The control programme launched in A, B and C wards in January 1998 targets defaulters since studies have shown that two thirds of TB patients do not complete their course. As each TB patient can infect 10 or more persons, 100 patients back on treatment will mean a check on at least 1000 new cases. `Case-holding', or prevention of default, is also the goal of the new programme.

``Leaving a course midway often leads to multi-drug-resitant(MDR) TB,'' according to Dr A J Desai, Director of RC Bombay Harbour's TB project. ``The patient then spreads MDR bacteria, making it even tougher to control the disease,'' he added. Out of 329 listed defaulters, the NGOs could follow up on only 303 cases but had to narrow down to 94 cases to be taken up for DOTS treatment.

On several reasons for default, Desai revealed, ``Most patients cannot afford to leave their work and come for treatment. Many, on feeling better after a month, stop coming, assuming they are cured. In alcoholics, the combination of poor nourishment, strong medication and alcohol causes side-effects such as dizziness, so the patient defaults.'' By constantly interacting with the patient, reassuring him, and watching him take the drugs, the programme has countered most of these problems.

Nigama Mascarenhas, Director, FSC said, ``We focus on the social aspect of TB, reminding patients of the consequences for their family if he does not recover.'' She says, ``Our field worker goes totheir homes to ensure that he takes the dose. Though municipal workers do the same thing, they have fixed hours of work, during which the patient may not be home.''

A Central TB division document claims that DOTS model `ensures cure by providing the most effective medicine and confirming that it is taken.' It is based on good diagnosis through top quality microscopy, an uninterrupted supply of high quality drugs, treatment that is directly observed and systematically monitored by a health worker. Perhaps the most important aspect of RNTCP is that seeks to treat the patient at a time and place convenient to him/her, and each patient has his/her own marked treatment kit with the full course supplies. Member-Secretary of the Mumbai District TB Control Society and Deputy Executive Health Officer of the BMC Dr K N Khergamkar said, ``We have set up 256 DOTS centres in Mumbai. The patient can visit the centre closest to him. And the kit ensures that the patient is not told midway that there are nomedicines.''

However, Dr Sheela Rangan, Consultant to the Foundation for Research in Community Health points out that the programme fails to look at some crucial social and economic factors. ``Many women are not allowed to travel alone to the centres for treatment and cannot leave household work.'' Success in any TB project depends ultimately, on the motivation levels of the health and community workers who actually talk to patients, said BMC's Deputy Executive Health officer Dr Ramesh Kathuria, at a recent discussion hosted by RC of Bombay Harbour. He mused,``I don't know how many of us would be willing to spend half an hour with an MDR TB case.'' Kathuria stressed that ``different theories of motivation need to be applied, again and again, to ensure success.''

Another critical neglected area is the private sector. According to Rangan, `` About 60 per cent of the population still visits Private Medical Practitioners (PMP). RNTCP must build faith in the public health system. Mahashur says,``PMPs have tobe taken into confidence and explained the efficacy of DOTS.''

Khergamkar assures that the BMC is planning workshops for PMPs in August. ``We are trying to establish a standardised treatment. Since we have enough supplies of drugs, we can give the GPs treatment kits free of cost.''