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TUBERCULOSIS: BETTER TREATMENT ACCESS IN INDIA
Change and challenge is in the wind as 2008 comes to an end. The same is true when examining this month's ReachMD XM 160 special series Focus on Global Medicine. We take a look at both the changes and the challenges impacting global medicine.
In 2006, there were 2.2 million new cases of tuberculosis and 4000 thousand deaths from tuberculosis in India. This epidemic continues unabated. The numbers are worse the following year, but are we beginning to see a possible solution to this problem. Welcome to The Clinician’s Roundtable, I am Dr. Morris Pickard, your host and with me today is Dr. Shelly Batra. Dr. Batra is a practicing gynecologist, author of best-selling book "Intimate Self and 20 Minutes To Total Fitness." She is also president of Operation Asha.
DR. MORRIS PICKARD:
Thank you for joining us.
DR. SHELLY BATRA:
Thank you Dr. Pickard.
DR. MORRIS PICKARD:
Dr. Batra, could you tell me what is Operation Asha?
DR. SHELLY BATRA:
Operation Asha is a 501(c) registered non-profit for tuberculosis treatment in the urban slums of India. Now in India, we have so many cases of tuberculosis. It is an epidemic and sheer number of cases far exceed those even in Africa. The problems with TB control is this that the medicines are not given for home consumption, they have to be taken for 6 months, on an average a patient has to go to a Registered Center 60 times and these centers, believe me, are few and far between open at inconvenient times. Now, my patients who earn less than a dollar a day cannot spend half day wages in bus fare and they cannot miss there work because they have to go for the medicines. So, when the choices between food and medicines, they choose food for the family and this is where Operation Asha sets in. We are providing medicines to the doorsteps of slum-dwellers. We are taking TB treatment deep into the urban slums. Our centers are open from early morning, may be, 6 a.m. to late at night and no patient has to miss his work, no patient has to take leave, and no patient has to disclose that she has got tuberculosis to his family or to his employer and in this way we are able to treat a lot of patients successfully and without default.
DR. MORRIS PICKARD:
How many patients are you taking care right now?
DR. SHELLY BATRA:
Right now, we have about 1000 and almost 700 have been treated fully. They have finished the course of treatment. In the past 1 year, we have scaled up 30 times over and I am very happy with the progress.
DR. MORRIS PICKARD:
How far would a patient have to walk to get to one of your clinics?
DR. SHELLY BATRA:
Not more than 15 minutes walk. Most of our centers are located at a maximum distance of say 30 to 40 minutes walk, so even patients who are living the farthest away do not need to walk more than 20 minutes in order to reach the treatment centers. Another innovation is that our centers are situated near major bus stops, near large factories, so it is very convenient for the patients to get off the bus early in the morning, take the medicines, and then go to work.
DR. MORRIS PICKARD:
Who are your patients?
DR. SHELLY BATRA:
Our patients are the slum-dwellers. Our slums are unbelievable. They cannot be accessed even by bicycle, let alone by car. We have to walk at least 2 miles on foot. There are no roads. There are no houses either. These people live in cardboard boxes or small shanties, 6 feet x 6 feet x 4 feet, made of paper and cardboard and twine, may be with the sheet of plastic on top which collapses every few days in the rains and in the wind. There is no running water, no toilets. The children are defecating in the open and food has been cooked there itself. In the rag pickers colony, there are mountains of garbage all around and the stench is unbearable, and these mountains of garbage are the source of every kind of infection possible. Whose families are sorting out garbage? Little children and elderly women sit there and separate the plastic from the wood, from the metal, which can be sold.
DR. MORRIS PICKARD:
When they don’t come back who goes into this area and how do you find them, how do you convince them how important it is to take their medication?
DR. SHELLY BATRA:
A very important part of TB treatment is TB education. This is our module. We start with education. We start with telling whole communities, whole groups of people that TB is a treatable disease, it is not anything to be scared off, there should not be any social stigma attached to it. You come to us and we will treat you. What we do is we have hired counselors and our counselors belong to the community. For every 3 centers, we have 1 counselor who supervises the work and every evening he goes to find out if any patient has missed a dose. In case any patient has missed even a single dose, the counselor who knows where the patient stays will walk to his house the next morning and the whole counseling is done all over again, the patient is told you have missed the dose, you will get drug resistance, you might die and before dying will infect your family, your loved ones, your near and dear ones with the same drug resistant form of tuberculosis which can be fatal, so please do come and take your medicine and invariably they come back.
DR. MORRIS PICKARD:
You mentioned multiple drug-resistant tuberculosis. Could you give me an idea what it costs to treat the patient before he becomes drug resistant as opposed to he does become drug resistant and needs multiple drugs?
DR. SHELLY BATRA:
In my module, I am spending only 11 dollars to treat a TB patient for the entire 6 months. This is because we can leverage a dollar 35 times over. The reason is the medicines are for free from the World Health Organization and US Organization, which come directly to the Indian Government and our expenditure is only on the TB education and the default tracking. Our volunteers are free. We are taking people from the community, the priest, small shopkeepers, treated patients; any person who is inclined to social work is welcome to join us by starting a TB Treatment Center after getting trained by us and by the public hospitals. Our costs are very low, but if a patient becomes drug resistant, the cost goes up almost 300 times. The medicines are not available so easily nor are they for free. It's practically impossible for people who earn a dollar a day to afford this kind of medication, they invariably don't get it, and the epidemic that spreads is that of MDR tuberculosis. There is a saying in the medical profession "prevention is better than palliation" and we cannot treat a person pouring blood with a bit of bandage stuck on it so we have to prevent MDR tuberculosis. The writing on the wall is that we are on the blink of another epidermic and that is of drug-resistance tuberculosis and that can be prevented by implementing DOTS effectively.
DR. MORRIS PICKARD:
Which is direct observation of treatment systems?
DR. SHELLY BATRA:
Yes.
DR. MORRIS PICKARD:
It's been recently reported that patients in tuberculosis hospitals and therefore by definition have multiple drug resistance were not getting the drugs and that actually Human Rights Organizations were protesting the fact that there are people in hospitals and not being able to get multiple drugs for their tuberculosis. Are you aware of this?
DR. SHELLY BATRA:
Yes, I am aware of this that the problem with multidrug-resistant tuberculosis is that we have no statistics and therefore no policy to implement treatment. All over the world MDR cases exist and not only that we now have something called XDR or extensive drug resistance and we have no statistics. We do not know how much percentage of the world’s TB population is drug resistant and that is why there are not adequate facilities to treat. Now most governments are now trying very hard to treat MDR cases. Even in India now, there are a few centers where sputum culture is done because MDR cannot be treated without culture, but a culture is very different from a smear. AFB smear takes a few seconds and can be done by technician. For a sputum culture to diagnose MDR and to diagnose which medicine will be suitable, it requires a proper laboratory setup. It is an expensive, time-consuming job, and this is why it is so difficult to treat. Even the diagnosis is difficult, not just the treatment.
DR. MORRIS PICKARD:
Have you thought about taking the model that you described which sounds like it has tremendous potential to other cities in India?
DR. SHELLY BATRA:
Yes Dr. Pickard, we are planning to expand rapidly now and we have already planned to expand to 10 other cities before the end of the year. In each of these 10 cities, we have volunteers, we have supporters, and we have people who are well established in society, who will take the responsibility of doing a proper job in the sense that there should be no drug default and all patients to be taken care of properly. Expansion is very much on our list and not just to 10 cities. we want to expand all over India and may be later on to other countries. I firmly believe Operation Asha is not just a non-profit. Societies evolve because of revolutions and I believe Operation Asha is a revolution in tuberculosis treatment that will sweep the entire world.
DR. MORRIS PICKARD:
You are in the United States now and I had an opportunity to talk to you 6 months ago and I would like to know one how things are going in the last 6 months and also why you come to the United States at this particular time?
DR. SHELLY BATRA:
In the past 6 months, we have increased our work more than 3 times and not only that just sheer medicines but our other support to the TB patients has gone up for example distribution of blankets, food items, groceries, we even had a hepatitis camp where all patients were given hepatitis B vaccine free of cost so we are doing a lot for our patients apart from expanding rapidly and opening many more TB Centers which is the need of the hour. Yes, I come to US again and again, two reasons. One, the spirit of giving is there in Americans and they genuinely feel from the bottom of their heart that they should do something for those who are not so privileged, for those who are suffering they believe that they can make a difference, and every little goes a long way to help the poor as I said my cost is 11 dollars to treat 1 patient and there is 1 more thing in Operation Asha we have the management structure and the internal resources to treat half a million patients in the next 2 years for which we need 2.5 million dollars which is a big amount, but I firmly believe that with so many good people in the world someone or the other will come forward and help and make our work a success.
DR. MORRIS PICKARD:
Dr. Batra, you are a practicing gynecologist, you have written 2 best-selling books, you have been on the BBC, and you have been a TV personality in India. What has made you take this carrier change and become so involved in Operation Asha?
DR. SHELLY BATRA:
I have achieved a lot of success in life both as a doctor and as a writer. I have a good innings and I feel it's my time to give back to the community. Doctors especially specialists tend to live in their Ivory Towers. They get a lot of respect, but they do tend to get a little isolated from the underprivileged and every person I have met in India and especially in the US has taught me to give and not to count the cost and I feel it's my time now to give my time and energy and talent and whatever little I have to serve the poor.
DR. MORRIS PICKARD:
As a gynecologist your practice was women, has the gender difference in India also motivated you to reach out to help women in need?
DR. SHELLY BATRA:
The gender difference is so terrifying that it cannot be described. In our country we have families, most families where women eat last and if there is a meal of carbohydrates and proteins, rice, and lentils, the women don’t' get the lentils out of choice, quite often out of choice, and sometimes out of compulsion. If there is food on the table, the best quality food goes to the men folk. If 2 children have tuberculosis, a boy and a girl, the boy will be given treatment the girl might be left alone. This is what motivates me to spend more and more time with Operation Asha.
DR. MORRIS PICKARD:
I want to thank Dr. Shelly Batra for being our guest today and we have been discussing Operation Asha, an attempt to bring the epidemic of tuberculosis under control in India.
I am Dr. Morris Pickard and you have been listening to The Clinician’s Roundtable on ReachMD, The Channel For Medical Professionals. For questions and comments, please send your e-mails to xm@reachmd.com or visit us at www.reachmd.com. Thank you for listening.
Thank you for listening to our special series - Focus on Global Medicine. As we celebrate this annual holiday season everyone at ReachMD wishes you and your family a happy holiday and a successful New Year.
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Dr. Shelly Batra talks about the reasons she shifted her focus from her private practice as a gynecologist, and a career as a best-selling physician-author and television personality, to fighting tuberculosis in India's urban slums. In India, this disease carries a stigma and, for women, can mean the loss of a job, ostracism from their own family and little hope of being married. Dr. Maurice Pickard hosts.
Dr. Shelly Batra talks about the reasons she shifted her focus from her private practice as a gynecologist, and a career as a best-selling physician-author and television personality, to fighting tuberculosis in India's urban slums. In India, this disease carries a stigma and, for women, can mean the loss of a job, ostracism from their own family and little hope of being married. Dr. Maurice Pickard hosts.
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