title: Low castes have poor access to visceral leishmaniasis treatment in Bihar, India.
abstract: OBJECTIVE
  Bihar, the poorest state in India, concentrates most of the visceral leishmaniasis (VL) cases in the country. A large proportion of the poor rural communities where VL is endemic are marginalized by their socio-economic status, intrinsically related to the caste system. In this study, we evaluated whether people from low socio-economic strata had difficulties accessing VL treatment in Bihar. As a secondary outcome, we evaluated whether people delaying their VL treatment had poorer clinical indicators at admission.
  
  
  METHODS
  Data on 2187 patients with VL treated by Médecins Sans Frontières (MSF) in Vaishali district from July 2007 to December 2008 were analysed. Patients who reported having onset of symptoms ≥8 weeks before admission were defined as 'late presenters'. Logistic regression models were used to evaluate whether low castes had higher risk to be 'late presenters' compared to the rest of castes and whether 'late presenters' had poorer indicators at admission (i.e. haemoglobin level, spleen size).
  
  
  RESULTS
  After adjusting for age, gender and distance to VL treatment facility, Mushars (the lowest caste in Bihar) had twice the odds to be 'late presenters' compared to the rest of castes (OR 2.05, 95% CI: 1.24-2.38). Subjects that had VL symptoms for ≥8 weeks had a larger spleen and lower haemoglobin level than those that were treated earlier.
  
  
  CONCLUSIONS
  Low castes have poor access to VL treatment in Bihar, and late presenters have poorer clinical indicators at admission. These findings have implications at individual and community levels and should stimulate targeted VL control programmes to ensure that marginalized communities in Bihar are properly treated.
authors.affiliation: Médecins Sans Frontières-Operational Center Barcelona-Athens, Barcelona, Spain. fernando.pascual@barcelona.msf.org
authors.forename: F
authors.initials: F
authors.lastname: Pascual Martínez
authors.forename: A
authors.initials: A
authors.lastname: Picado
authors.forename: P
authors.initials: P
authors.lastname: Roddy
authors.forename: P
authors.initials: P
authors.lastname: Palma
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D007898:Leishmaniasis, Visceral / Q000188:drug therapy* / Q000453:epidemiology*; D008297:Male; D011203:Poverty / Q000706:statistics & numerical data; D012423:Rural Health / Q000706:statistics & numerical data; D012424:Rural Population / Q000706:statistics & numerical data; D012923:Social Class; D055815:Young Adult