Written by Jessica deJarnette, MD, PGY-2 at Kaiser Permanente San Francisco Ob/Gyn Residency Program while on Global Health rotation at Tibetan Delek Hospital in Dharamsala, India in July 2017.
“Zero TB Tibet”
“Despite significant improvement in TB situation in the community, TB still continues to remain one of the serious health concerns particularly in Tibetan schools. This project could not be more timely, given the rising rate of TB and MDR-TB incidence in our schools.” –Kalon Ngodup Tsering Dept of Education
This past August I had the pleasure of spending a month volunteering in Delek Hospital, a charitable organization started in 1971 for the Tibetan refugees fleeing to India after the Chinese occupation. Being non-citizens, many of the refugees found themselves without a way to get healthcare through the public system. Delek Hospital was founded as a way to meet this gap through charitable contributions and a grant from the Central Tibetan Authority or CTA. It has grown from its humble beginnings of a small clinic to a 40-bed hospital offering comprehensive adult, pediatric and prenatal care medicine along with a tuberculosis treatment center, emergency room and radiology, dental, and laboratory departments. I was so impressed by many things at Delek, but one of the most novel and interesting projects I witnessed was the Zero TB project run in conjunction with John Hopkins University started in April, 2017.
Tuberculosis can be a devastating disease, especially the Multi-drug resistant (MDR) or Extensive-drug resistant (XDR) forms of TB, which can take years to treat. India has the highest burden of TB in the world, with an estimated 2.2 million new cases diagnosed in 2015, out of a global incidence of 9.6 million.1 Forty percent of the population is suspected of having latent, or inactive, TB. To say TB is an epidemic in India would be an understatement. Incidence among Tibetan refugees in India is particularly high at 431 cases/100,000 persons compared with 181 cases/100,000 persons overall in India in 2010.2 One reason for this high incidence is that many Tibetans live in close quarters; more than half of TB cases in Tibetan refugees occur in monks, nuns, and students in boarding schools, and 75% are less than 30 years old.
The Tibetan Children’s Village is a boarding school that was started 54 years ago for Tibetan children in exile; it has multiple branches in India and currently has over 16,000 students. In Dharamsala, there are two branches, Upper TCV and Lower TCV, which have 1500 and around 500 students, respectively. TCV is an amazing institution as it preserves the Tibetan culture for refugee children by continuing to teach Tibetan language, writing, Buddhist teachings, along with Hindi and English. It is a boarding school though, so most of the children who attend live in crowded dormitories with varying degrees of ventilation. The unintended consequence of a boarding school is that large groups of children and staff are in very close quarters, so diseases can be spread very quickly.
The high (and rising) incidence of TB among Tibetans and particularly Tibetan students is what led to the creation of the Zero TB project. The essential goals of the project are to increase TB case detection, treatment, prevention, and outreach in high-risk populations such as school children. In phase one of the project approximately 2,000 children were screened; 13 active and about 345 latent TB cases were found among students (2 MDR-TB). I don’t have exact numbers for the staff who were screened but about 49-50% of staff at one school site had latent TB. Through grant donations; Delek hospital is paying for the treatment of these cases, which cost less than $100 USD. The treatment is through direct-observed therapy (DOT) at the school sites; thanks to training for the school nurses and the “house mothers” (basically dormitory supervisors) the children are able to take free medications and are continuously monitored for side effects and treatment progression through regular site visits from the Delek team of nurses and doctors.
Although in its nascent stage, I am hopeful that this program will meet its goal of eliminating TB in Tibetan children. Although just one facet of the comprehensive care provided to Tibetan refugees in India by Delek hospital, the Zero TB project is an impressive example of the creativity and dedication of the Tibetan people in protecting their culture, their health, and their future.
- Dierberg, et al. Improved Detection of Tuberculosis and Multidrug-Resistant Tuberculosis among Tibetan Refugees, India. Emerging Infectious Diseases. March 2016:22(3). https://wwwnc.cdc.gov/eid/article/22/3/14-0732_article. Accessed 12, September 2017