INDIA: Fighting TB and a cycle of violence

© Laura Hakokongas/MSF Click image for larger view In 2003, the MSF program was refocused on direct patient care in Mumbai city, where many are excluded from the national TB program and the needs are immense. While providing treatment for referral patients, MSF staff are strategizing on ways to improve the level of TB diagnosis and treatment, and are also working to document cases of multi-drug resistant TB and co-infection with HIV. In India, MSF activities range from a psychosocial program in Kashmir, an area of protracted conflict, to tuberculosis diagnosis and care in Mumbai city. MSF assists displaced people living in Assam state and also runs an emergency preparedness and response program from the capital city of Delhi. Each year, nearly two million people develop tuberculosis (TB) in India, and more than 450,000 people die of this disease. Since 1999, MSF has worked closely with the national health authorities in support of the Revised National Tuberculosis Control Program. The program is based on the DOTS strategy (Directly Observed Treatment Short-course), which helps ensure that patients continue taking medication until they are completely cured. In 2003, the MSF program was refocused on direct patient care in Mumbai city, where many are excluded from the national TB program and the needs are immense. While providing treatment for referral patients, MSF staff are strategizing on ways to improve the level of TB diagnosis and treatment, and are also working to document cases of multi-drug resistant TB and co-infection with HIV. Some challenges to providing high-quality diagnosis and treatment for TB include locally produced drugs of unknown quality, poor diagnostic tests and equipment and problems with the public health system. Since January 2003, MSF has assisted internally displaced (IDP) populations in the Kokrajhar district of Assam state. Violence between Bodo and Adivasi tribal groups in the late 1990s and threats from militant groups displaced more than 300,000 people, many of whom continue to live in IDP camps. MSF provides basic health care to those living in eight camps (an estimated 45,000 people) and to people in the surrounding villages. Activities include primary health care, malaria diagnosis and treatment, pre-natal care, and water and sanitation supply. MSF staff support existing health centers, run independent clinics and conduct health promotion activities. Malaria is an important focus. MSF has conducted drug efficacy studies as part of efforts to change malaria treatment protocols from chloroquine to artemisinin-containing combination therapy (ACT) and as of April 2004, MSF has been allowed to use ACT as a first-line treatment. MSF is currently exploring the possibility of intervening in other troubled areas in northeastern India. In Jammu and Kashmir state, MSF has been working since 2000 to provide medical and psychosocial care to a population caught in the ongoing violence over Kashmir valley. Both sides of this 14-year conflict have targeted the local civilian population: disappearances, arrests, torture and rape are common. In this context, the people of Kashmir suffer from high levels of trauma and stress-related illnesses. In response to the extensive mental health needs, MSF teams work in the districts of Srinagar and Kupwara to raise awareness about psychosocial problems and to improve the level of mental health care available. MSF-trained counselors work with patients in an MSF-supported clinic and directly in communities through mobile "on-the-spot" counseling in Srinagar, which has an estimated population of 1.2 million. Approximately 200 patients are seen daily at the outpatient department of the Srinagar psychiatric hospital, many suffering from anxiety disorders, depression or post-traumatic stress disorder. During the past several years, MSF teams have worked to improve the level of patient care and treatment at this hospital, the only psychiatric referral facility in Kashmir. MSF staff conduct bi-weekly training sessions with hospital staff and also support other medical health structures in Kupwara district in an effort to reduce morbidity and mortality resulting from blood-borne infections. MSF teams also conduct psychosocial awareness activities and community initiatives to encourage coping mechanisms through the distribution of information in Urdu and English and activities such as traditional folk theater and a call-in program on Radio Kashmir. Future plans include a focus on expanding activities into insecure areas along the line of control and a maverick proposal for a TB pilot project in rural communities on the line of control. MSF staff recently carried out exploratory missions to Manipur and Nagaland states, where MSF is assessing needs for medical intervention. Potential future projects in these states could focus on people who have limited access to basic healthcare or who suffer from neglected diseases. As both Manipur and Nagaland are geographically very close to the "Golden Triangle" between Myanmar, Thailand and Laos where much of the world's heroin is produced, it has become a route for illegal drug trafficking, and drug use is a significant problem. Future MSF interventions could also focus on HIV/AIDS related to high levels of injected drug use and commercial sex work. MSF has worked in India since 1999.