CHAPTER-I Tuberculosis Control/Pro Introduction In the course of the last seventy five years remarkable progress has been

made in the early diagnosis of tuberculosis its prevention and treatment. The discovery of Mycobacterium Tuberculosis by Robert Hoch in1982 as the causative organism is a land mark in the history of tuberculosis. It became evident that tuberculosis was neither a hereditary disease nor a constitutional one and that the germ causing the disease could be demonstrated under the microscope in the sputum of patients suffering from pulmonary tuberculosis (Tuberculosis of lungs). The discovery of Xrays by professor Roentgen in 1895 further facilitated the diagnosis of early cases with dry cough and sputum. Today X-ray photography has been an established practice allowing the medical profession to discover early and latent pulmonary lesions and at a time when their treatment guarantees in a large number of cases a complete cure. The tuberculosis test since the first decade of this century has provided itself an invaluable tool in diagnosis and epidemiological study when refined in 1907 and 1908 by the method of pirquet, Hamburger and mantouX vigorous investigations in the chemotherapy of tuberculosis led to the introduction of Strepromycin in 1944 which was followed by the discovery of drugs such as Paraaminosalicyclic acid hydrazide in 1952. For the first time in the history of the long drawn out fight against the disease we are in a position to oppose the tubercle bacillus by specific drugs. Along with chemotherapy thoracic surgery too has progressively developed and they have revolutionalised the treatment of tuberculosis within the last decade besides B.C.G. Vaccination today hold promise for a certain amount of protection to uninfected persons likely to be undeely exposed. The road from Lister to Pasteur and Pasteur to loch from loch to fleming and wakesman marks the stages of conquests over various bacterial diseases. A number of countries today can justly be proved of the fact that by planned and sustained efforts they have succeeded in reducing tuberculosis mortality and morbidity rate. It is hoped that in the near future they will be able to eradicated the disease altogether. But where do we in Indian stand in the fight against tuberculosis? Since the dawn of history tuberculosis known as Kshayaroga, has preyed upon human lives in our country. In the earlier years of tuberculosis control in India emphasis was only on treating the individual patient rather than on controlling the diseases in the community. However the individual relief was slow

due to absence of any really effective treatment patients were usually advised open air treatment in a dry climate, this was restricted mainly due to early cases where there was some hope for recovery. Little was done for the patients with advanced disease for they were regarded as hopeless and incurable. In the absence of alternative methods of treatment open air treatment in Sanatoria were built on hills or near sea showers to provide plenty of fresh air to patients. Owing to prohibitive cost of treatment in such sanatoria they were not usually accessible to the poorer section of society that suffered from the disease very often a few philanthropic bodies and individual provided some facilities for the care of the poor tuberculosis patient in sanatoria. Some Christian missionaries in the country were pioneers in providing open air institutions for the isolation and treatment of tuberculosis. At the time of independence of the country there were 11000 beds available for tuberculosis patients as against the estimated needs for 500000. Dispensaries which played a large part in the campaign against tuberculosis in the west began rather late in India. Yet gradually people began to be tuberculosis conscious and antituberculosis societies were formed here and there with the main object of doing propaganda work about the cause and prevention of the disease. In methods of diagnosis and treatment India was for behind until fairly recently. Up to about 1920 the diagnosis of tuberculosis was by the ordinary physical examination X-rays were used but rare Y. the typical tuberculosis cases demonstrated to medical students who were of the chronic fibrotic type with omaciation and clubbing of fingers, patients who were often confined to huts on the out skirts of a general hospital and rarely visited by the doctors medical students except for demonstration purposes. With regards to treatment there was an atmosphere of hopelessness and there was an abnormal almost morbid fear of infection. Treatment was almost nill except for good food open air and dry climatic. It was only after 1920 that artificial pheumothorax widely used in the west from 1905 was tried in India and only from 1905 was tried in India and only from 1932 that thoracoplasty and similar operations were introduced. As these modern method of treatment became very popular the need for specialization was felt and tuberculosis diseases diploma was instituted in madras in 1939 later followed by several another universities. The discovery of anti-bacterial drugs and their use since 1945 in India gradually brought in a ray of hope about combating the disease. To this must be added the development of chest surgery and the increased use of lung resections. Public

opinion was also moving in the direction of finding out ways and means of controlling the diseases. The result was the formation of tuberculosis Association of India in 1939 to educate the public about the seriousness of the disease. By 1945 it presented a memorandum emphasizing the need to consider tuberculosis as a major health problem by the health survey and the developing committee of the Government of India. The government soon appointed a full time advisor in tuberculosis control has been evolved. Simultaneously international organizations such as the WHD and the UNICEF which were taking interest in tuberculosis as a world problem gave a stimulation o the B.C.G programme in different countries. It was in 1948 that the B.C.G campaign was first introduced in India on a small scale and from1951 onwards it has been extended on a max scale. For the Indian BCG campaign the country produces its own vaccine and tuberculin dilutions in the BCG vaccine laboratory in Guindy, Madras/Chennai. About 209 million persons have been tested so far and about 75 millions vaccinated. In spite of various obstacles and handicaps the campaign is going on and has achived something yet much remain to be done. But should the battle be fought on hemidial front only? For long tuberculosis has been regarded as an isolated medical problem. It is high time we started looking at its psychological components also. Medical measures are important no doubt for the diagnosis and treatment of the disease but there are certain equally important non remedial aspects of tuberculosis which need due consideration. In recent years there has dawned some understanding that environment also plays a significant parts in illness. A great impetus to the scientific understanding of environment was given in the late 19th century when the new technique of bacteriology was discovered and applied people came to realize that germs which lay in the environment of the individual could give rise to various diseases. With the growth of chemistry still more disease become casually related to external agents. All this however did not take in account the patient as a whole. It was the unhealthy throat or the leg or some other limb alone that seed to succumb to the forces of pathology. In spite of all the process made by me dicine in the course of centuries it is astonishing that medical men until a few years ago could not think of illness in terms of the organism as a whole scientific work in biology and psychology also demonstrated that function are less localized than was formerly believed and that the organism functions as a whole. Medicine of today in order to be effective, requires consideration of the total needs

and back ground of the individual biological, intellectual, psychological, social, physical, economic, spiritual and cultural. For the sake f spiritual these may be classified into personal and environmental factors. Modern medicine has to regards illness as a vital reaction or mode of behaviour of a person to environmental factors and thus take into account personal and environmental factors in dealing with the illness of the patients and introducing preventive measures. Symptoms and Diagnosis In pulmonary tuberculosis the infection usually takes place through inhalation. Tuberculosis bacill that are inhaled reach the bronchial tubes and penetrate the mocul membrane lining the bronchi. Then they find their way into tissues immediately underneath and step a tiny focus of inflammation. The immediate response of the body to the first attack of tubercle bacilli is dispatch of special body blood cells to the site of infection to surround and if possible to destroy the invading germs in most of us this process takes places without our being aware of it. To radical changes however occur in the body about a month and half after such a subclinical infection. The body acquires additional resistance to the tubercle bacillus and the skin becomes allergic to tuberculin. Though primary tuberculosis occurs mostly in children it occurs in adults also. It is regarded in general as a bengn disease that would heal spontaneously in fact there are however a number of cases of complications in primary tuberculosis that require active treatment including rest appropriate diet & hygienic measures secondary or clinical tuberculosis is that form of pulmonary tuberculosis which results from secondary infection with tuberculosis bacilli. In primary tuberculosis signs and symptoms are usually indefinite or absent if the patient is seen during the height of the acute inflammatory reaction which ordinerly eastsonly a few weeks a slight rise in the afternoon temperature with a feeling of malaise and failure to gain weight satisfactory are usually present. As a rule initial lesion in primary tuberculosis is singly only occasionally it is multiple in some cases specially in older children the primary lesson does not remain localized but spreads and infiltrates the surrounding fissues, and it becomes difficult to distinguish it from the typical infiltration of lungs in secondary tuberculosis. The latter type of tuberculosis shows a marked tendency to progress and to involve increasing area of the lung tissue in a destructive process.

The onset of secondary pulmonary tuberculosis takes many different forms but is usually somewhat insidious. Amongst the early systems are less of weight, loss if appetite night sweats fever and a combination of these or present at some stage if illness generally throughout. At first it often a dry, short ineffective cough with very little expectatoration. As the disease develops it becomes easier and the sputum is more The development of active tuberculosis leads to a consolidated area in the lungs. If this does not scar quickly a cavity may form. It may be mentioned here that unlike most inflammations a tuberculous. Inflammation is accompanied by a decerase in the blood supply to the inflamed part. In secondary tuberculosis as an spitting of blood may occure as an early feature on appear only late in the disease. The tuberculosis protion of the lung erodes in to a blood vessel. When there is heamo rhage. Pain in the chest occurs in some cases. As the disease progress the patient become emaciated the cough is constant and the fever and sweat become pronounced. The above in brief is the picture of the much dreaded disease known as tuberculosis. Owing to the insidious nature of the disease the diagnosis is often preceded by a period of varying length during which patients present symptoms which are suggestive but not necessarily typical of tuberculosis. As the major of the portion of our public is ignorant of the nature of the disease it has often been observed that patients do not usually attach any importance to symptoms. Like lassitude and loss of weight and appetite. Although cough & sputum not often the symptoms which make patient seek medical advice. Inter when they cause of some discomfort or the fever persists the tendency is to ascribe them to any factor present in the environment like excessive heat, worries and inability to obtain a particular type of diet. People do not think in terms if a physical checkup. It has also been observed that people who have some knowledge of the nature of tuberculosis and its symptoms are terribly afraid of the disease. Some may have the lurking fear that they have got the infection but when the facility for screening is provided to then. They try to evade it for fear that it may confirm their suspicion. The try to ignore the early warnings and continues normal life till the disease gains the appear hand and compels them to resort to some remedial measures. Usually the patients reactions to diagnosis is almost one of the panic. To most of the patients the diagnosis comes as a bolt from the blue. The feel that their life is

doomed, some patient after hearing the diagnosis re stunned and they have remarked later that they felt ther were in dream. They wanted to forget the harsh realistic of life and so thought that the world was not real and whatever was told to than was just imagination. Some tool calm and serehe after like diagnosis is revealed to them but in reality they go through a terrible inner turmoil. They are the people who have been taught from early childhood to keep their lips tightend and not to express feeling to others in short patients experience a mental shock as soon as they come know about the diagnosis. DOMICILIARY TREATMENT In recent years there is a growing tendency to give domiciary treatment to patients in techinaclly under developed countries. The realon is the insufficient number of hospital beds available to tuberculosis patients in countries, where the fight against the tuberculosis does not intend. Domiciliary treatment means treatment carried at home. The aim of the latter is to see that the patient is able to carry out the prescribed treatment at home. Domiciliary treatment thus definitely recognizes that the home has a district rule to play in the treatment. So domiciliary if it is to be called OPD treatment or outpatient department treatment must be regarded as a special type of OPD treatment. Where there is some link between the clinic and the home such a treatment programme must keep in touch with the patient at home and see whether he has adequate facilities for treatment. Domiciliary treatment without hospitalization has shown in a number of countries definely better results than where no treatment was given. Well organized domiciliary treatment can be a help in shortening the period of hospitalization for patients. As soon as the disease appears to be under control a hospitalized patient can be discharged to a long term home care programme. Domicilary treatment is short can be of value for. a. The patients who never likes to go the hospital. b. The patients who is awaiting hospitalization.
c. The patients whose disease is controlled in the hospital but who requires long

term treatment programme. d. The patient who breaks away from hospital treatment or signs out against medical advice.

In our country where there is an acute. Shortage of beds the value of domiciliary service cannot be minimized. But the medical profession should be extremely careful in the matter and not regard outpatient treatment as a substitute for hospital or sanatorum care. There are thousands of families in our country who live in one members in each of them. In such circumstances lives with healthy persons day in and day out he is sure to transmit the disease to others. The question of home segregation does not arise due to lack to space. The home treatment of tuberculosis has been made possible by the discovery of antibacterial by the patient himself in the some. Domiciliary treatment of tuberculosis patient on the basic of man chemotherapy has yet to be shown as operationed beasible. We are today aware of many effective antibacterial drugs but major difficulties associated with their use in our country, we have therefore to find an effective and cheap chemotherapy which could be used on domiciliary basis on a wide scale. Though it is true that the treatment away from home adds to certain problems one should not think that the treatment at home doesnt create problem of its own. The nature of treatment for tuberculosis has perhaps something to do with difficulty of successful completion of it. The most important principle is the treatment of inflammation of any organ is complete rest in order to give the damaged structure the maximum chance of healing. Again often the discovery of antimicrobials with their very repaid and definite favourable effect on the course of the disease symptoms, it is becoming more and more evident that it is difficult to convince the patient that he should not develop a false sense of security the short-term drug treatment brings to the patient. It is treatment for at least one year continuing which is the minimum period specified by even the most optimistic tuberculosis experts. There are certain social and emotional problem involved in the home care of tuberculosis. Many patients who feel exhausted due to the disease and want to rest and are adviced by physicians to take it cannot get it in a crowded home. Apart from the problem in tuberculosis treatment there is the big problem of nutrive diet for patients in India a large number of patients suffering from Tuberculosis some from poor families where they cannot get even two square meals a day. When they develop tuberculosis and are adviced a nutrive diet by their physicians they cannot afford it as aresult the treatment is not successful. REHABILITATION UNDER NRHM.

With the discovery of ant-microbials the prospect of tuberculosis patients surviving longer is no doubt more today that ever before. As a result the problem of after care and rehabilitation of tuberculosis patients is assuming supreme importance when the active treatment of the patient is over and he is discharged from the institution that was giving him care he is very often not secure. Many patients feel that their relatives will be afraid to accept them back in to their midst that they will not like to recognize even the relationship with them sometimes the relatives of the patient are afraid of the social stigomaj that can be cast upon them by the circumstances if they claim the relationship. Besides the fear of social stigma the fear of infection also aggravates this feeling. Patients thinks that relatives will be most unwilling to let their children mix with them for fear of infection. So far as dealing with relatives in general are concerned patients show various reactions. Some patients become very guarded in their dealings with their relatives. They do not like to visit them. Under certain circumstances if they have to do so they carry their own things like plates tumblers bedding for their use. They are careful to see that they are not accused of negligence. A few patients do not like their relatives visit them too; because they fell that they come with a critical eye to see how they are really cured or not. It has been found that some patients in order to overcome their sense of inferiority and in adequacy try to be too social. They invite people to tea or lunch and dinner even their disease it not completely arrested of there by perhaps they conscious try to show off that they are alright. Though patients often are glad to recover their freedim & to be out of the hospital or domiciliary treatment. They are not always able to enjoy it much. Thus thousands of patients face the problems of discharge from treatment. Their active medical care may be over but after care is essential not only for those who are chronic cases but also for those whose disease has reached the quiescent stage. For rehabilitating a tuberculosis patient is often becomes necessary to train him for a few type of work altogether. A long careful period of preparation is often required before the patient can start on a training programme. He may be timid or resistant & become extremely upset about the idea of having to take up a new line. The medical social worker does not take up responsibility for vocational training but when necessary he can be called upon to offer case work to help the patient to allay his anxiety and to enable him to work towards vocational rehalrilitation. I our country efforts are gradually being made towards giving better medical care to tuberculosis

patients & we here of some talk about rehabilitation but one should not think that treatment & rehabilitation are two different matters altogether. In reality rehabilitation beings at the point of diagnosis. How the diagnosis is given to the patient and how he accepts it go a long way towards his rehabilitation. It is necessary not only to allay the fear & depression on the part of the patient but also to create an atmosphere of cheerfulness around him & slowly instill in the patient the will to recover & the will to serve & adjust to the world. It needs team spirit between the members of various professions like physicians, nurses, medical social workers. Occupational therapists and physiotherapists to help the patient in the process of rehabilitation. Various professions can co-operateing motivation him, guiding him, removing obstacles or helping him on the way to recovery to & rehabilitation. Yet it is the patient who has to rehabilitation himself. An outstanding feature of the Industrial rehabilitation unit system is that rehabilitation is carried out under industrial conditions. In India very little work had been done so far in the field of rehabilitationof the tuberculosis the main thing for rehabilitation is good treatment. The aim of rehabilitation is to make good treatment complete by restoring the patient to as normal a life possible with his disability. A few cases medical treatment get very little aid towards rehabilitation. Apart from this it is necessary to provide diversional therapy that is work should be given to the patient during the period when mainly devised ro divert the mind away from illness and the boredom arising out of it. Drawing, patient, artificial flower making, basket making, clay modeling, leather work, toy making, kinitting & needle work can provide diversion to the patients. For rehabilitation of tuberculosis patients there will be need for right sanatoria too in our country. In a night sanatorium the patient after his return from work every evening gets medical supervision. We have many patients in our hospital who cannot be discharged home because of unfavourable home conditions and still are not sick enough to held up hospital bed which should be maintained for active treatment. The night sanatorium will provide opportunity to a patient to return to his work life without unnecessary delay & stabilize the gains made during his stay at the hospital or sanatorium. This will pave the way for gradual adjustment at home after discharge from active treatment in a hospital.

For the rehabilitation of the tuberculosis in small towns & cities too there is need for sheltered workshop. These workshops should be for those patients who are unable to take jobs in the open market and are willing to go to a colony. These workshops should produce goods that can be sold away easily in the market and the patient workers should be employed in wages based on the work performed and not on the basis of hour. So that a person can take long hours of rest according to his need and still can earn something. Patients should be allowed to choose the type of work they want in the workshop under medical advice. In the plan of rehabilitation we however should not overlook the fact that a larger number of our tuberculosis patients come from a very poor class. Unless they have a certain amount if financial security for themselves and their families during the period of treatment as well as during the period of training or preparation for taking up jobs in the open market. They will find it extremely difficult to complete treatment or go through any other rehabilitative plan to deserving cases certain amount of financial help has to be provided by tuberculosis organizations for the period of treatment. During the period of training patients can be paid stipends or wages for their work. Rehabilitation services should never be regarded as something extraneous and

exceptional but as an integral part of the normal health, social and economic systems of the country. Thus by gearing the treatment towards the rehabilitation of patients our hospitals and clinics will more remain as repair shops but become links in the chain between the period of health that is broken and restored. Institutional care of patients In country great emphasis is being held on domiciliary the tuberculosis patients are far from satisfactory even in big towns. At the end of the 1962 there were 140 sanatoria and hospitals 225, clinics 152 wards and over 27000 beds available for T.B. patients. There is always a great demand for beds and often the patient diagnosed as suffering from tuberculosis remains in the waiting list for admission in the hospital or sanatorium till his disease is aggravated and he dies. In our country great emphasis is being laid on domiciliary treatment that is treatment of patients in their own homes so that the pressured on hospitals beds is lessened and people get timely treatments. But there are many tuberculosis patients who live in our overcrowded houses and in unhygienic conditions. For them treatment at home is not feasible and is full of risk. If in an overcrowded home the patient under treatment does not have a place toile down the rest during the day when he is

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advised bed rest by his physicians or does not have anybody to take care of him when he is sick or has small children in his one room treatment, who can catch the infection easily it is really risky for him to stay there. However, all is not well when the patient is admitted to the hospitals. Often after getting admission an indigent patient is expected to pay for costly drugs like PAS and streptomycin. Many of our hospitals do not have a sufficient quantity of costly but effective drugs. Consequently all the patients in the hospital do not get the benefit of these drugs. They may occupy the bed sometime and get rest and food but are not in a position to get the full benefit of treatment due to their inability to purchase drugs. Such often discharged after a short stay in the hospital. The quick turn over of patients in most hospitals is due to the fact that there is a long waiting list with a limited number of beds available is institution authorises like to give the benefit of institutionalization even for a short while to the maximum number of patients. After discharge from the hospital patients are advised to go to the outpatient department. However a substantial number of these patients are poor and do not have outpatient department facilities near their residence. Some of them can ill-afford the cost of transportation to a clinics or hospitals. Outpatients department while a few are too weak to cover long distance for taking the treatment. So, they remain at home without any active treatment till they die. During this period if they are sputum positive they infect not only members of their own family but even their neighbours. It has been found that sometimes hospitals and sanatorium authorities are very reluctant to admit very advanced cases of tuberculosis. Some of them seem to have a burking fear that if such patients are admitted and allowed to remain in the hospital for long, they may die there and swed the mortality rate in the institution and consequently bring disrepute to it. It is true that some patients would die during the period of hospitalization. Yet their admission should be justified for the reasons stated above. It would take time to have sufficient beds for our tuberculosis patients and it is not intended that admission be limited to advanced cases only. What is necessary is a new outlook regarding hospitalization of tuberculosis patients. If we overlook the need for hospitalization of our advanced tuberculosis cases we may unconsciously refrain from putting forth efforts to create enough beds and may not care to help so many of our treatable or untreatable advanced cases. Our aim should be to make beds available for all those who need them. That is for those who need beds and whose home conditions are not satisfactory for successful treatment

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of the disease and avoidance of infections to others. The objective should be to provide the best of care to both early and advanced cases. Both Govt. and the public have equal responsibility for reacting this goal. Economical condition of T.B. Patients Hospital setting The hospital is little away from central Daleiput village. It is the only hospital in which there are facilities of Tuberculosis patients. So, generally tuberculosis patients use to come to this hospital from different corner of the state and districts. With rapid industrialization in and around the town and large expansion of administrative apparatus and for job perspective within it. The town of Bhubaneswar also has shown tremendous increase of population during the last decade. The T.B. ward is quiet separate from the main hospital. But at present there are eight patients in the T.B. ward. As shown from the interview that generally all most all patients are illiterate and have come from the rural area of different districts. Even two persons have come from the outside sates for medical facilities. Most the patients are daily labourer and land cultivater. So far as the condition of hospital is concerned the rooms are not very clean, there is no toilet facility. The relatives of the T.B. patients use to sleep on the floor of the hospital. As interview suggested that most of the T.B. patients are not economical very sound and due to their ignorant they fell in prey of the disease. The important facilities available to T.B. patients at this Unit VI hospital is medicine and proper treatment. Health Condition Health is another measuring rod of the economic condition of the tuberculosis patients. It is very difficult to find out a healthy man in this T.B. ward. Now the Govt. is trying his best to T.B. Ward. Now the Govt. is trying his best to eradicate tuberculosis within a very short span of time. Economic status and living As it is noted from the interview that the T.B. patients before coming to the hospital were engaged in different occupations. But most of them were daily labourers and cultivators. The economic condition of the patients are not too bad. Because most of the patients per head income was Rs. 300/- or little above and with reference to the

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families they have small families most of them are satisfied with little household with maximum three children. The consumption pattern, indebtedness, housing condition, possession of desirable consumer goods, etc. immediately indicate their standard of living. It is however collected through accurate data on various aspect of economic and moreover it is further possible to get the figures of net income. It is also possible to know the per capita income of the T.B. patients because it is fully depending upon their daily income. However from the data analysis it is found that the average income of the T.B. patient remain on Rs. 400/- per more. Standard of Livings Standard of living is another remarkable phase of index of socio-economic condition of the tuberculosis patients. Specially socio-economic factors by levels of living beings. The possession durable consumers goods and that standard of housing. An attempt has been made to know the consumption standard of the people in terms of physical intake. But it is not possible to know the fact because the T.B. People are very frustrated and having no boterant on for their own health and etc. But Generally they use to take rice, dal, curry, milk, fruit or eggs whatever available. As there is no any other source. As they do not observe various festival, because they have taken admission in the hospital. Clothing Clothing is as usual like poor people. The literate person of relatively higher grade family person of relatives higher grade family person generally use better standards of present. But the lower grade S.C. or general people used Lungi and Dhoti and women ordinary Sadhi and etc. All the T.B. patients are give beds for sleeping purpose. One or two patients also usually sleep on the floor. Supply of Essential Commodities Essential commodities are being supplied to the T.B. patients on the part of the medical and relatives. All the T.B. patients seem satisfied with such distributions. Because every patients has his own relatives who always takes care for him. So the relatives always provide the essential requirement prescribed by doctor. The hospital also provides bread and milk in each week. The doctor always checks up the day to day condition of the patients. But the nurses are appointed for whole day care.

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Segregation of the Children Segregation of children is the most vital factor of the tuberculosis patients. The T.B. patients also give birth to healthy children after affected by the diseases. So the question arises here either the patient one to keep all of their children with them or want the segregation. If they want segregation then when, where and what type of segregation they want. The researcher measure area of interest is to find out their attitude towards the above question. Preventive Measure B.C.G. vaccinations Two France Scientists, Dr. S. Calmetta and Guerin cultured and sub cultured bovine tubercle bailli in bile pototo media for a period of 1908 to 1921 when they could isolate a strain which was proved to be attenuated and harmless to human being. The vaccine this derived the name B.C.G. from its discoverers (B.C.G. Basille Calmette Guerin). Mass use of B.C.G vaccine was actually made by J.T.C. (International Tuberculosis Campaign) in war devastated European countries and vaccinated over 27 Million persons. Since 1951 Mass vaccination programme is in progress. In Odisha The mass B.C.G. vaccination campaign was started in 1953 August 15thwith six vaccination teams. Having their head quarters At- Cuttack, Sambalpur, and Berhampur. Each zone was allotted with two teams the zones were responsible to some districts to perform the vaccination programme. Firstly the B.C.G. vaccination was given to the individuals after montel test. Those who were found positive in the montuxtest were not given B.C.G. vaccination. The negative cases were given B.C.G. subsequently the teams raised from six to nine and were attached to the head office. The montuxtest and age. To avoid trouble of ice and refrigerator to store the vaccine and the tuberculin freeze dried B.C.G. vaccine has been introduced to avoid the cold chain system and it is more economical then the liquid type of vaccine. Now without montuxtest B.C.G. vaccination is given direct to the age group or 0-20 years. National T.B. Control Programme. Keeping in view of the principles for control of tuberculosis already described National Tuberculosis control programme in India has been formulated. Measures

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should be such as are acceptable to the people effective and are within the financial and technical resources of the country. Objectives of the programme. 1. To meet the felt-needs of the people which in the fundamental objective of any programme. 2. To deal with the T.B. problem through the integrated health services. 3. To give priority on detection and treatment of definite cases of tuberculosis with a view to decrease the people of infection. 4. B.C.G. vaccination of susceptible population aims at protection dangers of infection. Components of the National T.B. Programme. 1. Diagnosis and case finding through (a) T.B. centers/chest clinics cum Domiciliary units in cities, District Head Quarters and (b) Primary centers for the Rural areas of the districts. 2. Treatment- the T.B. Centers, chest clinics cum domiciliary units in the cities and the P.H.Cs take up the treatment of the patients. The districts. T.B. Clinics are provided with T.B. beds. 3. B.C.G. vaccination- Every district T.B. Control Programme has been provided with B.C.G. vaccination team to vaccinate all susceptible population. 4. Training of personnel and research to properly man all the institutions dealing with tuberculosis work, trained personnels are necessary to meet the demands the National Tuberculosis institute at Bangalore has been establishes. In each state a state T.B. demonstation and training center has been established to meet the demand of the state. 5. Record keeping- to maintain uniform record propers and uniform records should be maintained so that all cases are registered and the number of new cases detected may be known for systematic treatment and follow-up. Directorate- For the implementation of the total T.B. Control programme of the state there is a separate organizational set up at the directorate level under the director of health services. This organization works under the state Tuberculosis officer. Who will assist the Director of Health Services in Technical planning and supervision of T.B. control programme of the state health against

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close liaison with the state T.B. Demonstration and Training center District T.B. centers etc, will have to be maintained by this organization. T.B. Control Programme in Odisha There are 13 district T.B. Clinics attached to the District headquarters under this programme functioning in the state. Each T.B. clinics is headed by one Dist. T.B. Officer under whom one B.C.G. Laboratory a statistical unit are functioning T.B. beds for male and female patients are provided in the clinics T.B. Patients are treated there with streptomycin, P.A.S and I.N.H. and other medicines, after the cases are found negative they are adviced to take up domiciliary treatment remaining on their homes. The patients take the prescribed medicines from the nearest hospital, dispensary and P.S.C free of cost to continue their treatment for requires time. The state has a T.B. Demonstration and Training center at cuttack. The District T.B. Officers send their reports and returns indent of medicines and B.C.G, vaccines to the deputy Directors of Health Services (T.B.). the Dy. Director of Health Services (T.B.) is the visioning Officer with the Director of Health Services of the State the Director General of Health Services India, New Delhi. Staffing Pattern of District T.B. Control Programme. 1. Dist. T.B. Officer 2. Male Health Visitors 3. Treatment Organization 4. X-Ra

5. Laboratory Assistant 6. Statistical Assistant 7. Clerks 8. Nurses 9. B.C.G. Team leader 10. B.C.G. Technicians Voluntary Organization T.B. Association of India

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This is a voluntary organization. The President of India is the patron of the organization. Besides this there are President, Chairman, Treasurer and Members. While the President and Chairman are elected and Ex-officio others are paid. The executives formulate the policy matter of the organization. This organization get financial assistance from Govt., besides that it raise funds through selling of T.B. seals. He organization helps T.B. patients and runs T.B. Hospitals, takes UP Educational activities by producing literatures, posters and through other medicals. It organizes refreshers course to the Medical and para Medical personnels, arrange group meeting and seminar, etc. In every state there is a state branch of T.B. Association. Like the centre the state branch has President, Chairman, Secretary, Treasurers and Members. The Governor of the state is the President while the Health Minister is the Chairman, others do the honorary services. The state branch works with the coordination of central assistance. Position of T.B. patients and bed in Orissa It is estimated that nearly 5 millions T.B. patients are in India. While in Odisha it is 0.5 million. It is practically difficult to provide beds in the hospital for their treatment. To avoid such demand domiciliary treatment is encouraged to the patient. The total bed strength in the state is 701 as follows: 1. B.M. Swasthya Nivas 220

2. Udit Narayanpur T.B. Hospital, Kalahandi 65 3. I.D. Hospital, Puri 4. S.C.B. Medical College, Cuttack 5. T.B. Demonstration Center, Cuttack
6. M.K.C.G. Medical College, Berhampur 7. V.S.S. Medical College, Burla 8. Ganjam District Others 9. Sambalpur District Others 10. Dhenkanal District 11. Koraput District 12. Keonjhar District

75 13 30 13 24 16 16 6 36 28

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13. Mayurbhanj District 14. Sundaragarh District 15. Balasore District 16. Bolangir District 17. Kalahandi District 18. Phulbani District 19. Puri District

28 39 28 6 18 16 19

Chapter 2 Methodology and Research Design In Khurda District the District Hospital is situated in the end of the Khurda District. In the District one of the upcoming Industrialized place. So it is quiet natural that a lot of people from different place migrate to this place. The tuberculosis patients are one of them. Generally the tuberculosis patients come to this place for the better treatment. Because this place is both a healthy as well as better medical facilities are also available here. The tuberculosis is such a stigma in our society that people generally fear to mix persons and as a rule cut off all their social opportunities and decide to live a place and form a separate community where they can have better medical facilities and other amenities or in the hospital. But so far as Khurda is concerned the tuberculosis patient generally prefer to stay in the hospital. It is here noticeable that not the patients stay in the hospital but there are some who live in their own houses and do not expose themselves openly in the general. In this hospitals patient of different caste, religion and occupation groups, so the researcher selected this tuberculosis department purposefully for the universe of the study. Scope of the Study Most of the tuberculosis patients are socially isolated and economically strangulated and psychologically exploited by the society. So far the above cause they always keep themselves off the mainstream of society and from socially and economically new structure for their livelihood. So in this study the researcher wanted to find out their family background and to explore the change that has brought about in their present families and the researcher was also interested their psychological view towards the past and the present.

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Objectives 1. To study the psycho-economic conditions of tuberculosis patients. 2. To study the attitude of the tuberculosis patients towards the segregation of their children. 3. To study the occupational change of the tuberculosis patients before and after affect. 4. To study the attitude of the tuberculosis patients towards tuberculosis and towards society. Definition T.B. is a specific contagious or communicable disease caused by mycrobacterium tuberculosis. It affects both the pulmonary and non-pulmonary issues. The disease may accute or cronic, general or local. It is an unbiquitous disease that is found almost everywhere. Tools of Data Collection For the above study data were collected from structured schedule with interview. Looking into the necessary of the study tools like questionnaire observation and interview were taken help of both open ended and close ended questions were asked to the respondents in general preference was given to close ended questions. An information thus gathered by questionnaire was not satisfactory and fully reliable on certain items of the study so timely and necessary observation was made by the researcher. So a structured interview was administered to the patients. Limitation of the study Despite the proper planning and execution of the study certain handicaps which might have crippled up the study are the following. 1. Time factor was a main problem for the study.
2. The members being illiterate were not able to express the factors details.

3. Some of them were not able to answer some questions 4. The disinterested or frustrated tuberculosis patients did not give the full information and some of the answer from them were vague, irregular and with the element of carelessness.

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Chapter Scheme The short dissertation is comprised of six chapters. The title of the first chapter being introduction it touches upon history of the disease, symptom and diagnosis. The second chapter has devoted to methodology and research design which include universe of the study, scope of the study, objectives, research design, tools of data collection, limitations of the study and etc. The last chapter comprises of conclusional and suggestion of the researcher questionnaire has been included in the fifth and sixth chapter respectively as usual Table 1 From the table No.1 it is clear that, tuberculosis more common among males than females. The male population consists of 88% and the female population is only 12%. The comparative low rate of occurances of tuberculosis among females may attribute to biological or environmental factor. Table No. 2 The above table No. 2 shows that the group of 40-50 constitute the majority that is of tuberculosis patients. Then under it the group 30-40 which is 24% and then the lowest number of percentage that is 11% each below to the age group of 10-20, 5160 and 61-70. The researcher has collected datas of both married and unmarried person and is belongs to all age group. Table No 3 Religion is another remarkable feature of each and every society. In my study I found the total number of Hindu patients. The tabulation No. 3 which shows the 100% of Hindu. The percentage may show that the highest percentage of tuberculosis among Hindus due to ill-health condition and lack of proper education. Because almost all patients come from the rural districts and they quite ignorant about health. Table No. 4 Table No. 4 which reveals the mother tongue into various class. In this study the above table analysis which shows most number of respondents belongs to mothertongue Oriya is 78%, Bengali language contains 22%.

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Table No. 5 Caste is the next important accept in the laper society. Above table analysis in No. 5 which shows the existence of maximum number of upper caste belonging to 78% among the tuberculosis patient, I found in that village but schedules tribes is very less percentage that is 11% of total study the schedule caste also comprises the same percentage as schedule tribe that is 11%. The upper caste constitute as many caste as Khandayat, milkman, carpenter, etc. So, it is clear that individually among Brahmin community prevailing rate of T.B. is nil. Table No. 6 Education is the remarkable characteristic of modern age basically education in such a thing which is required in every sphere of society. The above table shows the educational qualification among the tuberculosis patient. According to this analysis it is well evident that illiterate percentage is more among tuberculosis patients which is 66%. Among the tuberculosis patients of this hospital primary education, middle English School, High School and College Education is prevailing in the percentage of 11% and 23% respectively. From the above table it is clear that most of the tuberculosis patients are illiterate. Table No 7 From the above table No. 7 it is found that 44% of the total respondents present occupation is agricultural labourers and daily labourers each which is maximum in number. Business and service holder are very less in number that are only 11%. Out of 9 patients in the hospitals one lady does not any money earning work. She only does her daily routine work in her house. It may be due to the conservativeness of our society or our society does not allow woman to work outside the house. Table No. 8 Income is one of the most vital factor on everyman. From the occupational table is known that most of the tuberculosis patient belonging to agricultural labourers.

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From the analysis of the table shows maximum 50% of respondent belongs to the income group of 05-10. Then this income followed by the income group of (10-15) and 15/- to 20/-. This income shows the socio-economic conditions of tuberculosis patients. This income group primarily dependant. Table No. 9 The researcher has taken all the persons in his study. So only question arise who are married after affected or before affected by tuberculosis. According to table analysis it is clear that 100% respondents marriage occurs before affected. It is known from here that all the patients are suffering tuberculosis very recently or much after their marriage. Table No. 10 Above table No. 10 shows that the number of children of the respondents in of the village. The maximum 57% of the respondents have children under the class of 0-3. It shows that the patients are conscious about the population problem. Then the 43% of the respondent have children under the class 4-6 followed by 43% in 4-6 class. At the time of researcher data collection the researcher has found that most of the respondent have children before affected by the disease. Table No. 11 Table No. 12 The table No. 13 deals with the behaviour of the respondents whose either wives or husbands are affected by the disease. 66% of the respondents answers were that their husband wives are adjusting with them those they are not suffering by the disease. 34% of the respondents told that their wives/husbands are hating them. Table No. 11 The above table which reveals the duration of suffering shows that 33% of the respondents belongs to the age group of one month to 6 months and 7 months to 1 year each. Then 22% of respondents come under the category of 1 year to 2 years whereas 12% belongs to 2 years to 3 years. Table No. 13

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Table No. 14 deals with the respondents interest towards segregation. Majority 55% of the respondents which is maximum in number shows that they have suffered because of their poor health 45% of the respondents opinions are due to curse of God. Table No.15- the last table No.15 which deals with the felling of the respondents towards society shows that majority 66% of them 34% of the respondents view was that the society is non-co-operative towards them. Chapter- 4 Summary, Conclusion and Suggestion Analysing all the facts and figures about the condition of Tuberculosis patients staying in hospital the researchers draws the following conclusions. In Khurda district hospital T.B. wards is very small only 9 beds are available there. People in both sexes coming from the faraway villages and from distance town and villages. Age Group: The age group 35 to 45 bears a good majority of T.B. patients. So that it is found that young persons are suffering more than the older persons percentage is laser in comparison to the young persons. Caste and Religion From the analysis it is found that the whole patients ate Hindu People. It is because Odisha is dominated by Hindu religion people. The upper represent 78% of the total respondents whereas schedule caste and tribe belong to 11%. Education Qualification Illiteracy rate is very huge in the hospital that is 66% against literate rate 23% of the respondent. Among the literacy person primary school respondents are more in number which is 11%. Occupation The occupation of the patients of different types. The highest which is 34% both Agricultural labourers and daily labourers. Then come business if different types. Income Majority 50% of the T.B. Patients income is up to Rs. 5% to 10% and some persons income Rs. 10% to 15% per day.

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Marital Status As per the marital status it is seen that majority 88% of the T.B. Patients are married before affected by the diseases. Number of Children The majority 57% have the children between 7 to 3 in number while only 43% respondents have children in between 4- 6. So it is found that T.B. patients have children before affected by disease. Native Places In this hospital it is found that 22% from Andhra Pradesh 34% from Cuttack and 44% from Puri have come this Hospital. The largest being Khurda districts. ] Duration of Suffering In this hospital it is found that the patients are fairly recent affected by disease. The average period of their affection is 1 year to 2 years. Medical Treatment Due to ignorant it is found that patients had taken any medical advice or treatment but after their consciousness they immediately consulted the doctors. Affected Wives and Husband Neither the husband in case of wife nor wife in case of husband is affected by this disease. They are all out of disease affection. None of their children are affected by the disease. Segregational Aspect It is found that 55% respondents are not interested for Segregation and 45% are interested for segregation. They are interested for segregation for their welfare of their family. Opinion towards Disease The majority of the respondents opinion shows that they are aware that they are affected because of their poor health that constitutes 55% and the rest 45% patients tell that they are affected due to the course of God. Feeling towards Society The majority 66% respondents feeling towards society that the society is cooperative with them and 34% respondents feeling is that society is non-cooperative.

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Concluding Remarks Analyzing all facts and figures the researcher come into the conclusion that the pscho-social conditions of the T.B. patient is not so good as most of the patients are ignorant in knowledge and financially not very sound. About segregation aspect most people do not want segregation while a few T.B. patients want that. Most of the T.B. patients attitude towards societies is cooperative and only a few attitude is that society is non-cooperative. SUGGESTION 1. Tuberculosis is curable if detected in early. Strategies and treatment is continued without any disturbances in the middle. The stigma of T.B patients are such in our society that they are always neglected by all. So that the environment shows the environment should be created such that the T.B. people can live like a dignified person. So more T.B. rehabilitation centre should be opened in addition to treatment center. 2. Both the people and voluntary agency have to come in the big way to boster off the efforts of official agencies in getting T.B. rooted out forever. 3. The patient oriented approach should be replaced by community oriented approach. The school teacher should be trained properly as a result he can give new ideas in the mind of young. 4. It should be spread among the people that T.B. like any other diseases is less infectious. 5. T.B. caused by germs. It is neither hereditary nor a curse of God. 6. The T.B. patient should continue to live at home and do normal work under regular treatment and it is also advisable to the family members not to isolate them and accept them in family & community. 7. Economic generating activities should be continued there as a result people can be self dependent. 8. Patient should be take care to their health and also should take regular treatment. Bibliography 1. The Tuberculosis patient-By G.R.Banerjee 2. A Treatise on Hygiene and public health-By B.N.Ghosh.

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Chapter-5 Questionnaire 1. Personal Data Name of the respondent Sex Age Religion Caste Mothertounge Educational Qualification Literate/illiterate 1. Primary school 2. M.E. school 3. High school 4. College 1. Occupation 1. Service holder 2. Daily labourer 3. Rickshaw puller 4. Begger 2. Income 0-25 25-10 10-15 Above

2. When did you marry? After affected

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Before affected

3. How many children do you have? After affected Before affected

4. What your occupation was before affected? Agricultural Agricultural labourer Industrial labourer If any other specific

5. Is this place is your native place? Yes/no

6. If no give details. 7. When have your migrated to this place? Between 1 to 5 years 6 to 10 years 10 to above

8. Why have/ are you migrated to this place? For professional purpose For treatment purpose To separate yourself from your family

9. How long you have been suffering from this diseases? From 1 to 5 years 6 to 10 years 11 to 15 years 16 to above

10. Is there any of your family affected by this disease? Yes/no.

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11. If yes give details. Sl.no No. relationship Age Sex Educational qualification occupation

12. Have you taken medical treatment at the beginning of this disease? Yes/no.

13. If yes what kind of treatment you have taken? Ellopathy Homeopathy Ayurverdic Sidha

14. If no give details. Lack of medical facility Not curable No money Ignorant etc.

15. Do you take medical treatment now? Yes/no.

16. If no. Frustration Lack of medical facility Negative patients

17. Whether your wife affected by this disease? Yes/no.

18. If yes how she/he is behaving with you? Loving

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Hating Adjusting

19. Any of your children affected by this disease? Yes/no.

20. If yes details. Sl. No Age Sex Educational qualification Occupation years

21. Are you interested to keep all of your children with you? Yes/no.

22. Do you like to segregate them? Yes/no.

23. What is the reason for segregation? For a bright future To make them good citizens To keep away from the disease To keep away from the social stigma

24. Have you made any arrangement for your children after segregation? Yes/no.

25. If yes details. 26. What do you think about this disease? Curse of God Hereditary Poor health No idea

27. How do you feel about society? Co operative

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Non co operative No idea

28. how do you feel about society Cooperative Non-cooperative No idea

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