A Clarion Call . . . for Life

Most of my posts have been mainly on maternal healthcare with very few focus on the children. We all know that in places where maternal health care is poor, child survival is much worse. And it has not been quite different at NJH and the surrounding communities. There are quite a few incidents of still births which happen in the villages and even among deliveries that arrive late to hospital. 

However, recently I had a shocker of how prevalent is infant and child deaths in the community. 

The above is snap taken on a recent visit to the ancestral village of one of our senior staff. This is the graveyard of the village which is predominantly Christian (almost 100%). Hope you noticed the small mounds of earth (which are many more) compared to the bigger mounds (graves of adults). These small mounds of earth are those of children - - - most of them children. Of course, there are few (very few) mounds which represent revered ancestors. 

I've read that the start of collection of vital statistics started from church registers in medieval Europe. The information thus gathered proved to be key in the estimation of birth and death rates. 

Considering into fact that churches in these remote villages such as the one I went should be keeping information on Baptisms and Requiem Mass (Mass for the dead), there should be a mine of information out there. 

Some more information about the background of the region. 

The village is about 5 kms away from the State Highway connecting Mahuadanr and Netarhat. Mahuadanr is 25 kms away and Netarhat 15 kms away. Located on a plateau, the soil is of poor quality. And the water table is quite low (means you have to dig a lot for water - - almost upto 1000 feet)

I saw lot of millets being grown. The villagers informed me that they grow quite a lot of sorghum, samai rice  (little millet) and ragi (finger millet). A nice place to start off a project on encouraging millet farming. 

Health facilities was a premium. There was poor transport facilities. The nearest proper hospital is in Mahuadanr. Which sort of explains the high number of child and infant graves. 

And similar to many such areas, the area is rich in minerals . . . bauxite. One of the major mining companies have set up mines. And it is such thing to see the place especially as you travel to this village. 

Almost everything is red. And so dusty. The villagers informed me that there is constant pressure to cede their lands on long lease to the mining companies. Life is tough. There is no electricity in the village. For that, there is no electricity even in Mahuadanr. 

From a healthcare point of view, things are bleak. If there is need for secondary care, NJH is the nearest place . . . 135 kilometers. Ranchi is 175 kilometers away. Not an easy thing when someone needs specialised care in this village. And there are quite a few villages, all heavily populated in this area. 

After I visited the place, there were villagers requesting this NJH staff to ask me if we could make up a plan for a healthcare and community development facility somewhere near this place. Quite a huge ask . . .  But, very relevant request. 

One does not need rocket science to prove that that the dead children lying in that grave yard have died of preventable and easily treatable causes. The villagers informed me that a lot of young men and women are also buried there. 2 middly aged men took me to couple of graves and told me that it is of their sons who died of tuberculosis few months back. 

Our countrymen dying young in the age of computer science and jet engines should be a matter of concern for each one of us. I can only hope and pray that this post penetrates the hearts of people who read it. 

A great opportunity for anyone in public health or community development who want to start from scratch. 

A Justification . .. ...

I need to keep reminding myself on how I started off this blog . . . I've had many a person writing back to me  telling me how inappropriate it is to put many of my posts in the blogsphere. 

Very recently, after my post on the very unusual post about the rupture uterus, after I cross-posted it in a public healthcare site, I had someone ask me if it was appropriate to have posted it there. I thought it was appropriate . . . I don't mind if someone thought that it was inappropriate . . . 

About a week back, one of my staff told me that I belittle the region I'm in by portraying deficiencies of healthcare in the region by stuff I post. I asked him about what I should be posting. He told me he would think about it and let me know . . .  I've not heard from him ever since. 

Everybody loves to have beautiful romantic stuff posted . . . And it's not that I don't do that. 

Why do I write about cases of maternal deaths, near misses, tuberculosis cases etc. etc. 

It's because they are all so successfully treatable if not preventable to quite a large extent. 

The lady with the rupture uterus . . .  You should hear her story. 

We shall call her AAD. She had her first baby by Cesarian section for a reason about which she has no clue about. According to her after she was discharged after her Cesarian, nobody told her about not trying to deliver at home for her next deliver. Result . . . she did not bother to even do a routine antenatal care for her next pregnancy.

AAD started to have contractions early morning. The local village dai (traditional birth attendant) was called. She told the family that everything was fine and she should deliver by afternoon. Sometime mid morning, the dai felt that he was not progressing well and gave her four intramuscular injections . . . by our usual experience, it's pitocin. By afternoon, AAD had started to contract violently. It was excruciating pain. 

By around 3 pm, the family felt that she should take her to the district hospital. Whoever saw her at the district hospital was sure that the baby was doing well and she would deliver soon. She was there till around 7:00 pm, when they decided to move on. 

She reached us at around 9:00 pm. We did not need rocket science to find out that it was a rupture uterus. Per operatively, it was very evident that the rupture uterus had happened quite recently. The baby was a fresh still birth. 

I did not have any choice other than to do a tubal ligation (Family Planning) as the rupture was quite a bad one . . .  Like many of our previous stories, the husband would most probably abandon her for another woman who will be able to offer him more babies . . . 

The first time, when I told a similar story to one of my classmates, he told me that it was so unthinkable a story. But the fact remains that we have so many similar stories in our country and the world which are unfathomable to have occurred in an era when cutting edge medical science is looked upon with awe . . .

I've taken it up as a duty to bring to light such stories so that nobody who reads them will ever tell that they never knew there were such regions where such basic issues of healthcare were never taken care of and they could have played some role in alleviating the pain . . . .

That would bring me once again to the point of inviting more of my fellow healthcare professionals (rather nagging) to move out into needy areas of the country where your presence would end up saving lives and showing people that there is a God who cares . . . 

Pharmaceuticals - The Paradoxes in Indian Healthcare . . . Part 1

We are all well aware of how sick our system of healthcare is. While for the rich and the famous, it is nothing much of a major concern . . . for the middle class and the poor, healthcare is a major issue of concern.

However, what concerns me are reasons for the government being only hardly bothered about what sort of healthcare the common man has access to. One on side, we are proud of how good we are with tertiary care and we are looked upon as one of the major spots for health-tourism. We have states such as Tamil Nadu who are looking at up scaling of cadaver organ donation whereas on the other side, we've states where something as basic as availability of blood is a major issue.


I'm a bit concerned about the sort of media attention that issues such as cadaver organ donation, celebrity health issues garner compared to the status of basic public health care in the country. One issue which has been sort of been ignored is the state of tuberculosis in the country. I've taken up the issue many a time in my blog.

Well, you may say that we have the Revised National Tuberculosis Control Programme, a world award winning public health program which has won accolades at many a venue.

I take the issue of Tuberculosis today on account of one patient whom Titus saw in Outpatient today.

SDS was a unmarried 26 year old man who hailed from a village within 10 kms of our hospital. Hailing from a rich family, SD had been diagnosed to have Type 1 Diabetes Mellitus 7 years back. Then he had been diagnosed to have tuberculosis about 4 years back.

The sad aspect was that he did not access the free government tuberculosis drugs. He had quite a large file of his medicine prescriptions. It was quite a sad array of paper work he carried around.

Initially, he was started off only with Rifampicin and Isoniazid. Nobody was there to monitor his treatment. He took medicines for about 2 months and he left treatment when he started to feel better. Then, he became sick again. He went elsewhere and was started on medications again . . .

Unfortunately, by early 2010, someone had sent his sputum for culture testing. Below is the report.

But, I was in for a shock when I saw the prescription from the 'tuberculosis specialist'. All protocols of Multidrug Resistant Tuberculosis was thrown to the wind. It's more than 30 months. He's still on treatment.

And the worst shocker of all . . . He never had a sputum AFB done. . . of course, there was a sputum culture done about 2 years after the first diagnosis.

Well, you could blame SDS for not taking interest in the government run RNTCP programme.

But, I wonder why anti-TB drugs of all combinations and dosages are available in the open market when there is a government run programme to combat tuberculosis.

To make matters worse, there are quite a large majority of doctors who openly tell their patients that government medicines are of no good. SDS was told the same thing by every doctor whom he accessed for treatment.

Recently, the government has come out with an order on generic drugs. The pharmaceutical industry has already launched an all out cold war against this. They have even invented a term for generic drugs - 'unethical drugs'. And the branded drugs are called 'Ethical drugs'. So much to educate the common man on the terminologies of drugs.

Well, it was quite incidental that I came to find out that there is no Iron tablets in the Primary Health Centres around our place. But, Iron capsules are available in the Pharmacy shops and they were doing great business. Even, we are doing great business with Iron capsules. I remember that during my stint elsewhere in the South, the Medical Representatives were all out 'educating' us on how unpalatable the Iron tablets are compared to their 'double coated chocolate flavoured' and of course expensive Iron capsules.

SDS is most probably going to pay for his ignorance of the existence of a government scheme which would have monitored his drug compliance and disease progression. Now, he is getting a MDRTB treatment protocol which is totally out of line from what he should be getting.

I'm sure that this is part of the influence of private players who are very well aware of the inexhaustible gold mine of profits made in the name of healthcare. It is sad that the government is not realising the folly it is in by allowing such a back-door entry for private players in healthcare. The influence looks subtle, but the consequences are going to be disastrous for the common man.

The government order on making generic drugs freely available is a decision in the right direction. I was quite encouraged to see the 'Generic drug store' in the Latehar district hospital during a recent visit. I'm sure that the private drug companies and retailers would go on an all out war against it, at least indirectly if not directly. More initiatives such as these are necessary if the common man has to regain his confidence on public healthcare.

However, it is going to be quite a long journey for all of us who are mooting for a full fledged robust public healthcare. The question is how many of us are going to continue fighting to see a day when that happens.

Rose Trampled . . . The Indian Woman . . .

It has been busy at NJH since the last rains. However, the monsoon rains has made life easier as the weather has cooled. For me, it has been all the more busy as I prepare for the annual meetings of the organization. After the spate of patients with eclampsia last week, I had been expecting a lighter week. Moreover, the rains will keep the rural populace busy with agriculture work. 

As I ensured that the Outpatient Department was functioning smoothly for the early morning rush, there was this young man trying to get my attention. He told me that he has been by someone I knew in Latehar. The next thing I know is that he puts a mobile onto my ear saying that the person I knew wanted to talk to me. It was nothing new. The young man had brought someone whom I should see. 

The young man took me to the patient. A young lady, obviously pregnant - but severely pale, with a swollen face and legs which looked as if she had filariasis of both the legs. And she could hardly sit. 

They had couple of prescriptions from elsewhere. Both of them were illegible to me.

The history - We'll call this lady AD. AD had become pregnant for the second time while her first child was still not one year old. She did not have a date from which we could calculate her expected date of delivery. She had not been doing well for the last couple of weeks. She was in her husband's house - but her husband was away; working in Bangalore. She lived with her in-laws and her daughter. 

Without much of an examination - the diagnosis was obvious. Severe anemia, malnutrition and probably pre-eclampsia. And most probably a baby with intra-uterine growth retardation. I scribbled off some investigations and send her to the ward for admission and observation. 

I called the young man, who happened to be AD's brother and asked further about how she could be so malnourished. It seems that there was hardly anything to eat in the family. It was a hand to mouth existence. He was sad that she was married into this family. It seemed that AD's husband also did not care much for the family. And the fact that the first child was a girl did not make things easy. 

As we talked, I received information that her blood pressure is on the higher side. Initially, it looked normal. However, they had been elsewhere before reaching here. Then the investigations came. Hemoglobin of 6 gm%, Serum albumin of 2 gm%, Urine albumin of 2+ . . . Well, I did not require anything more. To top it all, a blood group of AB positive . . .

I told him about our limitations. She needed blood . . .There was the impending eclampsia round the corner. She was terribly malnourished. . . I gave him all the options. . . The problem was the costs involved . . .I talked to this acquaintance in Latehar. He told me not to take any risks . . . And AD's brother was also not ready to take any risks . . . After some time, they were off to Ranchi . . . 

I wonder if AD's husband's family had somehow found out that the fetus was a girl. Or was it just poverty. It was difficult to say . . . 

It is terrible. A country where goddesses are venerated to enormous proportions - the state of the girl child and the woman is in doldrums . . . The same neglect was seen in the last patient about whom I mentioned in my last blog . . . The welfare of the lady or the girls in the house seems to be the last concern . . . 

And what do we have . . . Pregnant women with severe anemia . . . giving birth to underweight babies . . .and if they are girl babies, they are all the more neglected. Growing up in a suppressed environment where they are made to believe that they are the 'flowers in someone's garden', they yearn for the day of their wedding after which they can redeem themselves by giving birth to a boy child . . .

Now, all this - if they make it alive through the different phases of their life's journey. They are lucky if a neighbourhood ultrasonologist do not make an early diagnosis of a girl fetus and inform it to the relatives. And then, all the childhood illnesses which could have killed her had she not had God watching from above. . . To suffer the taunts and evils of eve-teasing and a risk of being physically abused. . .  Then comes marriage . . . the undernourished body strained into conceiving and nourishing another human being . . . 

I'm sure that the Indira Gandhis, Pratibha Patils, Mamta Banerjees and Jayalalithas are just not representative of what the state of the Indian woman is. . . Many of the time, we trumpet about the great women leaders that we've had starting all the way from the Rani of Jhansi. . . I feel that all of that is of no use unless the average Indian woman especially in our slums and villages are given decent care and respect . . . 

I pray the AD would have a non-complicated delivery and post-partum period. It is a very costly and dangerous path that she is on . . . I wish that AD's brother would have the wisdom to treat his wife in a better manner . . . May wisdom dawn on the menfolk that they treat their wives and daughters better . . .

Maternal Health Care in Palamu - Red letter day

Today was a red letter day in the history of maternal health care of our region.


The UNICEF along with the district health authorities of Palamu district had arranged for a training session on Facility Based Maternal Death Review. I understand that soon there would also be efforts taken for training grassroot workers on Community Based Maternal Death Review.


Mr Prabodh Kujur and myself represented NJH as we have quite a large burden of adverse maternal events including maternal mortality. Over the last 1 year, we calculated about 20 maternal deaths within the facility. This excludes at least 5 patients who were brought dead.


One of the key messages which was conveyed to all the doctors who came was about the absence of a blame factor in the whole exercise. Many a time, adverse health events are not reported because of a fear of punishment. I was very glad that the message was conveyed well.

As I sat there, images of mothers who died or almost died, those who ended up with lifelong complications and dead babies flashed before me.

I remembered AB's baby who just made it whereas she should have been referred faster. BD, whose life has turned for the worse was a poignant face whom I would remember for the rest of my life. One of the major finding I would expect from the reviews is the strong association between malnutrition and anemia. 

The mental stress that KD's family endured was still fresh in my mind. Our experiences with patients like RD, who lost her baby or SD, for whom we had to intervene heroically have already taught us that the delay in taking the decision to go to the healthcare provider and the delay in implementing the decision is quite costly in the lives of mothers and newborn. I'm certain that this is going to be one of the major learning in this exercise.

I'm excited about the whole excercise. We look forward to a time of learning and understanding determinants influencing maternal health care in this region during the maternal death review meetings at the institutional and district level.

More than that we look forward to a period in our surrounding communities where pregnancy is more safe whereby families will cherish and enjoy motherhood which would be the ultimate aim of such an exercise.