Rab Ne Bana Di Jodi

Bollywood movies are not my favorite genre of entertainment. But among Bollywood movies, Rab Ne Bana Di Jodi is the best I´ve seen. The movie is set in Amritsar, site of the Golden Temple in Punjab, Northwest India. It stars Shahrukh Khan, king of Bollywood. Everybody I´ve met in India has seen the film.

Here is a link to a New York Times review published Dec 13 2008. I believe the movie is still playing in America and Europe. Running time: only 2 hours and 47 minutes.

Aid Workers in Chad

The Jan 5th issue of the New Yorker has an essay on aid workers in Chad. This part of the reporter´s interview with an employee of an unnamed "large well-known humanitarian organization" hits a little too close to home:

One night, she took me to a tiny restaurant run by two Chadian women. She drove through the dark, chaotic streets of N’Djamena in her agency’s jeep, past sheds and mud-brick buildings where groups gathered around small cooking fires, past an endless procession of people along the road, all coming into view and going out again as the headlights swept by. The restaurant was in a dim, stony courtyard lit by kerosene lanterns, and consisted of a few plastic tables and chairs. She knew the women who ran the place and greeted them warmly. She ignored the cold stares from a table of men drinking beer in the shadows.

Over a meal of fried plantains and bony fish from the Chari River, she told me that, among the variety of aid workers, two broad categories stood out: the runners and the seekers. The runners were fleeing their past lives; the seekers were looking for adventure or enlightenment. She was a runner, she said, but offered no details.

She went on to say that she had reached a point in her life where she must make a choice. She was thirty-three, young enough to return to her country and try to establish a life with marriage, children, and a home. Or she could continue on as she was, with reassignments every few years and little chance for marriage and children. “Look around,” she said, “and you’ll see that this business is full of women thirty-five to forty-five who are strong, competent, good at what they do, and single.” She had never had a long-term relationship. She must make a choice, she said. It seemed to me that she already had.

Rounds on the Kala-Azar Ward

I round with the team in the kala-azar ward every morning, unless I need to travel to one of the distant clinic sites. The kala-azar ward in Hajipur hospital has 55 beds. In the high season--when it is hot, before the monsoons-- the ward is often full. The patients rarely complain. They don’t tell me they have pain or vomiting or diarrhea or cough unless I ask them specifically about each symptom. In addition to kala-azar, we see a lot of malnutrition (body mass index < 16), severe anemia (Hemoglobin < 4), as well as protozoal and helminth (worm) infections. We also see plenty of tuberculosis/kala-azar coinfection and HIV/kala-azar coinfection.

Kala-Azar Expats in Bihar

There are four expats working on the kala-azar project in Bihar. Anne (left) is a nurse from Berlin. Marlise (middle) is our field coordinator. She is from the Netherlands, but has most recently lived in Madagasgar where she worked with UNICEF. Othman (right) started with MSF as part of the National Staff in Colombia.

There are 45 Indian National staff members on our project, including five doctors and six or seven nurses.

Kala-Azar Basics

Leishmaniasis is a protozoal infection that is transmitted by phlebotomine sandflies. The disease is usually classified into two main groups: cutaneous leishmaniaisis (CL), which causes a skin rash or ulcer, and visceral leishmaniasis (VL), a disseminated form of the disease which causes a systemic febrile illness. VL is sometimes called Kala-Azar, which means “black sickness” in Hindi. Most CL is found in Central/South America and the Middle East, whereas most VL is in South Asia and Africa. More than 90% of the world’s kala-azar cases are in India, Bangladesh, Nepal, Brazil, (about 60% of cases in India, Bangladesh, or Nepal). More than 90% of Indian cases occur in Bihar State, the Kala-Azar capital of the world!

The CDC cartoon above diagrams the leishmaniasis lifecycle. When an infected sandfly bites a human, it injects the promastigote form of the protozoa. The promastigotes enter macrophages in the blood, then change into the round amastigote form. Infected macrophages travel to the spleen, lymph nodes, bone marrow, and other organs. The amastigote form multiplies inside the macrophages. Infected macrophages eventually burst, releasing amastigotes into the tissue. When a non-infected sandfly feeds on an infected patient, it ingests macrophages filled with amastigotes. The amastigotes turn into promastigotes in the gut of the sandfly. Eventually the sanfly feeds on another person, which spreads the disease. Pics below are of amastigotes inside macrophage on a biopsy sample, and of the type of sandfly that transmits VL.


I had never seen a case of kala-azar before I came to Bihar. Patients with kala-azar usually present with high fever, weight loss, and weakness. On exam, the spleen is enlarged. Often the patient has low white blood counts, red blood counts, and platelets. It is important to rule out malaria, tuberculosis, and typhoid, which are diseases that can look similar to kala-azar. [The picture below is an African child with massive splenomegaly. Not all patients have such dramatic spleens.]

The gold-standard for VL diagnosis is a spenic or bone marrow biopsy that shows macrophages filled with amastigotes. We do not routinely do white blood counts or biopsies for diagnosis, , as they are time consuming, expensive, and require lab facilities and trained technicians. We diagnose the disease based on the patient’s clinical history, splenic enlargement, and results of a rk39 blood test. Rk39 tests for the presence of VL antibodies. It only requires a few drops of blood, and results are available in 15 minutes. The availability of the rk39 test is one of the reasons we are able to have a successful treatment program for Kala-Azar in the field.

The traditional treatment for visceral leishmaniasis is a drug called sodium stibogluconate (SSG), a toxic IV infusion that requires a 3 week hospital stay. In Northern Bihar, much of the VL is resistant to SSG. Amphoteracin B, a potent antifungal, is another drug effective against VL. Ampho B is nicknamed “ampho-terrible” in the USA due to its many side effects. It also requires several weeks of IV treatment. In this project MSF is providing the liposomal form of Amphoteracin B, which is better tolerated, requires a shorter course of treatment, and is effective against SSG-resistant VL. It is also expensive. At current prices, India cannot afford to treat all VL patients with liposomal ampho B. Advocacy for generic production and price reduction of Liposomal Ampho B is an important part of this project.

Hajipur

It has been a challenge to adjust to my new life in India. Bihar is one of the poorest and most corrupt States in the country. The infrastructure is crumbling or nonexistent. We live in a town called Hajipur, which is about 20 km from Patna, the State capital. Because rickshaws, cars, bikes, and cow-carts gridlock the road, it takes more than an hour to drive the 20 km between Patna and Hajipur.

I had prepared myself for dirt, noise, and chaos, but Patna and Hajipur have exceeded my expectations on all fronts. The hygiene is the worst I’ve ever seen. The roads are lined by pools of water /sewage filled with garbage. Pigs and cows and children wade through the garbage swamps. Open defecation and urination are common. The road often cuts a canyon between mountains of garbage and plastic refuse on either side.

Hajipur is considered a “small town” in India—about 300,000 people. The locals are unused to Westerners. People gape or shout at us when we walk outside the house. There are no comfortable restaurants or bars nearby, and no greenery or peaceful outside retreats.

Still, my discomfort is a small price to pay for the opportunity to work here. The complexity of Indian culture and religious, ethnic, and socioeconomic diversity are fascinating. I’m getting a lot of hands on experience in tropical medicine and public health, which complements the book and lab-based learning that I did in Liverpool.