Ethical Aspects of the Revised National Tuberculosis Control Programme

Abstract

This paper identifies some ethical concerns regarding the Revised National Tuberculosis Control Programme (RNTCP). Only 10% of those with chest symptoms visiting public health facilities get specific treatment as they are diagnosed with TB. The remaining 90% who suffer from non-TB diseases are not given scientific treatment. This compartmental approach denies treatment to millions of people with chest symptoms. It has also eroded the popularity of public health facilities. Second, though 87% of those diagnosed on the basis of x-ray alone are unlikely to have TB, such unethical wrong diagnoses continue to be carried out under the TB programme. Still worse, the RNTCP’s expectation that only half of TB cases should be smear positive effectively permits up to 50% of diagnoses to be wrong. The actual extent of wrong diagnosis is even higher as the majority of people with chest symptoms first visit private health facilities which base their diagnosis almost exclusively on radiological examination. Third, though 25% to 33% of TB cases get cured spontaneously, and at least two-thirds were cured even with incomplete treatment, the RNTCP insists on full treatment for all TB cases. This over-treatment is unethical, wasteful and also tantamount to scientific dishonesty. Studies to identify different categories of cases (those needing full treatment, short treatment or no treatment) have not been attempted. The introduction (under the RNTCP) of the “success rate” in preference to the well recognised “cure rate” was unethical and unwarranted. “Crying wolf” over Multiple Drug Resistant (MDR) TB to justify DOTS when there is no apparent alarming increase in the incidence of initial MDR tuberculosis cases is also questionable. Other ethical concerns about the RNTCP include the irrational choice of districts leading to exclusion of those that need the services most; exclusion of diagnosed patients from the DOTS scheme, and exclusion from treatment on non-medical grounds. Such exclusions can be up to 58% of TB cases.