| Nepal:
National Immunization Day
I
feel privileged to be a part of the
first STOP team. We are literally racing
against time (to eradicate polio).
Nepal borders one of the last remaining
hotbeds of polio in the world: the
northern Indian states of Uttar Pradesh
and Bihar. People cross the border
in both directions every day. Our job
will be to set up surveillance networks
for polio, especially in Nepal’s poor
but highly populated Terai districts
on the Indian border. We have to know
where the disease is and where it isn’t,
and we have to move fast. It’s the
most exciting job I’ve ever done.
Our first
day in Nepal was a National Immunization
Day (NID) for polio. Everywhere we saw
little tables under blue signs proclaiming
in Nepali script, “National Polio Vaccination
Day.” There were vaccination teams at
bus stops, at the bazaar, in clinics
and by the side of the road. In the temple
city of Bhaktipur, we saw roving teams
going door to door, vaccinating. We saw
a tiny parade of uniformed Nepali scouts
marching the cobbled streets announcing
by megaphone, “Free polio vaccination!
All children under five.”
The vaccine
is oral: just two drops in the mouth.
It’s about the easiest vaccine in the
world to give, which is one of the reasons
we think polio can be eradicated. No
needles, no shots. It was impressive
to see how the community mobilized. There
were people from all walks of life, all
motivated, all pitching in: nurses, midwives,
sports clubs, shopkeepers, politicians,
and at least one veterinarian (me). Over
three million Nepali children received
polio vaccine that day. The previous
day, India had vaccinated over 130 million
children! Support for polio eradication
is so universal that even countries in
the midst of war have called cease-fires
for NIDs. El Salvador, Sudan, Afghanistan
and Sri Lanka all have had cease-fires
for NIDs.
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Bangladesh:
Working around strikes
As
soon as we arrived in Dhaka, we have
been plagued with hartals (strikes) which
shut down the city. No cars travel during
hartals, but rickshas (bicycle driven
passenger vehicles) are allowed to operate.
There was a hartal this past Thursday,
and we traveled by ricksha to our meeting.
It was actually quite fun without the
congestion of cars on the road.
Each
of us has been assigned to two districts
and will work with the surveillance medical
officer responsible for this area. I
have been assigned to Kurigram and Lalmonihat
districts in the Rajshahi Division. This
division is one of the largest and is
in the northwest corner of the country.
It is primarily agricultural (wheat,
rice) and is the center of the silk industry.
I am impressed with the roads here, which
are well paved. My two districts are
considered to be “hard to reach” areas.
The Lonely Planet guidebook does
not even mention them.
I
was scheduled to fly to my division last
Saturday. However, yet another hartal
was planned for Saturday. Fortunately,
the hartal was only scheduled for half
the day. Exactly at noon, cars appeared
on the road, and I was whisked to the
airport in time for my 1 p.m. flight.
The
surveillance medical officer had scheduled
a workshop to strengthen surveillance
and routine immunization for one of my
districts on Sunday. So, I hit the ground
running and spoke to the participants
about the importance of surveillance
for acute flaccid paralysis (AFP) and
their role in polio eradication. Later
that day, we did a 60-day follow-up of
an AFP case. The child ran away from
us as we approached, so it was not a
case of clinical polio.
The
next day I went to Romari, a sub-district,
which is a char (island). I traveled
by boat for three hours and then by motorcycle
to the health clinic. I only saw one
car, the ambulance, while there. The
SMO and I gave an orientation on AFP
to the nurses and visited an outreach
immunization clinic. We then traveled
to the Indian border through paddy fields
by motorcycle. The sub-district
health officer is doing a great job providing
services considering the obstacles in
his way (shortage of manpower, hard to
reach villages).
Hartals
were scheduled for Wednesday and Thursday
so we traveled back to Dhaka. I'm not
sure if I will have e-mail access while
in the field. So, I wanted to give you
an update while I was in the city.
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Ghana:
Preaching about polio
Finally,
I am on the Internet, and it is really
working well for the first time since
I've been here. It's the rainy season,
and the storms caused power blackouts.
No power today until 4:00 p.m.
Right
now I'm in Wa, the Upper West Region.
I have been out in some extremely remote
villages not too far from Burkina Faso.
We went to Hamile, which is on the border,
and I sort of made a border guard angry
by not asking for permission to take
a photo. We have been visiting all the
clinics and I've been asking, and preaching,
about AFP. Looking around, I can see
they really do mobilize and do an excellent
job during their NIDs (National Immunization
Days). I'm impressed with their hand-drawn
maps showing where to go and give the
two drops of polio vaccine.
"You
are welcome," is the standard greeting.
I'm truly happy to be out preaching the
message. I'm getting so that I am wishing
that I could extend and keep on doing
what I'm doing.
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India:
A "refreshing" story
On
Sundays, if there are no acute flaccid
paralysis (AFP) cases to investigate,
we generally have that day off to relax
and rest for the next week. However,
being cooped up in a hotel room all day
gets old, so I decided to go for a serious
hike around Muzaffarpur (along the mid
Indian-Nepal border area).
Starting
at noon I walked for two hours in one
direction outside of town. Realizing
I was on the verge of heat exhaustion
as I had stopped sweating, I decided
it was time to head back which again
took two hours (I drank pump water along
the way).
Arriving
back in town I stopped by a shop and
got an ice-cold Limca (lemon-lime drink)
which tasted great as I was pretty dehydrated
at this point. Noticing a nearby well
I decided to take a picture with my digital
camera just to have a reference shot
of standard water sources in India. The
shop owner who was standing next to the
well asked if I wanted my picture taken
also so I decided what the heck, I didn't
have a single picture of myself so far
during my stay in India. As I stood by
the well about 20 people rushed in quickly
to be in the picture (other shop owners
and people standing nearby). I guess
they thought I was a photographer for
National Geographic or something!
As
one of the men rushed in at the last
second to squat down on the front row
he fell into the person standing to my
left who fell into me (elbow to my sternum),
and I then fell backwards over the low
wall of the well into the water, taking
another person with me. Fortunately,
the well mouth was easily large enough
for both of us to fall in without hitting
our heads, and the water was only eight
feet from the top of the well. It was
shallow enough so that I could touch
bottom too.
Upon
surfacing and overcoming my shock I realized
three things. First, the water felt incredibly
great, and this accident was a sort of
blessing. Second, that there were about
25-30 faces staring down at me from above,
and third, something was nibbling on
the back of my neck! Turns out there
are fish in the well.
Within
a couple of minutes we had been hauled
out using bamboo poles and about seven
minutes after that I was almost completely
dry as it was so hot. Sadly, the man
working my digital camera never did figure
out how to work it and was too excited
once I fell in to take a shot of me dog
paddling inside (which I'm almost thankful
for).
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India:
Expanding surveillance by working
with a local priest
This
last week has been the most rewarding
so far and I am starting to see the results
of my efforts. I had left for our mid-assignment
break in Delhi wondering if I was making
any sort of difference, but after a restful
and food-filled weekend and another week
in the field, I definitely feel like
I am contributing, at least in some small
way.
My
best meeting was with a priest at a temple
that is famous for seeing paralysis patients.
After some discussion and assuring him
that we didn't want to take away any
of his business, the priest indicated
that he would be more than willing to
help us, and if we gave him a register
he would keep track of the (paralysis)
cases, obtain their addresses, date of
onset, and symptoms. He said that if
we sent a community health worker each
Sunday (when cases come to the temple)
he would pass the information along.
The next step was to go to the local
Primary Health Center. There I was able
to round up five community health workers
- ANMs (auxiliary nurse midwives) and
MPWs (Multi-Purpose Workers). I had a
great meeting with them and their enthusiasm
was wonderful; they were really willing
to listen, learn, and participate in
acute flaccid paralysis (AFP) surveillance.
It was agreed that Mr. ______, an MPW,
would go to the temple each Sunday evening
and look for cases. I left there feeling
like I had actually reached some key
people, but was unsure if I had left
a system in place and wondered if the
community health worker would really
go to the temple on his day off.
I
returned from Delhi and went directly
to the field without returning to my
base, and we arrived at the temple around
6 p.m. Apparently, patients start arriving
at the temple Saturday afternoon/evening,
rituals are performed Saturday and Sunday.
On Sunday at midnight, some final rituals
are performed and then the cases must
leave. Depending on the case, the patient
must come back for several weeks. When
we arrived, there were at least 100 people
milling around - quite different from
the quiet place we had visited in the
afternoon the week before. Families were
caring for sick family members, and both
my driver and translator knew people
there who had brought their sick mother
or paralytic child (an indication of
how famous this place is).
But
the most rewarding experience was when
I got out of the vehicle. The MPW who
I had trained a week and a half before
was standing there like he was expecting
us and handed me a register of all the
information he had collected last Sunday
and this Sunday! I was so happy to see
him, and it was clear that he was proud
of the work he had done. We proceeded
to the nearby public health clinic, found
the doctor, and with the District Immunization
Officer (DIO), formalized a system where
the MPW and the doctor would go to the
temple each Sunday, and the DIO would
call each Monday morning for a report.
Then we all went back to the temple and
examined the cases - all of which were
chronic cases. But, I really think this
will work and that there is great potential
here to find cases. I am going to make
sure that I return one more time before
I go and I am definitely taking that
MPW a present!
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India:
Learning to be more effective
You
were right about the final month in the
field being our most effective period.
I actually feel very comfortable in the
field now, like I know which questions
to ask and when to refuse that third
cup of chai (tea). I've verified three
ORIs (outbreak response immunizations)
and they are really being done and very
quickly.
I
heard of a case of acute flaccid paralysis
yesterday in Mirzapur, so we headed there
this morning. The MOIC (medical officer
in charge) had already completed the
outbreak response immunization, and the
child had just returned home to the village.
The child was definitely malnourished,
and I felt, along with the MOIC, that
the present neck weakness was secondary
to hypokalemia and dehydration. The child
was continuing to have 4-5 bouts of diarrhea
a day but was eating, according to the
mother. Anyway, the MOIC wrote out a
prescription for some supplements, and
I asked that an auxiliary nurse midwife
return with the child to the public health
clinic for oral rehydration at least.
The villagers have been educated about
homemade sugar/salt solution but prefer
the ORS packets. We'll have to return
after the child is hydrated and diarrhea
is gone to reassess and make sure that
the neck weakness has resolved. This
is one of those iffy cases -- hard to
call right now. It was a Muslim village
and the first time I encountered real
resistance to vaccination. They were
pretty much OK with oral polio vaccine
since it's oral but completely refused
injectable vaccines. Some think the vaccines
will sterilize their children.
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Haiti: "People
are genuinely kind and generous"
The
voice from the tropics is back! I'm recuperating
from three grueling but very rewarding
weeks in the south of Haiti.
I
arrived there with a group of four WHO
consultants (an Algerian doctor and three
Haitian nurses) to find a vaccination
campaign that was supposedly finished
but had covered only 30% of the target
population. We paired up with two local
nurses, worked 12 hours a day, six days
a week, and I'm proud to say that we
were able to reach over 100% of the children!
(There has been a serious underestimation
of all age groups because there hasn't
been a national census here since 1982
and the population growth has greatly
surpassed anything any of us imagined.)
I spent most of my time evaluating vaccination
coverage and planning the revaccination
of areas with low coverage. Now, I am
back in Port-au-Prince where I am analyzing
data, writing reports, and trying to
find a wheelchair for the little girl
with polio I visited while in Delmas.
The
Département du Sud is beautiful; truly
another Haiti as compared to Port-au-Prince.
It is very green and lush, with rolling
hills, rocky roads, numerous rivers and
beautiful vistas of the Caribbean Sea.
I had the opportunity to perfect my Creole
(Kombien timoun gen nan kay la? Tout
timou té vacsiné kont maladi polio?)
as few people understand French. The
level of education is very low and families
are large. I could spend ten minutes
sitting in someone's yard trying to figure
out how many kids lived there. Often,
parents (especially dads) couldn't recall
the number of children they had or how
old they were. But the people were genuinely
kind and generous. I left houses with
small piles of mangos or avocados under
my arm or would slurp down coconut milk
from a freshly plucked coconut people
would offer (a surprisingly refreshing
and rehydrating drink, perfect for this
hot and clammy climate). They were extremely
curious about me, the blanc with
the funny hat and thermos in hand. Often,
half a dozen kids would gather round
us when we went into homes and followed
us around for the next two hours.
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Pakistan:
Phenomenal local efforts to eradicate
polio
From
my one afternoon of SNID (subnational
immunization day) monitoring and from
the others in my group who have many
days exposure in this work, it's clear
that many people here in Pakistan are
making phenomenal efforts to eradicate
polio. Just imagine in your own town
if you were asked to knock on the door
of every home and convince the parents
to let you immunize all their children
under age five for a disease that is
now relatively uncommon.
Now
imagine doing it for over 20 million
children spread over an area larger than
France in 100 degree weather for the
grand sum of 80 rupees ($1.60)/day and
having people refuse because they believe
it's a surreptitious form of birth control
-- a not uncommon belief here. I'm sorry
but I'm sure I'd drop out by the second
day. It's expected that this will likely
have to be done twice a year for the
next two-three years here in Pakistan!
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India:
Overcoming rumors about vaccines
We
just finished the second round of the
National Immunization Day. It was very
exciting, especially since one of my
districts was also having an enormous
Mela (fair) on the same day. Apparently
this time of year about 1 million people
come to Ayodha to take a holy dip in
the river and also walk 52 kilometers
around the city--barefoot. In fact some
people travel the whole 52 kilometers
on their hands and knees! As you may
guess this made planning the immunization
day a little difficult in the area.
My
greatest success so far has been convincing
a village to accept the polio vaccine.
There is a rumor going around that the
vaccine causes sterility, so many families
are refusing to vaccinate their children.
On this particular day, the nurse had
visited the village three times to vaccinate
children but the people refused. I went
with the nurse to the village to talk
with the women. I was able to find a
local woman who was a supporter of the
vaccine and brought her with me to talk
to the people. At first the women didn't
want to vaccinate their children, but
after we spoke with them about the benefits
of vaccination, they agreed.
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