Tuesday, July 2, 2013

Visit to Patna Medical College Hospital

For the last of our Field Visits, Ishani from the Patna CARE Hub took us to Patna Medical College Hospital (PMCH). This public facility is considered one of the higher-level hospitals in the area, and it was mentioned by the Rural Medical Providers (quacks) as the place to which they would refer kala azar patients.

The initial impression was that it was a huge and sprawling campus, as you might expect in a city of 4.5 million people.

However, it was good that we had been prepped not to expect the kind of facilities that Clara and I were used to seeing in the US or UK.

Aside from a couple of security guards at the main door (who didn't require anything of us), there was nothing to stop us from going anywhere in the campus -  and no information desks or staff to ask for guidance on most floors.

It took a bit of searching for Ishani to find the Kala Azar Ward. It was in the Infectious Diseases Department of the hospital, across the hall from a tuberculosis ward. The ward was bare-walled, with peeling paint, no air conditioning (though it did have a functioning ceiling fan and windows – no screens).
PMCH sign for the TB (top line) and Kala Azar (second line) wards
 There was one kala azar patient in the ward, alone in a room of six beds. No staff were present, so we asked the man standing by the patient’s bed if we could ask him a few questions. He happily obliged.

As Ishani translated, we learned that the man was the patient’s father-in-law; though he lived about an hour (by bus) away from the patient, he felt obliged to take him all the way to Patna from his home in Arrah, which is about 60km away, as he wanted to ensure his daughter’s husband would survive the illness.
Kala azar patient Ram, resting in the ward
Looking into the KA ward
Speaking with Ram's father-in-law (left)... and curious
 visitors from the TB ward across the hall

The patient was a young man named Ram, who looked like he was in his late teens – and though his father-in-law said he was 25, his chart said 18.

These men were Musahars (the subcaste mentioned in my previous blog post), and were very poor. The cost to travel to Patna along with the expensive cost of the treatment - about 3000 rupees, over $50 - plus another 1000 rupees for various other expenses were a small fortune for them, and it had been difficult to raise the funds. The father in law had to go to the chemist himself to purchase the medication, and was also asked to purchase blood for a transfusion. Ram was in bed for the past few days, and had several more weeks of treatment to go.

We asked about Ram’s home; he lives in a mixed mud-and-brick home, probably similar to some of the ones we saw in the tola we visited the previous day. While he didn’t have cattle living in or near their shelter, he did have pigs (some of which he had to sell to fund this) – which would of course contribute to a better environment for sand flies to breed. He works in the fields of a rice plantation.

Ram had been sick about ten days with fever and a sore stomach when he first sought help from a quack. He was given treatment for jaundice and fever for two months, during which his skin turned black (as often happens with kala azar patients) before being referred to a private doctor and had gone through several more months of various treatments (no doubt at great expense) before being sent to PMCH, where he was admitted to the emergency room and was finally diagnosed, seven months after falling ill.

Neither Ram nor his father-in-law had ever heard of kala azar before this, and they didn’t know anyone else who was ill.

Ram was being treated with Fungizone, which is amphotericin B – not the Liposomal variety which is much less toxic - so he was being evaluated daily with blood and urine tests (and, we assumed, cardiac monitoring, though there was no equipment in the ward besides his IV infusion drip). He would be getting the medicine once every two days for the next month.

He was already feeling better, just a slightly tender abdomen, and his skin had returned to its normal color.
The doctors had not discussed much, if anything, with Ram or his father-in-law; they still had not been told his prognosis (which actually should be positive – now that he is on treatment, he should fully recover), details of the disease, or how to prevent it in the future.

Overall, we were left with a vivid portrait of a family who really had limited control over their own health needs, barely afloat in a complicated health care system.

After speaking with Ram and his father-in-law, we waited in the hall for a nurse to arrive, as heavy monsoon rains started outside along with some startling thunder. I noted that water was simply splashing in the sections of the hall open to the outdoors, as well as through open or paneless windows. Most of the lights were off, both in the hall and the wards, though a couple came on when it got particularly dark from the gathering clouds.

Heavy rains surprised us
Water flooded the hallway as we
waited for the nurse to arrive
As we were about to give up on our wait, we met the young Ward nurse coming up the stairs. Ishani asked if she would mind speaking with us and she answered something to the effect of “I have nothing better to do!” She made a very quick check in the KA and TB wards (everyone was comfortable), and led us to a small records room, where we sat to talk.

Talking with the Ward Nurse
She explained that her role was simply to check up on the patients, assist them in getting some exercise now and then, and take basic physical stats. The current KA patient was the second in the past month, and she showed us a handwritten record book that listed all the Infectious Disease wards’ patients for this year – apparently the only record-keeping system they had.
Looking through the
patient record books
We asked her to walk us through all the patients this year, and found that they had already had eight in 2013. I had expected that there may have been several patients from the same area, but almost all of them were from different Districts within Bihar. We then looked back over the previous two years and found they had just nine cases in 2011, and 12 in 2012. A few district names came up more than once, but there didn't seem to be much of a pattern, other than seasonality – the periods just before (April-May) and just after (September-October) the Monsoon season were the heaviest for KA cases. This was consistent with what I've found in the literature review I've been doing the past few weeks.

As many of the cases seemed to have been sent to the Ward from the ER, we decided to go there next, after thanking the kind nurse for her assistance.

The ER was quite an experience – many, many people crowded in the cavernous, dimly-lit waiting area, most of whom were standing or sitting on the floor. Queues to get forms and to get admitted into different areas of the ER were quite long. 

Outside the emergency room
We wound our way through the halls, asking directions from several people, before finding the right room, where a ER physician, Dr. Kumar, who would refer infectious disease patients to the Ward, was reviewing forms and directing patients on where to go next.

He handed his duties off to another staff member outside the room, and invited us to sit and talk.

When we started asking about Kala Azar, Dr. Kumar mentioned that he had studied under a quite famous authority on KA, one Dr. C.P. Thakur (I had read some of his work on the subject). He said KA was not a very common occurrence here recently.

A peek inside the ER

Here at the PMCH, they tended to diagnose the disease by the guidelines – looking for long-term, unresponsive fever and enlarged spleen, followed by the rapid diagnostic blood test (rK39) and then a splenic puncture to confirm the presence of the Leishmania protozoans. Importantly, they first would rule out the more common malaria and typhoid, as patients with these diseases often present with similar symptoms.

The treatment they usually used was amphotericin B, which the patient, Ram, was receiving. This was in contrast to the rural Health Center we went to the previous day, which used the newer treatment, miltefosine (which was being provided for free by the government there). Apparently the government programs are focused on the rural centers and not the larger district- or state-level hospitals; I will try to confirm this on my next visit to Patna.

Dr. Kumar said that kala azar used to be much more prevalent; in the epidemic of the early 1990’s, they would have as many as 400-500 KA patients in the hospital at a time (I wondered to myself where they would put all these patients, as the KA ward had only six beds – appropriate for today’s lower occurrence rate, of course).

I was very glad to hear of the declining rate of infection, but it seems this also presents some problems – KA is now rare enough that many have not heard of it (like Ram and his family), and many more do not know how to identify a potential patient (like the quack and the other doctors Ram had seen before arriving at PMCH, where trained physicians like Dr. Kumar know what to look for).


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