How Can We Leave Those Behind Who Are At Higher TB Risk?

A female migrant worker who lives in an urban slum in India’s national capital Delhi lost both her children to TB. When the best of standard TB diagnostics and latest treatments are available (and also made in India), even one TB death is a death too many. Over 1.25 million people died of TB worldwide in 2023, as per the latest WHO Global TB Report 2024. Every TB death is a reminder that we could have done better to prevent, find, treat TB and support those dealing with the disease.

If people are facing barriers in accessing public services, then why cannot public services go to the people instead? It is critically important for public health and social support services to go closer to the communities and serve them - so as to find TB early, treat them promptly, stop the spread of infection, reduce the risk of untimely deaths, and also help needy people avoid catastrophic costs and diagnostic delays.

We can only be on the track towards ending TB if we are finding, treating and preventing all TB – especially among those who are at a very high risk of it. And we have to do it in a people-centred, rights-based and gender transformative manner. Failure to do so will move us on a wrong track, further away from ending TB.

With technological advancements (and a lot of them are made in India), there is no excuse now to not take laboratories and healthcare services closer to the communities, or even at their doorsteps, in a people-centred and rights-based manner.

Integrated health and development responses are key

Homeless and migrant people in urban cities have higher rates of not just TB but also alarmingly high levels of malnutrition – which is the biggest risk factor for TB too. Other TB risk factors are also high in key and other vulnerable populations for TB.

That is why Dr Sreenivas Achuthan Nair calls for well-integrated and coordinated multi-sectoral health and development responses which would not only help us do better in finding, treating and preventing TB but also improve programme outcomes towards achieving zero hunger, zero poverty, prevention and control of non-communicable diseases (NCDs) like diabetes, ending tobacco and alcohol, ending AIDS, among other goals and targets enshrined in the UN Sustainable Development Goals (as well as in several domestic and regional plans, declarations and agreements). Dr Nair came to India’s national capital Delhi to speak in India Innovation Summit organised by the Government of India’s National TB Elimination Programme and the Indian Council of Medical Research (ICMR).

Dr Sreenivas Achuthan Nair, Senior Advisor of Stop TB Partnership (hosted by United Nations OPS), has contributed to strengthening TB responses over the past two and a half decades. He has earlier served as the government TB Programme Officer of Kerala state in India, as well as worked with the International Union Against Tuberculosis and Lung Disease (The Union), and also with WHO India supporting India's national TB programme.

Commit, invest and deliver

World TB Day is observed globally on 24th March to amplify the urgency of ending TB – which is the world’s deadliest infectious disease. This year’s theme, “Yes! We Can End TB: Commit, Invest, Deliver” is a bold call for hope, urgency and accountability.

Dr Nair visited few sites where female TB Affected Street Activists (TASAs) work with female homeless and migrant women (and other genders). TASA themselves are TB survivors or affected by TB. This model is developed by Humana People to People India, and funded by Stop TB Partnership’s Challenge Facility For Civil Society Grant (through which, 143 local groups get support to do similar community-led work to reach the unreached people with TB and supporting them).

There are twenty TASA frontline leaders in Delhi serving female homeless people and migrant workers. Each TASA works with 5 or more ‘Sahelis’ (a Hindi language word for female friends). So a network of 100 or more Sahelis and TASAs have united to stop TB among female homeless and migrant workers.

The female migrant worker mentioned in the opening of this article is also one of the Sahelis, helping others get diagnosed with TB early on and promptly treated, supported and get cured.

Dr Nair went with TASA workers Chanda and Geeta, their coordinator Ravindra and other ‘Sahelis’ to a government-run shelter home which is hardly a kilometre away from a prominent government-run Jhandewala TB clinic in the heart of India’s capital Delhi. But challenges which homeless and migrant people face in accessing services make the journey of a kilometre almost impossible for many, without the help and support of frontline workers.

Jahangir Alam, who is himself a TB survivor, works with Humana People to People India and has played a defining role in helping roll out a high impact intervention model to reach the unreached homeless and migrant people in Delhi, as well as in other places across India. Subrat Mohanty, is also with Humana People to People India and member of the Board of Stop TB Partnership. Subrat has contributed over the past years in strengthening community engagement and partnerships to boost India's TB response. They both accompanied Dr Nair too.

When a person with presumptive TB is identified, then frontline workers of Humana People to People India get an X-Ray and TB test done. If found positive the treatment is initiated without delay at the nearest public TB clinic. TASA follows up on a daily basis.

There are over 400 homeless people who live in this dilapidated multi-storeyed shelter home. Some residents said that it is threatened with demolishment. The upper floor looked as if it had been demolished already.

One female homeless resident of this shelter home shared that she even confronts discriminatory behaviour in accessing public bus or transport. Another said they face discriminatory or stereotypical behaviour by the staff of health facilities which deters them from going there. But when Chanda, a TASA worker helped support them, took sputum samples to the government TB clinic, helped those with presumptive TB get an X-Ray done, TB test done, then those found positive for active TB disease, could access TB treatment. About 15 people are currently on treatment in this shelter home and neighbouring areas who are followed up daily by the TASA worker.

The trust quotient between TASAs, Sahelis, and homeless and migrant people is evidently high - which speaks volumes for the laudable community work done collectively.

Homeless people shared with Dr Nair the help they got from TASA Chanda in getting their Aadhar Unique Identification Card made as well as Permanent Account Number (PAN) Card made with due process. Many got major help from Chanda in getting bank accounts opened. Without these, they would not have got the social support benefits which the government provides to the people with TB. For example, every TB patient gets INR 1000 transferred directly to their bank account every month during the treatment.

One homeless woman who is currently on TB treatment, confirmed that she has received INR 3000 so far in her bank account, thanks to Chanda for helping her get her IDs made, bank account opened and supporting her access the social support via due process.

Another ‘Saheli’ Maya (name changed upon request) told Dr Nair that she has lived in an urban slum (close to the shelter home) for over 30 years and she along with her family members do rag picking. Her sister got diagnosed with TB, accessed treatment and thankfully is cured now.

Last year in February 2024 this slum was demolished, making life even more difficult for them. Now, there is only a temporary plastic sheet which they stretch out in the night to sleep under. And during the daytime, wrap it aside to avoid any confrontation (with authorities who want them removed) and also to have some open space for rag picking and sorting. She feels that by April 2025 they would be forced to completely vacate the area they have lived in for three decades, as barbed fencing and wall construction work is about to complete soon.

Maya says that other Saheli members like her do not want others to delay seeking care for TB. In Saheli support group meetings with TASA, they regularly educate each other on a range of TB related and other health issues. Unless they themselves are informed how will they help others, rightly says Maya.

She shared that with support from Humana People to People India they have held regular health camps too, to screen people for TB as well as for other health conditions and link them to public care services.

For example, a mobile van equipped with ultraportable handheld artificial intelligence enabled X-Rays (managed by Medanta Hospital) comes close to their slum area where those with presumptive TB can get screened and linked to public services.

Another woman rag picker, who is also a Saheli, said that earlier most of the children went to government-run school but post-demolishment of their slum, either they have missed studies in the last year or dropped out completely. Addiction is another problem that is catching the young early – especially those out of school.

Bending the curve

Dr Sreenivas Nair said at the India Innovation Summit that India has demonstrated a commendable leadership in trying hard to bend the TB curve. Indian government's 100 days campaign to reach the unreached key and other vulnerable populations with best of TB services is laudable, said Dr Nair.

Government of India launched its 100 days campaign (in over half of districts in the country) on 7 December 2024 to screen everyone, regardless of symptoms, among key and other vulnerable populations, with ultraportable handheld artificial intelligence enabled X-Rays and offer an upfront molecular test to confirm TB to those with presumptive TB. A van equipped with such a facility is going daily till 24 March 2025 (100 days duration) to make this difference. Those who are found with TB disease are put on latest TB regimens as per the guidelines, and linked to care and support.

India's National TB Prevalence Survey (2019-2021) showed that almost half of TB patients were only found because of an X-Ray as they were asymptomatic back then. That is why it is vital to find people with active TB disease early on (symptomatic or asymptomatic) so that they can be put on the right treatment (and those with lung TB may become non-infectious soon after starting an effective treatment).

Dr Nair said that India's 100 days campaign heralds a major programmatic shift to find more TB (early and accurately) among those who are a higher risk.

Along with this, we have to advance progress on all other SDG goals and targets, especially for those most likely to be left behind: such as, achieving the goals of zero hunger, zero poverty, prevention and control NCDs, ending tobacco and alcohol use, ending AIDS, among others.

India Innovation Summit which was attended by over 900 people showcased over 300 innovations (almost all made in India) to prevent TB, screen TB, diagnose TB, treat TB and community-led interventions that are making (or could potentially make) a major difference.

Bobby Ramakant – CNS (Citizen News Service)-

(Bobby Ramakant is a World Health Organization (WHO) Director General WNTD Awardee 2008 and Health Editor at CNS (Citizen News Service). He is also on the executive boards of Global Antimicrobial Resistance Media Alliance (GAMA) and Asia Pacific Media Alliance for Health and Development (APCAT Media). Follow him on Twitter/X: @BobbyRamakant)

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