communityhealth.in

The link has been sitting demurely on the right side of this blog for quite a while but I realise that I have never actually written about communityhealth.in so far. In short, communityhealth.in is an experiment in creating an online resource on community health in India, something that is very close to my heart. Starting this January I hope to be doing a lot of talking about this project and I have created chdotin.wordpress.com for the same purpose. Do check it out.

Stone River Hospital

Occasionally I write poetry. There, I finally said it. Most of it is terribly personal, vulnerable and badly written. Over the last two months however I have occasionally written something that I feel comfortable about. Both the poems below are based on my experiences here and meticulously portray life as it really is.

A short note on the label of this blog post. 'Stone River Hospital' is a literal translation of Kal Aath Aspatre as we are locally known. Below is a photo of the river which runs about 200 feet away from my room. If someone had to literally translate what I am known as in the area it will be' Stony River Little Doctor' :-)

M's Betrayal

When the skin on the bottom of your feet
Burns. Burns really red hot.
It becomes hard and black. Like
Old cracked leather.
It makes a 'tok tok tok'
Noise like a coconut shell. Dry.

Inside creamy pus waits patiently.
The doctor will soon quit tapping
the skin with his pen.
He will mumble instructions in Tamil.
Nurses will scurry. The woman will
Starve to avoid vomiting with the anaesthesia.

In the evening Dhanam Akka will
Crack open a beautiful glass ampoule.
With the deftness of experience she will
Pull ketamine into a plastic syringe.
M lies on the steel operating table
Softly moaning under her green blindfold.

Soon cold steel clasped in latex
clad fingers will pare through
dead skin. Patient pus will burst
forth and dribble into a plastic
kidney shaped tray. Raw red
flesh will make a shy debut.

Akka, will you promise not to tell
Anyone. Promise on your heart.
Promise on your head. Promise. Promise.
I didn't fall into a cooking fire
because I fainted being two months pregnant.

I took some tablets because I didn't
Want a second child right now.
Ten pills from the local doctor. They
They knocked me out and then
Then my husband came home drunk.

Promise you won't tell anyone. Promise.
On your heart. Promise on your head.
He was in a murderous rage. He.
He tied me up and then he.
He stuffed a cloth in my mouth.

---------------------------------------------------------

You might be tempted to ask why this has been the best year of my life. Here's why ....

A Rural Practitioner's Happiness

Tiny hands. Big eyes.
The cutest damn expression in the world.
That's my reward. That's happiness.

Then I walk out of the labour ward.
I can see hills all around. Green.
That's my reward. That's happiness.

My cottage sits on the edge of the forest.
Full of books, art films and insects.
That's my reward. That's happiness.

The local women who work at our hospital
Call me 'Anna'.
That's my reward. That's happiness.

An old therakoote vadiyar
Is grateful I was with him during his second MI.
That's my reward. That's happiness.

When death comes. Despair.
Loneliness and gastritis.
I think of my rewards. I try happiness.

communityhealth.in posters

I had spent the whole of yesterday in the OP clinic seeing patients. Occasionally I would nip back to my room for a break and to read a little more of Helping Health Workers Learn, a book that is slowly revolutionising the way I understand community health. Inspiration struck at 1 am after reading the passage which I subsequently used in the first poster. The pictures are from my travels over the last year.

Click on the poster to enlarge.

The second poster is more personal. It was a sort of artistic representation of what being a community health activist at 1 am at night feels like. It uses a lots of ideas about art that I have been slowly developing such as where the artist situates himself, the progression of time between the pictures (look at the guava) and creating different messages depending on the distance between the viewer and the poster among others. I don't expect it to be popular or even be printed at all but it is my personal favourite. Poetry, art and community health :-)

Click on the poster to enlarge.

Lousy T design idea

Understanding Health For All

There seems to be so much confusion regarding terminology within People's Health Movement. We hear talk of 'upper-case People's Health Movement' and 'lower-case people's health movement'. 'Health For All' seems to be the buzz word used by everybody today, from private insurance companies and corporate hospitals to Right to Health lobbyists and community health workers.

Here is Dr. Halfdan Mahler, the grand old man of the Health For All movement breaking it down in the simplest of terms. According to him the concept of Health For All is a value system/ spiritual belief. It requires a leap of faith. You have to believe that everyone is entitled to try and live in perfect health. You have to believe that any attempt to take away this freedom is wrong. Then you act.

Taking it from there, People's Health Movement is then the largest network of Health For All believers. It is the most visible face of such a belief. Using new technologies such as the internet and cheap air travel it unites individuals, organisations and networks to work towards Health For All at all levels. Its core manifesto is the People's Charter for Health, an action plan to achieve the world it believes in.

So People Health Movement is not a movement after all. It is the biggest network within the Health For All movement. If it was called the Network Of People Believing In Health For All And Then Deciding To Do Something About It then half the confusion would be cleared away. But there is no denying that PHM rolls of the tongue more easily than NOPBIHFAATDTOSAI.

If you dont believe that everybody, I mean everybody, has the right to try and live a life in perfect health then you cant use 'Health For All' in its profound, genuine sense. In the world we live in everyone suffers from some curtailment of this freedom. The poor, the sick suffer more. However such curtailment can never be morally right. While forcing people to live in unhealthy environments, preventing their access to the best possible medical care, allowing them to be subject to humiliation and hate may sometimes be temporarily unavoidable it can never be morally condoned.

An individual or institution who then uses the 'Health For All' term to promote itself but condones even the temporary infringement on people's Right to Health is then merely 'HFA washing' or 'hfasing'. Similar to pink washing, the phenomenon of corporate houses using breast cancer awareness and charity as an excuse to market their products. See Think Before You Pink for more.

To sum it up. The idealistic concept of Health For All finds practical expression in the lives of thousands of individuals and institutions who constitute the Health For All movement. The largest network of such believers is the People's Health Movement. However there seems to be others who use the 'Health For All' term carelessly and sometimes for selfish purposes.

Trust Me Ts design idea

Click on the images to enlarge.

Varavara speaks my mind on reservations in medical colleges

Merit Rule of Brahmin

a poem by Varavara Rao

Lucky
You are born rich
To say in your language
“Born with silver spoon in the mouth”

Your agitation sounds creative
Our agony looks violent

You are meritorious
You can break the glass of buses
In a shape

As symmetric as sun’s rays

You can deflate the tires
With artistic elan
While indulgent police look on
With their jaws rested on rifle butts

You can tie ‘Rakhis’
Even in
The dark chambers
Of a police station
You do not buy bus ticket
Not because
Your pocket is empty
That is practical protest

The beautiful roads
Are all yours
Whether you do a `Rasta Roko’
Or drive vehicles with `save merit’ stickers

We are bare-footed
Sweat-stinking road rollers
What if we built the roads?
The merit of plan is yours
The credit of contract is also yours

Those exhilarating sixty days, what fun!
When your cute little girls
And their daredevil mates
Were going on a delectable rampage,

Everybody was delighted
Parents, their parents
Brothers and sisters
Even the servants
And reporting Newspapers?
Oh, absolutely thrilled!

Boys and girls
Hand in hand
In protest
Of buried merit and dashed future
Going off to a picnic
O Yaar,
How heroic!

You are the marathoners
In merit competition
Poor tortoises
Can we run with you?

If
You serve “Chair” in Chikkadpalli
Sell “pallies” in cinema hall
Polish boots in Kothi Circle
Stop a Maruti or Priya on the Tankbund
To demand agitation fund

Well
Media persons are `merit’ creatures
Their camera hearts `click’
Their pens shriek,
“Youthful brilliance”!

We are drab faced duds
Sitting in the stink of dead animals
We make shoes
By applying color with our blood
And polishing them
With the sinking light of our eyes

However,
Isn’t the shine different
When polished
By someone in boots?

We clean up your filth
Carry the night soil on our heads
We wear out our bodies
Washing your rooms
To make them sparkle
Like your scented bodies

We sweep, we clean; our hands are brooms
Our sweat is water
Our blood is the phenyl
Our bones are washing powder
But all this
Is menial labor
What merit it has?
What skill?

Tucked-in shirts and miniskirts
Jeans and high heels
If you sweep
The cement road with a smile
It becomes an Akashvani scoop
And spellbinding Doordharshan spectacle

We are
Rickshaw pullers
Porters and cart wheelers
Petty shopkeepers
And low grade clerks

We are
Desolate mothers
Who can give no milk
To the child who bites with hunger

We stand in hospital queues
To sell blood to buy food

Except
For the smell of poverty and hunger
How can it acquire
The patriotic flavor
Of your blood donation?
Whatever you do
Sweep, polish
Carry luggage in railway station
Or in bus stand
Vend fruits on pushcart
Sell chai on footpath
Take out procession
With `Save merit’ placards
And convent pronunciations

We know
It is to show us that
Our labor of myriad professions
Is no match to your merit

White coats and black badges
Hanging over chiffon saris and Punjabi dresses
`Save merit’ stickers
On breasts carrying `steth’s (stethoscopes)
When you walk(ed) in front of daftar
Like a heaven in flutter
For EBCs among you
And those who crossed 12000 among us
The reservation G.O.
Is not only a dream shattered and heaven shaken
But also a rainbow broken

Yours
Is movement for justice
On the earthly heaven
That is why
`Devathas’ dared more for the amrit

The moment
You gave a call for `jail bharao’
In the press conference
We were shifted out
From barracks
To rotting dungeons
Great welcome was prepared
Red carpet was spread
(`Red’ only in idiom; the color scares even those who spread it.)

We waited with fond hope that
The pious dust of your feet
Would grace not only the country
But its jails, too

How foolish!
The meritorious cream
The future
Of country’s glorious dream
How can they come
To the hell of thieves,
Murderers and subversives?

We read and rejoice
That function halls
Where rich marriages are celebrated
Became your jails

Ours may be a lifelong struggle till death
But yours is a happy wedding party of the wealth
If you show displeasure
It is like a marriage tiff
If you burn furniture
It is pyrotechnical stuff
If you observe `bandh’
It is the landlord’s daughter’s marriage

Lucky
The corpse of your merit
Parades through the main streets
Has its funeral in `chourastas’
Amidst chanting of holy `mantras’

But Merit has no death
So
You creatively conduct symbolic procession
And enact the mourning `prahasan’
In us
To die or to be killed
There is no merit

We die
With hunger, or disease,
Doing hard labor, or committing crime,
In lock up or encounter
(Meritorious will not agree inequality is violence)

We will be thrown
By a roadside;
In a filthy pit;
On a dust heap;
In a dark forest

We will turn ash
Without a trace
We will `miss’
From a hill or a hole

Our births and deaths
Except for census statistics,
What use they have
For the national progress?

We take birth
And perish in death
In and due to
Miserable poverty
You assume the `Avatar’
When Dharma is in danger
And renounce the role
After completing the job
You are the `sutradhar’

You are lucky
You are meritorious.

Varavara Rao (b. 1940) is a member of Viplava Rachayitala Sangham (VIRASAM: Revolutionary Writers’ Association). He lives in Hyderabad.

Merton's violent activist

“… there is a pervasive form of contemporary violence that the activist fighting for peace by non-violent means mostly succumbs, viz. activism and overwork. The rush and pressure of modern life are a form, perhaps the most common form of innate violence. To allow oneself to be carried away by the multiplicity of conflicting concerns, to surrender oneself to too many demands, to commit oneself to too many projects, to want to help everyone with everything, is to succumb to violence, more than that, it is cooperation in violence! The frenzy of the activist neutralises his work for peace, it destroys the fruitfulness of his own work because it kills the root of inner wisdom which alone makes work fruitful.”
– Thomas Merton

Teaching renal failure

Teachers help students believe in patterns in the real world. In any discipline everything seems so chaotic and impossible to understand at first. The descriptions of patterns in our textbooks seem sterile and nothing like what we have seen in the real world. A desperate, breathless man with a wailing entourage looks nothing like what a textbook patient with end stage kidney failure is supposed to look like. My reading on poverty, class and caste conflicts wont let him breathe easy. Wont let me breathe easy. At Sittilingi I've had two patients like this already. One died holding my hand after twelve hours of struggling to breathe as fluid irreversibly poured into his lungs for the last time. One went home after being successfully pumped with diuretics. He will come another day to die.

Why do people die of kidney failure? Its a long complex story involving chronic NSAID abuse, undiagnosed hypertension, drugs prescribed by unqualified local 'doctors' and blinding ignorance of methods of prevention. Add to that poverty, exploitation and a historical tendency to screw over tribal communities.

What do the current pundits of community health have to say about managing people with kidney failure in the community. Precious little. There is a huge difference between those who do things and those who write about things. The doers are brilliantly innovative yet deathly silent. Amazingly innovative ways of managing such situations do not leave the local context where they are practiced. There exists no peer review journal, no website/blog, no conscious effort to put suchlike into current textbooks. On the other side we have the suave publishers. Toting degrees from posh institutions that inculcate snobbery they fly around collecting data and creating analysis that serves them well. However they act like they never met a poor, dying man ever. Never shared his pain.

I realize that my previous paragraph is harsh. I am in danger of putting myself on a pedestal. But I write because of frustration. Because I lack good teachers. Because my textbooks are nothing like the real world. The chapters on renal failure make no sense because they don't talk about patients. I know how to manage a rising blood urea level better than I know how to manage people dying. I cant prevent death because of the silence maintained on the people causing renal failure. By selling dangerous medicines and by their failure to create a working system people of my community cause people to die stupid deaths.

Its time we saw a chapter on renal failure that reflects reality.

Becoming an MFC writer

My parents wrote in the MFC journal when they were little older than I am currently. Its managed to survive all those intervening years and the latest issue carries and article by me. Ruminating about what it meant to be a slightly lonely medical student. Check it out here (Its on the last page.)

Sometimes I cant really say whether I like the style it is written in or not. Why don't you tell me?