Agra

I spent my last weekend in India visiting Agra with Liza and Gareth. My plan was to ease the transition between Hajipur and the USA by a luxury weekend in Agra. We visited the Taj Mahal, of course, as well as Fatehpur Sikri, capital of Akbar's Mughal empire in the 16th century. The luxury weekend was great, but I am not sure it helped make my transition back to the USA any less difficult.

Here are a few pics from the Agra weekend. At left, Liza in front of the Taj Mahal. Below, MSF-Spain Coordination Dream Team outside Amarvillas hotel, Agra, and several pictures of Fatehpur Sikri. I recommend William Dalrymple's City of Djinns for a brief history of the Mughal empire and Akbar's reign. The book actually chronicle's the history of Delhi; there is a chapter devoted to Akbar.

Frieden to Head CDC

I was happy to read in the New York Times today that Obama picked Tom Frieden to head the CDC. Dr. Frieden went to medical school and did his residency at Columbia, just like a few other people I know. He later went on to work for WHO in India for five years on TB control. In 2002 he became the Comissioner of the NYC Department of Health, where he has made many bold decisions to protect the public's health. The NYC Department of health website says there are now 300,000 fewer smokers in the City than in 2002, which will prevent 100,000 premature deaths in years to come.

I like the following anecdote about getting things done quickly (from the Oberlin College Alumni Magazine, 2006):

Describing Frieden—then in his early 30s—as “driven and brilliant, with an incredible passion for public health,” Larkin was amazed by how quickly he took steps to hire new employees, greatly speeding up a process that had taken “months and months” before his arrival. “He brought applicants in on Saturdays to interview, and those who qualified would be offered the job that same afternoon. And then, when they arrived a few days later for their physical exams [another potential bottleneck], they discovered that the doctor who would be giving them their physicals, quickly and efficiently, was none other than … Tom Frieden.”

Calcutta

I spent a relaxing three-day weekend in Calcutta. I realize that it might seem like an unlikely choice for an escape from Bihar--given that the city has an international reputation for extreme poverty--but in fact there are lovely spots in Calcutta. I had plenty of opportunities to pamper myself: I stayed in a luxury hotel, ate Chinese and Indian food, drank espresso, and browsed in bookstores. I am told Calcutta is the last Indian city that still has hand-pulled rickshaws (pic upper left). The man in the upper right pic is a Paan-walla, he makes Betel-nut, spice, tobacco sweets rolled up in a leaf. Below left is a lassi shop where they serve chilled yogurt drinks in the stacked clay cups.

Civil Unrest and Communicable Disease Control

The current issue of Lancet Infectious Disease has a news story on the continuing neglect of visceral leishmaniasis.

The author makes the point that war and civil unrest are major impediments to control of endemic communicable disease. This article uses the example of the political situation in Sudan hampering programs for treatment of leishmaniasis.

This is only one example of many, of course. Regional elimination of disease is impossible if even one country in an endemic area has an ineffective government program. An even better example is the onchocerciasis control program (OCP) in West Africa. The OCP was a major effort to eliminate onchoceriasis in West Africa in the 1970s-1990s. In many countries the OCP worked to control onchocerciasis and prevent river blindiness. However, despite international investment, aggressive vector control, and coordinated government/NGO treatment programs, the OCP failed to eliminate onchocerciasis from West Africa primarily due to the decades of conflict in Sierra Leone.

Heat Wave Hits Bihar

We did not think life in Bihar could get harder, but our local staff assure us that it can. From the Patna Daily Today:

The current heat wave gripping much of the state forced most people to stay indoor on Monday as temperature soared to 42° Celsius (108° Fahrenheit), at least 5° more than the average around this time.

Those who were forced to step outside their homes were seen covering their faces with scarves and towels while making frequent pit stops at roadside vendors to grab a cold glass of sugarcane juice, watermelons, or 'sattu' drink to quench their thirst.

I like the rickshaw driver in the background of this pic. Can you imagine driving a bicycle rickshaw in 108 degree heat?

Something "More Personal"

The people at El Periodico asked me for something "more personal" for the kala-azar blog. I am not sure what they want, but this is what I sent them:

In this entry, I describe a typical day as a field doctor in India. I hope this helps convey what it is like to work as a doctor in with MSF in Bihar.

7:00 am- I wake up to the noise of my ceiling fan. The fan functions more as a noise-making machine than a cooling device. It also turns the room into a dust storm. The mosquito net over my bed started out white, but now it is a dark shade of grey. I take a cold shower. As soon as I dress, I start to sweat.

7:30 am- While I am eating breakfast, Sara--the field nurse-- comes into the room. She is doubled over in pain. She says that she started getting diarrhea and abdominal pain at 11pm last night. She looks terrible. I am responsible for the medical care of all expat field staff. I advise her to drink a lot of water mixed with oral rehydration solution and to hold off on taking any antibiotics. She tells me that she has already started herself on antibiotics. I advise her to rest all day in bed. She tells me that the medical order is due in the capital today, and that plans to work on it whether she is sick or not.

8:00 am—I walk down four flights of stairs and arrive at our office, which is located on the ground floor of our apartment building. I rejoice that the internet connection is working again. I check my personal email account. There are six SPAM messages, two or three work-related messages, and no personal messages from friends or family. I feel depressed.

8:15 am- I have almost two hours to work on administrative issues before I need to leave for the hospital. I review the medical coordinator’s report on his recent visit to the field. I write a memo to the project epidemiologist and medical coordinator about reorganizing our follow-up visit system. I make a list of essential medical books for our project library. I work on the national doctors’ rotation schedule for Sept-Dec 2009.

10:15- I arrive in the hospital for ward rounds. We round as a team of 4 nurses, 3 doctors, and a ward attendant today. The ward is almost full; there are about 40 patients inside, and ten patients on cots in the hallway. I feel bad for the patients outside; it is 40 degrees C and they are covered in flies. There are many complicated cases. Some patients may have typhoid that we have misdiagnosed as kala-azar. We suspect many patients are coinfected with tuberculosis. There are a couple patients who I think have neither kala-azar, enteric fever, HIV, or tuberculosis, but they are spiking fevers and look sick.


3:00pm- National staff nurses, doctors, health educators, and logisticians gather in the office for a brainstorming meeting on how we can improve our activities in the rural facilities. There is active participation in the conversation. Several good ideas are discussed, clarifying our priorities for the next 18 months of the project. Marlies—the project field coordinator—and I agree that the meeting has been productive.

6:30 pm—My commute from office to home takes less than a minute. I want to exercise, but it is impossible to do anything outside. Rafa and Marlies are doing yoga in the room where I often jump rope in the evening.

7:30 pm—I am having trouble getting work-related thoughts out of my head. I feel trapped inside the house. We are not allowed to walk outside the house alone in the evening or drive the car. When yogis are finished, Marlies and I convince Rafa to turn on the generator for three hours so we can watch a DVD.

10:30pm-- By the end of the movie I feel more relaxed. It has cooled down enough to make sleep a possibility.

El Periódico

El Periódico--a Spanish newspaper-- is publishing a filtered and distilled version of this blog. I wrote it to help publicise MSF´s work on the neglected tropical diseases. Here´s the link. It´s in spanish (translated by MSF-communications in Barcelona).

Obama on Community Service and MSF

Obama gave press conference/town hall meeting in Strasbourg on April 3rd. I like what he said about community service. And he mentioned MSF! Thanks dad, for telling me about the speech.

Question: wanted to know if you -- did you ever regret to have run for presidency till now? I mean, well, did you ever ask yourself, am I sure to manage -- yes.

PRESIDENT OBAMA: Yes, it's a good question. (Applause.) Michelle definitely asked that question. (Laughter.) You know, there are -- there have been times, certainly, during the campaign, and there have been times over the last several months where you feel a lot of weight on your shoulders. There's no doubt about it.

During the campaign, the biggest sacrifice -- the thing that was most difficult was that I was away from my family all the time....You also lose privacy and autonomy -- or anonymity. You know, it's very frustrating now -- it used to be when I came to Europe, that I could just wander down to a café and sit and have some wine and watch people go by, and go into a little shop, and watch the sun go down. Now I'm in hotel rooms all the time and I have security around me all the time. And so just -- you know, losing that ability to just take a walk, that is something that is frustrating.

But having said all that, I truly believe that there's nothing more noble than public service. Now, that doesn't mean that you have to run for President. (Applause.) You know, you might work for Doctors Without Borders, or you might volunteer for an -- or you might be somebody working for the United Nations, or you might be the mayor of Strasbourg. Right? (Applause.) I mean, they're all -- you might volunteer in your own community.

But the point is that what I found at a very young age was that if you only think about yourself -- how much money can I make, what can I buy, how nice is my house, what kind of fancy car do I have -- that over the long term I think you get bored. (Applause.)

I think your life becomes -- I think if you're only thinking about yourself, your life becomes diminished; and that the way to live a full life is to think about, what can I do for others? How can I be a part of this larger project of making a better world?

Now, that could be something as simple as making -- as the joy of taking care of your family and watching your children grow and succeed. But I think especially for the young people here, I hope you also consider other ways that you can serve, because the world has so many challenges right now, there's so many opportunities to make a difference, and it would be a tragedy if all of you who are so talented and energetic, if you let that go to waste; if you just stood back and watched the world pass you by.

Better to jump in, get involved. And it does mean that sometimes you'll get criticized and sometimes you'll fail and sometimes you'll be disappointed, but you'll have a great adventure, and at the end of your life hopefully you'll be able to look back and say, I made a difference. All right.Thank you, everybody.

ARV Therapy and HIV Elimination

I'm waiting for my train in Ernakulum in an internet cafe that must be 40 degrees C. While sitting here sweating, I noticed a January 2009 Lancet article that has generated a lot of debate. The article (vol 373, issue 9657: 48-57) uses a theoretical model to asses whether testing everybody for HIV, then starting all positives on immediate ARV would eliminate HIV. [Note that the word "eliminate" does not mean the same as eradicate. They define eliminate as incidence of transmission less than 1 case per 1000 per year.] The idea of treatment as prevention is not new, of course, but this article takes it to the extreme. From the accompanying editorial:

In The Lancet today, Reuben Granich and colleagues (including two of us, KMDC and CFG) use mathematical modelling to assess the impact of expanded HIV testing and earlier antiretroviral therapy (ART) on HIV transmission.1 These researchers evaluated a theoretical programme of annual universal HIV testing and immediate treatment on HIV diagnosis, irrespective of CD4+ cell count, in an HIV epidemic with southern African population dynamics. The exercise suggested that HIV transmission could be substantially reduced within a few years. Elimination of HIV transmission, defined as an incidence below one case per 1000 population per year, could be achieved within a decade, and the overall prevalence of HIV infection reduced to below 1% before the middle of the century. Compared with current practice of starting ART at a specific CD4+ count, deaths would be halved between now and 2050.

The article generated a lot of interesting correspondence, some of which is published in vol 373, 9669. For me, the most important issue was raised in the letter by Jaffe et al:

In their important and provocative article,1 Reuben Granich and colleagues argue that universal voluntary HIV testing and immediate antiretroviral therapy, irrespective of the degree of immune suppression, could eliminate HIV from countries where the infection is highly prevalent. However, we agree with Geoffrey Garnett and Rebecca Baggaley2 that this approach could strongly shift the benefits of treatment from the individual to the population.

Although current HIV treatment guidelines favour earlier treatment, the risks and benefits of treatment for people with CD4+ cell counts above 350 per μL are unknown. Trials of therapy for patients with higher counts are yet to begin.

Within the field of communicable diseases, we are aware of little precedent for the approach of “treating for the common good”. Treatment of diseases such as tuberculosis might have the effect of decreasing transmission, but the primary goal is to decrease morbidity and mortality for the affected person. A better analogy might be found in immunisation programmes—eg, rubella vaccination of infants and children aims to reduce exposure among pregnant women. However, there is still a clear benefit and minimal risk for the individual vaccinee.

The World Medical Association international code of medical ethics states that “A physician shall act in the patient's best interest when providing medical care.”3 If we are to deviate from this basic principle, we will need a robust ethical model for balancing individual and societal benefits.

World TB Day 2009

World TB day came and went a few days ago, while I was stuck in Bihar up to my neck in kala-azar. Now I'm in Kerala, where nobody has kala-azar, but people are coughing up clouds of mycobacteria to my left and to my right. MSF access campaign published a beautiful summary document on the current challenges to TB control.

The White Tiger

I read The White Tiger, Aravind Adiga´s novel that won the 2008 Booker prize.

From the New Yorker review:

In this darkly comic début novel set in India, Balram, a chauffeur, murders his employer, justifying his crime as the act of a "social entrepreneur." In a series of letters to the Premier of China, in anticipation of the leader’s upcoming visit to Balram’s homeland, the chauffeur recounts his transformation from an honest, hardworking boy growing up in "the Darkness"—those areas of rural India where education and electricity are equally scarce, and where villagers banter about local elections "like eunuchs discussing the Kama Sutra"—to a determined killer. He places the blame for his rage squarely on the avarice of the Indian élite, among whom bribes are commonplace, and who perpetuate a system in which many are sacrificed to the whims of a few. Adiga’s message isn’t subtle or novel, but Balram’s appealingly sardonic voice and acute observations of the social order are both winning and unsettling.

The narrator of the book was born in Bihar--which he calls "the Darkness:"

I am talking about a place in India, at least a third of the country, a fertile place, full of rice fields and wheat fields and ponds in the middle of those fields choked with lotuses and water lilies, and water buffaloes wading though the ponds and chewing on the lotuses and lilies. Those who live in this place call it the Darkness. Please understand, York Excellency, that India is two countries in one: an India of Light and an India of Darkness. The ocean brings light to my country. Every place on the map of India neaer the ocean is well off. But the river brings darkness to India--the Black river.

Which black river am I talking of-- which river of Death whose banks are full of rich, dark, sticky mud whose grip traps everything that is planted in it, suffocating and choking and stunting it?

Why, I am talking of Mother Ganga, daughter of Vedas, river of illumination, protector of us all, breaker of the chain of birth and rebirth. Everywhere this river flows, that area is the Darkness.

One fact about India is that you can take almost anything you hear about the country from the prime Minister and turn it upside down and then you will have the truth about that thing. Now, you have heard that the Ganga called the river of emancipation, and hundreds of American tourists come each year to take photographs of naked sadhus at Hardwar or Benaras, and our prime minister will no doubt describe it that way to you, and urge you to take a dip in it.

No!--Mr Jiabao, I urge you not to dip in the Ganga, unless you want your mouth full of feces, straw, soggy parts of human bodies, buffalo carrion, and seven different kinds of industrial acids.

Kidnapped MSF Staff Released in Sudan

What a mess! A few days after MSF-Holland and MSF-France were ordered to leave Sudan last week, four staff members of MSF-Belgium were abducted. The Guardian report on the kidnapping is here. According to MSF´s press release, the four kidnapped staff members were released yesterday. Unfortunately, more MSF projects will evacuate after the kidnapping, and more IDPs in Darfur who depend on International Aid will suffer.

Follow-ups

As I mentioned in the last post, we see our patients at 3 months and 6 months after they have been discharged from the hospital. If fever and splenomegaly are still present at the follow-up visit, the patient may have relapsed. These patients need to come into the hospital for a splenic aspirate. Most patients are symptom free; these patients have been cured.

Despite the cost and the hassle, approximately 80% of our patients come back to the hospital for follow-up visits. If they don’t come back, we go out and look for them.

I went out with our follow-up team last week. It turns out that finding each patient is more difficult than you might think. The process involves going to nearest town and asking directions to the village. When we find the village, we need to ask if the patient is known there. Half the time, this involves a long discussion of the father’s name, the grandfather’s name, etc. A child is sent off to the fields to bring back the patient. Sometimes the person found is not the person we are looking for (e.g. same name but different age, height, etc). It took, on average, an hour or two to find each patient from the nearest town.

I enjoyed the follow-up visits, particularly because it took me from urban India to rural India. At each village, everybody stopped what they were dong to watch; there’s not much privacy in village life. Within minutes there was always a big crowd around us. Our health educators took each opportunity to educate the people about kala-azar. There were many questions.

Childhood Malnutrition in India

In the New York Times today, an article about malnutrition in India. MSF-Spain started a project last month in Darbhanga Bihar to treat malnourished children. I hope to visit the project while I am in Bihar.

Response to Treatment

In this project we are using Liposomal Amphoteracin B (brand name Ambisome) to treat kala-azar. We use this treatment because there is a high rate of resistance to SSG-- the standard first-line treatment—in Bihar state. The L. donovani parasite is exquisitely sensitive to Liposomal Amphoteracin B. Our treatment protocol uses four infusions of Ambisome; each dose is 5 mg/kg body weight. By the end of the second infusion, there is a dramatic improvement in the patients’ status. The fever curves pictured above are typical. [The temperature in degrees F is plotted on the y axis vs time on the x-axis.] In fact, if a patient remains febrile after the 2nd or 3rd dose, we are suspicious that the patient has another source of infection. The speed and magnitude of response is unusual in infectious disease treatment. In most bacterial infections, we see a much more gradual response to treatment; the peak of fever usually decreases gradually over the course of several days.

The response to Liposomal Amphoteracin treatment is also enduring. Of the first 2000 patients we treated in Bihar, 98% of patients are symptom free at the end of treatment. In order to demonstrate the efficacy of this treatment over time, we are careful to follow-up the patients we treat 3 months and 6 months after treatment. Careful follow-up is not the standard of care in Bihar. Most patients who feel well do not return to the hospital for check-ups. The journey is too long and expensive; it requires time away from childcare and work. Despite the challenges of follow-up, we work hard to find each patient in order to prove to skeptics that patients treated with Ambisome do not relapse after cure. In the first 250 patients treated in this project, we managed to find and examine 201 of them at 6 months. 96% of these patients were still symptom free, which satisfies our definition of complete cure of visceral leishmaniasis.

Aid Agencies Expelled From Darfur

I have not seen the news for the past few days. I just found out that MSF and 12 other aid organizations were expelled from Darfur. What an outrage! NPR's coverage here. MSF's press release here. Kristof's NY Times column here.

Stress Reduction

We cannot exercise outside in Hajipur. Locals would gape at us and laugh. The streets are crowded with traffic and sewage. Without exercise, I am at high risk for takeover by my dark side.

Anne and Othman hired a local yoga instructor to come to our house. He gives them lessons three times per week at 6:30 am. The only words of English he knows are “relax” and “leg.” The rest of the lesson is in Hindi. I tried some sessions, but I find that the stress from the language barrier outweighs the benefit of yoga. I’ve been jumping rope instead.

Still alive

I have not been able to post anything lately because our internet connection has been broken. I hope it stays alive long enough to upload this two sentence reassurance to family and friends: I´m surviving Bihar. Earplugs are serving me well. I miss you.

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. “

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.

My India Stint Starts with an Adventure

I was supposed to fly from NYC to Delhi via London, leaving JFK Sunday Dec 28th, arriving in Delhi on Tuesday Dec 30th at 2am. Fifteen minutes before landing, the captain announced on the loudspeaker that he could not land due to the poor visibility. The plane would be diverted to Mumbai.

Now I'm now stuck at a hotel in Mumbai until further notice. It was a bit scary to arrive in the middle of the night, 2 hours by air from my destination. One billion people in this country, and I don't know anybody! Luckily, I was able to contact the team in Delhi to let them know what happened. I will fly to Delhi as soon as British Air is ready, brief with the team in Delhi, then fly to Bihar state the following day.

Bihar India

In three days, I will leave for Bihar India to work on another MSF project. Bihar is one of the poorest States in India. It is in the Northeast part of the country, just south of Nepal and West of Bhutan. The project is on diagnosis, prevention, and treatment of visceral leishmaniasis (also known as Kala-Azar). Kala-Azar is a protozoal infection transmitted by the sandfly. More on this disease in future posts.

I first heard about the project just two weeks ago, when I was in Liverpool, finishing up my tropical medicine course. I have not had enough time prepare for this trip, but I am excited nonetheless. I feel lucky to have the opportunity to work in Asia (my fourth continent in three years!).

Leptospirosis Outbreaks in Triathletes and Adventure Sportspeople

Leptospirosis is a bacterial infection of rats and other rodents. It can be transmitted to humans when they swim in fresh water bodies contaminated by rodent urine. Although many American doctors regard this disease as an exotic tropical infection, leptospirosis infections actually occur world-wide. The organism is a spirochete-- a coiled bacteria similar in shape to the organisms that cause syphilis and lyme disease (see electron micrograph pic at left).

Most people who get leptospirosis have a non-specific flu-like illness about a week or two after exposure. About ten percent of patients get serious complications, including kidney and liver failure (Weil's disease). Textbook cases present with subconconjunctival hemorrhage (red eyes), but of course this symptom is hardly sensitive or specific.

I was surprised to learn that there have been several outbreaks of leptospirosis in triathletes and adventure sportspeople. The largest outbreak in the United States was after a triathlon near Lake Springfield in 1998, when 12% of participants reported a post-triathlon febrile illness. Of 474 participant blood samples tested, 11% were spirochete positive (Clin Infect Dis. 2002 Jun 15;34(12):1593-9. Epub 2002 May 24). ] In 2000, there was an outbreak in Athletes who competed in the 10-day Borneo "Eco Challenge 2000, multisport endurance race." The event included jungle walking, swimming, kayaking, spelunking, climbing, and mountain biking. About half the athletes got leptospirosis. There's an interesting report of the epidemiological investigation in CDC's Emerging Infectious Diseases, Sejvar J, Bancroft E, Winthrop K, Bettinger J, Bajani M, Bragg S, et al. Leptospirosis in "Eco- Challenge" athletes, Malaysian Borneo, 2000. Emerg Infect Dis [serial online] 2003 Jun. The CDC suggests that athletes who participate in these events might want to consider taking Doxycycline for pre-adventure sport prophylaxis!

Hookworm

Hookworm is a major cause of anemia-related morbidity in the developing world. The Ancyclostoma Duodenale hookworm species looks scary under the electron microscope. Actual size is only 8-11 mm. The worm sinks those teeth into the wall of the small intestine and drinks blood from the capillary rich mucosa.

Each adult worm can consume up to about 0.25ml of blood per day. Many patients--especially children--are heavily infected. An infection of 100 worms could cause 25 cc blood loss per day, which is one unit of blood every 10 days. On top of HIV, tuberculosis, malaria, sickle cell, and poor nutrition in subsaharan Africa (all causes of anemia), it is easy to see how hookworm-related anemia is a big problem.

Kristof on XDR-TB

Kristof has a column in the New York Times today on XDR-TB in Armenia. Nothing new here, but I find it reassuring that other people are getting as worried about this as I am.

Excreta Control and the VIP Latrine

I am reviewing the water and sanitation module this morning. One of our practice essay questions: "describe briefly how you would provide an excreta control programme in a refugee camp during the first few weeks of an emergency."

Let's see... well, I would definitely pull out my Sphere Project Humanitarian Response and Minimum Standards in Disaster Response handbook. The sphere project was started in 1997 by a group of humanitarian NGOs. They collaborated on a comprehensive disaster response handbook, which is free and downloadable from www.sphereproject.org. WHO also publishes a "Guide to the development of on-site sanitation." Of course there is always MSF's "Refugee Health: An Approach to Emergency Situations,"also free and downloadable.

These resources say that at the start of an emergency, you might only have time to build shallow trench latrines, which are essentially shallow pits that are covered by a thin layer of soil after defecation.

After a day or two, you will need to build something mroe permanent, such as a simple pit latrine, or better yet a Ventilated Improved Pit Latrine (VIP). A simple pit latrine is just a slab with a hole over a pit that is at least 2m deep. The bottom of the pit needs to be at least 1.5 meters above the water line under the soil, so that the excreta doesn't leak into the surface water supply. There should ideally be at least one latrine for each 20 people.

The ventilated improved pit latrine (VIP) has several clever features that make it a better option than the simple pit latrine. There is a superstructure over the latrine part that keeps the it darker inside than outside. There is also a ventilation pipe that exits the latrine roof. Odors from the latrine exit from the pipe. Flies and mosquitoes are also attracted to the light of the pipe, rather than the dark of the pit. You can put a trap at the top of the pipe to kill the insects as they fly towards the light. Image from Water Aid, an International Charity that helps poor people gain access to safe water, sanitation, and hygiene.

The Dispensary

I've been studying a lot for our upcoming exams, but I've still had enough time to get some medicine from The Dispensary.

NYC Public Health and Human Rights Event Dec 5th

I wish I could be in New York on December 5th for this Public Health and Human Rights event sponsored by the Johns Hopkins Bloomberg School of Public Health and Physicians for Human Rights. The speakers will discuss progress since the UN adopted the Universal Declaration of Human Rights in 1948, and the many challenges that remain. The list of speakers and the panel discussion topics look promising. It should be an interesting afternoon. The full program and list of speakers is here.

Giardia Trophozoites

Giardia protoza can cause chronic diarrhea in hikers and travellers who drink contaminated water. The trophozoite attaches to the mucosa of the small bowel, preventing nutrients from being absorbed into the bloodstreem. To my eye, the trophozoites look like cartoon characters. At right, a Kohn stain, below left, a giemsa stain (pics from CDC DPDx).

Practice quiz

Try your hand at three questions that were on our Vector Biology Revision Quiz.
Hit the "comment" button at the end of the post to see the answers.

Q #1: What is this?


Q #2: Pic at left. Which mosquitoes may commonly be associated with this environment? What mosquito-born infections may be transmitted by these vectors?



Q#3: Which two insect vectors breed in this environment (pic below)? What diseases do they transmit?

World Trip Practical

In our lab practical yesterday we were assigned the stool sample of a patient who took a trip around the world. He came back to Liverpool with 22 gastrointestinal parasites. I was only able to identify 10 out of 22 species in 45 minutes. My paper was graded "average marks," which is english for C+, I believe.

Afterwards, they told us the stool contained:

Bastocystis hominis
Entamoeba coli
Entamoeba histolytica/dispar
Endolimax nana (below left)
Chilomastix mesnili
Giardia duodenalis (below right)
Iodamoeba butschilii
Taenia species
Diphyllobothrim latum
Hymenolepis nana
Schistosoma mansoni
Schistosoma japonicum
Opisthorchid group
Paragonimus westermani (above left)
Fasciola
Ascaris lumbricoides
Trichuris trichiura (above right)
Capillaria philippinensis
Hookworm
Enterobius vermicularis
Strongyloides stercoralis larve