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).

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! 

Centrifuge!

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!

"Girl Rising" India premiere

In the midst of a busy week of research, I was invited by CARE to attend the "Girl Rising" Premiere on Tuesday evening.

The event was focused upon calling attention to the continued efforts to empower women in India. As I've mentioned in previous posts, India is truly a nation of contrasts when it comes to gender equality - in a place where women have served at the highest levels of government, as beloved leaders, and where mothers are revered by their sons, there is still an enormous level of inequality in even basic social constructs.

And while you see modern, educated women everywhere in the major cities, in leadership and managerial roles in companies large and small, you also have millions of women unwilling to leave their home for fear of harassment on the street - or worse. Sexual assault and rape are far too common.

Ms. Srinivasan

The program opened with a presentation by the President of Intel India, Kumud Srinivasan. She highlighted the work in the corporate and development worlds that has been underway to try to address this inequality.

Ms. Bhan moderating the panel

Afterward, CNBC anchor and Delhi Bureau Chief Shereen Bhan moderated a panel discussion including CARE's own Andrea Rodericks and other NGO Executives about the work they are doing and their perspectives on progress in gender equality. There was overwhelming agreement that the single most important factor in bridging this divide is through educating girls.

Panel discussion - NGO executives. CARE's Andrea
Rodericks is on the far left.

Ms. Bhan interviewing Ms. Ghosh

Ms. Bhan then conducted a one-on-one interview with Debjani Ghosh, who is Managing Director for Intel South Asia, focusing on what it takes to succeed as a woman in this region, and what still must be done to empower more girls and women to take leadership roles.

Ms. Pinto introducing the film

Freida Pinto, the lead actress from "Slumdog Millionaire," introduced the film. Ms. Pinto has been a strong and active voice for gender equality in India, and played a pivotal role in bringing the film here. She gave a moving speech about the enormous return that investment in girls' education can bring.

Mr. Robbins, director of Girl Rising

She introduced Richard E. Robbins, director of "Girl Rising," who explained his thoughts behind creating such a film to highlight the plight of girls in impoverished countries, but also show those who have fought the odds and found a path to education - or who are still fighting that fight.







Each segment was written by a female author from each girl's home country, in partnership with the subject herself, and narrated by famous actresses like Meryl Streep, Anne Hathaway, and Cate Blanchett.

Opening scene of Girl Rising - featuring Sokha, who had
worked as a garbage picker at a dump in Cambodia as a little girl, before
finally going to school - and becoming a star pupil 

The film was truly moving. These girls struggle in a way that it is impossible to fully understand for one brought up with the privileges that birth in a developed country like the US can bring. One particularly heartbreaking story was of a young girl in Afghanistan struggling to be educated - yet was married to an older cousin at 12 and became a mother at 13. In another story, a family in India stays in Calcutta despite losing their home, just so their children can stay in school - something that would not be possible if they returned to their native village.

CNN has picked up the film and aired it in the US and Internationally already. Viewings can also be arranged via the website GATHR.

I highly recommend it!

Post-film reception - with information booths from the
NGOs who took part in bringing the film to life

After the film, there was a small reception/dinner. I had the chance to meet Mr. Robbins, and thanked him for creating such a beautiful and meaningful piece of art.

Second week of work and other matters

Happy Fathers' Day to all the dads out there. I'm missing my stepfather, Earl, today, but luckily caught him and Mom on Skype this morning!

So - two weeks down now with CARE, and I feel like I'm finally getting up to speed here.

I've been devoting much of my time in the office to learning about the Indian public and private health care systems, more about the disease, Kala Azar, and planning my research study and my first visit to Bihar state and the Patna CARE office.

The really fascinating thing about all of this is the Indian health care system. You would think in a country with so much poverty (and I'll provide some stats about this below), if the government offered free or low-cost diagnosis and treatment for a deadly disease, everyone would take advantage of it - perhaps subject to limitations of travel, communications about what is offered, etc.

A Primary Health Centre

But in this case, many people in the villages in places like Bihar are reluctant to go to a public health center (which are mostly in the form of health sub-centers, which serve maybe 8 villages, or Primary Healthcare Centres/PHCs at the local level, where one center serves maybe 15-20 villages) and instead seek treatment from private providers - many of whom have no formal training (called "quacks" here!).

Quacks are obviously looked down upon by the qualified medical establishment and the government (some pose as real doctors, which is of course illegal) - but they actually serve an important role in rural India.

There are a lot of factors that play into this.

First, the government sub-centers (which are really built around maternal and newborn health, staffed with a nurse-midwife) and Primary Healthcare Centres have a reputation for being in pretty shabby shape - the doctors stationed there are not always present, stocks run out of critical medicines, and often the key medicines are older treatments, not newer, innovative, more tolerable ones. So patients naturally are reluctant to take time from work and travel there only for what they expect to be sub-par care.

An example of a quack office

Second, as the majority of health-related issues that villagers face are minor infections and physical injuries, the local quacks are usually more than sufficient to help them for most of their needs - they usually can provide antibiotic shots (sure, not always the right one for the particular infection), set a minor fracture, clean and bandage wounds.

The quacks are usually someone who has built up a relationship with people in the community - sort of a step up from the traditional village healer. And while sometimes the quacks refer a patient to a PHC or district or state medical hospital if there's someone that they clearly can't help, they don't usually keep patient records, don't always do much (or anything) to follow up with patients, and may well miss the diagnosis.

So patients who seek the help of a quack end up being "invisible" to those researching how widespread the disease may be.

The problem that arises is with a disease like Kala Azar, which starts out feeling like malaria or a bad viral infection, with a fever which persists for more than two weeks, and doesn't subside if given more common treatments, including malaria medication. But many villagers are not aware of the other ways to tell when a patient has Kala Azar - there are a lot of misconceptions about the disease.

Kala Azar patient with splenomegaly -
 the arrows point out the enlarged spleen

Researchers have determined a fairly simple way to screen a patient for KA: along with the persistent fever, they can also feel the patient's abdomen to look for an enlarged spleen (a condition called splenomegaly).

Patients with the >2-week fever and splenomegaly can then be given a quick blood test - it can be done on the spot, with just a drop of blood from their finger, right in their home. If positive, they would normally be sent to a health center to confirm they have the Leishmania parasite - but most likely they do have KA.


And while the old treatments for Kala Azar were long-term IV drugs that were pretty toxic, there are now drugs which have been shown to cure the disease with as little as one injection, with a 98% cure rate, and with few side effects.

A single dose of AmBisome (liposomal amphotericin B) has
been shown to have a 98%+ cure rate in Kala Azar patients

As the sand flies that carry KA only have a life span of about two weeks, and as they need infected humans to spread the disease, KA should be one of the easier parasitic diseases to eliminate!

So, you might ask, why is it still a problem?

Mostly because almost all of the currently-trained medical providers are located in the afore-mentioned PHCs, or District or State-level hospitals - and they rely solely on "passive reporting" of cases - people showing up in their facility to be examined and diagnosed. Aside from the programs run by non-profit organizations or studies conducted by government researchers (which are all limited in scope), there is no mechanism to actively go out and find KA patients, and rapidly address the problem in the local community by spraying houses with insecticides, issuing bed nets, and educating other villagers about good preventive behavior, and what to do if they suspect they have KA.

And in the state of Bihar alone, there may be 100,000 cases or more in a year - and they are spread out among multiple villages in different districts (like our counties). The problem is immense.

So an approach is needed to not only find ways to reduce the sand fly population but to also make sure that KA patients somehow find their way to someone who is trained to detect the disease and can get them properly treated - and also to report this to a government office so that follow-up is possible and so local Social Health activists can scour the surrounding community for additional cases.

My project will be to work on the Private Sector side - to do research with the quacks, pharmacies (some patients go straight to the chemist when they are sick - and are given treatments which may or may not be for their illness), and other private health providers to determine what they know about KA, how patients tend to come to them, how they diagnose and/or treat the disease, and what happens with patients afterwards.

This work will better help CARE and others to understand how better to prepare local communities to identify when there is a case of KA and what to do should one be discovered.

As promised a few stats about Bihar:

• The state is less than twice the size of New Jersey - but has the population of the entire Eastern Seaboard of the US, from Maine to Florida - over 100 million people!
• Bihar is about 90% rural - the largest city, its capital, Patna, is only about 2.5 million people, and no other city is more than half a million in population.
• The per capita income for Bihar is about 13,600 rupees - about $240. Imagine trying to live on $20/month per person!
• Many villages have limited or no electricity, no paved roads, and are often affected by flooding and other issues.

I leave for a week in Bihar on the 24th - I should have more to report afterward!




Note: all pictures in this post were found on the web and reproduced without permission - I haven't been in the field yet! I do not own the copyright.