Patient who taught me - 2

Anotherpatient who taught me something important.

This again happened during my previous stinct at NJH.

It was midnight of a really hot summer. The hospital was not very busy. I was called to attend to a girl, about 12-13 years old who presented to emergency with severe breathlessness.

On attending to this girl whom we shall call AK, I realised that I was dealing with a long term cardiac condition,  most probably a congenital cardiac disease with end stage cardiac failure.

The X-ray confirmed it. Her heart occupied almost the whole of her chest. The veins in her throat were all bulged up. Her eyes were bulging and was very congested. She had central as well as peripheral cyanosis. I could not record her blood pressure.

I put her on the bed in the acute care. I called one of my colleagues who confirmed that nothing much can be done other than make her feel comfortable.

I talked to her parents. In fact, AK had been sick from the day she celebrated her first birthday. They had not shown her to a proper doctor. Only quacks (jhola chaps) and faith-healers (ojhas) had seen her. The family appeared to understand that there was nothing much to do other than pray.

I went to talk with AK. To my surprise, AK also was sure that she was dying. As I told her that I shall see her in the morning and was leaving, she clinged to my hand.

In between her breathlessness she told me, ‘Please ensure that I die here in this place.’ I told her that my nurses will take care of her well. Then she continued, ‘Doctor, I’ve never slept on a bed. I never knew that it is so comfortable. Please let me die on this bed’.

AK died early morning, before I reached for rounds. Her face was so peaceful. Not the contorted faces that I’ve seen in many of my patients who die a horrible death after being breathless.

All she wanted was to remain in the bed on which she ultimately died.

Tells a lot about basic human needs and wants, especially those of the poor. 

Patients who taught me - 1

Patients teach us a lot about life. And I’m sure that they are not one-off incidents. I’m thankful for these patients who instilled qualities in me which I value very much.

The first incident occurred during my previous stinct at NJH. Ms. RK was a 9 year old girl who came to us with a perforated intestine, most probably following enteric fever. The family did not look poor to not afford surgery at our place.

The treatment which included surgery went on without any hitches. Their total bill had come to around 12000 INR. Since there was not any complications and the admission period was uneventful, we did not remember much about RK and her family.

Not until about 6 months later.

I had been part of setting up a TB Clinic at another hospital about 100 miles away from our place. I usually travelled to this place by jeep early morning.

In one of the trips, I stopped at a wayside shack for tea early in the morning, when this middle aged man who was making the tea came out of his shop and touched my feet. He told me that we had saved his daughter’s life some time back.

I could not place the identity of the family till RK came running out from behind the shack.

The shack comprised mainly of 4 heavy pieces of wood in the corners and plastic sheets and sack cloth dividing the space into 3 rooms. Bricks were arranged in a very haphazardous manner to make the outer walls.

It took me some time to recognise RK.

I was surprised at the severe poverty in which the family lived. The father was ready with the tea.

As I sipped the tea on that cold winter morning, I asked the father how he was able to pay our bill 6 months back, considering the poverty he was in. I was in for a shock.

The father replied, ‘We had seen better times till RK fell sick. By the time, we reached your hospital, we had already spent about 20,000 for RK’s treatment. It was just after planting our crops that RK fell sick. So, I did not have any money with me. Therefore, we had to take a loan from the local money lender. Unfortunately, the crops failed because of a poor monsoon. We had to sell our home and the little land that we had to repay the money lender. After that, our life has been this shack.’

He took me about 50 metres down the road and pointed to a hut, much better than their present residence and told me that they used to live there before RK fell sick. 

The winter appeared to sort of envelope me in a terrible chill when I heard this.

We had not even bothered to ask the family about their resources when they came to pay their bill.

The family was very thankful that their little girl did well after our treatment. There was no hint of any remorse in the father’s or the family’s conversation with us about the poverty they were dragged into because of their daughter’s illness.

But, I learnt a very important lesson. I’ve heard only about statistics of how 40% of poverty was caused by ill-health in the family. I was seeing a real life story of one of our patients.

From then on, I make it a point to enquire if our patients our selling their only possessions to pay their healthcare bills. Yeah, the situation has occurred because of a poor public healthcare system.

I’m sure that I may be taken for a ride by many of my patients when they know about my attitude towards patients who have to sell their land or homes to pay for their treatment.

However, I believe that there will be genuine patients who’ll be benefited for life if we enquire about where their resources come from.

The ultimate answer would be to push for a well oiled and competent public healthcare system.

But till that happens, mission hospitals like ours can make a difference in the lives of at least few of such families.

Who comes to us?

It has been some time since someone requested me to look at who accesses services in our hospital and we wanted to look at whether it was the deserving people who had the RSBY (Rashtriya Swasthya Bima Yojana) Smart Card with them. 

One of the major problems with all welfare schemes is that many a time it is middle class who corner away most of the benefits which are supposed to go down to the masses who have are worse off than them. 

Below are the preliminary results. 

The socio-economic score we used was the Uday Pareekh scale for rural areas. The duration of the study was 5 days somewhere in the first half of December. And we looked at all patients who came to general outpatient department on those 5 days. The number of patients who accessed outpatient during those 5 days were very less because of the severe cold. 

So, the first question .. .. .. We at NJH, consider ourselves to exist for the welfare of the most marginalised and backward community groups of our region. So, who are the people who access our services?

Socio-economic category	Nos of patients	Percentage of total
Lower class	46	24%
Lower middle class	115	61%
Middle class	27	14%
Upper middle class	2	1%
TOTAL	190	100%

The second question was about the number of people in each socio-economic category who possessed a RSBY Smart Card . . . a major welfare initiative by the Government of India for the poor. And below is the result. 

Socio-economic category	Number of patients	Number of patients with RSBY Card	Percentage of patients with RSBY Smart Card
Lower class	46	16	35%
Lower middle class	115	22	19%
Middle class	27	7	26%
Upper middle class	2	0	0%

So, there you are . . . It is the middle class who garner quite a lot of the benefits and more needs to be done to ensure that the benefits seep down to the more poor among our countrymen . . . However, I feel that 35% of the lower class possessing the RSBY Card is quite an achievement for the government. 

One can say that the sample size is small and it was done during a very lean season. I wish I could do the study during a very busy outpatient like what we have nowadays. I've a hunch that the results are not going to be much different. 

Comments are invited .. .. ..

(Acknowledgement: Special thanks to George Savio Chalam who helped us with the survey and part of data entry and Ms Pheba Zachariah who did the other half of the data entry and rechecked data)

Injustice . .. ... (RSBY)

The RSBY Programme, has been there with us from the last 8 months. The cycle for the Palamu district finishes by 30th November, 2012. Which means that we'll have to wait for re-enrollment to treat patients from December 2012. However, patients from Garhwa and Latehar would continue to benefit. 

Yesterday, we had a very well off patient come to us and waste quite a lot of our time demanding that we admit under RSBY. I had an issue as they were insisting on having a private room. They started off by bugging the nurses. Then, they demand that they see me. I happened to see the family while doing my night rounds. They started to boss about saying who they were and what all connections they had. It was nauseating. 

I could only think of some of my patients whom I had seen earlier in the day who were very poor, but did not have a RSBY Card. But, here was one patient with bystanders sporting branded jeans, leather jackets, gold chains on the neck . . . they were claiming that the patient was Below Poverty Line . . . 

The next day, the group was back. This time, they targeted the Nursing Superintendent. But, to no avail. They came again back to me. They wanted us to adjust. I stood my line. Ultimately, they got the RSBY facility cancelled for their patient and got her admitted in the private ward. 

I thought of doing a small exercise. There was about 40 patients in the hospital at that point of time. To my horror, I found out that 5 out of 9 patients who were in the private ward possessed the RSBY Card (and of course the BPL card) whereas only one out of the rest of the patients who were admitted in General Ward had the Smart Card. (we did not give any benefit to the patients in private ward)

So much for social equity. 

We've raised this issue in many forums. But to no avail. I'm not sure whom to blame. Everyone says that things will become fine from the next time onwards. However, I'm doubtful. 

We see this phenomenon of well off families possessing social benefit schemes for the poor very often. It is not very difficult to explain. Most of the time, when the people for enrolment arrive, it is usually the empowered people in the village who benefit. The people with no voice are left behind. 

Well, the story does not finish here. One of the relatives of this patient commented to one of the nurses that they shall teach us a lesson. They did not show any outward emotions . . . later, they were quite good to me. 

I got few call couple of hours later from couple of people who told me that they were from the press. They asked me about details of the RSBY programme. And how we were running it. 

However, there was no news report today morning. Maybe, they realised that it was futile to put any sort of report on this. 

Unfortunate, but true. How the high and well off retain their 'high status' in the society at the expense of the poor and the marginalised. 

Today, I happened to read the story about poor working conditions of factory workers who died in a fire in Bangladesh. Factories which manufacture apparels for the big brands. These big brands would do all possible to keep their names a secret. Another type of exploitation of the poor so that others can remain rich. 

From the last few years in the heartland of mines and factories, I can tell you that almost all of the success stories of shining India are at the expense of the poor and marginalised of this country. 

The exploitation of government welfare programmes by the rich at the expense of the real needy are just the tip of the iceberg . . .  And I'm sure that I would have enough people who would share similar stories. But, the question remains on whether anybody is interested in changing this. 

Another accident . . . provoking thoughts. . .

There has always been a debate on the cost at which societies have achieved development and progress. However, it is not an unknown truth that most of the progress we see around us happens at the expense of the poor and the marginalised. The issue becomes more sad when lives are lost in the process.

It has not been many days before we had another accident in front of our hospital which claimed yet another life. The difference being that the unfortunate victim this time was a boy on his way to school.

The accident occurred at around 9 in the morning. I got to know it as it involved one of our senior staff. Mr. Tapeswar oversaw the functioning of a hostel for kids from remote villages who went to schools nearby. There were not many kids – but it was enough to keep him busy.

The unfortunate victim was about 6 years old. And was on his way to school when an overspeeding Bolero jeep smashed into him. From the people who had seen it happening, it was obvious that the boy died on the spot.

The site soon after the accident. The body lies on the road and the locals prepare to block the road 

Well, the stretch of road in front of our hospital is quite good and there is a tendency for vehicles to speed up. I wonder if the number of accidents would increase once the whole of the terrible stretch of road between Ranchi and Daltonganj is repaired.

And we are having our road repaired on a war footing since couple of days. We’ve heard that the Deputy Commissioner of the district has given an ultimatum to the Public Works Department to complete the work by the 15th of April. This is good news for us especially our school children who travel about 60 kms to and fro daily.

That night, I wondered about how inequality reigns in our society is. Most of the infrastructure development happens which do not directly benefit the real poor. Rather, the development occurs at the expense of the poor and the marginalised.

We’ve high speed express highways between cities that speed up traffic but which hardly brings any development in the poor villages that line the highway. It is not an uncommon scene where electricity high tension wires pass through villages which has not seen electricity. High speed express trains whiz past malnourished children waving at the passengers.

The little boy may not have died if the road was not too smooth for the Bolero to whiz past at such a high speed. I tried to contact some officials from the Public Works Department about the possibility of putting couple of humps on the road where there is a possibility of drivers trying to speed. I was told that humps are not permitted in the National Highways. I’m not going to give up.

The accident brought into light the aspect of development about which I had been referring to at the beginning of this post. The collateral damage that communities pay to ensure smoother lives for better off fellow citizens is sometimes quite large. I remember an incident that an agrarian family narrated to me while I was doing part of my post-graduate posting in RUHSA. It was about herds of cattle and goats being mowed down by high speeding trains.

The railways have of course brought the land for laying the rail tracks. But, they created a barrier to many a family from accessing prime pasture land or water bodies. It is of course impossible to provide throughfares at short intervals. But, I understand there are countries like Japan where elevated rail lines were specifically created so that there would not be disturbance to normal lives of people living along the route.

But, there are instances within our own country where the needs of the ‘people along the way’ have been taken care of. The first one I can remember is the service roads which are provided alongside high speed expressways. The Chennai-Bangalore have quite a lot of them especially in small towns. Another example is of railways building footpaths beside rail-bridges allowing local villagers to use them rather than the rail-bridge to cross.

However, there are larger stories of exploitation prevalent in areas of our country whereby entire people groups are displaced for the purpose of bringing about development. Well, that is an entirely different story and a larger issue which has brought people groups into conflict.

Like the road blockade that was put on after the incident in front of the hospital, there are similar protests which only serves to bring the attention of the administration and community for a short duration. However, there are no long lasting solutions achieved nor attempted. Once the road blockade is over, everybody forgets about the root cause of similar accidents and nothing more is done. 

I’m sure there are interventions possible in development of public infrastructure whereby loss to life and resources can be brought down to a significant extent. If that happens, we can prevent more of such ghastly incidents from happening. However, this would require quite a lot of political will as well as community mobilisation . . .