Acting Pharmacy Director

I have felt important for the last few days. Anne-the field nurse—has been away since Saturday, leaving me in charge of the pharmacy. Managing the pharmacy is a big part of all MSF projects. Every project is different, but most require: hundreds of pharmaceuticals, ready to use foods, IV fluids, needles, cannulas and plastic tubing, gloves and sterile dressing materials, laboratory reagents and tests, vaccines, and all the other equipment necessary to run a medical ward. Storage and management of the equipment is more complicated than it looks; it involves inventory, meticulous organization of materials, quarterly domestic and international orders, and temperature control. Our project requires importation and storage of liposomal amphoteracin B, which requires strict cold chain from the factory in the UK to the patient’s bedside.

I have never managed a pharmacy before. Even though it was only for three days, and I did not have to order or take inventory, I was still nervous when the hospital nurses told me they needed IV infusion sets, mosquito nets, dressing materials, and sterile water for injections. Which bottles are those? Do you need the size in the red package or the size in the blue package or the size in the green package? Are they in the room with the medicines or the room with the tubing or the room with the dressings? How many come in a bag? How many bags in each box? What's the difference between a lot number and a batch number. Where do I record the expiry date?

I also had to send the Ambisome to the hospital each day in cold chain. I’m proud to say that I mastered this without too much difficulty. All I had to do was ask the nurses how many patients were due for infusions that day, then estimate the number of vials per each patient. I checked the thermometer on the pharmacy refrigerator, packed the vials in coolers lined with ice packs and insulation, and noted down how many vials I sent out each morning and got back each evening.

Noise Pollution

One of the hardest things for me to tolerate in Hajipur is the noise. Traffic is part of the problem. There is 24-hour gridlock in Patna and Hajipur: walkers, bikes, mopeds, bicycle-rickshaws, motorcycles, auto-rickshaws, 3-wheeled tut-tuts, four-by-fours, buses, trucks, ox-carts, camels, and elephants share the road. There appear to be no traffic rules, other than that each driver must hold down his horn at all times, whether or not there is room for anybody to move.

The rest of the noise comes from festivals. I do not understand significance of each festival, but the order of events seems to follow the same general pattern:

1. Statues representing gods and/or religious figures are built out of concrete, clay, and paper

2. Statues are decorated with paint, textiles, and jewelry

3. Faces remain covered with cloth or newspaper until start of festival

4. After the ceremonial part of the festival, caravans parade through town. Caravans consist of: (1)cart loaded with loudspeakers and bullhorns blasting Hindi techno music, (2) throng of Indian youngsters gyrating in trance, (3) large generator for power to speakers, (4) cart carrying god-statue.

5. Dozens of caravans parade through the streets of Hajipur for 1-7 days. At the end of festival, each statue is tossed into the holy Ganges river, which is conveniently located at end of our street.

Luckily, I brought a 24-pack of earplugs with me to Bihar. I wear earplugs when I eat, when I sleep, when I read, and when I am in the car. Of course, cultural education and immersion are part of the reason I do this type of work in the first place. But sometimes I miss the peace and quiet of Manhattan.

HIV in India

Robert Steinbrook’s March 2007 essays in the New England Journal of Medicine helped me understand more about HIV/AIDS in India, as well as global HIV/AIDS epidemiology. Steinbrook reports that in 2006, UNAIDS estimated that there were 5.7 million people HIV positive people in India. This was shocking news at the time, as it meant India had more HIV positive people than South Africa, which was estimated to have 5.5 million in 2006. Of course, the HIV prevalence in India would have still been much lower than South Africa (0.5-1.5% of 15-49 year-old Indians infected, verses 16.8 to 20.7% of 15-49 year-old South Africans infected), but given the sheer size of the population in India, the raw number of HIV positive people would have been the largest of any country in the world. This brought a lot of attention to HIV/AIDS in India, and expansion of India’s National AIDS Control Organization (NACO).

In 2007, UNAIDS revised the prevalence data for India based on new survey data. As of late 2007, UNAIDS estimates that India has 2.5 million people living with HIV/AIDS, less than half of the 2006 estimate. In fact, the correction of India’s estimated HIV prevalence was the major reason for the 16% reduction of estimated people with HIV/AIDS worldwide in 2007. In the 2007 report, UNAIDS estimated that there were 33.2 million people living with HIV/AIDS worldwide, 16% less than the estimate from 2006 (39.5 million). From the 2007 UNAIDS report:

The major elements of methodological improvements in 2007 included greater understanding of HIV epidemiology through population-based surveys, extension of sentinel surveillence to more sites, and adjustments to mathematical models from better understanding of the natural history of untreated HIV infections in low and middle-income countries. Although prevalence has stabilized, continuing new infections (even at a reduced rate) contributed to the estimated number of people living with HIV. HIV prevalence tends to reduce slowly over time as new infections decline and through the death of HIV-infected people; it can increase through continuing HIV incidence and through reduced mortality of HIV-infected people on ARV treatment.

Steinbrook’s essays on HIV also say that the tradition of female sterilization as a form of contraception in India is a barrier to HIV prevention efforts. In many Indian States more than 50% of woman use sterilization as a method of family planning before they turn 30, the article says. It is nearly impossible for sterilized women to negotiate for condom use. The article quotes Broun of UNAIDS, who says “In Africa, a woman who is not pregnant is probably using condoms as a method of contraception, so is therefore also protected against HIV. In India, a woman who is not pregnant is probably a woman who has been sterilized and her behavior toward HIV is not known. “