Editorial: Geographical information systems (GIS) and the tuberculosis DOTS strategy

New perspectives and ways of addressing TB treatment and control are needed ( Porter et al. 1999 ). These include different ways of implementing the World Health Organization's directly observed therapy short course (DOTS) strategy, a management package which encompasses government commitment to a national TB programme; case detection through passive case finding; short-course chemotherapy for all smear-positive pulmonary TB cases (under direct observation for at least the initial phase of treatment (DOTS); a regular, uninterrupted supply of all essential anti-TB drugs; and a monitoring system for programme supervision and evaluation (WHO 1994, 1995). The strategy emphasises the importance of the creation and maintenance of a standard, well-managed health delivery structure through which to develop and maintain TB services. Putting this package into action is proving to be slow and difficult (WHO 1998), and there is a need to find ways of being flexible and creative in implementing the strategy. New technology, such as geographical information systems (GIS), may be useful in this process. In a paper in this issue, ‘Spatial implications of the tuberculosis DOTS strategy in rural South Africa: a novel application of GIS and global positioning system (GPS) technology’, Tanser and Wilkinson argue the importance of these new technologies in TB control research and evaluation. They state that ‘with recent advances in software and hardware, and with falling prices, GIS/GPS is no longer exclusively a research tool, but may be a cost-effective technology that can be used to drive development and health care provision in developing countries’ ( Tanser & Wilkinson 1999). GIS and GPS certainly provide an opportunity to identify problems, produce hypotheses and further develop public health strategies for control of infectious diseases like tuberculosis. So far GIS has been applied to several communicable diseases, but there has been little work conducted on its uses in tuberculosis control ( Beyers et al. 1996 ). GIS is an automated system for the capture, storage, retrieval, analysis and display of spatial data (i.e. data pertaining to variables that assume different values at different locations) ( Van Beurden & de Lepper 1995; Boelaert et al. 1998 ). It may therefore be a useful research tool for problems involving distance, location or area – important dimensions in epidemiology, medical geography, public and environmental health, and particularly health service planning ( O'Dwyer & Burton 1998). In epidemiological research relating to tuberculosis, much remains to be understood about transmission dynamics in developing countries ( Wilkinson et al. 1997 ) and GIS/GPS will be a useful addition to molecular techniques and conventional epidemiology, elucidating for example transmission pathways and clusters of multi drug-resistant cases ( Tanser & Wilkinson 1999). In the field of medical geography, GIS/GPS might help the rational development of community-based care by providing maps, by locating potential supervision points, and by focusing on areas of particular need. In the field of health service planning, GIS may assist in the development of aspects of the DOTS strategy, in particular the links between drug delivery systems, smear collection centres, supervision sites and physical access of patients to the health care system. So, GIS can usefully be applied both to research and development of health care provision for TB, as it has to other infectious disease control programmes ( Boelaert et al. 1998 ), but are there dangers implicit in its development and use in the delivery of TB health care? Three potential problems are highlighted below. One disadvantage of using GIS for the development of TB health care provision in developing countries is that it will erode the importance of addressing the human issues of relationship and communication and stress only the importance of the health service structure. It focuses on what to do about the health care structure rather than on how to improve it. Indeed, the most difficult operational issue in TB control is how to ensure that TB patients receive their medication (the ‘direct observation’ component of DOTS). Although it can be argued that this is a logistics or management issue (i.e. to do with the structure of the health care delivery system), it is also to do with the interaction between the health care system and the patient (i.e. with process). Because of the long treatment schedule for tuberculosis (6–8 months), the people who organize and manage TB health care delivery systems are forced to address the relationship between health care provider and TB patient; an issue which has less perceived importance in infectious diseases such as malaria where treatment is for days rather than months. This is a human issue of communication, support, and care; a relationship between the health care worker and the patient. Many of the problems in tuberculosis control relate to the interaction between patients and health care providers, patients and their communities, health care providers and their managers and organizations. GIS will help with the logistics and structure of the health care delivery system, such as the distance to supervision points and the drug distribution system, but it is not a tool for tackling the issues of relating and communication. As Tanser and Wilkinson (1999) point out, ‘further research will be needed to fully understand how important reducing distance is to improving access to treatment’. GIS may be able to help map physical distance to TB treatment sites, or even to look at questions around economic and social access, but it will not be able to determine how these issues should be addressed. A second potential problem is that people may increasingly use GIS without discrimination and in inappropriate situations or contexts. GIS and GPS need to be seen simply as tools to assist in the process of the development of a more efficient and appropriate TB health delivery system. A danger is that these tools become the central means of problem-solving rather than new additions to the myriad of ways of approaching the problems. The tool becomes overimportant and displaces simpler methods like drawing a map or a graph. The creation of maps by a community may in itself be an important creative contribution to the development of improved communication and relations between health care workers and a community, and computerization of this process may remove a significant component for developing these links. Tanser and Wilkinson stress the importance of context and health care priorities, indicating that GIS is not always necessary: ‘In settings where this technology is not available, hand-drawn maps, produced with the help of the community through participatory rural appraisal techniques, could yield similarly helpful data’ ( Tanser & Wilkinson 1999). Third, the technology system may distort other priorities in TB control. Although prices are falling, the systems are nevertheless expensive and require the development and maintenance of an infrastructure. Also, because of our fascination with hi-tech, once a new technology such as GIS has been introduced, people often become unable to work without it! The cost is less of a problem in industrialized countries which can afford to maintain a high technology system, but has consequences for low-income countries. If management systems contain highly sophisticated equipment which needs to be regularly serviced, updated and maintained, funds need to be available to maintain the service. Developing countries are littered with examples of inappropriate north–south technology transfer. Cost effectiveness studies are essential to determine the appropriateness of using GIS in different contexts. GIS and GPS are fascinating and extraordinary inventions which have a variety of uses. The pivotal point, however, is how they are used. Researchers and TB programme managers must not get on the bandwagon simply because the technology itself is exciting, but must ensure that these new tools are applied appropriately. How this is done will once again depend on us as human beings, on the interactions we have with each other and on the process we develop to incorporate the use of GIS in our work in tuberculosis control. GIS and GPS are potentially useful tools for assisting in the development of TB control strategies and infrastructure, but let us not destroy their usefulness by using them inappropriately.