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The Social Anthropology of Rabies Epidemiology and Elimination

Periodic Reporting for period 1 - SAREE (The Social Anthropology of Rabies Epidemiology and Elimination)

Reporting period: 2018-09-15 to 2020-09-14

Rabies is a devastating zoonotic disease transmitted from bites of infected animals. This zoonosis annually kills more than 59,000 people globally, with the highest number of deaths occurring in India. Still, only 4.4% of the global rabies expenditure is directed towards understanding the disease in India. As rabies affects mainly poor and marginalized people, it is widely neglected by Indian health authorities. Rabies has also implications for the health of international travellers and poses continuous threats to Europe as a result of the increase in trade of dogs from endemic countries. In 2013 the EU recognized the importance and the economic benefits of the One Health approach, which is the most effective method to eliminate rabies worldwide.
The elimination of human rabies is feasible through vaccination of 70% of reservoir dog populations and Post-Exposure Prophylaxis for exposed individuals. While these measures are highly effective, canine rabies continues to kill thousands of people in India for reasons that are as much socio-cultural as they are biological, such as poverty, poor literacy, and high-risk jobs. Also, rabies is linked to people’s cultural and religious background, which greatly affects health-seeking behaviours and beliefs.
So far, the number of rabies victims in India has emerged only from estimates, as many rabies victims die at home. Thus, the need to determine the actual burden of this disease is pressing. Contact tracing is the only method to generate a more comprehensive picture of the reality facing communities in marginalized areas where rabies is endemic and bite victims do not enter the health system. Yet, it has not yet been applied to India. SAREE will fill the epidemiological gap India currently suffers from and will lead to a much-needed change in the priorities of the Ministries of Health and Agriculture.
The ultimate goal of SAREE is to identify potential cultural and religious factors affecting rabies control, and to turn them into valuable resources for rabies risk reduction.
I established a new partnership with Dr Abi Vanak at the Ashoka Trust for Research in Ecology and Environment, Bangalore, and Dr Prashanth Srinivas at the Institute of Public Health, Bangalore.
I developed a 25-page standard operating procedure, a participant information and consent form, a form to collect first-hand medical information at local hospitals, a form to collect first-hand medical information at Hadkai Mata temples, a map of Hadkai Mata temples, a patient questionnaire with 152 questions, a follow-up patient questionnaire with 8 questions, and a dog questionnaire with 63 questions. As SAREE is a trilingual project, all these tools were developed in English, Marathi, and Gujarati. A collaboration with a software designer was established and contact tracing questionnaires were developed (two main forms + 10 sub forms, in three different writing systems).
SAREE fieldwork has been interrupted and hence delayed by the current COVID-19 pandemic and uncertainties remain for the near future. Since March 2020, I have moved some components of SAREE online and on the phone. At the same time, since this pandemic has become an integral part of SAREE and many connections exist between COVID-19 and rabies (both are zoonotic diseases that largely depend on how humans relate to animals), I am using this opportunity to explore interactions between rabies and COVID-19 pandemic (e.g. how stray dog management and rabies control were managed during the Indian lockdown, how contact-tracing capacity for rabies could be effectively deployed in controlling the spread of emerging infectious diseases).
Summary of completed deliverables:
Map of hospitals and list of key informers in the selected tehsils.
55 questionnaires collected through an online survey addressed to managers and veterinarians at Non-Governmental Organisations.
320 online newspaper articles on dog population management issues and dog bite cases and rabies cases collected and coded in Nvivo.
36 interviews with traditional/faith healers collected.
Mapping of 108 Hadkai Mata temples, visit of 65 of them, intensive participant observation (resulting in photos, videos, and notes systematised and coded in Nvivo) at 12 of them.
250 contact tracing questionnaires collected until March 2020.
For the first time, SAREE is focusing on rabies in rural India, where it applies an integrated One Health approach that until now has been used only in urban settings. Moreover, only a few studies have attempted to comprehensively address the social, cultural, and religious elements relevant to rabies prevention. By reflecting the interdisciplinary nature of this project, SAREE contact tracing questionnaires are providing much-needed qualitative and quantitative data. Through participant observation and interviews at temples, and content analysis of devotional songs, I am developing the first body of academic knowledge about this goddess of rabies. For the first time, this project is applying the pioneering rabies contact tracing methodology outside Africa. I have already identified several local barriers to effective contact tracing efforts and I have recently submitted a recommendation document for the Indian National Centre for Disease Control about their National Action Plan for Eliminating Dog Mediated Rabies from India. Also, I have prepared ad-hoc recording forms for bite cases and rabies cases to be used in local hospitals in Maharashtra and hopefully in the rest of India.
Many public health interventions fail, resulting in wasted resources and mistrust in local communities, because insufficient attention is devoted to pre-intervention preparatory research and initial programme design. By investigating the cultural and religious landscape of rabies, SAREE will contribute to the early development of integrated rabies prevention interventions. Moreover, by focusing on marginalized and rural areas where rabies control and prevention interventions are poorly implemented, SAREE is expected to provide unique epidemiological data and a much-needed understanding of the current barriers to human vaccination, dog vaccination and, more broadly, efficient communication among medical and veterinary services.
As this project promotes strong intersectoral collaboration beyond academia, all the results and the contact tracing protocols used for SAREE will be shared with the Indian Council of Medical Research. Furthermore, I am currently discussing with the WHO, the FAO and Mission Rabies a Social Science Operational Research Tool to Improve the Effectiveness of Dog-Mediated Rabies Elimination in Africa and Asia. While COVID-19 has galvanized the world’s attention on the dangers posed by zoonotic diseases, this project will further stress the importance of considering the cultural and religious determinants of health in the study of diseases. These issues are of tremendous importance for our society, since there is increasing recognition that health issues can only be comprehensively addressed through research agendas that integrate multiple factors.
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