Failure of Directly Observed Treatment for Tuberculosis in Africa: A Call for New Approaches

Abstract

The tuberculosis pandemic continues to evolve. In some parts of the world, tuberculosis case rates have decreased to historically low levels, whereas, in other parts of the world, the incidence of tuberculosis is increasing. In sub-Saharan Africa, tuberculosis continues to be a major threat to individual and public health as incidence rates surpass 1000 cases per 100,000 population in some regions. In 1994, the World Health Organization (WHO) declared tuberculosis a global emergency and introduced the directly observed treatment, short course (DOTS), strategy for global tuberculosis control, but the plan has produced variable success. In the face of this intensified effort to diagnose and treat tuberculosis, the rates in sub-Saharan Africa continue to climb. Various experts have argued that the failure of the DOTS strategy to control tuberculosis results from failed implementation, poor public health infrastructure, poverty, the lack of interventions that are sensitive to personal preferences, and the HIV epidemic. Although each of these reasons may contribute, the problem with the DOTS strategy may be even more fundamental. What is the rationale for the DOTS strategy? Is it a public health intervention designed to curb the spread of tuberculosis, or is it a treatment guideline for tuberculosis?