Madwa 2014 . . .

As part of our Community Development project targeting Climate Change, our team has facilitated the reintroduction of finger millet cultivation in the region. Last year (2013), we had about 40 farmers who cultivated in a total of about 4 acres. This year, we had about 230 farmers who cultivated a total of about 12 acres.

Last week, during the US-led “Dialogue on Nutrition” held at the Food and Agricultural Organization (FAO), FAO Deputy Director-General Daniel Gustafson highlighted that "good nutrition must begin with agriculture." 

It was a privilege to have Professor Z A Haider from the Birsa Agriculture University, Ranchi visiting the region, to follow up on our work among the farmers. The program becomes all the more significant in the light of the Fifth Assessment Report of the Intergovernmental Panel on Climate Change – Impacts, Adaptation and Vulnerability. I’m yet to go through the whole report. But, from a  news-item of the same in Down To Earth, the future looks pretty grim.

Snaps of the visit . . . and more discussions later . . .  

At Patna village . . .

Walking into the fields . . . 

Another field . . . Prof. Haider was very much impressed . . .

Prof. Haider interacting with the farmer . . .

This plot of ground was a major revelation for the entire team. More on this in the next post . . .

Going further . . . 

More interaction with farmers . . . 

Field at Charwadih . . . 

Quite a large field at Murma . . . 

The field at NJH campus . . .

Field at Bohita village . . . 

Interacting with people from potential new cultivation areas for the next year.
We had a very interesting dialogue. Shall write in detail about it in the next post.
Looking forward for madwa cultivation in Barwadih block next year. 

To treat or not . . .

As mentioned in my previous post of malnutrition, one of the major aspects that most of us doctors forget is the innate ability of the body to heal itself.

What happens if you don’t treat your pneumonia. Yes, there is a higher chance of dying and getting complications in the absence of treatment. However, there is a good chance of escaping unscathed even without medicines. Maybe, there would be delay in your getting better. Of course, there are major determinants of spontaneous healing like non-extremes of age, good nutrition, hygienic environs etc.

As public health consultants, we’ve been taught in school about risks and benefits. One of terms that helped me quite a lot was the concept of number needed to treat (NNT).

I was so happy to see a website called TheNNT.com where one can find out more about the concept. Recently, there was a good article about it. I’m sure you’re going to get quite a few surprises about many of the traditional treatment protocols that we commonly use.

Some of my favorites . . . 

- Combined inhalers vs Steroid Inhalers for Adults with Asthma

- Coronary Heart Bypass for Prevention of Death

- Diagnostic testing for patient reassurance

- Vitamin D for fracture prevention

- Screening mammography for reducing deaths

- Routine health checkups for reducing mortality and morbidity

- Anti-hypertensives for cardiovascular event prevention in mild hypertension

So, do check out if you really need to prescribe something about which you're not really sure about. You save a lot of money for your patient and maybe even prevent unnecessary complications . . . 

Itch, Itch, Itch . . .

Few days back, a mother brought her 10 year old boy to the clinic. Her complaint was that the boy told her that something was wrong with his private parts. I asked him what the problem was. He told that he is having severe itching and there is infected wounds filled with pus in his genital areas.

After quite persuasion, he agreed to let me examine him. His scrotum and penis was covered with pus filled ulcerated areas. There were few lesions which appeared to have healed resulting in quite bad scars in his scrotum and penis. I asked him if there was pain. He told that the pain was tolerable, but what he could not tolerate was the itching at night.

There was only one diagnosis – scabies with secondary infection. However, I had never seen this much extent of secondary infection in scabies. After advising the parents on the possible diagnosis, I got assurance from them that they would come within couple of days after I start treatment for review.

I was surprised to find the boy back after couple of days. He appeared quite cheerful. Once I was inside the clinic, I realized that the parents and his brother also had registered themselves for check-up. To my horror, all three of them had scabies over various parts of their body. And for the boy on whom I had started antibiotics, all the pustular lesions had healed and the lesions which are very typical of scabies was very obvious.

All four of them were started on topical applications to treat the scabies.

However, I was in for another surprise later that day. For the first time in my life, I saw an infant of less than 2 months of age with scabies. Of course, the mother also had scabies infestation on her body. The interesting thing was that the mother never thought of the skin lesions very seriously. Her main complaint was that the baby was crying throughout the night as if he was in pain. Little did she know that the itching was bothering the baby.

Scabies as an indication of poor personal hygiene. 

Yesterday, I was on a field visit with Prof. Haider, Professor of Birsa Agricultural University. It was very obvious during the visit to most villages that the drought has started to affect the daily activities of the villagers. Water was a precious commodity. Taking bath even once a day was a premium. The women were the worst affected.

The issue is that treatment of scabies also involves advise to take bath regularly as well as to wash all clothes, especially undergarments in boiling water. I wonder how this family is going to find enough water to do all that. 

I’m sure that I would be seeing a lot more of scabies over the next few weeks. I would also be interested to see what other diseases can a drought bring about. With an obvious issue with food security, my gut feeling is that we would be seeing an increase in the number of chronic infections especially tuberculosis.

Immuno-compromised by Malnutrition

One of my favorite quotes is that by William Osler about the usage of medicine.

Unfortunately, almost all of us believe that medicines are the elixir of life. And when we take medicines, we want quick relief. Almost all over the country, quacks and non-qualified practioners have thrived on this and one of the major challenges in the healthcare scenario of the country is the unbridled use of medicines especially antibiotics and steroids. Of course, the pharmaceutical industry all the more promotes such usage. 

And as doctors we fail to understand the inherent nature of the body to heal itself, which is very evident by the way many of us prescribe medicines.

This becomes a major issue in poor and marginalized communities of the world as it is quite a fashionable thing to resort to medicines and injections and get well. A very dangerous trend when we look at the fact that issues of sanitation and nutrition are hardly given any serious thought.

I personally believe that in India, malnutrition is the most serious form of immune-compromised state. As medical students, we were trained to think of only HIV patients and patients on immune-suppressive medicines to be immunosuppressed. I hope to see a change in the attitude that many of our medical colleges have towards malnutrition. We don’t see many HIV patients or patients on immunosuppressive medicine, but we see so many malnourished.

In Barwadih, the population of which comprises mainly on permanent residents of the Kherwar tribe and a migrant population of people from Bihar and Munda tribals from the Ranchi plateau, we are stunned by the amount of malnutrition we see. We did a rough survey of children who come to us and it was quite alarming to find that almost 70-80% of under-fives who come to us are at least moderately malnourished. I’m sure the situation would be worse if we do a community based survey.

And I dream to do a community based survey to highlight the gravity of the problem in hard-to-reach areas. I’m sure that there are going to many determinants of this health issue which could be different from other regions.

The challenge is to find long term solutions especially in a situation where more than half of the nation’s under fives are malnourished. 

And Primitive Behavior . . .

The second story is that of CC, a 2 month old boy. Similar to BB, CC also was brought in a very serious condition. The baby was small for his age and he was in full blown sepsis. CC was born with a birth weight of 2.3 kilograms and now, after 2 months, he weighed 2.4 kilograms.

We all tried our best to refer CC to a higher centre. CC’s parents were dirt poor. They told that they had some problems at home and therefore it was totally out of question to take him elsewhere.

With the customary high risk consent, we started off treatment. There was no respite for the first 2 days. The baby was listless and was not at all feeding. Both these days we tried our best to ensure that he is taken to a specialist centre.

On the evening of the 2^nd day of admission, his condition looked so bad that the local parish priest went to the parent’s village to convince the village elders to take the baby to a higher centre. He was surprised to find a panchayat in progress with the baby’s father sitting in the centre.

Later, we found out that the panchayat had met following a complaint against the baby’s parents from the grandmother of the baby that she was thrown out of the house and that they were not taking care of her. We also found out that CC’s mother was the second wife and the first wife was also living in the same house. And it was not uncommon for either of the wives to mistreat the other as well as the other’s children.

And to make matters more complicated, there was hardly any hour of the day when the father did not have alcohol running in his veins. In fact, after the panchayat was over, he came to the clinic reeking of alcohol. 

We confronted the father about the problems in his home. There was hardly anything to eat at home. The customary breakfast was boiled corn meal and the dinner was rice gruel. There was no lunch. No lentils (dhal) . . . no vegetables . . . leave alone egg, milk or fish . . .

It was by now very obvious that the family had hardly any resources to take the baby even to a local private clinic. He brought him to us expecting us to give concessionary treatement.

By God’s grace, the child showed some amount of improvement on the third day and by the fourth day, he started to feed.

We’ve written off the entire bill.

Well, this is quite a common story for me since I’ve come to know this region. And from colleagues and friends working in similar situations in many of the EAG states, the situation is no different.

I wonder what does the Mangalyan mission mean to parents of CC and BB and similar families in the rest of the country? 

Of dark ages . . .

Recently, we’ve had quite a lot of debates about propriety of having a mission to Mars when quite a large part of the country is so backward and in dire poverty. Of course, the Mangalyan program is commendable and we all are proud of it. However, I strongly feel that stories of neglect and backwardness of our great nation have to be shared. The major reason being the fact that a widening gap between the rich and the poor is something which could hamper the progress of the nation.

So, stories of 2 families in this series .  . . The first one . . .

BB, a 3 week old child was brought by his parents more than a week back. It was so obvious that BB was very very sick. He was not crying and only had a blank stare on his face. Of course, he was not feeding. BB has been sick since the previous day afternoon. BB was brought to the clinic where I sit twice a week the previous evening. However, since I was away, the nurses had referred him to a higher centre.

BB’s parents were very poor. They had taken him to a wizard and he told them that he needs some costly procedures to be done. They had no money to take the baby to a higher centre or to pay the wizard.

We had no choice but to admit the child. By God’s grace, he responded well to antibiotics. However, as soon as the baby was active, the parents wanted to take him home. Later, we came to know that a grandparent had suggested that he be also shown to the wizard so that the disease is completely cured and therefore the urgency to go home.

The parents left with the baby with a promise that he would be brought twice a day for his intravenous antibiotics. They kept their promise. However, the next day, the parents were very anxious to meet me. They narrated to us that the witch doctor has taken out a dozen pieces of bones from the baby’s stomach which was causing all the disease.

They were very confident that the baby will be totally alright now. One of colleagues was quite flabbergasted at their story. He gave them a good piece of his mind.

However, it was quite obvious that they very much believed what the witch doctor has told them.

Occult in its various forms are quite common in our country. However, the poor suffer from it the most. BB’s parents told me that the cost of ‘taking out the stones’ was couple of country chicken which costs a minimum of 600 INR.

We commonly hear about worse forms of occult practice. Elderly women, mostly widows are branded as witches when something untoward happens to someone. These women are hounded, beaten up and in many instances mercilessly killed. One police officer told me of an incident where a widow was decapitated and the head was brought to the police station by the entire village, and nobody could do anything about it. Even, FIRs (first information report) are filed against suspected witches for ill-happenings. And the police are at a loss to do anything.

I wish that witch-craft is something that needs to be dealt with in rural communities of the country. It is not easy. It would need quite a lot of advocacy among the community and its leaders and the success in eradicating it would need community support. However, the benefits would be quite a lot.

The second story in my next post . . . 

Clinical Establishment Act - Please respond

This is a post which I should have posted much before. I’m not sure about how many know about the Clinical Establishment Act 2010 which is being slowly implemented in the country. Couple of states like Assam and Orissa have already implemented it. There are many a hospital in both these states that have been closed down because of the regulations stipulated by the Act.

Recently, there was a notice from the the National Council forClinical Establishments under the Chairmanship of Director General of Health Services, Government of India inviting comments, suggestions, objections, including deletions /additions in the draft documents prepared by them from the public at large and concerned stakeholders.

I personally have much misgiving to the regulations of the Act in the present form.

1.      In a country like India which is very vast and the majority of the population (about 70%) lives in villages, it is going to be very difficult for anybody to set up hospitals in semi-urban and rural areas. The stipulations are going to be very hard to meet that setting up a hospital would hardly be a profitable venture. The other side is that even if hospitals are set up, the cost of care would be quite expensive. Almost all of us have mostly depended on small clinics or nursing homes which are run by a single doctor with the help of a nurse or by a doctor family. In fact, quite a lot of us may have knowingly or unknowingly gone to a unqualified practitioner or quack for our small medical problems. At present I live in a place where almost 95% of the population go to a quack first for treatment. They have bungled up cases where the patient ultimately died. However, nobody has been able to do anything. The only reason being that these guys are the only people who have some knowledge about medicine in remote settings. And they come very cheap. The regulations appear to be giving more importance for corporate multispecialty hospitals. This is quite protectionist in nature towards encouraging a corporate model which will ensure that healthcare is only available at a premium in the absence of an efficient public health care system.

2.      There is enough scientific evidence that family practice and nurse practioner based primary care is as efficient, and rather more people friendly than specialist doctors in full fledged hospital set ups.

3.      If you consider any of the complex clinical conditions one can think of, the primary level of care is much more important than high tech healthcare. We have examples of countries like Brazil and South Africa, where Family Medicine graduates have major role in healthcare. The present regulations would only increase costs. If you look at the regulations, the first level of treatment is going to be a Level 1 Hospital which needs to have a staffing of at least 6 for a place which do not have inpatient care.

4.      Most of our tertiary care centres are burdened with primary care. It is not uncommon for any faculty in our medical colleges who end up complaining that most of the patients that they see could have been easily managed at a Primary Health Centre or even by a Nurse Practioner. The ultimate result is that quite a many of our specialists are over-worked to the extent that they are not able to do justice to the specialised skills they’ve obtained.

If we can think of changes that can be proposed, I would propose the following –

1.      Legalising Nurse-Practioner Care: Nurses should be trained to treat simple illnesses allowed to prescribe medicines. A major need would be to allow a category of healthcentres which are entirely run by nurses who may or may not supervised by doctors. At least for populations who have poor access to healthcare, they would be a major boon. In fact, such nurse-led primary care centres have already been in existence in the country, mainly facilitated by various congregations of the Catholic Church.

2.      Provision for single doctor healthcare centres: We are all very familiar with such single doctor establishments. A 100 square feet room with a familiar friendly face to whom you ran when you had a toothache or a cold. You pay about 50 rupees and then you pay some more for the medicines and some basic investigations. The whole process took not more than half an hour. If the regulations in it's present form are accepted and finalised, the family doctor would be history.

May I encourage you to write back to the government, details of which can be found at http://clinicalestablishments.nic.in/WriteReadData/896.pdf.

Images from a hockey match

More than a year back, I had posted snaps of a hockey ground in rural Jharkhand. Although Jharkhand did not have any representation in the team that won the Asian Games gold medal, hockey has always been a favored game among the tribal population. 

Recently, my friend, Fr. Joshi (Nellissery Varghese, CMF) shared snaps of a hockey match from a nearby village. I'm sure this would wake up sports administrators in the better off parts of our country to the untapped potential of rural India. 

All snaps, courtesy Fr. Nellissery Varghese, CMF. 

Pre-match session . . .

The chief guest, Fr. Rajesh Barla, CMF getting to know the teams

The toss . . .

An unwilling spectator . . .

Another one . . . but smaller

The cheer girls . . . and ladies

After the match . . . not difficult to guess who won

Waiting for the presentations . . . 

Post match analysis . . .

The runner-up trophy . . . 

The championship trophy . . . 

 . . . who almost ran off . . .

Post match congratulations . . . 

The prize also gets to know the spectators . . .