Experiences and Issues at the Intersection of Faith ...

Experiences and Issues at the Intersection of

Faith & TuberculosisJuly 16, 2010

A Collaboration with the World Faiths Development Dialogue supported by the Henry R. Luce Initiative on Religion and International Affairs

1Experiences and Issues at the Intersection of Faith and Tuberculosis • July 16, 2010

Luce/SFS Program on Religion and International Affairs The Luce/SFS Program on Religion and International Affairs has been exploring the intersection of faith, world politics and diplomacy since September 2006. A collaboration between the Henry Luce Foundation and the Edmund A. Walsh School of Foreign Service (SFS) and Berkley Center for Religion, Peace, and World Affairs at Georgetown University, the Luce/SFS Pro-gram initially focused on two issue areas: Religion and Global Development and Religion and US Foreign Policy. A follow-on award from the Luce Foundation in November 2008 has enabled the continued growth of both program areas and the addition of two more: Government Outreach and an online Religion and International Affairs Network.

The Berkley Center The Berkley Center for Religion, Peace & World Affairs, created within the Office of the President in March 2006, is part of a university-wide effort to build knowledge about religion’s role in world affairs and promote interreligious understandings in the service of peace. The Center explored the intersection of religion with contemporary global challenges. Through research, teaching, and outreach activities, the Berkley Center builds knowledge, promotes dialogue, and supports action in the service of peace. Thomas Banchoff, Associate Professor in the Department of Government and the School of Foreign Service, is the Center’s founding director.

The Edmund A. Walsh School of Foreign Service Founded in 1919 to educate students and prepare them for leadership roles in international affairs, the School of Foreign Service conducts an undergraduate program for over 1,300 students and graduate programs at the Master’s level for more than 700 students. Under the leadership of Dean Carol J. Lancaster, the School houses more than a dozen regional and functional programs that offer courses, conduct research, host events, and contribute to the intellectual development of the field of international affairs. In 2007, a survey of faculty published in Foreign Policy ranked Georgetown University as #1 in Master’s degree programs in international relations.

World Faiths Development Dialogue The World Faiths Development Dialogue (WFDD) bridges between the worlds of faith and secular development. Established by James D. Wolfensohn, then President of the World Bank, and Lord Carey of Clifton, then Archbishop of Canterbury, WFDD responded to the opportunities and concerns of many faith leaders who saw untapped potential for partnerships. Based in Washington, D.C., WFDD supports dialogue, fosters communities of practice, and promotes understanding on religion and development, with formal relationships with the World Bank, Georgetown University, and many faith-inspired institutions.

2 Berkley Center for Religion, Peace & World Affairs Experiences and Issues at the Intersection of Faith and Tuberculosis • July 16, 2010

Acknowledgements and About the Authors

The report’s principal authors are Thomas Bohnett and Claudia Zambra. Katherine Marshall provided in-valuable guidance, oversight and inputs to the work.

Zaina Awad contributed research, writing and editorial sup-port, and Chris Lumry also made significant research contri-butions.

Thomas Bohnett is a law student at the University of Michi-gan, and was Program Coordinator for the World Faiths De-velopment Dialogue from 2008-2010. He graduated from the Woodrow Wilson School at Princeton University in 2007, and was a 2007-08 Princeton-in-Africa Fellow in Uganda with the International Rescue Committee.

Claudia Zambra is a Program Coordinator for the World Faiths Development Dialogue. She began her career in in-ternational development after completing the Master of Sci-ence in Foreign Service program at Georgetown University in 2004. In her previous work at the World Bank, Organization of American States and the private sector, she focused on gov-ernance, poverty reduction and aid effectiveness.

This report is the result of a collaborative venture by numerous individuals representing a wide range of organizations that are involved in the fight against TB. We acknowledge with special appreciation the partnership of several institutions, especial-ly the World Health Organization (WHO) and its Stop TB Partnership, Christian Connections for International Health (CCIH) and the Center for Interfaith Action on Global Pov-erty (CIFA). We would like to express our deep appreciation to individuals from these and other institutions, listed below, for their cooperation in this effort. Colleagues provided invalu-able inputs to this work, ranging from technical expertise to personal anecdotes, and devoted time and effort to interviews, written exchanges and comments on drafts of the report.

We would like to thank the following individuals: Paulo Lopes, Country Director and Ravi Bhatnagar, Project Man-ager, ADRA India; Heng Bunsieth, Executive Director, Action for Health and Development (AHEAD); Dr. Kechi Achebe, Deputy Director, Office for Health and HIV/AIDS, Africare; Jean-François de Lavison, Ahimsa Partners SAS; Msgr. Rob-ert J. Vitillo, Caritas Internationalis; Dr. Sok Pun, Health and HIV/AIDS Project Manager and Dr. Elena McEwan, Senior Technical Advisor, Catholic Relief Services (CRS); Jean Duff, Executive Director, CIFA; Ray Martin, Executive Director, CCIH; Heidi Linton, Executive Director, Christian Friends of Korea (CFK); Samuel Mwenda, Christian Health Association of Kenya; Amy Metzger, International Health Specialist and Dr. Lourdes Mata, Compassion International; Patrice Wed-derburn, Policy Associate, Friends of the Global Fight Against AIDS, Tuberculosis and Malaria; Bernhard Liese, Chair of the Department of International Health at Georgetown Univer-sity School of Nursing and Health Studies, Georgetown Uni-versity; Dr. William Clemmer, Chief of Party Project AXxes/USAID, IMA World Health; Lea Lindero, Nurse, Kwai River Children’s Hospital; Dr. Donn Gaede, Loma Linda Univer-sity; Deliana Garcia, Director, Migrant Clinician’s Network; Dr. Naomi Komatsu, Municipal Program for the Control of Tuberculosis; Wayne Ford, Chairman and Dr. Simon Thaung, Director of Agape Clinic, Myanmar Christian Mission; Paul Zintl, Partners in Health; Dr. Neth Sovirak, Director, Phnom Penh Municipal Referral Hospital; Kayt Erdahl, Program Spe-cialist, Project HOPE; Blessina Kumar, Consultant, Rahein Health and Development; Dr. Ian Campbell, Salvation Army International; Dr. Gerlinda Lucas, Deputy Director of Ad-ministration, Sihanouk Hospital of Hope; Jaime Bayona, Di-rector, Socios en Salud (Partners in Health); Dr. Salem Barg-hout, WHO Medical Officer, MDR-TB, Pakistan National TB Control Program; Dr. Kola Akinola, Senior Policy Officer, Tearfund; Dr. Nelle Temple Brown; Alexandra Farnum, The

Berkley Center for Religion, Peace & World Affairs 3Experiences and Issues at the Intersection of Faith and Tuberculosis • July 16, 2010

Bill and Melinda Gates Foundation; Dr. Mohamed Aziz, Se-nior TB Adviser, The Global Fund to Fight AIDS, Tuberculosis and Malaria; Dr. Ngoma M. Kintaudi, Medical Director, The Protestant Church of Congo, Department of Medical Works (ECC/DOM); Dr. Rachel Karrach, Hospital Director, United Mission Hospital, Tansen; Dr. Clydette Powell, Medical Of-ficer, Heather MacLean, Senior Advisor, Center for Faith-Based and Community Initiatives and Ari Alexander, Deputy

Director, Center for Faith-Based and Community Initiatives, USAID; Dr. Marcos Espinal, Executive Secretary, Stop TB Partnership Secretariat, Dr. Giuliano Gargioni, Team Leader, Partnering and Social Mobilization at the Stop TB Partnership, Canon Ted Karpf, Office of the Director General, Program on Partnerships and UN Reform, and Dr. Mario Raviglione, WHO Director, Stop TB Department, WHO; Dr. Zari Gill, TB Program Specialist, World Vision Canada.

This report surveys the contributions of faith-inspired organizations to the global fight against tuberculosis and suggests ways to increase their participation and

effectiveness. TB is known as one of the “big three” infectious diseases affecting the developing world, but has received less attention and funding from donors than have HIV/AIDS and malaria. However, the rising incidence of drug-resistant strains of TB, as well as co-infection with other deadly diseases, have resulted in the recent prioritization of TB on the agendas of lo-cal as well as international development organizations. A col-laboration between the Berkley Center and the World Faiths Development Dialogue, the report highlights the critical roles that faith-inspired actors play in addressing TB challenges in

About This Report the developing world. It characterizes faith work on TB as “organic and chaotic,” and calls for increased efforts to bring faith-inspired organizations into coordinating mechanisms at the country and global level. The report acknowledges and de-scribes the capacity issues that may be preventing faith actors from being more involved with TB control, and points clearly towards more concerted action at the country level to engage faith actors who are already are, or could be, working to ad-dress TB. The report formed the basis of a consultation held at Georgetown in June 2010. It is one of a series of Berkley Center issue surveys made possible through the support of the Luce/SFS Program on Religion and International Affairs.


Table of Contents

Abbreviations and Acronyms 7 Introduction and Overview 9Section I. What is Tuberculosis? 11

Tuberculosis in History 11Box 1. TB in Literature and the Arts 11

Transmission and symptoms 12Box 2. TB in the Millennium Development Goals 12

Drug-resistant TB 13 Diagnosis 13 Treatment 14

Box 3. Tuberculosis Control by National Governments 14 Box 4. World Health Organization 14 Box 5. The TB Alliance – Global Alliance for TB Drug Development 15 Box 6. Aeras Global TB Vaccine Foundation 16

Vaccines 17

Section II. Co-infection Issues 18TB/HIV co-infection 18Other forms of TB co-infection 19

Box 7. Africare: Integrating TB and HIV/AIDS Programs 19Box 8. Caritas Internationalis – TB Work in Swaziland 20

The impact of culture on TB diagnosis and treatment 21Box 9. Catholic Relief Services – Integrating TB and HIV/AIDS Programs in Cambodia 22Box 10. PASADA and the NTLP Tanzania – Discovering Potential for Future Collaboration? 22Box 11. Medicine vs. Faith: Holy Water Healing in Ethiopia 23

Section III. TB Advocacy and Funding 26The “rediscovery” of TB by the public health community 26The Stop TB Partnership 26

Box 12. The Stop TB Strategy 27The Global Drug Facility 27The Green Light Committee Initiative 27Eli Lilly and the MDR-TB Partnership 27TB Funding Needs 28

Box 13. The World Bank’s Role in the Stop TB Partnership 28The Global Fund 29

Box 14. Friends of the Global Fight 29Box 15. BMGF Partners with the Chinese Government to Fight TB 30

United States Agency for International Development (USAID) 30The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) 30The Bill and Melinda Gates Foundation 30


Section IV. Tuberculosis – What Does Faith Have to Do With It? 32Local hospitals and clinics 32Congregations and their associated voluntary groups 32International faith-inspired non-governmental organizations 33

Box 16. World Vision’s TB Program in the Philippines 33Box 17. NGO Tuberculosis Consortium – India: Working towards an India without TB 33

National religious coordinating bodies 34Funding for faith-inspired organizations to fight TB 35

Box 18. Catholic Relief Services - Engaging Faith Leaders for TB Education and Stigma Reduction in the Philippines 35Box 19. ADRA (India) Advocacy, Communication and Social Mobilization (ACSM) Project for TB Control in Bihar 36

Dearth of data on faith-tuberculosis work 37Box 20. Socios en Salud (SES) - Building on Catholic Community Networks in Peru 38Box 21. Treatment for One is Prevention for All - ADRA’s TOPA Project 38Box 22. A Collaboration to Control TB amongst Bolivian Migrants 39Box 23. World Vision: Working with Migrant Communities in Thailand 40

Faith leaders working to address stigma surrounding TB 40Close community links of faith institutions help facilitate effective TB treatment 41

Box 24. Catholic Relief Services: A Picture of TB in Cambodia 41Faith communities have a keen concern for communities vulnerable to TB 42

Box 25. Combating TB in the Democratic Republic of the Congo: A Shared Effort 42Box 26. Christian Friends of Korea - Combating TB in a Closed Society 43Box 27. “Preaching the Gospel with a Sandwich” – Providing TB Care in Myanmar 45Box 28. World Vision’s TB Programs in Somalia 47

Faith institutions work in countries with repressive and / or unstable governments 47Other faith-inspired organizations working on TB 48

Section V. Questions, Issues, and Opportunities 50Capacity 50Horizontal vs. vertical interventions 51Coordination 51Interfaith work 52

Appendix 1: Maps and Tables 53Map 1) Estimated new TB cases (all forms) per 100,000 people 53Map 2) Distribution of countries and territories that have reported at least one case of XDR-TB as of January 2009 54Table 1) High Burden Countries and Incidence Rates 55Table 2) Funding for TB control by line item, high burden countries, 2002-2010 56Table 3) Estimated epidemiological burden of TB (2008) 56

Selected References and Endnotes 58


ABBREVIATIONS AND ACRONYMSACSM Advocacy, Communication, and Social MobilizationADRA Adventist Development and Relief AssociationAHEAD Action for Health and DevelopmentAHRC Asian Human Rights CommissionAIDS Acquired Immune Deficiency SyndromeANERELA+ African Network of Religious Leaders Living With or Personally Affected by HIV/AIDSARC American Refugee CommitteeART Anti-Retroviral TherapyBCG Bacillus Calmette-GuerrinBMGF Bill and Melinda Gates FoundationCBO Community Based OrganizationCCM Country Coordinating MechanismsCDC Center for Disease Control and PreventionCFK Christian Friends of KoreaCHAN Christian Health Association of NigeriaCHE Community Health EvangelismCIFA Center for Interfaith Action on Global Poverty

CMMB Catholic Medical Mission BoardCRS Catholic Relief ServicesDFIT Damien Foundation India TrustDOT Directly Observed TherapyDOTS Direct Observed Therapy (Short Course)DRC Democratic Republic of the CongoDPRK Democratic People’s Republic of KoreaECC/DOM The Protestant Church of Congo, Department of Medical WorksEMEA European Medicines AgencyFBO Faith-Based OrganizationFDA Food and Drug AdministrationFRIENDS Friends of the Global Fight Against AIDS, Malaria, and TuberculosisGDF Global Drug FacilityGFATM Global Fund to Fight AIDS, Tuberculosis, and MalariaGLC Green Light CommitteeGNP Gross National ProductGSK GlaxoSmithKlineHBC High Burden CountriesHIV Human Immunodeficiency VirusIC Infection ControlICF Intensified Case FindingIDES International Disaster Emergency ServiceIFAPA Interfaith Action for Peace in AfricaIPT Isoniazid Preventive TherapyKRCH Kwai River Christian Hospital


ABBREVIATIONS AND ACRONYMSMCN Migrant Clinician’s NetworkMDG Millennium Development GoalsMDR-TB Multi-Drug Resistant TuberculosisMDT Multi-Drug TherapyMOH Ministry of HealthNTBLCP National Tuberculosis Leprosy Control ProgramNTCP National Tuberculosis Control ProgramNTLP National Tuberculosis Leprosy ProgramNTP National TB ProgramPASADA Pastoral Activities and Services for People with AIDS in the Dar Es Salaam ArchdiocesePATH India Program for Appropriate Technology in Health, IndiaPCI Project Concern InternationalPDP Product Development PartnershipPEPFAR President’s Emergency Plan for AIDS ReliefPLWHA People Living with HIV/AIDSPPM Public-Private MixR&D Research and Drug DevelopmentRNP Religious Non-Profit OrganizationsRNTCP Revised National TB Control ProgrammeSANRU Basic Rural Health ProjectSES Socios en SaludSIDA Swedish International Development AgencySSM Sputum Spear MicroscopyTB TuberculosisTBAI TB Alert IndiaTLCP TB and Leprosy Diseases Prevention and Control ProgramTOPA Treatment for One is Prevention for AllTSR Treatment Success RateTST Tuberculin Skin TestUSAID United States Agency for International DevelopmentVCT Voluntary Counseling and TestingWFDD World Faiths Development DialogueWHO World Health OrganizationWV World VisionWVFT World Vision Foundation ThailandXDR-TB Extensively Drug-Resistant TuberculosisZACH Zimbabwe Association of Church Related Hospitals


Tuberculosis (TB) has been described as an ancient disease that is now a modern epidemic. A scourge to mankind throughout history, the complexity of

the different strains of TB confounds medicine to this day, and presents a profound challenge to efforts to improve global health. Alongside HIV/AIDS and malaria, TB is one of the “big three” infectious diseases that are the leading causes of death in the developing world.1 An airborne disease, TB is highly contagious; a new TB infection occurs somewhere in the world every second, and two billion people around the world are infected with TB (though most of these cases are latent, and not threatening to individuals).2

TB has characteristics that differentiate it – and make it more difficult to treat, both individually and from a public health perspective – from other major infectious diseases, including HIV/AIDS and malaria. TB is difficult to diagnose, and treat-ment regimens are lengthy and exacting. As the availability of antibiotics effective against TB resulted in the disease’s decline in the developed world, interest in research and development for additional treatment options and a vaccine diminished. The recent resurgence of TB – there were 9.4 million new cases and 1.8 million deaths in 2008 – in addition to issues arising from TB and HIV/AIDS co-infection and the emergence of new, drug-resistant strains of the disease, has spurred increased TB-related awareness and activity.

TB is a disease of poverty, and most TB-related deaths occur in the world’s poorer countries. The segment of the population most affected by TB tends to be young adults, who are also, typically, the most productive members of society. Treatment is often not available in poor communities, and when it is, entails significant indirect costs (such as travel expenses and lost time at work).

There is damaging stigma associated with TB because of links, both real and perceived, with poverty and with other diseases, HIV/AIDS most prominent among them. Changes in physi-cal condition that are common with TB can make infection noticeable and open the door for prejudice.3 As a result, diag-nosis rates are lowest, and treatment abandonment rates high-est, where TB stigma is at its most severe.

Governments, corporations, global institutions and NGOs are actively engaged in the fight against TB. Faith-inspired orga-nizations generally play active roles in this global effort, espe-cially where religious organizations act as primary healthcare providers. Several of the largest faith-inspired development organizations acting against TB include international NGOs such as World Vision, Catholic Relief Services (CRS), and the Adventist Development and Relief Agency (ADRA). Other major faith-inspired actors include local or regional organiza-tions, such as the Christian Friends of Korea or the Myanmar Christian Mission, which may have had at one point, or may continue to have, links with faith communities in developed countries. Finally, religious organizations that are linked with local congregational structures, representing the gamut of world faith traditions, play varying roles in meeting TB.

Despite their evident and extensive reach, the work of faith-in-spired organizations addressing TB has not yet been explored in any significant depth. This report reflects the findings of an investigation into the varied contributions of faith-inspired organizations to TB control. The investigation focused on the following questions: Where do global TB efforts stand today? What are faith leaders, organizations, and communities doing to treat and slow the spread of TB, and what roles can they productively play in the future? How can the potential of faith-inspired actors working on TB be effectively harnessed at the global, national, and local levels to improve health outcomes

Introduction and Overview


related to TB? The findings of this report were informed by in-depth discussions and exchanges with representatives from a range of development organizations and religious traditions involved in TB work, as well as desk research. The data con-tained in this report was current as of May 27, 2010.

Section I of this report presents an overview of TB in order to capture the medical and social complexities of the disease and to provide a snapshot of global TB efforts. This section includes a discussion of TB in medical history, examining past theories of the disease’s epidemiology, contagiousness, and treatment options. It also provides background information and statistics about drug-susceptible and drug-resistant TB.

Section II focuses on TB co-infection with other diseases, namely HIV/AIDS, leprosy and diabetes. Due to high rates of TB/HIV co-infection, the diseases are often associated in communities where one or the other, or both, of the diseases are prevalent. This association drives much of the stigma cur-rently associated with TB (though TB had its own stigma, wrapped up in associations with poverty and poor hygiene, long before the emergence of HIV/AIDS). The section also discusses the benefits, which include speedier diagnoses, of in-tegrating health programs that jointly address TB and HIV/AIDS. It highlights a case study of collaboration between a faith-inspired organization, PASADA, an HIV/AIDS care provider, and Tanzania’s National Tuberculosis and Leprosy program.

Section III summarizes the financing of global TB efforts, and describes the efforts of some of the major donors that contrib-ute to the fight against TB. These organizations include the Aeras Global TB Vaccine Foundation, the TB Alliance, the Bill and Melinda Gates Foundation, the Global Fund to Fight AIDS, Malaria and Tuberculosis, and bilateral donors includ-ing the U.S., Japan, the Netherlands, and Germany. Section IV focuses on the roles of different faith communities in addressing TB. This section includes detailed accounts of the work of faith-inspired organizations active in TB control around the world. These stories, while largely anecdotal, il-lustrate some of the important roles that faith organizations are playing in the fight against TB. This section includes a discussion of the relationships between donor organizations and faith-inspired organizations.

Section V, the report’s concluding section, looks at questions, issues, and opportunities around faith-inspired work on TB. Capacity issues are a central challenge, as faith-inspired organi-zations have special characteristics that enable them to fill im-portant roles in healthcare delivery in poor countries, but also often lack the organizational and accountability standards that are required by international donors. Other issues discussed in this section are the horizontal/vertical intervention debate, which has special relevance to TB because of co-infection is-sues; the possibilities and caveats associated with interfaith work on TB; and how a lack of coordination of anti-TB ef-forts, especially among faith groups, may hinder achievement of global TB goals.


Tuberculosis has afflicted mankind throughout history; there is evidence of a form of tuberculosis in fossil bones that date back to around 8000 BCE. It has been

surmised that Tutankhamen, the young Egyptian pharaoh of the 18th dynasty whose cause of death remains a mystery, may have died from TB. Meanwhile, Hammurabi’s code, the oldest legal text in the world, also mentions a disease with symptoms similar to those of TB.5 Hippocrates (460-370 BCE), perhaps the most well-known of ancient Greek physicians, described “phthysis,” now known as tuberculosis, as a dangerously com-mon and supposedly hereditary disease that typically resulted in death. Hippocrates even warned his colleagues not to visit patients suffering from advanced stages of phthysis, as the pa-tient would undoubtedly die and therefore ruin the physician’s reputation.6

As medical knowledge developed, theories circulated that “phthysis” was not a hereditary disease, but a contagious one. Because the disease results in significant weight loss and gen-eral “wasting away,” it was commonly referred to as “consump-tion” (as in the quote above). The anatomist Giovanni Battista Moragni of Padua (1682-1771) was so convinced of the con-tagiousness of consumption that he refused to conduct post-mortem examinations of patients who died from the disease for fear of infection. During the same era, Fracastorius of Verona (1458-1553) postulated that consumption was “transmitted by an invisible virus” – one that could survive for two years on the clothing of the infected. The foreboding presence of TB both in literature and theater (see Box 1) added to the notoriety of the disease.7

Sylvius de la Boë (1617-1655) advanced scientific knowledge of the disease when he identified tubercles, growths which he described as nodules or lesions in the lungs and other organs that progressed into ulcers and cavities. In 1882, Robert Koch

discovered the tubercle bacillus8 (M. tuberculosis), the bacte-ria that attacks the lungs and body and causes infection that can lead to TB; in 1884, the term “tuberculosis” was coined to describe affliction with tubercles.9

In the early 1900s, sanatoriums were established to house and quarantine TB patients and enforce a sensible diet, rest, and a healthy lifestyle. The sanatoriums resulted in the removal of a large proportion of the infected population from the general public, and thus succeeded in limiting the disease’s spread in much of Europe and the United States. Sanatoriums were only partially effective as a TB remedy; statistics from the late 1880’s show that more than 60 percent of the American patients discharged from sanatoriums, including 17 percent of those who were “cured,” died from the disease within six years.10

Section I. What is Tuberculosis?

Box 1. TB in Literature and the Artsi

TB has featured in a number of literary and theatrical works, not least Giacomo Puccini’s La Bohème. Thomas Mann, George Bernard Shaw, Gertrude Stein, D.H. Lawrence, and Katherine Mansfield, among many others, have chosen TB as an affliction for main characters in their stories.

A number of authors have also fallen victim to TB. Eight members of the Brontë family, including Charlotte, Emily and Anne, died from the disease between 1825 and 1855. The disease also killed several other notable authors, including John Keats, Robert Louis Stevenson, George Orwell and Franz Kafka.

http://www.essortment.com/all/tuberculosislit_rnwk.htm (accessed 27 i. May 2010).

“The Lord shall smite thee with a consumption, and with a fever, and with an inflammation, and with an extreme burning, and with the sword, and with blasting, and with mildew; and they shall pursue thee until thou perish.”

– Deuteronomy 28:22, King James Version4


In 1921, the Bacille Calmette-Guerin (BCG) vaccine was de-veloped. Astonishingly, given medical advances on almost all other fronts, the BCG vaccine remains the only TB vaccine in use today. While the vaccine has proven effective in preventing the most serious symptoms of TB in children, it is completely ineffective against adult pulmonary TB, which accounts for the majority of the TB disease burden worldwide.11

In September 1943, significant progress towards an effective treatment for TB was made when physician Selman Waksman discovered that the antibiotic streptomycin effectively inhib-ited tubercle bacillus, and with only limited toxicity.12 The antibiotics regimen currently in use is a product of scientific advances of the 1960s, and consists of four medicines: isoni-azid, ethambutol, pyrazinamide, and rifampin.13 This treat-ment is only effective against drug-susceptible TB, and works only if patients consistently adhere to a complicated treatment regimen that can last anywhere from six to nine months.

As the tools to fight TB improved, the attention and resources devoted to researching the disease steadily declined.14 This was partly because, in the wealthier regions of the world, TB treatments and the BCG vaccine became readily available. Ex-panding healthcare systems and accessibility to drugs seemed to dull TB’s threat. In poorer, less privileged regions, TB re-mained a critical problem. Limited access to anti-TB drugs in the developing world resulted in higher incidence rates of TB in some places and, where supplies were intermittent, also fueled the development of drug-resistant strains of TB disease. It was not until the mid-1990’s – about two decades since the last concerted focus on TB by global institutions – that health authorities, including the World Health Organization (WHO) and the World Bank, realized the scope of TB as a public health problem in developing countries and acknowl-edged the need to re-focus on TB as a global epidemic (for more on the WHO’s anti-TB efforts, see Box 4). Concern about TB escalated to the point where, during the formulation of the Millennium Development Goals (MDGs) in 2000, TB was included alongside malaria and HIV/AIDS as the diseases of greatest concern to the developing world (see Box 2).

Transmission and symptomsTuberculosis infection begins when the bacterium Mycobac-terium tuberculosis (M. Tb) enters the body. At first, M. Tb primarily targets the lungs, but can also attack the brain,

kidney, or spine. TB bacteria are airborne, and can be dis-seminated when an infected individual coughs or speaks, for example. Contrary to common misconceptions, tuberculosis is not spread through casual physical contact or kissing.15

One third of the world’s population – an estimated two billion people – has been infected with TB bacilli; however, only 5-10 percent of those who are infected will develop active tubercu-losis disease. Infections remain latent when an individual’s immune system is capable of fighting the bacteria; in these cases, an infected person does not show symptoms of the dis-ease and cannot spread it to others.16 Symptoms afflicting those infected with active TB include

Box 2. TB in the Millennium Development Goalsi

During the Millennium Summit held in September 2000, 189 United Nations member countries adopt-ed the UN Millennium Declaration, signifying their dedication to sustainable international development and poverty reduction. From the Declaration emerged the Millennium Development Goals (MDGs), a set of eight goals focusing on national targets for issues re-lated to poverty, education, gender equality, health and environmental sustainability.

The sixth MDG is to “combat HIV/AIDS, malaria, and other diseases.” Sub-target 6C is to “halt and be-gin to reverse the incidence of TB and other major dis-eases by 2015.”

Progress towards meeting the tuberculosis targets is mixed. In developing countries, the reported TB inci-dence rate fell by 0.7 percent between 2005 and 2006; if such progress is maintained, the goal of reversing the incidence rate will be met by 2015. However, in the same years, progress in detection rates reached only 61 percent, falling short of the 65 percent benchmark for 2006. Slow detection rates could offset the over-all progress in incidence rates, resulting in failure to achieve all TB-related targets in the MDGs.

United Nations Development Plan, “Millennium Development i. Goals,” http://www.undp.org/mdg/basics.shtml (accessed 27 May 2010).


prolonged periods of coughing, lack of appetite, weight loss, night sweats, extreme fatigue, fever, and chills. TB-infected in-dividuals can also suffer from hemoptysis (coughing up blood) and / or chest pain.17

Drug-resistant TB

“There is a saying in TB circles that poor TB treatment is worse than no treatment at all.”

– Dr. Mark Dybul, former United States Global AIDS Coordinator

Medical professionals have battled drug-resistant strains of TB ever since the release of the first TB antibiotic, streptomycin. Strains of multi-drug resistant tuberculosis (MDR-TB) can emerge when TB patients do not complete the full cycle of treatment with anti-TB drugs, allowing some TB bacteria to survive; these surviving bacteria adapt and become immune to certain drugs.18 The WHO estimated that in 2008, there were 440,000 cases of MDR-TB, with India and China re-sponsible for almost 50% of the global MDR-TB burden.19 However, as a recent article in the Lancet makes clear, the data informing estimates around MDR-TB prevalence are far from precise; a massive upgrade of laboratory capacity is required before the global distribution of drug resistance is properly understood.20

MDR-TB is classified as such when the disease is resistant to at least two of the current first-line anti-TB drugs, isoniazid and rifampin. Treatment for MDR-TB is more complex and expensive than treatment for regular TB. Extensive chemo-therapy, using drugs that are often more toxic than the first-line TB medicines, is required to treat MDR-TB and can take up to two years to completely eliminate the disease. In addi-tion, treatment of MDR-TB can cost up to 1,400 times more than treatment of non-drug resistant TB.21

Graver still is the threat presented by Extensively Drug-Resis-tant TB (XDR-TB). XDR-TB develops through the misuse or mismanagement of drugs used to treat MDR-TB. XDR-TB is defined as TB that is resistant to any fluoroquinolone (chemo-therapeutic antibacterials), at least one of the three injectable second-line drugs used to treat MDR-TB, in addition to the first-line drugs isoniazid and rifampin.22

The spread of drug-resistant forms of TB is a broad and grow-ing phenomenon, but to date it has been little remarked on in the press. The 2007 case of an American lawyer infected with drug-resistant TB who flew into the United States de-spite restrictions briefly drew attention to the potentially ex-plosive danger of the spread of MDR-TB; however, this con-cern quickly dissipated.23 Meanwhile, XDR-TB has shown its devastating potential in KwaZulu Natal, South Africa, where outbreaks of the disease have been characterized by an extraor-dinarily high mortality rate.24

DiagnosisDiagnosing TB is a complex and time-consuming process, the inaccuracies and costliness of which contribute to TB’s profile as a public health threat in countries with limited resources. The front-line method for diagnosis is Sputum Smear Microscopy (SSM), which consists of an examination of sputum (phlegm) for a certain type of bacteria. According to the WHO, SSM’s most significant shortfall lies in the fact that it represents tech-nology that is over 100 years old; it is slow, labor intensive, and often needs to be supplemented with further testing.25 Another standard test for TB infection is the Mantoux Tuberculin Skin Test (TST). The Mantoux test can be problematic because it requires patient follow up, can yield false reactions that result in incorrect diagnoses, and because it shows positive in people who have had the BCG vaccine and so is not as useful for TB diagnostics in many developing countries where BCG is used widely.26 A recent series on TB in the Lancet suggests that several promising diagnostic technologies are in development, but that an inexpensive, point-of-care test – the most important goal of TB diagnostics in poor countries – is still out of reach.27

Cell culture techniques are largely considered the “gold stan-dard” of TB diagnosis, as they are extremely sensitive to TB mycobacteria in the sample. While the accuracy of cell culture is unrivaled among TB test methods, the process can take from two to six weeks. The procedure’s accurate diagnosis of TB is also dependent on the presence of M. Tb in the sample, which is not always possible to obtain, particularly when the patient is unable to produce enough sputum. With all testing methods, including SSM, TST, and cell culturing, chest x-rays and physi-cal examinations are important complementary components for diagnosis of active TB.28


TreatmentTreatment for non-drug resistant TB is typically provided on an outpatient basis, where infected patients are put on a strictly-regimented six to eight-month course of antibiotics but are not hospitalized.29 The predominance of outpatient, versus inpa-tient, treatment is due in large part to the inability of hospi-tals and clinics to house patients for extended periods of time (though this is not true in all places – the former Soviet repub-lics focused on in-patient treatment whenever possible). The potential dangers of an incomplete drug sequence, which could even lead to the development of MDR-TB and XDR-TB, has led to the use of so-called Directly Observed Therapy (DOT, or DOTS, if short course)30 programs. In programs implemented in line with the DOT and DOTS strategy, health workers mon-itor and directly supervise TB drug intake, either at hospitals, health centers or patients’ homes.31 Box 3 contains an explana-tion of national tuberculosis programs.

A 1999 study by Botswana’s Ministry of Health found that home-based DOTS treatment was 44 percent cheaper than hospital-based DOTS, and that adoption of a DOTS program reduced the cost to both patients and the health system.32 World Bank research has documented a significant marginal benefit in implementing the Global Plan to Stop TB’s recommended practices (which include DOTS), compared to strategies that do not include DOTS treatment. One World Bank study re-ported that the marginal benefit was 15 times greater than the cost of implementing DOTS in the 22 TB high burden coun-tries (HBCs),33 and nine times the cost of doing so in Africa.34 Effective implementation of DOTS requires consistent contact with and surveillance of TB-infected communities. Because of their extensive community links and highly regarded positions in society, faith communities can be well positioned to provide DOTS care. There are a number of faith-related organizations that have worked to provide DOTS in high TB burden coun-tries, such as Zambia, Cambodia, and Peru; stories document-

Box 3. Tuberculosis Control by National Governmentsi

International partners are heavily involved in advocacy, funding, and research related to TB. However, it is national gov-ernments that are responsible for the planning and execution of tuberculosis programs at the country level, and most anti-TB efforts are funded through national governments (though much of this funding comes indirectly from international donors). The efforts of national tuberculosis programs (NTPs) are informed by the WHO Stop TB Strategy. Ideally, NTPs govern the equipping and functioning of diagnostic laboratories; provide a continuous supply of drugs to treatment outlets; coordinate the efforts of government and non-government health care actors; and set policy related to TB treat-ment. The Lancet reported that in 2008, 91% of countries (including all HBCs) that responded to its survey were at least providing DOTS therapy.

K. Lonnroth, K. Castro, et al., “Tuberculosis control and elimination 2010-50: cure, care, and social development,” The Lancet (May 2010), http://www.thelancet.com/jour-i. nals/lancet/article/PIIS0140-6736%2810%2960483-7/fulltext#article_upsell, (accessed May 2010).

Box 4. World Health Organization

The WHO, in addition to hosting the Stop TB Partnership secretariat, is deeply involved in the global fight against TB. It provides technical support to NTPs and ministries of health in its 193 Member States about the prevention and treatment of TB. It sets the global research agenda related to TB, and publishes an annual report on TB which assesses national, regional, and global efforts to control the disease. WHO does not directly fund the implementation of TB-related pro-grams; however, it often plays a catalyzing role for grant applications to the Global Fund (as well as other funding sources) by NTPs, as exemplified by its coordinating role in Swaziland, highlighted in Box 8. The WHO maintains a range of private sector partnerships related to TB, including with the Aeras Global TB Vaccine Foundation, the Bill and Melinda Gates Foundation, and the Global Alliance for TB Drug Development.i

G. Gargioni, “Community Involvement in Tuberculosis Care and Prevention: Towards partnerships for health”, World Health Organization (Geneva 2008), i. http://whqlibdoc.who.int/publications/2008/9789241596404_eng.pdf (accessed 15 July 2010).


ing their successes, and the challenges they have faced, follow later in this report.

Care that isolates patients, in a manner similar to tradition-al TB sanatorium practices, is more frequently employed in MDR or XDR-TB cases, or in regions where more resources for treatment are available. The Centers for Disease Control and Prevention (CDC) recommends that MDR-TB patients seek treatment at specialized centers. However, there is debate surrounding the effectiveness of inpatient treatment, as some

argue that contained spaces for XDR-TB and MDR-TB pa-tients are breeding grounds for even more dangerous drug-re-sistant strains. For example, a study of an XDR-TB outbreak at a hospital in Tugula Ferry, South Africa, in 2006 found that a lethal strain was spread through airborne contact and was not the result of a failure to complete the drug treatment.35

The search for new, more effective anti-TB drugs is ongoing. Organizations and researchers associated with the Global Alli-ance for TB Drug Development (Box 5)36 are working to de-

Box 5. The TB Alliance – Global Alliance for TB Drug Development

There have been no new classes of TB drugs in over forty years, and the current treatment requires at least six to nine months to administer. The TB Alliance, a not-for-profit product development partnership (PDP) between the public, private, academic, and philanthropic sectors, was founded in 2000 to advance the development of dozens of potential new diagnostics, drugs, vaccines, and microbicides.i The Alliance has received pledges of more than US$250 million in financial contributions.ii, iii

The TB Alliance has a broad range of drug development partners that include Anacor Pharmaceuticals, Bayer, GlaxoS-mithKline, the Korea Research Institute of Chemical Technology, Novartis, Sanofi-Aventis, and Tibotec. The TB Alliance’s drug development projects are screened on the basis of their ability to shorten TB treatment, compatibility with other drugs, and affordability. They are monitored by the TB Alliance staff members and the Scientific Advisory Committee, a group of technical experts on drug research, development, manufacturing, and distribution.iv

The TB Alliance is currently managing three potential drug candidates in drug trials and screening thousands of com-pounds that have possible uses related to TB treatment. Its objective is to develop an updated drug regimen that will improve patient compliance, increase cure rates, lower toxic side effects, act more quickly, and be freely distributed.v

Two projects that are approaching clinical trials are nitroimidazoles and quinolones, both of which are expected to treat TB more quickly and effectively than the treatment currently used. Patients are also currently being enrolled in the RE-MoxTB Phase III trial testing of Moxifloxacin, a drug that has the potential to shorten TB treatment to four months.vi The long-term goal of the TB Alliance is to advance treatment through antibiotics to the point where tuberculosis can be cured in less than two weeks, which is the general length of time in which antibiotics cure other infectious diseases.

The TB Alliance is also engaging with regulatory agencies, such as the Food and Drug Administration (FDA) and the European Medicines Agency (EMEA), in pushing for new guidelines for TB drug registration, since none currently exist.vii Also, because successful drug delivery is impossible without up-to-date information regarding existing treatment supply networks, the TB Alliance has developed a drug database as a resource for the drug research community.

Global Alliance for TB Drug Development, Business Model, http://www.tballiance.org/about/business.php, (accessed 27 May 2010).i. Global Alliance for TB Drug Development, TB Drug Portfolio, http://www.tballiance.org/new/portfolio.php, (accessed 27 May 2010). ii. The following is a list of the major donors, as well the proportion of their overall funding to the Alliance: the Bill & Melinda Gates Foundation (50%), U.S. iii. Agency for International Development (18%), UK Department for International Development (14%), the Netherlands Ministry of Foreign Affairs (7%), the Rockefeller Foundation (6%), and Irish Aid (5%). Source: Global Alliance for TB Drug Development, About Us: Donors, (accessed 27 May 2010).Global Alliance for TB Drug Development, TB Drug Portfolio, (2010), http://www.tballiance.org/new/portfolio.php (accessed 27 May 2010).iv. Ibid.v. Global Alliance for TB Drug Development, Confronting TB: What it Takes: 2008 Annual Report, (2008), 14, http://www.tballiance.org/downloads/publica-vi. tions/TBA_Annual_2008_web.pdf (accessed 27 May 2010).Global Alliance for TB Drug Development, Regulatory Engagement, (2010), http://new.tballiance.org/new/regulatory.php (accessed online: 27 May 2010).vii.


velop new ways to treat and prevent the disease. The Alliance aims to develop a drug therapy that is capable of reducing treatment duration, is effective against drug resistant strains of TB, and is compatible with anti-retroviral therapy that is used to treat individuals with TB/HIV co-infection.37

A 2010 assessment of drug development efforts in the Lan-cet reports that ten compounds possibly related to tuberculosis treatment are in the drug development pipeline, six of which were specifically developed for tuberculosis; the Lancet called this rate of drug development “insufficient to address the un-met needs for treatment,” and said that, “additional and sus-

Box 6. Aeras Global TB Vaccine Foundation

The Aeras Global TB Vaccine Foundation (Aeras) was founded in 2003 as a PDP with the objective of developing and bringing to market at least one new TB vaccine regimen for infants and children, and another for adolescents and adults.i Aeras has partnerships with two of the largest vaccine producers in the world – GlaxoSmithKline (GSK) Biologicals, and Sanofi Pasteur.ii According to Lewellys Barker, a Senior Medical Advisor at Aeras, Aeras’ private partners guarantee that a successful vaccine will be accessible to the developing world.iii

Each of the vaccines undergoing screening by Aeras must have the potential to prevent TB infection as well as stop it in its various stages, which include: active infection (when an individual is infected with TB and suffers from symptoms of the disease), latent infection (when an individual is infected with TB bacteria that has not activated the disease, and therefore does not show symptoms), and reactivation (when active TB relapses due to incomplete treatment).iv Because a single BCG vaccine currently given to infants is insufficient for long-term protection from the disease, Aeras is working to supplement the existing vaccine with what they refer to as a “prime boost” strategy. This strategy is comprised of a “prime” vaccine (Recombinant BCG, or rBCG, which is a genetically modified version of the current BCG vaccine) that is given to infants in order to teach their immune systems how to identify and respond to the TB pathogen (disease causing agent). The rBCG vaccine is then followed by a booster given at intervals throughout the individual’s lifetime to stimulate the body’s immunological memory, which is created from the initial encounter with the pathogen and serves to trigger enhanced responses to secondary encounters with the same pathogen in order to fight infection. The prime is currently in the stage of pre-clinical development, during which it is being tested on animals and its safety and ability to provoke an immune response to TB infection are being evaluated by a panel of independent experts.v This stage of development is then followed by clinical trials, which include three lengthy phases in which the vaccine is tested on volunteer human populations. Following the clinical trials phase, bulk manufacturing of the vaccine takes place. The Aeras headquarters, located in Rockville, Maryland, are equipped with the facilities required to manufacture the vaccine immediately upon approval.

In 2008-09, Aeras actively pursued the scientific advancement of aerosol delivery of a TB vaccine directly into the lungs. According to pre-clinical studies conducted by the National Institutes of Health, aerosol delivery of TB vaccines can trig-ger an immune response more powerful than that which an injection is capable of inducing.vi If delivered through single-use inhalers, the vaccine could be made available at very low cost and, according to Aeras, could have significant impact on the spread of the disease.vii

One of Aeras’ largest donors is the Bill and Melinda Gates Foundation, which, according to Barker, “totally changed the landscape” of the future of TB vaccine development.viii In 2006, Aeras received a US$82.9 million grant from the Bill and Melinda Gates Foundation in order to expand the capacity of its TB vaccine laboratory. In 2007, the Gates Foundation made an additional grant of US$280 million to Aeras for further research on the origins of the disease and to determine what types of vaccines would be most effective in preventing future TB infections.ix With its clinical field site partners in South Africa, Kenya, Uganda, Mozambique, India, and Cambodia, Aeras has supported the development of six different TB vaccine candidates. Volunteers are recruited from these high TB burden countries by Aeras and its partners to conduct efficacy trials.x


tainable funding is needed to further improve the pipeline.” 38

The TB Alliance is also engaging with regulatory agencies, such as the Food and Drug Administration (FDA) and the European Medicines Agency (EMEA), in pushing for new guidelines for TB drug registration, since none currently ex-ist.39 Also, because successful drug delivery is impossible with-out up-to-date information regarding existing treatment sup-ply networks, the TB Alliance has developed a drug database as a resource for the drug research community.

VaccinesDespite ongoing efforts to control the spread of TB, one-third of the world is currently infected with TB.40 This fact, com-bined with the increasing incidence rates of TB/HIV co-infec-tion and drug-resistant strains of TB, demands more research into TB prevention methods. The Aeras Global TB Vaccine Foundation (see Box 6) is dedicated to developing innova-tive and affordable vaccines against TB. Research into new vaccines is prioritized as a complement to drug development efforts, and is an essential component of the fight against TB.

The BCG vaccine has some effectiveness against TB in chil-

dren, and is widely administered across the world (it has been administered an estimated four billion times). The current BCG vaccine contains a weakened strain of mycobacterium bovis (a less virulent strain of tuberculosis that causes the dis-ease in cattle). Of late, there has been concern regarding the safety of the vaccine, especially in individuals whose immune systems are weakened by diseases such as HIV/AIDS. When the BCG vaccine is administered to such individuals, their im-mune system is not strong enough to fight the m. bovis strain and they become more susceptible to contracting the disease. Because of these dangers, there is an urgent need for a vac-cine that will uniformly protect individuals of all age groups from the disease, as well as its drug-resistant strains. The need for such a vaccine becomes more pressing as TB/HIV co-infection rates increase. The Lancet reported in May 2010 that 11 vaccine candidates intended to replace or “boost” the BCG vaccine, have entered clinical trials. The same survey in the Lancet said that, “after decades of inactivity, research and development for tuberculosis vaccines is slowly increasing, al-though there is still a substantial shortfall in funding.” 41

Currently, the AERAS485/Oxford MVA85A booster TB vaccine candidate is the most clinically advanced of any of the TB vaccine candidates and is nearing Phase III (the final round) of trials. The vaccine uses the 85A antigen, which is a protein found in all strains of M. Tb, in order to boost the immune reactions of cells that have already been primed by the BCG vaccine.xi The vaccine successfully passed through Phase I of clinical trials in the UK, The Gambia, and South Africa.xii The vaccine’s Phase IIb trials began in South Africa in April 2009, through a partnership between Aeras, the Wellcome Trust, Oxford University, Isis Innovation Ltd., Emergent Biosolutions, and SATVI. Aeras’ facilities are designed to produce 200 million bulk doses of a live recombinant BCG vaccine per year, which should be enough to meet global estimated needs.xiii

Aeras Global TB Vaccine Foundation, Innovate, Vaccinate, Eliminate: Annual Report 2008, (2008), 3, http://www.aeras.org/newscenter/downloads/presskit/i. Aeras%202008%20Annual%20Report_Final_9.29.08.pdf (accessed online: 27 May 2010).Aeras Global TB Vaccine Foundation, Transforming the Global Fight Against TB, 10.ii. Lewellys Barker, Project 55 Public Health Seminar, 15 January 2010.iii. Ibid.iv. Aeras Global TB Vaccine Foundation, Vaccine Development Process, (2010), http://www.aeras.org/our-approach/vaccine-development.php#oxford, (accessed 27 v. May 2010).Ibid.vi. Aeras Global TB Vaccine Foundation, Transforming the Global Fight Against TB, 10.vii. Lewellys Barker, Project 55 Public Health Seminar, 15 January 2010.viii. Aeras Global TB Vaccine Foundation, History of Tuberculosis Vaccines, (2010), http://www.aeras.org/about-tb/history.php (27 May 2010).ix. Aeras Global TB Vaccine Foundation, Annual Report 2008, 14.x. Ibid., 10. xi. Aeras Global TB Vaccine Foundation, Vaccine Development Process, http://www.aeras.org/our-approach/vaccine-development.php#oxford, (accessed 27 May xii. 2010).Aeras Global TB Vaccine Foundation, “Manufacturing – Overview,” http://www.aeras.org/our-approach/vaccine-development.php?manufacturing-overview xiii. (accessed 27 May 2010).


TB/HIV co-infection TB and HIV/AIDS are commonly referred to as the “deadly duo.” 42 The WHO stresses that HIV is the main reason for the failure to meet TB control targets with a high prevalence of HIV, and TB is the leading infectious killer of people living with HIV/AIDS. Currently, over 50 percent of patients with active TB in many African countries are also HIV positive. The dual epidemic is also of growing concern in Asia, which has two-thirds of the world’s TB cases, and in Eastern Europe, where rates of MDR-TB are particularly high.43

In 2010 an estimated 42 million people are infected with HIV/AIDS, and almost one-third of those individuals are co-infected with TB.44 The epidemics tend to thrive off one an-other; as HIV weakens the immune system, it makes it more likely that a TB infection will progress to disease.

UNAIDS, The Stop TB Partnership, and the WHO each ad-vocate for the prioritization of a global effort to control TB in-fection in populations living with HIV. The Stop TB Strategy, which was developed by the WHO and members of the Stop TB Partnership, is the internationally recommended standard for preventing, diagnosing, and treating TB and includes rec-ommendations for how to treat co-infected individuals.

The WHO’s Policy for Collaborative TB/HIV Activities in-cludes the following four steps:

Setting up a coordinating body for TB/HIV activities 1. that is effective at regional, district and local levels in each country;Surveillance of HIV prevalence among TB patients to in-2. form program planning and implementation;Joint TB/HIV planning, where there are clearly defined 3. roles and responsibilities in guiding activities;

Monitoring and evaluation to assess the quality, effective-4. ness, coverage and delivery of collaborative activities.45

According to the strategy, there are three essential activities that all HIV programs should include to protect infected in-dividuals from contracting TB. These activities, also known as “the three I’s,” are Intensified Case Finding (ICF) through aggressive screening in order to diagnose TB at an early stage; provision of isoniazid preventive therapy (IPT), which is an antibiotic that reduces the risk of developing active TB disease in people infected with it by 33-62 percent; and practicing TB infection control (IC), which consists of measures to reduce the spread of TB to HIV-positive individuals, health workers and other members of their communities.46, 47

A recent assessment of the WHO policy in a Lancet series on tuberculosis called the WHO policy a “milestone” at the time it was released, but criticized its lack of emphasis on “the cru-cial preventative role of antiretroviral treatment (ART).” The Lancet article also suggested that in countries with HIV and TB epidemics, treatment of the two diseases was in practice rarely harmonized.48

Africare is an example of an organization that has made im-portant progress in following the steps recommended by the WHO and the Stop TB Partnership in implementing collab-orative TB/HIV activities. Details of Africare’s work, and the challenges it has faced, are described in Box 7.

The strong TB/HIV link means that a single-disease or “verti-cal” approach, that would treat TB in isolation, would not be nearly as effective as an approach that took on TB and HIV/AIDS at once. Faith actors with broad health offerings on a national level – either faith-inspired NGOs or health systems sponsored by indigenous faith-inspired communities – are of-

Section II. Co-infection Issues


ten well-positioned to adopt an approach to fighting TB that integrates an HIV/AIDS treatment component. For example, member organizations of Caritas Internationalis, a federation of Roman Catholic relief and social service groups, are active in healthcare in hundreds of countries across the world; an account of Caritas’ combined TB/HIV efforts in Swaziland can be found in Box 8. Box 9 contains a country case study of Catholic Relief Services’ integration of its TB and HIV/AIDS programs in Cambodia. Finally, Box 10 provides examples of challenges encountered, and successes achieved, through coop-eration between a faith-inspired organization focused on HIV/AIDS and the national TB control program in Tanzania.

Other forms of TB co-infection TB co-infection with leprosy and diabetes is also of concern, though not on the level of urgency of TB/HIV co-infection. TB and leprosy have been historically linked; the connection between diabetes and TB has become an issue more recently with the surge in diabetes cases worldwide.

TB and LeprosyResearchers from the Hebrew University in Jerusalem and London have suggested that the spread of tuberculosis led to a reduction in leprosy cases in Europe, resulting in the nearly complete eradication of leprosy by the 16th century.49 Leprosy, while rarely fatal itself, weakens individuals’ immune systems

Box 7. Africare: Integrating TB and HIV/AIDS Programsi

A U.S.-based NGO founded in 1970, Africare implements HIV/AIDS programs that are integrated with TB control. Dr. Kechi Anah, Deputy Director of Africare’s Office for Health and HIV/AIDS, explained in an interview that, despite high rates of TB/HIV co-infection in many countries where Africare is active, healthcare workers and community members as a whole fail to appreciate the importance of the link between the two diseases. This is partly due to limited financial and human resources available to deliver interventions, and to a lack of TB/HIV leadership and effective tools to diagnose and treat TB amongst those infected with HIV/AIDS.

In accordance with the priorities and steps set forth by UNAIDS, the Stop TB Partnership, and the WHO, Africare focuses on TB/HIV collaborative efforts from both the prevention and treatment standpoints. With its support, numer-ous health facilities have begun conducting regular risk assessments for TB transmission among HIV/AIDS patients, and are also developing TB infection control plans. Africare has also assisted existing health facilities in the implementation of a model of integrated care that routinely offers TB screening for HIV-positive patients, and vice versa. Furthermore, through its community-based program, Africare has supported education efforts that provide information about the link between poor nutritional status and mortality amongst TB/HIV co-infected patients.

Africare’s main partners are its stakeholders – community members, African governments, faith-inspired organizations, and local religious leaders. Dr. Anah commented that Africare gives priority to working with faith-inspired organizations representing a number of religious backgrounds, including Christian, Muslim, and traditional religious groups. The organization offers training and capacity building to religious leaders in order to help them reach community members with accurate and consistent information about co-infection and treatment. Its funding comes primarily from the United States government, particularly through the United States Agency for International Development (USAID) and the Cen-ters for Disease Control and Prevention (CDC).

Africare’s largest TB/HIV collaborative programs are in South Africa and Nigeria. Prior to 2004, before the collaborative program was implemented in South Africa’s Eastern Cape Province, TB and HIV/AIDS programs worked separately, and were divided into the TB directorate and the HIV directorate. Following Africare’s involvement, the programs have been integrated and all home care-givers provide both TB and HIV support and treatment.

Interview with Dr. Kechi Anah, Africare, conducted 16 September 2009.i.


Box 8. Caritas Internationalis – TB Work in Swaziland

Monsignor Robert Vitillo, who heads the Caritas Internationalis Geneva Delegation, is a prominent leader within the community of Catholic health organizations and calls persistently for recognition of faith based organizations as “signifi-cant partners” in strengthening health systems and TB control efforts.i

Caritas Internationalis is one of the world’s largest humanitarian networks, and is comprised of 164 Catholic relief, devel-opment and social service organizations working in more than 200 countries and territories. Caritas is active in Swaziland, where an alarming 79.6 percent of TB patients are also infected with HIV/AIDS, and where TB is the cause of 50 percent of HIV/AIDS related deaths.ii In Swaziland, roughly 14,000 new cases of TB are diagnosed in a population of 1.1 million each year.iii The country has a fragile health system, and 80 percent of its population lives in rural areas with no access to healthcare. Swaziland has no medical school, and thus a severe shortage of doctors.

In response to the country’s urgent need for improved care, Caritas and the WHO cooperated in a joint mission to pro-mote and strengthen partnerships between national and local government structures, international agencies, and faith-inspired organizations. Recognizing the importance of FBOs in disease prevention efforts, the WHO has noted that, “On account of their longevity, technical support, and networking,” faith-inspired organizations have a “key role in advocacy and prevention, […] and have enormous influence over the cultural norms that guide individual and community behav-ior.” iv, v In the case of Caritas, the organization’s active presence in Swaziland and its unparalleled reach into the country’s most isolated and impoverished areas contributed to the mission’s success.

The mission, which took place in February 2008, included field visits to three local TB and HIV/AIDS sites, followed by a consultation to discuss “best practice” models and to strategically plan future cooperation between the government and faith-based organizations. During the field visits, clinic staff had the opportunity to discuss specific challenges they encountered in their efforts to provide TB care. One such challenge was that laboratory work was centralized in govern-ment facilities; bureaucratic delays and substandard infrastructure delayed the dissemination of results to clinics. Other obstacles included lack of access to adequate medical supplies, as well as difficulties in arranging transportation of patients to referral hospitals.

The consultation fostered sustained dialogue among Swaziland’s government and faith- and community-based organiza-tions active in TB control efforts. Following the meeting, the WHO brought together the National Tuberculosis Control Program (NTCP), NGOs, and faith-inspired organizations to come up with a common plan, which then formed the basis of an ultimately successful grant application to the Global Fund. Swaziland’s National Emergency Response Council on HIV/AIDS received a grant of US$11.2 million in Round 8, which will be used to sustain and scale up the existing TB control programs in the country. A notable aspect of the proposal was that it emphasized that the NTCP has embarked on an “elaborate process” to identify possible implementers among community and faith-based organizations, and that a significant portion of the funding will be allotted to them.vi Monsignor Vitillo observed that, “The joint mission and col-laborative planning could serve as a model in other countries that are heavily affected by TB and TB/HIV co-infection.”

vii

and makes them more susceptible to other diseases.50 Leprosy is caused by the bacterium mycobacterium leprae, which is very closely related to the bacterium that causes tuberculosis.51 Researchers claim that when individuals became infected with leprosy, they were more vulnerable to tuberculosis. Scientists theorize that so many lepers contracted and then died from tuberculosis that there were too few remaining to spread lep-rosy.52

Along with the rise in tuberculosis, additional contributing factors to the decline of leprosy have been efforts by the WHO, local health ministries, and other NGOs. Twenty years ago, leprosy was a public health problem (defined by a prevalence rate of greater than 10 per 100,000) in 122 countries.53 How-ever, in 1993, the WHO recommended a regimen of multi-drug therapy (MDT) to treat the disease, comprised of three separate antimycobacterial drugs and antibiotics. In 1995, the


WHO began distributing the MDT to leprosy-endemic coun-tries without charge.54 According to the Novartis Foundation for Sustainable Development, the work of the WHO and in-tensive international efforts have helped to cure 14 million people of leprosy since 1985, and leprosy is currently classified as a public health problem in only three countries – Brazil, Nepal, and Timor Leste.55

A study of health services provided in Madagascar by Catholic health centers showed that leprosy cases treated had decreased by 28 percent from 1992 to 1994 while tuberculosis cases at the clinics had increased by about 300 percent. The data sug-gested a shift in focus and treatment from leprosy to tubercu-losis at the Catholic clinics, which treated about 15 percent of all people infected with TB in Madagascar at that time.56

In the early 1990s, Ethiopia created a joint leprosy and tuber-culosis control program that sought to take advantage of the existing leprosy program’s efficient and successful methods in combating the rising threat of TB. An early test of this model at a former leprosy hospital in Shoa was successful.57 The simi-larity of the microbes that cause the diseases and treatment plans for the infected also make it likely that leprosy treat-ment infrastructure can often be transitioned into TB work.58 In 1994, the Ethiopia Ministry of Health combined its TB and leprosy programs into a unified body, the TB and Leprosy Diseases Prevention and Control Programme (TLCP).59

TB and DiabetesDiabetes, a condition characterized by high blood sugar levels as well as complications in blood circulation, can hinder the immune system’s ability to fight infection. Numerous studies conducted suggest that diabetics have three times the risk of developing active TB when infected. The prevalence of TB and diabetes can rise together, as evidenced by India and Chi-na, where high TB burdens are coupled with a rapid increase

Rev. Msgr. Robert Vitillo, FBOs: Serving People’s Health Where People Live, presentation at the third Stop TB Partner’s Forum, (March 2009). i. Gugu Shongwe, Country Experience and Response to MDR and XDR-TB, presentation at the TB/HIV Planning Meeting (November 2008).ii. Doctors Without Borders, HIV-TB in Swaziland: A Deadly Co-Infection Epidemic, Special Report (October 2009).iii. Fawzia Rasheed, “Faith-Based Organizations (FBOs): A Note on Terminology,” World Health Organization (April 2010). iv. UNAIDS, “National Responses: Turning Commitment Into Action,” (2002). v. Global Fund, Swaziland Proposal to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (June 2008), Global Fund Grant Portfolio, http://www.theglobal-vi. fund.org/grantdocuments/8SWZT_1761_0_full.pdf (accessed 27 May 2010).Rev. Msgr. Robert Vitillo, FBOs: Serving People’s Health Where People Live, presentation at the third Stop TB Partner’s Forum, (March 2009). vii.

in the prevalence of diabetes.60

Amongst TB patients who are also diabetic, symptoms can be more severe, including expectoration (coughing up blood), cavities found in lung tissue, increased morbidity, and a poor-er response to drug treatment. A 2008 study conducted by the Harvard School of Public Health revealed a causal link between TB and diabetes, finding that, in a manner similar to leprosy, diabetes weakens the immune system, making af-fected individuals more likely to develop active TB. Patients co-infected with diabetes and TB take longer to respond to TB treatment, and those with Type 2 diabetes are more likely to contract MDR-TB. According to the Harvard study, the es-timated 180 million incident cases of diabetes mellitus (DM) will increase to 366 million by 2030. Experts agree that such an increase will undoubtedly lead to an increase in TB mor-bidity rates worldwide. 61

The strong link between diabetes and TB is directly relevant to the achievement of the sixth MDG. Currently, the clinical importance of this relationship appears to be largely unrecog-nized by international organizations that focus on TB treat-ment and prevention. Some scholars urge giving priority to research into the correlation between diabetes and TB to guide future practice and treatment recommendations.

The impact of culture on TB diagnosis and treatment Clinical challenges inherent to the prevention, detection and treatment of TB are but one factor in the struggle to keep the disease under control. Many of TB’s defining characteristics, such as high incidence rates in poor or migrant communi-ties, its strong yet frequently misunderstood associations with HIV/AIDS infection, and its complicated treatment regimens, invite a wide range of cultural and social stigmas about the disease. Very little is known about the way in which differ-


Box 9. Catholic Relief Services – Integrating TB and HIV/AIDS Programs in Cambodiai

Since 2005, CRS has led a project in Cambodia that addresses TB/HIV co-infection. Supported by the Global Fund, CRS works in internally displaced and mobile communities along the border with Thailand. It has worked to improve existing healthcare structures and spread social awareness by recruiting community members and leaders. Dr. Elena Mc-Ewan, a senior technical advisor to CRS, observed in an interview that regional faith leaders tend to be their communities’ most appropriate representatives, because they have a better understanding of their communities’ needs. Because of this, CRS has facilitated the inclusion of faith communities in the Health Center Management Committee which determines allocations for the budget of the Ministry of Health.

CRS underscores the value of open and free discussion and cooperation with local communities, and strives to connect with and understand their traditions, values and cultures. Dr. McEwan explained that, “Without community involve-ment, we [CRS] could not do anything, or make a real difference […] It’s a learning experience for everyone – we can all learn from each other. When we do, we realize that no one’s role is more important than the other’s.”

Interview with Dr. Elena McEwan, Catholic Relief Services, conducted 20 August 2009.i.

Box 10. PASADA and the NTLP Tanzania – Discovering Potential for Future Collaboration?i

In 2004, Tanzania’s National Tuberculosis and Leprosy Program (NTLP) and an NGO called Pastoral Activities and Services for People with AIDS in Dar Es Salaam Archdiocese (PASADA) cooperated in a study to determine the feasibility of future collabora-tion between NGOs and national programs in the provision of joint TB and HIV/AIDS care. The study was conducted in the Temeke district of Dar es Salaam, Tanzania, which has a population of 700,000 and a heavy burden of TB/HIV co-infection. There are an estimated 120 government health facilities in the district, eighteen of which provide TB services. PASADA, a member of the Maryknoll AIDS ministry, a U.S.-based Catholic missionary movement, is located just over half a mile away from the main TB clinic at the district hospital. A small clinic equipped with a basic laboratory, PASADA offers free routine testing, voluntary counseling and testing (VCT), home-based services, and psychosocial counseling to its patients. It also provides care for more than 1,600 orphans, and is a leader in community education about HIV/AIDS prevention.

Prior to the study, there was no established collaboration between PASADA and the NTLP, and their respective staffs received no training for treating patients with TB and HIV/AIDS co-infection. In fact, most NTLP staff felt they lacked HIV/AIDS counsel-ing skills and therefore did not discuss the disease with their patients, despite the district’s significantly high rates of co-infection.

As part of the study, 24 TB patients were referred to PASADA for VCT, and 48 AIDS patients were referred to the NTLP clinic for TB testing. Initially, there was a delay in collaboration due to a weak referral system, limited follow-up from patients, the distance between the two clinics, and poor communication and lack of trust between PASADA and NTLP. Many felt that despite their agreement to cooperate, the two clinics worked in isolated arenas and had no forum available to meet and discuss their activities. There was no shared agreement about the responsibilities of each clinic, or how money would be handled. In the study’s early stages, most NTLP staff shared the opinion that NGOs (and PASADA, in this case) were not transparent in their activities, and did not follow national guidelines for treatment provision. Conversely, PASADA members viewed the NTLP as overly bureau-cratic, rigid, and less efficient in providing quality service.

These obstacles were overcome by delegating specific responsibilities to each clinic, holding joint meetings to improve dialogue between the partners, and the employment of a nurse whose responsibility was to ensure patient compliance and understanding. Also, because of the distance between the two clinics, a TB clinic was opened on PASADA premises and PASADA’s staff was for-mally trained on different aspects of TB diagnosis and management.


Box 11. Medicine vs. Faith: Holy Water Healing in Ethiopiai

Ethiopia, which ranks seventh on the list of 22 high TB burden countries, is a country where faith and religion feature prominently. There are “holy water” springs throughout the country, one of the most sacred of which is located at Mount Entoto, Ethiopia’s highest peak overlooking the capital city of Addis Ababa. Mount Entoto draws more than 100,000 people per year to the healing power of its water, which is believed to cure even the most deadly of diseases, including tuberculosis and HIV/AIDS. A common belief amongst Ethiopian Orthodox Christians is that disease is caused by the manifestation of wrong doing and evil spirits, and can be banished through holy water treatment.

This belief is held so deeply that many Ethiopians feel that they must be completely dependent on the healing power of religion; the use of “westernized” drugs and treatment would signal disrespect to, and a departure from, their faith. Such distrust of medicine can only be dispelled if clergy members signal that it is permissible to combine both medical and holy water treatment. The Global Fund and PEPFAR have provided the Ethiopian government with funds to provide TB test-ing and treatment at St. Peter’s clinic, which is located opposite the entrance to Mount Entoto’s holy water shrine. Clergy members working in partnership with the clinic endorse the use of medicine, preaching that medicine is the creation of the scientist, who is, in turn, the creation of God.

The Entoto clinic, which treats dozens of patients per day, does not seek to compete with holy water or disprove its effec-tiveness, but functions on the principle that religion and science need not conflict, and that followers of each faith ought to benefit from both medicine and the healing power of religion. With that goal in mind, the Global Fund and PEPFAR are working closely with Ethiopian clergy to spread this model across the country.

The Bill and Melinda Gates Foundation, “Holy Water Healing,” http://www.gatesfoundation.org/livingproofproject/Pages/holy-water-healing.aspx (accessed 27 i. May 2010).

This collaboration resulted in a number of key successes, including the improvement of the clinic staff’s knowledge and skills for treating and counseling co-infected patients. This led to a more comprehensive, cost and time-efficient provision of services and care to the patients. The study led to general consensus on the potential for future partnership between the NTLP and NGOs, in particular faith-inspired organizations, because of their good community involvement. It was recommended that such collaboration should begin with a limited set of shared activities that would gradually increase upon establishing greater trust.

Following the study’s completion in 2004, its findings were presented to local and national government authorities in Tanzania. Since then, partnerships between the NTLP, PASADA and other NGOs have been cemented in the Temeke region. Meanwhile, a similar study in Zambia also demonstrated that partnerships between NGOs and national programs can lead to improved TB program performance. This illustrates growing interest at the national and international levels in linking the TB efforts of NGOs and government programs to improve the effectiveness and quality of available TB care.

Eliud Wandwalo, Neema Kapalata, et al, “Collaboration between the national tuberculosis programme and a nongovernmental organization in TB/HIV care at a i. district level: Experiences from Tanzania,” African Health Sciences, 4(2):109-114, Makerere Medical School (Uganda: 2004).


ent populations experience tuberculosis and its stigma, or about the role that cul-ture plays in the control, treatment and spread of TB.62

There are a number of social factors, such as education, income, family, and tradi-tions that affect how individuals perceive TB. For example, social scientists who have studied TB in the context of low-income immigrant communities in the United States have identified a number of negative stereotypes and fears surround-ing TB diagnosis. One study found that Mexican immigrants avoided use of the word “tuberculosis” when discussing their illness because of the severe social stigmas attached to it. Once individuals found out they were infected with the disease, they often voluntarily cut off ties with family members and fellow community members alike. Ignorant of the per-vasiveness of this stigma, physicians and health practitioners continued to use the word “tuberculosis” frequently around their patients, with no understanding of the impact and sensitivities surrounding their word choice.63

In a 1997 study examining Latino immigrants who were re-ceiving TB treatment, nearly all of the 65 respondents were concerned that their diagnosis would lead to termination from their jobs and ostracism from social groups. Of these respon-dents, 32 had no explanation for the source of their infection, and did not understand how the disease was spread.64

According to a 2007 study of TB stigma and gender in Ban-gladesh, both men and women infected with TB suffered from significant feelings of shame and embarrassment. Such stig-mas not only have a negative impact on patients’ psychological wellbeing, but also their financial and socioeconomic circum-stances. Examples from Bangladesh (that have also been found in other settings, including Pakistan and Ethiopia) have shown that TB stigma diminishes a woman’s prospects for marriage, or increases her vulnerability to divorce. This is particularly

damaging considering the weight that certain cultures and re-ligious traditions place on a woman’s reputation and eligibility for marriage. In the Bangladesh study, women reported “low self-esteem and lack of pride,” as well as feelings of “social iso-lation and rejection by in-laws and husbands.” Furthermore, a combination of TB’s social stigma and the physical weakness stemming from the disease has led patients to decide to leave work and avoid social interactions and group activities.65

Several studies have highlighted that some negative associa-tions surrounding tuberculosis are rooted in cultural traditions and practices, as well as in general misinformation. Whereas health workers are prone to categorize their patients as “non-compliant” when they choose to abandon their treatment, medical anthropologist Arthur Kleinman urges treatment pro-viders to make an effort to understand the underlying mo-tivations and cultural reasoning behind patients’ behaviors.

Figure 1) The TB Photovoice project is an initiative that provides TB patients with cameras so that they can take photographs that exemplify their experience with the disease. Above is a photograph and narrative by Rachel, a TB Photovoice Project participant from Mexico, about her experiences dealing with the stigma of TB. (Source: Teresa Rugg, TB Photo-Voice Project )


Successful completion of treatment is far more likely once pa-tients are able to connect with the treatment and adapt their understanding and experiences to help them find the best way to adhere to treatment for the necessary duration.

In order to effectively reduce the burden of TB, efforts be-yond the clinical realm need to be undertaken (see Box 11). Many examples from faith-inspired organizations, which can be found in Section V of this report, demonstrate how the reduction of social stigmas surrounding TB can be targeted through advocacy and educational programs that dispel false notions about the disease. Community-level outreach and support, which faith leaders are in a position to offer, are also important in encouraging individuals to seek out and properly complete their treatment.


The “rediscovery” of TB by the public health community

Prior to the 1980s, TB was not on the radar of public health communities in the developed world. TB had become rare in those countries due to the efficacy of antibiotics treatment, and the disease was considered unimportant and of little cause for concern. However, data and experience from the mid-1980s in several poorer countries like the Philippines and China underscored that TB was still prevalent in much of the world. This coincided with the appearance of the HIV/AIDS epidemic on the global health agenda in 1981, which drew the public’s attention to other rising global health threats, includ-ing TB. Throughout the following decade, funding directed towards TB was largely characterized by small grants award-ed by the National Institutes of Health (NIH) to individual researchers studying the disease. According to NIH budget estimates, TB research expenses in the early 1980s amount-ed to between US$1-2 million per year. The funding land-scape slowly changed towards the late 1980s, when increas-ing amounts of funding were made available to small research groups investigating the epidemiology of the disease with the goal of developing tools to prevent it.66

In 1993, WHO data provided stark evidence of a speedy re-surgence of TB, due to drastically deteriorating TB control in certain parts of the world (particularly Eastern Europe and the former Soviet Union), the spread of HIV/AIDS, and popula-tion growth. These findings led the WHO to declare TB a global emergency, and take its first steps in giving a higher pri-ority to TB control efforts. At the time, the World Bank was asked by the Chinese Ministry of Health to assist in strength-ening the country’s TB program. The program successfully developed DOTS in half of China, and was one of the first examples of a large-scale TB control strategy that could be ap-

plied effectively.67 Today, DOTS has been implemented in 184 countries that account for 99 percent of estimated TB cases.68

A significant challenge that most governments encountered in implementing TB control programs was the need for continu-ously available TB drugs, and for staggered and reliable treat-ment deliveries. Because they did not have enough stock on the ground, a number of governments resorted to airlifting drugs – a method that was both expensive and unsustainable. While this was a problem worldwide, drug deficits did not necessarily reflect the overall incapacity of countries’ public health programs. Rather, drug procurement policies and sys-tems and pharmacy management were simply unsuited and unprepared at the time for the immense challenges and com-plexities of TB control.

The Stop TB PartnershipIt was in response to a dire need for coordination among actors involved in TB prevention and treatment, that the Stop TB Partnership was formed by the WHO in late 1998. Today, the Stop TB Partnership is comprised of more than 900 members, including governments of TB-endemic countries, donors, re-search institutions and NGOs; several faith-inspired organi-zations are also members. The Partnership has an expansive portfolio and is involved in a range of anti-TB activities. It consists of six working groups that address priority areas of TB control, including DOTS expansion, MDR-TB, TB/HIV co-infection, and research for new drugs and vaccine develop-ment.69 At the country level, the Partnership also provides the resources needed to strengthen national program activities, as well as grants for anti-TB drugs. The WHO is both a leading agency in the alliance and the home of the Stop TB Partner-ship Secretariat.70 The World Bank is another prominent actor in the Partnership (see Box 13).

Section III. TB Advocacy and Funding


In 2006, the Stop TB Partnership announced its “Global Plan to Stop TB 2006-2015,” one of the primary goals of which is to detect over 70 percent of all cases of TB, and to successfully treat 85 percent of those cases (see Box 12). In line with the sixth MDG, the Global Plan to Stop TB also aims to halt and reverse the current TB incidence rates by 2015. Taking this target a step further, by 2015 the Global Plan also aims to halve TB prevalence and deaths (relative to 1990 levels). Ul-timately, the Global Plan’s goal is to eliminate TB as a global health problem by 2050.71

The Global Drug Facility One of the primary challenges to effective DOTS programs in resource-strapped countries is uninterrupted access to TB drugs. In order to overcome the obstacle of intermittent drug procurement, the Stop TB Partnership launched the Global Drug Facility (GDF) in 2001. The purpose of the GDF is to ensure the availability and accessibility of high-quality and affordable adult and pediatric TB drugs – a step that will, in turn, facilitate DOTS expansion.72 The GDF has proved generally successful in improving drug procurement; since its inception, it has supplied more than 16 million patient treat-ments to over 100 countries.73

GDF funding is intended to complement, and not replace, fi-nancing from national and international sources. Parties that are eligible for assistance include governments and NGOs that have insufficient finances to afford uninterrupted drug stocks; priority is given to those countries that have a gross national product of less than US$1000 per year. The GDF’s drug sup-ply is only available to parties that are committed to DOTS standards of treatment.

The primary funders of the GDF include UNITAID and the Global Fund; it also collaborates with the WHO Global Labo-ratory Initiative and the Green Light Committee.

The Green Light Committee Initiative

Trying to treat MDR-TB requires going beyond ordinary methods – you need something extraordinary. – Stop TB Partnership scientist, Rajesh Gupta

The Green Light Committee Initiative is a component of the Stop TB Strategy aimed specifically at controlling the spread of MDR-TB. Working in partnership with the pharmaceuti-cal industry and the GDF, the Green Light Committee has made arrangements to provide second-line drugs to DOTS-Plus Pilot Projects at a reduced price. DOTS-Plus projects are an adaptation of DOTS programs that are specifically tailored to combat MDR-TB in countries where there are moderate to high levels of drug resistance.74 Since DOTS-Plus serves as a supplement to the DOTS strategy and is dependent on a DOTS program, it is only recommended in countries where the standard DOTS strategy is fully in place.75 Through DOTS-Plus, the Green Light Committee’s goal is to prevent further resistance to TB, and to cure over 800,000 patients with MDR-TB – 100 times the number of MDR-TB cases that have been treated in the last decade.76

Eli Lilly and the MDR-TB PartnershipIn 1971, the Interfaith Center on Corporate Responsibility (ICCR) was formed with the goal of encouraging socially re-sponsible investment and integrating ethical values into the corporate world. One of its main objectives is to improve global healthcare, based on the fundamental belief that medi-cal treatment is a basic human right that should be afforded to everyone, regardless of wealth. In line with this focus, the ICCR engaged in dialogue with Eli Lilly, the world’s tenth

Box 12. The Stop TB Strategy

In 2006 the Stop TB Partnership released the Stop TB Strategy, a six-part plan that is intended to frame ef-forts to reach global, regional, and national TB-related goals (these are to reduce prevalence and deaths due to TB by 50 percent by 2015, and to eliminate TB as a public health problem by 2050). The six components of the strategy are:

1. Pursue high-quality DOTS expansion and enhance-ment2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations3. Contribute to health system strengthening based on primary health care4. Engage all care providers5. Empower people with TB, and communities through partnership6. Enable and promote research


largest pharmaceutical company, and successfully encouraged it to commit its resources to ensuring the accessibility of drugs in underprivileged, developing countries. In 2003, Eli Lilly established the MDR-TB Partnership, an alliance of eighteen global health and development organiza-tions, academic institutions, and private institutions pursu-ing the exchange of innovative ideas, resources and services to combat the rise of MDR-TB.77 The Partnership invests in factories in the highest MDR-TB burden countries, including China, Russia, India, and South Africa, in order to improve their capacity to ensure the availability and accessibility of MDR-TB drugs, which are expensive to manufacture. More broadly, the Partnership’s multi-pronged approach supports a range of programs aiming to transfer antibiotic manufactur-ing technology, enhance diagnostics, train healthcare work-ers, and raise community awareness about drug-resistant TB. Such a multi-faceted approach is geared to foster sustainable solutions to MDR-TB, by allowing patients to gain access to medicine at lower prices, as well as supporting local economies and the production of high-quality medicine. The Partner-ship has donated US$135 million in finances and technol-

ogy towards these efforts, and is set to continue committing resources through 2011. Efforts by the MDR-TB Partnership have played important roles in meeting the WHO’s goal, es-tablished in 2003, to treat 20,000 new MDR-TB patients by 2010.78

TB Funding NeedsFunding directed towards TB control has increased markedly since 2002, and is expected to reach US$4.1 billion in 2010. In 2009, US$3 billion was made available to 94 countries (representing 93 percent of the world’s TB cases). Funds were provided by the following sources: 87 percent from govern-ments, nine percent from Global Fund grants, and four per-cent from other donors.79

According to the WHO’s 2009 Global Tuberculosis Report, there was a funding gap of US$1.2 billion between available funds, and those required for the implementation of country TB control plans (US$4.2 billion). Of the funds required, 72 percent was allocated towards strengthening and supporting DOTS programs. Twelve percent was for MDR-TB-specific projects; three percent for joint TB/HIV activities; and two

Box 13. The World Bank’s Role in the Stop TB Partnershipi

Before the Global Fund was established in 2001, the World Bank was the single largest source of multilateral funds for TB prevention and treatment. The World Bank is currently a permanent member of the Stop TB Partnership’s Coordinating Board.

The World Bank’s TB interventions have resulted in an increased understanding of the disease’s epidemiology as well as of its socio-economic impacts; this knowledge has been utilized in the creation of new strategies, such as DOTS, that are essential to combating the disease. Since the Partnership’s inception, the World Bank has also provided the organization with an annual grant of US$700,000. Between 1997 and 2006, the World Bank supported five major TB control opera-tions: two single disease projects in India and China, and three multiple disease programs in Argentina, Ukraine, and the Russian Federation.

In contrast to the extent of its activities in other parts of the world, the World Bank has not supported TB-specific projects in Africa. Civil society organizations, such as RESULTS, have voiced criticism for this funding gap, especially because of Africa’s clearly demonstrated need for assistance. As an explanation, the Bank has cited the demanding preparation requirements, as well as high implementation costs, that are unique to certain health programs in Africa. The Bank has designated an African “focal point” for TB and worked towards a laboratory improvement project in southern Africa. In 2009, the Bank’s Institutional Development Fund approved a grant to the Medical Research Council in South Africa to improve the country’s TB diagnostic services.

Independent Evaluation Group, Stop TB Partnership: Global Program Review, Vol. 4, Issue 1, ix, http://siteresources.worldbank.org/INTGLOREGPARPRO/i. Resources/stop_tb.pdf (accessed 27 May 2010).


percent for Advocacy, Communication and Social Mobiliza-tion (ACSM). The remaining 11 percent was assigned to pub-lic-private mix (PPM) work, community-focused TB work, prevalence surveys, and other purposes. Of the funds budget-ed for MDR-TB work, a noteworthy 76 percent was targeted to the Russian Federation and South Africa, highlighting the severity of the MDR-TB burden in those countries.80

Funding gaps reported by NTPs since 2007 have been greater than gaps from the period between 2002 and 2006. This is likely due to the fact that NTPs have expanded their interven-tions, therefore increasing budget needs, in accordance with the Global Plan to Stop TB. In 2010, the funding gap in HBCs is US$500 million. Most of the extra funding re-quired by the Global Plan is for MDR-TB diagnosis in the European, Southeast Asia and Western Pacific regions, and for the implementation of DOTS and collaborative TB and HIV/AIDS activities in the Africa region.81

The Global Fund Since its creation in 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) has provided a quarter of total international financing directed to HIV/AIDS, two thirds for TB, and three quarters for malaria. The Global Fund approved proposals worth a total of US$3.9 billion for TB control efforts in more than 102 countries between 2002 and 2008.82 In 2008, US$327 million were allocated for TB work, which was substantially higher than in previous years.

A leading Global Fund priority is to prevent the spread of TB and the proliferation of drug-resistant strains of TB; this re-quires the presence of an accurate recording and reporting sys-tem, a laboratory network capable of performing good quality sputum smear microscopy, and a national reference laboratory performing high quality culture and drug susceptibility test-ing. Improved laboratory networks would lead to improved diagnostic and treatment capabilities, alongside more accurate surveillance of drug resistance.83

The Global Fund also emphasizes operational details, such as expansion and enhancement of DOTS, as well as expedit-ing testing, diagnosis, and drug delivery because speedy and comprehensive action must be taken in order to prevent the spread of MDR-TB and XDR-TB. It prioritizes funding on a country-by-country basis to address region-specific bottle-

necks that hinder the realization of these objectives.84

The Africa region accounts for 30 percent of estimated global incidence rates of TB, and receives 29 percent of the Global Fund’s total TB expenditures. The Southeast Asia and Western Pacific regions receive 42 percent of TB funding, a substantial if perhaps insufficient amount, considering the TB burden of these regions is 55 percent of total estimated cases. Lastly, 29 percent of Global Fund TB expenditures go towards the East-ern Mediterranean, European and American regions, which is proportionally higher than their share of the global TB burden (15 percent of total estimated cases).85

Overall, proposals submitted to the Global Fund seeking TB funding have tended to be somewhat more successful (ratio of proposals to awards) than those which focus on HIV/AIDS and malaria. However, Dr. Mohamed Aziz, Senior TB Adviser at the Global Fund, notes that the Global Fund receives far

Box 14. Friends of the Global Fighti

Friends of the Global Fight Against AIDS, Tuberculosis and Malaria (Friends), is a non-profit advocacy organi-zation dedicated to securing support from the United States government for the Global Fund. Founded in 2004, Friends does not have a specific TB focus, but works to bolster commitment and funding for work against the disease. It is a leading resource of accurate, up-to-date information regarding the Global Fund’s application process, activities and priorities. This in-formation is particularly useful to the organizations that are applying for funds.

Friends also advocates on behalf of the Global Fund in Congress, and works to engage and educate political leaders and policy decision makers in order to stimu-late government and social mobilization against TB. It provides the Global Fund’s Secretariat with strategic direction and legislative counsel, and the two organiza-tions work together closely in TB education activities. Friends’ main TB advocacy partners are the United Nations Foundation, the Global Health Council, RE-SULTS, and ONE.

Friends of the Global Fight Against AIDS, Malaria and Tuberculo-i. sis, About Friends, http://www.theglobalfight.org/#/about-friends/ (accessed 27 May 2010).


fewer proposals for TB-related projects than for the other two diseases. Of the Global Fund’s total grants for the three target diseases, 14 percent is dedicated to TB, compared to 21 percent for malaria and 65 percent for HIV/AIDS. Dr. Aziz observed that proposals coming from faith-inspired organizations have in fact had lower success rates. Dr. Aziz led a 2003 WHO in-vestigation that looked at factors responsible for the failure of proposals submitted by faith-inspired organizations; these in-cluded misrepresentation of the programs’ circumstances and capabilities, as well as proposals with weak financial sustain-ability and coherent planning.86 Although such problems are not limited to FBOs’ applications, the study found that they occur more frequently amongst them.87 Consequently, the WHO has noted that although FBOs, and in particular those working on the grassroots level, “have a wealth of community insights that represent assets,” they tend to “communicate and coordinate poorly with one another, donors, governments, and civil society organizations.”88

In part to address those communication and coordination concerns, the Global Fund has in recent years attempted to reach out to faith-inspired organizations, exemplified by the publication in 2007 of a guide directed at faith-inspired orga-nizations interested in obtaining Global Fund grants.89

United States Agency for International Development (USAID)In 2009, USAID allocated US$176 million to TB control ef-forts, and US$15 million to the Global Drug Facility. Between 2000 and 2008, USAID provided a total of US$777 million

towards TB programs worldwide, in its efforts to expand and strengthen TB control programs in 41 countries worldwide. USAID is the largest bilateral donor in the fight against TB, and was instrumental in the formation of the Stop TB Secre-tariat and the Stop TB Partnership.90

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)Between fiscal years 2005-07, PEPFAR funding for TB/HIV programs increased five-fold, from US$26 million to US$131 million. In fiscal year 2008, the US Congress authorized a contribution of US$840 million to the Global Fund. Howev-er, the amount budgeted91 for the 2009 fiscal year dropped to US$500 million, a level linked to budget cutbacks stemming from the financial crisis that began in 2008.92

The Bill and Melinda Gates FoundationSpurred by outdated treatment approaches and the dire need for funding for TB vaccine and drug development, the Bill and Me-linda Gates Foundation focuses its investments on TB research and development. The Foundation increased its investment in R&D from US$57 million in 2005 to US$165 million in 2008, raising it to the top of the TB R&D funding donor list, followed by the National Institute for Allergies and Infectious Diseases (NIAID) and other organizations that are part of the National Institutes of Health (NIH).93 Seventy-five percent of the foun-dation’s investments are in PDPs, and are earmarked for the de-velopment of new drugs, vaccines, and diagnostic capabilities. The remaining 25 percent of the Foundation’s TB investments have focused on the prevention of TB/HIV co-infection.

Box 15. BMGF Partners with the Chinese Government to Fight TBi

In an interview with Alexandra Farnum, a member of the Gates Foundation’s Global Health Policy and Advocacy team, she said that the foundation considers its funding “one piece of the puzzle, and that other partners and factors are essential. There are important government partners engaged, and part of our work is figuring out how to continue to ensure that other funders believe that TB is a priority.” ii The Chinese Ministry of Health is one such government partner; in China, MDR-TB is nearly twice as common as it is in the rest of the world, and 25 percent of all new TB cases are resistant to at least one type of TB drug. In conjunction with the ministry, the Gates Foundation has initiated a project that will pilot the use of innovative tools, such as mobile phone technology and other electronic devices, to remind TB patients to take their medication. China is an example of an emerging economy that has recently played an active role in TB prevention; the country hosted a WHO meeting in April 2009 and also sponsored a resolution on MDR-TB that was approved by the World Health Assembly in May 2009.

Interview with Alexandra Farnum, the Bill and Melinda Gates Foundation, 31 August 2009.i. Interview with Alexandra Farnum, 31 August 2009.ii.


The Gates Foundation works with organizations that follow a variety of models and approaches to TB advocacy and aware-ness (for more information, see Box 15). However, of its 54 grants for TB work since 1999, none have gone directly to faith-inspired organizations.94 One reason for this is the or-ganization’s preference for supporting efforts to develop new treatment drugs and vaccines for TB, rather than service de-livery programs.95 Many of its grants have gone to academic institutions, large health organizations, and drug research foundations.

The Gates Foundation has three main partners in TB advo-cacy. They are the Treatment Action Group, which aims to strengthen community-driven support for improved TB/HIV programs; RESULTS, a partnership that conducts advocacy work in five donor countries, including the United States and the United Kingdom as well as high burden countries like In-dia and Kenya; and the WHO’s Stop TB Partnership. The Gates Foundation also collaborates with the Global Fund, particularly in high burden regions, such as sub-Saharan Af-rica, that lack the necessary domestic resources to combat TB on their own. In 2008, the Aeras Global TB Vaccine Founda-tion received the largest single award from the Gates Founda-tion (US$62.8 million). The second largest award, US$25.5 million, went to the Global Alliance for TB Drug Develop-ment, and the third largest, US$23.6 million, went to the Foundation for Innovative New Diagnostics (FIND). FIND, an NGO based in Geneva, with offices in Uganda and India, works to develop diagnostic technologies that allow accurate diagnosis to happen as quickly and as near to the point of care as possible. FIND comes from the perspective that, “the greatest obstacle to care and control of many diseases in the developing world is a lack of effective and appropriate diag-nostic tests.” 96


Faith and health are closely linked throughout the world, including countries where TB is present. Care for the sick and infirm is at the center of many faith tradi-

tions, and faith-inspired institutions fund or operate extensive medical facilities, often in places where government health-care offerings are inadequate or totally absent. Noteworthy characteristics of faith health “assets” 98 have special relevance for discussions about TB: faith-inspired health institutions are often closely tied to communities, and therefore may be in a position to facilitate the intensive, community-level work re-quired in order for current TB treatments to be effective; faith leaders often have special influence in their communities and can play roles as educators about important social and health issues, including TB; and faith-inspired institutions work in places and with populations especially vulnerable to TB. This section showcases faith work on TB, beginning with a descrip-tion of the categories of actors that are included under the “faith” heading, as many different types of individuals and or-ganizations, with varying capacities and interests, are involved in addressing TB. The activities of these different types of actors overlap significantly.

Local hospitals and clinicsA first category is the constellation of clinics, hospitals, and other health facilities that are funded, staffed, housed, or oth-erwise supported by either individual, independent congrega-tions or, more commonly, a national or international denomi-national structure, such as the Roman Catholic Church. Many of these outlets offer TB treatment either as a single-disease program or as a part of broader healthcare offerings. Many of these local clinics and hospitals were founded by missionaries, and in some cases still have transnational links and are funded by religious groups from the U.S. or other western countries.

These hospitals and clinics frequently partner with govern-

ments or NGOs; there are countless types of “hybrid” arrange-ments, in which the partners divide up responsibility for staff-ing, supplies, and/or the physical plant. The prevalence and sometimes fluid or ad hoc nature of these hybrid arrangements make it difficult or impossible to categorize certain health as-sets as either “government” or “faith”; current estimates of the proportion of healthcare services provided by these facilities in the developing world are imprecise, and are the subject of cur-rent investigation and debate. This lack of data notwithstand-ing, the prevalence of faith-supported clinics and hospitals is plainly evident in most of the countries where TB is a major public health issue. Faith-supported clinics and hospitals are often associated with national umbrella organizations, such as the Christian Health Association of Kenya, that provide technical assistance to their members, and coordinate (to varying degrees) activities among members. These umbrella organizations have been engaged by development partners on a number of health-related initia-tives, including malaria and HIV/AIDS. Examples of the TB work of these types of organizations are described in Boxes 25 and 27.

Congregations and their associated vol-untary groupsRelated to explicitly health-focused outlets are congregations and their affiliated structures, which most often include wom-en’s groups and youth groups. These groups are often engaged in development-related activities, including income genera-tion, education, and health-related undertakings including, as detailed in Box 21 (which describes a project of the Adventist Relief and Development Association to address TB in Tamil Nadu, India), TB treatment and prevention. At the head of congregational structures are religious leaders, who are often among the most visible, influential, and trusted figures in their

Section IV. Tuberculosis – What Does Faith Have to Do With It?

“The Church can do more for a struggling African village than any other organization, because it is with the people all of the time. Organizations come and visit, but the church is here not only on Sunday, but every day of the week.”

– Pastor Harry, Fombe village church, Malawi97


communities. These leaders regularly speak about social and health issues in their congregations, and have been engaged by development assistance partners as key delivery points for development-related messages on a range of topics, including on TB treatment and prevention, as detailed in Box 16 (which highlights a CRS project in the Philippines).

International faith-inspired non-gov-ernmental organizationsCritical to any discussion about faith work on TB, as well as on development issues more broadly, are the large, international

faith-inspired humanitarian organizations such as World Vision and Catholic Relief Services, which have a faith identity (Chris-tian in the case of World Vision, Roman Catholic in the case of CRS). These organizations operate in ways that are often indis-tinguishable from international humanitarian and development NGOs with no specific faith orientation, such as CARE or the International Rescue Committee. For tuberculosis, as well as for programs that address other development issues, large faith-inspired organizations regularly succeed in obtaining grants from the major funders of development assistance, such as the Global Fund and the major bilateral and multilateral donors.

Box 16. World Vision’s TB Program in the Philippines

TB claims 75 lives every day in the Philippines, a mortality rate that puts the country in the ninth spot on the list of high TB burden countries. In many Filipino communities, the belief that TB is incurable has led to severe stigmatization of those infected with the disease. Dr. Zari Gill, World Vision’s Director for Infectious Diseases, recounted how the Filipino government requested World Vi-sion’s cooperation in “intensifying DOTS expansion” throughout the country. “Our role was to facilitate community-based DOTS programs, which means improving diagnosis, decreasing stigma, and then working for treatment adherence.” In partnership with the government as well as with the Global Fund, World Vision has also organized task forces comprised of teachers, farmers, local officials, and other community members, to educate their neighborhoods and to help identify indi-viduals with symptoms of TB who require treatment. The program has seen marked success, and has mobilized over 5,100 volunteers throughout the country to take part in raising awareness and providing support for TB control.i

Karen Riviera, Volunteer taskforces preventing TB in the Philippines, World Vision Philippines. http://www.worldvision.org.ph/index.php?option=com_content&tai. sk=view&id=73&Itemid=28 (accessed 27 May 2010).

Box 17. NGO Tuberculosis Consortium – India: Working towards an India without TB

World Vision India and ADRA are members of the NGO Tuberculosis Consortium - India, an initiative made up of eight NGOs working to implement India’s Revised National Tuberculosis Control Program (RNTCP). The consortium was created in November 2007 to fill critical gaps in the supply of medication to India, which has one-fifth of all TB cases globally,i and to increase knowledge of TB prevention through advocacy, communication, and social mobilization.

Through the RNTCP, the consortium aims to achieve its objectives by increasing the participation of civil society and community structures and catalyzing public and private health systems. According to India’s Ministry of Health and Family Welfare, targets for detection rates of at least 70 percent and a treatment success rate of at least 85 percent in the covered districts, are currently being met.ii However, while the RNTCP has succeeded in scaling up the DOTS program throughout the country, it has yet to reach some isolated areas. This is largely due to India’s vast size and the enormous needs of its population. Effective coverage requires the creation of new, and utilization of existing, networks between international NGOs, government agencies, and local organizations working at the grassroots level.

“The NGO Tuberculosis Consortium – India,” National TB Consortium, India (2007). i. Directorate General of Health Services, Ministry of Health and Family Welfare, “TBC India,” http://www.tbcindia.org/home.asp (accessed 27 May 2010).ii.


World Vision and CRS do frequently partner with local con-gregational structures and local faith-inspired NGOs, often but certainly not always with ones that share their faith ori-entation. The large, international faith-inspired NGOs, when they address TB, appear most often to do so through disease-specific interventions, though also through multi-sectoral in-terventions and in the context of broader support for govern-ment or faith-inspired health systems. Large, international faith-inspired NGOs frequently engage closely with govern-ment on the local and national levels in the countries in which they operate. Boxes 16 and 17 describe the work of two of the largest faith-inspired NGOs, World Vision and the Adventist Development and Relief Association (ADRA), on TB in the Philippines and India.

National religious coordinating bodiesPresent in TB endemic countries (and indeed, throughout

most of the world) are national-level faith-inspired coordinat-ing bodies, such as national councils of churches, national Is-lamic councils, and interfaith organizations, either nationally initiated or part of global networks like Religions for Peace or Interfaith Action for Peace in Africa (IFAPA). The activities and efficacy of these bodies varies widely by country. In large measure, their attractiveness as development partners is their representativeness – they are normally comprised of the formal leaders from the major faith communities in any given coun-try. They offer the possibility of coordinating development messages and programs among many different faith commu-nities, and they sometimes fulfill this function. The national councils are, however, not always well known and on occasion are perceived as organizationally weak and inefficient, even corrupt; views on their influence over member congregations and communities also vary (as does the reality). This investi-gation could not identify any TB-specific activities undertak-

Figure 2) “He hasn’t lost his faith. He is a role model. I, like him, continue to fight with God’s help. For those individuals that be-lieve that Tuberculosis is a deadly disease, this is not always the case. I encourage everyone to continue to fight with faith and hope.” – A narrative by Alfredo, Photovoice Project Participant, Juarez, Mexico. (Source: Voces e Imagenes de la Tuberculsosis Ciudad Juarez, Mexico - Voices and Images of Tuberculosis Ciudad Juarez, Mexico).


en by national religious coordinating bodies. However, these types of bodies are involved in advocacy and activities related to HIV/AIDS and malaria, and so it may be that work on TB by these groups is taking place but was not identified.

Funding for faith-inspired organizations to fight TBThe Global Fund is the largest source of funding, after na-tional governments, for TB prevention and treatment. The Global Fund’s Senior TB advisor, Dr. Mohamed Aziz, has said that faith organizations “are not playing the role they are ca-pable of” in receiving and putting to use those funds to fight TB, malaria or HIV/AIDS. This observation does not, for the most part, apply to organizations like World Vision and

CRS, both of which have been recipients on multiple occa-sions of Global Fund grants; he is pointing, instead, to the local and national networks of clinics and hospitals supported wholly or in part by faith communities, such as the Christian Health Association of Zambia (which is one of few such organizations to have received a Global Fund grant). These health outlets are responsible for a substantial proportion of overall healthcare in TB-endemic countries (though, as stated earlier, the exact proportion is unknown, and perhaps impossible to convey as a simple proportion); however, only 3.1 percent of overall dis-bursements from the Global Fund went to faith-inspired orga-nizations (and this percentage includes organizations like World Vision and CRS) in the first eight rounds of grant-making.

Box 18. Catholic Relief Services - Engaging Faith Leaders for TB Education and Stigma Reduction in the Philippinesi

CRS began its TB-focused work in 1994 in Latin America and since then has expanded its TB offerings to numerous countries, such as India, North Korea, Timor Leste, Cambodia, and the Philippines.

CRS began the Maguindanao TB project in partnership with the Integrated Provincial Health Office, in the Philippines in 2005. The project’s goal is to reduce TB stigma and morbidity by upgrading health facilities and training health workers to become more effective in their TB control efforts.

The province of Maguindanao is one of the poorest and most isolated in the country, surrounded by impassable roads and mountainous terrain and with little healthcare infrastructure. Due to lack of education about TB’s causes and effects, the disease is widely stigmatized there, and is commonly associated with poverty and dirtiness. This stigma was so powerful that some men with TB sought care at alternative health clinics located far away from their homes, despite the cost and inconvenience, in order to hide their infection from the community. Women, on the other hand, had far fewer opportuni-ties to access TB treatment outside their community, due to high costs and the travel restrictions imposed on them.

To counter this, CRS is working with Maguindanao’s religious leaders, who are predominantly Muslim, in heightening awareness about the disease. Armed by CRS with information about TB, over 135 Muslim spiritual leaders agreed to campaign for TB prevention in their mosques before beginning formal worship. These religious leaders are well-respected by the communities and take an active role in educating them about the spread of TB, as well as about its treatment and prevention in order to diminish TB-related stigma. Community members treated for TB have been encouraged to join support groups and awareness programs led by religious leaders.

With funding from USAID, CRS’s project in Maguindanao has also upgraded existing medical facilities, hired additional medical technicians, and provided training for proper testing and handling of TB samples. In addition, CRS has worked to strengthen MOH staff skills in implementing DOTS care in these units and at the community level. In 2009, the Maguindanao project was announced as the International Relief and Development Project of the Year by the Association for Project Management.

Interview with Dr. Elena McEwan, Catholic Relief Services, conducted 20 August 2009.i.


Why have faith-inspired organizations been largely unsuc-cessful in pursuing Global Fund grants for TB and other dis-eases? Monsignor Robert Vitillo, the representative of Caritas Internationalis in Geneva, argues that the reasons lie partly in history; most faith-inspired health outlets in the develop-ing world survived on contributions from their associated

congregations and denominational structures. However, they can no longer do so because of the increasing costs of modern medicine. He said, “In the past, FBOs have concentrated on serving people at the local level and mainly through church-based support. There is increasing recognition, however, that through traditional and existing means, they cannot generate

Box 19. ADRA (India) Advocacy, Communication and Social Mobilization (ACSM) Project for TB Control in Bihar

ADRA-India’s ACSM project, based in the Bihar state in Eastern India, aims to alter and improve the attitudes of local religious and opinion leaders towards TB, and educate them about how the disease is transmitted and controlled. The one-year project is funded by USAID and World Vision India, and seeks to benefit 21.5 million people living across eight districts of Bihar.

ACSM engages religious leaders to educate their communities about the dangers of late case detection, inconsistent treatment regimens, and treatment options and availability. Ravi Bhatnagar, Project Manager of ADRA India, explained in an interview that faith leaders are targeted specifically “Because they hold the trust of their congregations, [and] the healthy behaviors [faith communities] promote are more readily accepted.” i

With assistance from local NGOs, ADRA-India locates influential religious leaders in the district and invites them to partici-pate in the ACSM project. Due to lack of familiarity with TB treatment options, religious leaders initially tend to be opposed to adopting DOTS. However, Bhatnagar noted that, following education about the realities of the TB epidemic and the ben-efits of DOTS, “many clerics will come to accept most, if not all, aspects of the project’s RNTCP programs.” ii

As an example of the education that takes place in the workshops, religious leaders are taught the “two figures signal,” which serves as a reminder that a cough that persists for more than two weeks warrants testing for TB. Once they have been sensitized to the challenges surrounding effective TB control, religious leaders, including imams and priests, conduct weekly sermons on proper methods of treatment and prevention. According to Bhatnagar, “When religious leaders endorse new ideas or behavior change initiatives, change is seen more quickly than when messages are spread by purely secular means.” iii The ACSM project has also organized a series of educational Nukkad Nataks, which are street plays to educate particularly vul-nerable members of Bihar’s communities who are especially difficult to reach. These groups are often members of stigmatized ethnic or social minorities, such as Muslims, Mushars (“Rat eaters”), and “Scheduled Castes” (or “Untouchables”). The shows generally cover issues surrounding the “availability, accessibility, affordability, and adaptability of DOTS at the community level.” Specific themes include the following:

1.Symptoms of TB and the “two week cough”2.Side effects of TB medication3.Myths and misconceptions about TB4.The importance of adherence to the treatment regimen5.The role of family in treatment compliance6.The availability of free treatment at nearby government facilitiesiv

The ADRA-India ACSM team trains the actors for three days, and also prepares the script to avoid any misrepresentation or miscommunication with the audience. The actors are chosen from local NGO partners and are taught to communicate in local dialects, including Maithili, Bhojpuri, and Maghai, so that they are better able to connect with their viewers. A total of 32 Nataks were performed in Bihar in May 2009.v


enough resources to sufficiently scale up in order to deal with the global problems that face us today, including those of the major pandemics.”

Vitillo claims that faith-inspired organizations also do not al-ways easily meet the expectations of donors such as the Global Fund on transparency and accountability: “Many FBOs are very accountable, but they often do not frame it in the same way as secular development organizations. Monitoring and evaluation must be integrated into the daily activities of faith-based organiza-tions. It is simply not acceptable to claim, ‘We are serving people

and do not have time for bureaucracy.’”

Vitillo cited a third road-block to increasing funding for faith-inspired organizations: governments are often reluctant to include faith-inspired networks in national-level disease control plans. Vitillo observed, “In my opinion, progress must be made to in-fluence governments to be more open to partnerships with FBOs and to pass on needed funding to these organizations.”

Dearth of data on faith-tuberculosis workAs is the case for malaria and HIV/AIDS, no studies have set

Such “entertainment education” provides various elements of TB education that are vital to successful prevention of the disease. ADRA-India’s strategy of communicating through media and entertainment is both unique and useful, because it not only promotes behavior change but also removes the stigma of TB by bringing audiences together. The ACSM project assists TB-infected members of society who otherwise would have been pushed aside and ignored.vi

According to the ACSM’s 2009 project evaluation report, TB case detection rates have significantly improved within the Bihar state since the project’s implementation. While the project ended in March 2010, an expanded project began in April 2010, financed by Round 9 of the Global Fund. The new project will cover thirteen districts of Bihar, and is set to continue until 2015.vii

Interview with Ravi Bhatnagar, ADRA India, conducted 23 December 2009.i. Ibid.ii. Ibid.iii. Ibid.iv. ADRA India, “Ayushman: The ADRA-India Bi-Annual Advocacy, Communication and Social Mobilization Newsletter,” Issue No. 2, Vol. No. 2 (January 2010). v. Ibid.vi. Interview with Ravi Bhatnagar, ADRA India, conducted 23 December 2009.vii.

Figure 3) Crowds gather to watch the ADRA’S TB awareness "Folk Show" in Bihar, India (Source: Ravi Bhatnagar, ADRA-India).

Figure 4) The staff of ADRA-India's ACSM folk show. (Source: Ravi Bhatnagar, ADRA-India).


Box 20. Socios en Salud (SES) - Building on Catholic Community Networks in Perui

Socios en Salud (SES) has been dedicated to tuberculosis prevention in the Carabayllo community of Lima, Peru, since 1994. Inspired by the work and life of a Catholic priest who worked closely with community members and died from MDR-TB, SES focuses particularly on the prevention of drug-resistant strains of the disease. The organization pioneered one of the first community-based TB treatment programs in the world, in a poor area where most believed it would be too challenging and costly to succeed. SES began with support from other branches of Partners in Health, and its work later flourished with financial assistance from the Gates Foundation and the Global Fund.

SES has been community-focused since its inception. It began by training a group of twelve adolescents from the Cara-bayllo district in qualitative and quantitative research methods, and sending them to conduct surveys that asked com-munity members to rank the most troubling social challenges they faced. Second to pollution and inadequate garbage disposal, the majority of respondents identified tuberculosis as the most pressing threat. Soon after, SES partnered with Peru’s National Tuberculosis Control Program and enrolled more than 70 patients in TB care. At the core of the program is a host of community health workers and volunteers, many of whom have past experience working for various Catholic charities. The volunteers were sent to families not only to test for TB, but also to identify related problems such as unemployment, lack of electricity, or poverty. The volunteers were key assets, as they had an appreciation for which members of the community needed the most assistance. With support from these volunteers, SES’s work resulted in higher treatment cure rates and lower default rates than many clinics that were based in the U.S. and Europe. Furthermore, with financial assistance from the Gates Foundation and the Global Fund, SES has expanded its capacity to 1450 patients and has also recruited more than 700 volunteer workers.

A defining feature of SES’s work is its understanding of the relationship between health and poverty. SES’s Executive Director, Dr. Jaime Bayona, considers comprehensive TB prevention unattainable without significant improvements to educational opportunities, poverty levels, and housing conditions. Alongside its delivery of medical treatment, SES also offers practical skills training designed to help TB patients enjoy successful careers, and to overcome the negative effects of stigma associated with TB. A telling sign of their overall success is that many former patients now serve as community health workers, and are actively involved in ongoing TB education programs for patients. SES continues to work closely with the National Tuberculosis Control Program, local religious organizations and individuals, and international partners to combat tuberculosis in Peru.

Despite the fact that Peru currently has one of the most successful National Tuberculosis Control Programs and was recently removed from the list of high burden countries, Dr. Bayona insists that there remains a long, challenging road ahead for the achievement of successful TB control in Peru. His main regret was that the organization has “failed to pass on the message that TB is still a serious problem in Peru.” In order to address this failure, SES is working with the national government and other NGOs to create a multi-sectoral plan summarizing future steps for improved TB control.

Interview with Jaime Bayona, Socios en Salud, conducted 31 July 2009.i.

Box 21. Treatment for One is Prevention for All - ADRA’s TOPA Project

Tuberculosis is a critical health concern in Tamil Nadu state, India, where the disease claims more than 400,000 lives each year. The Treatment for One is Prevention for All (TOPA) Project, which ran from March 2006 until August 2009, cov-ered 138 villages in coastal districts devastated by the 2004 tsunami. The project, funded by ADRA Germany and Aktion Deutschland Hilft, had a budget of €431,000 (approximately US$626,400).


Box 22. A Collaboration to Control TB amongst Bolivian Migrantsi

According to official figures, Brazil’s population includes 60,000 illegal immigrants; however, international agencies esti-mate that the numbers are as high as 200,000 illegal immigrants living in the country. Of these, 42,000 are thought to be Bolivian, a significant number of whom live in Sao Paulo, Brazil’s largest city.

In 2008, 5,785 new cases of TB occurred in Sao Paulo, resulting in 301 deaths. In response to increasing TB incidence rates amongst the city’s migrant population, Pastoral for Migrants, an NGO led by the Catholic Church, reached out to the Municipal Program for Tuberculosis Control.

Today, the two groups work alongside the Bolivian Consulate in educating migrant populations about TB. A number of incentives have been put into place in order to ensure that migrants commit themselves to treatment, which is difficult because the majority of the migrant TB patients work in the clothing/textile sector and are poorly paid. TB patients con-sistently undergoing treatment receive a food basket at the end of each month. Also, travel subsidies are provided for the patients’ trips to and from the health center.

Brazil’s health system is unified and provides health services to the population (including migrants) free of charge. The public health system is complemented by a private health network that serves about 20 percent of the country’s popula-tion, mostly from the upper economic classes. However, Brazil’s health system mandates that TB medication cannot be made available by the private health network or in pharmacies, and can only be obtained in TB public health centers. Such measures decrease treatment abandonment rates, and ensure that medications are not sold at inflated prices.

Interview with Dr. Naomi Komatsu, Municipal Program for the Control of Tuberculosis, conducted 18 February 2010.i.

The TOPA Project’s objective was to improve TB case detection and cure rates amongst Tamil Nadu’s population through health education, community outreach, field work, and strengthening of the DOTS system. The project also had a strong gender component. In India, men are generally considered “bread winners” for the family in the patriarchal societies, and, because of this, they are the first to access treatment.i A particularly successful strategy adopted by the TOPA Project involved women’s self-help groups and anbiums, which were church-based groups in the Kanyakumari district. These groups empowered and motivated women to play active roles in self-reporting and referring others to TB clinics. Accord-ing to the Evaluation Report, the selection of young, married women (as opposed to unmarried girls) has helped reduce the stigma surrounding TB for women in particular, as it negates the idea that association with the disease can ruin one’s chances of marriage. TOPA also increased children’s awareness about TB control and prevention, although education geared towards children was limited.ii

Unlike India’s RNTCP program, the TOPA Project integrated components of food security and nutrition into its TB work, increasing the program’s success rates. By working with local philanthropic resources to provide food support to the extremely poor areas of the districts, the TOPA Project established partnerships on the ground and managed to mobilize a number of organizations to act against TB.iii

Interview with Ravi Bhatnagar, ADRA India, conducted 23 December 2009.i. ADRA India, “Treatment for One is Prevention for All: TOPA Project End Evaluation Report,” August 2009.ii. Ibid.iii.


out to analyze the efficacy, or even the extent, of faith work on TB at an aggregate level. There is no overall data to support the logical hypothesis put forward by informed observers that the distinguishing characteristics of faith-supported health actors – close community links, broad networks of health outlets, and the influence of faith leaders in their communities – have any spe-cial relevance to TB prevention or treatment. One study of healthcare provided by faith institutions in Uganda suggests that faith-inspired healthcare providers operate as effectively, and at less cost, than government healthcare outlets, but there simply is no empirical data to demonstrate whether these find-ings are broadly applicable or how they might suggest specific action avenues for a discussion about TB.99However, there are a number of individual projects with strong links which have benefitted from a variety of evaluation studies which point to general success and suggest some of the ways in which these partnerships can enhance the quality and effectiveness of na-tional and international TB strategies.

This investigation, which canvassed major faith-inspired NGOs, local faith-inspired NGOs, nonprofits, development institutions and academic institutions, does not suggest that faith work on TB is necessarily of a higher quality than that undertaken by government or organizations without any faith inspiration or affiliation, or that it should be given any special

priority or status, simply because organizations have a link to faith. It did, however, suggest several avenues of investigation that may warrant further scrutiny or discussion, as follows.

Faith leaders working to address stigma surrounding TBStigma against TB inhibits individuals from sharing their diag-nosis and adopting and maintaining a treatment regimen. As-sociations of TB with poverty or poor hygiene prevent many infected individuals from ever seeking treatment. Failure to adopt or complete a drug regimen has severe negative conse-quences for individuals, increases the chances that an infected individual will spread the disease, and also increases the likeli-hood of developing drug resistance.

By combating stigma, faith leaders, who typically have sub-stantial influence in their communities, could positively con-tribute to addressing TB. Faith leaders have already been use-ful partners in promoting education about HIV/AIDS and malaria. Canon Gideon Byamugisha, a Ugandan Anglican Priest and the first African religious leader to admit his HIV-positive status, founded the African Network of Religious Leaders Living With or Personally Affected by HIV/AIDS (ANERELA+), as a way to engage religious leadership in combating stigma associated with that disease. Thousands of

Box 23. World Vision: Working with Migrant Communities in Thailand

The World Vision Foundation in Thailand (WVFT), the recipient of a Global Fund grant of US$9.3 million, has part-nered with Thailand’s Ministry of Public Health in a project to catalyze efforts to fight TB in the country’s border hotspots. The five-year program aims to improve community awareness about the spread of the disease and trains volunteers to iden-tify cases and ensure that patients responsibly complete their treatment regimens. Another of the project’s main priorities is to ensure that both legal and illegal immigrants gain access to treatment and care at Thai public health facilities.i

World Vision will be cooperating with the American Refugee Committee (ARC) in order to implement the program amongst migrant populations in the provinces of Tak, Kanchanaburi, Phuket, Phang Nga, and Chumporn.ii According to the WVFT’s Principal Recipient Manager, Dr. Jaruwaree Snidwongse, TB prevalence in Thailand is difficult to gauge due to the “transient nature of migrant workers in these areas.” iii Because of the lack of surveillance, there is currently little control over drug-resistance in the country. The WVFT program aims to extend TB treatment and education services to 135,000 to 200,000 non-Thai migrants living in the country.iv

World Vision, Thailand: Support for Migrant Communities, World Vision Asia Pacific, http://wvasiapacific.org/media-releases/thailand-support-for-migrant-i. communities.html (accessed 27 May 2010).Ibid.ii. Jaruwaree Snidwongse, qtd. in Thailand: Support for Migrant Communities, World Vision Asia Pacific.iii. World Vision, Thailand: Support for Migrant Communities, World Vision Asia Pacific, http://wvasiapacific.org/media-releases/thailand-support-for-migrant-iv. communities.html (accessed 27 May 2010).


religious leaders from across the continent are now members of ANERELA+, and regularly preach to their congregations about compassion and understanding for HIV-positive individuals.

Boxes 18 and 19, describe how large NGOs such as CRS and ADRA are attempting to leverage the influence of faith leaders in order to address the problems associated with stigma around TB, in addition to strengthening the clinical component.

Close community links of faith institu-tions help facilitate effective TB treat-mentThe most heavily relied-upon treatment regimen for TB is DOTS, which requires daily one-to-one observation of TB drug intake. Strict adherence to the treatment regimen is nec-essary to cure the individual, and also to minimize the rate of emergence of drug-resistant strains of TB. The experience

Box 24. Catholic Relief Services: A Picture of TB in Cambodia

With an estimated 64 percent of the population infected with TB, Cambodia currently ranks 21st out of 22 high burden TB countries in the world.i Having worked with World Vision International in Cambodia in the early 1990’s, Dr. Zari Gill, World Vision’s Director of Infectious Diseases, was familiar with the country’s public health system at a time when HIV/AIDS was fairly new in the country and had a heavy stigma attached to it. Comparing Cambodia’s response to TB today to the country’s response to HIV/AIDS then, Dr. Gill remarked: “In Cambodia, whatever happens to you is supposed to hap-pen, and that can induce a sort of fatalism. If I have TB, for example, that’s my fate. I just have to live with it, and I can only live as long as I am supposed to live. That was the attitude that we were facing when HIV/AIDS emerged in Cambodia.” ii

Dr. Gill argued that faith leaders are well equipped to address feelings of helplessness and defeat. “The Buddhist monks were able to help the people understand that, yes, your fate is your fate, but there are still things you can do to live with that fate […] They were able to teach people how to live positively with their fate,” she said.iii

A number of partnerships exist on the ground in Cambodia between faith-inspired organizations and NGOs without a faith inspiration working on TB control. For example, CRS is currently engaged in TB projects with Maryknoll Sisters, Caritas, and Action for Health and Development (AHEAD), which is a prominent local organization. In the Battambang province, AHEAD has promoted TB awareness activities to educate community members about the origins of the disease, its signs and symptoms, and available treatment options. AHEAD also campaigns in pagodas (Buddhist places of worship), particularly on Buddhist holy days, which occur on the eighth day of every month and are widely attended by elderly members of the community.iv

In partnership with AHEAD and Caritas, CRS also engages with health staff in Cambodian prisons in order to build their capacity for identifying and treating prisoners infected with TB. This work is being done in response to a steady rise in the rates of MDR-TB in Cambodian prisons, where unhygienic conditions are common and health treatment is typically inadequate.v

Together with the Ministry of Labor and Vocational Training, CRS has also implemented a program that reaches out to migrant workers within their home communities, educating them about TB before they travel to find work.vi Due to their constant travel, migrant workers often have little access to health clinics and have trouble adhering to a specified treatment regimen. Currently, an estimated 180,000 undocumented Cambodian workers are in Thailand, a large group that is at espe-cially high risk for contracting and spreading MDR-TB.

The World Health Organization ranks the high burden countries based on those which, collectively, account for 80% of the global tuberculosis burden. Source: i. Stop TB Partnership, Tuberculosis in Countries, http://www.stoptb.org/countries/ (accessed 27 May 2010). Interview with Dr. Zari Gill, World Vision, conducted 14 October 2009.ii. Ibid.iii. Interview with Dr. Sok Pun, CRS Cambodia, conducted 27 August 2009.iv. Ibid.v.


of Socios en Salud (an NGO founded by a Catholic priest working in the slums of Lima, Peru, building on networks of volunteers trained by churches), suggests that there may be value in exploring whether or not existing community groups formed within, or associated with, congregational structures could undertake, in a systematic way, DOTS programming in their communities (Box 20). ADRA’s TB programming

in Tamil Nadu, a state in India devastated by TB, relies heav-ily on anbiums – Tamil for church-based women’s groups, for messaging and DOTS strengthening (Box 21).

Faith communities have a keen concern for communities vulnerable to TBTB is a disease that disproportionately affects low-income

Box 25. Combating TB in the Democratic Republic of the Congo: A Shared Effort

In the late 1800s, Protestant and Catholic missionaries established some of the first hospitals in what is today the Demo-cratic Republic of the Congo. In 1975, the Protestant Church of Congo Medical Office (ECC/DOM), working alongside the Catholic Church and the Ministry of Health (MOH), initiated the process of forming models for primary healthcare through decentralized health zones. While a few pilot health zones were developed in subsequent years, it was not until 1981 that the MOH established a formal five-year health plan to create 300 health zones. Given the importance of the work of church hospitals at that time, the MOH opted to decentralize health zone management around existing infrastructure, rather than strictly adhering to administrative boundaries.i

In 1981, USAID signed a bilateral agreement with the MOH to appoint ECC/DOM to manage the Basic Rural Health Project (SANRU I). Seventy-five percent of the first 100 health zones created through SANRU I were built around existing mission hospitals with a spirit of co-management; for example, the MOH assigned certain church hospitals the responsibil-ity of supervising, coordinating and managing all health services in their health zones.ii

The success of the SANRU I project led to a second cycle of funding for SANRU II. At the time, the SANRU I project had helped the MOH to establish 100 of DR Congo’s 306 health zones.iii Approximately 50 percent of those health zones were co-managed on behalf of the MOH by mission hospitals. The mission hospitals, both Catholic and Protestant, provided curative care not only to their patients, but also preventive care to communities through satellite health clinics, water and sanitation systems, and vaccination campaigns. Decentralization, co-management and primary health zones became stan-dard practices throughout the country and greatly improved access to basic health services, including TB treatment.iv

The SANRU II project was abruptly discontinued when USAID was forced to withdraw due to political violence in 1991. At a time when there was little to no support from the government for health systems in rural areas, the ECC/DOM per-sisted in its efforts to provide TB care, and a range of other medical services, by partnering with other funding agencies.v

In 2001, IMA World Health partnered with ECC/DOM, which then represented approximately 65 faith-inspired com-munities throughout the country and was also responsible for 80 hospitals that were in desperate need of assistance. Dr. William Clemmer, IMA’s representative in the DRC, described the partnership as one of “grant management, procurement, and logistical support of the IMA coupled with the passion and commitment for the ECC.” In 2001, USAID re-engaged with the ECC/DOM and the IMA, providing US$25 million towards the five-year SANRU III project, which had the aim of rebuilding 56 health zones co-managed by faith-inspired organizations.vi

At the time, DR Congo was emerging from a five-year civil war that resulted in nearly four million deaths. A substantial contributor to the mortality rate during the conflict was the dearth of functional health NGOs in place to address pressing needs for treatment of diseases that were, in most cases, easily preventable.vii

Clemmer said that the challenges of organizing a medical relief operation in a country without infrastructure, roads, com-munication, or security, and where rebel forces occupied and controlled two-thirds of the nation, “required local patner-ships, networks, ingenuity, and prayer.” viii


The health zone concept and its geographic limits were updated by the MOH in 2003. The DR Congo now consists of 515 health zones, each of which contains a reference hospital and surrounding health centers, and serves an average population of 125,000. The DR Congo currently ranks tenth on the list of 22 high burden TB countries. TB is especially prominent in a number of health zones where healthcare systems were affected by the armed conflict. In certain zones, TB prevalence rates are 10 to 20 times higher than the average for sub-Saharan Africa.ix

The USAID-funded AXxes project, a follow-on project to SANRU III, was launched in 2006 and is led by IMA World Health, with implementing partners including CRS, World Vision International and ECC/DOM. Project AXxes focuses on providing healthcare to Southern and Eastern DR Congo, where neglect and pockets of ongoing conflict have devastated the lives of thousands. In terms of TB, the project adopts a community-focused approach by spreading awareness campaigns through radio messages, flyers, and other forms of media advertisement. Project AXxes also emphasizes the importance of training community members to facilitate diagnosis and treatment, as opposed to relying on outside and short-supplied doc-tors and nurses. The project’s greatest resource has been the village-to-village and home-to-home visits by volunteer commu-nity health workers and leaders empowered to bring messages and relief to their own people. Such steps have been successful in raising the DR Congo’s TB diagnosis rates, so much so that the current shortage is not of patients but of medicine.x

Interview with William Clemmer, IMA World Health, 27 January 2010. i. Ibid.ii. Interview with Franklin Baer, IMA World Health, 10 February 2010.iii. Ibid.iv. Interview with William Clemmer, IMA World Health, 27 January 2010. v. Ibid.vi. International Rescue Committee, The IRC in Democratic Republic of Congo, http://www.theirc.org/where/congo (accessed 27 May 2010).vii. Interview with William Clemmer, IMA World Health, 27 January 2010. viii. Ibid.ix. Ibid.x.

Box 26. Christian Friends of Korea - Combating TB in a Closed Societyi

In the mid to late 1990s, North Korea experienced a terrible sequence of disasters, including severe floods that destroyed infra-structure, crops, and stored food provisions, resulting in widespread famine and a subsequent dramatic increase in TB rates. In response to overwhelming need, a number of NGOs initiated work in North Korea; however, only a handful of those organi-zations remain active today. This is partly because the situation in North Korea poses a number of unique challenges to these organizations, including basic logistics, heavy supervision by the North Korean government, and limited freedom of travel due to diplomatic tensions.

Formerly known as the Eugene Bell Centennial Foundation, Christian Friends of Korea (CFK) was established in April 1995, three months before devastating floods hit North Korea. Since its founding, the organization has donated more than US$36 million in aid and has provided assistance to more than 20 tuberculosis facilities throughout the region. Working directly with the North Korean Ministry of Public Health, CFK also maintains regular contact with the WHO to ensure that efforts are nei-ther conflicting nor duplicative.

CFK receives its financial support from churches, individuals, businesses, and foundations. A significant number of its support-ers are former missionaries to the region, many of whom have dedicated their lives to ministering to Koreans (through evange-lism, education and medical work), speak the language fluently, and understand local customs and perspectives. Some of the missionaries supporting the Foundation were even born in the Northern part of the Korean peninsula before it was divided into North and South in 1948. CFK’S Executive Director, Heidi Linton, told us that, due to its founders’ deep understanding of the culture and perspective, CFK is widely respected and viewed as a dependable and committed organization by North Koreans.ii


As one of very few openly faith-inspired organizations working in North Korea, CFK provides assistance largely within a clinical context. Nonetheless, CFK also provides food support to the country as malnutrition is a leading cause of vulner-ability to disease. To date, CFK’s assistance has included regular shipments of supplemental foods (usually canned meat, nutritional drinks and vitamin supplements); small tractors to help grow more fresh food locally; greenhouses to increase local food production, especially in the winter season; blankets and toiletry kits for patients; doctors kits and bicycles; water remediation (including well-drilling and water distribution projects); and general medicines (such as painkillers, general antibiotics, and cough suppressants).

Due to infrastructural challenges and the lack of necessary diagnostic supplies and equipment, there is a lack of current and verifiable data on the prevalence of TB and MDR-TB in North Korea. The country lacks comprehensive laboratory capabilities to diagnose TB, as well as the statistical abilities to generate studies on the spread of different strains of the dis-ease. Currently, CFK is partnering with Stanford University, the Bay Area TB Consortium and Mercy Corps in a project to renovate and reequip the National TB Reference laboratory. This project was made possible as a result of CFK’s long-standing relationship with the Ministry of Public Health and builds on the different strengths of each organization which are vital to the successful completion of this complex technical project.

The majority of CFK’s support is provided to patients served by the hospital/rest home system in the country. Patients generally remain in the system for the first two months of their treatment (or until they are sputum negative). Once they become sputum negative, the patients are released to continue their treatment at home, where they receive continued oversight and limited support.

Prior to the introduction of DOTS by the WHO and with CFK’s support, North Korea’s TB recovery rate was reportedly between 10-15 percent. Today, the recovery rate is 70-85 percent. During the autumn of 2008, CFK completed large-scale renovations of operating rooms in four North Korean hospitals. According to hospital officials, after the renovations were completed, the rate of post-operative infections decreased by 50-70 percent.

Reflecting on how CFK’s success has the potential to influence long-term improvement, Heidi Linton remarked, “A small stone can make really big ripples in a place like North Korea.”

Interview with Heidi Linton, Christian Friends of Korea, conducted 29 September 2009.i. Ibid.ii.

Figure 5) Christian Friends of Korea TB Clinic in North Korea. (Source: Christian Friends of Korea, June 2009 Newsletter).

Figure 6) The renovation of the Fourth Operating Suite of the Kaesong Provincial TB Hospital, partly funded by CFK. (Source: Christian Friends of Korea, June 2009 newsletter).


countries and, within those countries, vulnerable popula-tions. This characteristic of the disease’s public health profile may match well with the geographical distribution of faith-inspired health assets. All faith communities have at their core a concern for the poor and dispossessed; current faith work on health is often an expression of that concern, and frequently takes place among the most destitute populations, including

migrants and prisoners.

Migrant populations, which are inherently disconnected from normal government social service offerings, appear to be es-pecially vulnerable to the effects of TB because of the diffi-culty of maintaining a regular treatment regimen (and their inability to maintain a consistent treatment regimen in turn

Box 27. “Preaching the Gospel with a Sandwich” – Providing TB Care in Myanmar

Myanmar ranks twentieth out of the 22 countries with the highest TB burdens. In 1962, a military junta overthrew the civilian government and placed severe restrictions on religious freedom as well as on faith-inspired organizations operat-ing within the country. David Steinberg, a Georgetown University professor and specialist on Myanmar, explained that, “There are a lot of Christian organizations in Myanmar that are allowed to operate, but foreign missionaries are not al-lowed. You can go in, but not to preach […] Christian organizations face glass ceilings as to what extent they can work.” He said that Christian organizations within the country are considered “influential but suspect,” and shares that the junta has become more stringent in its control over the activities of NGOs throughout the country.i

The Agape clinic, located in northern Myanmar, was founded in 1996 by the Myanmar Christian Mission, an organization that was founded in Pennsylvania. The Mission’s chairman, Wayne Ford, described the inspiration behind the clinic: “We believe that we are the body of Christ, as well as His hands and eyes here on earth. […] When a family visits the clinic, we treat them

Figure 7) Community Health Evangelists after receiving their medical kits. (Source: Dr. Simon Thaung, Agape Clinic).


and then have an opening to talk to them about their spiritual needs.” Ford called this approach “preaching the Gospel with a sandwich” – the idea that giving a hungry person food is preaching compassion by setting an example, and that “Christ cares as much for our physical needs [such as starvation or health] as He cares for our spiritual needs.” ii

Prior to the military junta’s takeover, there was an active missionary movement in the area that sought to convert the pre-dominantly Theravada Buddhist population to Christianity. As a result, 60-70 percent of the clinic’s patients are Chris-tian. Seventy-two percent of Myanmar’s population lives in rural, isolated villages that are difficult to access. With a small staff of local volunteers, the Agape clinic opens for four hours a day and provides free-of-charge health services, including DOTS, to its patients. Tuberculosis is a major health concern in the country, second only to malaria. Simon Thaung, a Myanmar native and one of very few doctors at the clinic, explained that this is because of a serious lack of hygiene and that, “we have let go of our health education.” Much of the problem is due to congestion and the fact that there are thou-sands of people living in a small area without reliable health support.iii

In Myanmar, shared drinking wells are the norm, making it easy for diseases to spread. Furthermore, the lack of a sewer system has led to unsanitary habits such as urination into river beds. Thaung explained that every village is in need of Community Health Evangelists (CHE) to educate the population about TB prevention through improved hygiene prac-tices. Although Thaung supports CHE, the Agape clinic does not officially identify as Evangelist because of the ban the junta has placed on preaching and foreign missionary work.iv

Alarmingly high rates of MDR-TB in Myanmar are substantially due to insufficient education for patients on how to properly administer their treatment. Although the clinic provides TB treatment for free, many patients simply stop taking it, share it with their families, or sell the rest because it is so expensive. With a staff of community volunteers who have not been trained to administer TB vaccinations or treatment, the Agape clinic struggles to meet the demands associated with providing comprehensive TB medical care. The clinic provides home-based care, and equips staff with motorcycles to travel to the patients’ homes during emergency situations. Other health workers have to walk for two or three days in order to reach the villages. Because of the distance and mountainous terrain, health workers are able to visit the homes only two to three times a week at most, although their presence is required much more often. Meanwhile, despite the desperate need for more efficient healthcare, the junta has continued to expel foreign aid workers from the country. Many of the clinic’s donors have attempted to visit Myanmar, but are limited to a 28 day tourist visa at best.v

Recent events have awakened the international community to Myanmar’s humanitarian crisis. For example, following the Nargis cyclone, which killed tens of thousands of Burmese and displaced hundreds of thousands more, the junta refused to allow foreign organizations to enter the country. Describing the challenge of educating the Burmese about TB control and prevention in a confined environment, Ford remarked, “It is not that they are ignorant. It is that they are living in such a closed community.” In Ford’s opinion, faith-inspired organizations are especially well equipped to work within such an environment, compared to government agencies that use a “shotgun method,” meaning that “they put aid out there for those who can reach it. Those who can’t simply don’t get any.” Ford also said that faith organizations work on a more individual basis and are capable of providing more holistic care.vi

The Agape clinic receives funding from personal donors as well as from Churches of Christ located in a number of states, primarily Pennsylvania, New Jersey, North Carolina, Ohio, Iowa, Nebraska, Indiana, and Wyoming. The clinic also de-pends on the International Disaster Emergency Service (IDES), a financial resource for missionaries and churches in


leads to increasing drug resistance). Migrants are often treated as outsiders, subject to friction with local communities, espe-cially in places where resources (health resources in this case) are extremely limited.

Faith ties tend to hold strong across international borders, and faith actors can be instrumental in providing TB care to mi-grant populations. Some organizations have targeted programs for migrant communities, exemplified by a program run by the Catholic Church in Brazil serving migrants from Bolivia (Box 22), and another run by World Vision in Thailand (Box 23).

For a variety of reasons – including high rates of intravenous

drug use, high turnover rates, and unsanitary conditions – prison populations also experience higher than average rates of TB prevalence, and typically have limited access to TB treat-ment. CRS’ work in Cambodia (Box 24) includes a compo-nent that addresses TB in prison populations.

Faith institutions work in countries with repressive and / or unstable govern-mentsFaith institutions often maintain health and other operations during conflict situations or in failed states, when service pro-vision by government is either limited or nonexistent. Conti-nuity of service provision is particularly relevant to discussions

more than 90 countries. With this funding, the clinic purchases TB medication and antibiotics from within Myanmar.vii

Despite the political unrest and the dangers of working as a faith based organization in Myanmar, the Agape clinic aims to expand its services, pending sufficient financial support from its donors. “The health needs are tremendous and cannot be ignored,” Ford insisted.viii

Interview with Dr. David Steinberg, Georgetown University, conducted 16 November 2009.i. Interview with Wayne Ford, Myanmar Christian Mission, conducted 19 January 2010.ii. Interview with Ahsipha Thaung, Agape Clinic, conducted 15 January 2010. iii. Ibid.iv. Ibid.v. Ibid.vi. Interview with Wayne Ford, Myanmar Christian Mission, conducted 19 January 2010.vii. Ibid. viii.

Box 28. World Vision’s TB Programs in Somaliai

World Vision is currently conducting a TB control program in Somalia, where the disease poses a major public health problem affecting the most productive age groups in the country. In Somalia, TB is linked with both poor economic conditions and conflict and is most prevalent amongst refugees returning from neighboring countries. In May 2003, World Vision International partnered with the Global Fund in establishing a five-year TB control program in Somalia. Its primary objectives were to increase access to DOTS facilities and improve the quality of care available to patients, so as to decrease TB incidence and make treatment more affordable. The program works to strengthen and supplement existing health centers, while establishing new centers in other areas. It also ensures a regular supply of drugs and laboratory sup-plies to the medical staff working in the clinics, provides training and strengthened supervision, and conducts monitoring and evaluation activities.

Despite the emergency situation in which it has had to operate, Somalia’s World Vision program has yielded positive re-sults, with an 80 percent treatment success rate and 42 percent detection rate. However, with the available resources, the Somalia TB program is fast approaching its maximum expansion capacity. To reach more members of the community there is a need for new centers, as well as additional resources in terms of funding, equipment, and supplies.

World Vision International, Somalia Tuberculosis Programme, Briefing Summary. http://www.gftbsomalia.org/index.php?option=com_i. content&task=view&id=20&Itemid= (accessed 27 May 2010).


about TB, which cannot be eradicated on an individual or population-wide basis when treated inconsistently. Faith ac-tors have made concerted efforts to combat TB in several frag-ile states and closed societies such as the Democratic Republic of the Congo (Box 25), North Korea (see Box 26), Burma (Myanmar) (see Box 27), and Somalia (see Box 28).

Other faith-inspired organizations working on TBWhat follows is a brief list of other faith-inspired organiza-tions that are implementing TB-related programs:

Tearfund100 Tearfund is a UK-based, Christian relief and development agency working in partnership with Christian agencies and partners worldwide to eradicate poverty and overcome HIV/AIDS. The church is often the most trusted institution in some of the places where Tearfund works. It is able to mobi-lize people and raise awareness effectively within communities. Church leaders are usually respected within their communities and are able to advocate on behalf of the poor. In an inter-view with Kola Akinola, Senior Policy Officer (HIV/AIDS) of Tearfund, he said that one of the Church’s strengths lies in the fact that “church workers are committed and are motivated by more than financial remuneration. A lot of people who work for the church are there because of other values.”

While Tearfund has focused on HIV/AIDS, there has been an increasing recognition that HIV cannot be effectively ad-dressed without also addressing TB. Tearfund works with or-ganizations that focus on TB control and prevention in order to address HIV/TB co-infection and a number of Tearfund’s partners work on both HIV and TB.

Salvation Army International101

The Salvation Army has a number of different mission hospi-tals around the world, particularly in poor and needy areas. In addition to conventional TB treatment offerings, it is working to eradicate social stigma and improve TB drug management. Utilizing its strong links with the community, the Salvation Army takes an approach to TB that involves communities directly and prioritizes their needs and values. The Salvation Army’s decades of experience working with leprosy shaped its approach to TB.

United Mission Hospital, Tansen102

The United Mission Hospital in Tansen, founded in 1955 by physicians Dr. Robert Fleming and Dr. Carl Fredericks, was initially one of the main providers of TB care in Nepal. The hospital once treated 40 percent of the diagnosed TB cases in the western region of the country. In 1996, the hospital joined Nepal’s national TB program. The hospital relies on its pasto-ral care team to provide assistance and support to its patients. The Tansen mission hospital’s patients are drawn from a wide geographical area, mostly from surrounding districts but even from parts of India. According to Dr. Rachel Karrach, the Hospital Director, UMH Tansen’s broad base of patients is likely due to the hospital’s good reputation for treating TB that has developed over the years. In 2001, the hospital was awarded the “Dixa Daxa” award, which is given by Nepal’s Ministry of Health to honor individuals who have made sub-stantial contributions to TB control.

ADRA PeruWhile ADRA-Peru, one of the largest NGOs operating in Peru, has made significant progress in eradicating TB, steadily increasing rates of MDR-TB in the country have proved to be a major challenge. Drug-resistant strains pose a serious threat to the effectiveness of Peru’s TB control strategy.103

In July 2009, ADRA launched a TB program in conjunction with the School of Medicine at San Marcos National Univer-sity and the Peruvian Association of Persons Affected by Tu-berculosis (ASPAT-Peru). The project, which will run through the end of 2011, was designed to increase access to TB care for those affected with TB and MDR-TB, and expand the capaci-ties of caregivers to effectively treat the disease. The program is set to directly benefit 1,368 patients with MDR-TB, 120 patients with XDR-TB, and medical personnel in 25 health centers.104

ADRA-Peru also works alongside the Peruvian Ministry of Health and local government authorities in executing the US$4.2 million initiative, “Closing Gaps to Achieve Millen-nium Development Goals for TB and HIV/AIDS in Peru.” Financed by the Global Fund, this project benefits the regions of Ica, Arequipa, La Libertad, Piura, Lambayeque, Cusco, An-cash, Junin, Puno, Lima and Callao.105


Kwai River Christian Hospital The Kwai River Christian Hospital (KRCH) is a 25-bed public health center in rural Thailand on the border with Myanmar. Established in 1960, the hospital provides care to patients who otherwise would have no access to treatment; each week, two new TB patients begin treatment at the hospital. The KRCH is associated with the Church of Christ in Bangkok, and also serves as a research facility for infectious diseases. In 2006, the hospital was a sub-recipient of a Global Fund grant for US$21,741 (the primary grantee was the Thailand Ministry of Public Health’s Department of Disease Control). This funding has enabled the hospital to provide patients with free TB med-ication in addition to food and transport. To date, KRCH has treated approximately 100 patients using its Global Fund grant.106

Zimbabwe Association of Church Related Hospitals (ZACH)Founded in 1974, ZACH’s membership currently stands at 126 hospitals and clinics throughout Zimbabwe. In Round 5 of the Global Fund, ZACH received a grant of nearly US$3.5 million to reduce TB morbidity and mortality in the country. ZACH’s mandate is to assist and support member institutions in the provision of quality healthcare and service delivery to the most poverty-stricken groups in Zimbabwean society.107

Christian Health Association of Nigeria (CHAN) During Round 5 of the Global Fund, the Christian Health Association of Nigeria (CHAN) received a grant for US$24 million for the national Tuberculosis and Leprosy Program (NTBLCP) to ensure a reduction in the burden and human impact of tuberculosis and its transmission. The program aims to do so by expanding knowledge in communities about TB prevention and treatment, raising TB detection and treatment rates, and reducing the incidence of TB among PLWHA (Peo-ple Living With HIV/AIDS) by at least 25 percent.108

Central Board of Aisyiyah - IndonesiaIndonesia currently ranks as the country with the third highest TB burden in the world. In Round 8 of the Global Fund, the Central Board for Aisyiyah, a member of the broader Islamic organization Muhammadiyah, was approved as the principal recipient of nearly US$6 million to strengthen DOTS within Indonesia. The Board will work alongside the Faculty of Pub-

lic Health at the University of Indonesia in putting this grant to use with the goal of decreasing the number of TB deaths through prevention techniques. The partnership’s objectives are to pursue quality DOTS expansion and enhancement; contribute to health system strengthening; engage TB affected communities; and address TB/HIV co-infection, MDR-TB, and other complexities of the disease.109

Fundación Visión Mundial GuatemalaClosely linked with World Vision, Fundación Visión Mundial Guatemala received a grant for approximately US$3.7 million from the Global Fund in Round 6. The Foundation’s main objective is to eliminate TB as a major public health concern. It focuses its activities on poor populations and vulnerable groups. Some of the Foundation’s main activities include en-suring effective coordination with different extension coverage programs in the sector, as well as developing TB interventions that combine information, education, and media coverage to change behavior and attitudes towards TB. The Founda-tion’s goal is to reduce TB incidence in Guatemala from 19 per 100,000 inhabitants in 2004 to 16.8 per 100,000 inhabitants in 2011. The organization also seeks to re-organize and guar-antee TB diagnosis and quality by providing training to health clinic and laboratory staff.110

Sarvodaya - Sri Lanka Active in more than 15,000 villages throughout Sri Lanka, Sarvodaya is an organization that was developed around a set of philosophical tenets drawn from Buddhism and Gandhian thought.111 During the first round of the Global Fund, Sarvo-daya received its first TB grant of nearly US$500,000 in order to strengthen Sri Lanka’s TB control program. Sarvodaya then received a second grant amounting to nearly US$1 million in Round 6 of the Global Fund, in order to widen the scope of DOTS so it can reach the marginalized and vulnerable popu-lations of Sri Lanka.112


The work of faith actors addressing tuberculosis is ex-tensive and varied, ranging from the Global Fund-supported projects of international faith-inspired

NGOs, to the preaching of pastors and imams about TB prevention in their congregations. There have been isolated attempts to bring the experience of these actors to bear on national or international plans to combat TB, but no coordi-nated effort to engage the wide range of faith actors. This is, in large measure, due to the tendency to focus on government-led health programs. Overall, the discussions about TB have not devoted sharp attention to the challenge of mobilizing the possibilities of community-level engagement with TB preven-tion and treatment, despite the fact that such mobilization is a central plank of the Stop TB strategy. In this connection, in particular, the relationship of faith leaders and organizations to communities in high-burden countries is an area that begs greater attention.

At the outset of a discussion about issues and questions around faith work on TB, it should be noted that there remain funda-mental data and research questions about faith contributions in this area. Donors and international development partners, including the Global Fund, cannot say accurately what pro-portion of their financial support is implemented by faith-inspired actors; this is due in part to monitoring systems not being geared to measure faith work, and also because of the complexity of hybrid arrangements in TB-endemic and other countries – it is genuinely difficult in many cases to categori-cally assign a “faith” or “non-faith” label to health assets in these places. Much work by faith actors on tuberculosis, as is the case with faith work on health in general, is very often embedded in services funded or supported by government or NGOs without a faith affiliation.

With these fundamental data issues as a backdrop, several is-

sues and opportunities emerge from our investigation which bear further discussion and exploration.

CapacityIn discussions about faith work on tuberculosis, and on health issues more broadly, issues of organizational capacity are often cited. “Capacity” in this case encapsulates the range of orga-nizational functions – from procurement, to accounting, to monitoring and evaluation – critical to successful implemen-tation of tuberculosis or any health-related programs. There is the perception that faith-inspired healthcare outlets are in some way less professional, accountable, or capable than their secular counterparts. This criticism is generally not directed at the large, international faith-inspired NGOs, such as World Vision, CRS, and ADRA. These organizations are recognized as being in the same class, in terms of organizational account-ability and performance, as organizations like CARE or the International Rescue Committee, which lack a specific faith orientation.

The criticism is meant to apply more to the array of faith-inspired organizations associated with indigenous health ministries. Within this large category of actors and organi-zations, there is significant variation in the size, experience, and qualification of staff – some are highly professional, and have already begun to partner with the Global Fund and other funders of development assistance. Others, having never had to meet benchmarks for organizational capacity and monitor-ing required by international donors such as the Global Fund, would struggle to work within the expectations and constraints of donors. Addressing these capacity issues would have to begin at the country level. Desperately needed are solutions that offer a bridge between the “organic and chaotic” faith actors at the

Section V. Questions, Issues, and Opportunities


community level, and the requirement of international devel-opment partners for order and method.

At the same time, faith-inspired healthcare providers have cer-tain capacities which distinguish them in positive ways. Faith health assets are often located in the places least served by gov-ernment. Their presence in these places is long-established and lasting – faith structures seem to have particular resilience during times of conflict and desperation. These characteristics make them ideal “end of the road” delivery points for messages and commodities related to TB.

The ability to bridge transnational partnerships is another characteristic strength of faith communities and, in the case of TB, one that has not apparently been exploited fully. Faith communities in western countries actively lobby governments and donors to devote resources towards the fights against HIV/AIDS, malaria, and poverty. There appears to be less activ-ity among U.S.-based congregations on tuberculosis than on malaria or HIV/AIDS, both of which have been the focus of fundraising and advocacy campaigns by major Christian and Islamic populations in western countries. This is at least par-tially because TB is more complex and expensive to treat than malaria and, in cases involving drug-resistant strains of TB, than HIV/AIDS; there can be no campaign with as simple a message as the numerous malaria-related injunctions coming from U.S. faith communities to “Buy a Net, Save a Life.”

Attached to almost all Christian congregations are women and youth groups; these groups often participate in development-related activities, many of them centered on healthcare. These groups meet regularly, and tackle the most pressing issues in their communities. Given this fact, and that care for children’s health almost always falls to mothers, women’s groups should be engaged in TB-related education programs. Few models of women’s groups engaging with DOTS responsibilities emerged in this investigation, but it seems reasonable to think that they could play roles that could reinforce the DOTS process.

The youth component emerged only rarely as an explicit fea-ture of work by faith actors on tuberculosis. This is a possible opportunity – youth could be engaged in education efforts aimed at dispelling stigmas around TB, and also about pre-vention and treatment. The strong work of groups like the Interfaith Youth Corps on malaria suggests the potential for

youth engagement on TB.

Horizontal vs. vertical interventionsThere is broad agreement among practitioners and medical ex-perts that a single disease, or “vertical” approach, to fighting TB is not desirable, in large part because of the TB/HIV co-infection issues. A “horizontal” approach, in contrast, would address TB along with a wide range of other diseases and health conditions, HIV/AIDS most prominent among them.

An example of a vertical TB intervention would be a nation-wide TB drug roll-out, where all clinics and hospitals were stocked with adequate supplies of effective TB drugs. A hori-zontal approach might focus on training community health workers in diagnostics for common diseases including TB – this would strengthen the overall capacity of healthcare pro-viders to address TB, as well as other diseases.

Horizontal approaches are often more difficult to evaluate, as their effects may be spread across a wide range of health out-comes, and as such are not as easy to “sell” to donors. Partners in Health Medical Director Dr. Joia Mukherjee discussed the way PIH balances the tension between fundraising “vertically” and implementing “horizontally”:

Interest in and money for AIDS allowed us to rehabilitate ba-sic health infrastructure in Haiti’s central department. Our philosophy was that we could not find AIDS cases or treat them if clinics stood understaffed, empty, and without essen-tial medicines. Thus, the investment in AIDS became our Chwal Batay, or battle horse – a tool to bring us into a larger battle against poverty, inequality, and poor health.113

The need for horizontal approaches to fight TB is perhaps more dramatic than with malaria, and perhaps also HIV/AIDS; treating TB without taking into account HIV/AIDS and nutritional status is a recipe for failure. This need for horizontal programming is perhaps what makes it difficult to advocate and raise funds for TB in a “vertical” way – there is no simple message that one can use to sell the eradication of TB.

CoordinationA theme that preoccupies many people in the development world, and is applicable to discussions about TB control, is


poor coordination; this problem can be termed the challenge of “getting a grip” on development assistance. The current reality of countless groups working without respect for local situations, without a common strategy, and all too often at cross purposes is daunting. There are so many organizations that no one – much less a leader in a poor country like Tanza-nia or Papua New Guinea – can keep track of them. In many ways, the situation is truly out of control, in the sense that coordination is nigh impossible with so many actors and mov-ing parts.

An alternative narrative suggests, however, that uncoordinated aid is indeed healthy, because it is able to avoid the heavy hand of bureaucratic oversight; many would note that out of com-petition and creativity come good things. And if coordination is indeed essential, then another important question remains: Who should undertake it? With much suspicion of imperfect government, there are plenty of doubts. But most observers and actors agree that there is an urgent need for better coordi-nation, and new aid coordination modalities are being actively explored among international institutions under the heading of aid harmonization.

These dual narratives have special relevance for religious com-munities, because they tend to fall in the minority group that sees virtues in diversity and decentralized initiatives. This re-port has highlighted a wide range of approaches, on vastly dif-ferent scales, pioneered by faith-inspired actors addressing tu-berculosis. A challenge going forward with TB is to encourage the organic, often locally-driven approaches of faith actors to addressing TB, while “getting a grip” and ensuring that these efforts are within, and supported by, national and global TB control structures.

Interfaith workThere may be cases where interfaith cooperation to address TB could address public health goals, and also foster positive relations between different faith communities. Also, given the importance placed on coordination by global plans, co-operation within and among faiths could help further overall progress on TB. Interfaith coordination, in areas where faith-inspired health providers constitute a substantial percentage of overall healthcare options, could help complete a network of coverage; blanket treatment is crucial to TB eradication, as inconsistent efforts lead to drug resistance.

There have been recent, national-scale attempts in Mozam-bique and Nigeria to address malaria on an interfaith basis, but the viability and effectiveness of these schemes is unknown; there simply is no data to support the idea that resources de-voted to interfaith efforts to address single diseases are impact-ful with regards to the containment of the disease.

The focus on interfaith engagement by the US government, stretching back at least to the Clinton Administration, and by funders of international development assistance, suggest that interfaith work on TB could be a future focus. Important to consider in the planning stages of interfaith development programming are the diversity of local and national religious communities and their leadership; local tensions between faith communities; and the extent to which interfaith work truly could add value to development initiatives.


Appendix I.Maps & Tables

Map 1) Estimated new TB cases (all forms) per 100,000 people

Source: World Health Organization, “Figure 1: Estimated TB Incidence Rates, 2008,” Global Tuberculosis Control: A Short update to the 2009 report, 2009: 6, http://whqlibdoc.who.int/publications/2009/9789241598866_eng.pdf (accessed August 13, 2010).


Map 2) Distribution of countries and territories that have reported at least one case of XDR-TB as of January 2009

Source: World Health Organization, “Map 7: Distribution of countries and territories that have reported at least once case of XDR-TB as of January 2009,” Multidrug and extensively drug-resistant TB (M/XDR-TB) 2010 Global Report on Surveillance and Response, 2010: 29, http://whqlibdoc.who.int/publications/2010/9789241599191_eng.pdf (accessed August 13, 2010).


Country(Listed by rank)

Population(Thousands)

TB IncidenceThousands of new cases per year / New cases per 100,000 pop/year

1. India 1,169,016 1,962 168

2. China 1,328,630 1,306 98

3. Indonesia 231,627 528 228

4. Nigeria 148,093 460 311

5. South Africa 48,577 461 948

6. Bangladesh 158,665 353 223

7. Ethiopia 83,099 314 378

8. Pakistan 163,902 297 181

9. Philippines 87,960 255 290

10. Democratic Republic of Congo 62,636 245 392

11. Russian Federation 142,499 157 110

12. Viet Nam 87,375 150 171

13. Kenya 37,538 132 353

14. Brazil 191,791 92 48

15. United Republic of Tanzania 40,454 120 297

16. Uganda 30,884 102 330

17. Zimbabwe 13,349 104 782

18. Thailand 63,884 91 142

19. Mozambique 21,397 92 431

20. Myanmar 48,798 83 171

21. Cambodia 14,444 72 495

22. Afghanistan 27,145 46 168

Table 1) HIGH BURDEN COUNTRIES AND INCIDENCE RATES, 2007

Source: World Health Organization, “Table 1.2: Estimated epidemiological burden of TB, 2007,” Global Tuberculosis Control 2009: A Short Epidemiology, Strategy, Financing: 7, http://www.who.int/tb/publications/global_report/2009/pdf/full_report.pdf (accessed August 13, 2010).


Population Mortalitya Prevalence Incidence TB/HIV% b

Afghanistan 27,208,324 9,201[3,923-17,964]

73,621[41,568-117,413]

51,456[41,165-61,748]

--

Bangladesh 160,000,128 79,252[31,463-152,003]

659,586[418,373-982,401]

359,671[287,737-431,606]

0.1[0.1-0.1]

Brazil 191,971,504 7,284[2,714-15,249]

55,694[12,407-112,628]

89,210[73,395-107,052]

21[17-25]

Cambodia 14,562,008 11,449[4,792-22,262]

99,007[58,019-154,174]

71,382[57,106-85,658]

15[12-18]

China 1,337,411,200 160,086[64,683-329,249]

1,175,048[408,980-2,203,167]

1,301,322[1,041,057-1,561,586]

1.7[0.2-2.7]

DR Congo 64,256,636 49,417[19,701-94,920]

423,350[267,368-631,855]

245,162[196,130-294,195]

8[6.4-9.6]

Ethiopia 80,713,432 51,532[20,831-99,280]

455,430[281,164-688,741]

297,337[237,870-356,805]

17[15-19]

India 1,181,411,968 276,512[119,082-553,196]

2,186,402[1,044,202-3,739,672]

1,982,628[1,586,103-2,379,154]

6.7[5.5-7.9]

Indonesia 227,345,088 62,246[26,826-124,570]

483,512[229,832-828,415]

429,730[343,784-515,677]

2.8[2.2-3.6]

Kenya 38,765,312 7,365[2,653-16,092]

71,340[17,436-143,440]

127,014[101,611-152,417]

45[36-54]

Mozambique 22,382,532 8,155[3,050-16,805]

105,097[64,989-159,949]

94,045[75,236-112,854]

60[48-72]

Table 3) Estimated epidemiological burden of TB (2008)

Table 2) Funding for TB control by line item, high burden countries, 2002-2010

Source: World Health Organization, “Figure 13: Funding for TB control by line item, high burden countries, 2002-2010,” Global Tubercu-losis Control: A Short update to the 2009 report, 2009: 20, http://whqlibdoc.who.int/publications/2009/9789241598866_eng.pdf (accessed August 13, 2010).


Population Mortalitya Prevalence Incidence TB/HIV% b

Myanmar 49,563,020 28,219[12,181-55,967]

230,921[117,941-385,034]

200,060[160,048-240,072]

11[8.8-13]

Nigeria 151,212,256 94,826[33,833-181,508]

922,575[625,992-1,299,190]

457,675[366,140-549,210]

27[22-33]

Pakistanc 176,952,128 69,482[29,910-136,428]

555,237[304,242-897,731]

409,392[327,513-491,270]

1.3[0.9-1.8]]

Philippines 90,348,440 46,996[19,943-91,576]

378,098[217,088-597,488]

257,317[205,853-308,780]

0.3[0.2-0.3]

Russian Federation 141,394,304 20,888[10,233-36,654]

97,644[21,259-195,563]

150,898[128,263-181,077]

5[4.8-7.2]

South Africa 49,667,628 19,349[8,257-39,064]

301,079[142,051-514,650]

476,732[381,386-572,079]

71[70-73]

Thailand 67,386,384 12,890[5,557-25,404]

110,129[59,410-178,829]

92,087[73,660-110,504]

17[14-20]

Uganda 31,656,864 8,526[3,217-17,516]

108,524[66,744-165,870]

98,356[78,685-118,027]

59[47-71]

UR Tanzania 42,483,924 5,447[2,601-9,395]

54,956[36,198-77,478]

80,653[75,613-86,414]

47[38-56]

Viet Nam 87,095,920 29,981[12,254-62,097]

244,559[121,713-419,052]

174,593[143,782-238,468]

3.7[3-4.5]

Zimbabwe 12,462,879 6,761[2,666-13,030]

98,482[62,614-146,929]

94,940[75,952-113,928]

68[66-71]

High-burden coun-tries

4,246,251,879 1,065,865[878,777-1,515,671]

8,890,291[7,611,821-11,596,165]

7,541,660[7,076,649-8,124,477]

14[13-16]

African Region 804,865,016 385,055[323,496-554,236]

3,809,650[3,429,910-4,473,415]

2,828,485[2,685,695-3,009,670]

38[34-41]

Region of the Americas

919,896,357 29,135[24,186-41,611]

221,354[181,300-345,426]

281,682[264,584-302,394]

13[12-16]

Eastern Mediterra-nean Region

584,354,906 115,137[78,633-195,852]

929,166[702,873-1,342,886]

674,685[601,842-764,917]

2.2[1.8-2.7]

European Region 889,169,869 55,688[44,905-76,173]

322,310[250,661-539,714]

425,038[398,508-457,822]

5.6[4.8-6.4]

Southeast Asia Region

1,760,485,706 477,701[321,234-804,372]

3,805,588[2,745,818-5,884,647]

3,213,236[2,841,409-3,663,645]

5.7[4.5-7.2]

Western Pacific Region

1,788,176,627 261,770[170,216-466,350]

2,007,681[1,336,179-3,623,886]

1,946,012[1,706,148-2,241,112]

2.3[1.3-4.2]

Global 6,746,948,481 1,324,487[1,090,085-1,667,321]

11,095,750[9,607,465-13,307,187]

9,369,038[8,877,248-9,923,728]

15[13-16]

a Mortality excluding HIV, according to ICD-10.b Percentage of incident TB cases that are HIV-positive.c Estimates are provisional, pending further analyses and data collection in 2010.– Indicates data not available.Source: World Health Organization, “Table 1: Estimated epidemiological burden of TB, 2008,” Global Tuberculosis Control: A Short update to the 2009 report, 2009: 5, http://whqlibdoc.who.int/publications/2009/9789241598866_eng.pdf (accessed August 13, 2010).


Endnotes

World Health Organization, “WHO Reinvigorates Role to 1. Fight ‘Big Three’ Diseases” (1 March 2005), http://www.who.int/bulletin/volumes/83/3/interview0305/en/ (accessed 27 May 2010).

World Health Organization, “Tuberculosis,” Infection and 2. Transmission (March 2007).

Ross Kid, Sue Clay et al, “Understanding and challenging TB 3. stigma: Toolkit for Action” (International HIV Alliance: 1 March 2009).

Although this Bible verse does not reference tuberculosis di-4. rectly, the term “consumption” has been commonly associated with the disease throughout history.

H. Basel Herzog, “History of Tuberculosis,” Respiration Vol. 5. 65, No.1: 5-15 (Jan/Feb 1998).

Ancient physicians were largely preoccupied with a disease 6. known as “phthysis,” a form of pulmonary consumption characterized by TB-like symptoms of emaciation, debility, cough, and fever.

H. Basel Herzog, “History of Tuberculosis,” Respiration Vol. 7. 65, No.1: 5-15 (Jan/Feb 1998), 6.

Bacillus: a specific genus of bacteria that is rod-shaped and 8. long (plural is bacilli).

H. Basel Herzog, “History of Tuberculosis,” Respiration Vol. 9. 65, No.1: 5-15 (Jan/Feb 1998).

Ibid.,10.10.

Aeras Global TB Vaccine Foundation, “Need for New TB 11. Vaccines,” (2010), http://www.aeras.org/about-tb/need.php (accessed 27 May 2010).

H. Basel Herzog, “History of Tuberculosis,” Respiration Vol. 12. 65, No.1: 5-15 (Jan/Feb 1998), 13.

TB Alliance, “An Outdated Treatment,” (2010), http://www.13. tballiance.org/why/outdated.php (accessed 27 May 2010).

Interview with Bernhard Liese, conducted 19 October 2009.14.

Centers for Disease Control, “Tuberculosis (TB): Basic TB 15. Facts,” (1 June 2009), http://www.cdc.gov/tb/topic/basics/default.htm (accessed 27 May 2010).

Centers for Disease Control, “Tuberculosis (TB): Fact 16. Sheet,” (1 June 2009), http://www.cdc.gov/tb/publications/factsheets/general/LTBIandActiveTB.htm (accessed 27 May 2010).

Ibid.17.

Partners in Health, “Tuberculosis and MDR-TB,” (2009-18. 2010), http://www.pih.org/issues/tb.html, (accessed 27 May 2010).

WHO. Multidrug and extensively drug-resistant tuberculosis: 19. 2010 global report on surveillance and response. Geneva, Switzerland: World Health Organization, 2010.

N. Gandhi, P. Nunn, et al., M”ulti-drug resistant and 20. extensively drug-resistant tuberculosis: a threat to global control of tuberculosis,” The Lancet (May 2010), http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960410-2/fulltext#back-bib19 (accessed 13 July 2010).

Global TB Alliance for TB Drug Development, “Drug-Resis-21. tant TB,” (2010) http://www.tballiance.org/why/mdr-tb.php (accessed 27 May 2010).

Partners in Health, Tuberculosis and MDR-TB, http://www.22. pih.org/issues/tb.html.

Greg Bluestein, “Man in 2007 TB scare sues CDC over pri-23. vacy,” Denver Post (30 April 2009), http://www.denverpost.com/headlines/ci_12258920.

USAID, USAID’s Response to Extensively Drug-Resistant 24. Tuberculosis (XDR-TB), Infectious Diseases, http://www.usaid.gov/our_work/global_health/id/tuberculosis/techareas/


xdrtb.html.

World Health Organization, “What is DOTS: A guide to 25. understanding the WHO-recommended TB control strategy known as DOTS,” (1999).

Centers for Disease Control and Prevention, “Tuberculin 26. Skin Testing,” http://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm (May 26, 2010).

R. Wallace, M. Pai, et al., “Biomarkers and diagnostics for 27. tuberculosis: progress, needs, and translation into practice,” The Lancet (May 2010), http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960359-5/fulltext# (accessed 13 July 2010).

Ibid.28.

SABCOHA, Prison-like hospitals for drug-resistant TB 29. patients (South African Business Coalition on HIV & AIDS: 2009), http://www.sabcoha.org/in-the-news/prison-like-hospitals-for-drug-resistant-tb-patients.html (accessed 27 May 2010).

While DOTS differs from DOT in its addition of S, stand-30. ing for “short course,” there has been confusion within the health industry as to their actual meanings. DOT stands for directly-observed treatment, and is more basic in its meaning of supervised care. DOTS, by technical definition, includes a range of interventions, including short-course chemotherapy. However, due to confusion between the two, some health professionals are seeking compromise where DOT and DOTS can be used with the understanding that directly observed treatment is involved in both but is only one possible answer or solution to the problems of TB treatment. Source: Dermot Maher, Raj Gupta, et al., “Directly observed therapy and treatment adherence,” The Lancet, Volume 356, Issue 9234, Sept. 16, 2000, accessed online at http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4FVCHYK-1GS&_user=655954&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=973206805&_rerunOrigin=google&_acct=C000035538&_version=1&_urlVersion=0&_userid=655954&md5=ab0d4dae28ddbb8c97881b6325a42dd8.

Partners in Health, Tuberculosis and MDR-TB, http://www.31. pih.org/issues/tb.html (accessed 27 May 2010).

G. Moalosi, K. Floyd, et al, “Cost-effectiveness of home-32. based care versus hospital care for chronically ill tuberculosis patients,” International Journal of Tuberculosis and Lung Disease (September 2003), http://www.ncbi.nlm.nih.gov/pubmed/12971658 (accessed 27 May 2010).

High burden countries (HBCs) consist of twenty-two coun-33. tries that account for the majority of the world's TB burden (approximately 80% of new TB cases each year). HBCs are determined by the World Health Organization.

Ramanan Laxminarayan, Eili Klein, et al, “Economic Benefit 34. of Tuberculosis Control,” World Bank Human Development Network Policy Research Working Paper (August 2007), http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2007/08/01/000158349_20070801103922/Ren-dered/PDF/wps4295.pdf

SABCOHA, Prison-like hospitals for drug-resistant TB 35. patients (South African Business Coalition on HIV & AIDS: 2009), http://www.sabcoha.org/in-the-news/prison-like-hospitals-for-drug-resistant-tb-patients.html (accessed 27 May 2010).

The Global Alliance for TB Drug Development is the one of 36. the world’s most influential and important tuberculosis drug R&D networks. Source: Global Alliance for TB Drug Devel-opment, Confronting TB: What it takes,” Global Alliance for TB Drug Development 2008 Annual Report, accessed online (27 May 2010) at http://www.tballiance.org/downloads/pub-lications/TBA_Annual_2008_web.pdf.

Global Alliance for TB Drug Development, “Confronting 37. TB: What it takes,” Global Alliance for TB Drug Develop-ment 2008 Annual Report, http://www.tballiance.org/down-loads/publications/TBA_Annual_2008_web.pdf, (accessed 27 May 2010).

Z. Ma, C. Lienhardt, et al., “Global tuberculosis drug devel-38. opment pipeline: the need and the reality,” The Lancet, (May 2010), http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960395-9/fulltext#article_upsell


(accessed 14 July 2010).

Global Alliance for TB Drug Development, Regulatory En-39. gagement, (2010), http://new.tballiance.org/new/regulatory.php (accessed online: 27 May 2010).

World Health Organization and the Stop TB Partnership, 40. 2009 Update Tuberculosis Facts, (2009), http://www.who.int/tb/publications/2009/tbfactsheet_2009update_one_page.pdf (accessed online: 27 May 2010).

S. Kaufmann, G. Hussey, and P. Lambert, “New vac-41. cines for tuberculosis,” The Lancet (May 2010), http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960393-5/fulltext#article_upsell, (accessed 14 July 2010).

Center for Global Health Policy, Deadly Duo: The Synergy 42. between HIV/AIDS and Tuberculosis, In-fectious Diseases Society of America (Arlington: 2009).

USAID, HIV/AIDS and Tuberculosis Co-infection, (24 43. March 2010), http://www.usaid.gov/our_work/global_health/id/tuberculosis/techareas/tbhiv.html, (accessed 27 May 2010).

USAID, HIV/AIDS and Tuberculosis Co-Infection (March 44. 2010), http://www.usaid.gov/our_work/global_health/id/tu-berculosis/techareas/tbhiv.html (accessed 13 July 2010).

World Health Organization, Policy on collaborative TB/HIV 45. activities, http://www.who.int/tb/challenges/hiv/tbhiv_collab-orative_activities.pdf (accessed 27 May 2010).

Think TB in People with HIV, HIV & AIDS Treatment 46. in Practice (July 2008), http://www.aidsmap.com/files/file1002936.pdf (accessed 27 May 2010).

Other important steps to decrease the burden of HIV in TB 47. patients include fulfilling the following requirements: provi-sion of HIV testing, counseling, and educational programs, because the vast majority of HIV infected people are unaware of their infection; introduction of HIV prevention methods such as ensuring the safety of blood supplies and sterilization of medical equipment; introduction of co-trimoxazole thera-py, which is a low cost treatment that prevents several second-

ary bacterial and parasitic infections; ensuring HIV care and support during and after TB treatment; and the introduction of antiretroviral therapy (ART) to improve the quality of life and survival rate of those individuals living with HIV/AIDS (Source: Think TB in People with HIV, HIV & AIDS Treat-ment in Practice [July 2008], http://www.aidsmap.com/files/file1002936.pdf [accessed 27 May 2010]).

A. Harries, R. Zachariah, “The HIV-associated tuberculo-48. sis epidemic – when will we act?” The Lancet (May 2010), http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960409-6/fulltext#article_upsell (accessed 13 July 2010).

Mike Adams, “Once Dreaded Leprosy Replaced by Tubercu-49. losis, Say Researchers,” ScienceDaily (6 August 2005), http://www.sciencedaily.com/releases/2005/08/050814172940.htm (accessed 27 May 2010).

Ibid.50.

ILEP Federation, Transmission and Control of Leprosy, 51. (2010), http://www.ilep.org.uk/facts-about-leprosy/transmis-sion-and-control-of-leprosy/ (accessed 27 May 2010).

Mike Adams, “Once Dreaded Leprosy Replaced by Tubercu-52. losis, Say Researchers,” ScienceDaily (6 August 2005), http://www.sciencedaily.com/releases/2005/08/050814172940.htm (accessed 27 May 2010).

Novartis Foundation for Sustainable Development, Leprosy 53. elimination – a public-health success story, (2010), http://www.novartisfoundation.org/page/content/index.asp?MenuID=217&ID=493&Menu=3&Item=43.2 (accessed 27 May 2010).

World Health Organization, Leprosy Elimination, http://54. www.who.int/lep/mdt/en, (accessed 27 May 2010).

Ibid.55.

G. Auregan, F. Rakotomanana, et al, Role of catholic centers 56. in the control of tuberculosis, Arch. Inst. Pasteur (Madagas-car: 1995), Volume 62(1): 37-40, http://www.ncbi.nlm.nih.gov/pubmed/8638976, (accessed 27 May 2010).


Diana N.J. Lockwood and Paul R. Sanderson, Letter from 57. Ethiopia: Harnessing the strengths of the leprosy programme to control tuberculosis, (BMJ: 1995).

G. Auregan, F. Rakotomanana, et al, Role of catholic centers 58. in the control of tuberculosis, Arch. Inst. Pasteur (Madagas-car: 1995), Volume 62(1): 37-40, http://www.ncbi.nlm.nih.gov/pubmed/8638976 (accessed 27 May 2010).

World Health Organization, Tuberculosis and leprosy control, 59. WHO African Region: Ethiopia, http://www.who.int/coun-tries/eth/areas/cds/tb/en/index.html, (accessed 27 May 2010).

Christie Y. Jeon and Megan B. Murray, “Diabetes Mellitus 60. Increases the Risk of Active Tuberculosis: A Systematic Re-view of 13 Observational Studies,” PLOS Medicine (Harvard School of Public Health: Boston), http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050152 (accessed 27 May 2010).

Christie Y. Jeon and Megan B. Murray, “Diabetes Mellitus 61. Increases the Risk of Active Tuberculosis: A Systematic Re-view of 13 Observational Studies,” PLOS Medicine (Harvard School of Public Health: Boston), http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050152 (accessed 27 May 2010).

Patricia Kelly, “Isolation and Stigma: The experience of 62. Patients with Active Tuberculosis,” Journal of Community Health Nursing (1999), 16(4), 233-241.

Ibid., 234.63.

Ibid., 235.64.

Fazlul Karim, A. M. R. Chowdhury, et. al, “Stigma, Gender 65. and their Impact on Patients with Tuberculosis in Rural Ban-gladesh,” Anthropology and Medicine, Vol. 14, No. 2 (August 2007).

Stefan Kaufmann and Parida Shreemanta, “Changing funding 66. patterns in tuberculosis,” Nature Medicine Vol. 13 (2007).

Interview with Bernhard Liese, Chair of the Department of 67. International Health at Georgetown University School of

Nursing & Health Studies, 19 October 2009.

Bill and Melinda Gates Foundation, “Tuberculosis Strategy 68. Overview,” Global Health Program, November 2009.

Independent Evaluation Group, Stop TB Partnership: Global 69. Program Review, Vol. 4, Issue 1, ix, http://siteresources.worldbank.org/INTGLOREGPARPRO/Resources/stop_tb.pdf (accessed 27 May 2010).

Stop TB Partnership, About the Stop TB Partnership (2009), 70. http://www.stoptb.org/stop_tb_initiative/ (accessed 27 May 2010).

World Health Organization, The Global Plan to Stop TB: 71. 2006-2015/Stop TB Partnership (2006), http://www.stoptb.org/assets/documents/global/plan/GlobalPlanFinal.pdf (ac-cessed 27 May 2010).

The Stop TB Partnership, “Global Drug Facility Briefing 72. Note,” (24 March 2010), http://www.stoptb.org/assets/documents/gdf/Briefing%20note%20GDF%20March%202010%20final.pdf (accessed 27 May 2010).

Stop TB Partnership Global Drug Facility, TB Facts and 73. Figures, http://www.stoptb.org/gdf/whatis/facts_and_figures.asp (accessed 27 May 2010).

World Health Organization, “DOTS-Plus and the Green 74. Light Committee,” Tuberculosis – TB, http://www.who.int/tb/dots/dotsplus/management_old/en/ (accessed 27 May 2010).

Stop TB Partnership, “Time-Bomb: Multidrug-resistant tu-75. berculosis,” Newsletter of the Global Partnership to Stop TB (2002), Issue 7, 4.

Ibid. 76.

Actors involved in the Lilly MDR-TB Partnership include As-77. pen Pharmacare, Harvard University and Partners in Health, Hisun Pharmaceutical, the International Council of Nurses, the International Federation of Red Cross and Red Crescent Societies, the International Hospital Federation, Purdue University, the Results Educational Fund, Shasun Chemi-


cals and Drugs, TB Alert, the Tuberculosis Survival Project, U.S. Centers for Disease Control and Prevention, the World Economic Forum, the World Health Organization, and the World Medical Association.

“The Lilly MDR-TB Partnership,” Eli Lilly and Company, 78. http://www.lillymdr-tb.com/question_answers.html (accessed 27 May 2010).

World Health Organization, Global Tuberculosis Control: 79. Epidemiology, Strategy, Funding (2009), 3, http://www.who.int/tb/publications/global_report/2009/pdf/full_report.pdf (accessed 27 May, 2010).

Ibid.80.

Ibid.81.

Interview with Dr. Mohamed Aziz, conducted 23 September 82. 2009.

Mohammed Abdel Aziz, Wright, De Muynck, and Laszlo, 83. Anti-tuberculosis drug resistance in the world, Third Global Report, The WHO/IUATLD Global Project on Anti-Tuber-culosis Drug Resistance Surveillance (Geneva, Switzerland: 2003).


World Health Organization, Global Tuberculosis Control: 85. Epidemiology, Strategy, Funding (2009), 3, http://www.who.int/tb/publications/global_report/2009/pdf/full_report.pdf (accessed 27 May 2010).


Interview with Patrice Wedderburn, conducted 10 September 87. 2009.

Fawzia Rasheed, “Faith-Based Organizations (FBOs): A Note 88. on Terminology,” World Health Organization (April 2010).

Friends of the Global Fight Against AIDS, Malaria, and 89.

Tuberculosis, Engaging with The Global Fund To Fight AIDS, Tuberculosis and Malaria: A Primer For Faith-based Organizations, http://www.theglobalfight.org/view/resources/uploaded/FBO_Manual.pdf (accessed 15 July 2010).

USAID, “Infectious Diseases: Tuberculosis,” http://www.90. usaid.gov/our_work/global_health/id/tuberculosis/ (accessed 27 May 2010).

Prior to commitment to funding, the amount that is budget-91. ed towards HIV/AIDS and TB efforts requires authorization by the United States Congress.

Multi-drug Resistant Tuberculosis: Assessing the U.S. Re-92. sponse to an Emerging Global Threat, Committee on Foreign Affairs, The House of Representatives, United States Govern-ment (27 February 2008).

Treatment Action Group, “Tuberculosis Research and Devel-93. opment: 2009 Report on Tuberculosis Research and Funding Trends, 2005-2008,” The Stop TB Partnership,

The Bill and Melinda Gates Foundation, http://www.gates-94. foundation.org/grants/Pages/search.aspx (accessed 27 May 2010).

Ibid.95.

Foundation for Innovative New Diagnostics, Delivering on 96. the promise: Summary on five years of progress, 2003-2008. http://www.finddiagnostics.org/export/sites/default/resource-centre/find_documentation/pdfs/delivering_on_the_prom-ise_sep08-summary.pdf (accessed 14 July 2010).

Pastor Harry, qtd. in What We Do, Tearfund, http://www.97. tearfund.org/About+us/What+we+do/default.htm (accessed 27 May 2010).

The African Religious Health Assets Programme (ARHAP) 98. defines religious health assets as faith based initiatives in health, which are understood to exist beyond the more tradi-tional focus on facilities such as hospitals and clinics. Accord-ing to ARHAP, religious health assets tend to be rooted in the community and have significant potential in finding long-term, sustainable solutions to public health issues [Source:

62 Berkley Center for Religion, Peace & World Affairs

ARHAP, “About Us,” (July 2008), http://www.arhap.uct.ac.za/about.php (accessed 27 May 2010)].

Ritva Reinikka and Jakob Svensson, Working for God?, 99. CEPR Discussion Paper No. 4214, (January 2004), http://ssrn.com/abstract=508042 (accessed 27 May 2010).

Interview with Kola Akinola, Tearfund, conducted 30 Sep-100. tember 2009.

Interview with Ian Campbell, Salvation Army International, 101. conducted 15 October 2009.

Interview with Rachel Karrach, UMH Tansen Mission Hospi-102. tal, conducted 13 January 2010.

Britton, Walter, qtd. in Peru: Drug-Resistant Tuberculosis 103. Threatens Progress Against Epidemic, John Torres (28 July 2009), http://www.adra.org/site/News2?page=NewsArticle&id=10285&news_iv_ctrl=1141 (accessed 27 May 2010).

John Torres, Peru: Drug-Resistant Tuberculosis Threatens 104. Progress Against Epidemic, (28 July 2009).

Ibid.105.

The Global Fund to Fight AIDS, Tuberculosis and Malaria. 106. Report on the Involvement of Faith-Based Organizations in the Global Fund, http://www.centerforinterfaithaction.org/files/0000/0020/GlobalFund_FBO_Report_en.pdf (accessed 27 May 2010).

The Global Fund to Fight AIDS, Tuberculosis and Malaria, 107. “Proposal Form” (17 March 2005), Zimbabwe and the Global Fund, Global Fund Grants Portfolio, http://www.theglobalfund.org/grantdocuments/5ZIMT_1259_0_full.pdf (accessed 27 May 2010).

The Global Fund to Fight AIDS, Tuberculosis and Malaria, 108. “Proposal Form” (17 March 2005), Nigeria and the Global Fund, Global Fund Grants Portfolio, http://www.theglobal-fund.org/grantdocuments/5NGAT_1184_0_full.pdf (ac-cessed 27 May 2010).

The Global Find to Fight AIDS, Tuberculosis and Malaria, 109.

“Proposal Form” (1 July 2008), Indonesia and the Global Fund, Global Fund Grants Portfolio, http://www.theglobal-fund.org/grantdocuments/8INDT_1693_0_full.pdf (accessed 27 May 2010).

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Experiences and Issues at the Intersection of Faith & Tuberculosis is a project of the Berkley Center for Religion, Peace & World Affairs; the World Faiths Development Dialogue; and the Edmund A. Walsh School of Foreign Service at Georgetown University.

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