Compliance of patients and physicians: experience and lessons from tuberculosis-I.

For over 30 years I have been engaged in full time research into tuberculosis. Our major aims have been to improve chemotherapy, particularly of pulmonary tuberculosis, in a large series of controlled clinical trials and then to introduce the advances made into tuberculosis control programmes under routine service conditions. Over this long period a dominant and continuous factor influencing the direction of the Medical Research Council's programme of research into pulmonary disease has been the problem of ensuring that patients take their medicaments regularly and for the prescribed period. World wide, poor patient compliance has been, and remains, the principal cause of treatment failure. Among the major advances in the past25 years resulting from controlled clinical trials was the demonstration that admission to hospital was not necessary to treat pulmonary tuberculosis effectively. This was already well documented in the early 1960s, particularly in the Madras study of patients and their family contacts.' This development, however, highlighted the problem of patient compliance with outpatient self medication, which had already been recognised in the mid-1950s.' A consequence was the development in the 1960s of regimens of intermittent, usually twice weekly, chemotherapy, every dose being given under full supervision.5 An alternative approach, developed in the 1970s, was to shorten the duration of chemotherapy. This became possible with the advent of rifampicin and the reintroduction of pyrazinamide into primary chemotherapy,8 -"