7 pills to swallow

On Tuesday morning our group arrived in Delhi eager to check out a new city in India. While Delhi is still a major metropolitan area that is similar to Bombay in many ways, it is much more geographically spread out (think LA) and less congested, though it feels like everything is at least an hour away from wherever you are. Hello, quality time on the bus!  

Our first stop in Delhi was at the U.S. Embassy where we met with Nandita Chopra, the NIH representative based in India. The security checkpoint to enter the embassy compound was thorough – there’s no place like home. When we entered, we immediately noticed a building that looked identical to the Kennedy Center in DC. We quickly learned that the architectural inspiration for the Kennedy Center came from the U.S. Embassy in India. Sorry, no cameras were allowed inside, so you’ll have to trust me that they were identical. Pictures of Obama, Biden and Clinton lined the walls. Nandita took us to a conference room and discussed the portfolio of NIH in India, which is quite comprehensive. One of the initiatives she works on is a bilateral collaborative between researchers and scientists in the U.S. and India that fosters project and idea sharing to assess and improve various health indicators. Much of the NIH work is research-based and they serve as a leader in field of development and in testing new technologies and pilot studies. Additionally, the NIH supports centers of excellence addressing various diseases throughout the country. Since the process of applying for funding is so complex both in the U.S. and in India, one of Nandita’s many roles is to support researchers in pursuit of funding. She has fully utilized her network of contacts and has become a master at navigating the complex systems in both countries. Without her, much of these partnerships would likely not materialize or would take much longer to naturally filtrate through the system. After our meeting, we took a brief tour of the embassy grounds, including housing for diplomats, restaurants, a bowling alley and a pool. Pretty cool stuff!

The following morning, we met with Operation ASHA (Op ASHA) in Delhi. Many of the NGOs that we’ve met with have multi-pronged strategies that address different populations and health issues. In this respect, Op ASHA is completely different from the majority in that they focus on one thing: treating tuberculosis (TB). To provide a touch of background information for those who are unfamiliar with TB, it is a communicable disease that is spread through the air by someone coughing or sneezing. With 2 million new cases each year, India has the highest burden of TB in the world. TB thrives is crowded spaces where the disease can more easily spread, so slum areas are an ideal setting for the disease to permeate. Just because you come in contact with TB does not mean that you will necessarily contract the disease; many people (I believe one in four), in fact, have latent TB that will never manifest. However, when your immune system is weakened, then TB thrives. The great thing about TB is that it is treatable. However, it is difficult for people to understand the need to take medication when they have no visible symptoms. As one of the Op ASHA staff members said, “People value their health in India, but there is no concept of prevention.” As a result, people start taking their medications and don’t finish them and, as a result, develop a drug-resistant strand of TB, which can then be passed on to someone else. Multiple drug resistant strands require longer-term and more intensive regimens.

One dose of TB medication

Op ASHA aims to enable people to have easy access to their medications and uses the DOTS intervention (directly observed treatment short-course) to ensure that people are taking their meds every other day. Since there’s significant stigma associated with TB (people are fired from their jobs, kids are kicked out of school, etc…), Op ASHA has found a way to discretely provide and track patients with TB. They partner with local shops or small businesses in slums and villages. The owners of these shops are paid a stipend to house the small operation and are trained in medication distribution. They use a biomedical tracking device that scans a patient’s fingerprint, which pulls up their medical record through a system. Then they are given their medication while the business owner watches them take their medication. Usually, there is also an Op ASHA nurse present as well. If a person misses a dose, the Op ASHA nurse is notified and follows up with a house visit to see what’s going on. Our group visited one such site nested in a store in a village and it was excellent to see the process first-hand. While Op ASHA is hugely successful in ensuring that people adhere to their TB medication, our group of public health students could help but wonder if there was some sort of missed opportunity in the process. Couldn’t they also provide family planning services since they already have such a high rate of daily traffic? Or perhaps they could screen people for HIV or provide vitamins to address malnutrition? I completely understand that a large part of the success of Op ASHA is due to its simplicity and directness and without that, people would likely not be as adherent, but could they be doing more? Couldn’t we all, though?

Biomedical tracking computer used by Op ASHA

The afternoon brought with it an unexpected surge of infectious energy from our guest speaker, Kiran Bedi. Dr. Bedi is a well-known social activist in India. She was the first woman officer in the Indian Police Service, which inspired her quest to seek justice for many of the underserved. She is the founder of two NGOs: the Indian Vision Foundation, which supports the children of women prisoners who often grow up with their mothers in jail, and the Navjyoti India Foundation, which aims to serve vulnerable populations throughout India. She believes that there is a huge amount of corruption within the Indian government, which contributes heavily to the myriad of basic problems facing India’s poor. Dr. Bedi wants to rid this corruption so that the next generation can grow up in a safe and healthy environment, fully supported by their government. She speaks about her work using metaphors and conveys her points with such conviction that many of us found ourselves lingering on the edge of our seats so as not to miss a word. It’s rare to be in the presence of someone with so much charisma and chutzpah and it was quite refreshing. Only time will tell what will happen with India’s next round of political elections, but there is no doubt that regardless of the outcome, Dr. Bedi will rest assured that she did all that she could as an activist to rid much of the corruption that she perceives exists with the current regime. While she is passionate about her cause, she has no interest in dabbling in politics (yet). “I want to be accepted by all; I don’t want to compete, I just want reform.”

Dr. Bedi and I in her office

We ended our day with a trip to the India Gate and Rashtrapati Bhavan, the president’s house. We ate at a fabulous Indian restaurant called Punjabi by Nature where I had the best dahl of my life!

The group at the India Gate