Losing India’s Guardian Angels

BIHAR, INDIA – Sitting outside his modest house in India’s eastern state of Bihar, Sudeshwar Singh, 48, scrolls on his smartphone through the recent Global Tuberculosis Report released by the World Health Organization (WHO) last month to check India’s status. Just eight countries account for 67 percent of global TB cases, according to the report, with India contributing 25 percent of the total, topping the chart.

Seeing India leading in global TB disappoints Singh. As the day starts to fade, he puts on a jacket with a “Stop TB” logo, packs a few copies of handbooks and pamphlets in a tote bag, and starts walking toward a nearby village.

Singh, himself a TB survivor and a renowned health advocate, has been a guide for a network of TB advocates in the region, working toward a global commitment to end the epidemic by 2030 under the United Nations Sustainable Development Goals. As he reaches the village, he is joined by a few older people, and they begin to distribute resources together, going door-to-door. Kumar counsels a group of teenagers at a local tea kiosk on smoking and the risk of TB.

For the past year, Singh has been voluntarily guiding and supporting patients across Bihar, one of India’s poorest states, which has the highest number of TB cases in the country. Before that, he acted as founder of TB Mukt Vahini (TMV), which means the Army for a TB-Free Community. The organization collaborated with government-run health centers and a network of hundreds of survivors of tuberculosis who were coached as “TB champions,” working at the grassroots level to educate and assist patients across India, while offering psychological support to combat social stigma.

TMV was funded by the U.S. Agency for International Development. However, this February, Singh and the leaders of multiple other small organizations across India had to shut down their operations abruptly, after the Trump administration decided to take apart USAID, effectively ending most development and humanitarian assistance overseas.

“It came as a shock when I heard the funding had been dismantled, and the news broke me from inside that we won’t be able to serve people anymore,” said Singh while distributing pamphlets in the village. “Fighting TB is a long journey and without proper counseling and support, it’s impossible to win, and that’s where organizations like ours came into action and worked on the ground … This disease eats patients, particularly the poor, and their families like a termite if they are left alone.”

Since 1998, USAID has allocated more than $140 million in funding to combat TB in India, supporting government bodies, NGOs, and the private sector with an epidemic afflicting approximately 2.8 million people across the country. Globally, USAID funding has assisted low- and middle-income countries in prevention, testing, and treatment with $250 million in annual outlays, according to the WHO. In 2024, this funding helped to save 3.65 million lives. But now the money has stopped flowing.

A study by the Stop TB Partnership, published in PLOS Global Public Health, estimated that a freeze in USAID funding could result in a 36 percent increase in cases and a 68 percent rise in deaths in 26 high-burden countries, reaching 2.24 million by 2030. This is particularly urgent in India, where TB is one of the deadliest infections, responsible for 2.5 percent of all mortalities between 2021 and 2023, far greater than HIV and malaria, which collectively comprised just 0.2 percent.

Singh didn’t just lose a cause along with USAID funding; he lost a job. He has been actively seeking work, despite continuing to provide free assistance to TB patients whenever possible. For him, it’s a service to humanity, and someone has to take the responsibility. “I have received hundreds of calls from TB patients, particularly from marginalized sections, asking for guidance and support, as medicine alone is not enough,” he said. “But I can’t voluntarily fill this huge void alone for a long time, and if nothing is done soon, it can prove to be devastating.”

FOR PINTU KUMAR, TB IS NOT JUST A DISEASE that kills you physically, but also socially, economically, and mentally. With a stained piece of cloth wrapped around his face, the 27-year-old told the Prospect that he has rarely stepped outside of his home in the last few weeks in Gaya, a city in Bihar state. Kumar was diagnosed with TB a few months ago and was fired immediately from the construction site where he worked as a day laborer. Since then, he has been unemployed.

“The people over here see TB as a curse, and you are made to feel like an untouchable; sometimes it comes from your own family and friends,” said Kumar. “I don’t blame the people completely, as they are not educated and have no awareness of this deadly disease.”

He had heard about organizations like Singh’s that provided mental health support and guidance to TB patients as they underwent treatment. “But when I asked around, they don’t work anymore,” he explained. “Hearing that left me heartbroken, as they would have made society understand that TB patients are also humans and eased my journey to fight TB.”

The most recent WHO report shows that on average, India witnesses two deaths related to tuberculosis every three minutes. “Since childhood, I have seen people dying of TB close to me, as they feared going to hospitals because they would be seen as outcasts. At times, I would face the same fate,” said Kumar.

With the majority of his savings exhausted, Kumar has spent most of his last few weeks seeking employment, announcing his willingness to work for lower pay. After multiple requests and a referral from an acquaintance, he managed to secure work as a daily laborer starting next month, despite his doctor’s suggestion to take complete rest for recovery.

The idea of not working during treatment is impossible for Kumar. “If I decide to take a rest, hunger will kill me and my family before the disease does,” he said. Kumar has nine family members dependent on him for survival. He previously made around 9,000 rupees per month, enough only to maintain a “bare minimum life,” he said. “Imagine now if I decide not to work, what will be the condition of my family?”

India’s National Tuberculosis Elimination Program (NTEP) provides free tuberculosis diagnosis and treatment, including free medication. Yet despite these benefits, according to a study published last year by Global Health Research and Policy, nearly half of tuberculosis patients suffer from “catastrophic” costs due to loss of income and hospitalization.

Initially, Kumar borrowed money to cover his travel to the hospital and the nutrition prescribed by the doctor, but he stopped once he realized it wasn’t sustainable. “I stopped taking the food suggested at the hospital, as it was something I couldn’t afford throughout the treatment,” he explained.

In 2018, the government of India launched the Nikshay Poshan Yojana scheme to provide 500 rupees per month to support the nutrition of all TB patients in the country, which was later revised to 1,000 rupees per month. But it has proven difficult for Kumar to obtain. “To date, I have not received any aid from the administration, nor have people I know who suffer from TB,” he said. “Even if I do, it’s a minimal amount and won’t be of any help in these times when inflation is at its peak.”

Kumar fears that in the coming months, he will have to stop going to his hospital appointments as well, because his co-workers may find out about his illness. “No work means no money,” he said.

WITH USAID FUNDING GONE AND ORGANIZATIONS like Singh’s halting their operations, health policy specialists in India are bracing for a rise in infections and mortalities from TB.

No doubt, NTEP continues to provide medication and treatments, with its annual budget of $492 million funded by the Indian government. But since USAID became dysfunctional, awareness programs and help required to curb social stigma on the ground are gone. USAID was the backbone for addressing the social aspects of the TB epidemic in India, providing support for nutrition, capacity building, and other activities. “Now, with a drop in all of these essential supports, they have gone absent,” said Blessina Kumar, CEO of the Global Coalition of TB Advocates in India.

For Blessina, medicine alone can’t succeed in eradicating the disease if other factors are not taken into consideration. “What is the point of having drugs if TB patients have to suffer daily stigma, forcing them to become hesitant to receive treatment? Where will this lead? Eventually, we will witness even more persons with TB and deaths,” she said.

Previously, the Indian government had pledged to eliminate TB from the country by the end of 2025, five years ahead of the WHO’s global target. But with just a month left, Blessina sees this as an impossible task to achieve, and without USAID-funded efforts, even the 2030 global goal looks remote.

“India needs new strategies. TB needs to be addressed as a crisis, and [the country] should develop an emergency mechanism to deal with it,” said Blessina.

According to the Geneva-based Stop TB Partnership, governed by the United Nations, reports indicate that globally, foreign aid accounted for around one-fifth of the money used for treating TB, with 55 percent of those funds provided by the United States alone.

Patients whom TB champions like Sudeshwar Singh have helped during their treatment still can’t imagine how they would have managed it without their support. They call the TB champions their guardian angels.

Wearing a pair of gloves and a mask, Julekha Bibi, the wife of a farmer, prepares fodder for her cattle in a rural village in Bihar. Last winter, Bibi complained of chest pains, followed by persistent coughing for a week. Her husband noticed and took her to a local doctor in the village, who prescribed antibiotics, suggesting that it was a regular occurrence during the winter. With no improvement, only then did her husband come into contact with a TB champion, who accompanied her to the government hospital and assisted with her admission, as Bibi was diagnosed with TB.

“The person who took me to the hospital was an angel; otherwise, I would have been dead long ago due to wrong treatment,” Bibi said. “Not only that, he made sure to check on me every week and counseled both me and my family about the treatment.”

For Bibi, the biggest hurdle was admitting to herself that she had TB, a process that took her a few weeks. But she said the experience, and the work of the TB champion, transformed her. “That noble soul didn’t just give me the courage to fight TB; he also inspired me to support other patients,” she said as she tied her cattle and started to walk back toward her home. “I recently learned that he, along with hundreds like him, had to stop their work, and for TB patients like me, it feels as if we are orphaned.”