A Cottage at the Santoshapuram Sanatorium

We have seen in the second part of this series that apart from the Government-run sanatorium in Tambaram, there was second, private initiative – Dr Mathuram Santosham’s facility at Santoshapuram. A friend who had been watching Dr Santosham invest his little all in the Sanatorium once asked him as to what he would do if a wonder drug were discovered the next day with which any doctor could treat TB. And sure enough in 1951, new chemothearapeutic drugs were found to be effective in curing people of the disease. While this was good for the patients, it meant the beginning of the end for sanatoria.

But such was the shortage of medicines in India and other third-world countries that their distribution was through Government approved institutions of which the Santoshapuram facility was also one. Patients therefore continued to throng the Sanatorium. India, with its large population, non-availability of drugs and active Government control appeared to have bucked the worldwide trend of sanatoria closing down or being sold to nerve specialists for setting up nursing homes. There was however considerable confusion in the minds of the general public and among patients in particular, as to which treatment was the most effective for fighting TB. The Government had begun a determined BCG vaccination drive which prevented TB and to add to the confusion, that was often mistaken as a cure for those already stricken with the disease.

It was at this time that Dr Santosham authored What Everyone Should Know About Tuberculosis. Privately published and released on 1st July 1952, it had a foreword by Dr Sir A Lakshmanaswami Mudaliar, eminent gynaecologist and the Vice-Chancellor of the University of Madras. Couched in simple language and richly illustrated with photographs and sketches, it was a guide to understanding TB, and its treatment. It highlighted the importance of drugs such as streptomycin and Para Amino Salicylic Acid (PAS), which were being used in combination to help patients fight off TB. The book also showed that while these medicines could cure victims of the dreaded disease, they could not help in restoring damaged tissues, which were so important for a normal life and for prevention of a relapse. It was here, Dr Santosham argued, that sanatoria had a role to play. By providing clean air, a stress-free life and good food, they helped those recuperating from TB recover their vitality much faster

Dr Wallace Fox, sourced from the http://www.telegraph.co.uk

In 1952, with the discovery of Isonicotinic Acid Hydrazide (INH) as a wonder cure for TB, matters moved into fast-forward. The drug began to be studied for use in India from 1953 onwards.The Government in 1956  established the Tuberculosis Chemotherapy Centre, later known as Tuberculosis Research Center (TRC) in Madras, under the auspices of the Indian Council for Medical Research, the Government of Madras, the World Health Organisation, and the British Medical Research Council (BMRC). This Centre was to provide information on the mass domiciliary application of chemotherapy in the treatment of pulmonary TB. The same year, Dr Wallace Fox, a UK-based clinical researcher into TB became the Director of the Madras Chemotherapy Centre. He had by then successfully demonstrated with his collaborator Denny Mitchison that INH, together with Streptomycin and p-aminosalicylic acid (PAS) was very effective in fighting TB. In Madras, he would take this finding to the next stage.

Fox embarked in 1959 on what is known world over as the Madras Experiment. The details are available in The Lancet’s obituary on Dr Fox in 2010 -“One of the researchers he worked with was statistician Sistia Radhakrishna. “His greatest contribution in the field of tuberculosis in India and other developing countries was the randomised controlled trial of home and sanatorium treatment of pulmonary tuberculosis”, says Radhakrishna. “This demonstrated that treatment at home is as effective as sanatorium treatment, not only in the initial success rate but also in the subsequent relapse rate.” It also showed that so long as drugs are taken regularly, a good diet, rest, and well-ventilated accommodation are not essential to a good outcome; that randomised controlled trials can be undertaken even in difficult settings; and that treating the infectious patient at home poses no additional risk to close family contacts. “It was one of the most cost-effective pieces of research ever”, says Mitchison. “It was probably responsible for closing down sanatoria worldwide.”

Fox also tackled another of the practical treatment hurdles: the need to take drugs daily for a year. Still collaborating with Mitchison, he showed that intermittent treatment could do the job just as well—and so laid the foundation of what became WHO’s standard treatment regime. Less recognised than these major advances was Fox’s attention to the practicalities of their implementation: details such as the accuracy of patients’ addresses and procedures for retrieving non-compliers. “Both these were major stumbling blocks for Indian tuberculosis programme managers when they tried to implement research-based recommendations in real-life situations”, says Radhakrishna.

Dr Fox, writing a foreword for a book by Dr Santosham almost a decade later, recalled the help that the latter provided in the experiment even though he knew that it would end his sanatorium. But Santoshapuram would be kept going. Sternly resisting any temptation to apply for Government aid, Dr Santosham decided to continue running his creation, despite all odds. The place began to be increasingly used by those below the poverty line. They could not afford even routine medicine and opted for Santoshapuram, confident that they would get the same treatment as someone who could pay for it. Thus the Sanatorium remained continuously busy though it hardly generated any income. Writing in 1971, Dr Santosham computed that after assuming human effort to be free of cost, the Sanatorium gave a return of 1 ½% per annum, and that income was ploughed back into the institution itself! Eventually however, Dr Santosham decided to close the sanatorium, selling the land to his brother -in-law PD Boaz and today it houses the Dr GD Boaz Memorial Hospital and School for Psychiatric Treatment, named after Gunamudian David Boaz, India’s first psychologist and father of PD Boaz. Located on the campus is a jewel of a chapel that Dr Santosham built and which has memorial stones to him and his mother.

After a full life in TB treatment and politics, he serving as a MP for the Swatantra Party and later being part of the Janata Dal, Dr Santosham died on January 30, 1990. Dr Wallace Fox passed away in England on January 22, 2010.

The TRC continues its good work. Dr Sowmya Swaminathan, who is now Chief Scientist at the WHO, was its Director too.

This article is the last in a four-part series that looked at the role Madras played in the fight against TB. You can read the other three parts below

  1. The Pioneers
  2. The Hospitals and Sanatoria
  3. When we fought BCG

You may also want to read How Madras eradicated smallpox

This article takes material from

Goodness & Mercy, the Life and Times of Dr Mathuram Santosham, written by me in 2012 and form which I have taken extracts with the permission of the Santosham family

The obituary written by Geoff Watts in the March 27, 2010 issue of The Lancet, which can be accessed here