Non-communicable diseases - 'Ottamooli'

Sometime in the middle of last month, the United Nations had convened a high level meeting on Non-Communicable diseases (NCDs). It is praise-worthy that the world has recognised the burden that NCDs poses to communities.

Even in a remote community where I serve, NCDs are turning out into a major force to deal with. Along with diabetes and hypertension, the most recent phenomenon that we had been witnessing is the huge number of young adults and children in whom we are diagnosing Bronchial Asthma. 

Today, in the outpatient department, I diagnosed 6 new cases of bronchial asthma. In the Indian context, one of the most challenging facets in the management of NCDs is the concept of the 'single drug concept' present in Ayurveda. I'm not sure if there is English word for that. In Malayalam it's called 'Ottamooli'

When we explain to the patient that he/she may need to be continuously on some form of treatment for his condition, the family is very much crestfallen. With bronchial asthma, it is a bit easy as I also have it - and most of the time, I take out my Inhaler and show them that I regularly use it. 

Coming to Bronchial Asthma, it is disease with quite a lot of stigma. Couple of weeks, I had a young couple who had brought their 5 year old son whom I diagnosed to have Bronchial Asthma. When I prescribed them an inhaler with a spacer, they did not realize what I had prescribed. When they brought it and came back for helping them use it, the mother started to sob, when I opened the packet and took out the inhaler. 

She told me that if anybody finds her son use it, her son would have difficulty finding a bride when he grows old. Well, it was terrible to hear that. She wanted me to cancel the prescription for the spacehaler and instead give them tablets. According to her, nobody would know that her son is on tablets. The father also ultimately started to beg me to change the prescription. No amount of counselling could help them. 

Coming back to diabetes, the attitude towards finding out a 'ottamooli' prevails. Quite a lot of practitioners have been claiming to bring about a radical cure for the disease. I've had enough patients who have come in a very uncontrolled state of diabetes after having being misled about such treatments.

With the number of patients which we encounter in our outpatient department with conditions such as diabetes, hypertension and chronic lung diseases such as bronchial asthma on the increase, the burden it is going to pose to poor agrarian communities is massive. I wonder what do we have to offer them. Or would it ultimately end up as a major business opportunity to the pharmaceutical industry - there are already signs of such a phenomenon. 

Murder of the voiceless - abortions in rural India

I just finished counseling a 22 year old lady who we unwittingly diagnosed to be pregnant. She is not yet married, but has a boyfriend. She came yesterday with features which were very suggestive of an early pregnancy with a severe urinary tract infection.

We had repeatedly asked her if there was a chance of her being pregnant and she had vehemently denied of any possibility. Today morning, Nandamani who reviewed her for a vague discomfort of the lower abdomen took her in for ultrasound and found her to have a 7 week fetus. Not an uncommon event in many hospitals.

Nandamani called me in to deal with the crisis. The girl was already in tears and then confided that she had sexual relations with her boyfriend about couple of months back and she had never thought that it could end up such. Very familiar statements for me and Nandu. We get to hear it almost every month.

The issue was on how to deal with it. The girl had a very easy solution. 'I'll abort it'. After sometime we talked with the boy over the phone and he was also very cool about taking a decision to abort. I was very uncomfortable about how fast they had made such a decision.

'Murder planned so easily. Not a hint of remorse in the young voices.'

I know I'll face the brunt of many by making such a statement. The institution of marriage is breaking all over the world. Questions are being asked about the very fabric of it's institution.

However, what I'm more concerned is the cold blooded killing of the unborn. The unborn are most probably the most voiceless of all the people in this world. Recently, I read an article in 'The Hindu' which has put it quite well.

As told by the Dr Ronald, it is very common to see girl babies being killed all over the country. However, the killing of the innocents for sexual freedom is not something which is prevalent only in the West. It is very much present even in remote areas of third world countries such as ours.

The girl is an adult. She took the decision not to tell about the pregnancy to her parents. After a whole lot of counselling, she has still decided to go ahead with the abortion. Tomorrow, the boy has promised to come. Kindly pray that I can convince them to go ahead and have the baby.

However, as I pen this, I'm very much aware of the umpteen number of abortions which take place in very unhealthy and unsterile environments all over the world and more in rural areas of Asia and Africa which is a major challenge to maternal healthcare. There are no easy answers but to kill off unborn babies without any reservations is not the best choice.

Hunger and Tetanus - Yet Again

CD, who has been with us for the last 4 weeks ultimately showed signs of recovery couple of days back. The story of the penury that his family faced and which got to be ultimately addressed made quite a lot of my followers writing back to me.

Meanwhile, there was one more tetanus patient, a 7 year old boy, BS who has been having symptoms since the last 8 days and has been on treatment at many places. Dr Shishir who was on duty 3 days back when BS came in diagnosed tetanus and we started off treatment.

Today morning, BS's parents told the nurses that they wanted to take the boy home. The reason, they do not have any money. We had been giving them hospital supply. On arrival, I wrote them a prescription for Injection Tetanus Immunoglobulin which we did not have in the hospital pharmacy. They were asked to buy it from outside.

It was only when they reached one of the pharmacies in Daltonganj, someone told them that the treatment of tetanus could be very expensive. In addition, without our knowledge, the family had not been having food since admission. The father had told one of the nurses initially that they have lot of people whom they knew and they could easily find food.

I confronted the parents. The father started to sob. He told that they have spend quite a lot of money on treatment before they reached NJH. They did not have any money that they did not have any food. Few of the local eateries had given him food for the first couple of days. But, not anymore.

They have somehow got something to eat for the boy. But, the parents had been surviving on water for the last 2 days.

I was stunned. It was about 2:30 in the afternoon. I knew that there should be food left in the mess. I summoned Dinesh. There was quite a bit of rice and dal, enough to feed 2 adults.

I just went to meet the family. The mother and the boy was eating to their heart's fill. It was such a pleasant sight to see. From the way they were eating it was obvious that both the mouths had not tasted food for quite some time.

The father had gone home. I had made a deal with the father that if he gets some vessels to cook food, we shall provide him with the rice and pulses for cooking.

Hunger . . . The issue continues to mock us . . . We may be the Cricket World Champions, we have one of the largest armies, our information technology industry is one of the leaders in the field, our healthcare industry is booming, we are one of the leaders in space and nuclear sciences . . . but the bottom line remains that we have quite a lot of our people who still goes to bed without food on account of overspending on healthcare.

One gram hemoglobin and survived - The Miracle

SD came today afternoon to my office. I thought we had discharged her. She told me that she wanted to go only after she was absolutely sure that she would survive. So, the delay in discharge. She had been with us for almost 4 weeks.

She was quite thankful. Her family had gone through the valley of the shadow of death. She had seen my anxious face as she was wheeled in. She might have even got a glimpse of my gestures while I explained to her husband that there was very little chance of her making through.

For all of us in the hospital, it was a miracle. With hemoglobin of 1 gm%, I’m not sure on how many could have survived.

It has been a long haul for the family. They had to face quite a number of hurdles. She received a total of 7 pints of blood during her time in the hospital including the one given by Mr. Dinesh, our maintenance supervisor. In addition, getting poor quality blood from the blood bank in town did not help.

We waited for the hemoglobin to rise before we could attempt anything regarding her placenta accrete. Ultimately, we decided to go ahead with a hysterectomy with a hemoglobin of 3.2 gm%. When we saw the uterus, we were sure that it was a miracle that SD has pulled on so far. It was stinking so bad and the placenta was so well adherent to the uterine wall.

The gangrenous uterus along with the adherent placenta

SD has two little boys. She looks forward for a new life with her family and she knows she is extremely blessed to have survived against all odds.

There is a sad part of the story too. The treatment has taken a toll on SD's families' finances. The total hospital bill had come to a whopping 26,000 Indian Rupees. In addition, they must have paid quite a lot of money to get the 7 pints of blood. SD's husband was not going for work. And there were mouths to feed in the house.

When SD's husband came to pay the bill, he told me that he was ready to pay Rs. 5000. I asked him how he managed that much money. He had sold quite a lot of his land. It was heartbreaking to hear that. Another family pulled into selling off valuable assets just for want of poor public healthcare.

The Mob

Violent responses to adverse events in healthcare is a very common feature nowadays. It has been there for quite some time. Most of the EHA hospitals face the brunt of it on and off. The latest incident was in Chattarpur where few of the senior doctors and officers of the hospital was beaten up after the death of a lady who had come for delivery.

And I had to face a fuming mob today afternoon. The reason was a boy whom we had seen in our Out Patient Department couple of days back. He had been prescribed Tablet Perinorm for nausea and vomitting. Today afternoon, he had developed abnormal posturing which we call extrapyrimidal syndrome secondary to perinorm.

The boy was from the local village and of one of the prominent upper caste families. Couple of people were shouting that the hospital was trying to poison him and another two were babbling about poor quality of medicines kept there. I recognised two quacks from the nearby villages. I was expecting at least couple of slaps or beatings. I had not yet come into the room where the boy was.

By God's grace, nothing happened. As I walked in, there was a sudden silence. Dr Johnson, the doctor on duty had already told me that it looked like extrapyramidals secondary to perinorm. So, it was a bit more easier for me to talk. And, of course, it was extrapyramidal syndrome most probably secondary to perinorm. I asked the nurse to give Inj Phenergan. The boy recovered very soon.

The incident was over in a flash. But, I am well aware that things could have turned for the worse. The mob dispersed quite quickly.

Meanwhile, I wonder whether there could be some law whereby doctors and other healthcare providers are protected from such violent responses from patient's families. One option would be to make violence against healthcare providers a non-bailable offense and increase the punishment for such offenses. That could deter people from doing such acts against healthcare personnel and institutions.