Periodic Reporting for period 2 - SAREE (The Social Anthropology of Rabies Epidemiology and Elimination) Reporting period: 2020-09-15 to 2021-09-14 Summary of the context and overall objectives of the project Rabies is a devastating, lethal zoonotic disease transmitted from bites from infected animals, mostly dogs. In Asia and Africa, rabies is estimated to kill more than 59,000 people each year, with the highest number of deaths, 20,000, occurring in India. In India, human rabies was made notifiable only in September 2021, so the on-the-ground reality of this disease, including the disproportionate burden of social inequality it inflicts on disadvantaged populations, is still poorly known.The current global plan to eliminate dog-mediated human rabies grounds on the One Health approach, which integrates human, animal, and environmental health. With rabies, this strategy involves mass dog vaccination, the vaccination of bitten people, and close community engagement. While these measures are highly effective, rabies continues to kill thousands of people for reasons that are also cultural and religious. They determine how people take care of their health and that of their dogs, and influence local perspectives about One Health. In two selected rural areas of Gujarat and Maharashtra, in Western India, this study used contact tracing and ethnography to investigate the impact of the cultural and religious background of individuals and communities on the prevention and management of dog and human rabies. In Gujarat, where the Hindu local goddess Hadkai Mata is venerated in case of dog bites, this project investigated the impact this may have on people’s health-seeking behaviours and dog keeping practices. The ultimate aim was to provide policymakers with the evidence they can use to inform the design of appropriate One Health interventions. Results indicate that strong and specific understandings of rabies exist at the local level, and they deeply influence rabies management, mainly by delaying (and, occasionally, even excluding) life-saving human vaccination, and by rejecting dog vaccination. This project highlights the importance of understanding and addressing, together with local communities, different culturally- and religiously- mediated ways in which humans relate to animals, and of looking for points of convergence and mutual understanding, upon which context-tailored, linguistically accurate, locally acceptable, feasible and effective strategies can be designed. Work performed from the beginning of the project to the end of the period covered by the report and main results achieved so far Completed deliverables include: • 139 Hadkai Mata temples mapped.• 65 Hadkai Mata temples visited.• 36 interviews with traditional and faith healers at Hadkai Mata temples and Kuttarwadi collected. • About 400 photos and a dozen videos taken at Hadkai Mata temples.• 8 devotional songs for Hadkai Mata collected.• 92 dog bite victims who visited Kuttarwadi (i.e. the well of the dog) interviewed via phone survey.• 435 contact tracing questionnaires collected through in-person and phone interviews. • 55 questionnaires collected through an online survey for local and national animal welfare associations.• 320 newspaper articles on dog-related issues during the first Indian lockdown systematically collected from four local and national online newspapers.Main findings include:• In Gujarat, at Hadkai Mata temples, rabies is considered a social illness and is usually explained as the deity’s wish to correct misbehaving people and restore positive interpersonal relations. Nevertheless, there is also some appreciation for the biological processes of transmission and infection that lead to rabies as a physical disease. While Hadkai Mata is believed to be able to cure rabies if her patients undergo the necessary process of moral growth, post-exposure prophylaxis is usually not opposed per se, but it is often delayed. More reluctance exists towards mass dog vaccination, because it is seen as an interference in how the goddess controls dogs and spreads rabies as a punishment to wrongdoers. • In Maharashtra, dog bite victims who visit Kuttarwadi to drink its supposedly curative water engage in risky dog bite management practices. Half of them do not wash the wound and 15% of them apply irritating substances. While 85% of bite victims go to Kuttarwadi only after seeking post-exposure vaccination, 70% of those who first go to Kuttarwadi, never seek medical attention later, because they believe that traditional healing works as well as vaccination, they do not trust biomedicine, or they underestimate risk.The results of this study will be shared with the Ministry of Health and Family Welfare and it will be hopefully taken into account for the implementation of the new National Action Plan for dog mediated Rabies Elimination. This rabies control plan will be the first to be applied nationwide and to involve rural communities. As shown by SAREE, pre-intervention preparatory research on the locally-specific dynamics of rabies is crucial, as a one-size-fits-all strategy is unlikely to succeed.This project's results are being disseminated through 7 peer-reviewed, open-access papers/book chapters, one international workshop on One Health and infectious diseases in the Anthropocene, one panel at the Association of Social Anthropologists of the UK and Commonwealth’s Conference, and more than 20 oral presentations at conferences, webinars, and SAREE-related institutions. Progress beyond the state of the art and expected potential impact (including the socio-economic impact and the wider societal implications of the project so far) By focusing on socially and geographically marginalized areas, where surveillance is weak and research is scarce, this study provided, through contact tracing, unique epidemiological data and a much-needed understanding of the current barriers to human and dog vaccination. Contact tracing data are still being analyzed, but they are offering first-hand qualitative and quantitative information on: what are the circumstances of exposure in humans and dogs; whether and how rural dog bite victims perform any dog bite management practice; what kind of healthcare they seek and receive in a context of medical pluralism (hence at hospitals, places of worship, and traditional healers’); what reasons inform their choice; whether and what challenges they face in accessing and receiving healthcare; whether and how they manage rabies in dogs; what they think about dog vaccination; etc. In India, SAREE was the first to apply contact tracing to rabies. The data collected at Hadkai Mata temples resulted in the first body of scholarly literature about this goddess – which is among the very few rabies-related deities to exist in any current world religion and has never been studied before – and the knowledge about rabies that is built and shared at Hadkai Mata temples. A first recommendation document, based on SAREE preliminary research results and aimed at improving the National Action Plan for dog mediated Rabies Elimination before its finalization and launch, was submitted to the Indian National Centre for Disease Control in November 2020. Ad-hoc recording forms for bite cases and rabies cases to be used in local hospitals, initially developed as SAREE research materials, were also shared. The adoption of these forms will make sure that basic but precise information is collected from local communities, in order to strengthen surveillance and, more importantly, enable the healthcare system to not only provide vaccination to exposed individuals, but also work together with the veterinary sector to prevent exposure in humans and dogs by interrupting chains of transmission and controlling local rabies outbreaks. Hadkai Mata temple, Gujarat, India
