Village Medical Camp

Quite a many public health experts think of a one time medical camp as a waste of resources. However, we get invited many a time by organizations to conduct medical camps in villages. 

I usually oblige. The prime reason being that I need to have a very good relationship with the organisations who call us for these camps. The other reason being that many patients who need surgeries are identified and referred. However, experience says that very few of them turn up. 

But, the major reason for going for a camp is that we doctors get a hang of what is happening in the communities only if we go for such camps. 

Last week we had a medical camp was in a remote village in Chinia block of Garhwa district.

My quick notes about the place – 

- The impoverishment of the area strikes you. There were only about a dozen people who had an average physique. Almost all the women were poorly built and nourished. 

- There is a high incidence of hypertension. We calculated about 40 newly detected patients with high blood pressure in the crowd of about 400.

- There is a high incidence of cataracts. The fact that the elderly are quite disabled by cataract is comfortably ignored. Very few families were bothered about it. The attitude was that they are old anyway and therefore there is hardly a need to worry about their sight. They only want some medicine to be put and we found it difficult to convince the families that these elderly would benefit from a simple surgery. And we were doing it free. Of the 40 odd patients whom we referred, only one turned up for free surgery.

- Another striking aspect which was also seen in camps we did earlier was the high incidence of corneal opacities in the young. Most of them were secondary to trivial injuries to the eye.

Of the above, the most worrying . . . the relatively high incidence of hypertension in rural communities. With the amount of follow up that non-communicable diseases such as hypertension warrant, they could spell the death knell for quite a lot of our agrarian populations.

The quite a few number of strokes we get in NJH is good enough proof.

 
I wonder how serious we are about the morbidity and mortality that non-communicable diseases can do to agriculture economies . . .

Maternal Mortality . . . Struggling

The press has reported a United Nations Report saying that India is going to miss the Millennium Development Goal (MDG) related to maternal health. We had targeted to reach a Maternal Mortality Rate (MMR) of 109 per 100,000 live births by 2015. However, the MMR as of today is about 212 per 100,000 live births . . . a far cry from what we want to achieve. . .

If you had been following my blog, the state of poor maternal and child health has been something I had been trying to portray. Recently, I had been trying to put some statistics from where I could look at what we may need to do extra to bring down the high maternal mortality rate. 

Thanks to Mr. Luke, a visiting student who has been helping us with computerizing our data, we have been able to look at maternal deaths. So far, we have been able to data for the last 3 years. Considering the way we keep our statistics, I'm sure that the data is incomplete. 

However, below is data related to diagnosis of the 89 maternal deaths which happened over the last 3 years - 2009-12. 

Diagnosis	Nos.
Anemia	8 (10%)
Eclampsia	48 (57%)
Malaria	1 (1%)
Unknown	3 (4%)
Obstructed labour	1 (1%)
Pneumonia	1 (1%)
PPH	5 (6%)
Rupture uterus	4 (5%)
Sepsis	10 (12%)
Unknown	3 (4%)
TOTAL	84 (100%)

Table 1

We had been suspecting it for some time. Although this is institutional based data, a diagnosis of Eclampsia causing death in 57% of the Maternal Deaths over the last 3 years is a major finding.

Well, for the uninitiated, according to the 2005 World Health Report, the following are the causes of maternal deaths - - - 

Causes of MM	%
Hemorrhage	25%
Infections	13%
Unsafe abortions	13%
Eclampsia	12%
Obstructed labour	8%

Table 2

I did some calculations for the populations that we serve. I hope the following table is self-explanatory . . .

	Total pop.	Pop. catered	Birth Rate	Births	MMR	Maternal Deaths
Palamu	1936319	1452239	0.026	37758	0.0021	80
Garhwa	1322387	661194	0.026	17191	0.0021	36
Latehar	725673	362837	0.026	9434	0.0021	20
TOTAL	3984379	2476269		64383		136

Table 3

According to our rough calculations, NJH caters to about 75% of the Palamu district and 50% of Latehar and Garhwa districts - this means that in our catered population, we would have a total of 136 deaths every year . . . 

There are documents putting the institutional delivery rates as low as 18% as well as those putting it at 50%. We estimate that about 30% of deliveries happen in institutions. Therefore, we recalculated and got the following statistics . . . 

	Maternal Deaths	Institution Del Rate	Maternal Deaths
Palamu	80	0.3	24
Garhwa	36	0.3	11
Latehar	20	0.3	6
TOTAL	136		41

Table 4

So, it means that 41 maternal deaths occurs in hospitals. However, this can be an underestimation as most of them had been trying for home delivery and reach hospital quite late after realizing of possibility of a complication.

I thought about re-looking the statistics for 2011 alone . . . We, at NJH had a total of 29 maternal deaths in 2011 . . . Below is the table showing the diagnosis of the maternal deaths. . .

Diagnosis	Nos (%)
Anemia	2 (7%)
Eclampsia	10 (34%)
Malaria	1 (3%)
Unknown	2 (7%)
Obstructed labour	1 (3%)
Pneumonia	1 (3%)
PPH	3 (10%)
Rupture uterus	2 (7%)
Sepsis	4 (14%)
Unknown	3 (10%)
TOTAL	29 (100%)

Table 5


The predominance of Eclampsia being the commonest diagnosis in a maternal death remains. For the 29 maternal deaths that happened at NJH in 2011, I have put an additional column in Table 5 and looked at where the 29 maternal deaths came from . . .

	Maternal Deaths in target community	Institution Del Rate	Maternal Deaths in institutions (calculated)	Maternal Deaths at NJH (2011)
Palamu	80	0.3	24	16
Garhwa	36	0.3	11	4
Latehar	20	0.3	6	7
Others	-	-	-	2
TOTAL	136		41	29

Table 6

2 of the patients had come from Gaya district. Well, table nos. 6 speaks volumes of the influence NJH has in the Maternal and Child Health Care in the region.

Well . . . there is quite a lot that we need to learn. We had looked at the possibility of a community based survey about maternal health care. Unfortunately, the clinical load has prevented us from doing it . . .

There are quite a lot of people who has put in their input behind this post . . .and I'm indebted to them. Just a couple of names without whom this would not have been possible. First of all, for a discussion with Dr Anil Cherian, the Director at Community Health, Emmanuel Hospital Association which stimulated me to look at this and Mr. Luke Gray who computerised all the records . . .

So, at the end of it . . . questions remain. . . The major ones being . . . 

1. Is hemorrhage the commonest cause of maternal death in the country?

2. Eclampsia is a major problem in many of our rural areas . . .Does nutrition have a role in the pathophysiology of hypertensive diseases of pregnancy?

3. How serious is our public healthcare about maternal health? 

To answer the last question . . . The saddest part remains that at least our local public healthcare authorities are hardly bothered about maternal deaths . . . We had been filling up the Institutional Maternal Death Review Forms since last August. It is going to be one year. I'm yet to be called for at least one meeting about this . . .