It is to be commended that the profile of the disease TB is being highlighted in your paper as a major problem in Nepal and that sadly awareness of this public health problem outside of World TB days tends to be minimal ('TB or not TB', #248). There is, however, one stark contradiction in the article. How, on the one hand, can concerns about 'constant Maoist blockades' interrupting treatment, be reconciled with the statement that the DOTS strategy has faced minimum difficulties in the conflict situation? More empirical evidence needs to be provided to support such claims. In rural areas too, many health posts are closed, or are un- or under-staffed as a consequence of the current conflict. As a program that is run through the state's primary health care delivery network, the extent this has been affected by the conflict is a question that needs to be urgently addressed and further researched. Despite the DOTS program in Nepal being continually held up as an exemplar of good practice for other developing countries, there remain a number of questions that need to be posed to the program. While DOTS remains linked to state sector provision, how many TB patients never come under the NTP surveillance and receive treatment from the private sector? The truly prolific growth of TB treatment in the private sector (particularly in urban areas but also in the rural) and the consequent wider availability of TB drugs from this unregulated market, for the most part lies outside of any state control. How many sufferers of tuberculosis never get into the DOTS program and what are the implications of this for both control of TB and the way that the strengths or weaknesses of the TB program are portrayed? It is surely not sufficient to just state that 75 percent of the population has access to treatment. It is also likely that the 'directly observed' component of treatment is not in the interests of ALL patients and that greater flexibility may be necessary to support them in taking treatment. Rather than propagating the unsubstantiated statement that the Nepal TB program is one of the best in the world-and I don't deny that it has achieved a great deal given the limitations of the government health services in Nepal-it would help those of us who wish to understand these claims and see a stronger TB program, to be provided further evidence.

Ian Harper,
University of Edinburgh