In November 2009, Prajnopaya started its community-based TB treatment program in Moradabad, U.P. There are 8 centers distributed throughout poor neighborhoods in the city. The centers are run out of homes, small shops, or small clinics. The program is managed through a partnership with Operation ASHA, an NGO based in New Delhi. We choose respected members of the community to manage a center so that they are trusted and have good relations with the patients. For every two centers there is a counselor who is responsible for following up on any patients that miss their medication. This is a critical role to ensure the treatment is properly administered and the patient finishes a full and successful course of treatment. Treatment takes from 6 to 8 months.

An alleyway leading to a TB treatment center in Moradabad.

One of the challenges in TB control is seeking out new patients and gaining their trust to stay with the treatment program. By relying on community based centers, located close to peoples’ homes, we are able to do this much more effectively.

A young patient taking her TB medicine at a Moradabad treatment center

The program is not only saving lives, but also provides steady jobs to the counselors and supports their families. The counselors receive training in basic health care and documentation skills. Those who show a strong aptitude have the opportunity move into a management role as the program expands. Our counselors are the core strength of the program. They need to remain motivated and adhere to high standards of quality. This attention to their performance sets our program apart.

Checking over the log books showing patient visits and counselor activities at another Moradabad treatment center.

By keeping our overhead to an absolute minimum and by working hand-in-hand with the government TB program, we have managed to keep costs very low; much lower than typical non-profit supported TB programs. For only $20, we can provide for a patient’s full 6-8 month treatment. Please consider making a donation to spread our program further and save more lives.

In April 2010, Prajnopaya teamed up with Innovators in Health to start a new TB treatment program in the district of Samastipur, Bihar. Our partnership with Innovators in Health goes back to their first days as a team of MIT graduate students working with Prajnopaya to design the uBox, an “intelligent” pill dispenser for delivering TB medicine. It’s a great source of satisfaction to see them evolve from their incubation at MIT to become a committed non-profit focusing full time on TB treatment in India.

Addressing village doctors in Keota at the Lal Mandir (literally "Red Temple").

The Challenge of TB in Samastipur

Existing TB treatment options in Samastipur, as in many regions with a large destitute population, are failing to reach the majority of patients. The government program, while free of charge, is not trusted and ineffective. We conducted a survey that revealed that a majority of TB patients had never visited a government hospital or treatment center. Instead, they turn to either private physicians or uncertified village doctors. Without subsidized medicine, patients can usually only afford treatment for a few weeks; not the required 6-8 months. It is not uncommon to hear of patients undergoing intermittent and ineffective treatment for months or even years before finally succumbing; all the while spreading the infection and increasing the risk of developing drug resistant strains.

Samastipur is not the poorest district in Bihar, but many living there suffer from a similar lack of infrastructure, education, and services as in other parts of the state. A few socioeconomic statistics give a picture of the situation.

• Population: 3.4 million (96% rural)
• Literacy rate: 45% (58% male, 32% female)
• Average income: 93 cents/day (PPP)
• Health care access: 1 health care provider per 8,300
• Electricity access: 16%
• Piped water access: 0.2%

A gathering of the top private medical pratitioners (MDs) in Dalsingh Sarai at the Hotel Rajendra (August 27, 2010). Clockwise from left: Dr. Rajeev Pathak (WHO), Dr. Harendra Tiwari (DTO, Samastipur), Dr. P. K. Singh, Dr. Jitendra Kumar, Abhishek Raut, Dr. P. Kumar, Dr. Yogendra Mahto, Dr. Rajeev Kumar, Dr. A. K. Rai, and Dr. Manish Bhardwaj

Our Community Specific Approach

The objective of the Aahan program is to develop a model TB control program that is community specific. Official statistics rarely give an accurate picture of the situation on the ground, and are a poor guide for program design. For this reason, it is essential to spend considerable effort in collecting data, building relationships and training staff to make sure the program is a success. Our initiative can be summarized by the following key actions:

• Get the Facts: We conduct detailed surveys of TB patients, physicians, village doctors and the general population to characterize the current treatment situation, understand complex relations among the different agents, and identify challenges and possible improvements.
• Build Local Capacity: We select, train and motivate local staff to carry patients through the entire treatment chain, from the initial detection to the final confirmation of being cured.
• Reach out to Stakeholders: We build a supportive base of local stakeholders, including government and private physicians, diagnostic labs, community organizations, village doctors, and the government TB program officials.
• Utilize Local Networks: We set up a referral system that incentivizes village doctors and others to send potential suspects to our program to receive diagnosis and proper treatment.
• Fill Diagnostic Gaps: We investigate alternative diagnostic procedures to overcome the significant limitations in existing microscopy approaches.
• Document and Disseminate: We carefully monitor and track program performance, building a database for internal evaluation and for sharing lessons learned with others.
• Support Patients: We guide and advocate for patients through the entire process, we provide nutritional supplements to combat malnourishment and improve treatment, and we strive for 100% cure rates for everyone entering the program.

The Aahan program is still very young, with the first patients starting treatment in July 2010, but we are already gathering very useful information on how to improve TB control. Representatives from the World Health Partnership and the World Bank recently visited our program to learn how we have engaged the local community and interfaced with the existing private and public healthcare networks. We are very optimistic that this program will develop into a leading model for community based TB control.

Delivering medication to a patient at his home in Keota, Samastipur.

Of course, we need your support to keep this program running. Please do not hesitate to contact us to learn more and find ways that you can support this important work.

Prajnopaya is pleased to join The Dalai Lama Center for Ethics and Transformative Values at MIT and the Foundation for Universal Responsibility to encourage social entrepreneurship by developing an innovative leadership program. The Transformative Leadership program, initiated at the Central University for Tibetan Studies (CUTS) in Sarnath, India, is training more than 40 young student leaders from India, Nepal, Mustang, Bhutan, Mongolia, and Russia to become agents of change. These students, who are primarily from backgrounds in Liberal Arts or Tibetan Medicine, have been developing sustainable models to effectively combat social menaces such illiteracy and the lack of health care. These pilot programs are run in the neighboring slums in Varanasi and will later expand to the communities from which these young leaders originate.

A number of young leaders have also been spearheading a "Save the Environment" project by cleaning trash and litter in the surrounding city. They have been instrumental in raising awareness of local merchants to use re-usable cloth bags instead of plastic. The group has distributed over 300 re-cycled and re-usable bags in its first few weeks of operation. Another team is helping to raise awareness for more humane treatment of animals on the streets.

Multiple day "Transformative Leadership" seminars were held at CUTS in March and July of 2010. More workshops are scheduled for the latter half of this year and in 2011. The teaching faculty includes Professors Erica Dawson and Rodrigo Canales from the Yale School of Management and Venerable Tenzin Priyadarshi of The Dalai Lama Center.

Seed Funds for the student projects and the leadership program have been crucial in inspiring determination and innovation among these dedicated youths. To learn more and support this program, please visit us online at http://thecenter.mit.edu

Upaya Care continues to assist the poor in rural India by increasing their access to basic health care services. The program also oversees the distribution of blankets and hearing aids to the needy. Currently, we run two small clinics in Rajgir and Vaishali in the state of Bihar. However, due to funding constraints we have not been able to supply free medicine for the past few months. We are also hoping to build additional clinics in Sarnath (Varanasi) and in a few remote villages of Laddakh. Clinics proposed for Laddakh may not be concrete building but simply temporary locations with visiting physicians.

On an average each clinic gets over 500 patients a month. The need is certainly there, but more resources to maintain and expand the program are required. Funds support the upkeep of the clinics, the cost of medicine, and the cost of visiting physicians.

As the Aahan program manager, Jagdeep Gambhir plays a key role in ensuring the program’s success. Jagdeep currently splits his time between Dalsingh Sarai in Samastipur, where he oversees the program staff and patient activities, and in Patna, the state capital, where he interacts with physicians and TB officers and visits diagnostic facilities.

Jagdeep Gambhir (on left)...
Jagdeep Gambhir conducting an interview to determine current TB awareness and treatment options for a villager in Samastipur.

Prior to joining Aahan, Jagdeep worked at Goldman Sachs in Bangalore as a Technology Analyst. Before that, he earned an engineering degree in Information Technology from NITK, Surathkal. Looking for an opportunity to broaden his experience and make a positive social impact, he joined Prajnopaya in March 2010. Coming from a family of physicians, a job dedicated to public service and health care came naturally to him. His experience in co-founding the Sparsh Scholarship Foundation, a non-profit extending financial support to students at his alma mater, and coordinating Gurudakshina, a non- profit that mentors underprivileged children, were also valuable preparation for his current position.

The significant burden that TB imparts on these poor communities has left a strong impression on Jagdeep. In his own words, “the impact of Tuberculosis in a rural context as a deterrent to development is disturbing. Affected families lose the productivity of an adult family member and at the same time need to muster additional resources to seek treatment and care for the patient. The total costs, and particularly the indirect costs, are relatively high ranging from loss of wages to school dropouts.

“Aahan has given me a unique chance to understand grassroots execution of projects in rural India ranging from identifying suspects to ensuring accurate diagnosis and ensuring timely drug delivery. Providing nutritional supplements to the patients, use of SMS based tracking system and referral system for village doctors are some of the innovative solutions we are trying. I am hopeful that these solutions will provide a blueprint for our program as well as other programs working in tuberculosis care."

The Prajnopaya Foundation depends on your contributions to sustain our work. Please visit our website at http://www.prajnopaya.org/index.php/get-involved/donate to find out more about how you get involved and support our activities.