Friday, June 28, 2013

Field Visit to Bihar - Day 1-2

This week, I am on my first field visit to Bihar, to better understand the Kala Azar situation here, to meet the Hub Team who work on the two Gates Foundation-funded programs, Integrated Family Health Initiative (IFHI) and Strengthening Kala Azar Elimination Programme (SKAEP), to meet the district-level implementation teams, and to see patients, doctors, quacks, and other people involved in diagnosis and treatment of KA.

I am here with my counterpart, Clara, who comes from GlaxoSmithKline Pharmaceuticals (GSK) - she is part of their PULSE Volunteer program, very similar to our Global Health Fellows program, and she has 30 years' experience in laboratory and clinical research (much of it in infectious diseases) to draw from, complementing my market research and strategy experience well.

We arrived in Patna on Monday evening (it was about a ninety minute flight from Delhi), and went into the CARE IFHI office on Tuesday. We had the full day to meet the SKAEP program team, hear about their progress on studying Kala Azar here in Bihar to date, and discuss how Clara and I might be able to help them better understand how private treaters (especially quacks) figure in to the equation - as well as how they might better be part of the solution for the elimination of kala azar.

The CARE District Office for Patna
Wednesday was our first foray into the field here. We started early, traveling first to the District Office that serves as the base of operations for the team that works here in the Patna District. The team includes a Regional Manager (named Sumit Kumar), a Regional Outreach lead (Jasprit Mahal), other technical colleagues, administrative workers, and Link Workers (there are about 60 link workers - who actually do the bulk of the work on the ground - in Patna District).

Clara (2nd from left) and I with Ishani (2nd from right)
 from the IFHI Hub and the Patna District team

We talked about the research that we are hoping to do, and how it might be complementary with what they have been doing, and they offered some great suggestions on how best to accomplish it.

Sumit and Jasprit, plus Ishani from the Patna IFHI office (whom we met on Tuesday) then accompanied us to a rural hospital in Patna District, at the village of Bihta. There we also met up with one of the link workers, Anil.

The facility is what they call a referral hospital - it is a public primary health clinic, where patients who can't be served at by more basic facilities can get treated for most illnesses - including KA.
Bihta Hospital - a public referral center
Outside Bihta Hospital

With CARE Link Worker, Anil (next to me) and the
health inspector and Medical Officer from Bihta Hospital
We met with the Medical Officer In Charge as well as the Health Inspector for the district, and asked questions about Kala Azar in the area.

The told us that so far this year, they have only had two KA cases referred to them (this is a relatively low-incidence area, apparently), and only 8 in 2012 - and they serve an area that includes about 250,000 people. This seemed quite low, but they explained that some patients are treated at lower level facilities sometimes, and others are referred by public or private doctors (or quacks!) in their area to higher-level institutions as well, so they just happen to get a few now and then.

The doctors were generally knowledgeable about the disease. They have been treating KA patients with a relatively new drug, miltefosine. Why? Because a) it is easy to administer - it's an oral pill taken every day for 28 days, and they can simply send it home with the patient, and b) because it is provided free of charge by the government.

But when I asked about one of the newer effective treatments (Liposomal Amphotericin B), they apparently had not heard that it has been used successfully, despite the fact that the World Health Organization (WHO) guidelines include it as a first-line drug of choice!

Liposomal AmpB has been shown to cure KA in 95+% of patients with a single dose (similar to miltefosine's cure rate), but with the added bonus that you don't have to be concerned with the patient forgetting or refusing to take all his or her pills. You can also combine it with a week's worth of miltefosine, which cures at about a 99% rate (shown in recent clinical trials), with less concern about resistance developing to either drug.

I guess there's still a long way to go to figure out the best way to treat KA - and part of the issue is availability and/or cost of the drugs.

Anil - outside Dhanare Chak schoolhouse
After our discussions at the Hospital, we parted ways with Sumit and Jasprit, while Ishani, Clara, and I were led by Anil to a tola, or small community, where he had heard of several recent KA cases.

This tola, called Dhanare Chak, is a community of Musahars, who are the lowest ranking group within the lowest caste (Dalits, or Untouchables) in Indian society.

"Musahar" means, literally, "rat-eater." Indian sub-castes often got their name from their occupation, and Musahars were originally employed to work in agricultural fields to root out an eliminate rat or mouse burrows; as food was extremely scarce, this also became a source of food for them as well. While today the Musahars are often agricultural day laborers instead, they still are extremely poor, almost all illiterate, and they are often shunned from society in general. Malnutrition, diarrhea, worm infections, and fevers are all part of their daily life.

This tola comprised of families living in a combination of "kuccha houses" - dwellings made of mud and straw - and "pucca houses," which are made of brick and/or cement, and may have been provided to them by the Indira Awaas Yojana, a government program which builds the pucca houses for the Musahars and other backward castes and tribes.

As one key element of controlling kala azar is trying to eliminate breeding habitats of the sand fly which carry the parasite, I took a quick look around. Some of the hallmark sanitation problems were present here; livestock were walking around freely, and some of the buildings looked like combined dwellings for people and animals (which are prime breeding grounds for the sand fly). In addition, most of the dwellings were patched up with cow dung - obviously a free material they can easily obtain and stands up to rain better than plain mud.

Ishani speaking with the people of Dhanare Chak
We asked about the Indoor Residual Spraying program the government funds twice a year. This tola was sprayed as recently as March 2013. However, the villagers - not truly understanding the value of spraying their homes - said they disliked the smell of the insecticide, and often went right around behind the sprayers, covering the sprayed walls with cow dung, completely defeating the purpose altogether.

Two of the women from the tola were kala azar patients in 2012, and were cured through getting treatment from the local primary healthcare center; they had been identified by a local Accredited Social Health Activist (ASHA), who are public health workers who live locally. While ASHAs are primarily focused upon maternal and infant care, they are often enlisted by the government and NGOs to help with other issues like kala azar detection. Last year, these two women were brought by the ASHA to the healthcare center, properly diagnosed with KA, and were given miltefosine (they said they both took all their pills, completing the full treatment cycle).
Above and below - Two former
 Kala Azar patients - who
 think they  may be re-infected
They were also both currently ill, however; and they both said that they though they had KA again (which typically does not happen - relapse is rare). One went to the healthcare center recently, but said she was turned away, being told she "smelled." Unfortunately this kind of treatment of Dalits is not uncommon, despite the fact that discrimination based on caste is illegal. The link worker, Anil, will follow up on this and see if he can get her properly diagnosed.

Overall, the villagers were quite interested in talking about kala azar - we attracted quite a crowd! - and helped us to better understand how and why many KA cases can go undetected - it was a long journey by foot to reach the local health center, and of course KA is one of many diseases that these people suffer through year after year. In addition, the discrimination experienced at the public health center perhaps is part of the reason that villagers might turn to unqualified providers - quacks - instead.

We attracted quite a crowd

Group shot with most of the tola dwellers
Speaking of quacks, we next traveled to try to visit a few. Quacks run small shops where people can get some of their basic needs attended to - help with minor wounds, and treatments for the fevers and diarrhea that are so common here, etc.

Unfortunately, we seemed to have tried during the wrong time of day, and our first couple of attempts to see a quack were unsuccessful (we at least got a look at one office, but the quack was not around), so we tried instead to check out a rural diagnostic lab that Anil had heard about. We found the lab tuck back behind some open shops off the main street through a village.

Bustling village street - off to find a diagnostic lab!

The lab turned out to be a little open booth with a desk and a few medical supplies, with an enclosed room behind it, and another (labeled "Biochemistry Lab") across the lane from it.

Like most people we've encountered, the technician who ran the lab was very happy to talk to us (and, like in most places we visited, we drew a crowd). 

Technician running
 the little diagnostic lab
It turns out that this lab actually did handle diagnosis of Kala Azar - and in fact he had a couple of of the rapid blood test strips (both negative) right next to him on the desk! I asked him if he took a simple blood sample from a patient's finger to do the test, and he said no - he actually draws whole blood from the arm, then pointed to a vial of separated blood, indicating he uses serum only. This made me scratch my head, as to separate blood, you have to have a centrifuge. I asked "Centrifuge?" and he casually pointed over his shoulder at the door behind him. I took a peek inside, and he did indeed have a centrifuge - an expensive piece of equipment which I didn't expect to find on this poor rural street! 

He then took us the the "biochemistry lab" across the street - which was a (roughly) 8x8 room with expensive pieces of machinery to perform blood analysis and a computer - a pretty nice setup in such a small space! It was the only place we found air conditioning since we left the city.

Negative rK39 kala azar test!
CBC machine!

The technician explained that several of the private doctors in the area - we weren't able to really ascertain whether that included quacks - refer their patients to him to get properly diagnosed for kala azar; if he felt patients were very poor, he would accept the usual charge of 300 rupees (about $5), but then give them back most of it, keeping just enough to cover his costs for the test. He was very proud of his little shop - and we were quite impressed.

 We turned our attentions again to trying to find a quack - and we struck gold, finding three of them, all on the same road, not too far from the tola we had visited.

The first quack we were able to meet - this little
 shack has been open for business since 1982.
A line developed while we interviewed the quack -
 the little girl on the left had an upset stomach, and the
little one sitting on the right had a fever

The first quack had been running his office for over 30 years; he said he serves people from two villages, and everyone knows him because he situated his shack very close to the market (location, location, location!). He was well aware of Kala Azar, as he had previously worked for a well-known doctor as a compounder (preparing medicine mixtures, etc.), and learned about KA through this doctor. However, he rarely sees kala azar patients; he would identify them because of a persistent fever, enlarged spleen, and sometimes blackening of the skin (all actual symptoms of KA) - and would refer them to a private pathology lab to get diagnosed with a blood test, or would otherwise send them to Patna Medical College Hospital, a high-level public facility that would be able to handle the disease. And while he had the ability to give patients an IV or obtain some medicines from the local pharmacy, he wouldn't attempt treating KA.

Predictably by this point, a  crowd developed at the quack's
office as well. These young men wanted to see their picture
after taking the shot.  
The other two quacks were a bit different. Both were younger (one had 6 years' experience, one 16), and neither knew so much about KA. They both said that typically if they had a fever that resisted treatment, they would simply send patients to the hospital.

Quack #2 - just next door to quack #1. This was pretty much
 the extent of  his "office" - the back of the space was covered
by the tattered blue medical curtains behind him

Despite their at-least-basic understanding of medicine, we could see the kind of facilities within which quacks operate here; most of the facilities were old, with dirt floors, no front door, full of flies and other insects (such as the occasional trail of ants). We saw a wooden plank that served as an exam table (and hopefully NOT, we hoped, an operating table!) in one office, but mostly patients sat on benches to be examined.
Quack #3 in his office
Outside the quack's shack

Overall, it was clear that their long-standing presence in the community and their willingness to see anyone were the reasons villagers often went to quacks first rather than to the cold, sterile facilities that the government centers might represent to them.

 These discussions helped Clara and I to better understand how we could engage the quacks for our study, which questions we should ask, and how we might come to an understanding of how the quacks might become an integral part of achieving KA elimination - namely by educating them to think about KA more often and consider it a likely cause of long-lasting fever.

As we drove back, we drank in the sights in rural Bihar - bustling village markets, green farms, cows, goats, pigs and chickens everywhere, and so much life!

A typical scene driving through the village
Monsoon happens

Snack vendor and his cute little kids, on the village road

Next - a visit to the Patna Medical College Hospital!

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