Spend now or pay later

An American advertisement for engine oil filters says, “You can pay me now or you can pay me later!” This challenge might do equally well for directly observed therapy for tuberculosis. With the oil filter, buyers are weighing the cost of routine preventive oil filtering against the cost of eventually overhauling the engine because of lack of maintenance. With tuberculosis, the balance is between the costs of routine monitoring to ensure that treatment is completed versus the enormous expense of poor adherence, treatment failure, recurrent hospitalisation, drug resistance, and continuing transmission of infection.

Directly observed therapy refers to the process whereby a health care worker or trained lay person watches while a patient swallows anti-tuberculous drugs over the six to nine months of treatment. The drugs can be administered in daily or intermittent (two to three times a week) regimens in a wide range of clinical settings or at home, work, school, or any convenient designated area.1

Directly observed therapy for tuberculosis has its origins in the late 1940s and early 1950s, when British researchers used it in trials of chemotherapy in Africa, Asia, and London.2 In the United States, despite the arguments of Sbarbaro and others that all patients should receive supervised therapy,2 self administration was standard practice except for patients predicted to …