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Sep 12, 2014

On #Cholera #Nepal

Sep 11, 2014

Glimpse of Vaccine Delivery in “Remote and High Altitude” areas of Nepal

“In remote of continents like Africa or Asia, a vaccine typically survives only five days before it spoils due to improper storage. This leaves millions of children without life-saving vaccines for preventable diseases.  In order for vaccines to stay fresh, they need to be kept between 0-8 degrees Celsius (32-46 degrees Fahrenheit).  That’s a hard thing to accomplish in warm, desert-like regions.  And it will be even harder if those places are remote and without electricity. Research organizations are working hard to figure out how to make a portable, sturdy and, most imperatively, reliable way to keep vaccines at that precise temperature.  To do that, researchers looked to a basic technology for inspiration.”


Today, I am going give you an overview of “Vaccine delivery” in remote high altitude areas of Nepal. As of now, I presume, each of us has received vaccination shots against common childhood illnesses. We must also remember that thousands and thousands of “unfortunate” children are still victim from infectious diseases at this very hour like measles, tetanus, cholera, which are otherwise easily preventable. My intention here is not to inspire or preach or convince you of what needs to be done. Instead, I am going to show you what I have personally observed and experienced the challenges while delivering vaccines in remote high altitude areas. First thing first, let me dedicate this blog post to those ladies, who are the foot soldiers for immunization in low income settings like Nepal. They are known as Female Community Health Volunteers (FCHV). They are directly involved in vaccinating the children in rural communities. Without them, immunization program would falter!!

Source: Anuj Bhattachan
The focus here would be on the challenges that we face delivering vaccines in remote and high altitude areas. So, before jumping into vaccine delivery let me give you an overview of Nepal, which is a land locked country in South Asia. The estimated population is around 27 million. It is surrounded by two giants – China in the North and India in the East, West and South. It is divided administratively into 5 regions and 75 districts. It comprises 3 ecological zones that run from east to west – Southern Terai plain, Middle Hilly and High altitude Mountainous regions in the north. Altitude increases from south to north. There are 16 -districts in the mountain region. Among these 16 districts, my particular focus would a district named “Mugu” – this is one district which has the lowest human developmental index in Nepal. 

In Mugu, there is a district health office (DHO) at district head quarter. Its responsibilities lie in the provision of both curative as well as public health services. There is only one PHC below district level. And there are several health posts or sub health posts in every village development committee (VDC), which is the lowest government administrative unit. Under each health post or sub health post, there will be FCHVs, Outreach Clinic (ORC) clinics and Expanded Program on Immunization (EPI) ORC that function to provide public health services in the community. DHO is therefore a command centre for all public health activities. In remote districts like Mugu, the sustainability of energy requirement and transportation of health commodities are of the highest priority to the district management. Once we have commodities like vaccine or delivery kits, it cannot remain in district headquarter. These have to reach people and if it is vaccine in particular, then it has to reach the children at the earliest since it has to be kept cold within required temperature.

Energy is scarce in this part of the world. The basic source of energy here is firewood. This does not help them maintain cold chain temperature for vaccine. Next nearest energy source is kerosene, which is very expensive and it is difficult to sustain for the whole district. So the next reliable source would be either solar or wind or hydro energy. Here in Mugu DHO, the source of energy is only solar energy. There is no reliable electricity source as of now.

As we are aware by now, the cold chain maintenance of vaccine is of highest importance in vaccine delivery. If we fail maintain it properly due to various reasons – human or technical error, we are committing crime to humanity. You may ask,” Why is that?” It is primarily because vaccinating a child with “impotent” vaccine is as good as giving child a poison. Therefore, the continuous monitoring of temperature and documenting those numbers is very important. However, our experience based on field observation or monitoring visit tells that this is not always done. More than technical errors, we have observed that it is in majority of cases due to human factors and partly technical. This is one area many research organizations are utilizing their innovative ideas that can address and solve both human as well as technical limitations in the system.

The primary goal of EPI is to deliver safe and effective vaccine to the children of every country, every province, every district and every village. Apart from it, we also need to realize that getting vaccinated is the birth right of every children and delivering complete dose of vaccine thereby fully immunizing them. Therefore, reaching every child is has to be our mission and we all have a moral responsibility to achieve this mission.

Source: Anuj Bhattachan
But a very practical question comes to us, “Are we able to achieve these objectives?”  This is challenging but is also doable. Why sort of challenges do we have to face.  Look at the picture (above) – these are vials of oral polio vaccine (OPV) given to protect child from “paralyzing” poliomyelitis. Unfortunately, we found in one of field inspection that many vaccine vials had to be discarded because Vaccine Vial Monitor (VVM) showed stage 4, which means they are damaged due to excessive temperature exposure.  So you may ask, “Why does it happen?” It has various reasons, as a result of human as well as technical limitation in those areas. One of the main reason, many of times, we find vaccine carriers – old, leaky and dilapidated conditions.

Another aspect of challenge in the delivery of vaccines is high drop out that leads to incomplete dose(s) of vaccine received by the child. In this, the role of mothers, health workers, community leaders, engineers, volunteers, teachers and students are vital.  Another important target for vaccination, which we tend to miss from getting them vaccinated, is all new borne babies. They are highly prone to infectious diseases. Many of times, thousands of babies are still home delivered in low income settings. Therefore, we need to serve these family and community living in hardest to reach area of any geography the most. This is one challenge that every government in low income setting are trying to solve to serve the most impoverished population and save children from preventable diseases.
Source: Anuj Bhattachan
To understand the real scenario from family and community perspective, “why many parents fail to vaccinate their children?” we have to understand the socio – economic dynamics of the community. These are some of the scenarios which we can observe or find in the community:

  1. There are parents, family or community,  who will walk for hours and hours to get their children vaccinated,
  2. There are parents, family or community, who wants to vaccinate their children but they are not aware “where and when” to vaccinate
  3. There are parents, family or community, who will vaccinate their children but are busy with family works because they have to worry about what to eat next day more than getting their child vaccinated.  
  4. There are some children, who are in the wild playing happily. Many of them are “Zero Dose” which means that they have not received even a single dose of vaccination.
There is another socio – economic aspect of a community which does affect the health of the family as well as to reach them. In South Asian society, there still exist millions of people considered “untouchables”. These people are perennially pushed at the lowest of low in the socio – economic strata. The children from these communities are usually those who are either “Zero Dose” or “incompletely” vaccinated. And it is in this community, where most of the disease outbreak occurs.

So as a vaccinator or local public health manager, s/he has to face a practical question – how do we reach these children and vaccinate them? Vaccinator has to think – how to reach there? She has to think – do I need to travel on foot or on horse and is “per diem” covered or am I insured? Many of times, these field level health workers have their own social responsibilities like we do.  I have to say, these are real public health dilemma that many of field level health workers have to go face because, on the other hand - if s/he does not carry out her duty well, then somewhere, an “unfortunate” child may get diseased or even lose his/her life!!  

In remote and high altitude areas, we need to walk for hours and hours to reach from one village to another. There is no other option. This is going to be your daily routine, if you decide to live there or serve these people.  Sometime, we have to risk our lives. Many health professionals have lost their life while in duty.  Therefore, most of the time, vaccine transportation is through human vehicle, walk for many hours to days even up to 10 days in some places. It is definitely heavy and painful, while paid less and walk for days to reach these children and vaccinate them. We have to acknowledge, the office helpers, who are indispensable in carrying out vaccination program in these remote high altitude areas. Sometime it is not easy to carry so they have devised a local method – carry it on your, shoulder, back or head.



Finally, it is said, it takes a whole community to educate a child. In our case, it takes a whole district or country to vaccinate each and every child. However, there are challenges which we have to negotiate through, so we reach each child and vaccinate them.  So, let me conclude this post with wisdom, “The best way to escape from a problem is to solve it”

Anuj Bhattachan

12 Sept, 2014

Aug 17, 2014

Dalit Reality - Poverty and Health



Dalit (दलित) =  untouchable (अछुत )

Watching this video on Dalit reality, I am angry to what goes around us.

Yes, "anger" can be natural response to protect yourselves or even your family from  "outside" dangers or can be a plethora of emotional expressions that explodes out of an individual or a community !! Here, my "anger" is a symbolic representation of what is prevalent in our society as of this year 2014. I know, anger is said to be negative energy but how can you justify not to be angry, when some souls are treated less than animals !!  I am angry at this caste system, which has pushed certain segment of your community to the bottom pit of the socio - economic ladder. In this bottom pit of the social ladder, they have forgotten to even dream or even utter a word to express their pain and sufferings, because their mental process is so clouded with fear, everything seems impossible !!

Before proceeding further, let me be very clear upfront, the purpose of this 'anger" is not to point finger or muscle flex at anybody. This is simply to turn the negative energy (that boils in your psyche) to a positive outcome that benefits all of us. So, the best way is to write what comes in your mind and what you have seen in your community. This is what I am going to do. After all, writing is so powerful !!

Today, it is gloomy outside and is raining, so I have decided to write on this (un)social, unjust or even barbaric act that exist and still goes unnoticed in our South Asian society especially India and Nepal, where millions of socially marginalized people live in abject poverty to this day. To be a bit balanced or fair to all those social activists and government agencies, who are working or advocating  tirelessly in this area,  some of these practices may go noticed and treated lawfully but this is just a "centimeter" of journey, when we need to travel "kilometers" of proverbial rough road to eradicate such social practices. Therefore, I am pretty sure that i will not be overstating when I say, "The practice of untouchability is still rampant all over the country." This is what I can say of Nepal !! 

Photo - Anuj Bhattachan (verbal consent +)
As an example, let me share a story I usually come across in various parts of Nepal. Here, I would like to share an anecdote of a Dalit family (as shown in the picture above) that I had to come across in Sankhuwasabha in Eastern part of the country. This was in the year 2008, the month of rain. I had to visit one remote village since there was a report of measles like illness outbreak, so I had to travel all the way on foot for 2 whole days. Sometime, we had to walk for hours uphill and sometime, walk downhill for hours straight to river between a gorge. We had to cross the river in an old leaky boat. 

Once we reached the village and responded to the outbreak with necessary preventive measures including samples collected to confirm the diagnosis. The local office aid from the health post advised her to consult with me. The health professionals who were supposed to be serving this unfortunate people were on long leave, and the health care delivery was the mercy of the health aid. Utilizing his knowledge and experience, he did what was supposed to be done for any kind of illnesses. At least, he was there to be beside these people in their sickness. 

Photo - Anuj Bhattachan (verbal consent +)
On that day, I came across a young girl with a worried face in a dirty clothes covering her whole body (shown in above picture). From my cursory assessment, she was in a terrible situation and top of it, being a girl from a Dalit family. She was taken to local health post after everything done to cure this skin lesion failed. Her parent told me they applied all kind of herbal ointment suggested by locals. In the health post, there was not enough medication and trained health personal. The health aid was the only guy to dispense whatever medicine was there in their cubicle. When I asked them, " What is the white ointment applied in her weeping sore?" To my surprise, it was paracetamol (anti fever drug) applied in its powder form (after they grinded the tablet) !! No comment further, I carefully examined her and came in a conclusion that she was infested with scabies.  Once the disease was recognized, the girl including family members were advised what needs to be done. I knew, if i prescribe the anti scabies drug, it would be difficult for them to purchase it. So we arranged a way that she gets the drugs and all the members also gets necessary precautions.

Photo - Anuj Bhattachan (verbal consent +) 


What stands out from this story is social ills that keeps people perennially poor & illiterate. In this environment, we are bound to suffer from every kind of exploitation, so women suffers the most. If women suffer, their children also suffer. This is where every kind of diseases take root like scabies, tuberculosis, worm infestation, skin diseases, and many others - you name it and you will find it. Therefore, I am of the opinion, it is only through healthy dialogue and discourse that we can bring change in the society. The change that accommodates people's aspiration for equal opportunity and treatment. This is one of initiative to start dialogue and discourse in this area of social justice, which is root to any kind of disease dynamics. This is one of my realization over the years. Now, i think, i have matured enough to justify my graying of hair. May Wisdom Prevail !!

17 Aug, 2014



Jul 30, 2014

Let us know more of Ebola Virus Disease (EVD)

This year 2014 started with accidents or vanishing of Malaysian Airlines (no one knows where !!) and recent sinking of a ferry carrying school children heading for Jeju Island, South Korea. We were trying to forget this sad event, now we are bombarded with news about Ebola Outbreaks in some African countries, mainly Guinea, Sierra Leone and Liberia. I am particularly interested in this news because of my personal interest scanning anything that are emerging and re - emerging diseases in literature or social media.


Though we may think, these African countries are far  away from us, so we may plainly say, "Why do we have to worry about it?" On contrary, we need to get worried. First, humanity is suffering and dying from this disease. Second, we can not rule out that this disease may spread to other continent if ecology favors it circulation. I feel, therefore, the argument, " We are geographically distant so we are not at risk" no longer holds true !! To support my point, we can talk of recent cholera outbreak in Haiti that preceded a major earthquake that ravaged whole of the country in the year 2010. This was one of the worst disaster of massive scale that human kind has to face and deal with. This natural disaster affected thousands of family losing their near and dear with high death tolls.

Once Haiti was hit by cholera outbreak, the detailed epidemiological investigation(s) along with massive humanitarian relief activities was carried out by various international organizations and universities. It was reported that the bacterium was introduced into the country by those who actually came their for humanitarian assistance in the country. This brought about lots of academic as well as political debate, which is still haunting United Nations. Some academicians asserts that the organism was introduced in there from Nepal based on genotyping study.

Let us not go into dispute and argue who brought this bacterium or who did not and play political game. My main point here is - we are now living in a global village. Our travel time is much reduced, it is also said humorously that "Nowadays that we can have dinner in Asia and Toilet in Europe!!' Partly, this is a fact, we may like it or not !! Another popular saying that floats among disease detectives is that "lethal organisms do not need passport like we humans need!!" and to add some experts even say, " Some of them even evade immigration very easily" This two statements really stress that no body is out of danger. Infectious diseases can travel across continents in disguise.We have to be extra vigilant more than ever.

Ebola virus (source: commons.wikimedia.org)

Ebola Virus Disease (EVD) is caused by Ebola virus (EV). This virus is named after Ebola river in Zaire (now DRC) and first reported in 1976. There are five species of  EV and are named after their place of origin: BundiBugyo, Sudan, Reston, Ivory coast and Zaire. This disease spread through close contacts with
blood, secretions and other bodily fluids. It is said that EVD is highly contagious and fatal. This virus circulates in animals population - Bats and primates such as Chimpanzee and even deer. Human are accidental host. (Please look up at he EV Ecology below). There is no medicine or vaccines for this disease. Some experts say that this is the result of human economic activities interfering with natural habitats. So, this is unfortunate, the people have to face this deadly diseases on top of economic hardship in low economic setting. This outbreak this year has caught many international newspapers' headline, however, I am interested to understand the gravity of this disease outbreak myself.

Source: http://www.cdc.gov/vhf/ebola/resources/virus-ecology.html

Another thought that I am playing with for these few days -" What does this outbreak means to other countries in Indian subcontinent like Nepal?" As I read in MSF blogs, EV circulates in fruit bats as its natural host and these bats are found in this continent as well. As of now, we have no report of EVD here. We should remember, there are similar kind of viral illnesses linked with fruit bats that feeds on cell sap of a tree. This are Nipah and hendra virus. These viruses have been reported from Bangladesh (to my knowledge), which is just few km away from Eastern border of Nepal. Therefore, my only concern is whether this EV can get introduced in this geographical region? I need to better understand this disease through literature. My only wishful assumption is EVD  is still geographically at distance and may be, the ecosystem here in our continent does not favors for EVD to spread. To understand more of Ebola, please visit: 

  1. WHO website - http://www.who.int/csr/don/archive/disease/ebola/en/
  2. CDC website - http://www.cdc.gov/vhf/ebola/outbreaks/guinea/
  3. PLOS Neglected Tropical dieases - http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003056