Mistrust

By today almost all of our high risk obstetric patients whom I mentioned in my previous posts would have got discharged. Yesterday, as I did rounds, I wondered how easily the patients ended up putting their trust in quacks and witch-doctors than qualified medical graduates and post-graduates.

However, ever since I started my practice of medicine, I've sort of come to the conclusion all of this is because of the way we communicate. A quack or a witch-doctor takes his own time to talk with the patient and to quite an extent explains diseases in terms that they can understand.

And to the Indian mind, unexplained mysterious things are more easily believed than a rational stream of thoughts or a scientific explanation.

To a certain extent, many of the modern medicine doctors have learned to communicate well and have ended us as popular clinicians with roaring practices.

But, recently I came across quite popular clinicians doing things which were totally non-evidence based. To make matters worse, it bordered quite a lot on the tendency to make easy money at the expense of the patient.

I got such a typical patient yesterday in out-patient. The young lady had delivered 3 months back. And since the last 2 weeks she had been complaining of severe tiredness and burning sensation of the feet. She was from a well to do family and therefore all her treatments were taken with the best clinicians in the cities around our place . . .Ranchi, Varanasi, Patna etc.

She did not come to us for a consultation. Rather, she came to show the huge list of investigations that one of the well known doctors in one of the above cities had written for her . . . It was a bit difficult to make any sense of the tests that were done . . . Below is the list . . .

Thyroid function test - T3, T4, TSH. 

Liver function test - Total and direct bilirubin, SGOT, SGPT, Gamma Glutamyl Transferase, Total Protein, S. Albumin, Alkaline Phosphatase

Lipid Profile - Serum cholesterol, HDL Cholesterol, LDL Cholesterol, Triglyerides

Blood Urea Nitrogen, Serum Creatinine, Serum Calcium, Serum Uric Acid, Serum Iron, Total Iroan Binding Capacity, Percentage of Transferrin Saturation

It is not difficult to find out about the cost . . . should be around 1500 to 2000 INR. 

Clinical examination wise, she was pale. I thought there may be a investigation slip that she misplaced. She was absolutely sure that there was no other slip.

Our doctor only thought that she must have Dimorphic/Nutritional Anemia. What she wanted was only a  hemoglobin and a peripheral smear. But, the patient would not have any more investigations. In fact, she was furious, when we suggested that she does couple of more tests. 

She just walked out . . . We did not see her again. Later, one of the nurses told us that she told one of the staff that she was on her way to see the doctor who prescribed all these tests. Someone had suggested that we have quite good doctors and therefore she could benefit without having to go all the way to this city. 

I could only feel pity for this well off lady who would have benefited from a course of Iron and Vitamins. I was also sad for my own professional colleagues who have started to behave more like quacks rather than students of science and God-fearing men and women. 

Praise and Prayer Bulletin, November 2013

1. We thank the Lord for the 24 hours electricity supply we have since the last week. 

2. Almost all of our high risk patients survived and went home well. We thank the Lord that that we've been used to be a blessing in the lives of these patients. We specially thank the Lord for the baby whom we could save after a rupture uterus. However, we're very well also aware that we would do better with specialists in the areas of obstetrics and pediatrics. Please pray. 

3. We thank the Lord for the success we've had with the Finger Millet cultivation and the SRI Method of Rice Cultivation which we did as part of the project on Community Based Adaptation towards Climate Change. Please pray for the efforts we take to promote millet (rather, reintroduce) in the community. 

4. We thank the Lord for the Mr. Ashurosh (Pharmacist) and his wife Mrs. Tabitha (Staff Nurse) who joined us since last week. Please pray that the Lord will bless them and they would be a blessing to the hospital and the community. 

5. Duncan Hospital, Raxual has been kind enough to depute Mr. Shivnath, laboratory technician as we have a shortage of lab technicians. We thank the Lord for the Mr. Shivnath's life as well as pray that the Lord will bless him. 

6. We thank for the Lord for Dr. Titus and his wife, Dr. Grace. Kindly pray for them as they plan for the future, especially post-graduate studies. 

7. We thank the Lord for the smooth construction of the water tank. The contractors plan to complete the construction by the end of this year. 

8. There were 2 of our staff families who were blessed with babies over the last couple of weeks. Mrs. Sudha (staff nurse) was blessed with a baby boy. Mr. Rajeev (laboratory technician) was blessed with a baby girl. We thank the Lord that both the deliveries were uneventful. 

9. Please pray for the financial needs of the hospital. The new transformer and the high tension electricity connection has been a major financial burden for the hospital. In addition, we need to upgrade the Acute Care Unit, put in place a new Hospital Information System, construct the Sarai and at least couple of new residential apartments for our staff. 

10. We look forward for new consultants in the specialties of General Surgery, Obstetrics and Pediatrics to join us. Please pray and pass the message along. 

11. We appear to be heading into a very harsh winter. We already temperatures dipping to as low as 5 degree Celsius. Please pray for the health and protection of the staff.

12. Please pray for couple of our staff who are sick. 

Ragi Chilka Roti

This is another type of flatbread which is can also be made with wheat and rice. This used to be common food stuff in rural Indian homes in North India.

Ingredients:

   Ragi flour (madwa atta): 2 cups

   Sugar: To taste

   Salt: To taste

   Lukewarm water: 2 cups

   Oil/Clarified butter: 1 tsp spoon per roti

Method:

Mix ragi flour, sugar and salt

Gradually add the lukewarm water to make a thin batter. This should only be just watery to flow without sticking.

Heat the griddle in medium flame. After smearing the griddle with about a teaspoon of oil/butter, pour one ladle of batter to the middle of the pan and spread in a circular motion to form a 8 inch roti.

Cover the roti with a vessel for couple of minutes. Then, turn it over and heat the other side too.

Your madwa chilka roti is ready.

The chilka roti can also be made with mixture of rice/wheat flour and ragi in varying proportions. 

The fatal massage

The word 'massage' brings into most of our minds scenes of serenity and comfort. Quite a lot of us are quite familiar with traditional massage systems starting from quite complicated massage processes in the Ayurveda for which Kerala is quite famous to the massage you get at the barber's saloon. 

However, in quite a few parts of the country, including ours, there is a process of massaging the uterus just as the pains of childbirth starts. And they also do that when they feel that the gestational age of the baby has gone beyond term. 

The massage ranges from very tender rubs on the gravid tummy with oil to vigorous working up of the abdomen with ones fist extending to even using planks of wood. Even today, the last patient whom I've just seen in the Labour Room has had a massage. 

But, last week, we had a patient who had got the most horrible massage one can imagine. Yes . . . a massage with a plank of wood on her tummy. I had seen quite a few during my earlier stint at NJH. 

We shall call our patient PhD. A 30 year old mother of one, who had crossed her expected date of delivery of her fourth pregnancy came to us 4 days back. Yes, of her earlier three deliveries only one had survived . . . A 7 year old girl. 

All her previous deliveries were at home. And she had taken her fourth delivery as just another chore. But, this did not go as she had thought it will. When she reached NJH, she was already in labour for 48 hours. In addition, she had got quite a lot of massages, culminating in the massage with the plank of wood. 

The process was well evident on her tummy. The angry looking skin was quite obvious. And the uterus was tense. It was like a balloon. Couple of us thought that she had ruptured. The blood tests turned out to be very bad. She was in full blown sepsis (total leucocyte count of more than 30,000) and was anemic. I was sure that she was dehydrated and therefore the hemoglobin was more low than we expected. 

And she had a hand presentation . . .

The only choice she had was to undergo an emergency Cesarian to remove the dead baby and to repair if she had ruptured. My only fear was gangrene of the intestine. We had lost a similar patient couple of years back after she had intestinal ischaemia following massaging of the abdomen. 

We somehow got hold one pint of fresh blood and she went to theatre . . .

We were relieved to find out that she was yet to rupture. But, the lower segment of the uterus was totally battered into a pulp between the endometrium and peritoneum. There was a good chance that the lower segment will not hold well when I deliver the baby. After thinking it out, we decided to put a inverted T incision on the uterus. 

We were glad that we took that decision. As soon as I put a nick on the uterus, there was a gush of putrid gas which gave us quite a tough time. The baby was badly macerated. The surgery was over in an hour. Thankfully, the patient did quite well after surgery. She should be discharged over the next couple of days.  

I've been trying to convince our local community about this totally unscientific practice. Unfortunately, nobody seems to listen. I came to know that the procedure of massaging the abdomen is so much ingrained into the local traditional healthcare of the pregnant woman. 

For PhD, the massage brought in quite a lot of troubles. Her socio-economic situation made things even worse. She was from quite a remote area. When she was brought by the government nurse in her village, none of her relatives were accompanying her. Her husband was a tuberculosis patient. I'm sure that we'll have to write off quite a lot of her bill. 

Another story of one more live saved because of the Lord working through the team at NJH. 

Please scroll down if you're interested in seeing few snaps taken of the lady and her baby. May I warn you that the snaps are very very repulsive. Be warned . . . the snaps are horrible . . .

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Sr. Sushma, our Nurse Anesthetist praying hard before we start the surgery. 

The badly macerated baby

The uterine incision. You can see the vertical portion of the inverted T incision is sutured.
The lower segment was very very unhealthy and we just got the edges opposed.

24 Hours Electricity

By today evening, it will be 48 hours since we got connected to the government electricity supply which provides us with almost 24 hours of electricity. As in most parts of the country, we don't expect the supply to be there for the whole 24 hours. So far, there was a interruption of only about 2 hours. Otherwise the voltage has been very good. 

We praise God. 

And coincidentally, we got our connection on the 53rd Founder's Day (November 20th). 

There are few aspects for which we specifically want to specifically praise and thank the Lord. 

1. Not having regular electricity has been one of the reasons why quite a few staff did not stay on at NJH. Now, that is going to be old story. 

2. We have an exclusive connection to the hospital now. The village connection is separate. Earlier, the nearby village and the hospital had shared the same transformer and that caused a lot of problems. 

3. Along with the new connection, the electricity board was kind enough to remove all the high tension wires which crisscrossed the campus. 

4. Almost all of our voltage stabilizers are of no use. Because the voltage is too good. We praise God. 

5. The best of all . . . We did not pay any speed money for obtaining the exclusive High Tension Connection and our own transformer. So, we can get things here without bribes. We praise God that we found favor in the eyes of many an official of the Jharkhand Electricity Board. Of course, there were times, when there was quite a lot of pressure to make some payments to speed up the process. We thank the Lord that we could hold on to our principles. 

I thank the Lord for the maintenance department under the leadership of Dinesh who worked worked untiringly and generously in spite of many setbacks and challenges. 

We've ended up spending almost 700,000 INR to get the infrastructure that has facilitated the process of exclusive and seamless connection. So far, we've spend all this from funds generated from patient care. We pray that we would be able to receive gifts from friends and well-wishers to recover this spending so that we can spend more on patient care.

Revisiting the traditional

'In the olden days we never fell ill. We worked and worked hard. We did not feel the heat of the sun in the middle of summer nor the chill of the winter. Our elders lived to ripe old ages and our women were much healthier. We went walking to distant lands and would never get tired. We ate things we cultivated in our fields and drank the water from the streams which passed through our village'

This is a common refrain that I hear again and again in agrarian communities of different parts of the country . . . . Kerala, Tamil Nadu, Andhra, Maharashtra, the North East and now Jharkhand. 

They continue - 'not anymore. Our young men do not like to work. In fact, they are not strong enough to work hard. They are tired always. They find it difficult to walk on foot to the next village. They prefer to sit chitchatting and day-dream. We cultivate new things in our fields about which we do not have much idea. Our water bodies are dry most of the time and when they are full, the water is polluted . . . And to top it all, we have diseases which we've never heard before . . .

If one has the time to listen, there are umpteen stories of change that a wizened old man in a village can narrate. 

Having served in the area of healthcare for the last 10 years, the major issues that seem to have changed the susceptibility of the population to poor health and diseases all point to malnutrition as the primary cause.

Many of us think about malnutrition as only a condition which occurs when there is a shortage of food. However, that is not the case. It means much more than that. Classically, it is defined as the condition that results from eating a diet in which certain nutrients are lacking, in excess or in the wrong proportions.

In almost all the rural areas that I visited, I was shocked to find out that in the olden days rice was only one of the options of the cereal in the diet and wheat was quite foreign in many regions especially in the south of the country. There were other choices which got wiped off with the advent of the green revolution. The green revolution guaranteed wiping off hunger and ushering in prosperity to farmers. 

We all thought that we had hit the goldmine. 

Not any more. The high prevalence of non-communicable diseases in the country points to a different story. The high calorie diets of rice and wheat based food brought in diseases such as diabetes and high blood pressure and also ensured that the we became deficient in micronutrients and vitamins. 

What exactly were the other choices of food which our forefathers had? 

In Tamil Nadu, they talk about the good old days when Thinai (foxtail millet) or Pani Varagu (proso millet) with milk were common diets. Village born and city bred folk talk about the 'kool and kali' made out from finger millet (ragi) and pearl millet (bajra/kambu). Come to the north of the country, and they talk about the Thopa Roti made out of finger millet (madwa), the Gundali rice (another local millets) of yore and the Kodo rice which ensured that hunger stayed far away. 

As I talked to scientists in this area, almost all of them expressed helplessness in ensuring that these grains remained in common use. However, there has been major breakthroughs in the cultivation and propagating the consumption of millet grains like finger millets (ragi/madwa). However, there are many other types of millets which are unique to certain parts of the country. Unfortunately, many millet varieties are on the verge of extinction. 

Why are they so precious to us? And there one would find the answer to the hardiness and the disease resistance that our forefathers possessed. High in vitamins and micro-nutrients, these millets are virtual store-houses of immunity. 

The table below is quite self-explanatory . . .

	Protein (gm)	Fibres (gm)	Minerals (gms)	Iron (mg)	Calcium (mg)
Rice	6.8	0.2	0.6	0.7	10
Wheat	11.8	1.2	1.5	5.3	41
Finger millet	7.3	3.6	2.7	3.9	344
Kodo	8.3	9	2.6	0.5	27
Pearl millet	10.6	1.3	2.3	16.9	38
Proso millet	12.5	2.2	1.9	0.8	14

And it is not surprising that millet based porridges like finger-millet porridge is much recommended as good weaning food for infants. 

Now, there is one more angle to the story of millets. And this is the nature of the crop to withstand drought and for the grain to resist pests. Which makes it all the more an answer to climate change and farmer distress. 

Summing it up . . .

- Millet crops are hardy and require less water. 

- They can be grown in low fertile soils.

- Millets grow better with biofertilizers.

- Most of the millets are pest-free. In traditional societies, they used to be used as used as anti-pest agents to store pulses etc. 

- Nutrient to nutrient, most of the millets are much superior to rice and wheat.  

I'm glad that Dabur has given an opportunity to put this write-up. I'm sure that millet based diet is going to play a major role in building a stronger, healthier and a more immune India. 

Ragi Porridge

 

Well, this is how most of us got introduced to finger millets.

 

The classic Ragi Kanji or 'panjipul kurukku' as we used to know it.

 

One of the best weaning material for infants. The challenge is to get the right sweetness. The taste is much better if we use flour made from sprouted finger millet grain.

 

Ingredients:

   Boiled Milk: 1 cup

   Fingermillet flour: 2 teaspoon

   Sugar: 2 teaspoon or to taste. It also tastes good with jaggery.

 

Method:

Mix the three items in a sauce pan and keep the mixture in a low flame and heat till you get the desired consistency. You can increase the amount of milk if you want the porridge to be more liquidy.

 

Madwa Thoppa Roti

This flatbread used to be a common breakfast item in the regions of Jharkhand, Chattisgarh and Orissa in the olden days. In our nearby communities, this is still commonly eaten. And now, this would be more commonly eaten as our CH program is advocating cultivation and use of ragi in their regular diet.

After having made it quite a number of times now . . . my take on this. This needs some amount of practice before you get perfect rotis. If made well, it is a great snack for kids. And it is best eaten when it is warm. Once it is cold, it could become a bit hard. The amount of oil used is a bit on the higher side. For those who have a tendency towards heartburn (increased acidity), this causes a bit of heartburn.

Ingredients:

   Ragi (finger millet/madwa atta) flour – 2 cups

   Sugar – 3 teaspoons

   Salt – a pinch

   Lukewarm water – 1 cup

   Oil/Clarified butter – 3 teaspoons per roti

Method:
 

Mix the ragi flour, sugar and salt well.

 

Add the lukewarm water slowly to the above mixture and make into dough of average consistency. 

 

 

Divide the dough into 3 or 4 equal portions.

 

Heat the griddle (tawa) in medium heat. I’ve found that a heavy griddle works better than the thin non-stick pans. Once the griddle is hot, put 2-3 teaspoons of oil/butter on the griddle.

 

Keep one portion of the dough on the hot oil/butter and flatten it preferably with your fingers till you get a round flatbread of about 2-3 millimeters. If the dough is sticky, you can wet your fingers with water as you flatten it.

Turn over couple of times over 5-6 minutes without burning it.

 

If you successfully make this, do remember. This used to be one of the most common food stuff eaten in rural Indian households till rice and wheat based dishes took over. 

 

Ragi Dishes

As part of the Project on Community Based Adaptation towards Climate Change, we are trying to re-introduce usage of finger-millets and popularise it in our communities. 

Below are an array of food stuffs which used to be common in homes of rural India till few years back . . . 
 

Ragi porridge

 

Thoppa Roti

Chilka Roti

Mohan Bhog

Ragi Laddoo

Ragi Laddoo

Ragi Khichdi 

Ragi Idlis

Anarasa (also in the right)

 

Madwa Halwai

Madwa Poori

Ragi Puttu

I shall be posting the recipes of each of the items in the coming days . . .