Tuberculosis Unit . . . Supervisory Visit . . .

As part of our responsibilities of a Tuberculosis Unit catering to a population of about 650,000 (each TU usually caters to 500,000 population), we need to make supervisory visits to the different Primary Health Centres and Microscopy Centres in our area. 

It has been quite some time since I had visited the areas after Dr Johnson took over charge of the TU. Over the last week, it has been obvious that Dr Johnson may not be continuing with us and I thought it would be good to accompany the TU staff while they supplied the drugs. 

It turned out that there was a new MDRTB (Multi-drug Resistant Tuberculosis) patient in our area - in fact the first one in Palamu district to be started on DOTS Plus anti-tuberculosis treatment regimen. I had to visit him. 

Being summer, I was relieved that the air-conditioned Bolero was at my disposal. Along desolate, dry and depressing landscape, I made my way to each of the Primary Health Centres under us. For confidentiality's sake I do not wish to mention the names of any of the places I went to. Of course, there are photographs . . . 

The first place of my visit was a Community Health Centre. It operated from a new building since the last time I had visited it. Quite spacious and well planned, it was an administrator's dream. Well, I was told there were 10 doctors posted. About 2-4 of them visited the Outpatient every day. There was no resident doctor although there was a shabby quarters for them at the entrance of the CHC. 

From the staff, I came to know that there were about 30-40 deliveries every month. However, there were hardly any facilities to manage complications. This is was the CHC for our target area of around 600,000 population. 

The TB facilities were as expected. Lower number of sputum examination rates of chest symptomatics. 

We could not meet any of the Medical Officers or other staff as it was too early. But, late enough for the private lab run by the laboratory technician to have opened and started business. 

On the way to the next place, a Primary Health Centre, we met AD - supposed to be our first Multidrug Resistant Tuberculosis patient to have been started on DOTS-Plus.

We reached the PHC as the daily business was on full swing. Old buildings doted the compound. I was introduced to the Medical Officer in charge - I was quite surprised the way he was talking. He appeared quite incoherent and confused. I thought that he is old - nearing retirement - some amount of senile dementia setting in . . . 

As I came out after meeting the old doctor, one of the staff asked me if I understood anything he spoke. It seems that he was a die hard ganja (local name for cannabis) addict. It was sad . . . The situation about tuberculosis was the same at this PHC too. The best part was a very enthusiastic laboratory technician, RK who kept the numbers coming in a good pace. . . 

Then, was a long drive through some badly Naxalite infested areas to our third place. The PHC which caters to a population of around 120,000 did not have any doctors visiting the place for ages.

The PHC . . . No takers . . .

The labour room . . . Nobody had an idea about the number of deliveries per month. One staff told me it was about 5-10 per month . . .Remember that the served population is about 120,000.
A rough calculation says that there would be 3000 deliveries per year in the target area . . .

 

Indication of better times. The old dilapidated doctor's quarters

Poor electricity facilities, necessitating devices like this solar powered mobile phone charger

The staff appeared quite protective about the status of doctors visiting the place. Once more, we had a very enthusiastic laboratory technician who was very pro-active. 

We were quite tired by the time we finished the third place. 

In between the next visit, we visited one Catholic mission centre where they were trying for the upliftment of the tribal community. It had been 12 years since the work had started - but it seems that the community was hardly interested in any sort of development or progress. The mission centre was running a school for the local community. Of recent, they have sort of taken an foray into healthcare too - and we had been supporting them technically. A very potential place for virgin public healthcare work to start. . . 

By the time, we reached our last PHC, it was late afternoon. The outpatient was over and most of the staff had left. The lab technician was waiting for us to arrive. We were also in a hurry . . . 

It was around late evening by the time we reached back to NJH. . . 

Lessons learnt at the end of the visit - 

1. Rural public healthcare is a neglected area in our country.

2. There is a need for committed healthcare personnel in such places. 

3. We're not going to achieve much in terms of vital statistics if there is no drastic improvement of public healthcare facilities. 

4. Committed staff such as the two lab technicians we met do not receive any sort of accolades for the service they render to such difficult communities. Which of course prevents others from coming to serve in such areas.

5. There were many more patients like AD all over our communities. The challenge is to reach out and find them.   

MDRTB . . . Our first patient on DOTS Plus . . .

Last week, I had to do the fortnightly supervisory visit of our Tuberculosis Unit. In between the visits to the different PHCs,  we stopped to visit AD - supposedly the first MDRTB patient to be put on DOT Plus in the district as well as under our Tuberculosis Unit.

The drive . . . Desolate and dusty roads . . .

A young man, unmarried, looking emaciated but quite high on enthusiasm met us as we reached the village. He had been on Anti-tuberculosis medicines for quite some time. Unlike many of our regular tuberculosis patients, AD came from a high caste family. And we found something which we find in many of the upper caste tuberculosis patients - an aversion to free medicines available from the government. 

The street where AD lives . . . AD can be seen sitting in front of his home . . .

On detailed question, it was very obvious that this aversion to free medicines is what gave him away. AD, who was a very outgoing and fun-loving guy just did not have the discipline to stick to medications which he was supposed to take on a regular basis and his upper caste status discouraged him from getting himself free medicines for treatment. He had felt better many a time and had stopped treatment himself . . . 

Which ultimately landed him in this state of affairs . . .What surprised me was that he was still a bit careless. He was not very careful with what he ate and he loved roaming the village roads on his bike. 

Later we went to visit his DOTS provider. A quack who is very much sought out - I thought I should pay a visit to him and give him some encouragement for the work he was doing. The village was so remote and he was an obvious messiah to all those who fell sick in the villages near by. 

RS, the quack who's DOTS provider to AD . . .

He was quite proud of his clinical achievements and the succor he has been to the multitude of poor and sick villagers who were very much dependent on his skills. . . We did not have much of a time, but it was quite an entertainment listening to him. 

After, seeing AD one more time and reiterating about the need to stick on to his medications, we were on our way to the PHC.


As I drove, it was very obvious that there were many like AD in the villages I was whizzing through - it would take a herculean effort to treatment them and more so to detect as well as prevent such cases . . . Sometime during the next week, I would post on my visit . . . and you would realize a major reason TB is going to stay on with us . . .


Well, I almost forgot, AD's brother is also a defaulter who's sick with persistent cough and fever for almost a year and is awaiting his culture . . . He was away visiting when we met AD . . .  

The Occult . . . And Worse . . .

Below, is a clip of a news item published in our vernacular daily last week.

The translation is as follows -

It has been reported that a certain Mr. Mukhan Ram (55 years), a resident of Dharuwa village under Kanti Police Station was paraded in the village after having his hair tonsured. Mr. Mukhan Ram is a witch doctor by profession since the last 10 years.

The Panchayat had decided that Mr Mukhan should be punished in social, economic and psychological terms. In relation to the incident, villagers reported that the wedding of the daughter of a certain Umesh Ram took place on 23rd April. Mr. Mukhan had done a certain ritual during the wedding. After the ceremony, when the girl was leaving her house to her husband’s place, she had become unconscious. The girl’s father, Mr. Umesh Ram brought a new witch doctor for further ceremonies from Belchampa, Palamu. The new witch doctor proved by his magic powers that Mr. Mukhan Ram was responsible for the girl becoming unconscious after the wedding ceremony.

Mr. Mukhan Ram’s wife got into a fight with the family of the girl after hearing this. Mr. Umesh has demanded that Mr. Mukhan Ram pay up 25,000 INR which he had to spend towards getting his daughter alright after she had swooned during after the wedding ceremony. The Panchayat has given a time frame to Mr. Mukhan to pay up this amount.

Amazing, for two reasons -

1. First and foremost – the newspaper deciding to put this into print.

2. Second – to note that we continue to incidents like these in our country. Most probably, the girl would have too tired and probably hypoglycemic after the ‘long Indian wedding’ – and that was enough for a witch doctor to extract 25,000 INR from the family towards healing her . . .

My countrymen, we can only weep for our fellow brothers and sisters who are caught up in this mire of ignorance and sorcery . . . 

2 Eclampsias - Different endings . . .

Last week, we had 2 patients come in with very bad eclampsia. We managed one very much pro-actively whereas the other we could not do much as her blood parameters were already quite bad. The first made it and the latter died within 4 hours of arrival to the hospital.

SD, had suddenly thrown off fits sometime mid-morning and had come through couple of other hospitals before she landed up here. SD was very sick - her bladder was empty - rather there was some amount of darkish red fluid coming in the urobag, her creatinine levels elevated, Glasgow Coma Scale of 3 and Platelet Count of 59,000. And the baby was dead. And the birth canal was tightly closed. 

I was in a half mind to operate but the low platelets prevented me. The fact that operating rooms were not free made the decision easier. Unfortunately, she had a cardiac arrest sometime late evening and we could not resuscitate her. She was dead.  

However, there was another patient, UD couple of days before SD arrived. In fact, when SD had arrived, we showed UD who was on the adjoining bed. 

UD came to us after having been to couple of hospitals. She also came sometime late evening. We had done an emergency Cesarian to deliver a pair of undiagnosed twins. Both the babies were sick initially, but recovered over couple of days. UD had been having seizures over the whole day before she reached here. To make matters worse, when UD came in, she had a Glasgow Coma Scale of 3 and suffered a respiratory arrest in the labour room. 

We got her intubated and shifted her to Acute Care. After some amount of mechanical ventilation, we took a decision to do a Cesarian and deliver the baby. 

After the Cesarian, we were surprised to find out that she could be easily weaned out of the ventilator - but later found out that she had developed a focal neurological deficit - a left side lower limb hemiplegia which has since improved. 

We never expected UD nor SD to make it. We sometimes wonder what was the difference between the 2 ladies. Regarding SD, the facts that stood against her was the overt edema, sudden onset of symptoms, total renal shutdown and thrombocytopenia. UD did not have edema and all her blood parameters were normal. The blood pressure was high with a Urine Albumin of 3+. 

Now, the saddest part of the whole narration. UD's relatives were very upset with us after the surgery. The twins turned out to be girls. And UD already had a little girl of 3 years at home. After UD had become fully conscious, she was also psyched out by one of her relatives for her 3 children being girls . . .We had a tough time convincing UD that it is perfectly fine to have 3 girls and is possible to bring them up to be responsible citizens of the country . . . However, she is going to have a tough time doing that . . . I feel happy that the 3 girls will have their mother to be with them alive and well and raising them . . . I wonder, whether the family agrees with me . . . They may have wished that the mother and 2 girl babies had died rather than lived . . . How sad ? ? ? Most probably, UD will be under pressure to have one more baby . . . to try to get a boy . . . 

Praise and Prayer Bulletin . . . May 1

1. Dr Johnson's father passed away last week. Kindly pray for the family as they go through a difficult phase in their lives.

2. We had been busy over the last couple of weeks. We thank for the patients whom we could save. Please pray for families who lost their loved ones especially the family of the boy who died after 3 members of the family got burnt.

3. The last financial year has been a mixed experience for us. Although our statistics has been on a constant rise, we've had quite a lot of expenses which has kept us in the red. We pray that we would be of help to the surrounding poor communities and shall be witnesses of the love of Christ in the year ahead.

4. We thank the Lord for the safe deliveries of Dr Angel, Sr. Chandrakala and Sr. Kanchan. All the mothers and babies are doing fine. 

5. We praise God that there has been quite a major improvement in the quality of the road to Daltonganj. In light of this, we look forward towards purchase of a school bus for the children. Kindly pray for this need. It would cost us about 1,300,000 INR (26,000 USD/AUDs, 15,300 GBPs). The present vehicle is almost 12 years old. 

6. The public electricity supply in this region continues to be quite pathetic. We spend about 150 litres of Diesel per day to run the generator, which is a major expense to the hospital. We look forward towards exploring alternate sources of energy. Kindly pray that we would make some sort of progress in this area.

7. Obstetric care continues to be on the rise here. We thank the Lord for the joys we have had over the last couple of weeks. However, we have felt that we need to train more of our staff in obstetric care. It would be wonderful to have a full time neonatologist to help us in the work.

8. In addition to the pediatrician, we also look forward to have a medicine consultant. Cases of fever and complicated cases needing intensive care has been a major challenge for us. We pray for a pediatric consultant.

9. Summer has started. It looks like it is going to be quite a harsh one. Please pray that our water reserves would see us through. Do pray that the staff will be protected from sickness during the harsh weather. And that we would receive timely and enough rain once monsoon sets in.

10. After a gap of 3 years, we had a plentiful harvest of fish (112 kilograms) from our pond. We thank the Lord for this encouraging sign.

11. RSBY has been well received by the local community. We had over 350 outpatients and about 80 in-patients since its inception. Please pray that we would receive funds from the insurance agencies in a time-bound manner. On May 4th, the District RSBY Office has organised a Medical Camp at Satbarwa to mobilise surgery patients. We pray that we would have enough learnings in the process. 

12. Please pray for our lawyer, Mr. BK Pandey. He lost his wife couple of months back and had gone into a bad depression. We had been managing him. Thankfully, he has recovered well.