A vet in Delhi day 7: summary and conclusion

I’ve spent my final day in the slum and it’s time to draw it all together and reach some conclusions. What’s it all been about, what have I achieved, and what’s going to happen next?

First, to explain: the rationale behind my work has primarily been human health. It’s shocking that rabies is still a major killer in India, despite the fact that it’s completely preventable. If 70% of the street dogs in an area are vaccinated, the disease dwindles and disappears to insignificant levels. Surely this is a goal that is achievable?

The current estimated incidence in India of around 3 deaths per 100000 people per year means that over 20000 people, mostly children, die unnecessarily every year. In a slum like Mayapuri, with a population of 12000, there’s probably around one death every three years. Feedback from my questionnaire suggested that this may be close to the truth. Rabies is common enough to be a constant threat, but rare enough that it’s easy for people to forget about it. Yet it is such an horrific, unnecessary death that everything possible must be done to prevent even one fatality.

ASHA deals effectively with many health and welfare issues in the slums, vaccinating children with BCG, MMR, Hepatitis, Tetanus and Polio: before ASHA arrived 15 years ago, no babies were being vaccinated – the uptake is now 100%.  ASHA also treats adults for TB under the DOTS programme, and offers a range of birth control methods.

There’s no doubt that the charity’s work has transformed the lives of the slum dwellers. But what about rabies? When I asked this question last year, it seemed that it was a bit of a grey area: ASHA is so busy with other priorities that it’s easy for rabies to slip under the radar. When I discovered this, I felt that there was an opportunity for me to use my background as a vet to look into the issue when visiting the slum with a group of volunteers from my local church.

Mission Rabies – who are already in the process of vaccinating millions of dogs around India – do not have an immediate plan to focus on the Delhi area, but they were exceptionally helpful in assisting me with this project. They drafted a questionnaire for me to use while here, and they advised me on important aspects such as informed consent and male/female interpreters.

So what did I discover? Well, I found out how difficult it is to do social research. I had thought I might gather several hundred questionnaires over 3 days, but the process took longer than I had expected: up to 15 minutes for each interview via an interpreter, then time spent seeking out the next candidate. I ended up with just 40 completed questionnaires: not as many as I’d have liked, not enough to be significant in a formal sense, but still perhaps enough to gather valuable feedback about the subject.

What did I learn?

First, I discovered some interesting socioeconomic facts.

• 75% of households live in just one room, shared between an average of four people: no kitchen, no bathroom, no hot water
• 95% of slum dwellers own a mobile phone
• 90% own a television
• 65% own a bicycle.

Second, I discovered that street dogs are a significant part of the slum community, with an average estimate of one dog per 17 humans (the range was one per 5 to one per 20 people). The only way to get a more accurate figure would be to do a detailed dog census, which would be a major logistical challenge in itself, but the estimates are enough to make the point that there is a substantial population of dogs..

While only 15% of people said that they “owned” a dog, 57.5% said that they feed local dogs at least once a week. This ties in with the reported attitudes to dogs: 40||% said that they “liked” dogs, 15% were indifferent t while 45% of interviewees said that they “did not like dogs” (presumably the latter never feed them).

Third, I investigated the local people’s knowledge about rabies. I found a low level of awareness of the disease. 80% of respondents had not heard of rabies, and only half of the 20% who said that they had heard of rabies were able to explain the disease to someone else. Some people thought that rabies would make them “bark like a dog”. Furthermore, only 45% of people thought a dog bite could be fatal, with 55% of people disbelieving this. There’s clearly a need for community education about rabies in order to prevent future cases.

More positively, despite the lack of knowledge about rabies, 90% of people would go to hospital if bitten by a dog (where they would be given the post-exposure rabies vaccination). As well as doing this, some people would take other action, including putting red chilli powder on the wound, and resorting to “witchcraft”. The 10% who “did not know what to do” if they were bitten by a dog are worrying: they would be very vulnerable to developing clinical rabies if bitten.

What’s going to happen next?

If nothing is done, nothing will happen. The situation will remain the same, and people will continue to die of rabies at a rate of around one person every three years.

Clearly this cannot be allowed to happen.

ASHA already have an effective network of community health volunteers on the ground, keeping an eye on the health of inhabitants in their local area, and passing on information to them about health and disease using handouts and flash cards. On my last day in the slum, ASHA kindly arranged for me to give a presentation to a dozen community health volunteers from Mayapuri and another nearby slum. I was able to pass on the initial results of my survey, and to discuss the challenge of rabies awareness with them. I explained the issues of rabies and street dogs in detail, and handed out several hundred picture-based colour information leaflets about “Getting Along With Dogs” (designed by Mission Rabies). These volunteers will go back to their own areas and will talk to local parents and children, stressing the importance of avoiding dog bites by interacting appropriately with dogs. They’ll also mention rabies, the importance of wound cleaning and the need for a visit to a medical centre if a dog bite does happen. So far, so good.

But what about the other 58 slum areas (housing 400000 people) under ASHA’s care? And what about the other 500-plus slums (with millions of inhabitants) that ASHA has not yet reached? There is a massive population in Delhi that’s still unaware of the ongoing threat of rabies. What can be done to reach them?

This is where Alliance of Animals and People (AAP) may come in. In an earlier blog, I outlined a visit I made at the start of my Delhi trip to one of their slum programmes in a different part of the city. AAP has a stated aim of working with NGO partners to help children in need: their founder, Bondana Dutta, is an ex-regional director of CRY, a major children’s charity. The concept is simple: AAP sends a volunteer to nominated slums to teach groups of children about awareness of the risk of dog bites and the importance of rabies prevention and treatment. AAP also works with local communities to lobby municipal authorities to provide other helpful measures such as rabies vaccination and population control of street dogs. Could an AAP staff member visit ASHA slums like Mayapuri to give regular classes to children, raising awareness of these issues and helping to prevent future cases of rabies? If this generation of young people are educated now about the subject, they will soon grow into a well-informed generation of adults, and the entire slum community will then become rabies-aware.

This suggestion may sound sensible, but it isn’t always so easy on the ground. In particular, funding is a challenge. AAP staff members are already over-stretched. If extra work was scheduled (such as visiting ASHA slums), a new staff member would need to be recruited, costing at least €3000 per year. And a new initiative like this might also incur extra costs for ASHA. If funding is not there, new projects like this cannot happen.

So what do we do about it – people like you and I? Finish this blog and walk away? Or take some positive action to help?

I realise that I have just been on the front line of the slums, which makes it all very real and urgent to me. But I am heading home with a determination to follow this through by making a commitment to fund-raise for ASHA and for AAP. Over two thousand people have been viewing these blogs: if each of you donated just €2 per year, that would be enough to provide the financial resources to kick start this type of programme. With a small gift from each of us, the first steps could be taken to eradicate rabies from ASHA slums, and to help the welfare of the slums’ street dogs at the same time.

I’m happy to help to coordinate a plan like this, but I need your help.Visit our other ASHA-focussed blog and click on the “Donate” button on the top right of the page if you want to make a small donation. And watch this space: I’ll let you know what happens.