Saturday, June 24, 2017

How much poor ?

As health care professionals, Angel and me get exposed to horrible levels of poverty almost every day. There have been many many stories. Few days back, I was reminded once again on how bad the poverty can be. 

6 months back, we had an elderly man walk into our clinic with a retention of urine. He needed catherisation of the urinary bladder, which ultimately ended up with a permanent indwelling catheter. Leave alone the option of undergoing a surgery to open up his prostatic urethra, he could not afford the trip to meet the surgeon. 

The maximum we could offer was a permanent indwelling catheter, which is not exactly the ideal option of treatment. He needed to get it changed once a month. 

We also told him about the better options that he has. He laughed them off saying that unless someone does it on him for free, our treatment is what he preferred. In addition, he also had high blood pressure. 

He came regularly till January 2017. Then we did not see him. In fact, we remembered him. Maybe he died. Or, someone gave him some money to undergo the surgery. 

Today, he turned up. He was in severe pain. And his catheter had blocked. He had kept his catheter for a full 3 months.

It was a nightmare. There was skin enveloping over the catheter. It was dry and was very dirty. The attending nurse could not deflate the bulb. I could only shudder on what we will do if the catheter had become stuck. He would have to visit a urologist. The nearest one was 200 kilometers away. The maximum money he usually has with him has never crossed 200 INR, not even enough to cover the travelling cost of one person to the urologist. 

We could only pray. And reattempt to deflate the bulb. It just did not budge. As we attempted again, the valve at the balloon port, broke off. To our relief, as that happened, water started to drip from the broken balloon port and with a bit of a pull, the catheter was out. The balloon end of the catheter was covered with clotted blood for about 10 cms. Thankfully, there was no bleeding from the urethra. 

After everything was over,  I asked the elderly man for the reason for the long delay. He told me that his son reasoned to him that it would be cheaper to wait longer before the catheter is changed. And there was no money in the family. The elderly man and his wife were non-performing assets for his son. His son was away in Kerala now. 

The bill for today totaled about 400 INR. And there was a outstanding due of about 200 INR from his previous visits. I asked him how much he could pay today. He told 250 INR. We took 200 INR and wrote off the rest. 

For such a patient, I cannot see how he can afford a surgical procedure even if I could offer one. Unless, we wrote off the entire amount. 

There has been many a debate on how the poor can be treated. I believe there is only one way until full-fledged public healthcare becomes a reality in the country - teach them to prevent diseases, access treatment at the earliest and offer them options which they can afford. 

Of course, there are always better ways of treatment. Someone could fund it out. But, the question remains about how long . . . about how sustainable are many of the healthcare options we have today . . .

Friday, June 23, 2017

To do list


Few weeks back, I had a unique experience.

Early morning at around 7 am, a man was rushed into our clinic with complaints of chest pain since the last 2 days. He was taking some local treatment elsewhere when the pain became unbearable since midnight. He had a feeling that his life was coming to an end.

We made him comfortable, gave some analgesics and went ahead with an ECG. It was obviously a heart attack in progress.

He asked me if he was having a heart attack which he knew could be fatal. I told him that he appears to be having a heart attack. Although in severe pain, he asked one of the bystanders, who seemed to be his son to bring him a paper and a pen. We provided him with one.

He was in too much distress to write. He told his son to write as he dictated. It was basically names of people along with amounts of money which they owed him. It took some time for him to remember, but he thought he had all names. The total was quite a bit of an amount .. .. ..

As I witnessed this exercise, I remembered about how people like Moses, Joseph, Abraham etc. of the Old Testament in the Bible called all his children and blessed them as they lay dying.

I wondered what I will have to tell my children and grandchildren as I reach my last days on earth . . .

My prayer is that it would only be to tell my family about how good the Lord has been and how good is it to trust and follow the Lordship of Jesus Christ . . .


Thursday, May 25, 2017

Misleading . . .

One of the major group of patients whom we serve at Barwadih are those who present with diarrhoea. Since last few months, quite a many of the patients tell us not to prescribe Oral Rehydration Solution powder as there is a ready to drink ORS preparation available in the market. 

I did not care much as this drink called ORSL was quite commonly available in the market and patients especially children preferred it over the ORS powder which we prescribed. On and off, we used to get patients who said that they did not feel better and requested for the ORS powder. 

However, I was in for a shock today, when a patient with diarrhoea walked in with this packaged drink. The snaps of the tetrapack are self-explanatory. 


The manufacturer has very clearly stated that IT IS NOT TO BE USED FOR DIARRHOEA and there is no mention of the WHO accepted formulation for ORS. 

For those who don't know the formula for the current WHO oral rehydration solution (also known as low-osmolar ORS or reduced-osmolarity ORS) is 2.6 grams (0.092 oz) salt (NaCl), 2.9 grams (0.10 oz) trisodium citrate dihydrate , 1.5 grams (0.053 oz) potassium chloride (KCl), 13.5 grams (0.48 oz) anhydrous glucose per litre of fluid. This fruit drink has a whopping 12 gms of sugar per 200 ml. 

So, why the name - ORSL - which appears to stand for ORS Liquid. 

I've seen patients buy this drink in cartons from local pharmacy shops. 

Now, for the shocker . . . The below snap shows the price for this 200 ml drink which misleads people to think that it is a medicine. 


32 INR . . . when the ORS sachets are available free in public healthcare facilities and the maximum cost of a ORS sachet which makes 1 litre of the fluid is about 16 INR. So, a misled patient could end up spending 160 INR per one litre of ORSL instead of 16 INR. 

Quite misleading marketing strategy to make a quick buck . . . Can't someone take this company to task for misleading people into buying this sugary drink, which is in fact harmful to health. At least they should print 'Do not use during diarrhoea' in larger print and the local vernacular language. Instead they have printed ORSL in Hindi to mislead the unsuspecting poor and the half literate Indian. 

A typical example of how crony capitalism makes it's profits . . . 

Saturday, April 15, 2017

My goats are on the hill

It's diarrhoea season at our place now. Patients of all ages are coming in various stages of the disease. So far, the good Lord has healed everyone.

Yesterday, we got the sickest of the lot. Around late morning, an elderly lady was carried in with a history of high volume rice water diarrhoea along with severe vomitting. We could not palpate any pulse.

We were blessed enough to get a vein on her. After about 2 litres of fluid, we could measure her blood pressure.

By teatime, she was up and talking. However, she appeared so tired. During evening rounds, she wanted to go home. I told her that considering the state in which she was brought in and it being evening, it would be better for her to go the next day. I said to her that she looked tired and would benefit from a day's rest. 

She told me, 'I'm not able to close my eyes to get some sleep. The moment I close my eyes, I only see my goats which I had to leave as I was brought here. They are still on the hill. I need to ensure that they are back safe'. One of her sons told her that she needn't worry about the goats as someone had already brought them back home.

Amazing . . . even when she was so sick, the only thing she could think about was her goats. In rural areas, animals are the major asset for everyone. That was their bank balance. But, you had to regularly take care of them, unlike a bank account where you are assured of the money which was deposited there. Anytime they need some money one of the animals was sold. 

In the changing scenario of the country, when there is a push towards vegetarianism, I can only wonder at the fate of the poor who will have to look for other avenues of income. Or maybe, there will be no more poor . . . 

Sunday, April 2, 2017

Gas . . . Gas . . . and Gas


Three days back, we had a elderly lady being brought. Carried in her son's arms, she was worn out and thin with a protruding abdomen. Clearly a case of ascites or a large abdominal tumour. 

Since it was close to afternoon, I did a quick examination and sent her off for a 30 kilometer journey for an ultrasound abdomen. 

She was back just before sunset with the ultrasound report. It was just ascites. No tumour. There was mention of a possibility of a chronic liver disease.

That was when I took a detailed history. She had been having this much abdominal distension since the last 1 month. She had already been treated at multiple places and had spent almost 15000 INR. It was not that they could afford that much. That was what the quacks demanded for the treatment. 

The quacks had been telling the family since the first day that it was just gas that is pent up in the intestines. They even had a X-Ray abdomen to prove the point. 

She had not yet been seen by a proper doctor. 

I got into a mini-conference with two of her male relatives and told of the possibilities. They wanted me to give her some medicines to dry out the fluid collection. They did not want an ascitic tap to take out the fluid and do some tests. The only test we could do was a microscopic examination. Under no circumstances, they were ready to take her ahead for treatment. 

She did not respond to the diuretics that I tried. Ultimately, they agreed for a tap with the fiat that whatever tests I had to do with it has to be done here. They just did not want to take her nor the fluid ahead for any tests. 

I did the tap today. It was a hemorrhagic tap. Microscopy showed almost 99% lymphocytes along with the red blood cells. It was more in favour of a cancer. Well, it could be tuberculosis too. Liver function tests were all normal. 

The best I could do for her was to start her off on anti-tuberculous medication and send her home. 

But, it would have been better if she came straight to us before they blew up 15000 INR for the quacks to remove the gas . . . 

The big question is how I can enable families like these to see us as their first choice for access to healthcare . . . rather than these quacks . . .