Dhaka, Bangladesh – The job of saving lives wholesale, by the hundreds of thousands, is an especially complex one. Researchers dig through silos of granular data compiled from across the globe and try, using computers, experience, and intuition, to figure out why masses of people are dying and what can be done to save them.
This task is made all the more difficult because most of the world’s preventable deaths occur far from the appropriate health care – the combination of professionals, technicians, and diagnostic equipment necessary to find the answers. Here’s one example: Two-thirds of India’s 1.2 billion people live in rural settings, hundreds or even thousands of rutted miles from a decent hospital.
In the South Asian countries of India, Bangladesh, and Pakistan, newborn deaths — neonatal mortality — account for about 40 percent of all deaths of children younger than five. Newborn deaths in these three countries alone, with a combined population of more than 1.5 billion, make up more than a third of all neonatal deaths around the world.
Why are these babies dying? A current study – one of the most complex ongoing investigations in the world – aims to find out.
The project is called ANISA, for the Aetiology of Neonatal Infection in South Asia, and it’s as broad as it is deep, stretching more than 1,500 miles and two unfriendly borders across sites in Bangladesh, India, and Pakistan.
ANISA is unusual for a number of reasons, and it’s producing a wealth of new knowledge that will have a long-term impact in Asia and elsewhere.
Unlike many other big public health studies conducted in the developing world, ANISA isn’t run from the cozy offices of a university on the US East Coast, but from a microbiology lab housed deep inside a hospital that caters to poor children here in Dhaka, a megacity that the Economist Intelligence Unit regularly rates one of the world’s worst places to live.
Researchers say this project puts the scientific resources – and control – on the ground, where they’re most effective. ANISA “is a good example of a complex multisite study being managed by a low-income country institution,” says Dr. Steve Luby, a professor of infectious diseases at Stanford University who was a technical advisor to ANISA.
This is the first-ever study to look comprehensively at the microbiological causes of early infant deaths in their home communities, where newborns die without ever having seen a health care practitioner. It combines massive urban and rural field surveillance with sophisticated lab work.
In six locations –- including, in Pakistan, the slums of Karachi and the rural district of Matiari; rural corners Tamil Nadu and Orissa states in India; and the Sylhet district in north-eastern Bangladesh –- local health workers are monitoring every woman between the ages of 13 and 49 to keep track of who gets pregnant and to follow the course of their pregnancy, childbirth, and post-natal period. That’s a study population of more than two million people.
The health workers provide these mothers-to-be with basic prenatal care, such as iron and folic acid, immunization counseling, and childbirth counseling, while collecting information on potential risk factors surrounding the birth. They aim to visit each new mother within the first 24 hours of delivery; babies with neonatal infections are referred to designated study facilities for immediate care. There, ANISA collects blood samples and nasal and throat swabs from the newborns for analysis.
The logistical challenges are great and health workers sometimes don’t hear of a birth until days after the fact. Many children in the study areas are born prematurely, or are underweight.
“Though we have put a childbirth notification system in place, it remains challenging, for example when the delivery is happening late at night,” Samir K. Saha, who directs ANISA as executive director of the Dhaka-based Child Health Research Foundation, said in an interview.
The newborns who do see a community health worker receive immediate care that wasn’t previously available, and ANISA in turn gets clues to the bacteria and viruses that are ailing and sometimes killing newborns.
In other circumstances, those samples would be refrigerated and airlifted at great expense to North America or Europe, where technicians earning euro or dollar salaries would analyze them on advanced equipment.
In this case, however, site-based and central labs in Bangladesh, Pakistan, and India are collecting, processing and preserving thousands of samples. Local technicians can do the work faster and at less expense, thanks to state-of-the-art equipment like the LifeTech Viia 7 Real-Time qPCR System. This highly automated machine uses specially-designed micro-fluidic cards that can test a single sample for dozens of specially-targeted viruses and bacteria, dramatically reducing the amount of time and work needed to check for pathogens.
“Most of the time, technologies like this are not available in developing countries where most of the children are dying,” Saha said. The LifeTich machine reduces testing time for 23 different pathogens from 20 hours to three hours, according to the Centers for Disease Control.
This kind of technology usually resides in affluent countries that have a very low disease burden. For ANISA, the Child Health Research Foundation secured money from the Bill and Melinda Gates Foundation to put the tech and know-how thousands of miles closer to where it’s most needed.
High technology does its job, and so does the low. When ANISA’s several hundred community health workers and study physicians are in the field to register pregnancies, births, and referrals, they are transmitting real time data back to their bases using SMS codes via inexpensive 2G mobile phones.
Who came up with all this? It wasn’t Americans.
ANISA was designed by a large international team and is led by pre-eminent scientists in Bangladesh. Notably, the Child Health Research Foundation, based in Dhaka Shishu (Children’s) Hospital, controls the purse-strings, and has contracted leading institutions and scientists from the CDC, the World Health Organization, Aga Khan University, and the Johns Hopkins School of Public Health, for expert input.
ANISA also crosses trigger-happy borders. In a true South-South partnership, scientists from three countries with snarled histories of war, terrorism, and mass murder are in full collaboration, with centralized training and methods.
This approach has so far put more than 160,000 women under active surveillance, and resulted in the collection of thousands of important biological specimens from their children. Project researchers say these specimens are yielding interesting results that will soon be analyzed in fuller detail by a committee of leading microbiological and neonatal experts.
These and future results will leave ANISA well placed for influencing future public health policy. The people driving the project will remain on the case long-term. The samples – more than 6,300 so far — are banked in Dhaka and Karachi; and future studies of these samples will be performed by local people with a direct stake in the well-being of the region.
This is the opposite of what one friend of mine calls “parachute epidemiology,” where a foreign researcher arrives on the scene, takes blood samples from a study population, and leaves.
Policymakers in India, Pakistan, and Bangladesh will see proposals coming from their own scientists, based on quality studies they themselves conducted, drawing on data from local populations – the best way toward the adoption of life-saving interventions.