Fighting Tuberculosis in India
Becky Martinez, Staff Writer
After day upon day of sifting through trash searching for small treasures that can be recycled for cash, 19-year-old Akhil begins having a simple cough. Soon this cough has spiraled out of control and is defined by the blood-tinged sputum. Akhil has tuberculosis. Soon he spreads the infection his four family members who all reside with him in a 64 foot-squared hut.
Tuberculosis remains one of the most devastating diseases for humans, but often, lower risks of contracting the disease in industrialized countries markedly reduce the fatality of Tuberculosis in these nations. Indeed, given the level of industrialization of the United States, the prevalence of tuberculosis (TB)– 4.6 infected individuals per 100,000 citizens – is remarkably high. However, these number pale in comparison to the TB rates in India, where 299 individuals are affected in a population sample of the same size.
While Akhil is a fictional character, he represents one of the groups with the highest prevalence of TB in India. Known as the “ragpickers,” these individuals subsist by sifting through refuse to find recycled items to sell to large recycling companies.
Often in India, the prevalence, centralized among those with the most limited resources, and substandard living conditions, both facilitates transmission and compounds the difficulties of TB.
In a sub-culture already marginalized by society, Operation ASHA targets their care to these micro-communities. But this organization brings more than healthcare to these communities – they bring asha (hope).
Operation ASHA’s unique approach of increasing availability of people who can administer DOTS treatment seeks to fuse the ancient tradition of community care with the modern technology and health standards. Operation ASHA incorporates technological advances to treat the most economically marginalized citizens, moving healthcare to a patient-centered model in efforts to preempt the further spread of tuberculosis.
To understand the complexities and innovative nature of Operation ASHA’s program, first the typical treatment of TB must be discussed. Directly Observed Therapy/Treatment (DOTS) as implemented by the World Health Organization (WHO) was recently adopted to achieve the following five outcomes: 1) Governmental support for universal treatment and preventative measures 2) Diagnosis using simple yet effective tests for individual treatment and global resistance monitoring 3) A standardized treatment regime to ensure individual, and eventually, universal eradication 4) Readily accessible TB drugs 5) Accurate evaluations of the efficacy of the current anti-TB programs.
While these components have indeed succeeded in eradicating TB in certain communities, the biggest challenge to care still remains practical accessibility to care. Because DOTS requires that patients be monitored while consuming the drugs to ensure adherence to the treatment plans, often the logistical difficulties of arriving at an approved treatment site still remain too formidable. Public health experts worry that these DOTS programs miss the critical link to reach the constituency in greatest need of care.
Here, ASHA seeks to fill the gap between novel treatment approaches and ancient societal customs. By relocating treatment facilities to local neighborhoods, ASHA aims to simplify and return care centers back to the community. This strategy has brought about several important changes to not only the medical care, but also social attention to TB. Namely, this change increases access to care and augments community awareness to the dangers and treatments for TB, both of which contribute to lower levels of TB in the community.
According to Operation ASHA President, Dr. Shelly Batra, this organization further succeeds in maintaining the privacy of patients by improving access to care to such an extent that patients no longer need to ask their employer for permission to leave early to receive treatment for TB, “which often causes the patient to be fired.” This repercussion is due to the social stigma surrounding TB infection. Batra cited that 2007 government figures estimate that 100,000 women and children were thrown out of their homes because of the social stigma associated with TB, “which is probably only the tip of the iceberg.” By indirectly protecting job security and social standing for patients, Operation ASHA is able to boost adherence rates, which improves both individual health and minimizes the risk of multi-drug resistant TB.
Operation ASHA is not inert to criticism from outside sources that claim that while the organization’s work is impressive their low costs of operation are an anomaly, given that Operation ASHA can provide TB treatment to a patient at a cost of $15, 4% of the typical treatment cost of $375. Given this dramatic difference in price, many organizations think that Operation ASHA should not be considered statistically relevant in cost-analysis of TB treatment due to the disproportionate levels of funding that support Operation ASHA.
Despite this criticism, the number of patients ASHA claims to treat are impressive – with 34 centers, over 3,000 patients receive treatment annually. However ASHA calculates that the benefits of their program extend far beyond these immediate individuals because while the treatment “raises the productivity and saves lives” it also “prevents 36,000 [future] infections,” based on the assumption that each person infects an average of 12 others.
Ultimately, ASHA’s success lies in its ability to bring patient care to a level accessible by the population it serves. In adapting to the social structure of the environment as opposed to demanding unreasonable effort, ASHA brings together communities, raises awareness, and decreases the prevalence of one of the deadliest, but most treatable diseases.
ASHA gives the anonymous ragpickers like Akhil a chance.
 Trends in Tuberculosis Incidence–United States, 2006. JAMA. 2007;297(16):1765-1767.
 Global TB Database and Country Profiles, WHO