OPERATION ASHA, AN ATTEMPT TO BRING THE EPIDEMIC OF TUBERCULOSIS IN INDIA UNDER CONTROL
Change and challenge is in the wind as 2008 comes to an end. The same is true when examining this month's ReachMD XM160 special series - Focus on Global Medicine. We take a look at both the changes and the challenges impacting global medicine.
In 2006, in India, there were 2.2 new cases of tuberculosis and over 4000 thousand deaths. This epidemic is getting worse, not better, but are we beginning to see possible answers. Welcome to The Clinician’s Roundtable, I am Dr. Morris Pickard, your host and with me today is Dr. Shelly Batra, a practicing gynecologist and 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 Dr. Batra for joining us.
DR. SHELLY BATRA:
Thank you Dr. Pickard.
DR. MORRIS PICKARD:
Could you tell me a little bit about Operation Asha?
DR. SHELLY BATRA:
Operation Asha is a registered non-profit for tuberculosis treatment, treatment of TB patients in urban slums. Our aim is to bring medicines to the doorstep of slum-dwellers. The problem with tuberculosis is that the treatment is prolonged for may be more than 6 months and the medicines have to be taken under direct supervision in an established and approved center almost 3 times a week by the patient. Now, these centers are few and far between, opening at inconvenient times and it's not possible for a patient to spend half a day and a substantial amount of his day's wages in going to the public hospital to get the medicines. So, what I am doing with Operation Asha is doing is this. We are establishing TB Treatment Centers at a walk of maybe 20 minutes from a person's house, so practically in every road there is a TB Treatment Center and this is how we are serving the community. Our centers are open early morning and late night, so no patient needs to miss his job, the medicines can be taken while going to work or coming back late at night and a person, who is earning less than a dollar a day needn't spend half of it on bus fare instead of food for the family.
DR. MORRIS PICKARD:
How many clinics do you have now?
DR. SHELLY BATRA:
Right now, we have 35 centers operating and we have 22 registered with the Delhi Government, which will become operational very soon, but the need is so much, the demand is so overwhelming, there are so many patients, we need to expand much more rapidly.
DR. MORRIS PICKARD:
We have talked 6 months ago. Could you give me an idea what's been happening in the last 6 months as far as Operation Asha is concerned?
DR. SHELLY BATRA:
In the last 6 months, our work has gone up 3 times and in the past 1 year, we have scaled operations 30 times, but Dr. Pickard, as I said before, our work seems to be just a drop in the ocean, seeing the overwhelming number of patients we have and the millions of new cases every year. We have to have many more treatment centers, tuberculosis is the proverbial 100-headed Hydra of Greek mythology where you chop off 1 head and many more grow up at the same time. So, this is what TB is all about. One patient infects 12 others and they infect 12 patients more and the disease spreads by geometric progression, so unless we attack it from all directions and treat many patients at the same time, we will back where we started.
DR. MORRIS PICKARD:
What brings you back to the United States?
DR. SHELLY BATRA:
Well, Dr. Pickard, I have come to US because I believe that Americans believe in kindness and they have the spirit of giving and caring for the underprivileged and for the disadvantaged. This is why I come to the US. In all my experiences, I have found that Americans are genuinely concerned about global issues, not just about their own community and the country, of course they are concerned with that. At the same time, they believe that the world is one family and something happening in India is going to affect the whole world, something like tuberculosis for example.
DR. MORRIS PICKARD:
A well-known author has written a book The World Is Flat and I think your description fits in well with this image of how tuberculosis is a global problem. Could you describe what your patients are like? Where they live? What are their circumstances?
DR. SHELLY BATRA:
Patients live in urban slums and these slums are they have to be seen to be believed. You parked your car on the road, then there is a rough track on which a bicycle can go and then there is no track at all, no road at all. You have to walk for several miles and then you reach areas that are full of garbage. There are small hutments made of cardboard boxes, corrugated paper tied with twine with may be a sheet of polythene on top that collapse any minute. The stench is unbearable. There are no toilets, no running waters. The children are defecating in the open and the food is being cooked there. There are mountains of garbage there. This is the ragpickers colony where people collect garbage and sort it out in front of their houses. The first time I went there, I told my colleague Sandeep I said let's get this place cleaned and those people said "do not touch our garbage, this is our raw material, this is our capital" and whole families are doing this job of sorting out the rubbish, so what happens when they have no clothes to wear, naturally they have no gloves, every kind of skin infection. They get cuts because they are bits of glass in the garbage. They are inhaling dust and soot, every kind of respiratory disease from bronchitis to pneumonia to asthmatic attacks and tuberculosis. Another problem is the gastroenteritis because of the fecal-oral infection and the food and water-borne infection. The places teaming with flies, the flies settle on excreta, carry germs to the food that is cooked over there. These are the slums.
DR. MORRIS PICKARD:
Do your patients have any opportunity to get out of this slum?
DR. SHELLY BATRA:
It is very difficult because my patients are the lowest of the low. Even in the hierarchy of slum dwellers, ragpickers are not welcome anywhere because they live in dirt and disease surrounded by filth and other slum dwellers look down upon them. Ragpickers usually have no way of escape. Very often, even the land they live on, the little 6 feet x 6 feet square of land has been leased to them by a local contractor who makes them work for minimal wages, they are almost like bonded laborers to use a politically incorrect term. They cannot escape because they have taken a small loan and the loan has to be paid at the huge interest, may be 10%, 15%, 20% a month and there is no escape. The only escape is marriage, that too for girls.
DR. MORRIS PICKARD:
And who do they marry?
DR. SHELLY BATRA:
If they are lucky, they marry someone who is not a ragpicker, may be who is pulling a cart or who is doing some other menial job, but not a ragpicker, that is a step up on the social ladder.
DR. MORRIS PICKARD:
We know that the caste system in India has been out lot and that you are saying, ragpickers are the lowest of the low, they are almost what it used to be called the untouchables. They are the lowest caste in a world that no longer has a caste system.
DR. SHELLY BATRA:
Yes, Dr. Pickard. There should be no caste system. We were all born the same, we are all human beings and we should love each other like human beings. Unfortunately, the system, the caste system, exists in the minds of people, but not in the government.
DR. MORRIS PICKARD:
Having described where you provide care, could you tell me about the counselors, the people who are on your step, who are working in this particular situation that you have described? What are they like?
DR. SHELLY BATRA:
Our counselors come from the community themselves. They themselves are slum dwellers and they are very happy to work for us because we provide them a good wage, may be 25% more than other organizations, may be 25% more than what they would get for their education and background in other organizations. Now, because they belong to the community, they are able to identify with the people and their problems. Because they are living in that area, they have a record of the patients' addresses and they know exactly where each patient lives. Now, 1 counselor is in charge of 3 DOTS Centers. So, at night, he goes and finds out if any patient has missed a dose and if that is so, it's his job to go, meet the patient, persuade him to get back into the system and he has to explain all the risks of drug default. Our counselors are very good at it. They themselves have been trained by us and by the public hospitals and they make it clear to the patients, if you do not take your medicine, you will die. Before dying, you will infect your family, your wife, your children, your mother by the same disease, which itself will be a drug-resistant form of tuberculosis almost impossible to treat. So, not only do you lose your life, you are harming your own family, those who are close to you and invariably they come back into the system.
DR. MORRIS PICKARD:
You know in our country we would use quarantine and even incarceration when people do not follow the rules of the game as far as getting them to take their medication and return to good health. You don’t really have that particular weapon, shall we say you don’t have this particular tool at your disposal, you will really have to use persuasion.
DR. SHELLY BATRA:
Yes, we have absolutely no facilitates for quarantine and isolation for patients. For 1 thing, the numbers are so large, it is not cost effective at all. For another thing, persuasion seems to work very well because everyone is scared of dying and family's ties are so strong that a patient wouldn’t like to harm his near and dear ones. Another thing we do is to give them small incentives. One very big incentive is over-the-counter drugs, OTC drugs. Now, these patients who are earning less than a dollar a day do not have the money to go to a qualified physician if they have fever or cough or something. So, what we are doing in every DOTS Center, we are providing basic OTC preparations free of cost. This acts as an incentive both for the patient and for the volunteer, who is giving the medication because he gets a lot of respect from the community. So, our patients get free medicine and not only that, another thing we do is whenever we have kind-hearted people who are willing to give a donation of food, we distribute food items such as a piece of fruit, yogurt, or a peanut candy, something like that that is high calorie and nutritious and packed with vitamins for the patients and we have other incentives as well. Every patient who completes his regimen, we try to give something that is a good present. For example, last month we distributed, before the winter sat in, we distributed blankets to all our patients who had completed their TB treatment and now we are tying up with another non-profit, who will give us 15 dollars worth of groceries a month.
DR. MORRIS PICKARD:
What are some of the other incentives that you might be able to use to get people to keep coming back?
DR. SHELLY BATRA:
We are tying up with another non-profit, TB Association of Delhi, to provide groceries to our patients and they will be giving 15 dollars worth of groceries, rice and sugar and cooking oil and so on every month to the patient for the entire 6 months' treatment provided the patient stays with the regime and doesn’t miss a dose. So, this is going to be a very good benefit for these people.
DR. MORRIS PICKARD:
Dr. Batra, you have been a practicing gynecologist, who has written 2 best-selling books, I believe, with Penguin Publishers. It appeared on BBC. What has made you take this career choice to become involved in tuberculosis in your country?
DR. SHELLY BATRA:
Well, Dr. Pickard, there is a time in one's life when one thinks of doing something for the community, and I feel doctors and more so specialists tend to live in Ivory Towers. We get a lot of respect from the people and we tend to isolate ourselves from the community, but we should all make an effort to do so and there are so many people who have inspired me in this world. If I start counting the names, there is no end to the list, but almost every person I have met has taught me a little. As Helen Keller has said "Every struggle is a victory" and I feel Operation Asha is another victory because each day is a struggle and a fight against tuberculosis and taboos and social restrictions and so many customs that are outdated now.
DR. MORRIS PICKARD:
I want to thank Dr. Shelly Batra for joining us and we have been discussing Operation Asha, an attempt to bring the epidemic of tuberculosis in India under control and 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 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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