11 July began like any other Monday in KG Halli, meant to be a quick review of the last week and a plan for the one to come, but unfolded otherwise. We were interrupted by a phone call from Bharatmata slum; and another, and a third, until it became clear that we needed to be there soon. The information was that Juliet who had gone underground since her last ANC check-up, had surfaced, and the entire community was on the alert. They had seen our team go to unusual lengths trying to track her, and wanted to help.
So three bus stops and fifteen minutes later all five of us reached Ms. Pakyamary’s place and I met the young woman for the first time. Of indeterminate age, the right side of her face twisted and swollen with an infected tooth, she seemed the epitome of fear and misery. Juliet is well under five feet and looks as though a mild breeze will blow her away. Under the ‘dupatta’, the small swelling of her belly is barely visible, and surrounded by a group of loud and angry women, she was led to the small Jesus and Mary shrine nearby. A feature of this urban area are the small Christian, Hindu and Muslim shrines, where the old and infirm sometimes rest and shelter.
One more day in the field – and a million more questions
The first minutes were volatile, with the voices of many angry women creating a raucous backdrop to a highly charged scene. Ms.Pakyamary herself, a powerful local leader was loud in her accusations, asking why Juliet had “run away” and proved so elusive. She , of the soft voice became totally silent, when faced with all the questions. Finally, everyone departed, the local ladies to their chores, two team members for school permissions and two others for medicines and antibiotics for our patient. Antu and myself stayed on, and we tried to gently question and piece the story of the last two months together. Extracting information from this young woman was a huge challenge. We listened,cajoled,advised, entreated, listened some more…….. in a vain attempt to understand her actions.
It appears that this young lady is truly abandoned, she does not know where her mother is, her brothers are incommunicado (no one would admit to knowing them when enquiries were made in the area) and her equally young husband is addicted to drugs. She said her mother-in law fed her dosas this morning and told her to leave the house ……..
When faced with the question of what to do next, she seemed really clueless, at a term pregnancy with an intra –uterine growth retardation, and severe anemia, strangely uncaring but very fearful of the future. From bursting into tears and begging Antu to stay with her in hospital to stubbornly refusing to go back home, we had glimpses of a young child who has never known security and been driven by fear from one life-event to the next. She has spent much of her young life on the road, I suspect. Finally she agreed to wait there while we bearded the lion in the den…….her mother in law who had already given the team a mouthful.
This stalwart, mother of eleven children ( “I have buried five of them”) also appears of indeterminate age, albeit older than Juliet. Life is clearly an immense struggle, a drunken husband lolls on the bed, crying over the loss of the last child who was stabbed in a brawl two months ago, and her voice rings true as she describes the hard work and hunger that haunt her days as a rag picker. She is a survivor; when she speaks, I can see where the Tamil films get their salt –of-the-earth heroines from. After sometime as she repeats herself and her outrage at Juliet’s behaviour, it turns surreal and I am not sure if this is art imitating life or vice-versa. Here is a woman who has very strong ideas on “mariyadaya” –respect- and the fact that women must do their bit…… “I give her little work” she says, “not like I had to do when I was expecting my first child”……..And her eyes fill with unshed tears “ I lost one daughter, she is like another –see I have saved hundred rupees even hidden from my husband, for her delivery”….. “ But how can she go out and claim I do not care”……The ego is hurt, that despite all she has been maligned.
Finally, after much listening and some persuasion, she agrees to look after Juliet if we talk to her.
And this is where we lost the thread. We descended back to the shrine thinking we had “fixed it”. Juliet started out accepting but once her mother in law entered with the accusations, she turned the offer away. “ I will go to my Anni”……an older brother’s wife who has not featured in the story till now. A figment of her imagination? Is she clutching at straws?
And we are left wondering afresh at our definitions of health – not merely the absence of illness, but the state of physical, mental and social well being – and their relevance in our daily work. How supremely satisfying it is to say ‘holistic care’ or ‘cradle to grave’ and then be given pause to think just because a young and very lost woman wandered into our life by becoming pregnant.
Tomorrow the team is going back to ask if she would like to deliver in an institution that might extend care in such a case as this. If they find her…………..
Is Juliet’s fear of going to a health provider justified?
Are health providers sensitive to an unusual patient like Juliet ?
Let us explore the Issues further
Juliet is 13 years old and married to Narayana who is 15 years old. She lives in a congested small house in Bharathmata slum. She was detected as pregnant in the month of January by Dr.Roopa/ Dr.Thriveni . As a follow-up task Anthu and the Community Health Assistants (CHA) have been repeatedly motivating her to undergo antenatal check up (ANC) but she has never yielded to suggestions given by our team. Whenever our team visited the slum they consistently motivated her but unfortunately it was similar to watering a barren land. Somehow she would always escape from our sight. To avoid our suggestions or accompanying her to the hospital there would be an answer that she was not at home, she had gone to her mother’s place etc.
We would discuss her in our review meeting and feel helpless of being unable to motivate her. We were in dilemma whether to give up or pursue her to visit the urban health center. At that point Anthu said –“No I will take her to the hospital”.
Anthu was spurred into action, along with Josephine she took Juliet to the public health maternity home. Taking Juliet to the hospital was not an easy task. Anthu and Josephine reached Bharathmata slum at 9.45 am and waited till 11.30 am to meet Juliet and lure her into accepting to visit the hospital. Even on that day Juliet played the same tricks, unwilling to attend the hospital. After an hour of restless waiting Josephine went to her home to fetch her. She found her at home completely disconcerned about her health and need to go to the hospital. After long hour of convincing, Josephine and Anthu took her to the hospital.
When they arrived at the hospital it was 12.30 pm, past registration time and the hospital staff refused to take her in. After explaining their effort in motivating her to have ANC, the nurse agreed to allow her in. She was taken to the registration counter and later to the nurse for general check-up. Here the nurse collected general information about her family, marriage and occupation of her husband. When the nurse realized Juliet was 14 years old she made fun of her saying “What is your age, do you want a pregnancy at this age?” the rest of the staff started laughing at this remark. In addition, while gathering this information, the tone of the nurse was authoritative and insulting, this behaviour of all the staff made Juliet feel as though she had done something wrong. When Josephine felt the situation was getting out of hand, she intervened to tell them “Please do not insult and laugh at her, with great difficulty we have brought her for ante natal check up”.
Meanwhile she had completed blood and urine test including BP and weight check-up. All the results showed her to be a high risk patient (wt is 34kg, BP100/60, HB is 8.0gm). Later she was taken to the doctor for further checkup. The young interns visiting the maternity Centre realized this was a risk pregnancy and refused to do further check-up. Juliet waited for the senior doctor, who referred her to Bowring or Ambedkar for further tests like scanning and PPTCT.
Either a teenage pregnancy, or adult pregnancy, the responsibility of the public providers requires sensitive attitude at least towards unusual patient like Juliet. An insulting attitude of the public health staff induces fear among teen agers to get ANC. My perspective is strongly supported by Juliet’s view about the hospital and its staff. She told us that she was scared of going to the hospital since she had heard that they would be rude towards teenage pregnancy. With this attitude how can one expect the community to have trust in public health providers?
On one hand there is the community with no trust in public health services, and on the other handwe have public health providers with de-sensitized behaviour towards the community. This is a huge challenging for us.
Not how, but we are constantly exploring the ways and means of building the trust between the community and the public health providers!!!!!!!!!!
Institute of Public Health
The Bharathmatha slum community was facing a huge garbage problem. There was incomplete garbage collection in the area which had given rise to multiple health problems to the community. The IPH team working in the urban health project decided to meet health inspector to discuss this issue and find solutions to help the community at KG halli.
During our meeting with the health inspector, he explained that there were issues with the timings of garbage collection in the area. The garbage collectors (Pourakarmikas) would come early in the morning, when it was inconvenient for the community to hand away the garbage to them.
As a follow-up of this, the IPH team decided to bring the community representatives and the municipality of the area together for a discussion. A meeting between 40 community representatives and BBMP senior health inspector Mr.Rayappa was arranged.
During this interaction, community members articulated the problems they were facing in respect to garbage collection. These problems were that the Pourakarmika workers would come only once in a week and days when these workers would not come the garbage would be thrown outside.
Addressing their problems, the health inspector promised that 2 pourakarmikas will be posted for the area. He also promised that he would ensure that the garbage will be collected twice a day. Further ahead, he requested the community members to handover the garbage to pourakarmikas and not through it outside.
In the same meeting, the community representatives brought up other issues which they were facing on an everyday basis in the locality. These problems were improper cement road, inadequate water supply, bad drainage facility, and many others. Responding to these issues, the health inspector Mr.Rayappa proposed that in the forthcoming month a meeting including community members, representatives from BWSSB,( Bangalore water supply and Sewage Board) AE,( Assistant Engineer) MLA(Member of legislative assembly) and Councilor will be planned. This meeting would provide a platform for the community to interact with higher officials and put forth their grievances to be addressed by all.
One of the objectives of the urban health project is to facilitate a process to bring the community and government officials together on one platform. This activity would motivate the community members to discuss their problems and grievances directly and we anticipate this to be heard and addressed by the government representatives positively.
Blog posted by : Munegowda C.M.
The most exciting day of my undergraduate life at medical college was the day when I put the stethoscope on a patient’s chest and asked ‘can you take a deep breath’. Through the years at college, life completely revolved around patients and their diseases. In fact, our introduction to clinical medicine focused on comprehensive details that a student was expected to procure from patients during the course of history taking and clinical examination. To fare well in exams we were instructed to examine as many cases as possible and memorize exhaustive details of the innumerable diseases infecting people and populations.
The wait for us, would always be for an exotic disease like Kawasaki disease or a Marfan’s syndrome. The early morning walks, cancelled classes and evening tea times, would be filled with excited discussions on eliciting a particular murmur or a classical sign of the rare disease. Word would spread around and the spot light would suddenly dawn on patients infected with the rare diseases. Herd of students would bombard the patient with never ending questions trying to match the disease features to that as mentioned in ‘Harrison’ or ‘Bailey and Love’.
Looking back today, I try to reflect upon what I learnt 10 yrs ago. The search was always for something that was new, unknown and unheard of. I wonder how different would have been my learning if I was taught to ask patients some fundamental questions like ‘how far did they had to travel to reach hospital? Or ‘how could someone who struggled to earn 3 meals a day was able to pay medical bills running in thousands’ and ‘in quest of becoming healthy, how poor had they become?’.
From Reorientation of Medical Education (ROME) scheme in 1977 which aimed at developing medical doctors for the rural poor to the Vision of Medical education in 2015 which envisages creating a basic doctor, physician for first contact of urban and rural community, I see major changes. These have been mainly on the duration of the course, the curriculum and the delivery of the subjects. In every effort to transform medical education, the larger objective has always been to expose the medial undergraduates to the community, to provide insights into field realities of the country. But the conversion of this objective into action has been only through posting them into rural health facilities, sometimes during the course and some as interns.
What would multiple pages of a case sheet with in-depth information of the disease mean to a woman who is wondering what went wrong with her healthy son, the only earning member of the family?. She runs from pillar to post in a completely unfamiliar environment trying to follow and fulfill every instruction of a busy doctor, who cannot devote few minutes to explain why her son was so much in pain. I wonder which subject or part of medical life sensitizes medical students to the pain, sufferings, fears and anxiety of patients and their families.
The focus of medical education needs to shifted from treating the disease to treating the patient. While signs, symptoms, investigations and treatment are all vital, the situation and the context of a patient’s life are most fundamental to understand and internalise.
I am constantly in search of students who while can rattle out causes of maternal deaths, can also ask questions like why did the ANM discriminate the mother while providing ANC care? Why was the medical officer attending to private practice during duty hours? Why did the health facility fail to provide ambulance when it was most required?
I wonder when the search will ever come to an end.
Blog by: Dr. Kavya R
Another day in the field, accompanied by community health assistants (CHA) we started walking under burning sun for house visit. We visited few houses and left with many questions. But one of the issues made me think who decides when wife becomes mother??
CHA’s took me to Mumtaz (name changed), young charming pregnant ladies house to talk because she had history of previous two abortions!!! When asked about the incident and on further probing it seemed like something was not normal. She was enthusiastic to talk and show all the reports and prescription but could notice some inhibition to talk about abortion. We didn’t want to hurt her emotions, so left that issue and advised to go for regular check up and started talking to her neighbor.
It was her neighbor who gave an insight into the hidden side of the story, which raised many questions about wife’s freedom/choice, ect. The previous abortions were induced by her husband without the wife knowledge because he was not ready to be a father!! Did Mumtaz share the same feeling?? Nobody asked her nor her husband thought it was necessary to tell her before giving those medicines. The simple question anyone would ask is how he did that…it is so easy to buy medicine over the pharmacy counter and asking wife to take it, who has no clue what it may do to her unborn child!!!
My feeling was that she had no regrets or pain for that incident other than wanting to hide it from us. I felt she has accepted it without questioning because she choose her partner without her parents’ consent and now she has no support from both the families. We had nothing to say except that we are like your family please feel free to come and talk to us whenever you feel like.
Can this be a reason for husband to abort her baby without her knowledge or because he is not ready to father a child? Why people think that abortion is the easier way to prevent a child than to use contraceptive?? Is it a lack of knowledge? Should it be so easy for anyone to buy medicine over the counter and misuse it?? Who has to be blamed for this-system or the socio cultural aspect or male dominance in the society??
And what is the whole story??
Government hospitals in Tumkur district are facing shortages of drugs today. This was an issue that emerged during a recent field visit to the district in mid-April by the Institute of Public Health (IPH), Bengaluru. While most primary health centres and taluka hospitals are facing shortages, it is the district hospital that continues to suffer the most. This is a problem resulting from the interplay of many factors. Since last year, 100 percent of drugs are being provided by the State government. However, the alleged clampdown on procurement of drugs by the Lokayukta in June 2010, expiry of contracts of pharmaceutical firms and increased allotment of 24×7 PHCs have led to inadequate supply of drugs to the peripheral health facilities which in turn has translated into increased costs for patients. In Tumkur district, around 60% of the allotted drugs only were supplied last year. The remaining budget which lapsed in March 2011 amounts to nearly 1.4 crore rupees. The total shipment was distributed by the district drug warehouse to the PHCs, taluka hospitals and the district hospital based on their indents.
Initially when the required indent was supplied in less quantity, it was mainly the higher antibiotics that ran out of stock. However, now even basic tablets like ferrous sulphate (iron tablets), oral contraceptive pills and Paracetamol have run out of stock. This has made it difficult to provide treatment for minor illnesses, routine antenatal care services to pregnant women, and management of emergencies. To tide over acute crises, the district drug warehouse dipped into its buffer stocks to help provide at least essential drugs to the peripheries. The health centres for their part have been using their Arogya raksha samiti (ARS) fund and untied fund to procure drugs mainly from Janatha Bazaar. Drugs procured this way are purchased at a much higher rate and hence, in lesser quantities than actually needed. Smaller centres like PHCs have still been able to manage but larger institutions like the district hospital is struggling to provide affordable care to its patients as its supply fell short by around 45 per cent (approximately 35 lakh rupees).
Apart from Janatha Bazaar, private pharmacies have also been benefitting from these shortages. While the exact numbers are not available, some PHC medical officers when interviewed state that the number of private prescriptions issued has increased greatly in view of non-availability of common drugs at their centres. This situation has caused more inconvenience to patients and the community has been quite vocal in expressing their dissatisfaction with the health services. Some ANMs expressed concern for poor patients, especially pregnant women and children who mainly rely on government hospitals for care. They stated that for acute conditions patients are still able to purchase short course of drugs from private medical stores, however, the seriously ill patients and the chronic patients that are suffering the most as drugs like Inj.Cefotaxime are short in supply in government hospitals. Without oral contraceptives or intrauterine contraceptive devices being available, the staff is unable to provide family welfare services to the community.
Hence, the drug supply problem in the government health sector needs to be immediately looked into. Diverting funds meant for maintenance of infrastructure or procuring necessary equipment to purchase drugs may temporarily control the drugs problems but will only lead to provision of poor quality of health services at the government health centres.
Dr.H.Sudarshan, Chairman of the Task Force on Health & Family Welfare, accompanied the IPH team during their recent visit and discussed this issue with health staff from the district & taluka levels in Tumkur. He explained that the Lokayukta had tightened the drug procurement procedures in order to check irregularities in the system, however looking at the situation in the district, it appears that the anti-corruption measures are also worsening the credibility and quality of government health care services. Since this is a state wide problem, a similar picture could be expected in the remaining districts.