Treatment as diagnosis and diagnosis as treatment: empirical management of presumptive tuberculosis in India

BACKGROUND: Mismanagement of TB is a concern in the Indian private sector, and empirical management might be a key contributor.OBJECTIVE: To understand factors associated with empirical diagnosis and treatment of presumed TB in India's private sector and examine their effects on TB care.DESIGN: In this ethnographic study, 110 private practitioners of varying qualification who interacted with TB patients (90 in Mumbai and 20 in Patna) were interviewed, and a subset was observed while providing clinical care. Interviews and observations were analysed for indicators of empirical diagnosis and treatment.RESULTS: All non-specialist practitioners began antibiotic treatment, especially quinolones, for persistent cough before prescribing a test. Several factors contribute to empirical management. These include a common practice use of medications as diagnostic tools, a desire to provide rapid symptom relief to patients, a desire to manage illness costs effectively, uncertainty about the presentation of TB, the effects of broad spectrum antibiotics on TB symptomology, and uncertainty about the accuracy of available TB tests.CONCLUSION: Empiricism in general and in TB care is widespread in the urban private sector in India. Ethnography might offer useful insights for addressing this in public-private mix models.