Zero TB for Tibetan Kids

Madison's Zorba Paster, second from left, first invited the Delek Hospital team to GHI's Quality Improvement Institute, where they developed a TB project that attracted the Dalai Lama's support.

The project began in 2015 in a University of Wisconsin-Madison classroom. Madison’s Dr. Zorba Paster invited Tibetan health leaders from Dharamshala, India to participate in the UW-Madison’ Global Health Institute’s week-long Quality Improvement (QI) Leadership Institute. Their goal? To wipe out tuberculosis in Tibetan schools and monasteries, where the infection rate is six times higher than the global average. The effort will make a difference in their community and show that death and illness due to TB can be eliminated.

Fast forward two years. The Dalai Lama meets with the TB team led by Dawa Phunkyi, CEO of Delek Hospital, Paster and colleagues Kunchok Dorjee and Dick Chaisson from Johns Hopkins Bloomberg School of Public Health. They explain the TB dilemma, and the Dalai Lama agrees to record a public service message in Tibetan to underline the threat of the disease. He urges civil, government, school and religious leaders to work together on a new project, Zero TB in Tibetan Kids: Training to End TB Now.

“I hear you say that eliminating TB in Tibetan children is an achievable goal. Unlike many other diseases, TB is curable so it must be eliminated. … We should never let down our guard in the goal to eliminate TB.”—the Dalai Lama

TB in Dharamshala

Health professionals and community members have worked for decades to eradicate TB in Dharamshala. “TB used to be mostly in the adult population, but within past five or six years we are seeing it more in students,” Delek pediatrician Sonam Topgyal says. “We’re trying to bring the number of cases to 0.”

The QI Institute, hosted annually by the UW-Madison Global Health Institute, gave Delek a path forward, as the team in 2015 launched a highly successful active-case-tuberculosis-finding-program targeting schoolchildren. That QI-inspired program—aiming to reduce TB among students by 10 percent in 12 months—led to the Zero TB in Tibetan Kids initiative.

“The Dalai Lama’s interest is a direct result of the fact that the Delek group came here, decided to look at TB and did so as part of their QI project,” says Paster, a Madison physician and radio personality who has a long history of working with Tibetans. “He didn’t know how many Tibetan children had TB.”

Delek Hospital CEO Dawa Phunkya, left, joined colleagues from UW-Madison and Johns Hopkins Bloomberg School of Public Health, to meet with the Dalai Lama, who agreed to record a public service announcement supporting Zero TB in Tibetan Kids.

When Paster, Topgyal and others explained the Zero TB project during an audience with the Dalai Lama, he wanted to participate by recording a series of public service announcements to support it.

“His Holiness is the spiritual leader of Tibet, and to have him put his stamp of approval on the project means a lot,”—Zorba Paster, M.D.

 A community of Tibetan refugees

After China’s invasion of Tibet in 1959, more than 80,000 Tibetans fled to India. Many settled in Dharamshala—a city that has become the epicenter of Tibetan life, and home to the Dalai Lama and the Tibetan Central Government.

These Tibetans are among the most stable refugee populations, yet they have long been plagued with the highest incidence of tuberculosis in the world. For 40 years, they have turned to Delek Hospital for help. The 45-bed, not-for-profit hospital has a dedicated clinic and isolation ward for TB patients, and it is the primary hospital for refugees with complicated TB cases.

Delek teams participated in the QI Institute in 2015 and 2016 to further improve care. The QI Institute, which has trained over 100 health care providers from 14 countries, brings together health care practitioners from across the world with the UW community for a week of lectures and workshops on the fundamentals of strengthening health care systems through measurable steps. The Tibetan staff applied what they learned in 2015 as soon as they returned home. Seeing the effectiveness of the effort, Dawa Phunkyi returned to the 2016 summer institute with additional staff: pediatrician Sonam Topgyal, and nurses Yangchen and Namgyal Dolma. “The ideas of quality improvement should be known by staff of all levels, so that’s why we have a doctor as well as nurses here,” Phunkyi said during the Institute.

QI at work

Topgyal, who joined the Delek Hospital in 2015, became heavily involved in the team’s QI projects, surveying schoolchildren for TB through a series of screenings, as well as physical exams and laboratory testing. The screenings showed an alarmingly high prevalence of the disease when 17 of the 535 schoolchildren tested positive.

The Delek team, from left, including hospital CEO Dawa Phunkyi, pediatrician Sonam Topgyal and nurses Namgyal Dolma and Yangchen, used QI training at UW-Madison to develop a Zero TB in Tibetan Kids project. (Photo by Catherine Goslin.)

The QI experience helped the team tackle a wide range of factors contributing to the high number of infections, including poor access to TB clinics, infrequent screening and the stigma of the disease.  “We have used the tools we learned (in Madison) to implement new projects; we have learned to specify aims and objectives, set a goal, and analyze situations to make the best possible decisions,” Phunkyi says.

Once they identified active cases, the team needed human resources, especially to collect and analyze data. That’s where UW-Madison medical student Aref Senno came in.

Senno had heard of Delek’s QI projects. Having studied TB and the epidemiology of infectious diseases, he was particularly intrigued that the patients were refugees. Arriving in the summer of 2016, he worked with the Delek team to develop a data processing system that radically simplified day-to-day operations at the hospital.

“All the credit goes to them; the development, the organization, the funding,” Senno says. “They’re just a hospital; they don’t have to go out into the public to screen people for TB: But they do, they go.”

Lasting impacts

The combination of Delek’s highly skilled team, the pillars of QI learned at UW-Madison, and Senno’s work have helped reduce TB among Dharamshala’s children, and given Delek a strong foundation for the future.

“The experience that we have gained here through QI is going to help us in a lot of ways, in how to do things correctly. It’s going to be an immense help in the long run.”—Delek Hospital pediatrician Sonam Topgyal

“QI has played a huge role in organization, particularly in narrowing down and measuring progress,” Paster says in regards to how QI has impacted the hospital. “QI provides the concept of the infrastructure so you can see you can actually perform a project and finish it successfully.”

Zorba Paster, a Madison physician and long-time collaborator in Dharamshala invited the hospital team to the QI Institute. (Photo by Catherine Goslin.)

Collaboration like the one that has developed between UW-Madison, Johns Hopkins and Delek Hospital leads to successful programs with scalable potential, says GHI Associate Director Lori DiPrete Brown, who leads the QI program. ”When the local team has a network of partners that are investing in their professional development and supporting implementation everyone wins. ” We have created a foundation for ongoing partnership, and our health science students, residents and infectious disease experts and fellows are all ready to advise and collaborate as needed.”

“With this kind of partnership everyone learns, and lives are saved. We can really make a difference.”—GHI Associate Director Lori DiPrete Brown

DiPrete Brown visited Delek in April to work with hospital and school staff members on the implementation and evaluation strategy for the Zero TB project  and to further develop QI initiatives begun in Madison.

The 2017 QI Leadership Institute will be July 24 to 28 at the UW-Madison. To learn more, visit

By Catherine Goslin/ April 20, 2017