Thursday, August 1, 2013

Day 2 of Gopalganj Field visit; RMRI; Malda

Day 2 in Gopalganj

After night in a hotel in Gopalganj (I think they charged me extra for the small furry "guest" in my room - perhaps named "Mickey?") we set out for a second day of field work in the District.

This time, we again joined Atul, the local CARE Link Worker, and visited a Block called Barauli, starting with its Primary Healthcare Centre, which is just about 13km from the one we visited in Manjha. Unlike in Manjha block, the Indoor Residual Spraying (IRS) spray workers were not on strike here, and had completed spraying of homes this Spring.

They had treated 71 cases of Kala Azar over the past twelve months, with 29 since January - a number that has been decreasing (again, attributed to the effectiveness of the IRS campaign).

With the doctors of Barauli PHC
In Barauli PHC, the doctors first rule out malaria and typhoid, diagnose KA with the rK39 diagnostic test strips plus a clinical assessment, and then dispense the government-provided miltefosine for free to those who test positive. They mentioned that they sometimes have the ASHAs (see last post) distribute the meds and report back to the PHC doctors when dosing is complete.

The line was very long at the PHC...
When we probed a bit on the apparent issued we had heard about from the Tola yesterday (namely, discontinuation of treatment due to vomiting), the medical officer said that they would not reduce the dose, but if a patient came to them complaining of such a side effect, they would give them something (in this  case, an anti-emetic) to help them tolerate the medicine better.

...with lots of people waiting outside
The doctors here also told us about some of the educational efforts that they had organized to teach people on the villages about KA, and how to prevent it, which included informational sessions about how to recognize the symptoms of KA (long fever unresponsive to treatment, inflamed spleen), and where to go (the PHC!) if they suspect they might have KA.

This PHC - which was small, but tidy, serves 300,000 people! This helped explain the long lines of people outside waiting to be seen. Although they seem to be trusted and known for good service, it was easy to see why some patients might prefer to go to a untrained provider (quack/Rural Medical Practitioner) to avoid the waiting times.

We next drove over to a nearby tola, called Kahala, to meet with a Kala Azar patient named Mira.

Ishani, right, interviewed Mira, center
Mira is an anganwadi worker. An anganwadi is sort of like a government care center that focuses on health and child and maternal care, with nutritional and contraceptive counseling for mothers, and serving as a day care for children too young for school (the term means "courtyard shelter").

Adorable kids at the anganwadi

As her day-care kids sat by (remarkably well-behaved - and very cute!), Mira explained to us that she had once seen some KA educational material in a public hospital office, and had remembered it when she started developing the symptoms. She had gone to the PHC we had just visited, but had had some side effects from the miltefosine they had given her. Unlike the people we'd met in Dhai tola yesterday, rather than seeking help from a private doctor, Mira went back to the facility in which she'd seen the KA material, in Hajipur, near Patna, which happens to have a KA program run by Doctors without Borders. There, she received Liposomal Amphotericin B, which may be the best-tolerated new, effective drug for KA, and was cured.
All the people behind Mira have PKDL - she is sending
 them to Hajipur for treatment
She mentioned that many people in this area are afflicted with KA or Post-Kala Azar Dermal Leishmaniasis (PKDL - see last post), so she sends them to Hajipur to get treated there if they have trouble with the medication they get from the local PHC.

Interestingly, she said the villagers here in Kahala had welcomed the IRS sprayers. They understand the major problem that KA represents, and were happy to accept any help in controlling it. This attitude was similar to that of the people of Dhai yesterday, who had gone years without a spraying campaign, but would eagerly accept it if it meant less KA.

After thanking Mira for the time away from the children, we stopped by a nearby RMP (quack) office - a large hut with a couple of rooms, more spacious than those we'd visited in the past.

Our very experienced RMP
The quack said he had been a practitioner here for 44 years, and knew everyone in the three or four villages he serves. He didn't have any current KA patients (that he knew of) - a good thing, as of course RMP's should not be treating KA! HE said the number of cases has been going down, as (he thought) both "natural" (cyclical) reduction had been occurring, and the IRS had been working.

We asked him about how he manages a patient with a fever. He said he starts with some indigenous-medicinal methods (go home and wash their head, I think he said?), or prescribes paracetamol (a mild analgesic). After a few days, if that does not work, he sends them on to the PHC. We wish we heard more of this sort of response from other quacks! Ideally, patients would quickly get moved on to the PHC if they have an unresponsive fever, as it usually means malaria, typhoid, or KA.

Of course, he said he also sometimes sends the patient to a private doctor, if they request to do so. He was aware, though, that the PHC offered free medicine, so preferred to send people there. He had, he said, administered some injections of sodium stibogluconate (SSG - what the patients from Dhai had been prescribed by the private doctor) for some patients last year.

We moved on to visit another patient, and older gentleman who actually had had KA ten or eleven years ago, and now had PKDL. He sat us down and served us some hot chai and some snacks, and then showed us the PDKL lesions across his arms and neck.

PKDL lesions
We asked him what he was doing for treatment, and he said he had been seeing a Homeopathic doctor for three years, to no avail (unsurprisingly). Like all of the other patients we'd seen with PKDL over the past couple of days, he said he'd had SSG treatment for KA, which, at the time, was the only available treatment.

While we were speaking to the gentleman, a family with a young boy came by. The boy was nearing completion of a course of miltefosine capsules, which they had obtained from the PHC after seeing a quack.The boy's father mentioned that he had been away earlier this year, at the time the IRS sprayers had come through his village. As his wife had not been made aware of the reason for the DDT, she immediately plastered over the walls after the spray team had left.He said if they had been properly educated about KA and the IRS campaign, they would not have done so.

Overall, we found a lot more evidence of the fact that the RMPs/quacks were able to grasp the seriousness of KA, and what to do if they suspect a case - if they are properly educated about it. In an area like Gopalganj, with a much-higher incidence of KA than the districts we visited on our first field visit a couple of weeks ago, the quacks seem to already understand all of this, though of course the more education that is available to them, the better.

We also learned that there seem to be several gaps in the effort to eliminate Kala Azar:

1) The IRS process can be effective, and may even be welcomed by the villagers - but only if efforts are taken to ensure that all villages are thoroughly sprayed, and that people are properly educated about why the spraying is necessary and what they should do before and after the spraying occurs.
2) PKDL is starting to become better-recognized (and we saw evidence of it being treated by the PHCs) - but there are still lots of cases of PKDL around that are as-yet undetected by the public system. Lots of education here is necessary as well.
3) Patients who receive miltefosine, which is the only medicine provided by most PHCs in Bihar, sometimes react badly to it and discontinue its use. If that happens, care must be taken to provide a better alternative to SSG - which doesn't always work, is toxic, and often results in PKDL. Amphotericin B, especially the safer and more effective Liposomal variety, should be made widely available as a second-line treatment, if not first-line.

Lots of work to do for CARE!!
With Atul


The day after returning from Gopalganj, we went with Ishani and our team lead, Dr. Indranath, to Rajendra Memorial Research Institute in Patna, which is a widely-known facility that specializes in Neglected Tropical Diseases, especially Kala Azar.

Patna CARE team members with Director Das of
 RMRI and some of his team
RMRI is and has been conducting many of the research studies into different medicines to treat KA, different diagnostic tools and methods, the effectiveness of IRS, life cycles of sand flies and effective means to control KA transmission, and all the other aspects of KA management in India. Their studies include the full range of new medicines for KA (miltefosine, paromomycin, Liposomal Amphotericin B, etc), new products under development, and even potential vaccines for KA. They are also devoting a significant amount of effort to researching PKDL.

We met with the director of RMRI, Dr. Pradeep Das, as well as some of his key staff. They gave us a tour of the facility - which includes a KA ward, where patients who are part of their clinical trials are treated, and a sand fly research wing where they breed the insects for study. They also conduct training programs for doctors and government field workers like ASHAs.
We got to see sandflies here

We spent a little time in the KA ward speaking to a few patients. We heard the very sad story of one woman who had been on ineffective treatments for four months before reaching RMRI, losing a baby along the way.

KA ward at RMRI

Another young woman from the highly-endemic district of West Champaran was being treated after over a year, at a cost of thousands of rupees, on ineffective fever treatment by quacks and private doctors. Interestingly, she and her fiance seemed relatively well-to-do, in sharp contrast to the poorest-of-the-poor Musahar villagers we had seen last month. They had never heard of Kala Azar before this.

A third patient - a young man from another highly-endemic district, Vaishali - was being treated for PKDL. He had been sent here from the district hospital in Hajipur, which we had heard about from the anganwadi worker the previous day.

I was glad to see so much effort devoted to Kala Azar here - the top-notch research will undoubtedly save many lives in the coming years, and hopefully will eventually result in better ways to manage KA patients as well as better preventative measures.

Malda, West Bengal

Sunset on the way to Malda
After a great week in Bihar, we traveled to the neighboring state of West Bengal. We stayed the weekend in Calcutta (pictures later!) and took the train on Monday up to the district and town of Malda.

Malda is another highly-endemic district for KA, close to the Bangladesh border. While West Bengal has fewer overall cases than Bihar, and fewer endemic districts, some parts of the state between Bihar and Bangladesh, like Malda, have a high incidence.

We had to opportunity to travel around with Dr. Indranath and a cadre of representatives from the World Bank, the Government of India, and Government of West Bengal, in a review of the progress made in their elimination efforts.

During the course of the day, we visited several public health care facilities, including PHCs, Health Sub-Centers (HSCs) and a Medical College Hospital, as well as a tola to visit KA patients.

Most of the conversation was in Bengali, but we had plenty of translation from Dr. Indranath and some of the officials.

In our first stop, Moulpur Block's PHC, we heard that while a couple of years ago there had been shortages of miltefosine for KA treatment, now supplies were pretty steady, and they generally had enough to treat patients, with only the occasional stockout.

They have been getting quite a few KA cases as well as plenty of PKDL - it is good to hear that they are fully cognizant of the problem here as well.

We had to crowd into the Medical Officer-In-Charge's office - we were a party of about ten!

Outside the little HSC
The ANM in charge explained the function of the HSC
as it relates to Kala Azar treatment
After a tour of their facilities, we headed over to a nearby HSC. The sub-centers are usually simple, small houses built to receive and help pregnant women, young mothers, and their children through childbirth and early childhood care (nutrition, vaccines, etc), although they also serve as educational waypoints to communicate critical information about infectious disease like KA, tuberculosis, and malaria.

Kala Azar prevention poster inside the HSC
These centers are too small and ill-equipped for delivery of babies, but this typically happens in the home anyway, as most expectant mothers would be hard-pressed to secure transportation over rough roads to the nearest hospital (although of course there are always exceptional cases).

The head of the HSC is the Auxiliary Nurse-Midwife, to whom the ASHAs report. We had the chance to speak with the ANM and two of the ASHAs here. They explained how they are responsible for Directly-Observed Treatment for KA patients - basically, they travel to the patients' homes (or have the patients come to them, if possible) to watch them take their miltefosine capsules, to ensure compliance with the prescription.

We saw that there were some posters on the wall for educating locals about Kala Azar. Dr. Indranath suspected that at least one of them was put up for our benefit, but another looked like it had been on the wall for some time.

We then traveled to a nearby tola, to meet another young boy and his family. The home was a bit off the main road, so we left our cars and hiked a bit down a narrow lane to get there.

It was a bit of a hike to the patient's house!

When we arrived, he was actually away from the house, giving a bath to the family's buffalo - great to hear that he was feeling well enough to be out and helping the family!

While we waited for him to return, we had the chance to look around the tola a bit.Once again, we found mixed-material homes, with straw and mud predominating, but some concrete and some corrugated sheet-metal roofing. Plenty of livestock lived there as well - a few pigs were tied up between the house and a pond, and we had to dodge quite a few cow-patties along the lane.

Speaking with Deepak

The boy, named Deepak, eventually turned up, and the doctors had a nice conversation with him. He is 10 years old and not at all shy; he told us all about his treatment (with SSG, unfortunately - he was kept at a nearby hospital for the injections as an inpatient), and shared the little he knew about his illness. He was indeed feeling much better, and went off to play with his friends as we left.

We stopped by another PHC in nearby Gazole (pronounced "Gah-jole" - z's are pronounced like j's in Bengali) Block, in Hathibari village. We learned that this small PHC serves a whopping 400,000 people, and covers 66 HSC's.

Outside Hathibari PHC
Here we found a pretty nice system of record-keeping, as pictures of the referring ASHAs were stapled to the patient's records, which made it easier to keep track of those ASHAs who were owed incentives for referral. You see, ASHAs are not paid a salary, but instead are paid incentives for helping patients and expectant mothers.

We went to one of the Hathibari HSC's next, the Adina Sub-center.
We crowded into the tiny HSC

While we were there, a two-year-old patient and his parents dropped in for his injection of SSG for KA (miltefosine is a teratogen - it causes birth and growth defects - so is not prescribed for pregnant women, women of childbearing age, or very young children). Unfortunately, amphotericin B, which would be a much better alternative to SSG< was not available for him.

Little James with his mother
The little boy, James, belongs to one of the tribes who live in this area (he has a Christian name as he belongs to a family that had been converted to Christianity by missionaries here). He is from a remote village, Manglapara, which is about 12 km away from the PHC, and inaccessible by four-wheeled vehicles; he was brought in by motorcycle. James lives in a home with a couple of other families, and all three other children in the home had kala azar.

He had suffered from fever for about four months, treated by a quack, before he finally was taken to the PHC and received his prescription for SSG. He was pretty unhappy to be there - the ANM told us that he actually missed one of his injections because he "ran away!"

We concluded our day then - taking an overnight then back to Calcutta, and then a flight to Delhi. It was interesting to see the contrasts and similarities to what we had seen and heard in Bihar. In some places, it seemed like a lot of progress had been made to combat the spread of KA - and awareness of the disease was high among villagers. In others, KA still seems to be relatively unknown.

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