of drug-resistant TB; and innovative ways of using cell phones, electronic medical records, and biometric devices to monitor interactions with TB patients and provide incentives for private health care providers to find and treat these patients.

OPERATION ASHA: “GOING THE LAST MILE”1

Significant social stigma is attached to MDR TB, said Shelly Batra, President and Cofounder, Operation ASHA. It can cause the loss of a job, the loss of a home or family life, or the denial of education to children. In contrast with many other communicable diseases, MDR TB can be contracted just by being in the same room as a patient, and there is general awareness of this fact. Because of the stigma, many patients experience denial or hide their disease. Many patients also refuse to come forward for treatment, or if they do initiate treatment, they default. Because MDR TB treatment takes 2 years and requires continual management, keeping people in the system is a very big challenge, said Batra.

Many people in India with MDR TB live in the slums and are highly mobile, returning to villages for events such as marriages or deaths. Moreover, DOTS centers often are highly inaccessible. Many are open only during usual business hours—10:00 AM to 5:00 PM. If patients need to choose between food for their family and TB treatment, they will choose food. Some will go for treatment only until they are well enough to work.

The poor in India and elsewhere in the developing world live in absolute poverty, noted Batra, defined by the World Bank as earning less than $1 a day. The round-trip fare to the DOTS center and back is 20 rupees. A man accompanied by an elderly mother or a baby, then, must pay 40 rupees, which is 80 percent of the day’s wages; therefore, if a man goes for TB treatment, there will be no wages for the day.

Thus, said Batra, TB is not only a disease but also a socioeconomic crisis. In India, TB results in $300 million in lost wages every year (RNTCP Status Report, 2007). The indirect cost of TB to the Indian economy from lost productivity and absenteeism is $3 billion a year. Nearly one-third of 11,000 business leaders around the world expect TB to affect their business in the next 5 years, and 1 in 10 expect the effects to be serious (World Economic Forum, 2008). In the words of Jackson and colleagues (2006), “Ongoing poverty reduction programs must also include reducing TB.”

Operation ASHA has engaged in mobilizing the whole community to deliver MDR TB treatment, working in close coordination with the government of India and following RNTCP guidelines. Its focus is on the “last

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1 This section is based on the presentation of Shelly Batra, President and Cofounder, Operation ASHA.



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