Clinical Establishment Act . . .

Well, I’m sure quite a lot of Indians would have some sort of idea of what this is. Well, for the dummies, this act would lay down basic criteria for operationalising clinics, hospitals, laboratories etc.

For the uninitiated person, who has no idea about the masala of Indian healthcare, the natural response would be - ‘Great, this is something each citizen would definitely benefit from. Access to quality healthcare at your beck and call’. Well, appearances can be very deceptive.

Now, let me come to something which we at NJH do on a regular basis. Obstetrics . . . I’m yet to see the CEA (Clinical Establishment Act) of Jharkhand. But, the CEA made up by another state, Assam states that for a Maternity Home (Hospital with Obstetrics Department) you need the following -

1. Full time qualified gynecologist with PG Degree/Diploma in Obstetrics

2. Full time qualified paediatrician with PG Degree/Diploma in Paediatrics

3. Full time qualified anesthesiologist with PG Degree/Diploma in Anesthesia

4. Part time/Full time Physician with PG Degree/Diploma in Medicine

Well, the rules are not quite difficult to follow in maybe the metropolitan cities of the country and many of the towns of better off states like Kerala, Tamil Nadu or Gujarat . . . The rest of the country? ? ?

I thought of doing a small exercise yesterday. NJH caters to complicated obstetric cases of almost the whole of 3 districts in West Jharkhand. Only those who can afford to pay well go all the way to Ranchi which is 135 kms away.

I called up one of my acquaintances and requested names of obstetricians with either a Degree (MD) or Diploma (DGO) in the speciality of Obstetrics in these 3 districts. Below is what I got.

Palamu district – 1 MD, 5 DGOs

Latehar district – 1 MD, 2-3 DGOs (not certain)

Garhwa district - 1 MD, 2-3 DGOs (not certain)

Well, anybody interested in the population of the 3 districts . . . Approximately 4,000,000. Which means at a birth rate of approximately 25 per 1000, we would have about 100,000 births to be overseen by 15 obstetricians every year. Even after calculating a 50% institutional delivery rate, this would mean that each obstetrician would end up overseeing about 3500 deliveries every year.

The scenario which I’ve shown is the same rather worse for almost all the other specialities.

What would the CEA lead to in most of the regions of the country -

1. Healthcare which is already expensive would become more expensive.

2. Healthcare would become inaccessible to most of the Indian poor unless they live in a state which has good public healthcare.

3. Specialists would become more in demand. Their salaries would rocket sky-high

4. Most of the small nursing homes and hospitals especially mission hospitals would have to be closed down.

5. Healthcare would become an industry rather than a service.

One among the multiple thoughts I had about the CEA was the fact that in spite of quite stringent rules, all through these years quacks and allied health professionals have been practicing medicine in almost the whole of our country. I wonder why the government should insist on specialists alone handling the clinical work.

Please do note that in many of our medical schools, we’ve had non-specialists doing excellent work in various departments. So far, we did not have any problem. In fact, no patients have any problem going first to a quack before he tries to access a qualified doctor.

I wonder if the state would have problems if I wanted to show my child to a non-specialist with whom I’ve developed a good rapport throughout the years. Some of the best hands I’ve seen dealing in specialities are those with no specialist qualifications. I’m well aware that it would be ideal to have specialists. But, what worries me are the following factors -

1. Lack of adequate training facilities for specialists, both in terms of quality and quantity. Recently, I met a senior obstetrician who is in the faculty of a Medical School and she mentioned to me that her MD Obstetrics students do not do more than 10 independent Cesarian Sections during the entire course of their study. I remember going to one Medical School where the postgraduate students in Surgery told me that their course is more like an MD Surgery rather than MS Surgery. The reason, they read more theory and hardly get to do any practical work. Post-graduate medical training in India is at the cross-roads. 

2. Our huge population. For a 4 million population of the region, we calculated approximately 15 degree and diploma obstetricians. Now, I’ve read that in the US, during 1980s there were about 8 obstetricians per 100,000 population. Its 30 years now. If we used the same yardstick, we should have 320 obstetricians for the districts of Palamu, Garhwa and Latehar. I say, it would be a luxury to have 25% of that number, which is 80 obstetricians. Presently, the US has about 14 obstetricians for a 100,000 population and if you put that number for our region (Palamu, Garhwa and Latehar), that would be 560 obstetricians.

3. Inadequate medical graduates - There are quite a lot of medical schools in the country - the latest figures stating a total of 335 medical colleges churning out 40525 new doctors every year. The issues of emigration and non-practising doctors are quite a major factor. In addition, almost all of us prefer to work in urban areas, which ultimately results in a disproportionate distribution of doctors across the country. There has been news about the government trying to increase the number of seats.   

Taking the cause of obstetricians once again, according to the MCI website there should be 1214 OG Degree consultants and 637 OG Diploma consultants passing out every year. I thought of doing a small calculation to find out how many we need. If we use the standard we decided would be good enough which is 2 obstetricians per 100,000 population, for a population 1200 million we would need 24000 obstetricians; which means that 1800 odd obstetricians passing out each year would be well enough, provided we do not have the problems of urban flocking, migration and of those who decide to do 'armchair obstetrics'. 

But, mind you, there are major regional variations here. 

Let us take the example of Jharkhand. As per the MCI website, Jharkhand Medical Schools have a total of 9 MD seats and 2 DGO seats for Obstetrics and Gynecology every year. Which means that if the average practise period of a obstetrician is 25 years, there would be 275 obstetricians in the whole of Jharkhand at any point of time. And, we are dreaming of 320 obstetricians for Palamu, Garhwa and Latehar districts. 

The situation is entirely different in places like Andhra Pradesh Medical Colleges, which have a yearly total output capacity of 126 MD seats and 95 Diploma seats in Obstetrics and Gynecology.

Now, the total population of Jharkhand is approximately 33 million and Andhra Pradesh is 84 million, which means that to reach standards of Andhra Pradesh, we would need a total of about 70 Obstetricians passing out of Jharkhand Medical Schools every year. . .  

In the light of the factors, I would continue to trumpet the cause of 'Family Medicine' in the scheme of things in Indian healthcare. As of now, there has not been much of a support for the speciality of Family Medicine from almost the whole of the Indian healthcare fraternity. The issue of getting a team of specialists together at a given point of time in rural areas of the country such as ours. 

One needs to only ask any of the District Medical Officers on how practical are most of their First Referral Units are. I've been hearing those stories for some time now. It requires Anesthetist, Obstetrician, Pediatrician and Blood Bank Officer (Diploma in Clinical Pathology or MD General Pathology) at the same time together. One person's absence is enough to cripple the arrangement. And this is where the Family Medicine consultant steps in. With clear guidelines on when to refer, a group of Family Medicine consultants manning a Primary Health Centre or a Community Health Centre can make a world of difference to the healthcare in India. Unfortunately, I could not find any mention of a role for a Family Medicine Physician in CEA literatures of any of the states which are already implementing the law. 

The late Field Marshall Sam Manekshaw had made the following comment on lawmakers with regard to their knowledge of defence matters of the country. "I wonder whether those of our political masters who have been put in charge of the defence of the country can distinguish a mortar from a motor; a gun from a howitzer; a guerrilla from a gorilla, although a great many resemble the latter." I think the same applies to the healthcare sector. Could I paraphrase it this way. 'I wonder whether those of our political masters who have been put in charge of the healthcare of the country can distinguish labour pains from the labour department, an operation theatre from a cinema theatre, an obstetrician from an orthopedician, a consultant from a generalist, a quack from a quake . . . although a great many resemble the latter.

The CEA is a good step to standardise the quality of healthcare facilities in the country, but unfortunately appears to have been made by people who have no idea about grassroot level issues. There are umpteen number of pre-requisites to attain before we can plan to think of implementing the CEA. Almost all of the pre-requisites require a great amount of planning and willpower to operationalize with a long term vision. Otherwise the CEA would become another of the many Indian legislations which appear rosy on paper but has no use in bringing about the necessary changes. 

At least a smile . . .

'Change' - one of the themes through which most of the democracies elect their representatives in government. I think this word became all the more popular after the successful presidential campaign run of the present US President, Mr Barack Obama. 

However, when you start to wonder at the whole gamut of 'change', behaviour analysts will warn us that it is most difficult thing to bring about in institutions and individuals. 

For the whole of last year, Anna Hazare and his colleagues joined by millions of our countrymen have been clamouring for change in corruption patterns of our society. In fact, something which has become as common as the sun rising everyday in the east. We as institutions and individuals have gone to the extent of budgeting for shady deals. We would definitely like to see a change here - but no one needs to be an expert on this; this is going to take a lifetime and maybe another freedom struggle before we achieve it. 

Even Mr. Obama's countrymen have realised the emptiness of all the hype that was generated during the election campaign four years ago. 

We've heard many a philosopher say that 'change' starts with me. But the question is about what to change. Somewhere we need to make a start. 

Almost all of us are very much familiar about the story of the 'Good Samaritan'. For those uninitiated, below is the Holy Bible passage from St. Luke Chapter 10, Verses 25 to 36 . . . 

Behold, a certain lawyer stood up and tested him, saying, "Teacher, what shall I do to inherit eternal life?"

He said to him, "What is written in the law? How do you read it?"

He answered, "You shall love the Lord your God with all your heart, with all your soul, with all your strength, and with all your mind; and your neighbour as yourself."

He said to him, "You have answered correctly. Do this, and you will live."

But he, desiring to justify himself, asked Jesus, "Who is my neighbour?"

Jesus answered, "A certain man was going down from Jerusalem to Jericho, and he fell among robbers, who both stripped him and beat him, and departed, leaving him half dead. By chance a certain priest was going down that way. When he saw him, he passed by on the other side. In the same way a Levite also, when he came to the place, and saw him, passed by on the other side. But a certain Samaritan, as he traveled, came where he was. When he saw him, he was moved with compassion, came to him, and bound up his wounds, pouring on oil and wine. He set him on his own animal, and brought him to an inn, and took care of him. On the next day, when he departed, he took out two denarii, and gave them to the host, and said to him, 'Take care of him. Whatever you spend beyond that, I will repay you when I return.' Now which of these three do you think seemed to be a neighbour to him who fell among the robbers?"

He said, "He who showed mercy on him."

Then Jesus said to him, "Go and do likewise."

— Luke 10:25–37, World English Bible

I've always wondered whether this would be one of the best changes that can ever happen to the world. Being good neighbours. . . 

I've friends who keep on searching for what they should do in life waiting for some event to persuade them to do something special or unique. Needs of our own countrymen stare at us. Hands wanting to be held, ears yearning for comforting words, shoulders needing a pat, tears waiting to be wiped . . . I can go on and on. 

I remember a priest who once preached in my church, 'Many people have no problem being quite concerned about those who are sick and hungry in some deprived areas of the world, but have great problem to help out their neighbour when he is in need'. 

Having mercy to those who are in need. This is what we need today. People willing to open their hearts and purses to those in need. That would be the best answer to many of the problems plaguing us. Well, it needs a will power to do . . . and more than that a willingness of the spirit. The spirit which compelled many such  individuals and institutions which did yeoman service to humanity over the years. 

The spirit of giving seems to be on the wane. The change we need today is a renewal of the spirit to give. Our money for others . . . 

Our time for others . . . 

Our talents for others . . . 

Others who need them more than us. . . 

Couple of days back I read the story of an elderly couple who lived in the midst of a famine. They were just able to manage a square meal a day. One night, a lady with a baby came asking for help . . . The old man gave away a piece of jewel that he was saving for harder times. His wife was in the kitchen stirring up some gruel and did not know that her husband had given off the jewellery. When she came to know about it, she told her husband, 'Did you not know it's worth to give it away?' The old man told her to wait and went out. He ran after the lady with the baby. He found her and told her, 'My wife tells me that the piece of jewellery is quite expensive. I'm sure we would never use it. Please use it wisely'. 

We keep to ourselves quite a lot of valuable things which we would never use in our lives . . . In fact, I had recently read a newspaper report that rich Indians gave much lesser to charity than the rich elsewhere. I'm not sure how true it is. But if it true, it is unfortunate. 

I wondered on what all things we hold on to as much valuable, but find it difficult to share. One thing that struck me was about the way we bring up our children. We try our best to inculcate all sorts of values aimed at self-centredness and self-preservation into our children. 

Why not try bringing up our children with values aimed towards giving things for the society? The urge to contribute for the larger good rather than than an urge towards self-gratification and selfishness. 

Rather, it involves dedicating our children to the welfare of others . . . May be quite a difficult thought for us. Most of us look at our children as an investment for our future when we become old. . .  But, I need not tell you that most of the times, in reality, it does not work out that way. 

If that is a difficult thought, do find something which you can give to others. 

Something less expensive. A smile . . . Less expensive, but precious. . . That would be quite a good start towards initiating a culture towards giving. . . Well, I'm told that a smile involves using quite a lot of muscles of the face, but many a thing falls into place with a smile. Maybe, you may not end up giving big things. But, I tell you my friend, a smile to anybody, a friend or a stranger can be a good start for the habit of giving . . .

Dangerous obstetrics . . .

Over the last 3 days, we had 3 obstetric patients – each of the patients presenting some facet of reasons maternal mortality and morbidity continue to ravage third world countries, including India, who sees itself as an emerging superpower.

JK, 25 years old, married for 4 years and into her 3 pregnancy had been coming to us for regular antenatal check ups.JK had two major issues. On her first visit, which was at around 28 weeks, she had a haemoglobin of 5 gm% and she had severe kyphoscoliosis. We had taken a decision not to take her case at NJH – the question was about doing a Cesarian section with such a low hemoglobin as well as ending up with a child with severe growth retardation.

Nevertheless, she came for couple of more visits. And the final one, she came with mild labour pains. She continued to remain anemic and we referred her off to Ranchi on Sunday last.


It was a busy Monday and suddenly we had a commotion in the labour room. JK had come back – she was pouring out blood. There was no time to hear what had happened. We were wondering what to do, but we needed to act fast. One of the relatives told us that she had couple of blood transfusions at Daltonganj.

Daltonganj? ? ? What was she doing in Daltonganj? We had referred her to Ranchi. Well, this was not the time for questions. Someone shoved a sealed packet of blood to me . . . ‘We had arranged 3 pints. Only 2 pints of blood has gone. The doctors at Daltonganj had told that something can be done only at NJH . . .that is why we rushed’, panted one guy, whom we later realised was JK’s brother. . .

I checked the Fetal Heart . . . for 5 seconds. Must be around 80-100/min. The bladder was full . . . Then, she told that she felt like straining . . . There was only one diagnosis I could think off. . . The baby was on its way and the placenta had seperated . . . I decided to do a per vaginal examination. I was right. The vagina was fully dilated . . . But the head was a bit high up . . . Then, I realised that I had an advantage. The head felt a bit smaller for the quite spacious pelvic outlet.

We decided to put in a vacuum for pulling out the baby. . . And to the glory of God, it worked. The baby was of course sick . . . The placenta came out along with the baby. . . She had lost quite an amount of blood. I realised that the baby had also lost blood. . . The baby’s hemoglobin came as 10 gm% – whereas it should have been around 15-20 gm%. And the mother’s was 8 gm% after we transfused one pint blood today.

It was nightmarish . . . We could have lost both the mother and the baby . . .

As soon as JK’s drama was over, came in an eclampsia patient, MD. Unlike many of our Eclampsia patients, this one was of a different genre. The patient with only home based antenatal care had started to have seizures since 6 in the morning. The quack who was doing the antenatal care was summoned. He gave some treatment and his prescription is given below . . .

There were 3 more episodes of seizures from morning till mid-afternoon. After the last episode she became unconscious. And that was sometime around 12:00 pm and then the family took a decision to take her to NJH. By the time a vehicle was arranged, it was 2:00 pm. She was brought in at around 5 pm yesterday. On investigations, it was evident that she already showed low platelet counts and increased liver enzymes. She was already going into HELLP Syndrome. We asked the relatives to take her to Ranchi which they refused.

We asked them to arrange blood. But she was worsening. As usual – with a death on the table consent, we took her in for Cesarian section. The baby was caked in meconium, weighed a measly 2 kilograms – required quite a good resuscitation attempt. She could be easily weaned out of the ventilator. However, her blood pressure remains high . . . Please pray that she would make a recovery. Meanwhile, her platelets had come down to 45,ooo today morning. We sent the relatives for few pints of platelet rich plasma. . .

The last one was the most terrible one . . . At least we can console ourselves that the previous one was managed by a quack and therefore the 'near maternal miss'. Let's look at the 3rd one . . .

The lady, RD, who was G3P2L2 had presented dramatically with bleeding per vaginum at 36 weeks in emergency. Both her previous deliveries had happened by Cesarian section. She was on regular ante-natal check ups elsewhere. She had couple of ultrasound scans. Both of them were normal. Below are scanned copies of almost all antenatal check ups she had.


I have tried my best to remove any evidence about the concerned doctor/ultrasonologist who saw her before she turned up in emergency here. 

Well, we repeated the ultrasound and what did we have - a placenta praevia. The paradox was that she had films printed of one of the outside ultrasound scans and it clearly showed placenta praevia, whereas the report did not mention anything about it.

Worse was the blood report. There were 3 reports from the same place within a period of 14 days all of them showing varying values. You can make your own inferences. The scanned copies are shown below. The names of the ‘shops’ have been scratched out for posterity’s sake.

3 patients – each of them showcasing myriad shortcomings in our healthcare system . . . The sad part is that almost all of these shortcomings pertain to the basics . . .

JK’s case brought into the fore the following issues -

- Need for well run secondary care centres (if possible tertiary care centres) at district level.

- Need for Blood Bank facilities. One may need to relax few of the present regulations for licensing so that blood will be freely available.

What did MD have to tell us?

- Most of our populations live in remote regions without any basic facility of healthcare. They are dependent on the quacks for their regular medical care. Operationalising sub-centres and training ASHA workers and ANMs is a major challenge. 

- Transport remains one of the major challenges in almost all our rural areas. Many of our states have circumvented this issue by 109 Ambulance. In Jharkhand, we have something called the ‘Mamta Vahan’. I’m absolutely certain that we need to look beyond the ‘Mamta Vahan’.

And the last one RD?

- You cannot blame RD for the quandary she is in. The healthcare community let her down.

- 2 ultrasounds and a Grade 3-4 Placenta Praevia missed.
- Varying reports of hemoglobin from a single laboratory in a space of 14 days.
- No mention of RD being a high risk patient in any of the prescription charts.

As I had told in one of my previous blogs, the quality of healthcare is a major issue in almost the whole of the country. Each day, it is not uncommon to see diagnoses being missed, unnecessary investigations being done and lack of technical knowledge in paramedical services mainly laboratory and radio-diagnosis. Hope you remember one ASHA worker who failed to recognise her own complicated pregnancy and paid with her life.

Well, sorry for the quite long post. Before I sign off, just a passing reference to a law that is coming into force. The Clinical Establishment Act. More of that in my next post. Already in force in Assam and Orissa, it could sound the death-knell for hospitals such as NJH. . . 

Tuberculosis, continuing to ravage. . . Celebrating World TB Day . . .

One of the major clinical conditions that we manage at NJH is tuberculosis. In fact, I get this weird feeling that as we go forward, we see more and more cases of tuberculosis. And to make matters worse, we see all varied types of presentation of tuberculosis. I’m sure that almost all of my colleagues serving in various hospitals of EHA including my friend, Augustine at Madhepura would also vouch for that.

The X-Ray below is of a 26 year old man who came couple of weeks back with a cough of 6 days duration. We started to manage it like a usual Respiratory Tract Infection. Then, he came back saying that he was not feeling fully well. Which prompted us to take this Chest X-Ray . . . which says it all. Later, we got a previous history of cough from him for which he had taken treatment from a quack.

Most probably, he would have received some amount of anti-tubercular medicines which would have kept the bug suppressed to some extent for some time. Which has probably started to invade as soon as the effect of the medicines waned off. I’m sure that he would become sputum AFB positive if we waited for some more time . . .

Then we have people like HN, who had come here about 20 years back and took treatment for symptoms suggestive of tuberculosis. However, he took treatment for only about a month . . . and stopped it since he became alright . . . a common cause for discontinuation of anti-tuberculosis treatment even today. HN is 75 years now, a wizened old man who coughs badly affecting his sleep since the last one month.

Those findings have not appeared overnight. It is fibrotic bands from an old tuberculosis infection.

The worst sufferers are children. Many of them remain undiagnosed for quite a long time. I had this 4 year old boy with a 2 week history of cough. And this was how his X-Ray looked. I’m not sure if the findings appear clear in this picture.

And worse are those who suffer from tuberculosis meningitis. Lumbar puncture is not something that doctors do on a routine here. They do it only in higher centres. With a quite high incidence of cerebral malaria and encephalitis, tuberculosis meningitis is not thought of until the patient is quite bad.

We have two patients in the ward. One of them allowed a lumbar puncture whereas the other did not not. 

Unfortunately, the one who allowed the LP is quite sick – with a Glasgow Coma Scale of 5. The other patient improved quite well on anti-tuberculosis medication. Below is the typical cobweb formation which appeared in CSF on overnight standing . . .

Cobweb appearance in Cerebrospinal fluid . . . 

Well, after all this . . . snaps from the World TB Day celebrations which we facilitated in Palamu district, thanks to the Axshaya Project of the Global Fund TB Round 9 . . .

A rally being taken to spread awareness about tuberculosis in Panki

Another view of the rally at Panki

Flagging off the awareness rally at Daltonganj, the Palamu district headquarters

The rally moving on through Daltonganj town

Inauguration of the public meeting with the Civil Surgeon, ACSMO, DTO and DPM
along with our Axshaya Project District Manager, Ms Julita

Our TU-Medical Officer, Dr Johnson addressing the gathering

The awareness rally at Hussainabad

The awareness rally moving through Hussainabad town

Neonatal Care at NJH . . . cont'd

After the initiation of regular service of the NICU after Wendy and Jerry's last visit to NJH, we've had a steady stream of neonatal admissions all through the last month.

Dr Johnson has been kept really busy. We've already set into motion plans to upgrade facilities fast. Over the last month (March 2012) we had 40 admissions - which is quite a good number by our standards. 

Today, we've 4 babies - all of them who were quite sick or was sick at some point of time - - 

1. PD's baby - 1500 gms born at 34 weeks gestation. Doing well. 

2. KD's baby - Severe meconium aspiration. Uncertain history. Grade 3 Meconium with staining of uterus with meconium. Initially poor maintenance of saturation. Offered referral to Ranchi. Did not accept. Has improved quite well. 

3. SD's baby - Preterm, delivered by Cesarian section yesterday. Grade 3 Meconium stained amniotic fluid. Uncertain history. Poor maintenance of saturation. Offered referral to Ranchi. Did not accept. Continues to have episodes of apnea and poor saturation. 

4. LD's baby - I had mentioned about LD in one of my previous posts. Has made a remarkable recovery. Should be discharged soon. 

5. RM's baby - Birth weight of 4.5 kgs. Was kept for observation. Would be moving out soon. 

In addition, we've a mother at 35 weeks who's just come in with findings suggestive of intrauterine growth retardation, severe oligohydramnios and leaking since 18 hours. We've offered a referral to Ranchi considering into fact that they appear quite well off. But, they have not taken . . . She would be delivering soon . . . which means, one more admission. 

Well, it has been a privilege for us that Wendy and Jerry facilitated the production of a video for the Neonatal Unit at NJH.

Well for those who would like to help us out, our immediate requirements are as follows - 

1. Infant cots: 6 nos

2. Infant warmers: 6 nos

3. Phototherapy units: 6 nos

4. Pulse-oximeter for infants: 10 nos

5. Infusion pumps: 6 nos

6. Infant ventilator: 2 nos