When USAID funding for ACCELERATE 1 ended abruptly, years of work bringing TB screening, diagnosis, treatment and prevention closer to vulnerable communities in South Africa’s Eastern Cape came to a sudden halt. Dr Priashni Subrayen reflects on what was lost, what happened to patients and staff, and how an unexpected lifeline allowed a smaller team to return through PRO-TB and begin rebuilding what had been interrupted.
When statistics became personal
I have worked in TB for more than 15 years. I understand the statistics and the language we use: cases detected, people started on treatment, treatment coverage, loss to follow-up and mortality.
But there are moments when those words stop being statistics. The termination of ACCELERATE 1 was one of those moments for me.
ACCELERATE 1 was a large USAID-funded programme, but what mattered to me was what it looked like on the ground. Our teams were taking TB services to people who might otherwise never reach them, while helping to strengthen health systems across different levels of care.
Our digital chest X-ray trucks travelled into communities. Community health workers went door to door. We traced household contacts, collected sputum, linked people to diagnostic testing and helped those diagnosed with TB start treatment. We also identified people who could benefit from TB preventive treatment.
We were trying to close one of the gaps that has frustrated me throughout my career: we know how to diagnose and treat TB, but too many people are still diagnosed too late simply because the health system does not reach them soon enough.
By the time ACCELERATE 1 closed, approximately 2,880 people had been initiated on TB treatment and 8,250 on TB preventive treatment.
When the funding stopped
Then the funding stopped. The instruction was immediate, but the consequences could never be. TB does not stop because a project stops.
A person halfway through treatment still needed medication and support. Someone developing symptoms still needed to be found. A child living with a parent with infectious TB was still exposed. And the person who could not afford transport to a clinic still had that same barrier the next morning.
That was the hardest part for me. As a project director, I understood that funding agreements can end, even unexpectedly. As a doctor, it was much harder to accept that services could disappear while the disease continued exactly as before.
There was also the impact on our staff. ACCELERATE 1 had built teams who knew these communities and had relationships with clinics, community leaders and patients. Many had organised their lives around this work, with families to support, rent to pay and commitments made in good faith.
“What happens to the people we were caring for?”
Suddenly, we were no longer discussing how to find more people with TB. We were discussing how to close a programme. Vehicles stopped. Teams were dismantled. Staff left. Systems that had taken time to establish began shutting down. And behind every operational decision was the question that troubled me most: What happens to the people we were caring for?
We tried to transition patients into routine services, but anyone who works in public health knows that referrals are not the same thing as continuity of care.
A second chance to rebuild
For a period, I thought that was simply where the ACCELERATE story would end. Then something unexpected happened.
A donor who understood the urgency of what had been lost offered Aurum the opportunity to restart some of the highest-impact work in the Eastern Cape. That became PRO-TB.
I remember the relief of knowing we could go back. But returning was bittersweet. We could not recreate ACCELERATE 1 at its previous scale or simply switch everything back on. People had moved on. Teams had dispersed. Community relationships had been interrupted. Operational systems had to be rebuilt.
So we asked ourselves a different question: If we have another opportunity, what are the things we absolutely must restore first?
The answer was the work that brought TB services closer to people. We returned to Nelson Mandela Bay and Sarah Baartman districts with two digital chest X-ray trucks. We restarted community screening, door-to-door visits, household contact tracing, sputum collection, links to testing and treatment, and TB preventive treatment for eligible contacts.
I am deeply grateful that PRO-TB gave us the opportunity to return. Without that support, many of these services would simply not have resumed. But gratitude should not stop us from learning from what happened.
South Africa cannot build its TB response on the assumption that external funding will always be there. At the same time, we should not underestimate what carefully targeted donor funding can achieve when it strengthens the health system rather than standing apart from it.
PRO-TB has given us an unusual opportunity to think about both. We are showing what is possible when screening and diagnosis move into communities, while asking which parts of that model can be simplified, integrated and sustained within the South African health system.
For me, however, there is an even more basic lesson. During the shutdown, I learnt how quickly something we had spent years building could disappear. During the restart, I learnt something else: how quickly people will come together to rebuild when they believe the work matters.
Our teams came back. Our partners came back. Our communities opened their doors to us again. And our trucks started moving again.
I sometimes think about the people we did not reach during the months when those services were absent. We will never know all their names or what happened to them. That is difficult to sit with.
But it also gives me a very clear sense of responsibility for what we do next.
South Africa still has an enormous TB burden. Somewhere today, someone has TB and does not yet know it. They may feel well. They may not have money to travel to a clinic. They may struggle to produce sputum. They may simply believe TB is something that happens to somebody else.
Our job is to find a better way to reach that person.
“Our teams came back. Our partners came back. Our communities opened their doors to us again.”