My Final month at CARE India

It's hard to believe, but my Fellowship is over. Five months in India, several field visits, lots of poring over research papers and textbooks, partnering with my GSK counterpart, Clara, to develop a research protocol and survey, working with my CARE colleagues in New Delhi and Patna to train interviewers, collect and translate and analyze survey results.

Since my last post, we've spent time planning our final presentation. We ran into a few delays due to the October holidays as well as the fact that the Patna team had to attend to a new round of Indoor Residual Spraying (IRS) to help control the sandfly population in rural Bihar. As such, the data analysis got pushed back a bit, and though we ultimately received some of the initial data, we are still awaiting the final analysis package.

This means that we should have a clearer picture about exactly how the private sector physicians and unqualified providers function in the diagnosis and treatment of Kala Azar soon. That said, we were able to give a well-received presentation to some of the program leaders in the CARE HQ last week - on my last day in the office - which encapsulated everything we'd learned to date, including a snapshot of my literature review in June, details of our field visits with anecdotes from patients and providers, an overview of our study goals and methodology, and some of those aforementioned early results to help explain what we've learned to date.

Overall, the data already show that the Unqualified Medical Practitioners (UMPs, or Quacks) do indeed play a significant role in Kala Azar diagnosis and treatment in the highly-endemic areas upon which we focused for the study. The early results showed that they sometime send patients to get tested for KA, they sometimes treat them as well (with whatever medicines they can obtain or can be arranged via a qualified doctor for whom they serve as assistants, administering the drug in or near the patient's home). We can see that the UMPs also have at least a basic understanding of the disease and its most common symptoms; this means that, with a little training, they might become much more able to quickly get affected patients to the proper care they need. And they were almost all willing to participate in a government- or NGO-led tracking program which would help focus elimination efforts on the areas in most need, much more quickly than is currently possible.

There is still a long way to go to eliminate Kala Azar in South Asia, and in Bihar in particular. The Government of India and the Government of the State of Bihar have both put certain structures into place to help - Primary Health Centres are in place which have diagnostic tools and medicines for KA, available free for patients. Training has been established to give doctors the knowledge they need to quickly identify these patients and treat them properly. Preventative programs like IRS have been established.

However, we have seen firsthand that those prevention campaigns are not always effectively run, or conducted on time. We have heard that medicine stock-outs have happened as recently as 2012, something that the government must keep a close watch upon. And our survey shows that there seems to be some mistrust among patients regarding the Public Health Centres - certainly these facilities are often overcrowded and patients do not feel like they can get the one-on-one attention that they deserve.

Thus, the Private sector continues to be an important piece of the Kala Azar puzzle. Patients prefer the face-to-face time they get from both UMPs and private qualified doctors; they trust them because they are located in their own villages and are well-known to the community.

Thus, if there is a way to incorporate both private qualified doctors and UMPs into the elimination effort, it should be much more effective; our survey results should point to multiple ways with which CARE can improve local educational efforts to improve knowledge among both providers and villagers. We should be able to develop a proposal to incorporate Private providers into both medicine and diagnostic tool distribution programs, as well as patient tracking efforts.

I hope to continue helping out with this project long-distance from home. I am certainly looking forward to getting the final data package soon! Clara has a few more weeks in New Delhi to finish up, and our project lead, Dr. Indranath, will remain involved, so we will be in contact to review results and discuss the conclusions we can draw from the data.

This past five months has been life-changing in many ways. I've met some wonderful, passionate people; seen so much sadness and yet so much beauty in rural India. I've traveled around the country to meet people from all walks of life and see cultural and spiritual landmarks and events.  It's been quite a ride!

I leave India with a strong belief that I will be returning to continue my work here - hopefully with my family next time, so that they can see some of the things I've seen and learn from it as I have. I will definitely continue to find ways to stay involved with Development work in general.

I am so grateful to the people from CARE as well as Pfizer and the Global Health Fellowship team for giving me this amazing opportunity.

Field visit to Samastipur: Starting up our study

It's been a while since my last post. Unfortunately, there was not too much to report work-wise over the weeks in between, up until a couple of days before Clara and I made our third field visit to Bihar (though on the personal side, I had a joyful reunion with my wife, Kasia, who flew out here for a week - I'll post some pics from our visit to beautiful Bekal, Kerala, later!).

This field visit was a very important one: as we had built a questionnaire to interview both qualified (doctors) and unqualified rural medical practitioners  (RMPs, or "quacks") over the past month, we were finally able to put it into action, first training four interviewers on how to administer the questionnaire, and then accompanying them in the field to give them first-hand experience in taking the interviewees through the survey.

For this study, we are focusing on four of the eight districts (analogous to counties in the US) in which CARE is currently operating their anti-Kala Azar program, and we selected the four with the highest number of KA cases this past year.

In the weeks preceding the visit, we had a ton of help from Dr. Indranath, who is serving as our project head, as well as Indrajit, Ishani and Rahul from the CARE Patna office who aided us in finalizing the questionnaire, pressure testing some of the questions, giving advice on the format and structure to enable analysis of the data when the study is complete, hiring the interviewers, translating the survey, selecting two blocks within each of the our districts (blocks are similar to townships in the US) and arranging our field visit by coordinating travel with the Samastipur district office. Ishani has been with us for each of our field visits, serving as our interpreter, and Rahul is now our point man for the project in general. So grateful for all of their help!!

We arrived in Patna on Tuesday afternoon and we happy to get our old rooms back in the CARE Guest House (which is excellent!).

Our intrepid interviewers, Deepak, Vikash,
Ashotosh, and Ajeet (from left), with Ishani

Wednesday morning, we headed to the CARE office to meet with the team and the interviewers. Dr. Indranath provided an overview of Kala Azar - what the disease is, how it is spread, and whom it affects.

Then Clara and I tag-teamed on presenting an overview of the survey: the goals - namely, to better understand the role these private medical practitioners play in diagnosing and treating KA, to enable the development of a strategy to engage these people in the efforts to eliminate the disease, and to prepare for a much larger study next year - plus the methodology and a walk-through of the questions.


We made it clear that the interviewers were not to mention Kala Azar before or during the interview, at least until either the practitioner himself mentioned it, or until they finally reached the Kala Azar-specific questions, more than halfway through the survey.

Explaining the questionnaire to the interviewers

The reason for this is that we were really attempting to understand the thought process of these practitioners when the receive a new patient, especially a patient with a fever, and to determine at what point he (and 100% of the providers we have seen are male - there are virtually no female practitioners in rural India!) starts thinking about KA as a diagnosis.

After hours of discussion that took us through each question (and enabled us to tighten up a couple of them), we adjourned to prepare for the field visit the next day.

The drive to Samastipur was fairly pleasant, despite some traffic leaving Patna. It took about three hours - some nice, smooth stretches of road punctuated by the occasional ruinous mess of broken asphalt, deep gouges, and rutted gravel-and-dust you find all over Bihar. Samastipur district is the closest to Patna out of the four districts in which we'll be conducting the survey, hence our choice to do our field testing here.

At the CARE district office in Samastipur

We dropped by CARE's Samastipur District office to meet with the District manager and with MD, the Link Worker who would guide us to the different offices and clinics to interview the practitioners. We split into two interviewing teams:

"Team 1" - Ishani, Clara, Ashotosh and Vikash

"Team 2" - Deepak, Ajeet, Rahul and me

We first stopped by one doctor's clinic which was an Ayurvedic hospital, but he was a bit taken aback by the size of our group, I guess. The doctor was was pleasant enough but asked us to come back after hours (about 8PM) for the interview, as he had a lot of patients waiting.


Before heading to the next appointments, we split up to tackle more interviews (and thus give the interviewers more hands-on training), but also to make each group a more manageable size. I went with Rahul, Dr. Indranath, Ajeet and Deepak.

Crowded waiting room at the clinic 

We headed for a large private clinic (it felt like a small hospital), where we found a big crowd waiting to be seen by the doctors. We were escorted by one of the clinic staff to see the doctor...who happened to be administering an ultrasound to a pregnant patient! One of the things I've had to get used to is the lack of privacy in medical facilities here. The woman was fully dressed, but I certainly felt like I was intruding on what should have been a special (and private) moment for her and her family.

Our first full interview

The doctor wrapped up the ultrasound and sent the patient and her husband on their way, and settled in to talk. Dr. Indranath made the introductions and explained our purpose, in Hindi. The doctor smiled at me and introduced himself in English, and throughout the interview often stopped to give me a bit of a play-by-play. Ajeet administered the survey, and did a nice job (given that it was the first one!), with only a couple of corrections or clarifying comments by Rahul and Dr. Indranath. Midway through, the doctor had glasses of hot chai brought to everyone, a common practice here when entertaining visitors.

The survey took almost an hour, which again made me feel a bit guilty - there were plenty of patients waiting to be seen, after all, but the doctor explained that long waits are expected at the clinic or really any medical facility, and patients arrive prepared to wait. This didn't make me feel much better, but we thanked the doctor and left the clinic.

It felt great to have one successful interview under our belts, so we headed over to a second doctor's office to try a second go.

Outside the second doctor's office

As we entered his small clinic - only a few patients waiting this time - I took note that there were posters and gift items from multiple pharmaceutical companies (some multinationals, some Indian - though nothing from Pfizer!). Interesting to see that (apparently) drug reps make visits even to these remote private offices.


The doctor greeted us warmly - first in Hindi, and then (for me), in English. His English was quite strong, in fact. He introduced himself and shared with us that education of patients, especially about diabetes, was his passion, and he shared some educational pamphlets he had developed. He had small glass bottles of Coke brought to everyone as we went through the survey - again, Ajeet asked the questions - and the doctor often reverted to English to help me understand his comments.

The survey took a little less time, as Ajeet was gaining confidence in administering the survey, which was a very good thing. Our team had been concerned that the survey might take much longer, and of course it can be difficult to get the time and attention of busy doctors and quacks, let alone sustain their interest for a long time when they have patients waiting.

After the successful completion of this survey, we met up with the other group, and had lunch (at a place called Bollywood!). We chatted over our experiences for the morning and determined that we would complete a few more interviews in separate teams before heading to the hotel, and then the interviewers could complete a couple in the late evening.

The afternoon went much as the morning - more successful interviews with qualified doctors. All of the doctors we interviewed were quite familiar with KA (after all, these are heavily-endemic districts), knew the causes and treatment options. The final interview I attended was with a doctor who again was quite skilled at English, and despite the fact that Deepak asked his questions in Hindi, he responded in English for my sake (very kind, though honestly I was hoping to observe the interviews the way they would occur in my absence).

At one point, when we asked the doctor about his ideal scenario for a KA patient, he commented "we are treating the patient, but not treating society." By this, he meant that the real issue behind Kala Azar is poverty - impoverished communities are struggling to survive, relying heavily upon their livestock (and so keeping them close to their homes), lacking clean water and sanitation, and having little education about how to prevent disease.

Our hotel in Samastipur!

We checked into our hotel in Samastipur that evening. I was pretty tired from an early start date and a full day on the road, and fell asleep without dinner. Overall, we spoke with seven doctors, more than our planned four - a great success.

The next day was quack day! We set out to get at least four or five interviews with these unqualified medical practitioners before heading back to Patna.

The RMP's examination room

Our first stop on this hot, steamy morning was along one of the dusty roads in town. The RMP here had a
small waiting room and a small room to examine patients; these were adjoining a residence with a a family living in the back.

Vikash (right) interviewing the RMP (2nd from right)

As Vikash interviewed the quack (this time everything was in Hindi), I noticed that we were being watched by a couple of the children who lived in these rooms. I had brought a couple of bags of "superballs" with me (the small, super-bouncy kind), so I handed a couple to the kids. Their faces lit up, and they disappeared with their prizes. A little later, the kids' parents invited Ishani, Clara, and I to come and see their home.

Clara and I with our new friends

They really just had a couple rooms (a couple of sleeping rooms and a kitchen, arranged along a courtyard where they ate and the kids played), where the father, mother, and their children, plus the father's parents and his teen-aged sister-in-law (who was doing the housework when we arrived) all lived. They didn't seem to have electricity in the room, and their water was drawn from a pump - both pretty typical in the more rural areas as well as in some town outskirts, like this one.

Superballs!

Through Ishani, we conversed with the family, and took some pictures. Their adorable sons shyly came up to me and asked for another superball, so of course I obliged (more than once!). They offered us tea, and brought out chairs for us, so we sat for a while as the boys played. They asked us about our homelands and seemed really happy to have us visit with them. We exchanges mobile numbers, thanked them for their wonderful hospitality, and promised to send them pictures.

Meanwhile, MD, the Link Worker, had brought another RMP by, and Deepak had completed an interview with him.

Ajeet (right) interviewing the very-experienced RMP,
with Ashotosh (center) following along, and
patients and staff looking on

We rounded up the troops and moved further down the street, where we went into another quack's office. This man had a few patients in the room, but he sat us down, gave us (more) tea, and Ajeet interviewed him. He said he had been in this location for 46 years - so he certainly had been here through the times (late 1980s-90s) when Kala Azar was a true epidemic, afflicting hundreds of thousands of people in rural Bihar and killing likely thousands.

Luckily, indoor spraying, better medicines, and increased public awareness have made a difference since those days.

After Ajeet wrapped up the interview (by now down to about 40 minutes), we split into our "teams' again - this time Vikash and Ashotosh accompanied Rahul and I to a more rural location, a small tola further out in Waris Nagar block.

Our link worker, MD, leading us through the tola

This looked more similar to some of the places we'd visited in past field trips, small unpaved roads leading to mixed-material homes (some brick, but lots more wood, mud, and thatch). There were lots of young children around. We walked to the three-walled structure that served as the RMP's office; a young boy who couldn't be more than 10 or 11 brushed the dust off chairs and benches for us, and a couple of the local men sat with us to listen in.

From left - Vikash and Ashotosh, MD, and
the RMP, with his young "employee" looking on

Ashotosh conducted the interview with the young, bearded practitioner. As they spoke, a couple of young boys cam by, and I tossed them each a superball. When a couple of other kids saw this, they somewhat-sheepishly came up as well, and I waved them over and handed them a ball each as well. That's when I realized that I had underestimated the number of kids in the tola! A succession of little ones came up in small groups - sometimes chased away by the boy who "worked" there for the RMP. I think I eventually gave out about 40 of them (luckily I had enough).


After finishing the interview (and watching the kids racing around, bouncing their superballs high into the air), we drove a bit further to one last RMP office.



The office was a standalone structure, painted white outside, pink inside. The 40-ish practitioner was seated behind a small desk. He had a bench that served as a patient bed, where a thin man, clearly ill (though we weren't told his diagnosis), was resting with an IV drip in his arm.

Again feeling like an intruder, I sat next to Vikash, who gave the interview; Ashotosh sat next to me on a bench, and we fell into conversation - about KA, life in our respective countries, and other matters. While we chatted, the RMP had asked for glasses of tea and water to be brought in. I mistakenly took a sip of the water (a huge no-no out here), but quickly recognized from the metallic taste that it must be unfiltered well-water. I grabbed the glass of hot tea and downed it quickly (not that it would have helped, most likely, if I had acquired some kind of bug)...but luckily I haven't had any ill effects!





After Vikash finished the interview, on the way out of the office, I noticed a few little children, boys and girls, sitting on the ground. I gave them my last few superballs, once again happy to see little smiles beaming back at me.










The other "team" joined us there, and then we went to one last RMP's office - a small concrete room back in the outskirts of town. While the interview was conducted by Ashotosh, I sat with Clara and Ishani to discuss our impressions of the day and talk about upcoming plans.

Our last interview of the field visit

Over the course of the two days, we interviewed seven doctors and seven RMPs, well above the target of eight total.  More importantly, we gained a lot of information that allowed us to revise the questionnaire to make it more concise, with more "closed-ended" questions (where the interviewer had multiple choices to check off instead of having to write answers out by hand). This should allow for a faster interview, less intrusive of the practitioners' time.

Next week, the interviewers will start the full fielding of the revised questionnaire; Ajeet, Ashotosh, Deepak and Vikash will, each target twelve RMPs, six qualified western-medicine doctors, and two AYUSH doctors - practitioners of one of the five disciplines of Ayurveda, Yoga, Unani, Siddha, and Homeopathy, for which there are accredited medical degrees in India.

It will take them about a week to complete the interviews, and then the questionnaires will be turned over to our colleague Indrajit's team for coding and data analysis. After this, we should have some interesting results to pore over and to build into a presentation to share with the team!

Life in New Delhi

Looking back through my posts, I realized that I've devoted a lot of space to my field visits and, more recently, pictured from my weekend travels - but very little to day-to-day life here in Delhi.

I've now been here for more than half of my Fellowship, over two and a half months. While I've been doing a lot of weekend traveling, I've settled into a routine during the work week.

Home-away-from-home: my
apartment is the third floor

Breakfast - curry eggs, toast with butter and jam, mango lassi

A typical day starts with waking up a couple of hours before work. After a walk in the local park or a little stretching, I make breakfast, usually the same sort of stuff I have at home - cereal or eggs and toast, plus juice or coffee. I don't have an electric coffee maker (miss my Keurig!), so I use the simple Vietnamese drip coffee-maker that I brought from home - who knew that a $4 investment 10 years ago would pay off so well? Cereal and ground coffee are available in stores here, though they can get expensive if you go for imported brands.


After video-chatting with the family using Google Hangouts (an absolutely necessary part of the day - the only thing that really keeps me going), and showering/dressing, I catch up on the news or do a little reading until the car comes to pick me up. I use a local car company, arranged by CARE - it's affordable and my program covers the costs. I am not allowed to drive while I am here (not that I would want to!), and it's a bit far, and hot -and a bit dangerous with the crazy traffic - to walk, so it is worth the cost. Clara (the GSK PULSE Volunteer that I'm partnered with here) and I commute together, as we live in adjoining neighborhoods.

Typical view during the commute

It's about a 15-20 minute commute to work, though occasionally the rain or special events stretch the drive to closer to 30 minutes. And, of course, there's Ram. Ram is our regular driver, a genuinely nice and sweet Nepali guy, who has been driving here in Delhi for over 20 years, even though his family is back in Nepal. He seems to have taken a special liking to me, which results in him driving exceedingly slowly as he looks back in the mirror to talk with me...as angry Delhi drivers angrily honk and swerve to get around him! The best part is his stories - his English isn't so great, so I understand maybe half of what he says, so it's always an adventure trying to piece together what he means.

Crowded streets during the morning commute

The street where CARE's office is located

The office

Morning cuppa

We usually get to the office between 9:30 and 10, which is when most people arrive here. I have a cup of masala tea (provided by the office), and start work - which, while here in the office, consists of sifting through research about Kala Azar online, preparing materials for our research study on rural private medical providers, chatting with colleagues, and learning about CARE's other programs.

My little cubicle

Lunch here is later than in the US, usually starting a 1, though some people wait until 2 or so. Clara and I try to go around 12:45 to beat the lunchroom rush - there's limited seating in the small breakroom upstairs, which is a sort of permanently-covered-and-enclosed patio with a couple of tables and some couches. It adjoins an outdoor terrace space, though really it's been too hot and humid (or rainy) to eat outside - though it serves nicely for a little coffee break in the afternoon.

The terrace on a rainy day

Funny sign on the terrace

Plants on the outside terrace at work

Special event at work - a visit by the CARE
International leadership team

After a half-hour lunch, it's back to work. Most actual meetings with team members or leadership tend to occur in the afternoon between 3 and 5, though I really haven't had too many thus far.

I have some great co-workers - along with Clara, I often chat with my cubicle-neighbor,  Sheetal, who gives me lots of great tips about travel and Indian culture, and with MS, the HR director who sits directly in fornt of me, who imparts wisdom gathered from a long career at CARE as well as great info about foods to try and places to see (along with, of course, helping me with all manners of logistical challenges).

We usually head home at 5, wending through the rush-hour traffic. Ram doesn't always pick us up, so sometimes it's a quieter - and speedier - trip home.

I often go to the market before going to home - there is a larger market square about half a mile from the apartment, which has a small grocery store along with lots of clothes shops, coffee shops, restaurants, etc. Sometimes I go to the smaller market at the end of my street, where I can get some of the basics (there's even a small organic-foods store there). At the stores, I usually stock up on milk, water, juice (if I can find 100% juice, as a lot of what you find here is "juice drinks" which are full of added sugar), dry goods like flour and rice, eggs and cereals, cooking oil, and spices.

You can get pretty much anything you might
miss from home in the grocery stores here - for a price!

I prefer to get fruits and veg from the man who walks the neighborhood with his cart - his wares tend to be much fresher than what you can get at the brick-and-mortar stores, and the prices are similar.

From the fruit-wallah who walks through the neighborhood

To buy meat, I go to a place called "Green Chick Chop" in nearby Kailash Colony, which has fresh chicken and lamb in a clean, refrigerated space. The only other place I've found meat is in a shop off the big market square...but that one is, um, a bit questionable regarding hygiene. There is a particular butchering expertise here where a man sits on a raised platform, holds the knife with his foot, and holds the meat in both hands to get nice, precise cuts. But...he is holding the knife with his foot. After one visit there, the novelty wore off. The flies everywhere did not help.

Once home, my evenings usually consists of:

1) Turn on the air conditioner!
2) Start cooking dinner (or order it - there's a good variety of restaurants around, and some online-ordering websites keep me from having to communicate by phone, which can be an adventure!)
3) Catch up on Facebook, Twitter, news
4) Eat dinner
5) Read or watch a movie or TV (I brought a lot of DVDs with me, though I can watch movies in English on many of the cable channels here - and shows like Big Bang Theory, Lost, and many others are popular here!)
6) Plan weekend travel
7) Videochat with my family (once it's sufficiently late enough)
8) Hit the sack
The kitchen in the apartment works well - it's small, and doesn't have an oven, but has a two-burner propane range, a water filter, an electric kettle, toaster, and microwave.Good enough to experiment with cooking here!

Thai-style red curry chicken and sauteed karela (bitter gourd)

Okra and potato curry

I even get to make some of my
 favorites from home, like Jambalaya

Sometimes I go out to eat - usually with my friends Clara and Samantha (though Samantha has just returned home to the US). We've been exploring different cuisines - North Indian (what most people in the US are used to - curries and tandoori specialties), South Indian (dosas, utthapams, idlis - usually vegetarian), and Bengali (lots of fish, coconut, banana) from here in India, plus Thai and Chinese, and my new favorite, Tibetan food.

With Samantha and Clara at Oh Calcutta, a great Bengali restaurant

Delicious Tibetan thali, at Yeti

I've been traveling enough (both for work and for fun) that it hasn't gotten too monotonous!

My neighborhood in the evening

Sightseeing Snapshots! (Part 2)

More pictures! Apologies for just dumping without captions - but feel free to ask about any of the pics! :)


Nalanda University Ruins, Bihar:

                 


         


                                             









                                            


                                                                                   


                    


                                 



        


                                          


               


Victoria Memorial, Calcutta:


                                           

  


                                           

                                                                                


                      

                      




                                   


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In and around Calcutta

                     


                                     






                                

                                                                             


                                           




                                              


                                                                                


                                          





                                         


           

                                     


                              
       

               
                                                



Adina Mosque ruins, near Malda, West Bengal:




                                      

 
                                    


                     


                     



                   


                                       


                


                                   

                          


Boudhanath Stupa, Kathmandu, Nepal:

   
                 

                                         
                                      
                                      




                                     
                                                                        


                                          




                      

                                       
                                 
 
                                            

 
                                       


                                                                            
 
                                       



Swayambhunath Monkey Temple, Kathmandu:

                     



                                     

 
                                   
 
                                                                         
 
                                 

                          

           


                      



                                         


                         

                         


                                    


                                

 
                                            
 
   

                                      


                                                                             

                                                     


                        



                                         




                                                                                                                              
   

                                              


                                



                                              


                                                                  


Garden of Dreams, Kathmandu:

          


                                  





                                            


Old Patan City, and Patan Museum, Nepal:

                                                                      



                                               


 


                           


                                                      


                                            


  


                                        




             


                                 


                                                     


              



                                     


                    


            


                              


                                       


                


                



                                  


                        


                                       


                                                


                               


                                                

                                

                                





                        


                                                                            


                                   


            


                                      





                                  


                                                                     


                                 





                                 




Pashupatinath Temple, Kathmandu:

                                       


                            


                                      





                                          


                                                                            


                                    



                                      


                                 

                                           





                                   


                          



                       


                                       


                     


                                               


                                   





                                         


                                                                          



                           


                                   





                                                      


                                     


    


In and around Kathmandu: