While appreciating Nora Engel and Wiebe Bijker for their insightful article "Innovating Tuberculosis Control in India", which can make an impact on policy formulation, this critique stands in favour of public-funded laboratory research, drug and diagnostic manufacturing and clinical practice.

DISCUSSION

transmission of TB. The emphasis is on

research and development (R&D) of new drugs, diagnostics and vaccines (p 113, emphasis added).

Tuberculosis Control

Amit Misra The authors then reveal an insight

While appreciating Nora Engel and Wiebe Bijker for their insightful article “Innovating Tuberculosis Control in India”, which can make an impact on policy formulation, this critique stands in favour of public-funded laboratory research, drug and diagnostic manufacturing and clinical practice.

Amit Misra (amit.cdri@gmail.com) is with the pharmaceutical division of Central Drug Research Institute, Lucknow.

“Innovating Tuberculosis Control

in India” by Nora Engel and Wiebe

Bijker (EPW, 28 January 2012) is a timely, well-researched and insightful article on tuberculosis (TB) control. But I hope the authors and the readers of this journal will tolerate a critique that admits to a bias in favour of public-funded laboratory research, drug and diagnostic manufacturing, and clinical practice.

Missing Points

The complaints ﬁrst: it should be obvious to the most naïve among us that TB will not be controlled unless nutrition, sanitation and clinical judgment-based access to healthcare are available without hindrance to all in need. An analysis of innovation in diagnostic and chemotherapeutic intervention for TB control from a social science perspective, without referring to the core of the political problem contributing to the prevalence of TB somehow appears to miss a crucial point.

Next, Engel and Bijker have not addressed what I (and a few others, e g, Bharadwaj et al, Tuberculosis, Edinburgh, 2011) might call a signiﬁ cant happenstance in the supply-side of TB control; relating to innovative, and more signiﬁ cantly, “open source” drug discovery, drug development, drug delivery, and diagnostics development (OSDD), that about 5,000 researchers and students across 130 countries have subscribed to since 2008. The OSDD initiative is a sort of second cousin to “control”, choosing, as it does, to interpose “understanding” and “participation” between innovation and control.

Who proﬁts if I develop TB? In order of ﬁ nancial proﬁt, it would probably be the supplier of drug treatment, diagnostic method, prescriber and controller (who is paid his salary only so long as people like me develop TB). The authors state:

International organisations, donors and pharmaceutical companies are concerned with innovating TB control in order to stop

Economic & Political Weekly

april 14, 2012 vol xlvii no 15

acquired from a “consultant”:

The lack of R&D in TB diagnostics is generally attributed to the rigid price control of anti-TB drugs and diagnostics by the Indian government which prevents even established pharmaceuticals from entering the market, as a pharmaceutical consultant explains… This lack of focus, coordination and competition leaves the research potential within India for TB diagnosis underused. It means that actors conducting R&D often come from outside and lobby through international donors or organisations.

The worldwide market for anti-TB drugs is just about $300 million – add diagnostics to reach $500-700 million, and what kind of proﬁt is the ﬁ nancial world left with? If the dominant paradigm of innovation being led by proﬁ t is accurate, the world will witness no laboratory or clinical research innovation in TB until this ﬁgure climbs to at least 10 times its current ﬁ nancial value.

Putative Actors

The last complaint – the authors use the word “actors” for pharmaceutical producers, policymakers and clinicians. This is disturbing to a lab-rat, who assumes that these putative actors are real people imbued with goodwill, rather than the aggregate that the authors introduce (p 112) as some sort of captives of a sociological milieu:

Partly because TB is a social problem as much as a clinical problem, the ground level realities for innovation are very complicated… control strategies represent a particular balancing act between operational feasibility, biomedical knowledge and socio-cultural factors, …the efforts of coping with TB are a continuous struggle about the right balance between innovation and control. (Note lack of interposition of “understanding” and “participation” between “innovation” and “control”.)

Not very different is their (sympathetic?) perception that:

Qualiﬁ ed private practitioners resent…supervision. They experience the supervision by RNTCP staff, often less senior than qualiﬁ ed private practitioners, as disturbing, inadequate

DISCUSSION

and suspect. Private practitioners tend to perceive the public sector workers as arrogant and claiming to occupy a morally superior position….This arrogance is particularly felt with regard to the RNTCP’s moral judgment of private practitioners’ being only interested in proﬁ t….the TB programme makes use of various forms of supervision and a command and control style management. Qualiﬁ ed private practitioners have, in general, strong apprehensions against rule-based managerial practices which are different to the medical practice of private practitioners. The latter is based on ideals such as individualism, discretion and autonomy which are linked to their focus on individual health rather than public health (p 115, emphasis added).

It is signiﬁcant that the authors choose the word “qualiﬁed” over “competent” to describe medical practitioners, and apparently reduce the TB pandemic to a problem amenable to solution using “management” and “governance” approaches rather than the politically fraught approach of “understanding”. I acknowledge the need to be polite in academic discourse, but to absolve the private sector of responsibility on the basis of noble ideals (individualism, discretion and autonomy) putatively embraced by it, is much too generous to sit comfortably with academic rigour. I would love to be proven wrong by facts and ﬁgures when I say that our country is full of technically qualiﬁed, but clinically incompetent private practitioners who cannot diagnose TB (especially, extrapulmonary TB) from medical examination, lab tests and clinical acumen, have no idea that standard treatment guidelines and best practices are in place, or, despite clinical competence, are either too vain or too scared to refer patients to the public-funded TB chemotherapy programme. Vain, because they might think they know better, and scared, because the government programme, more often than not, it is politically correct to point out, does not deliver on its promise of directly observed therapy – either there are no medicines, or there is no observer. I could expand on horror stories (based on unveriﬁable anecdotal evidence), that adult patients weighing 40-45 kg presenting with haemoptysis are asked for bribes before admission to inpatient care in publicfunded facilities and that residents (junior doctors) obsess continually about their own body weight while posted to the TB ward, but that would be beside the point.

Notable Insights

Before this turns into a diatribe that is too long to print, I would like to reiterate my congratulations to the authors for their insights: (p 114): “there is no coordinated fostering of the innovative potential for new diagnostics within India…There are smaller players in Indian medical colleges, who have developed their own in-house test for multi-drug resistant tuberculosis (MDR-TB)… but who are not considered by the government for these evaluation studies. They feel excluded and blame the government for not taking them into account… (p 116): Current policy mechanisms that are focused on implementing one solution to a multiple and complex problem such as TB are outdated. These do not work… (p 116): There is thus also a need for policy innovation: how differences in practices of control and innovation can be constructively discussed and bridged (understood?) in order to cope with power relations, social hierarchies, vested interests, acts of blaming and apprehensions among actors involved.” ...and so forth. As a mildly cynical but eternally hopeful researcher, I venture to offer hope that their article will make an impact on the radar screen of policy formulation in India, and we should be grateful for their diligent documentation and analysis. Let us hope that policy will take the hard decision to support public expenditure in manufacturing and distribution of TB-control logistics, so that ﬁ nancial proﬁ t may gracefully take the backstage, while TB is controlled in a proﬁ t-indifferent manner throughout the world.

REVIEW OF RURAL AFFAIRS

January 28, 2012

Agrarian Transition and Emerging Challenges in Asian Agriculture: – P K Viswanathan, Gopal B Thapa, A Critical Assessment Jayant K Routray, Mokbul M Ahmad Institutional and Policy Aspects of Punjab Agriculture: A Smallholder Perspective – Sukhpal Singh Khap Panchayats: A Socio-Historical Overview – Ajay Kumar Rural Water Access: Governance and Contestation in a Semi-Arid Watershed in Udaipur, Rajasthan – N C Narayanan, Lalitha Kamath Panchayat Finances and the Need for Devolutions from the State Government – Anand Sahasranaman Temporary and Seasonal Migration: Regional Pattern, Characteristics and Associated Factors – Kunal Keshri, R B Bhagat

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