Hi there, I arrived in New Delhi on Fri 21 Jun 2013 and started my first day at the CARE India office. The week after (24-28 June) I was on my first field visit to Patna, Bihar (about 1.5 hours flight from Delhi) to understand the Kala Azar (KA) situation there as the Bihar State is an endemic area of the disease. Also to meet the CARE Hub Team who work on Integrated Family Health Initiative (IFHI) and Strengthening KA Elimination Program (SKAEP) – both are Gates Foundation-funded.
I was there with my counterpart, Matt, who comes from Pfizer – he is part of their Global Health Fellows program, very similar to our GSK PULSE program. This is an innovative partnership for the two Pharma companies to bring different skills and perspectives to the NGO. Matt has extensive experience in market research and strategy in oncology, complementing my clinical research & infectious diseases experience well.
Had an opportunity to meet with the SKAEP program team based in the CARE Patna office, heard about their progress on the Situation Analysis study of Kala Azar in Bihar, and discussed our plan for a research study to better understand how private providers might be an integral part of the solution for the elimination of Kala Azar.
Next couple of days was extremely busy, tried to fit in as many visits and talk to as many people as possible, managed to visit:
• Patna District Office & met the district level implementation team
• Bihta Primary Health Centre – a public referral centre, met with the Medical Officer In Charge & the Health Inspector for the district
• A tola – a small village called Dhanarey Chak
• A private diagnostic lab
• Some rural health providers
• Patna Medical College Hospital
This tola, called Dhanarey Chak, is a community of Musahars, who are the lowest ranking group within the lowest caste in Indian society. They are often agricultural day labourers, extremely poor, almost all illiterate, and often shunned from society in general. The families living in a combination of “kuccha houses” made of mud and straw, and “pucca houses” made of brick and/or cement. There are government programs to help eliminating breeding habitats of the sand fly which carry the parasite that causes KA e.g. the government provides pucca houses and funds Indoor Residual Spraying program twice a year. We asked the villagers about the spraying program, unfortunately not truly understanding the value of spraying their homes, they told us that they disliked the smell of the insecticide, and often covered the sprayed walls with cow dung or washed the walls, completely defeating the purpose altogether.
We were lucky in finding three rural health providers (RHPs) who were willing to talk to us. RHPs typically have some limited medical experience but no formal training. Villagers go to them to get help and treatments for fever and diarrhoea that are so common here. Almost all of Bihar’s very few doctors live in cities; over 70 million people live in villages in Bihar, far from any city & far from any doctor. This lack of available doctors has led to the RHPs filling the gap. The first RHP we met had been there for over 30 years; he said he serves people from two villages, and everyone knows him. He was well aware of Kala Azar but he wouldn’t attempt treating it. The other two were younger, and neither knew very much about KA. They said that typically if they had a fever that did not respond to treatment, they would simply refer patients to the public health centre or hospital.
We found a Kala Azar unit in the Patna Medical College Hospital (PMCH); and asked a patient’s father-in-law about the patient’s journey. From their account, it took about 7 months before he was referred to the PMCH, diagnosed and treated for KA. The patient has been cycled back and forth with a local rural health provider, and then went a public health centre, received treatment for fever and jaundice that didn’t really help him; eventually the patient was referred to the public hospital. What changes needed to happen to improve this? How can we make a difference for the patients?
The field trip helped Matt and me enormously to better understand the public healthcare structure, Kala Azar patient’s journey, the elimination efforts at different levels, and how we could engage the private sectors for our research study.