AlJazeera on health care in rural India

I just chanced upon this video on the state of health care in rural India by Al Jazeera English. For a network which is new to covering India they have produced a remarkably balanced report. In a span of a few minutes they give us a glimpse of India's huge burden of common yet potentially deadly infectious diseases such as diarrhoea, the worry and hardships faced by poor rural patients, the ailing government health care system, the frustrations of a doctor working for low pay in a remote area, the corruption within the system, the health movement with its activists and the private medical industry which is far away from all this reality.

Kudos Al Jazeera.

Snapshots of a doctor in rural Tamil Nadu

A few days ago the our health minister announced that that doctors will get better pay and 10% extra marks in competitive postgraduate entrance exams for every year spent working in a rural areas up to a maximum of 3 years. The proposal may not address to problem of the severe shortage of healthcare personnel in rural areas completely but it is indeed welcome news.

But what does working in a rural area actually mean? I spent two years working and taking pictures at the Tribal Health Initiative in Sittilingi in the Dharmapuri district of Tamil Nadu. Here are some snapshots.

Rural Tamil Nadu is beautiful.

This is the view from the kitchen window of the cottage I stayed in while working for two years at Tribal Health Initiative in Sittilingi, Dharmapuri District, Tamil Nadu as part of my rural service. Students from St. John's Medical College in Bangalore have to spend the first two years after graduation in one of the college's 400 recognised rural bond centres or pay Rs. 3,00,000 (Rs. 6,00,000 for the current batch).

The work is rewarding.

Apart from the three doctors and a couple of technical staff Tribal Health Initiative is run exclusively by people from the local community. Here is one of our health workers the day after the birth of her son. She was delivered by fellow health workers all of whom have grown up in the villages surrounding the hospital.  She had her baby in the sun when I came for morning rounds and we all shared her joy.

You might just get to live in your dream house.

I lived on the hospital campus at the edge of reserved forest land with a small stream a few metres away. My cottage had a small kitchenette, a shower and a high speed internet connection. (thanks to BSNL WLL technology). More than I could have asked for. Meals were in a common mess for all staff who stayed on campus.

You get chances to do surgery.

I learnt more in the two years I spent working with Dr. Regi and Dr. Lalitha than in all six years at college. One of the advantages of working in a rural hospital is that senior doctors have the time and patience to teach you unlike the competitive, hierarchical atmosphere of a city hospital.

You get chances to visit patients at home.

 

Every doctor should try this. If you visit your patients occasionally at home then you immediately understand what is making them sick and you realise that many conventional remedies are quite foolish to say the least. Practicing medicine also becomes a challenge when you realise that most patients can't read time, read labels or even begin to understand the nature of the medicines you prescribe.

You work with a dedicated, highly skilled team.

The health workers at Sittilingi are all drawn from the local villages and are predominantly from the Malavasi tribal community. I have never seen more competence and dedication. Our neonatal unit has a high success rate only because of the energy put in by our health workers in 24x7 one on one care of sick babies.

Things get scary occasionally.

A city boy like me had to get used to the occasionally enormous, allegedly poisonous spiders that used to sit nonchalantly on my cupboard door. My room was closest to the forest and a sort of immigration desk for snakes, scorpions, spiders and suchlike.

You learn about a different culture.

 

Living in Sittilingi meant I also saw a part of India I missed in the city. Pongal is one such amazing festival with anticipation building up for months before the actual date and the actual festivities being dissected for months thereafter.

You become family.

Being on duty 24x7 for a month at a stretch means you really get to bond with your staff. We worked, lived, ate and joked together and there was never a time when my inexperience and bad Tamil got them visibly  impatient. Here they pose with the newborn of another fellow health worker they helped deliver. Their pride in their work is obvious.

Come together, right now

I have just finished attending a workshop by the International People's Health University on 'Health and Equity', where for nine days we concentrated on understanding the growing difference between the health of the rich and poor, the economic and political forces that are causing this and the social movements that have arisen as a response to this. Most participants had years of experience working for health at the grassroots level and their shared stories contributed to making it the workshop a rich experience grounded in practical realities.

The course helped us link what many of us witness as local phenomena to the much more distant economic and political arena. This can be a discomforting connection at times once you realise that as an individual you are quite powerless against such distant, undemocratic institutions such as large corporations and international bodies. This was the point in the course where the answer to such an essentially political problem emerged.

In an era when economic and political decisions made by big businessmen and our politicians have a large influence on both our individual health as well as the health of the communities we belong to, the only protection against bad, corrupt decisions is community organisation. If communities come together from the street to the global level in order to monitor the decisions our leaders make, only then we can protect ourselves from the decisions that are detrimental to our health and lives.

What do I mean by community organising? This video says it much better than I ever could.

Miscarriage

A curtain of rain separates
My verandah from the hospital.
On any other day a hundred
Silent patients would pass through
The OP clinic. Each of them
Allowing us doctors to listen
Feel, touch and question them.
The warmth of their fever would
Make us uncomfortably hot.

Today the air is chilled downpour wet.
Water roars in the stony river.
Five nurses, Gi and I sloshed
Through muddy puddles to witness
Our stream in full spate.
Only one desperate couple managed
To make it on the early bus.
Wanting an abortion.

Kutti Thambi Chinna Doctor

He died five hours ago.
A small boy of three.
Looked so still and limp.
His family wailed.

His house is a few fields away.
His aunt works in our hospital.
He was born here.
He died at home.

He had a fever.
He vomited for three days.
His mother took him to a
Local traditional practitioner.

Our ambulance was called.
He stopped breathing before it came.
Tha held the mother.
And both were disconsolate.

His name is not tomorrow.

Poem in a car

Imagine if this poem was fashionable.
And was found in a book of fashionable poems.
Read by fashionable people in fashionable cars.

Then the name of this fashion will be
Fair fashion. And it will be fashionable to be fair.

To be fair one would need to look at the paper
On which this fashionable poem was written.
And wonder whether the paper is fair as it is
fashionable.

Who cut the tree to create a fashionable poem's paper?
Whose tree was it anyway? Does she read
fashionable poems?

Who sat in the car in which the fashionable poem was read?
Should we wonder whether the car is fashionable as it is fair?

Who mined the earth to create a fashionable car's body?
Whose earth was it anyway? Was he ever in a fashionable car?

Blood toads

We deliver babies here
In a spew of blood and amniotic fluid
That splashes on our feet
Seeps into our cuts and crevices
And does daily battle with immunoglobulins
Yet the worry of contracting Hep B or HIV
Does not seem to worry the blood toads
Fat amphibians of the labour cot drain hole
Whose eyes shine at the most recent surge
Of human fluid.

Will today bring a rare gush of O Negative blood?
Will it send them scampering over the floor?
Student nurses in vain set after them
Scattering carefully stacked urine sample bottles
And a patient’s husband rushes to Salem
To buy injections that cost him two months earnings.

At night the new mother dreams
Expensive Anti D Ig courses her veins
Tiny lips suckle her breast
A multitude of pale green toads
Spawn nourished on her blood
Invade the ward hungry for more
A fresh red river flows from her uterus
Which is lax in terror.
She awakes screaming.

The junior night duty nurse runs
She awakens a thin tired doctor
The patient is shifted to the labour cot
Methergine soon flows into her veins
The now contracting uterus
Pushes out a kidney tray full of blood
Half a litre of gelatinous clots
More nourishment for the blood toads.

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.