Anemia . . . ? Lack of Evidence

3 days before I started on my holiday, we had a pregnant lady at term who was bleeding from the morning come to us sometime in the evening . . .  and die couple of hours later. Dr Shishir who was on duty called me to report the maternal death. The history was appalling. The lady should never have died.

She had her routine antenatal care. Her hemoglobin done few weeks back showed 8 gm%. No ultrasounds were done. She was on oral iron. She had started to bleed in the morning. The relatives had taken her to the district hospital. She was there for quite a long time. The relatives were not sure what was done. Later they took her to a private hospital from where she was referred here. 

We could not measure any blood pressure on her and there was no pulse. She was white like paper. Hemoglobin came as 5 gm%. I'm sure it must have been lesser. There were no relatives to give her blood. We tried our staff. Although, the blood group was a common one . . .there was nobody who was fit to give blood . . . couple of them were sick, others had given recently. 

Her blood pressure or pulse never came . . . without blood, there was no option. She died . . .

Talking about her hemoglobin of 8 gm%, it is not an uncommon thing at NJH. We routinely see hemoglobin values of 8 and even lesser. The reason I write is the recent discussions I had with few of my friends and an article I read today about the use of parenteral iron in situations such as ours. 

If we keep the cut off of 11 gm% to diagnose anaemia in NJH, I'm sure we'll diagnose almost 100% of our pregnant women anaemic. Values of 9-10 is the highest you will find here. Almost all studies done at many places in India gives the prevalence of anaemia in pregnancy as something between 30% and 100%. 

So, I was quite surprised when I read in the article mentioned above that the patient Ahmedbi whose hemoglobin was 9.8 gm% got a drip of Iron-Sucrose. Well, I can imagine the justification of the doctors who have started doing this in spite of not much evidence for such a practice. 

Anybody who has taken the Iron tablets given by the government would vouch for how unpalatable it is. And to have it during pregnancy is something which many a pregnant lady would not really like. Over my clinical practice, it has been quite common to have patients confess that they have not taken their prescribed medicines and pregnant women not taking their Iron and Calcium form a major chunk. 

And even when they take it, there are other issues involved. I've somehow come to believe in the theory of the chronic malnourished state. I remember someone talking about it . . . but can't remember who it was. The theory is that in many of the impoverished regions of the world, the chronic state of malnourishment results in the body being adapted to function with a below optimum level of nutritional states. Which ultimately results in a poor absorption even in a situation when there is adequate nutrition available.

Otherwise, I cannot explain how in NJH we see so many people from rural areas who would have been labelled terribly sick in a tertiary hospital elsewhere survive tough surgeries and major illnesses like malaria, enteric fever etc. 

The chronic malnourished state continues even the lady becomes pregnant and no amount of iron and vitamin B12 pushed down the gut brings any change in the hemoglobin levels. 

Well, I'm sure that this would need to be researched well before we can draw conclusions. 

One more reason why I suspect a faulty absorption of nutrients in states of chronic malnutrition. We see quite a lot of patients with clinical features suggestive of Cyanocobalamine deficiency who do not respond to oral Vit B12 . . . but respond well to Vit B 12 Injection. I do not expect a high prevalence of Intrinsic Factor deficiency in the population . . .  Well, another explanation is the low IF values in people with chronic malnutrition states. 

Whatever it is . . . one thing have I realised. The knowledge we have about something as simple as anaemia is quite limited . . . leave alone complex diseases like cancer . . . 

So, anybody interested in research in this area . . . 

The parting shot . .. ... Sometimes I wonder, in a country like India . . . even evidence and scientific explanations are sometimes of no use. It might surprise you . . . We do not have provision of free Iron and Folic Acid tablets for our Antenatal patients . . . This is when we have enough of evidence about how Iron and Folic Acid tablets could be the lifeline to Antenatal patients . . . 

Preventing maternal deaths as the one mentioned in this post . . We do not have blood banks where there is round the clock availability of blood. And this holds true for the 4 million population in catchment population . . . Well, that is a post for another day . . . 

Holidays . .. ...

Well, I'm away from hospital and on holidays for the next 3 weeks. It's been 5 exhilarating months at NJH since the last time I was away. The major part being the huge increase in patient load compared to the previous years. Am I exhausted? Yeah, to a certain extent . . . but when I see the smile of the patients whom we could save from almost certain death, I don't mind the workload.

It's holiday time in our region for almost the whole of next 2 months . . . Dussehra, Diwali, Chatt . . . and they all keep people quite busy. The outpatients would think twice before coming to hospital. Only if they are really sick would they turn up . . . which makes the emergency a bit busier than usual. In addition, since the other hospitals may be closed or partially staffed, quite a number of patients would make a beeline to NJH. Then there would be deliveries, which have sort of tapered down over the last 2 weeks.

Talking of lives saved, I was sort of forced to look into statistics about a week back before I went off on holiday. The reason - A meeting facilitated by my post graduate Alma Mater, the Community Health Department, Christian Medical College, Vellore along with a whole lot of organisations - Emmanuel Hospital Association, Catholic Health Association of India, Catholic Bishops Conference of India, CCHDT.

Dr Kurien George, Head of the Department of Community Health,
Christian Medical College, Vellore addresses the gathering

Just wanted to share some of the calculations we came up with . . .

First, the populations, we deal with -

District	Total pop.	Pop. catered
Palamu	1936319	1452239
Garhwa	1322387	661194
Latehar	725673	362837
Total	3984379	2476269

The population catered has been arrived at by excluding the blocks within the districts which we know are more nearer to Gaya or Varanasi or Ranchi. For example, the blocks in Palamu district which border Bihar are more closer to Gaya, whereas there are blocks bordering Uttar Pradesh in Garhwa district which are nearer to Varanasi, and for Latehar, many of the blocks are nearer to Ranchi. 

Then looking at maternal deaths for the duration January-Sept 2012 - 

Then, we looked at Maternal Near Misses . . . and it was a rude shock. We did not look at all maternal misses, only those who went through Intensive Care. MNM definitions includes even those who had to have blood transfusions. I could not get those stats. 

There are quite a lot things being planned. And I'm really excited of what we could be looking at after one year if everything goes as planned. 

Talking about things I'm excited of, I cannot hide the excitement I have of the new Community Health Projects we are embarking on. There's this new project on disability which we are planning to implement in 8 blocks of Palamu district and 4 districts of Latehar district. In addition, there is the project on Climate Change where we try to empower communities to respond to climate change. There is a whole new team who will be working on this. 

For the Climate Change project, we were in for a surprise when Dr M S Yadav, Director, Zonal Research Centre (Agriculture) visited us. He is in charge of 6 districts in agriculture research and promotion. He requested our collaboration in the field of agriculture. The topics he dealt with ranged from need for watershed mapping and construction of check dams in the surrounding villages, millet cultivation, poultry - duck, turkey and quail, pig and goat rearing, mushroom cultivation, vermicompost and fish rearing in ponds, exploring the possibility of pilot projects within the campus in fish rearing (already being done - but to do it more scientifically), mushroom cultivation, pig and goat rearing and drip irrigation. 

Dr Yadav talks with the CH staff

Well, the list is mind-boggling. It only shows the potential we have in this place. Later, I had discussions with our Community Health Manager, Mr. Prabodh and our Manager-Technical Maintenance, Mr. Dinesh about the visit. We would be seriously looking at the possibility of an Agriculture Department and possibly a Veterinary Doctor too. 

Well, I'm sure that I will not be able to do all these things without additional help, but just a glimpse about the possibilities makes ones imaginations go wild . . . 

I'm of course on holiday, but I just can't wait to get back . . .  Please do help us to get new staff who would be willing to look at agriculture, veterinary sciences etc as well as a surgeon when Dr Nandamani leaves in mid-December.

Praise and Prayer Bulletin . . . October 15, 2012

1. We thank and praise the Lord for the new staff who joined NJH over the last month. We still need couple of more staff in Community Health including Social Work graduates and an accountant. There has been quite a few enquiries from other potential staff. We request prayers that the right people with the right aptitude for the place is selected.

2. We thank the Lord that we've been able to place orders for some new furniture and other equipment for the hospital. Some of the equipment including a new Olympus microscope and a compressor for the dental department has already arrived. For some others we need road permits for which we've submitted the required applications. Kindly pray that we would receive the goods smoothly without much hitches.

Mr. Anil Nand inaugurating the new microscope

3. We are into a holiday season in this part of the world. Lot of staff and families would be travelling as schools are closed for more than a week. Please pray that we would enjoy journey mercies as well as have a good time of rest. Do remember the team at the hospital who would be handling extra workload as most of the other hospitals would be closed or only partially functional.

4. We are in dire need of a Pharmacist in the unit.

5. The Regional Administrative Committees of the organisation would be happening soon in various parts of the country. We come under the Eastern Region, whose RAC is scheduled during 6-7 November in Madhepura. Kindly pray for all arrangements and the travel.

6. There is an initiative been taken by few Christian institutions - the Christian Medical College, Vellore; Catholic Bishops Conference of India; Catholic Health Association of India; Emmanuel Hospital Association,  SIGN (the social development wing of the Catholic Bishops Conference of Jharkhand) - to look at maternal mortality. The first meeting was held in Ranchi on the 10th October. We thank the Lord for the initiative. We request prayers so that we would be able to make a concrete response to the very pathetic state of maternal and child healthcare in the region.

Sr. Prabha from CBCI addressing the meeting

7. Our calendars for the year 2013 are already out. We thank the Lord for the hands that laboured.

8. We've heard that Mrs Wendy and Mr Gerry of the Grace Babies team is already in India and they would be visiting NJH sometime in February. We thank the Lord for this couple and the wonderful work they are doing. Please pray that their time in NJH would be very fruitful and a blessing to all of us.

9. We're planning for some amount of renovation of the hospital. There is need for more space and most of us feel that a number of private wards can be refurbished into general wards. The maintenance team is in the process of looking at the best and cost-effective way by which this can be accomplished.

10. The Community Health Project in the hospital is into quite a lot of projects. Please pray for Mr. Probodh Kujur who is giving leadership. In addition, we've project officers, Ms Rachel, Mr. Amit and Mr. Ebez who would value your prayers.

11. The project on Climate Change has garnered the attention of the government. We had a visit from a senior government official, Mr. M S Yadav, Director, Zonal Research Centre (Agriculture). He was wanting to partner with us in a multitude of areas. We pray that the Lord would lead us in this new area.

Dr Yadav addresses the CH team

12. Last week, the Lord protected us from what could have developed into a very bad fire accident after the old dental compressor caught fire.

New faces on the block . . .

Over the last couple of months, we've quite a number of new faces gracing the NJH campus. We thank and praise the Lord for each one of them.

VANDANA KUJUR: Manager - Human Resources. An engineering graduate from Sam Higginbotham University, Allahabad and a Masters in Business Administration from Birla Institute of Technology, Ranchi. This is her first job. The most important thing is that her grandfather, Theophilus Kujur was one of the first staff in the hospital. 

 This is ALINAH LUITHUI. Alinah was here at NJH for about 5 weeks after she was deputed to help with HR management before handing over things to VANDANA. Alinah almost looked a permanent staff in the office before she had to go back to her parent unit, Premsewa Hospital, Utraula. We thank the Lord for the time she spent here and pray that she would continue to be a blessing to people around her. 

EBEZ GEORGE, a non-resident Malayali, presently residing at Delhi found that his first job after he completed his Masters in Social Work would be along with us. He would be primarily working in the Disability Project based at Panki, which is about couple of hours drive from NJH. Ebez would be one of the first staff who would be based away from the hospital campus. Please pray that this initiative of placing staff within the community would be beneficial for the community and the hospital. 

 RACHEL BELDA RAJ resigned her job in the Physical Medicine and Rehabilitation Department of the Christian Medical College, Vellore to join us in the Community Health Department with primary responsibility of the Disability Project based in Latehar. Armed with a Masters in Social Work from the prestigious Madras Christian College, she would be blazing a new trail in Latehar district on our behalf. Please remember her in your prayers. 

AVINASH BISWAL, from Cuttack has joined the Community Health Team. He would assist the Disability Project team with base in Daltonganj. 

After quite a duration, we've had 2 GNM nurses posted from another EHA unit. Srs Ruth and Mimi are from Manipur and would be with us for at least the next 2 years.

Mr. AMIT BIHARI and Mrs JAGADHA  . . . Amit would be serving through the Disability Project with base at Daltonganj. Mrs. Jagadha is an RCH trained GNM nurse who's already quite busy in the labour room and NICU.

There are few more. But, I've not been able to get their snaps so far. There is Ms Sunita, Mr. Anand and Mr. Umesh who have joined the team. The new staff have already been a positive influence in the campus. We pray that they continue to remain so and that the Lord will use each of them for mightier things . . . 

Marthoma Church, Ranchi visits NJH

Yesterday, we were blessed to have more than 50 members of the St. Thomas Marthoma Church visit us. Below are few of the snaps from the visit.

Rev. Joseph Ayrookuzhy gave leadership to the visit. 

Front of the outpatient department

Registration

Taking a walk across the campus

Inside the outpatient department

Dinesh and our son, Shalom celebrated their birthdays with the visitors cutting cakes . . . 

At last, we all had lunch together

I wish I had taken more photographs. Before the visit to the hospital, the group had worship in the Mennonite Chapel. 

It was quite a tedious journey for all the visitors considering into fact that the road from Ranchi to Satbarwa has become all the more worse after the rains.