CMC - Day Four

India is a massive country, made up of 35 states and union territories. The CMC hospital serves millions of people from each Indian state, as well as the surrounding nations of Nepal, Bhutan, Bangladesh and Sri Lanka. On any given day the hospital hosts a floating population of around 5000.The diversity of the faces that one sees reflects this. As do the languages spoken. One is likely to hear not only English and Hindi spoken, but any of the 22 other recognized languages, and more. Among them are Telegu, Urdu, Assamese, Bengali, Gujarati, Marathi, Kashmiri, Tamil, Malayalam, Oriya, Punjabi, and Kannada. Off campus, on the small street in which my hotel is located, one can find restaurants to suit these guests from around south asia. So far i've had food from Bengal, from Kerala, from Nepal; i've had biryani, tandoori, pani poori, as well as dosas, idlis and lassis. Fresh fruit juice can be squeezed out of shops on each corner: apple, banana, coconut, grape, papaya, lime, pomegranite and watermelon. For someone who likes Indian food, this is heaven. But i digress.

You can imagine the problems this linguistic panoply creates for doctors. Most communication between patients and physicians takes place in three languages: Tamil first, Hindi second, and English third. However, if the patient doesn't speak any of these, i'm not sure what they do. The resident doctors, especially those from Tamil Nadu, vie for the charts of Tamil speaking patients. The three or four years of Hindi that most had in school isn't enough to make most of them feel comfortable using it. Each has perfect English, though. Some speak as many as 4 languages. Dr. Maneksh, with whom i have worked every day this week, speaks Tamil, Hindi, English and Russian, the latter because he went to medical school in Russia. I can't imagine this jolly, portly and dark Indian fellow in the Russian winter. It's winter here and while i'm out at night in a t-shirt, the indians are bundled in blankets and balaclavas. He claims to have put it out of his mind. In any event, even basic communication is not taken for granted when you have this diverse a population. And while physicians in the states, particulary Urban areas, have diverse populations, they also have interpreter phone lines to which they can turn. I don't think they have that service here.

CMC, on account of it's excellent resources and huge patient population, draws physicians from all around the world. Yesterday we heard a talk by a professor and pediatrician from Johns Hopkins School of Public Health - who happened to be on faculty at CMC in the 1980s. He was talking about a randomized controlled trial that he just completed in Bangladesh, looking at the efficacy of vaccination of pregnant women in the third trimester in preventing febrile illness in children less than 6 months of age.

Some background: we're all familiar with the flu season in the states. Basically, it correlates with winter, and if you look at an incidence curve starting in january and ending in december, its shaped like a big "U". This is consistent in temperate climates around the world. As one measures closer and closer to the equator, though, this curve flattens out. Researchers have found that in tropical climates, the incidence of flu is pretty steady throughout the year. That makes it harder to identify. At home, one can see the onset of flu season by looking at physician and hospital visits, which increase appropriately. Those most likely to become seriously ill or die from a bout of the flu are infants less than 6 months of age, who we don't vaccinate, and those older than 65 years, who we try to vaccinate. Neither vaccinations nor antiflu medications are approved for use in those under 6 months. One special thing about these young infants, though, is that they carry some of their mother's antibodies against various infections. We call that passive immunity. And while by the end of the first year of life, most of these antibodies are gone, they are an important guard against early infant illness.

So, this gentleman from Johns Hopkins wondered what would happen if you vaccinated pregnant mothers against the flu, something that is already recommended in the states, but done only about 10-20% of the time - "because obstetricians are not pediatricians." So they randomized women to recieve either the pneumococcal vaccine or the flu vaccine and then followed the mothers and newborns/infants with weekly clinic visits through the first 6 months. The results were impressive; in Bangladesh, where they completed this study, there was a significant - statistical and literal - decrease in the incidence of rapid-test confirmed flu and all febrile illness amongst both the flu vaccinated mothers and their infant children up to 6 months of age. There were no recorded complications of the flu vaccine in either the mothers or the children. They are continuing to monitor these mother-child pairs up to 1 year, though less frequently. Furthermore, they are currently evaluating the cost-effectiveness of vaccination, something that is not obvious in a country where the cost of care is as low as it is in Bangladesh. The vaccine itself costs around $5. At that cost, you can imagine that the cost effectiveness in the U.S. is clear; it would be so if it prevented even one doctors visit.. As i said, the flu vaccine is approved for pregnant mothers so keep this in mind the next time you see one. This research was funded by the USAID and the Gates Foundation, among others. This is the kind of quality research that is being conducted in the developing world, and from which we can benefit.

His talk was followed by an informal discussion with visiting researchers from Sweden and France, who wondered about the possibility of conducting studies to learn more about Rotavirus, a major cause of diarrheal illness around the world. I wonder what will come of it.

I spent this morning in the general outpatient pediatrics clinic. Pretty standard stuff. Runny noses, fevers and coughs. Nice to see that some things are the same for children everywhere.

My first week finishes tomorrow. It goes so quickly.

justin

ps. Indians publicly remembered Mahatma Gandhi on the day of his assassination, two days ago. Wise words from Gandhiji: What difference does it make to the dead, the orphans and the homeless, whether the mad destruction is wrought under the name of totalitarianism or the holy name of liberty or democracy?