir en aide à la paysannerie des Highlands. C’est dans ce climat de profonde instabilité que Thomas Mulock va commencer à mettre ses talents de journaliste et de polémiste au service de la cause de ceux qu’il cons..

La Question du Home Rule écossais, 1880-1914

Les débats parlementaires qui eurent lieu pour examiner les motions et propositions de lois sur le Home Rule écossais entre 1889 et 1914 constituent une remarquable source d’information sur les arguments qui furent avancés. L’étude des interventions des parlementaires permet de comprendre pourquoi le Home Rule s’imposa sur la scène politique écossaise à la fin du XIXème siècle. L’article tente également de déterminer la place et l’importance du sentiment nationaliste écossais dans les revendications formulées par les Home Rulers. Une partie importante de cette étude est consacrée à l’analyse des contours du dispositif proposé par les Home Rulers et notamment l’articulation entre le parlement impérial et les parlements nationaux et leurs compétences respectives. Sont également étudiés les principaux arguments et contre arguments développés par les partisans et les opposants au Home Rule : la corrélation entre Home Rule irlandais et Home Rule écossais ainsi que la question fondamentale de l’Union, préservée pour les uns et menacée pour les autres, figurent au centre de cette analyse. La conclusion de l’article mentionne certaines des raisons pouvant expliquer l’échec des Home Rulers.The parliamentary debates inspired by the introduction of motions and bills in favour of Scottish Home Rule between 1889 and 1914 are a remarkable source of information to assess the arguments that were put forward in favour and against Home Rule. Studying these debates allows to understand why the question of Home Rule came to dominate Scottish politics towards the end of the nineteenth century. This article also attempts to determine the weight of nationalism in the Scottish claims and to analyse the ins and outs of the schemes proposed by the Scottish Home Rulers — notably the way power was meant to be shared between the Imperial Parliament and the local parliaments. The main arguments and counter-arguments that were used respectively by the supporters and opponents of Scottish Home Rule will be examined, which will lead us to discuss the correlation between Irish Home Rule and Scottish Home Rule. The important question of the Scottish Union will also be focused on: some believed Scottish self-government was compatible with the preservation of the Union while others believed Home Rule threatened this Union. The article concludes by highlighting some of the reasons that may explain the ultimate failure of Scottish Home Rulers to obtain self-government for Scotland

La controverse de Dunrobin ou la résurgence des Highland Clearances, 1976-1977

L’élection, en 1976, de la comtesse de Sutherland au poste de présidente honoraire du Royal National Mod, la manifestation annuelle qui célèbre la culture gaélique en Écosse, déclencha une vague de protestation qui contraignit la comtesse à démissionner de son poste. Les nombreux éditoriaux, lettres de lecteurs et autres contributions d’historiens qui furent publiés dans les colonnes du Scotsman et de la West Highland Free Press démontrèrent que la question des Clearances continuait à diviser l’opinion écossaise. L’étude de cette controverse m’amènera à m’interroger sur la façon dont les historiens perçoivent les Clearances et à examiner la corrélation entre histoire officielle et tradition orale.The election in 1976 of the Countess of Sutherland to the post of honorary President of the Royal National Mod, the annual festival celebrating Scotland’s Gaelic linguistic and cultural heritage, triggered a wave of protest that finally compelled the Countess to resign from her post. As demonstrated by the numerous leaders, readers’ letters or historians’ articles that were published in the Scotsman and the West Highland Free Press, the Scots were still divided over the issue of the Highland Clearances. The analysis of the controversy will lead me to study the way historians have written about the Clearances and to examine the correlation between official history and oral tradition

L’irréalisable mise en application des dispositifs de recours prévus par la Scottish Poor Law de 1845

The Poor relief act is almost a dead letter, and the paupers on some rolls neither get what the law allows them, nor receive their unjust pittance with anything like regularity. On looking into the statistics of pauperism in the northern counties, we meet with some startling facts, which demand inquiry. The average annual allowance to each pauper in this shire (Inverness) is nine shillings, being only one shilling more than in 1741! (Mulock, 1850, p. 57) Thomas Mulock, qui fut, pendant les de..

The Transportation of the Scottish Martyrs in 1793: A Particular Form of Exile?

This article will focus on some of the essential traits of the concept of exile through the study of the transportation of the Scottish Martyrs, the supporters of the radical cause who marked the political history of the eighteenth century, and more particularly of their emblematic figure Thomas Muir, a lawyer from Glasgow and a passionate defender of the French revolution. Fearing the spread of radical ideas, the authorities decided to arrest the leaders of the movement and sentenced them to transportation to Australia.Drawing on the case of Thomas Muir, this article will try to determine whether the time of political exile differentiates itself from the time of other forms of exile, whether political exile is characterized by a state of “fundamental discontinuity”, to use the words of Edward Said, and whether the political, intellectual or ideological dimension of political exiles enables them to overcome, maybe more than other exiles, the essential sadness of exile.Cet article a pour objet d’étudier certains des contours du concept d’exil en prenant pour appui la déportation des « martyrs écossais », ces partisans de la cause radicale qui marquèrent l’histoire politique de la fin du dix-huitième siècle, et notamment leur figure emblématique, Thomas Muir, avocat originaire de Glasgow, ardent défenseur de la révolution française. Les autorités, craignant de voir le radicalisme se répandre dans la population, arrêtèrent les principaux dirigeants du mouvement et les condamnèrent à des peines de déportation en Australie.Cet article tentera de déterminer, en prenant comme point d’ancrage le cas de Thomas Muir, si l’exil politique se différencie des autres formes d’exil. La temporalité de l’exil politique présente-t-elle des traits différents des autres formes d’exil ? L’exil politique se caractérise-t-il lui-aussi par un état de « discontinuité fondamentale », pour reprendre une formule d’Edward Said ? Enfin la dimension politique, intellectuelle ou idéologique de l’exilé politique ne lui permet-elle pas de surmonter peut être mieux que d’autres l’essentielle tristesse de l’exil ?Si l’on se réfère à ce commentaire d’Emmanuel Levinas, qui estime que l’exil s’apparente à une violence qui « ne consiste pas tant à blesser et à anéantir, qu’à interrompre, à faire jouer des rôles où [les individus] ne se retrouvent plus, à leur faire trahir, non seulement des engagements mais leur propre substance », il apparaît que les autorités judiciaires qui condamnèrent Thomas Muir à l’exil ne parvinrent pas à atteindre leur objectif car Muir ne trahit aucun de ses engagements en faveur des valeurs de réforme, de liberté, de justice et de démocratie

La controverse de Dunrobin ou la résurgence des Highland Clearances, 1976-1977

L’élection, en 1976, de la comtesse de Sutherland au poste de présidente honoraire du Royal National Mod, la manifestation annuelle qui célèbre la culture gaélique en Écosse, déclencha une vague de protestation qui contraignit la comtesse à démissionner de son poste. Les nombreux éditoriaux, lettres de lecteurs et autres contributions d’historiens qui furent publiés dans les colonnes du Scotsman et de la West Highland Free Press démontrèrent que la question des Clearances continuait à diviser l’opinion écossaise. L’étude de cette controverse m’amènera à m’interroger sur la façon dont les historiens perçoivent les Clearances et à examiner la corrélation entre histoire officielle et tradition orale.The election in 1976 of the Countess of Sutherland to the post of honorary President of the Royal National Mod, the annual festival celebrating Scotland’s Gaelic linguistic and cultural heritage, triggered a wave of protest that finally compelled the Countess to resign from her post. As demonstrated by the numerous leaders, readers’ letters or historians’ articles that were published in the Scotsman and the West Highland Free Press, the Scots were still divided over the issue of the Highland Clearances. The analysis of the controversy will lead me to study the way historians have written about the Clearances and to examine the correlation between official history and oral tradition

Parcours et détours d’une loi

Un an après l’Irlande, en 1846, la pomme de terre des Hautes Terres d’Écosse est à son tour victime du mildiou. La famine qui sévit alors dans les Highlands, dont l’ampleur n’est certes pas comparable au fléau qui frappe l’Irlande, va néanmoins fortement contribuer à déstabiliser une région qui dépend en grande partie de la culture de la pomme de terre. Le sud de l’Écosse avait été touché dès 1845 mais les Hautes Terres avaient échappé à la contagion ; les récoltes dans les Highlands furent m..

Un étrange étranger

Lorsque Thomas Mulock arrive dans les Hautes Terres d’écosse au début de l’été 1849, il découvre une région meurtrie par plusieurs années consécutives de récoltes désastreuses dont la survie économique ne dépend que du Central Board, la structure mise en place en février 1847 pour venir en aide à la paysannerie des Highlands. C’est dans ce climat de profonde instabilité que Thomas Mulock va commencer à mettre ses talents de journaliste et de polémiste au service de la cause de ceux qu’il cons..