EXCLUSION OF ‘TB EXPERT’.
Program suffers from a unique lack of professionalism; the entire clinical operation appears somewhat non-technical. In the absence of any criteria for the selection of its key person (the district TB officer), non-experts are practically running the show. Leaving TB-expert unused means national waste. Worse, experts do not get to supervise, not even remotely, the clinical decisions of the vast army of field doctors some of whom, despite a solitary training on paper, have little motivation or aptitude for TB. TB-expert must be made to closely oversee each field doctor – like a big brother.
All key DOTS players in the field remain saddled with enormous non-TB work. They end up working part time for TB – a gloomy prospect in combating what the WHO deems ‘a global emergency’.
For over half a century, man has indeed possessed diagnostic and curative medical tools necessary to eradicate TB. Therefore, TB control is no more considered purely a medical problem; it is more of a socio-economic challenge – that of proper application of principles of public health management in resource-poor settings.
India is swarming with TB patients. Their sheer numbers overwhelmingly outweigh the tiny pool of experts; a logistical nightmare. Rather than being the monopoly of a handful of experts, TB-control craves participation of a rapidly growing number of non-specialized people, including physicians, nurses, technicians, government and international organizations. Within the design of DOTS there is a deliberate attempt to rescue TB management from being the fiefdom of a handful of TB-specialists. The baton has been passed on to an infinitely larger domain of qualified MBBS doctors – to be specially trained and mobilized – for this mammoth effort. However, “… a rather skeptical attitude has sometimes been observed on part of a few persons mostly specialists towards the new approach. This small but influential group has a deep-rooted if bona-fide belief in the omnipotence of sophisticated technology. They distrust inexpensive and apparently less-than-perfect procedures that can be used by non-specialized personnel, even though these procedures have proven their worth both in controlled trials and in regular practice.” * (11).
Such thinking was possibly behind expulsion of TB expert from DOTS.
Like a TB patient, TB expert too appears untouchable today; dubbed a skeptic who can’t be trusted to unlearn his age-old convictions, he stands isolated. India has the dubious distinction of harboring not only largest number of TB patients for a single country in the world but also TB experts, bulks of them serving under the government. But their potential remains untapped; a rich human resource thus remains un-exploited.
The architects of DOTS – themselves often experts in social, preventive, community and public health medicine – seem convinced that a TB specialist is a specimen best avoided – a phobia that has culminated in a unique lack of professionalism in the program – from top to bottom:
1. Were the scriptwriters and architects of Indian program TB experts?
It is not by accident but by design then that during the crucial years when various facets of this new program were being finalized, the top brass affecting the transition – from NTP to RNTCP in India – have been anybody but TB experts.
· For example, the prerequisite for the key slot of ‘Deputy Director General (DDG TB), Central TB Division, New Delhi’ (virtually the captain of this new RNTCP ship) happens to be ‘post graduate Degree/diploma in Public Health with sixteen years standing in the profession’.
· The key post of ‘TB Chief of WHO for South East Asia Region’ remained occupied by non-TB doctors during the relevant periods.
For all practical purposes, officials on these two slots between them delivered the newborn baby; they clinched the current RNTCP module.
2. Are the program- monitors and umpires TB experts?
Most of the 100 odd elite RNTCP consultants inducted by the WHO exclusively for monitoring the implementation of this program are not necessarily TB experts; and only the ones with Public Health or PSM background reportedly enjoy brighter future prospects. Several candidates are plain MBBS and possibly possess meager knowledge about clinical tuberculosis. With 10 to 15 days training, the selected candidates are deemed ready – to act as elite super-cops over everyone else – including genuine experts in the field.
3. Is the team leader of each district (the unit of the program) a TB expert?
A. District TB Officer (DTO):
There are no criteria laid down for selecting District TB Officers – the key players. Most of them are non-experts. While there is no dearth of TB experts or even physicians who possess the degree of MD Medicine, a non-expert (plain MBBS doctor) often remains at the helm of affairs – as District TB officer or as Medical Officers TB Unit. Of course, he often undergoes a 12-day special training. While readymade experts are brazenly ignored, millions of dollars are going down the Indian drains in the name of TB training of doctors, beginning from a scratch.
Of the 20 districts in the state of Haryana, probably only one district (Gurgaon) is headed by a TB officer who is a TB expert (as on 22.02.2006).
B. Similarly, there are no pre-requisites laid down for the selection of the other key leader – namely Medical Officer TB Unit (MO TU).
Furthermore, the annual ritual of transfer / posting is often a political tug of war amongst doctors; the situation perpetually remains fluid and uncertain like a musical chair race. Redeployment is an unscientific exercise in which if there is something that never gets counted, it is the qualification, merit, skill or dedication of a candidate. So, just anyone with political connections can effortlessly slide in to the driving seat – as DTO or Medical Officer TB Unit, the key program posts.
India is in the midst of a tragic comedy. While TB experts rot in non-TB assignments, experts in various other streams rot in TB. And TB patients rot at the hands of amateurs.
‘Health’ is a ‘state subject’ in India – another major impediment in quick solution:
In several states and union territories, a criminal mismanagement of the human resource is going on over which Central govt. that conceives every national program has no control whatsoever. The state govt. every year scores self-goals with impunity by disrupting efficient public service being provided by a dedicated surgeon, pediatrician or an eye surgeon etc. by way of exiling him to a national program e.g. TB or Malaria or Family planning or promoting him to purely administrative work. As a result, numerous families enjoying the fruits of dedicated service of that specialist suffer in silence. What can any one do when the fence itself eats the crop? Our very own government hurts the voiceless public incalculably, ironically in the very name of what it brazenly defeats – public interest.
Examples of such anomalies abound in Haryana* (12).
The missionary anti-blindness work of Dr. Raj kumar (MS Ophthalmology) was ruthlessly terminated while he was forced to languish as District TB (cum Malaria) Officer from 2004 to 2006 at district Panipat, Haryana. This highly accomplished eye surgeon with over 1000 cataract surgeries to his credit in the past, could easily have saved / restored vision of thousands of other human beings during the two fateful years that he was forced to grapple with an unfamiliar arena, most uncomfortably.
Prayer No. 3
Criminal mismanagement of the human resource, ongoing as a routine in public health, must be stopped forthwith and once and forever.
Scores of doctors remain posted at the wrong slots; examples galore in Haryana. Reprinting the lists or details at this juncture in this petition might be burdensome for the honorable court but scores of such heart-rendering examples can be found in the book titled The Test of Time* (12) on pages 75 to 83 (attached as annexure).
· Since 3.8 million Indians become blind annually, no eye surgeon in India should ever be posted to TB or malaria. Each one ought to stick to ‘eye’ alone. Even then, we may not be able to wipe out the daunting backlog.
· Unknown to the public, while specialists languish doing ordinary work in empty peripheral health centers, several large crowded referral hospitals in Haryana are clandestinely being run without the minimal quorum of 9 specialists –
1 physician, 1 general surgeon, 1 orthopedic surgeon, 1 anesthetist, 1 pediatrician, 1 ophthalmologist, 1 gynecologist and 1 radiologist!
· There is excruciating artificial (man made) scarcity of general surgeons in government hospitals. Poor patients have no option but to rush to expensive private nursing homes for common and easily correctible surgical emergencies; yoke of debt enslaves them for a lifetime. Then again, all that several gifted govt. surgeons are made to do with their golden fingers is flip through the pages of dusty files and write administrative reports as CMO or Director.
· Posting a surgeon or an anesthetist to a tiny health center devoid of any operation theater facility is no less than mockery of allopathic medicine.
· While several anesthetists are made to rot in administrative or mundane clinical work, several busy operation theatres in government hospitals in Haryana clandestinely run without a qualified anesthetist, endangering human life.
· Exiling Pathologists and Microbiologists to perform alien work as depicted earlier (on page 14) while amateurs manage our clinical laboratories and blood banks is like deliberately fitting a square peg in a round hole.
All such heartbreaking anomalies ongoing as a routine since independence are illegal, anti-allopathic, anti-social, anti-national and anti-humanity and must be set right – once and forever.
Alas! No agency in India has ever bothered to acknowledge this major flaw within health-care, forget beginning to set it right. And, going by the law of probability, no single agency can or will do so – for another 50 years.
Unless judiciary intervenes!
Part-time attitude of all DOTS workers:
Not only is the team leader a non-expert; by design he is incessantly kept distracted and burdened with trivial non-TB work:
Of the 667 districts that India is divided in to, the program has so far been implemented in about 632. A District TB Officer, who is the epicenter of entire activity, heads each of these districts. He is thus like TB God who shoulders an awesome responsibility for millions of local people. Apart from clinical duties of diagnosing and categorizing patients, he is a big time manager too. He has to tirelessly jeep around his vast district, inspecting TB work in numerous clinics; meeting, motivating and training a huge staff and compiling and then filing voluminous monthly and quarterly reports of this program.
As if he were a superman, it is not uncommon for him to be saddled with dual charge – additional full time work of the district concerning any one of the 18 national programs ongoing e.g. malaria, polio, leprosy, family planning, RCH, AIDS, PNDT etc.
The premise that every health employee (be it DTO, MO TU, a doctor in PHC, CHC; LT, STS, STLS, MPW, LHV) is responsible for every national program also means that there is no clear-cut charter of duties, no division of labor and hence no accountability. There is unfathomable ambiguity, overlapping, confusion and chaos, all of this ordered by higher officials, ironically, in the name of public interest.
Moreover, like every other doctor, the district TB officer too gets frequently drafted for sundry duties concerning administration, health camps, post-mortem, court evidence, floods, riots, natural disasters, elections, demolition squads, religious fairs, festivals, cultural events, sports fixtures, trade fairs, VIP visits, political events, drug-stores or purchase committees etc.
Trapped thus in a quagmire of non-TB duties, he ends up working merely part time for TB. In the wide spectrum of his duties, DOTS practically is just that – a tiny dot. Is the awesome task of TB eradication just a part time job?
Is the army of doctors, the real players in the field who are actually running this program all across the nation, TB experts?
The vast army of doctors diagnosing and treating TB patients at the grass roots level in peripheral clinics, dispensaries, primary health centers are mainly plain MBBS doctors, roped into the program – not by choice or self-motivation – but purely by default.
An average plain MBBS doctor, the real foot soldier of this program, cannot be deemed by any stretch of imagination to be a master of TB. The single RNTCP training of 2 days hardly does justice.
After all, could a couple of dancing lessons make you Michael Jackson?
In undergraduate medical schools, TB as such is a low-key subject, meriting just a few sleepy lectures. Fully aware that a branch dealing with the poor can hardly fetch money or be one’s passport to the glittering West (which is more or less TB free), the budding doctors accord low priority to it. Moreover, there is no systematic pressure on physicians to regularly update their knowledge. Educative events in doctors’ clubs revolve around lucrative branches (like cardiology), since offers of sponsorship galore. Profit oriented corporate hospitals and drug companies are hardly interested in sponsoring meets on non-revenue generating subjects like TB, malaria, diarrhea, anemia, leprosy, filaria, malnutrition etc. – the common ailments of the masses. No wonder, TB awareness amongst doctors themselves is often found dismal.
Alas, the big brother is NOT designed to watch over the shoulder:
Not only does a doctor of this vast army diagnose and categorize a patient independently, he is designed to do this highly complex exercise unilaterally and dictatorially – without an iota of supervision by anyone; the TB expert doesn’t so much as remotely watch his clinical judgments. Entire clinical operation of this program is thus non-technical; experts don’t supervise the army of amateurs. The crude arrangement is fraught with grave danger to human lives; it fosters wrong diagnosis, under or over-diagnosis especially in sputum negative, atypical, pediatric or extra pulmonary cases; and needs immediate remedial steps.
I know – I know syndrome: Furthermore, in the absence of both – an expert as well as a well trained district TB officer (who is on the move and unavailable), an ominous undercurrent of ‘I know – I know syndrome’ amongst lower employees appears to be fast gaining ground, further diluting the key process of diagnosis and categorization, the heart and soul of DOTS.
To clear the mammoth backlog of pending cases in the judiciary and for speedy dispensation of justice, would it be just and proper for the govt. to declare: “After imparting a special 6-hour crash course of training – the onerous adjudication duties shall also be delegated to each advocate of India. Furthermore, in his absence, even his ‘specially trained’ munshi stands authorized to dispose off cases there and then”?
Over-diagnosis of TB is a sin: Erroneous label of TB is most unfortunate. A human being must ‘earn’ anti-TB medication – through arrival at confirmed diagnosis or as close to it as is humanly possible. Because, the antibiotics of TB are highly toxic. If a healthy or a non-TB individual is condemned to an unwarranted 6-month-long course, the side effects can be highly injurious to – liver, kidneys, joints, eyes, ears, nerves, blood or skin etc., rarely, even fatal. So, when drug toxicity manifests, only a specialist can handle it.
Probability of over-diagnosis is far greater at the hands of a novice (as is highly likely to occur under the current design of DOTS) than when an expert himself examines the patient or he at least closely oversees like a big brother the clinical decisions of a non-expert (as prayed in the petition).
Deliberate exclusion of both – radiography as well as TB expert – from the menu of a TB program seems funny; cooking an omelet without the eggs?
First exclusion compliments the second:
Modern man craves automation and programming. Like in a calculator, response to every eventuality must be predetermined, automatic and reproducible. No patience for ambiguity or unpredictability. Either white or black, no gray, please.
Sputum test, which is either positive or negative, gels with such penchant for precision. X-ray shifts the paradigm – to gray, introducing abstract variables like clinical sense, X-ray reading skills – facets of the fading ancient art of clinical medicine. Detached objective evaluation of a statistician outweighs subjective impressions of clinicians. X-ray would make TB expert indispensable – just what the architects appear to have avoided by design. First exclusion, radiography, complements the second, TB expert.
Progressive programming of medicine in the West, obviating the need for grand clinical skills, is indeed occurring but is on account of foolproof, expensive and fathomless investigative backup; while here we are further depleting our dilapidated investigative faculty by relinquishing radiography.
Program expediency and sheer economical considerations rather than sound scientific reasoning and patient welfare seem to have been the overriding determinant in the unfortunate omission of radiography and exclusion of expert.
Prayer No 4
Create an exclusive TB constituency within the district health care network. Strengthen the TB Units, the pillars on which the program rests.
Minimum qualification for DTO and MOTC (MOTU) ought to be one of the following:
· MD (Chest & TB)
· MD (Medicine)
· Diploma (Chest & TB).
Furthermore, such an expert will closely supervise all other doctors. He will:
· Reconfirm diagnosis of each patient done by doctors at the periphery.
· Re-certify the category allotted to each patient.
· Certify at the end of two months of treatment that the patient has indeed sufficiently improved to be safely shifted from IP (intensive phase) to CP (continuation phase) of treatment.
· Certify cure.
A DTO (and MO TU) must be carefully selected, trained and then retained within the program for the next 10 years; being transferred only as a DTO of another district.
No part-time attitude please! : Every person involved with tuberculosis – DTO, MO TU, LT, STLS, STS – shall exclusively perform TB related work and nothing else except in a national disaster; he is exempted from non-DOTS assignments – for next 10 years.
Strengthen STDC: It is imperative that the STDC (State Training and Demonstration Cell) is systematically strengthened so that it is not just a figurehead but enjoys adequate powers in the states to be able to efficiently perform management, supervision, monitoring and training. All transfers / postings of DTO’s, MO TU’s, and other doctors on the forefront of DOTS must rest with STDC and not ignorant politicians or bureaucrats.
Improve quality of human resource: All DTOs, MO (TU)s, STOs, RNTCP consultants, Central TB division consultants and program managers / workers must undergo a mandatory annual ONLINE All India Technical TB Test Paper. Anyone failing to score a minimum of 60% marks must be shunted out. This will deter Central / state governments from appointing / transferring the key players arbitrarily, at their own whims and fancies.
Read Further? – The Test of Time (Criminal Mismanagement of Human Resource