I sometimes hear people complain about their jobs. They are overworked, frustrated by limited resources, or engaged in a struggle with a difficult boss or passive aggressive co-workers. Yet, even stressful, mundane or creativity deprived jobs can offer meaning as soon as you make the choice to start looking for it. Unconvinced? Please read on.
Early this summer, I came across an article about the 2019 recipients of the Padma Shri Award in India. It is one of the highest civilian honors and Dr Omesh Kumar Bharti received this award for his groundbreaking work in rabies prevention. I was quite pleased to learn that Dr. Bharti is based in Shimla and I was heading there in July. I immediately sent off an email and he graciously agreed to meet me in India to discuss his work.
He told me the most remarkable story which is described in detail in a wonderful article published this year in the Indian Journal of Medical Ethics: Using a modified rabies immunoglobulin protocol in a crisis of unavailability: Ethical and practical challenges. I encourage you all to read this as it really illustrates how someone committed to saving the lives of others can affect change through lots of hard work and engaging key people to assist. It’s an amazing story and I kept thinking someone should really make a documentary about it.
Dr. Bharti is a State Epidemiologist working at the State Institute of Health and Family Welfare, in Himachal Pradesh, India. He is also a member of the Jan Swasthya Abhiyan, a network of health advocacy groups that works to bring services to the poor. That group helped convince the state government of Himachal Pradesh to adopt ID administration of rabies vaccines, making it much more affordable. It is now provided free of charge by the Himachel Government.
Unfortunately, patients continued to die of rabies due to the lack of rabies immune globulin (RIG). WHO reports that worldwide, less than 2 % of category III exposed patients receive RIG. In 2009 Dr. Bharti was asked to investigate this problem after a 38-year-old woman died of rabies after a dog bite in Shimla. She was able to obtain the vaccine, but RIG was not available anywhere in the area. At that time, because of the high cost, it was only stocked in district hospitals and medical colleges. Other hospitals and clinics didn’t want to stock the less expensive equine variety because they feared an anaphylactic reaction. Local chemists wouldn’t stock it because of the short shelf-life (about 2 years). The crisis became even worse when in 2014, India ran out of stock completely.
Dr. Bharti was understandably very troubled by watching patients succumb to rabies without appropriate preventive treatment. He dug deep into the literature to see if there was some means of reducing the cost of RIG and increasing its availability. It appeared that providing any excess RIG in an IM injection (as per the WHO recommendations at that time, see comparison here) might be a waste and omitting that step would lower the cost and provide RIG for more patients. Dr. Bharti’s proposed cost-saving protocol included providing vaccine intra-dermally and injecting as much e-RIG as was required into the wound, but any remaining amount would be provided to another patient and not injected into the muscle. The protocol contradicted WHO guidelines regarding RIG administration but likely offered minimal risk to patients. The alternative would be to do nothing, and more patients would die. Getting buy-in for this approach was extremely difficult and required pushing a lot of heavy boulders uphill. He finally managed to get support from outside rabies experts both in and outside India. His institution didn’t have an internal ethics committee (IEC) but he eventually got approval from the IEC of a local university.
They treated an astonishing number of bitten patients – over 2000 between May 2014 to May 2015, and 26 of those were bitten by lab-confirmed rabid dogs. All the patients survived. Ultimately, WHO used this research to modify their own RIG protocol and published their new global recommendations in 2018. Guidelines that lower the cost of PEP and no doubt save more people. (As a reminder, the WHO guidelines are different from current CDC guidelines we follow in the US.)
What’s Dr. Bharti concerned about now? He told me that monkeys may be more of a concern as a rabies reservoir as this area has a lot more monkeys that have been interacting with dogs. In addition, he’s concerned that current WHO recommendations don’t go far enough for Category II exposures (nibbling of uncovered skin, minor scratches or abrasions without bleeding); which currently don’t call for RIG. He feels that RIG may be indicated as they have had a couple of deaths in patients that had the vaccine as per the guidelines but no RIG.
I love this story – it’s a magnificent story about a guy working in a government hospital in a town that sits way up in the foothills of the Himalayas in a resource poor area (the day I visited his office, we sat in the dark as they were experiencing a power outage). But Dr. Bharti started nosin’ around in his own backyard which led him on a journey well beyond the confines of his job. Sure, he had to work hard – much of it on his own time, do his homework, and go to great lengths to seek out others who could help him. Yet he persisted, and out of a serious ethical dilemma, a wonderful outcome emerged, and Dr. Bharti helped change the world for the better.
Julie Richards
Charter Fellow and Past President, American Travel Health Nurses Association
Julie Richards and Dr. Omesh Kumar Bharti
Shimla, July 2019
ATHNA 