India Robert Black and Christa Fischer-Walker
PhD Program, Department of International Health, JHSPH
Diarrhea is the second leading cause of under five mortality globally. Despite recommendations for the use of ORS and zinc supplementation, coverage levels and caregiver adherence to both treatments remain low. Knowledge gaps surrounding the promotion of ORS and zinc at the provider level pose a challenge to increasing adherence among caregivers. To address this paucity of evidence, I propose the addition of a sub-study to a planned evaluation of an ORS and zinc scale-up project in two states of India, which will determine the extent to which caregivers are adherent to the recommended treatment regimen. In this study I will also assess the relationship between caregiver actions, provider messages, and mass media message delivery channels, all of which potentially impact adherence or failure to adhere to treatment.
In preparing for my most recent trip to India, I was excited yet anxious. Though I had spent time in Delhi on previous trips, attending meetings and working at the headquarters location of the Society for Applied Studies, this trip would present my first opportunity to venture to the field. After much work on study design and sample size, I was looking forward to truly gaining firsthand insight into field-level operations in a way that could not be learned from an office in Baltimore or, even, New Delhi.
Still, I was somewhat uneasy for one main reason—Bihar. Our evaluation of a diarrhea treatment program was scheduled to take place in three states—Gujarat, Uttar Pradesh, and Bihar. While I had received very encouraging advice about working in the former two states, I had been met with apprehension and negativity whenever I mentioned the latter. Bihar seemed notorious among Indians for its unstable government, extremely unhygienic conditions, rough terrain, and presence of militant communist groups, known as naxalites. Despite some apprehension, I set forth on the flight to Patna and subsequent eight-hour, overnight train that would mark my first true adventure in the field. The data collection team and I spent the first week of our trip in Banka. One of the poorest districts in Bihar, Banka was suffering from a shortage of dry goods, including bread. Luckily, I was equipped with granola bars and mentally prepared for bucket showers and lack of electricity. Still, certain experiences in Banka pushed me out of my comfort zone. Shortly after arriving to the district’s only hotel, a small boy about four or five years-old pushed his way into my dingy room; scantily clad and barefoot, he quickly brushed past me and began cleaning the traditional inground toilet, which was filthy and located in a corner of the room. In that moment I was overcome by the reality of child labor in rural India, and it brought me to tears. I was also struck by the condition of the public sector PHCs (primary health centers), each of which caters to a population of about 40,000. Only one medical officer was on shift at any given time, and the waiting areas were completely packed with sick people who stood in the intense heat or squatted on the floor. The facilities were dimly lit or completely lacked electricity. I was overwhelmed by the number of pregnant women and young children that waited so patiently for the sole medical officer who held patient consultations out in the open while seated behind a large desk. The consultations were conducted swiftly and consisted of symptom review and the occasional use of a stethoscope. The majority of patients were handed prescriptions and instructed to wait in yet another line at the nearby and often inadequately stocked government pharmacy. The more serious cases were provided a bed, if available, or referred to the district hospital located at a substantial distance from most PHCs. Though many of the medical officers alluded to improvements in PHC conditions and disease outcomes in recent years, patient care at the facility-level was visibly lacking. Our visits to observe the ASHAs (Accredited Social Health Activists) and Anganwadi workers in the villages confirmed that health knowledge and access to supplies were also lacking at the community-level. Although facing the realities of the Bihari health system and way of life was difficult, the experience has greatly enriched my understanding of public health and the challenges of conducting research in a developing country. The team and I traveled across miles of bumpy, unpaved road in order to reach all of the providers that had been randomly selected with such ease by our statistician in Baltimore. When driving was not an option due to unpaved roads or flooding, we climbed hills and crossed rivers by foot and by boat. Despite the team’s determination, we were unable to reach some of the providers, including those located in areas with heavy naxalite activity where we were advised not to go without the protection of armed guards. In spite of these hurdles, I also had many encouraging experiences and was especially moved by the cooperative and welcoming nature of the providers and villagers asked to partake in our study. The participants immediately sensed I was not Bihari, but dressed in salwar kameez, they asked whether I was from one of the north Indian states. Once the team explained that I had come from the United States, the participants eagerly welcomed me with chai and thanked me for visiting Bihar, which is lacking in research and tourism compared to other Indian states. I met a diverse mix of people who challenged me with questions ranging from what I thought of President Barak Obama to how many people lived in my village in the U.S. Though I was limited in my ability to communicate in Hindi, I was fortunate that members of the survey team volunteered their translation skills; I was deeply touched by their helpfulness and quickly bonded with this group of diligent young people that had left their families in search of employment. By the end of my trip, I had shared more cups of chai with strangers in rural Bihar than coffee with neighbors in all my years living in the U.S. I truly feel blessed to have had the opportunity to hear the stories and see the faces behind the data.
 | Primary Health Center, Katuria (Banka, Bihar, India) |  | Anganwadi Worker providing ORS and zinc treatment to a village child sick with diarrhea (Banka, Bihar, India) |  | Village boy washing dishes at the hand pump (Banka, Bihar, India) |  | Patients waiting to see the only Medical Officer at a Primary Health Center (Bhagalpur, Bihar, India) |  | An Anganwadi Worker and her students at an Anganwadi School (Bhagalpur, Bihar, India) |
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