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Interview with François Saint-Sauveur, MSF Medical Coordinator in the Kala Azar Project in the state of Bihar, who has worked in the emergency intervention launched after the floods. MSF started treating Kala Azar patients in the Vaishili district, in Bihar, one of the poorest states in the country, on July 16. Barely one week later, intense floods affected this state in India. Immediately, MSF teams began assessing the field in order to address the most urgent needs. The results of various nutritional assessments showed high percentages of child malnutrition. Currently, the emergency intervention goes on in the district of Darbanga and Khagaria. The response to malnutrition is one of the main concerns. Following the intense floods in northern India, the MSF team started an emergency intervention. What are the main activities carried out so far? We firstly prioritised the areas where neither the Government nor other organisations were responding and therefore the situation endured by the population there was unknown. The most important problem we encountered when conducting the field assessments, both in Darbanga and in Khagaria, was the nutritional situation, including many severely acute and moderately acute malnutrition cases. So in the second phase we have focused on responding to this medical problem. In addition, we continue working through mobile clinics, carrying out water and sanitation activities and distributing relief supplies. We have given priority to about 25 locations in these two districts. Most probably there are other places where we have not conducted assessments and the needs are also important, but we have had to focus our activities also based on our capacity. Have the results obtained in the nutritional assessment struck you? Bihar is the poorest state in the country and we have conducted the surveys in the poorest areas and amongst the lowest castes. I mention this because we expected to find a precarious situation, but not as bad as the one we found. When conducting nutritional surveys, in various locations severely acute malnutrition was between 1% and 5% and moderately acute malnutrition between 25% and 35%, so the nutritional alarm was really evident. In addition, in other places chronic malnutrition is widespread, a situation already reported and acknowledged by UNICEF, the Government and various agencies. Floods have exacerbated the situation. Once you had these data, how did you implement the nutritional intervention? Despite the nutritional surveys published every two years showing a deficient nutritional situation in various places in this area, it is very different when one is with a team in the field and has to face the medical problem. We had the diagnosis and thus we had to respond. At that moment, we had treatment for severely acute malnutrition and we had Plumpy’Nut from our stock in our regular kala azar project. So we decided to launch an intervention in the locations where we had detected the most alarming needs and implement through our mobile clinics a nutritional component. This therapeutic product has been essential in the intervention; we have used Plumpy’Nut according to MSF’s medical protocols in order to treat moderate cases. For the MSF teams in the field this posed a dilemma because the emergency intervention was envisaged to come to an end in a few months and they did not know whether there was enough time to follow up the complete treatment or not. But there was no other organisation providing nutritional care. Based on your field experience, what are the advantages provided by these ready made products to treat malnutrition? In an emergency intervention of this extent, being able to use these therapeutic products is very good because they are less heavy and can be used easily even if drinking water is scant and hygienic conditions lacking. You give them directly to the mothers for them to give to their younger children and they are ready to use. This makes it really easy and in addition acceptance is high amongst children. It is effective. And to be noted too is the fact that no deaths have been reported amongst the children on treatment. When the floods took place in Bihar, the MSF kala azar project has been treating patients for only a few days. We would like to know how emergencies are managed in missions where more stable projects are implemented, as it is your case. We started treating patients on July 16 and just on July 25 floods affected the area. We, the MSF team in the kala azar project clearly knew we had to do something to mitigate as much as we could the consequences of the heavy rains, mainly when reports spoke of the worst flood in the area in years. The regular project has supported the emergency intervention by providing supplies and international staff until the arrival of more human resources. But despite this extra work, the kala azar project has gone on working normally. By the end of September we had treated approximately 300 patients and at the end of October we will have treated about 400 patients. We have also started awareness raising activities, but so far we are only working in communities close to the hospital where we are working. Why not further? Because of a very simple reason: if we go to a community where we are not working and tell patients to travel to the nearest health centre for treatment, first of all we do not know whether there are medicines available and then we do not know what medicine they are going to be given. So we have started education and information activities in areas closer to the hospital where we work. We explain people what kala azar is and also how MSF works. Explaining that both the diagnosis and the treatment are free, that they are effective and that patients will only have to stay 10 days in hospital is a must. What are the next steps you are going to take in the emergency intervention launched after the floods and in the project? Firstly, the emergency intervention has taught us that in an area such as Bihar, one of the poorest area sin India, one needs to be prepared to respond to at any moment to potential emergencies and this requires a major adjustment effort. On the other hand, despite the high levels of malnutrition found in Bihar, RUTF (ready to use therapeutic food) is not available for severe cases, because neither the Government nor other organisations respond to this problem. These products are very expensive. Each ration eventually costs more than one dollar so people do not have easy access to this treatment. We need to consider how we can lobby to make progress in terms of accessibility. In the kala azar project, the next step is to decentralise Ambisone treatment for kala azar, now given at district hospital level, and in a short time we would like to start treating in primary healthcare centres. In the emergency intervention, there are 11 MSF staff (6 national and 5 expatriates) including medical, water and sanitary and logistics.
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