Seven-year-old Manoj wriggled impatiently in his mother’s lap, longing to play outside rather than take his latest round of medicine. Months before, a health care worker had come to his home in Chennai, India, to give him a tuberculosis (TB) test after one of his family members had gone to a clinic seeking treatment for the disease. Manoj, it turned out, also had an active case of TB.

Were it not for active screening and immediate treatment, both supported by a broad consortium called the Zero TB Cities Project, Manoj would likely have become one of the 4,000 people who die of tuberculosis every day.

Tom Nicholson, associate in research at the Duke Center for International Development (DCID) and alumnus of the Master of International Development Policy (MIDP) program, is heading up the new project in partnership with Harvard Medical School’s Department of Global Health and Social Medicine, the Clinton Health Access Initiative, and the Municipal Corporation of Chennai.

Formed in 2014, the Zero TB Cities Project aims to bring the global tuberculosis epidemic to an end by fighting the disease at the community level in high-burden countries. The project utilizes partnerships between activists, researchers, NGOs and health care providers to provide a comprehensive spectrum of care for people at all stages of the disease.

“We’re trying to create a model that brings a single city’s TB cases toward zero by actively searching for cases, using the best diagnostics, and treating all forms of the disease,” Nicholson said. “We will see huge drops in mortality, as we have in projects all around the world, if we give TB treatment the resources and long-term attention it deserves.”

Creating ‘islands of elimination’

Chennai, as well as municipalities in Lima, the capital of Peru, have already announced their participation in the project. Other TB care delivery partnerships in talks with the project include Kisumu, Kenya; Ho Chi Minh City, Vietnam; Karachi, Pakistan; and Vladimir Oblast in Russia.

The project focuses on local and municipal governments, which can mobilize their own resources and are closest to the affected populations.

“[Municipalities] typically have their own resource streams and political networks, and they bring the strength of the public sector in terms of their priorities, focus and transparency, while being more oriented toward practical interaction with private clinics and associations,” Nicholson said.

The project targets populations that are particularly vulnerable to TB – including children, households with a diagnosed relative, and communal settings such as slum housing and elder care facilities – for intense screening and intervention. By catching the disease early, it heads off the spread of the disease and prevents more costly and aggressive treatments later.

The ultimate goal, Nicholson said, is to create “islands of elimination” that can be used as models for future efforts.

“Once we can point to these successes, neighboring cities and districts will want to follow suit,” he said. “Our job will be to provide a strong platform for translating the lessons our partners are learning during implementation to other sites.”

The forgotten disease

Governments bear most of the responsibility for fighting the global TB epidemic, Nicholson said, compared to the dominant role donor agencies play in the fight against HIV and malaria.

This is due, in part, to the socio-economic status of the patients who are most likely to suffer from the disease, Nicholson said.

“TB is often cited as the classic example of a ‘social disease,’ given its close correlation with poverty and political marginalization,” he said.

Despite the high success rate of treatment, TB receives less than 4 percent of total development assistance for health, according to the Copenhagen Consensus Center.

“The defeatist attitude about turning the tide against TB is itself infectious across institutions, even those that can do something about it at powerful agencies and governments,” Nicholson said. “Local partnerships, facilitated by local governments, need to take the lead to figure out a way to change this dynamic.”

‘Connecting the dots’ for health care access

The Zero TB Cities Project is the result of a collaborative research effort between faculty at Harvard’s Department of Global Health and Social Medicine, Duke University’s Sanford School of Public Policy and DCID. It is strengthened by an operational and strategic collaboration with the Stop TB Partnership, which is housed at the United Nations Office for Project Services (UNOPS) in Geneva, Switzerland.

The project is part of a larger grant on rethinking the global approach to stopping the global tuberculosis epidemic. Nicholson’s activities conducted in partnership with the Harvard Medical School are funded with support from Janssen Global, the public health arm of Janssen Pharmaceuticals, a subsidiary of Johnson & Johnson.

The project brings together implementing sites and potential partners every six months in Dubai, UAE, for practical workshops. The next event will take place there in October.

As head of program development for this partnership, Nicholson founded the Advance Access and Delivery (AA&D) initiative to support implementation at the sites. AA&D is being supported by donors to act as an independent fund and facilitator for drug access projects.

“AA&D was an unusual step for me: founding an institution to act upon policy challenges outlined in the research,” Nicholson said. “We wanted to make sure these efforts continued over time with or without research grants.”

Before enrolling in the MIDP in 2012, Nicholson spent nearly eight years with the nonprofit Partners in Health (PIH) working on health projects in Rwanda and the former Soviet Union. The MIDP, he said, gave him the tools he needed to have more effective discussions with policymakers.

“It helped me discern how patients make choices and helped me analyze institutional arrangements and performance when considering potential reforms and programs,” he said.

The wider partnership is also addressing issues such as access to hepatitis C treatment and affordable provision of drugs that reverse opioid overdose, a leading cause of death in the U.S. The goal, Nicholson said, is to “connect the dots” to strategically improve access to health care in both the developed and developing world.

However, tuberculosis remains his main area of focus.

“There is no excuse for 1.7 million deaths per year from TB in the 21st century,” he said. “I have a hard time convincing myself to work in any other area, in terms of our potential impact on people’s lives.”

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