TDR Global profile: Online operational research training addresses TB and smoking crisis

Raffi Balian

How tuberculosis and smoking rates in Armenia came to be analyzed by a 17-year-old American student is a story of heritage, technology, and community service. TDR’s operational research training called SORT IT (Structured Operational Research and Training Initiative) was the medium that allowed a young man to address a major health issue.

Raffi Balian (top) at Armenian orphanage
Raffi Balian (top) at Armenian orphanage
Provided by Raffi Balian

The story begins more than 40 years ago with John Balian, an Armenian who was raised in orphanages in Turkey and Jersualem until the age of 17. He was then adopted by a U.S. couple, attended Columbia University in New York and then Tufts University School of Medicine. Embracing his Armenian ethnicity, Dr Balian decided to help stimulate the economy by creating local health jobs in through his work with an American corporation.

In 2013, he returned with his 14-year-old son, Raffi Balian, to show him his home country. But this was not an ordinary tourist experience. At a time when many young men were spending their summers playing basketball and hanging out with friends, Raffi volunteered to help boys in an orphanage learn English and computer skills.

Living among one of the most vulnerable populations, Raffi became committed to giving back, just like his father. He ended up going back to that orphanage 3 summers in a row. “It was stressful because the boys had so many needs, and they wanted me to adopt them!” he explains. “I felt I had to continue.”

During those summers, he was horrified at the extent of smoking in Armenia. Everywhere he went – not only in the orphanage but in schools, restaurants, stores – people young and old were smoking.

Smoking is the trigger for the next phase

The summer before Raffi entered his senior year of high school, he decided he would go back to Armenia a fourth summer, but this time, to study smoking rates and their connection to tuberculosis (TB), another health epidemic. Armenia has one of the highest rates of multi-drug resistant tuberculosis in the world, with a correspondingly low overall treatment success rate of 79%.

Raffi reached out to Dr Karapet Davtyan, who worked in Armenia’s National Tuberculosis Control Center (NTCC). Dr Davtyan welcomed the 17-year-old to his internship programme at FMD K&L Europe Inc., a global contract research company that supports public services. The NTCC manager provided Raffi with access to their country’s data on tuberculosis and Dr Davtyan suggested he try a new electronic version of TDR’s SORT IT programme.

Online SORT IT training provides key resource

Dr Davtyan had taken the SORT IT training a few years earlier and gone on to become a trainer in his country. The course consisted of 3 weeks of customized training that helps disease control officers learn how to identify operational bottlenecks and test new solutions or approaches. The training takes place over a 9 month period, ending in the submission of a research paper.

Recently, each of the 48 lectures that form SORT IT had been video recorded and published online with the associated PowerPoint slides so that anyone could learn this process online, at their own speed and from wherever they were.

“I watched almost every one of them, and some of them more than once,” explains Raffi. “It took a while since these were new concepts to me.” This would probably be an understatement, since Raffi had no scientific, medical or public health background, only the motivation to make a difference.

New evidence for country policy-making

Through occasional checks with Dr Davtyan, Raffi managed to complete a full research study in 2 months and then entered the peer-review process. Five months later, Raffi was published in Elsevier’s Journal of Tuberculosis and other Mycobacterial diseases.

Using 2014 national data from all TB facilities in the country, he found that people who smoked during TB treatment had 1.61 higher odds of having an unsuccessful TB treatment outcome. In the article, he highlights the necessity of having specific restrictions and campaign programs to reduce smoking rates among TB patients. The study was reviewed by the national TB programme, and is being used to consider public health policy changes.

Raffi Balian
Raffi Balian using e -SORT IT

“Before Raffi’s study, we had no data on this issue, so he has filled an important gap in our evidence base,” points out Dr Davtyan. “I’d also like to reinforce that his use of this e-version of SORT IT shows that it is a skill that is completely adaptable to anyone’s background and interests.”

Armenia now hosts classes online via Skype to provide further support beyond the video lectures, and Dr Davtyan is looking into translating the videos into Armenian and Russian.

“This e-version of SORT IT allows full-time professionals to learn this new skill in a more flexible way, without having to spend weeks away from home,” he explains. “This allows more people to do it, at much less cost overall.”

Dr Rony Zachariah, TDR’s SORT IT coordinator, reinforces this: “We are delighted to see SORT IT evolve and be implemented in many different forms. This makes it a dynamic process that responds to patient, institutional and country priorities.”

Raffi Balian is now a medical student at Boston University where he is studying biochemistry and molecular biology. The SORT IT training has given him valuable experience as he gains further education and decides where to focus his next commitments. TDR looks forward to following this dedicated young scientist.

For more information, contact Dr Rony Zachariah