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Apr 15, 2016

Social Justice and Health issues at local level Part 6 of 24

Currently, I am reading a book "Freedom as Development" by Amartya Sen, Nobel Laureate in Economics. Prof. Sen used to be a professor in Delhi University, where started his intellectual adventurism to understand the social justice and all those values that dictates or let us say paint our social foundation, where we connect, live and identify ourselves from the period of birth to death generation to generation. I think Dr. Sen started his intellectual journey in early mid twenties with a deep desire to understand the social and economic inequality that were overtly visible in his surroundings in his youth. Also, I understood that he was trying to understand the dynamic of famines in relation to governance since there was a premise of understanding that famine can only occur where there is no democracy and civil right in the state. One key message that Dr. Sen is trying to inject in reader's mind is plain fact where we are better off in social and economic ladder only when our society (in more responsible term through state mechanism) invest in family through mother's education and their active participation in economic activities. To supplement his argument, he shares examples of another Bengali Nobel Laureate Professor Muhammad Yunus, who aligned the very structure of traditional banking system into micro financing whereby micro lending done to groups of women in the rural communities. This simple but groundbreaking financing of local community with full trust in their capability has changed the landscape of rural economy in Bangladesh, whereby this has brought immense social changes in terms of income generation and rise above the perennial misfortune of income & capability "poverty". The reason that we all agree as always in family values where mothers and sisters play vital role in the wellbeing of all the members.

For  me reading this book was a good start while trying to start the same of kind of journey a bit late nearing 40s. But still - I am now intellectually mature enough to get perspective wide open with any practical questions related to our society that torment me hard these days. So, let me start the our discussion with 4 different scenarios, which is clearly reflected in the pictures (as above), in relation to routine vaccination in remote parts of our country. In the center of this discourse for now would be focused around mother and child health through the lens of social justice and the principle of equality, which is what we all strive to achieve in a healthy community:


  1. Scenario 1: The mothers will walk for hours to get her children vaccinated and such was our conclusion when I met a family in Mugu in the midst of a jungle trail. 
  2. Scenario 2: There are mothers who believe in vaccination and want to get their children vaccinated but they do not have information where and when to get vaccine 
  3. Scenario 3: Another challenge that is bottleneck for any nation's vaccination program is when there are pockets of children who are "zero" dose and we like it or not, there are children who miss whole vaccination due to various obstacles that may originate anywhere in the path from provider (governmental health system) to family (lack of awareness/remoteness/lack of trust).
  4. Scenario 4: This is a common encounter we come across in the community when we try to understand on closer conversation related to incomplete vaccination, when the family do want to vaccinate but there priority lies on daily food earning for the family, when immunization remains secondary priority. 
The above scenarios are now, I realize, compelling piece of academic exercise to understand what goes in "real" public health sphere through the lens of biosocial approach, whereby we tend to dissect the very nature of interplay between various contributing or enabling factors such as the socioeconomic milieu, political leadership at all levels, literary situation, "existing" health delivery system from central level to family unit. Now, I again re iterate here that it is incomplete and myopic to analyze the above scenarios from the lens of vaccine science, where we limits ourselves into epidemiological tools or we give so much preferences to only "vaccine", while forgetting or little importance to the very idea of "vaccination".  Before moving further, it is also good idea to provide the distinction between these two words, which are inter - related but have some practical differences in terms of its nature of engagement with humanity. Here, I will try to distinct this two words using the vaccine development continuum, where first the candidate vaccine is discovered in laboratory and once the candidate vaccine pass the preclinical studies, then the vaccine goes into clinical trial phases until it gets licensed to be used for human use only when it is acceptable in terms of safety, efficacy and effectiveness in real field scenario. In this spectrum, the vaccine is common everywhere but the fact lies that all these vaccines are meaningless until and unless does not reach the community in acceptable and affordable way. It is only in the community when the importance of vaccine gets realized when it shows real public health impact in preventing unnecessary morbidity and mortality thereby saving lives in the community. It is in this sense linked to the use of vaccine in real community (in need) that the vaccination, which is the act of delivering the much needed vaccine, creates "value for its dollar spent" with immense impact in the community.

While trying to understand the real challenges that bring about the above scenarios whereby thousands of children are still either incompletely immunized or zero dose - we need to understand the factors that are in interplay from the "fractured" health delivery system, which is a bit explained in my previous blog post on "Glimpse of Vaccine Delivery in Remote High Altitude Areas of Nepal". Though the blog post provides a glimpse on how difficult and challenging it is for health professionals in those remote areas to provide the routine immunization - it does not provide the full explanation of other equally influential factors which are rooted in the socioeconomic landscape of the community. Before trying to explore the socio economic milieu - we have to agree to the basic premise that the "gap in immunization" portrayed above is not only health issue but also the issue of social justice, equality and liberty.  In next post - I will write more in details to socio political roots that play roles in above scenarios.

Also, I suggest you to go though this slideshare link to understand better of vaccine delivery challenges in remote areas of Nepal.

Link: 

Mar 11, 2016

Everybody is talking Zika Part 5 of 24

To start the first post for the month of March - let us take one step back and go through each previous month posts one by one and reflect on its content, meaning and relevance to what we are trying to infuse discourse among us. First - I had several questions primarily related to poverty, professional / global health dilemma (that in particularly haunted me!!) in the first January Part 1 of 24. As of this month - we are still struggling to understand "what is poverty?" Well for me, the plausible understanding to the root cause and its dynamics in the genesis of poverty is the intent of this exercise. So far - I am able to get the sketches of factors that plays role in the poverty. One point that I am clear now is that one is poor or considered  poor in his/her physical surroundings / neighborhood is not only his/her responsibility rather it is a  interplay of multiple factors from local to global influences. For example - the dire poverty in some remote village in Africa / South Africa could be dictated by the decision taken by a "influential" body in Europe. This is a fact now. Also, I have to highlight here - the question of poverty or the felt in the field of curative and preventive medicine and at large with "ongoing" discussion related with search for new guiding principle for "public health", "international health" and now "global health". This is what I can say from a perspective of a health professional who was born, raised, trained and worked for the communities in our own country. However, I can not for sure say or represent what public health professionals at the helm of global leadership have to say about their own experiences !! 

We all know that all the problems that relates with communicable and even non communicable diseases in low income countries are directly the result of poverty. Once we understand the root causes of the poverty and its social dynamics, then only can we institute sustainable, effective and affordable measures in alignment with prevailing social structure and  cultural milieu. With this idea ruminating inside my brain, I tried to tackle the question of poverty as a responsibility of each individual and even wrote that "may be it is your own responsibility and have to be responsible for being poor" For that case - I wrote the January second  post through the prism of cognitive theory, where human behavior is taken to be a interactive product of his/her personality with the surrounding environment, where he/she lives. Well - in one way it makes sense, but in  over all - we also need to understand the cause of poverty from broader perspective where politics, policy, economics, law of the land and so on. On reading the book - "Why Nation Fails" provided me a bit  panoramic view of what is our current understanding of poverty and what are the multitude of factors that interplay in its genesis in our community. For example - the prevalent social practice of "untouchability" is one that can be a case studies, where it is not only one's personality or even the environment that dictates one's behavior and lands him / her into poverty. It is systemic and systematic exclusion through the use of social and state mechanism to put one community in the state of abject poverty. Thereafter - I started to re define our understanding of poverty and its causal factors in a bit elaborate way in Feb 3rd and 4th  posts. For this - I would say "The  End of Poverty" provided me global perspective in terms of economic understandings and its dynamics. However, we still need to understand the meaning of poverty and its roots from our oriental "learning" and academia. Sometime, our understanding on the subject matter could be so much streamlined through ideology which I fear so I need to read books from our perspective, for which reading Amartya Sen would be a best choice.

Recently - I have come to a position that I have started to question our own involvement as an individual and or at the institutional level. This position though still not clear and founded on "confused" state of mind needs lots of fine tuning, which would happen only through serious scholastic work - that includes observation and analysis of real communities. Sometime (socially) but most of the time (academically) -  it is therefore good to be too critical, singular and methodical in approach to any problem or challenges like Sherlock Holmes. We wish - we could be singularly be thorough and go deep down to "root" cause analysis (of the question/challenges/crisis) to unearth the very meaning  of ongoing "hot" debate and discourse that we listen, hear and read even if we want to plug your ear or shut your mind in "pause" mode.

Yes - there is an intense discourse related with Zika everywhere around the globe. It seems, the "noise" is not only limited to global health fraternity nowadays, it has been the burning issue of global health security, which has been recently exemplified by Ebola outbreak in West Africa, particularly  those countries where the health system is ill functioning. I was listening to a recent live webcast: The Zika Crisis - Latest findings organized by The Forum Harvard T H CHAN School of Public Health on 4th March, 2016.  One of the speaker rightly cautioned all the participants that there is a valid fear that the "noise"could be slowly die down and whatever there was vibrant discussion and high degree of attention received in social media may slow down !! I also fear the same, and have a question whether and how does this kind of "public" health noise comes into light in the first place? Could it be a possibility that some scientific mind or most of us are victim of sensationalization? or it is just true and there is no other way than to panic and create noise? I do not know - I got read more and understand - I am confused more than ever. However, I agree - it is only in preparedness and keeping our home right that we will be able to deal with this kind of health threat pretty well !!

11 March, 2016
     Seoul

Feb 29, 2016

Understanding Possible Factors re: Poverty Part 4 of 24

I am happy - finally, I read "The End of Poverty" this month. I came across this book on several occasions. But i did not get the urge to read till this year when I have to go through "professional dilemma" that is directly the result of fair understanding of how the "machinery" of global health agenda functions. The global health agenda that is rooted in inherent conflict or friction as a result of our notion of developed versus underdeveloped countries in terms of poverty, inequalities, outbreaks, civil unrest, instability, hunger and so on. In this background, a question must come, why should we face a professional dilemma? Rather - we need to better equip and dedicate ourselves to deal with the existing and "would be" challenges that are surfacing around us. For examples - Haiti Cholera, West Africa Ebola, Seoul MERS, just recent ZIKA in South America. Well, exactly we are right but are we professionals from low income countries capable to tackle with such problems that has shaken pretty hard the global health security. From my personal experience - we damn have to work hard to earn an professional respect and confidence to be taken in in a team. 

Well - we may tell "just a gibberish" well - I am sharing this experience of mine for my own personal justification or valid reason. Time will tell !! What I think - it may be one of the reasons for my personal experience of "subtle cornering", which has to be linked to our "preconceived" ideas of what and how developmental partner organizations should be working to support poor countries in South Asia and Sub Saharan Countries. Myself - I have come all the way through lots of struggle to work in an organization that has a vision and mission to serve those communities living in utter impoverishment. However, I have to say honestly that after almost five years of struggle to assert a place in an competitive environment to be involved and heard within the team received deaf ear !! Well - it is always sometime the best strategy to delve inward and figure out what went wrong and what is supposedly to be improved in order to assert your place in the work place. Honestly - it did not work out despite many attempts so started to wonder what could be the reason that you are always "cornered" and "pushed aside" when your are supposed to be getting a place to utilize your knowledge and experience for what you paid for. Then  - it is hard to say - but i began to realize that it should be the case your "competencies" and "origin" that sometime matters and the kind of "subtle" discrimination unless proved otherwise !! Thereafter - I began to realize - the functioning of international organizations (not all) does not go the way as per vision most of the time (Here - I say this is all personal thoughts  and free speech allows me to express and share). I know this is too harsh to say but this is what Jeffrey Sachs also says in his book. Acutely - have I felt that your origin and competencies do matter !! So - you may again ask why professional dilemma? Well - for me - my simple assertion is how could you work with a team that sometime undermines the very public health ethics, which should enable us to respect the professional ethics that incorporate diversity and "differently" abled, competencies or even say background are also given space to grow? With this recent dilemma and also an assertion to voice you concern - I have begun to realize since our motherland is where after all we are connected and going through "dire" situation of instability, mismanagement and confusion that I realize I will put on some of my time to understand through reading and writing - "why we are in a situation that we are now in this 21st century? For us to get a clear answer - there is no ready made answer, instead we need to dig down into relevant books from available literature. That is how I have decided to read and write on "the business of poverty" as an thought experiment. 



Now going back to discourse on the book - I have to be honest - this book provided me a better understanding of poverty dynamic at local and global level. It is a bit clearer to me now that "being poor" is not only our own destiny or our own making but a mix of social, economical, political and also nature's role to play in the "genesis" of the condition that we would like to talk about, however, most of the time brush aside by saying " well - poors are poor because they are lazy and or its their destiny" Well, for me, at least from now onward - I will not be saying that statement after reading two books in row by Jeffrey D Sachs (The end of Poverty)  and Daron Acemoglu and James A Robinson (Why Nations Fail?). The following key factors stands out among multitude of reasons for poverty. So, I again say - poverty is an symptom of systemic failure like being malnourished could result from interplay of various causes - disease (malaria, aids, worms), poverty,  alcoholism, drugs, mental illnesses and so on. In this line, let us try to understand one by one the key factors of poverty: 
  1. The poverty trap: The name itself is self explainable that poverty itself leads to perennial poverty like we are trapped in quick sand. In terms of economics - when we are extremely poor then we are so poor that whatever we earn would be spent for our daily needs. There will not be any left for saving so we save some wealth and invest in land or do business. On top of it - those unfortunate people will be victim of all illness from infectious diseases, violence to all possible ills in the society. For this we can take an example of "Badi" community in Western part of Nepal, where significant proportion of population are still living with extreme poverty.
  2. Physical geography: Well - this is also one of the key reason but I would say that this can't always be the only reason because there are also some example like Switzerland which is a developed nation. Nonetheless - the physical geography most of the time put us in disadvantage, which is echoed loud and clear in recent "unofficial" blockade that Nepal as a landlocked nation had to face despite lots of voices against "rash" behavior of India in  local as well as international arena. This would not have happened should Nepal had sea port.  In this way - there are many "landlocked" countries at utter disadvantage due to their geographical location and position. On the contrary - some analyst say that the key reason for Singapore's immense development is primarily location , location and location. Howver, I would say - it could be one reason but it is not the only reason, since Singapore was fortunate enough to have dedicated and qualified leader like Lee Kuan Yew. 
  3. Fiscal trap: I think, Nepal could also be one of the best example for fiscal trap. Every year - we are repeatedly facing the same fate knowing that you land in the same "pothole" every time. This is utter foolishness but there is a need for strong political leadership with " robust" governance to address this problem. 
  4. Governance failure: I would say this is the primary reason for the case in Nepal. The failure roots back to our philosophy of daily undertaking to our habits that have been molded by our education and training. After all - it is from within us that all those representing only our government (permanent and temporary) originates from so I believe that governance failure roots within our our nation state and community. To address this factor, it is only through education and strict discipline implemented though governmental policy and law enforcement. In this respects - the leaderships should lead by example. In contrary - that is not the case in many poor countries where political powerhouses and government machinery is mired in corruption that has infected every sphere of the society. To treat such malaise of corruption rooting in the society as "malignant cancer" needs intense chemotherapy with surgical encapsulation if necessary. 
  5. Cultural barriers: In a way - this could be also a reason but should not the sole reason. Sometime we tend to say - our country is poor because the very reason for our circumstances is rooted in our 'lazy" culture and say religious misguidance. One thing i could say that for sure - that "untouchability" is one social or cultural illness that put huge population at social and cultural disadvantage whereby they are never given a chance to rise in the community. In this respect - Dalit community, who occupy one third population in Nepal, would be one example to mention and would be justified by evidence and even the constitution.
  6. Geopolitics: Sure, this could be one reason which fits well for Nepal. Sometime - it is said if your have neighborhood that is always in conflict or in friction or sometime i would say that your neighbor continuously undermines your existence then your existence would be pretty challenging. So is the condition for particularly many landlocked countries like Nepal. This was proved beyond doubt by recent incident between Nepal and India.
  7. Lack of innovation: Sure - this could be one reason but for our circumstances this factor would not weigh much significance when we are struggling for basic needs so "innovation" would be a distant dream.
  8. Demographic trap: Yes - demographic trap could be one reason that it is said that "if the community is poor then there tends to be more children's deaths and for that reason there tend to be more children to compensate for deaths and also some people reason that there tend to be more birth in such community because mother's education status and also social pressure leads to more children thereby increased population. That means, increased population with dire poverty would be unfavorable for economic and health well being in the community.
Note:
Now, after reading these two great books, I am of the opinion that any public health professionals or even scientist or project managers / administrators, who believe they want to contribute in the global effort to alleviate poverty related illnesses must read these two books to start with. The reason being - it is through our own personal experiences and realization of how people especially children and mothers have to suffer the hard reality of hardship, hunger and diseases in remote hard to reach communities. To explain a bit, let me share a recent example that I personally felt as a revelation while on a duty trip to Nepal. Here for the shake of confidentially - I will refer a person as X, who seemed a changed person after visiting a remote village in Nepal. X used to be very arrogant and too untamed to have a meaningful dialogue. X was raised and educated in a developed country and had never seen " grave illnesses" and extreme poverty from close. This lead always to confrontational dialogues while discussing about any project or program that related to low income countries or community. So - somewhere - we managed to convince X to visit a community for a few days and see the extreme conditions closely. Amazingly - that one week of stay in the community has transformed completely and I hope such transformation in outlook remains permanent. In this way - many administrative staffs from particularly developmental related organization (that works for poor countries) must be given a chance to closely understand the poverty and its effects that reflects in suffering as a result of cholera, typhoid fever, MERS, DENGUE and so on.

29 Feb, 2016

Feb 12, 2016

Yesterday, You Said Tomorrow !! Part 3/24

In the previous post of Jan part 1 of 24 – I was ruminating on thoughts that relate to poverty and said in one of the paragraphs that “it is through true in depth analysis and understanding of poverty that will help us deal with "real" public health challenges that we face in our day to day undertakings and have to solve in coming years.” I think this should be the approach when we try to understand the factors that contribute in the genesis of "perennial" poverty in any impoverished community/geography or state. While in Jan part 2 of 24 - I was trying to understand what contributes to poverty at an individual or family level. In this discourse – I tried to discuss the kind of understanding that relates with behavioral science, where one of the theories known popularly as “social cognitive theory” states the human behavior in any community or society is as a result of interplay between one’s personality and the kind of environment he or she lives in. In a way – this theory makes a sense when we see around us why one has to suffer? We know that the challenge to understand the root cause of poverty at your personal and academic level is a huge undertaking, however, it is needed and have felt acutely otherwise our engagement in this field of new public health with evolving global health security would be incomplete and meaningless !! 

For this post, therefore, I think it is right to share some observation I made while coming back from our office using a public vehicle. Interestingly, I came across “convincingly” a beautiful advertisement for a gym center which read:

 "Yesterday, you said tomorrow!!" 

Uhm…. for a while I thought what is it trying to say? Pondering for a while, I came to realize that the true meaning was “hidden and unsaid” – it was trying to say "why don't you do, what you said you would do, today rather than saying tomorrow?" The above encounter with a beautiful “phrase” in poetic theme is the true essence for this Part 3 of 24 posts on the business of poverty, infectious diseases and global health agenda that inflict and drag us into quick sand of “suffering” and neglect. One way - this observation in its deeper meaning seems to be a disconnect with the idea of poverty that we are trying to understand but in my point of view - this is where the "root cause" of poverty is linked with.  After all - it is famously said, " What you think, you do !!" What I am trying to tell is that it is in our mind set that we get as an outcome of what we think and how we think. That means, if our thinking is rooted in prejudices or superstition then we tend to behave and create a community in that closed environment in prosperity or poverty - that may be our "subtle" choice. 



It is with these thoughts popping up in your mind, I read a very good book on "Understanding the origins of power, prosperity and poverty - Why Nations Fail". This is a good book I recommend to anyone if you are interested to understand the idea of poverty. In this book - contrary to my usual understanding, the authors tries to argue that "poverty or why some nation state fails to prosper" is not limited to "geography, culture and ignorance" rather it is a complex interplay of all these factors which is compounded by  "extractive" political and "economic" machinery that has rooted in the country. It further says that in such state or community - it is hard for any innovative ideas to flourish because such ideas are thwarted as a threat to status quo. In saying so, it states that "idea of poverty"could be understood through "understanding" the interplay of political as well as economic engine of the state or community. So how do I connect and make sense of what this book is trying to explain with the poetic theme of this post "Yesterday, you said tomorrow!!" Well, for me, I think any social or political or economic mismanagement has root in us and particularly - it starts from your home and also notably your education. As we know, a family is collection of individuals who are related by birth and social ties. Further, when families are living in a village together forms a village. Many villages combining together forms a further unit in geography which could be based on local, regional or national relevance. The point is that whatever the culture of political or economic undertaking starts from us and our home. That means, if we are SMART enough to understand and use every aspect of our personal management (time, resources, ideas or culture, language) well then it does contribute positively to your family, which in turn affects the community. But if say we have a serious problem of saying "tomorrow" for everything then there starts stress, which later allows all sort of confusion to rise at personal, familial or societal level. This is what I see in our day to day life, while we tend to express this confusion in terms of ill spirit or undertaking of something evil. Therefore, in my simple understanding that "poverty" is an outcome of saying tomorrow for any task assigned for ourselves. And also, we can say poverty starts at your mindset. In this understanding, what I can say for our country would be that we are in deep sleeping with starts of "tomorrows" rather than today and now. This is one aspect of seeing or trying to explain "an idea of poverty". This is one way of looking at it but over continuous discourse, it may be more than this simple explanation. The discourse is open. After all - it is with open / transparent discussion and debate we can dissect the root cause of any social problems that we face in current space and time - that is "poverty" in terms of physical and psychological outcome.

For next post - let us try to understand the factors that may play a role in "brewing" poverty one by one:

  1. The poverty trap
  2. Physical geography
  3. Fiscal trap
  4. Governance failures
  5. Cultural barriers
  6. Geopolitics
  7. Lack of Innovation
  8. Demographic trap

Seoul - 13 Feb, 2016



Jan 29, 2016

My thoughts: The Business of Poverty - Part 2 of 24

Always, we are in search of "something" and that may be anything - happiness, wealth, health, mating partner, water to drink (or for some alcohol to get intoxicated!!) or else what would be a meaning of our "existence"? Wanting "something", therefore, dictates our livelihood. In contrary: -"not wanting or not knowing what you want" could also direct your life to nowhere or bliss otherwise !!  In this context, the word "existence" itself is a bit heavy in terms of its philosophical  (mind) or even physical (body) derivation. After all, we all know that our existence is a balance between our mind and body if one of these get tilted towards dysfunction, then we starts to suffer. This is a simple truth.

A "Dalit" family in Sankhuwasabha, Nepal @ Anuj Bhattachan
For  part 2 of 24 discourse for the month of January on The Business of Poverty - I would again stress that the word "existence" definitely does have important part to play because it is in our existence that we struggle, we work, we suffer, we cry, we get disease, we get old, we die and of course, it is in this existence too, there can exist disparity in wealth, imbalance in your cognitive skills, or other extremes that you are super rich like Bill Gates (US), Mark Zukerberg (US), Rata Tata (India),  Binod Choudhary (Nepal). All in all - it has been more of wealth as an scale that demarcates us in the metric of rich versus poor in today's material world. It is in this metric that you could be judged (we like it or not !!) - therefore, I like to ponder why there are inequalities, poverty and all other maladies that accompanies with it?? We know there are volumes and volumes of books written to explain why we become poor or to be more specific stuck in the quicksand of "poverty"? There are various explanations through the lens socio - politico - economic observations and understandings as purely the act of "invisible hands" in the realm of market forces or in some corner of academic powerhouses - there could be explanation through the lens of fairness, justice and ethics and even, we could explain the root cause of "being poor" or poverty in terms of behavioral psychology. Whatever may be explanations, one aspect of poverty that we all agree to would be that "in poverty - each human soul suffers !!". When I say "suffering" - it is primarily the health of an individual (which in turns affect the whole family and the  community at large) in terms of physical, mental, social and political well being.

In this discourse – it is always pertinent to start ourselves asking the very basic question: what is “being poor”? What do you understand by poverty? Also, this question can be answered in lay person’s understanding or through academic definitions. First – let us try to understand what it means to be poor in terms of material world? Well – one way would be how you perceive yourself and how other perceives of you or family in terms of wealth that you possess. That means – if your wealth is below what your community agrees as minimum then you are perceived to be poor, otherwise you are not poor. This is one way of perception for “being poor” but I think – this is not complete because many of times we have seen many families in communities who are considered poor in terms of material possession but they seems to be happy despite scarcity. In this case – it is their psychological, familial, philosophical outlook that may play a vital role in portraying yourselves as poor or not poor. Therefore, “being poor” is relative term but not based on an absolute yardstick. When I say this statement, let me give you an example from my observation - we used to wonder why shepherds who lives in highland are always looked happy and jolly though they used to live with bare utilities at their disposal? But now we realize – it is not always lack of material wellbeing that makes you poor but rather it is your mental outlook that may strongly determine whether you poor or not. That is why there is a famous saying that “If you are born in a poor family, it is not your mistake, but it is your mistake, if you die poor!!” This saying says a lot and matches well with a principle in behavioral science, which says human behavior (B) is a function of your personality (P = genetic makeup and habits) and the kind of environment (E) you live in (B = P * E). It is your accumulated bag of habits through learning, influences or education that we behave in a way that is either detrimental to our well-being or guide us for better living [1]. Which means the human behavior is one of the key factors for either “being poor” or “not poor”!!

Our understanding that human behavior is a function of our personality make up and the environment that we live in guides us through the proper channel for further discourse. Here, let us put forward the thesis that “human behavior dictates you being poor or not” This statement initially puts the total responsibility on oneself or control over your destiny, however we have to remember that on further dissection of each variable like personality and the environmental factors then it a bit complex and complicated task to really understand the business of poverty or “being poor”. In this complexity – understanding the personality is itself a huge field that takes us into behavioral science, psychology, psychiatry, genetics, anthropology, sociology, history and even the field of law. While, at the same pace, we have to go deeper into similar field of study to understand the environment we live in and with. After all, our living environment can be both external and internal. Even the internal environment can be further broken down into internal milieu that is the physiology of our body and most importantly - our mind – our control center.

1. Health Behavior and Health Education - Theory, Research and Practice (4th Edition): Karen Glanz, Barbara K. Rimer and K. Viswanath

Seoul, 30 Jan 2016



Jan 26, 2016

My thoughts: The New Year 2016 and The Business of Poverty - Part 1 of 24

Every new year bring freshness and hope for better of anything that we wish for - our health, wealth and happiness. It is only through this early beginning in time and space, we strive eagerly to do better with what we envision in upcoming days, weeks, months and years. Well for me - this new year 2016 is a mixture of celebration,  intro-inspection and challenges ahead !! Therefore - I would like to explore oneself, society and the evolving infectious diseases landscape through the lens of socio - political dynamics  in the community, the nations and the globe.

Looking into yourself deeper is a challenge in itself. We got to admit it upfront. For this task, either you  read and write seriously what you see, hear, feel and observe in your "surrounding" environment or seriously consider yourselves as an ascetics or yogi. Well for me - the first path is more realistic and practical, since the second path of ascetics is not wired inside my pysche !! So let us be practical and go into the thinking process now immediately. When we talk of intro inspection or even the act of observing the external world, Rudyard Kipling always comes in my mind the very first. Now and at this moment - I wish I had read and known about Rudyard Kipling - master author early in my early childhood when i was in my village far away from Kathmandu. I also wish, I was brought up in an "academic" environment where I could have read all children books and such books authored by Kipling and O Henry early on during my childhood. Well - not all are fortunate since we did not have even a single library in our district !! But, on the other hand, who else got that infinite liberty to climb up the hills, go fishing, catch frogs, ride buffalo  and taste wild berries and get stunk with wild bees !! Now i think - those days in the wild were our library of nature. It is after all -  it is you and most of the time - the physical and social environment that we grow with is more  environment. With this sensible thought - Kipling  said and wrote famously:

" I keep six honest servants - WHAT, WHEN, WHO, WHERE, WHY and HOW" [1]

Sanitation nightmare in KTM  @Anuj Bhattachan

We can also relate the above statement to "child - like" innocence with curious mind. It is only through curiosity we are able to inquire and raise brave and even funny questions. In ancient Sanskrit texts too - there is an equivalent mantra - कारण: कारण, which means "There are series of reasons for every reason !!" Succinctly - this is exactly the same principle what we strive to excel in the field of applied epidemiology or even in our day to day activities (most of the time we may fail to stick to  divine principle !!). Noteworthy, however, I would say in sincerity - being a student of public health, we have been trained and taught to think through an approach of bio - medical science, where our conceptual framework and knowledge in "real" field scenario seems to be limited !! This is being realized by many public health experts like Paul Farmer along with other prominent researchers, who have seriously felt "real" gap in global health practices in recent 2013 - 2016 Ebola pandemic that created havoc in West Africa [2]. So the question arise among us: "Are we the victim of compartment syndrome?" Here I am not referring to acute surgical condition of muscle inflammation within fascia, instead it is a derogatory term for behavior or thinking pattern that is a bit traditional or confined to narrow thoughts or practice, where our usual prescription would be to "think out of the box". In other word, we could see this pattern more in the field of medicine where there is a race for super specialization so much so that we sometime say that one day there could be "left eye specialist versus right eye specialist" !! This is an increasing trend even in Nepal.

Let us touch a little here and focus ourselves on the subject matter: it is therefore, we can openly debate what it means to be victim of "super - specialization" while forgetting the common problems like cholera / typhoid / HEV outbreaks,  those rampant  in front of our eyes in places / communities with compromised situation in terms of socio - economic - political landscape. Any realistic public health system will definitely prioritize the existing disease burden in the community. On an explanatory note: when I say "compromised" - those who have seen the "real" public health scenario of developing countries do understand well !! So, I will not expand more on this topic here (I will keep the discussion for other posts). All these thoughts and discussion will be the reading and writing tonique for 2016, so I will write more on details in the next posts re: business of poverty related diseases from an angle of "justice as fairness" in terms of fair treatment - health as basic human right. In this 24 part series, I will share more of what I would be able to understand after reading Paul Farmer (especially Infection and Inequalities), Jeffrey D. Sachs (The End of Povertyand  Amartya Sen (The Idea of Justice and Development as Freedom) in coming posts. After all - it is the truest analysis and understanding of poverty that will help us deal with "real" public health challenges that we face and have to solve in coming years to come [3]. Here, I also urge all those national and international staffs, who perceive and claim to work for the upliftment of people in the developing countries, have to understand poverty and visit those places to understand in real sense "what is suffering as a result of poverty?", otherwise we need to question the very work ethics of developmental works in the name of poverty !! So i would ask you - "have you seen very closely what is poverty? Have you seen children die because the nearest health post is 2 hours walk uphill? Have you dealt with a situation that family does not want to vaccinate their child because they do not know or have an idea what vaccine is and for?" 

In this "thinking" process and boldness to say "I do not have all the answers (in terms of knowledge and money) to solve these poverty re: problems" - I need to visit some of the slums in Kathmandu so I visited all those slums along the Bagmati and Bishnumati rivers. What I see and write here - Kathmandu is a "sanitation nightmare" (above picture). This visit has, therefore, provided me with many ideas to explore in many fronts utilizing science and its tools. Well - for now, let me leave you with these questions (as below) if you have ever  visited in and out of Kathmandu valley or else if you are serious public health researcher, then you should put aside at least 2 days to visit the major slums in the valley:
  1. What is poverty?
  2. Why people get poor in terms of socio-economic status in the community?
  3. What is the population dynamics and its actual understanding in Kathmandu valley?
  4. What is the actual pattern and distribution of water borne illness in Kathmandu valley? Can we map it??
  5. What are those policy, strategies and action plan from government of Nepal (particularly Kathmandu municipality) to solve huge sanitation challenges in Kathmandu valley?
Reference:

[1] Rudyard Kipling - https://en.wikipedia.org/wiki/Rudyard_Kipling
[2] Bio-social Approaches to the 2013 - 16 Ebola Pandemic -    http://www.hhrjournal.org/2015/12/biosocial-approaches-to-the-2013-2016-ebola-pandemic/
[3] The Neglected Dimension of Global Security - A Framework for Countering Infectious Diseases Crises - http://www.nejm.org/doi/full/10.1056/NEJMsr1600236?query=TOC&

Seoul, 26 Jan 2016

Dec 30, 2015

Review of 2015 - "Justice as fairness"

Let me start this post with the statement - "Justice is fairness". This will be the theme for the year 2016 in monthly posts, which will relate to global health agenda on the business delivering public health tools and utilities for vulnerable population in low income countries. Here I will not try to delve into detail of its definition for key words "justice" and "fairness" instead I would advice you to read Amartya Sen's thick book on justice - "An Idea of Justice" if ever you want get perspective on this topic.  However - it is still my responsibility to  elaborate a little on the context of this statement related with "justice", which could have both western and eastern meaning to it. Above all - again I would repeat "Justice is fairness" is the bottom line in my  discourse. Somebody said sometime "justice" could be  veiled in the  name of "just us" rather than truly believing in and practicing  fair treatment in our everyday life. In Nepali - Sanskrit - Hindi - we say "Nyaya" for the term "justice".  From my understanding - "justice" could be a vague word like "ethics" that relates to professional practice. It does have its meaning in our everyday only when it takes the shape of policy / law / statute or when  we truly practice what we believe. Otherwise - we can read and hear values such as fairness, transparency, respect for diversity in many organizations but do we really practice these values or we just preach for the shake of looking good?? I am asking this question to myself after years of observation and experiences at personal level at national and international fora and platforms. Sometime -  it takes lot of understanding, evidences and guts to  speak up against unfair treatment against any individual, community or citizens.
 
"Struggle against injustice should continue at any cost"
 

http://www.junglewatch.info/2015/11/time-to-fund-ccog-and-take-this-to-court.html

 
While writing this post - I am worried about our country and people when we are shaken terribly with recent earthquake and on  top of it - "undeclared & unofficial" blockade from our neighboring giant called India. This situation brings about serious discourse into the justice and fair treatment when such insane behavior sticking to the traditional practices like "big fish eats small fish" kind of wild justice. It is worrying that this should occur at diplomatic level when there definitely exist international understanding dealing with land locked country who is double hammered by earthquake of great magnitude and economic blockade. With current prevailing situation - I have firmly believed that unjust behavior occurs not only at person to person level but at the organizational and country to country level. All of us have become the witness to "insane" decision taken at diplomatic level. So what I am saying is all Nepali people are in a difficult situation that we did suffer after Maoist insurgency.
 
"Nepali people are going through an unprecedented magnitude of suffering  following Earthquake and blockade"
 

Source: www.google.com

 
Now - back to reality - 2015 have been a mixed experiences while we all Nepali people are suffering hardship as I said earlier and also 2015 was fruitful when it comes to my writing journey through blogging. I wrote about cholera and vaccination in Nuwakot and viral hepatitis E in Nepal. Some of the posts were also wrote on ad hoc basis, while majority of the postings were as per plan. After all this writing experience - one theme that stands out would be global health issues related with health security, equity and of course politics. All these issues could be addressed through smart advocacy and evidence generation from the community. Therefore 2016 needs to be the year of revelation of our writing skills and test of perseverance. I know - 2016 would be challenging for me, but I have decided that it has to be fruitful in terms of writing notes on health agenda for Nepal that links to global health landscape. In order to write effectively - I need to read on such issues and I think the best authors to read would be Paul Farmer and  Jeffrey Sachs. Any way - I would start my new year by finishing a book on Elon Musk (how the billionaire CEO of Spacex and Tesla is shaping our future). Having started reading this book - in one of the chapter - he shares his revelation after reading one of his favorite book " The Hitchhiker's Guide to the Galaxy" where the author points out " one of the really tough things is figuring out what questions to ask". I can imagine - how lucky was Elon able to understand and get to read such books at such tender ages. We also remember that we used to come across books but never got attracted or even read such kind of books so seriously. Now I can feel how reading books at such tender age could engineer your though process and become well informed. For us - I think this is what we missed the most !!
 
"Narja and Thingan visit"
 
Another remarkable moment in the year 2015 has been our Narja Mandap (Nuwakot) and Thingan (Makwanpur) visit this month in December. The main objective of the visit was to monitor the mother and child health survey in Narja and the follow up visit of Thingan regarding cold chain project. This visit was also an opportunity to witness ongoing "real" public health work in Earthquake affected villages outside Kathmandu valley. Anybody could feel the warmth Narja locals showed to us despite the hardship and it was our luck that we met a wonderful being Mr. Gokarna in Narja. He took care of us without any irritation. He was able to treat us with warmth and hospitality in his temporary tin roofed shelter. We all slept well in that harsh winter at such altitude. Also, he was taking care of Octogenarian mother, who was still walking around helping with household chores. Even she prepared tea and served us after our day long visit for the survey. This should be the best tea that I relished in that climate of Narja. All the locals including female community health volunteers (FCHV) helped us in the task  of survey. Otherwise - it would have been very difficult to conduct such survey within 3 days. For this conduct - district health office fully supported this small mini project. Mainly - Mr. Bishworam and Pradip were wonderful  persons in helping out this survey. We look forward to a final report which will bring out the issues related with mother and child health in the village. We believe, this survey will also help the local health post in addressing the gaps that relates to the health care delivery at the door level in the community.
 
2016 should be challenging and transforming - it is only through struggle we rise above the common pitfalls. When we look at our fellow citizens - we need to work hard and of course from my side - we need read more and write more. In such positivity of our outlook - we can do away with any challenges that befall upon us. Therefore - 12 chapters needs to be written so what I read and write should go parallel and meaningful. Otherwise - time and moment wasted would get wasted !!
 
31 Dec, 2015
Kathmandu
 

Dec 22, 2015

One Dose at a Time: Advancing Oral Cholera Vaccine Use Globally

[Note: This  write up  was published as  Partner News in Cholera Prevention  and Control (CCPC) Newsletter on 25 Nov 2015)
 
There were several milestones in 2015 for the oral cholera vaccine (OCV).  Originally based on a vaccine developed in Vietnam, the OCV was reformulated by the International Vaccine Institute (IVI) with support from the Bill & Melinda Gates Foundation, and the governments of Sweden and South Korea. Shanchol was finally WHO-prequalified in 2011 and is an example of successful international public-private partnership.
 
IVI continues to work on the cholera vaccine agenda by increasing the global supply of OCV and by increasing demand for OCV.  Among the 2015 highlights, IVI is partnering with additional manufacturers that include EuBiologics of South Korea and Incepta Vaccine of Bangladesh that will help ensure a sufficient supply of doses globally and for the stockpile. EuBiologics’ vaccine is expected to be WHO-prequalified by the year end.  Incepta’s vaccine, Cholvax, which is targeted for the domestic Bangladesh market, will be available by 2017.
 
IVI also contributed to the growing body of evidence on OCV use in real-life settings. In 2015, it provided technical and financial support to local governments to conduct pilot vaccination campaigns in Ethiopia, Malawi, and Nepal.  Each country had a different cholera scenario.  In rural Shashamene, Oromia Region, Ethiopia, cholera is endemic. Therefore, a preventive campaign was conducted in collaboration with the Ethiopian Public Health Institute, Oromia Regional Health Bureau, West Arsi Zone Health Department and LG Electronics. The campaign was conducted from February to March, vaccinating >40,000 people >one year old.  It was the first mass vaccination targeting people at risk for endemic cholera in Africa.
 
In Malawi, major floods struck the southern part of the country at the beginning of the year, resulting in cholera outbreaks in camps for people internally displaced by the floods and neighboring areas. To prevent the outbreak from spiraling out of control, an emergency vaccination campaign was implemented in Nsanje District from March to May.  With the Malawi Ministry of Health and Sanitation, WHO, JSI, Nsanje District Health Office and with funding from Kia Motors and South Korea’s Ministry of Foreign Affairs, approximately 160,000 people were vaccinated.  An additional 10,000 people in Chikwawa were vaccinated. With support from the Bill & Melinda Gates Foundation, IVI will conduct vaccine effectiveness and cost-of-illness studies in Nsanje to establish further evidence on the impact of vaccination.
 
Finally, following the devastating earthquakes that struck Nepal in April, the Epidemiology and Disease Control Division (EDCD) of the Nepali government called for preventive cholera vaccinations in selected villages of earthquake-affected districts due to concerns over possible outbreaks in high-risk areas, particularly rural, remote areas where infrastructure and health services were destroyed due to the earthquakes. A campaign was conducted by EDCD with support from IVI, UNICEF and GTA from August to September, vaccinating approximately 10, 486 people in Nuwakot District.  Coverage was high (100.5% during the first round and 96% during the second round).  Due to the success of the campaign, EDCD and IVI are under discussions to expand cholera control and prevention efforts next year through a possible collaboration with Rotary Club of Southwest Seoul and Rotary Club of Nagarjun Nepal.
 
Link:
 

 

Dec 5, 2015

Understanding Leptospirosis

Leptospirosis, also known as fall fever or mud fever, affects both animals and humans. This disease occurs worldwide, and the highest prevalence is in tropical climates and in warm and wet environments with poor sanitary conditions (6). Leptospirosis is an increasingly recognized cause of acute febrile illness throughout the tropical and sub-tropical regions of the world (2).Leptospirosis is presumed to be the most widespread zoonosis in the world; it is caused by pathogenic spirochaetes of the genus Leptospira (1–4). Humans are accidental hosts and usually become infected through contact with water or soil contaminated by the urine of infected animals such as rodents, dogs, cattle, and pigs. Exposure of skin or mucous membranes to leptospires can lead to infection. Clinical signs and symptoms are variable and range from subclinical to potentially fatal manifestations. Leptospirosis should be suspected in febrile children with contact with flood water (1). Interestingly, in this setting, many exposed people have asymptomatic seroconversion and some also undiagnosed fever; a small but important minority may develop severe disease. (3) The significant household clustering of Leptospira infection in slum communities, indicating that the household environment and related factors are important determinants for transmission of urban leptospirosis (4)

Leptospirosis is an emerging zoonosis that is often under-recognized in children and commonly confused with dengue in tropical settings. Unrecognized leptospirosis can be a significant cause of ‘‘dengue-like’’ febrile illness in children. Increased awareness of pediatric leptospirosis, and an enhanced ability to discriminate between leptospirosis and dengue early in illness, will help guide the appropriate use of healthcare resources in often resource-limited settings. In a semi-rural region of Thailand, leptospirosis accounted for 19% of the non-dengue acute febrile illnesses among children presenting during the rainy season. None of the children with leptospirosis were correctly diagnosed at the time of hospital discharge, and one third (33%) were erroneously diagnosed as dengue or scrub typhus (2)

Heavy rains were followed by an increase in laboratory-confirmed cases of Leptospirosis (5) Leptospirosis has become an urban health problem as slum settlements have expanded worldwide.  Deficiencies in the sanitation infrastructure where slum inhabitants reside were found to be environmental sources of Leptospira transmission (7)

This disease continues to have a major impact on people living in urban and rural areas of developing countries with inestimable morbidity and mortality.  It is widely recognized that the incidence of leptospirosis is remarkably underestimated and the disease underdiagnosed in endemic regions. Leptospirosis is estimated to affect tens of millions of humans annually with case fatality rates ranging from 5 to 25%. In endemic areas of leptospirosis, factors such as lack of sanitary conditions, mud flooring, together with rainy seasons and flooding catastrophes contribute to periodic outbreaks (3,8).

 Reference:
  1. S Karande, M Bhatt, A Kelkar, M Kulkarni, A De, A Varaiya : An observational study to detect leptospirosis in Mumbai, India, 2000: Arch Dis Child 2003;88:1070–1075
  2.  Libraty DH, Myint KSA, Murray CK, Gibbons RV, Mammen MP, et al. (2007) A Comparative Study of Leptospirosis and Dengue in Thai Children. PLoS Negl Trop Dis 1(3): e111 doi:10.1371/journal.pntd.0000111
  3. ER Cachay and JM Vinetz: A Global Research Agenda for Leptospirosis: J Postgrad Med. 2005 ; 51(3): 174–178
  4. Maciel EAP, de Carvalho ALF, Nascimento SF, de Matos RB, Gouveia EL, et al (2008) Household Transmission of Leptospira Infection in Urban Slum Communities. PLoS Negl Trop Dis 2(1): e154. doi:10.1371/journal.pntd.0000154
  5. Yu-Ling Chou, Chang-Shun Chen, and Cheng-Chung Liu : Leptospirosis in Taiwan, 2001–2006 : Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 5, May 2008
  6. Ken Brown and John Prescott: Leptospirosis in the family dog: a public health perspective: CMAJ • February 12, 2008 • 178(4)
  7. Reis RB, Ribeiro GS, Felzemburgh RDM, Santana FS, Mohr S, et al. (2008) Impact of Environment and Social Gradient on Leptospira Infection in Urban Slums. PLoS Negl Trop Dis 2(4): e228. doi:10.1371/journal.pntd.0000228
  8. M J Pappachan, M Sheela, K P Aravindan : Relation of rainfall pattern and epidemic leptospirosis in the Indian state of Kerala: J Epidemiol Community Health 2004;58:1054–1055

Nov 30, 2015

Nepal Situation after Earthquake, New Constitution and Unofficial blockade

All of us have to be vocal in what you believe should be the norms and of course fair treatment, be it at personal, professional or international level. Here, I am referring to Nepal situation. Well, the year 2015 has been historical and will remain  in  our memory for centuries. In this time, all Nepalese must listen to this TED talk: 

 

Nov 19, 2015

Landscape of Viral Hepatitis E - local issues (Part III)

On 6 and 7 November, 2015 - Epidemiology and Disease Control Division (EDCD) under of Department of Health Services (DoHS), Ministry of Health and Population successfully hosted the first ever national symposium on Viral Hepatitis E in Nepal (Picture 1) The main objective of the symposium was to bring all key government officials, academicians, physicians and public health professionals into one forum and thereby share, discuss, reflect and question on the epidemiology, surveillance, diagnostics, clinical presentations and associated complications and preventive measures so far in Nepali soil by Nepali themselves. In this way, I would consider, the symposium had left a remarkable impression among delegates that we have so much resources and understanding about the diseases that we are able to do any complicated studies with our own resources.
 
Picture 1: Inauguration of the first HEV symposium in Nepal (6 Nov, 2015)
Photo Courtesy: @Yeti4mNepal
In this effort, as I mentioned in the earlier post, this symposium would not have been possible without the leadership of Dr. Baburam Marasini, current director of EDCD, Dr. Guna Nidhi Sharma, Deputy Health Administrator, Mr. Resham Lamichhane, Mr. Bhim Prasad Sapkota and many other important personalities from the team at EDCD. Not to forget, UNICEF country office - Nepal wholeheartedly supported this symposium along with International Vaccine Institute (IVI) and GTA - Nepal. There are other  important dignitaries who have supported this symposium - namely Drs. Sarala Malla (Ohm Hospital), Buddha Basnyat (PAHS), Shyam Raj Upreti (GTA), Ganesh Dangal (NESOG), Ananta Shrestha (Liver Clinic), Nabin Rayamajhi (PAHS), Mr. Deepak Bajracharya, Lenjana Jimi & Kshitij Karki (GTA). Other dignitaries from BPKHIS, Dhulikhel Hospital under Kathmandu University, Sukraj Tropical Hospital were also actively involved for the success of this symposium. I would also say that Dr. Samir Dixit (Center for Molecular Dynamic Nepal) was also our attraction among our delegates, who made the symposium lively with practical questions and suggestions to the speakers. Above all, the  group discussion was very fruitful in that it brought significant numbers of practical recommendations.

We strongly believe with local voices that represent the "real" public health need of curative and of course, effective preventive measures have to be elevated to new heights. When we say "new heights" - it  means that there is a strong need for applying the available public health tools or medicaments through the principle of equal access to vaccine or diagnostics at affordable prices in the community. The symposium has generated recommendations both  programmatic and academic so the moral responsibilities lie with us (including international organizations / research organizations / vaccine companies) to move forward  with concrete measures in HEV prevention and control in future.

Recommended reading:

1. Report on the International Symposium on HEV, Seoul, South Korea, 2010
2. Hepatitis E Epidemic, Biratnagar, Nepal, 2014

20 Nov, 2015

Oct 23, 2015

Landscape of Viral Hepatitis E in Nepal - let us explore what can we do to advocate for its control and prevention (Part 2)

In my previous blog post - I wrote briefly to understand the basics of Viral Hepatitis E (HEV), which is one of the basic requirements before we even contest ourselves in the business of prevention and control of HEV in Nepal or anywhere. Again to review what I remember - HEV is RNA virus single stranded and in particular - genotype 1 and 2 are related with outbreaks in human beings. This is considered neglected tropical diseases, however slowly - there is a growing interest in this disease because it has significant health impact among pregnant women. Well, now it is time for funders, governments and academicians to work and bring out preventive and control measures in the table for discussion. Otherwise - it will always be limited to news media !! Bottom line - it is time to act through something concrete for people to rely on when they are sick or even before they are sick !!

In this respect, Epidemiology and Disease Control Division (EDCD) under the leadership of Dr. Babu Ram Marasini, who is the current director with support from his staff teams like Dr. Guan Nidhi Sharma, Deputy Health Administrator has taken a bold step to convene HEV symposium in Kahtmandu in middle of chaos and uncertainty. We have to acknowledge this step taken since we know this initiative will lay foundation for future initiatives. Simply - we do not want to hear any more HEV outbreaks in our vicinity and of course in news media. It should be made history forever !! We can do it and we have human resource and tools for it. For you information - HEV symposium will be held on 6 to 7 Nov, 2015.

 

In this effort, we have seen a close collaboration between EDCD, UNICEF, WHO, IVI and GTA. We look forward to engaging fruitful discussion thereby will bring out recommendation to formulate national strategy in the control and prevention of HEV in Nepal.

    24 Oct, 2015
Seoul, South Korea

Oct 16, 2015

Landscape of Viral Hepatitis E in Nepal: Understanding the basics first (Part 1)

I am not an expert but out of curiosity - I am again writing on Viral Hepatitis E as a public health physician and also who understand this disease at personal level out of suffering. Please also read my previous summary post on Understanding HEV in Nepal.

Most of the time, the word "poor" is painful !! This is what  I feel - so why is it painful? Well, being "poor" is after all a package full of "suffering, hunger, diseases and  of course struggle". I am not in a position to ventilate every pains of being poor here, however I would like to bring one public health issue that has plagued our communities since centuries. In the business of being poor and others considering you poor - there is lots of differences and of course paradoxes. Sometime, I feel the concept of "poor" is more of psychological assessment of yourself rather than other labeling you a poor chap or even a poor country !! Here is one example: I meet many shepherds in highlands of Nepal, they do not consider them poor and they are the happiest individuals I have seen and come across. But in the index of modern socio economic scale, he will be considered poor; that's it !! This is one aspect of looking at being poor, however "poverty" is rather a more appropriate word when we correlate the factors associated with enteric disease that I am touching upon in this post. So I would use the word "poverty" more often trying to connect with enteric disease that inflict a community where there are perennial problem related with the provision of adequate water, sanitation and hygiene practices. But sometime, let me be a bit critical - people shades crocodile tear in the name of poor and poverty and do business for their benefit. I have come to realize this inconvenient truth late and of course out of humble understanding that everybody is honest in what they do and work for the noble cause to end the suffering of those in living in poverty stricken community. In this regard, I agree with some of our colleague that one who stays in 5 star hotel and wears a pencil healed shoes can't work for the poverty stricken community. This is another bitter truth !!

Now to the subject of the blog post for now. There are long list of enteric diseases that catches attention of any physician working in low income setting from enteric to vector borne illnesses that can inflict an individual from your head to toe. Here, I am writing few words on enteric disease that has outbreak potential and has been yearly headline in dailies in Nepal. Yes, your guess - viral hepatitis and in particular hepatitis E. Popularly, this enteric disease is known by the name of "viral jaundice" among health professional and layperson in the country.  For our knowledge, this viral hepatitis is a recent discovery in early 1980s in Kashmir, India. Back then, it was known by the name of "epidemic non - A, non - B hepatitis" or "enterically transmitted non - A, non - B hepatitis". However, this disease entity was genetically characterized in 1990s, thereafter named formally Viral Hepatitis E (HEV).
 
HEV is explained as a spherical, non enveloped virus with a single stranded, positive sense RNA genome. This is the only member of a new genus, Hepevirus, in a new virus family, Hepeviridae. There is a description of 5 genotypes (G). G1 and G2 have been recovered only from humans whereas G3 and G4 are recovered from both humans and swines. G5 is an avian virus. It is clinically difficult to differentiate with other viral hepatitis in terns of clinical presentation, however on careful history taking and examination we are able to delineate from hepatitis B and C. The incubation period (IP) of HEV can approximately of 40 days. It is also reported that HEV infection never progress to chronicity and can be diagnosed by detecting viral RNA (RT - PCR) in the serum and / or feces during IP or early acute phase of disease or can be diagnosed by demonstrating anti - HEV of the IgG class in the serum during late phase or convalescence period of the illness. As a common knowledge, this disease is self limiting illness so need to be treated symptomatically and there is no specific therapy as of now. However, we hear that antiviral drugs are in research phase.
 
The most dreaded part of HEV infection and why there is so much interest in the HEV vaccine development and its prevention is its grave complication that occur if infect pregnant women. There are numerous reports of maternal deaths with serious (fulminant) hepatic failure or in mild or moderate, it can cause loss of pregnancy. Therefore, HEV has serious public health importance in terms of maternal child health protection. Also, there are lots of other medical complications among those with chronic liver ailment or even other chronic illnesses.

From public health perspective, HEV and other enteric diseases like cholera have been relevant in the backdrop of increasing disaster situation that has led to public health disaster like situation. Name it - very current would our Nepal experiences, though fortunately we did not have major outbreaks but you never know what comes up there in coming days. Last year, there was HEV outbreak in Biratnagar and we all know well - how tough it can be when such outbreak occurs in the center of bustling  town. Much to worry, however, would be if such outbreaks occur in hard to reach areas of the country like the one that occurred in the year 2009/2010 where cholera outbreak took hundreds of lives untimely. It is therefore always in the best of investment that we work on the preparedness now, so we know what, how, where and who kinds of approach when such outbreaks occur in remotest part of the country.

17th Oct, 2015
      Seoul
 
 

Sep 14, 2015

Glimpse of Acute Watery Diarrhea (AWD) Surveillance in Kathmandu (Part 3)

[This is a personal log and does not represent any organizational position]

Dr. David Sack in his May post in stopcholera blog writes "quick, efficient and reliable surveillance that is supported with robust laboratory surveillance do save lives". This is a fact that nobody can deny, however conducting a surveillance in an efficient manner do cost a lot of money and above all - an efficient coordination and collaboration is the key deciding factor. In this post, I would like to dive into the actual functioning of the surveillance activities in Kathmandu valley. Also, i hear "surveillance" as a buzz words among all stakeholders involved in the business of communicable diseases prevention and control in Nepal.

Basic first: the meaning of surveillance is data collection, analysis and its interpretation for prompt public health action. In this respect, data is power. Some people even go further in saying that power is political so data is political !! I think - there is partial truth in this statement. The main objective of disease surveillance is to rapidly identify any re-portable epidemic potential infectious diseases [acute gastroenteritis (AGE) / acute watery diarrhea (AWD) / cholera].

Currently, there are several sentinel sites established and enhanced within Earthquake affected 14 districts of Nepal. This is a syndromic surveillance. Also, there exist Early Warning Reporting System (EWARS) which started with 6 re-portable diseases in early years of 1990s. There is also Vaccine Preventable Diseases (VPDs) surveillance in parallel that runs through Program for Immunization Preventable Diseases (IPD), which is a collaborative effort of child health division (CHD) and WHO country office Nepal. As of now, there are EWARs surveillance going on in 81 sentinel sites in 75 districts, which reports and  alerts on daily/weekly basis. The collection method of surveillance data are said to be conducted through informers or through mobile - text and paper form. Additional responsive activities  are daily situation report and weekly bulletin and also the situation of AGE and cholera in KTM valley.

Today, Dr, Marasini, Director of EDCD started the meeting with opening remarks "Cholera is a severe waterborne illness that kills within hours not days." Also, he added historical anecdotes where people in the rural areas had to be abandoned in rivers or even their home to die because of extreme fear that was associated with this diseases and even a Nepali queen then died due to this disease. He also said that "Cholera does not spread in a straight path that can be easily predicted !!. Most importantly, Dr. Marasini referred to the first scientific paper reporting cholera outbreak in KTM valley in the year of 1886 published in British Medical Journal (BMJ). With this background, Dr. Marasini concluded by stating that "Surveillance is the heart of any public health system and further added that this plays vital role to avert public health disaster. Therefore, surveillance has to be inbuilt system that should be robust able to detect any potential outbreak early"

The core activities that have been done and planned in order to strengthen the surveillance system in Kathmandu valley are as following:
  • Issue official letter from EDCD to support the surveillance activities
  • Visit all important health institutions in KTM valley
  • Coordination with NPHL / lab
  • Identify for surveillance gaps
  • Orientation & training if and when necessary
  • Logistics and swift management when and where required
  • Regular M & E
  • Data mx and analysis
  • Lab sample collection and transportation
  • Response and action 
Finally - I liked Dr, Marasini stressing a point very effectively saying "Cholera spread does not take straight path instead it takes zig zag path - very unpredictable, if we do not have a robust surveillance to detect early and response." Also,  "Poverty is humankind's greatest injustice" said Mahatma Gandhi while we know cholera is a disease of poverty. This means very  straight - detecting cholera outbreak in the community means there exist injustice but not sure who are responsible for such injustice. This remains a question for next write up !!

14th Sept 2015 
Kathmandu

Anuj in Himalayas

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