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.