Monday, September 22, 2014

Legal Advice

Couple of days back, a friend called me up with a peculiar request.

My friend runs a small dispensary in a remote part of the country. One of her friends came with a young girl to her clinic few days back. The girl was pregnant, but not married. 

According to this lady, the girl was sent to her by one of her relatives from a remote village. The girl had become pregnant after being raped by her school teacher. The school teacher is a revered man in the area and nobody would believe her story. 

As is the case in a rural remote part of the country, the girl's parents are concerned that the girl's future would be ruined if the matter is raised in a legal/public forum. The girl’s family wanted to settle the issue quietly.

Someone suggested that she goes somewhere far away and deliver the baby. And that was when the family who was known to my doctor friend got into the picture. They plan to adopt the baby as soon as the girl delivers.

My friend is concerned about the ethics and legality of the issue. She feels concerned that a rape has happened and the offender has been left unpunished. She is also concerned that her family friend and the biological mother of their baby would know each other, and also about what happens if the girl refuses to part with the baby once she delivers. And mainly, the legal status of such an adoption. 

When the doctor confided about her concerns to her friend, she replied that she was also quite ignorant of these aspects. She has asked my friend to give the best advice.

Would an agreement between the childless family and the pregnant girl be valid if it states that the family would look after the girl provided the girl gives the baby to the family once she delivers? And what happens about the issue of rape? As responsible citizens of the country, can one close our eyes to the injustice that has happened to this girl?

The girl is only 16 years old and she is around 30 weeks pregnant. Should the doctor advice her friend to leave the girl back to her village? Should she advice her to take the girl to a place where she can deliver and put up the baby for adoption? Or can her friend continue with how things have been planned. 

Looking forward for your comments and advice . . . 

Monday, September 15, 2014

A Jharkhandi Onam

Snaps from an impromptu Onam feast we had at Barwadih . . .

Thursday, September 11, 2014

Giving hope . . .

The 10th of September, 2014 is going to be a day to remember for our family. My dad celebrated his 67th birthday. As a family, we took the decision to stay on in the Palamu region for the timing being. After I had to leave NJH, it has been one decision at a time. There were apprehensions of safety, about working in a very basic set up, about working closely with the Catholic church, about the remoteness of the region, about being close to NJH . . .

My team-members, Rachel and Satyaprakash, had a plan to visit one of the nearby villages. I told them that I will tag along. The place was a difficult one – inhabited in majority by one community. There had been quite difficulties in starting off the work. A group of disabled people and their families were in the process of joining hands to work together. 

We left the main road to travel about 3 kilometers to reach the village. It was so thickly populated. It looked more like a slum than a village. Overflowing drains, cobbled streets, mangy dogs running along the streets, sickly looking half naked children playing wherever they could find some space . . . The place looked quite out of place for the rugged agrarian communities that we usually have around this place.

Most of the people on the street were quite suspicious of our arrival. We reached the designated place of the meeting. There was nobody in sight. Satyaprakash told the lady of the house to inform everybody that we’ve arrived. We then drove on further down the road to meet couple of disabled families.

We returned in 10 minutes to find the meeting place teeming with children. They all looked alright to me. Then, I saw couple of children, limp with their drooping heads resting on the shoulders of most probably their parents. There was one young man with quite badly deformed legs.

Considering that Rachel and Satyaprakash were familiar faces, I opted to stay at a distance and observe. The faces of the parents were bereft of any hope. They looked quite lost in thoughts as my colleagues told them about the need to group together, work together, about what their children can do etc etc.

The father of one of the children with the cerebral palsy had come late and could not find space inside the room where the meeting was going on. Only the mothers of the disabled children were there in the room. His wife was there with the child. So, he silently came out.

I asked him about his child. He looked quite well off for the setting. Dressed in jeans and a branded shirt with jazzy looking goggles in his shirt pocket, he looked very unlikely to be an anxious parent. But, he was an anxious father.

His child was born in a private hospital in the local town. The child had not cried at birth. He was admitted for about 3 days in the same hospital before he was referred to a tertiary centre for neonatal care. The baby was admitted in the city hospital for about a month before the parents were told that nothing can be done and maybe some exercises could help.

They took the child to many places but nobody had told them that the child would never be how they would expect him to be. And of course, nobody was there to tell them on how to do things for the maximum benefit for this child.

On asking the man about number of similar children in the village, he told that he knew personally at least 10 of them. Rachel and Satyaprakash was discussing about the same issue in the meeting. And one of the ladies called out to the man to ask the same question.

We told the group about the need to form a caregivers group for such children.

Sheron, our physiotherapist would soon be visiting this village. I hope that the parents would take this endeavour seriously.

I felt so elated after the outing . . . I was looking out for a sign . . . to move on or stay. As we journeyed back, I asked Rachel about plans for the year ahead. She told about doing the same thing for 3 more years in this region . . . till there is a change in attitude towards the disabled.

The region we serve in is quite backward when it comes to even routine clinical care. Leave alone the disabled people, it’s a challenge for the rest of the population to access basic primary care services. If it were not for people like Rachel, Satyaprakash etc. who are the members of our team, the disabled in these regions would never have known that there is hope for them.

Over the last 3 weeks since I’ve been in Barwadih, I have been exposed to blunt fact that communities that have poor, almost no access to basic healthcare are much much more than I ever thought. So, the challenge to the disabled in such settings becomes all the more large.

However, the bigger challenge would to find like-minded healthcare and social work professionals who would be ready to go the extra mile to make a difference in the lives of these special people, especially in remote areas of the country, similar to the region we serve. 

Tuesday, September 9, 2014

Suing doctors . . .

It has become very common to hear about patients suing doctors for adverse treatment outcomes.

There was an article in The Hindu about the same. As I write this, I’m well aware about serious deficiencies in services in many hospitals which happen because of multiple reasons. Unfortunately, many a time, the reason for the deficient services are quite evident and there is not much one can do about it.

I’ve known cases where the treating doctor was too tired to make a logical decision with regard to the management of a patient.

One of the stories I personally know. The reason here being the poor guy had been working overtime in a government hospital in a remote location. He had finished an outpatient where he saw around 100 patients in the day time. His colleague was on leave. Later sometime after midnight, he had a pregnant lady at term who came with labour pain. On examination she was progressing well and was slated to deliver within couple of hours.

The doctor went back to sleep only to be woken up half an hour later by the nurse in the labour room. The lady had delivered, but the baby just did not cry. There was no meconium. The doctor put in his efforts to help to resuscitate the baby. The nurses had already started the basic resuscitation procedures. The heart rate was fine. However, there was no respiratory effort and the body was bluish. As the doctor did the resuscitation, he could get a faint decaying odor emanating from the baby.

He commented to the assisting nurse that the baby has a foul odour. The nurse who conducted the delivery also mentioned that she smelt a foul odor as the baby was being delivered.

The doctor turned to the mother and asked if she was having any leaking of the amniotic fluid. The mother replied that she had been leaking since the last 3 days. She had consulted a local quack who had told her to return when her contractions start.

That was when the doctor realized that that the mother was in chorioamnionitis going into sepsis. A blood test confirmed the same. The baby was obviously affected. He did not respond to any of the resuscitation efforts. He was soon dead. 

The relatives were very agitated. They wanted to know why the risk was not explained to them. They ranted that if this was told to them earlier, they would have taken the lady to a higher centre for delivery. The doctor also lost his cool and there were harsh words exchanged. In the melee, the doctor was firm and requested that the body of the baby be sent for post-mortem. 

The relatives got more agitated. He calmly explained that this was the only option. Somehow, he got them to write down their unwillingness for post-mortem. 

After about a month, the doctor received a lawyer’s notice to pay 2 million INR to the family as compensation for negligence. The argument was that the doctor was not present during the delivery of the baby which resulted in the death of the baby.

The case took about 15 hearings over a period of 4 years. The doctor ultimately won the case. However, the damage was done. The doctor left the remote hospital to work in a city hospital.

In a situation which is especially prevalent in most of the public healthcare services and in many private providers, doctors and nurses are overworked with hardly any time for rest. We've enough research material that shows that an overworked healthcare professional is hazardous to the patient.
Unfortunately, there is also evidence that graduates of medicine think twice before opting to serve in the specialties where there is always a risk of an adverse event. The main casualties are obstetrics and surgical specialties, which are quite in need.

I hope our communities would be careful when they drag health professionals to the court after having had a adverse event. Meanwhile, it is also a clarion call to health professionals to be serious about their work . . . your patients have high expectations from you . . . which could ultimately also mean that many a bright mind would not opt for healthcare when it comes to selecting a career. 

Monday, September 8, 2014

Antibiotic usage - Ofloxacin

I now live in a quaint small town called Barwadih. Along with the task of giving leadership to Community Health work at NJH, I help out in a small dispensary run by a congregation of the Catholic Church.

View from my window in Barwadih . . .
The local population is well serviced by a Community Health Centre of the government which is just next door as well as umpteen numbers of quacks in the surrounding villages. I understand that the total population of the region is around 50,000.

Most of the patients here usually come for a second opinion when they don’t feel well after a consultation elsewhere. Quacks are much preferred than the Community Health Centre where there are at least 3 doctors at any time of the day.

Over the last 2 weeks, I’ve been overwhelmed by the prescriptions that many of such patients received elsewhere where Ofloxacin in some form has been given. We noticed the same during our tenure at NJH too. Fevers of 1 day duration, sore throats, skin infections, suspected enteric fevers, urinary tract infections – all of them got ofloxacin.

The patient that prompted me to put in this post was one 10 week old boy who came with classical seborrhoeic dermatitis. He was prescribed Syrup Ofloxacin-Ornidazole and Ofloxacin ointment (I never knew there was an ointment preparation).

As far as I know Ofloxacin was an antibiotic we used when resistant strains of salmonella was suspected, a bad wound infection or after abdominal surgery.

I shall be much obliged if consultants in medicine and microbiology can comment on this unfettered usage of this antibiotic in remote areas of the country. I'm sure this is a easy recipe for antibiotic resistance . . . 

Tuesday, September 2, 2014

Unskilled migrants - The second young man

This is the continuation of my previous post

I was in my new place. It was evening and I was keeping an eye on our children playing with their cycles. A group of 3 men came to the compound where I lived and asked for my friend who was away. I asked them the reason for searching my friend. 

They introduced themselves and told that they hailed from a nearby village. Couple of days back, one of the young men from the village had left to the south of the country for earning a living. He had gone along with two of his friends who hailed from elsewhere. 

They have received news from police in Chennai that this young man was dead. The trio came to my friend to help in communicating with the policemen who called from Chennai. It seems that the policemen were speaking in Tamil and they just caught the 2 English words that this young man was dead. 

Unfortunately, we could not contact the given number till around late evening. The story was that the young man's dead body was found lying on the tracks of Chennai Central Railway Station early morning. He had an identity card with a contact number in his pocket and a general railway ticket from Hatia to Ernakulam. The policeman gave us the address of a police station where his relatives were supposed to go. 

The amazing aspect was that none of the villagers knew about the two other people who had gone along with this young man. Therefore, we did not have anybody to contact. 

We conveyed the news to the villagers. 

What happened to the young man will always remain a mystery. The timing of the discovery of the body well matches with the early dawn arrival of the Dhanbad-Alappuzha express at Chennai. He may have got out to go to the toilet. It's not uncommon for passengers in the general compartment to disembark on the wrong side of the train to use the water filling outlets for their ablutions. Or maybe, he got looted by his fellow passengers and was pushed out. 

The fact remains that this young man who has two little children will never return home. Things would have been better if it had rained well this year. He would not have died if he earned well in his village. Maybe, things may have been better if he was a skilled worker. 

Another sad story of migration ending up in a disaster . . . 

Monday, September 1, 2014

Unskilled migrants . . . dead end

One of the major issues in this part of the country is migration of the local population to distant lands for work. It is quite common to find the people from Bengal, Bihar, Jharkhand and Orissa doing manual labor in Kerala and Tamil Nadu. In our community work, we’ve found it difficult to work in many of the local villages because almost the whole of the village is away. It is very common practice that entire villages migrate in search of jobs once the sowing season is over.

Unfortunately, this year has been worse for many of the local communities of Palamu district as rainfall has been irregular, scanty and unpredictable. Migration has started in few of the villages I know. In most of the villages, they wait for rains to ensure that a crop is put before they migrate.

As we continue to serve in this region, it is not uncommon to find sad stories of people and families terrible miseries on account of the migration.

2 stories – both young men. Lives which should have been at the forefront of nation building. One alive, the other dead.

The first one, about 20 years old, we shall call AB. AB was brought in handcuffs to NJH about a month back. AB was caught in one of the local village markets as he was trying to snatch a necklace from a girl. He was given a sound trashing. And they recovered couple of mobile phones and some other stolen material from his pockets. AB was brought to us for a medical check up to ensure that he did not sustain any grievous injury in the course of his roughening up by the villagers.

AB had not sustained much of any injury. However, there was a very melancholic look in his eyes. I asked him if his parents know that he was involved in such a crime. He told me that he has been away from home for the last week. As we talked, he told me that he was feeling uneasy. He started to sweat. The policeman who accompanied the culprit was quite prompt in picking out the diagnosis.

‘Drug addict lagta hai,’ the constable said. The young man looked pleading to me and asked me if I could help him inhale some heroin. He motioned to his pocket to say that he had a bit of the substance stashed up there. That was the first time I saw heroin. It was not much . . . Just about the size of one fifth of an avil tablet. The policeman appeared to know what to do. He told me that he would take care of it. I asked the young man on how much it cost to have that much of heroin. That lot cost him 50 rupees.

He came the next day. The police needed a certificate to shift him to Ranchi as there was a possibility of him developing medical complications following withdrawal symptoms of the drug. They had obviously run out of heroin.

He just had a snort and therefore, he appeared much better. I had a good conversation with they guy. His father was a farmer. The family had shifted to newer agriculture techniques especially the use of hybrid seeds. The irregular rainfall of the region did all the damage. The family had run up into a huge debt. He talked of better days when the family was cultivating the traditional way – madwa (finger millet), kurthi (horse gram), samai (little millet), makkai (maize).

The situation became so bad that he had to drop out of school and go to Delhi in search of a job. That was the time when construction of the Delhi metro was in full swing. It was easy to land a job of a labourer . . . and easy to make friends.

That’s when things went awry. One of his room-mates introduced him to heroin. Almost his entire earning went to the purchase of the drug. He had come back home about 5 months back. He found out that the drug was available here too. It was expensive. But, then, he needed to have it. And then the dosages to get into a high also increased.

He found a better way to earn – he started to rob. And he was caught.

I asked him if he wanted to stop this addiction. He asked me if there was a way. It seems that all of his friends and family told him that there was no way back. I told him that we can always give it a try and with faith in the Great Physician, it was possible.

He promised to come back to us with his mother once he got a bail.

Climate change . . . migration . . . human greed . . . determinants of health . . . things could have been different if AB did not have to migrate in search of a livelihood . . .

The story of the other young man in my next post . . . AB was lucky to be alive . . . the next one was dead . . .