Research | Page 10 of 13 | Institute of Public Health Bengaluru

Three lives lost in a month!

As a researcher, this was another day of visit to KG Halli in our long series of interactions with the community, but this particular visit was critical from research and humane point of view. I had gone to to meet three women who had lost their babies recently. I was a bit apprehensive to go and talk with them though they had expressed interest to meet me. This was perhaps e my previous experience of feelings of helplessness when a woman had broken down narrating her story in a similar situation and the research team could only console her at that time.

I followed Leela (the community health assistant) to Ms Shagufta’s house in KG Halli. We got a warm welcome and we all sat on a mat on the floor. After an initial chat, she gave me a plastic carry bag with many sheets of paper in it. The ultrasound report stated intrauterine death (IUD). On further questioning, Mrs Shagufta shared that she had been to the nearby Maternity Home and the doctor had advised her to go to “big hospital” but she along with her husband took the decision to wait for two days and then see…… She visited the same doctor after two days, but it was too late!!! One wonders, if the baby could have been saved if the reason for referring to the bigger hospital was explained to the mother? or the consequence of delaying visit to “big hospital” was communicated properly?? Do the doctors in public hospital
have so much time considering the work load?? Or should they be spending few minutes if the case is complicated? Not sure where and what went wrong but the end result was one life was lost which was preventable!

We walked through the Bharathmatha slum and reached Ms Vimla’s house. Her house was a contrast to the surrounding area that was neat and things in the house were well-arranged.. While talking I could feel her frustration when she said in-spite of doing everything what the doctors had suggested, I lost my baby! This happened in one of the private medical colleges/hospitals, where she went for regular antenatal care (ANC) visit—that too every 15days as advised by the doctors for monitoring her blood pressure. All she knew about the reason for baby’s death was that due to her high blood pressure the baby was choked to death. She attributes the sudden rise in her blood pressure at that time to witnessing the death of women in labor opposite to her ……this in a way raises questions about the atmosphere women deliver which is supposed to be the one of the best moments of their life!! Are the concerned staffs in the labor ward even aware of the impact of this situation on women in labor pain? ………….I had no exact answer when she asked why did my baby die after half an hour of birth?

With many un-answered questions for possible reasons for death of babies, we walked to Ms Salma’s house. Met this young charming girl sitting next to her first child….her sister in law joined us….whom we knew very well so the talk went smoothly……it was obvious that this young mother had terrible experience while in the labor ward… one of the secondary public hospitals in Bangalore. She said she was shouted at for going there while in labor and was told “if things go wrong we are not responsible”…It is difficult to understand whether secondary hospitals should concentrate more on referred cases/complicated cases or on ANC? Or is this a way shying away from responsibilities and accountability?? To add to this, money was demanded by the aaya….she was repeatedly slapped during the process of delivery….constantly and repeatedly told not to scream if she did so the baby would die…finally it reaches a stage where the aaya sits over her chest to “PUSH” the baby. The out-outcome of all this torture was a still birth!! She had lot of praise for the doctor’s attitude but she said it was nurse and aays who were rude …but are the doctor not supporting this kind of behavior by not addressing and turning a blind eye to it ? Or are they helpless to address this? Is this not part of basic quality of care? The young mother goes through this stressful experience and lives with guilt of killing her own baby by screaming and she shared her decision that -“ I will NEVER go to hospital for delivery”. This time I had an answer to her question – the baby did not die because you screamed while in labor pain! Though I did not have immediate answers in the first two episodes, I feel that sharing the ‘unresolved’ and ‘unaddressed’ issues and concerns of the community would go a long way to actually resolve them and prevent future deaths.

Please note: Names are changed to protect privacy.

Dr Thriveni B S

Social exclusion/inclusion : Public health seminar

Social exclusion/inclusion : Public health seminar

IPH (Institute of Public Health) & ITM (Institute of Tropical Medicine) are partners in the Health Inc project. Werner  Soors elaborates on the development of the SPEC-by-step tool for layered analysis of social exclusion in health. Tanya Seshadri shares a practical example where  the tool is pre-tested on the preliminary data of an ongoing RSBY (Rashtriya Swasthaya Bima Yojna) WHO-Alliance study.

Date: 18th August 2011

The full presentation can be downloaded here (3Mb)

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Part 1
SE seminar image 1 exclusion
The twinned concepts of social exclusion/inclusion
We introduce the concepts of social exclusion, specifically social exclusion in health, and the interaction of social exclusion and inclusion. For the latter, the Indian example of reservation serves as an example.

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Part 2
SE seminar image 2 SPEC-by-step
Development of the SPEC-by-step tool
We develop the SPEC-by-step tool: a generic, structured checklist to provide guidance for analysis of social exclusion in social health protection programmes. We take you through each level and step of the tool.

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part 1

part 2


Part 3

SE seminar image 3 RSBY
Pre-testing the SPEC-by-step tool on an existing dataset

We exemplify the SPEC-by-step tool as an eye-opener by starting to apply it on the preliminary data of an ongoing RSBY WHO-Alliance study. (A cautionary note: preliminary unclean data is utilised for this example to understand application of this tool and is not related to the ongoing RSBY WHO-Alliance study)

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The end to a challenge and a new beginning for urban health Team!!

Call it the light at the end of the tunnel, or the pure relief that comes when the hoped-for, unexpected unfolds; but the urban health team experienced the adrenaline rush that goes with all this on August 8th at KG Halli’s community centre as we gathered for the first meeting with the health providers in the ward.

As the community links have strengthened over time, the household survey has moved steadily and imperceptibly into home visits, and contacts with schools and sanghas have regularised. The challenge was now to rope in the doctors in the area, both public and private providers on whom the 40 thousand odd people living there depend on for their health needs. Our initial meetings had revealed around 25 practitioners in the clinics and 4 hospitals, with a wide range of training from Allopathy to Ayurveda to Unani, and including alternative healers using natural remedies, a physiotherapist and counsellor.

Over the last two weeks we had met most of these practitioners and explained the direction our research was taking. We also invited them for a meeting at the community centre in Vinobhanagar, at the heart of ward no 30. Interestingly, we received no negative response; everyone said they would try to come, and the time was fixed for 3pm-4pm, as best suited the doctors. This, despite the fact that the fasting of Roza has begun for the predominantly Muslim community.

At the IPH  end, now started fairly intense preparations for this event. For the team it was the first time we were trying to explain our work to the doctor community. Even for the public health specialist, “action research” needs explanation, and the “platform” sounded nebulous to our own ears as we rehearsed. But the process of preparing for this meeting was such a joy and a challenge. Upen had put the skeleton of the survey results onto powerpoint, but as we progressed, discussing what we wanted to convey to the audience, the presentation came together. The red thread was kept tight by Thriveni , little details came from Amrutha , I brought in  a story for perspective  and Antu, Nagaratna, Leelavathi and Josephine brought the raw power of their field experiences, which we practised to a polished 30 minutes.

Munna came in with all the arrangements for the meeting (including the photo credits!) and by 2.30 pm we were awaiting our guests. We had already swallowed our disappointment when, over the weekend, our good friend and colleague from the UHC, Dr. Anantalakshmi had informed us that she had been transferred and could not attend. The other government centre, the CHC had also a prescheduled meeting, but Upen and I decided to make one last effort to meet Dr. Mangala, the doctor in charge. We were richly rewarded in that a young doctor Dr. Shweta was deputed to come, overcame her reservations and arrived at the meeting.

At this point, between 3 and 3.20 pm I must confess to having kittens, as we waited ….and waited….and waited. But soon, they started trickling in and by 4 pm we had seven guests, seated comfortably on the mats, and we closed the door on the pouring rain flooding the balcony, and started to share. It was remarkable how intense the meeting was, how carefully the practitioners listed to the team’s findings, and towards the end, how interactive the session became. The community workers voices had that note of passion and truth and their confidence had the audience listening. Equally remarkable were the guests, from the wisdom and hope of  Dr. Aftab , to the clinical expertise of Dr. Kulkarni, the participation was complete. Dr. Shweta stayed on well past her working hours with great attention and interest, her husband who came to pick her up was kind enough to wait until past 5 pm.  The presentation had focused on the findings of the survey, but the discussion took off, and as someone commented, we were all on the same page………….improving health care, concern for the poorest, how to share expertise and resources………..these were the topics around which the talk revolved.

Some very encouraging quotes from both the meeting and the IPH debrief later, may give you a sense of what transpired.

… “ I never thought it would happen at 3 pm……….but the meeting was much better than expected”

…. “ Even if few people came, it gave us the chance to get to know them and talk with ease”

…. “ Now that we know we have all these resources available , we can actually make health care happen for the community”

….. “ We must have meetings  like this every month, they are very informative”

….. “ It was a suuuper meeting!!”

….. “ There is lots of work ahead , but that was the point of all this, is it not?”

So where do we stand today? Surely able to answer our colleagues who have been asking with understandable impatience “Will you ever get a platform?”….in the affirmative. And ready to take the first step which is always the beginning of every journey, however long.

-Roopa Devadasan

ಬದಲಾವಣೆಗೆ ನಿಲುಕದ ಅ೦ಗನವಾಡಿ ಟೀಚರ್

ವಾರ್ಡ ಸ೦ಖ್ಯೆ ೩೦ರಲ್ಲಿ ನಾವು ಸುಮಾರು ಎರಡು ವರುಷಗಳಿ೦ದ ಕೆಲ್ಸ ಮಾಡುತ್ತಿದ್ದೇವೆ, ನಮ್ಮ ಗುರಿ ಸಮುದಾಯದ ಆರೋಗ್ಯದಲ್ಲಿ ಗುಣಮಟ್ಟ ತರುವುದಾಗಿದೆ. ಈ ವಾರ್ಡನಲ್ಲಿ ಭಾರತಮಾತ ಸ್ಲ೦ ಇದೆ, ಅಲ್ಲಿ ಒ೦ದು ಅ೦ಗನವಾಡಿ ಸಹ ಇದೆ. . ನಾವು ಕೆಲಸ ಮಾಡುವ ಸ೦ದರ್ಭದಲ್ಲಿ ಆ ಅ೦ಗನವಾಡಿಯು ಸರಿಯಾಗಿ ಕೆಲಸ ಮಾಡುತ್ತಿಲ್ಲ ಎ೦ದು ಗೊತ್ತಾಯಿತು.ಮಕ್ಕಳು ಸಹ ಆ ಕೇ೦ದ್ರಕ್ಕೆ ಸರಿಯಾಗಿ ಬರುತ್ತಿರಲ್ಲಿಲ್ಲ, ಬದಲಾಗಿ ಅಲ್ಲೆ ಪಕ್ಕದಲ್ಲೆ ಗ್ರೇಸ್ ಸ೦ಸ್ಥೆ ನಡೆಸುತ್ತಿದ್ದ ಅ೦ಗನವಾಡಿಗೆ ಮಕ್ಕಳು ಹೋಗುತ್ತಿದ್ದರು.  ಅ೦ಗನವಾಡಿ ಸಹಾಯಕಿ, ಅ೦ಗನವಾಡಿ ತೆರದು ನ೦ತರ ಅಕ್ಕಪಕ್ಕದಲ್ಲಿ ಮಾತನಾಡುತಾ ಕಾಲ ಕಳೆಯುತಿದ್ದರೆ, ಟೀಚರು ಸುಮಾರು ೧೧.೩೦ಕ್ಕೆ ಬ೦ದು ಶಾಲಾಪೂರ್ವ ಚಟುವಟಿಕೆಯನ್ನು ಮಾಡದೆ ಕೇವಲ ದಾಖಲಾತಿಗಳನ್ನು ಬರೆದು ಮನೆಗೆ ಹೋಗುತ್ತಿದ್ದರು. ಮಕ್ಕಳಿಗಾಗಲಿ, ಗರ್ಭಿಣಿಯರಿಗಾಗಲಿ ಪೌಷ್ಟಿಕ ಆಹಾರಗಳನ್ನು ಸಹ ಕೊಡುತ್ತಿರಲ್ಲಿಲ್ಲ. ಅ೦ಗನವಾಡಿಯ ಪಕ್ಕದಲ್ಲೆ ಕಸಕಡ್ಡಿ ತ೦ದು ಹಾಕುತ್ತಿದ್ದರು ಅದಕ್ಕೆ ಏನು ಕ್ರಮ ತೆಗದುಕೊ೦ಡಿಲ್ಲ. ಅ೦ಗನವಾಡಿಯೊಳಗೆ ಇರುವ ಆಹಾರಗಳು ಹೆಗ್ಣಗಳ ಪಾಲಾಗುತ್ತಿತ್ತು.

ಅ೦ಗನವಾಡಿಯು ಸಮುದಾಯದ ಅವಶ್ಯಕ ಸೌಲಭ್ಯವೆ೦ದು ನಮಗೆ ಅನಿಸಿತು ಹಾಗಾಗಿ ಇಲ್ಲಿನ ಪರಿಸ್ಥಿತಿಯನ್ನು ಬದಲಿಸಬೇಕೆ೦ದು ನಾವು ಟೀಚರೊ೦ದಿಗೆ ಸುಮಾರು ಸಲ ಮಾತನಾಡಿದೆವು, ಆದರೇನು ಅ೦ಗನವಾಡಿ ಸುಧಾರಣೆ ಆಗಲಿಲ್ಲ. ಟೀಚರು ತನ್ನ ಸಮಸ್ಯೆಯನ್ನೆ ಹೇಳುತ್ತಿದ್ದರೆ ವಿನಃ ಆ ಸ್ಲ೦ನಲ್ಲಿ ಮಕ್ಕಳು ಸೌಲಭ್ಯಗಳಿ೦ದ ಎಷ್ಟು ವ೦ಚಿತರಾಗುತ್ತಿದ್ದರೆ೦ದು ಕಿ೦ಚತು ಭಾವಿಸಿಲ್ಲ. ನಾವು ಅವರ ಸಮಸ್ಯೆಯನ್ನು ಸಹ ಅರ್ಥಮಾಡಿಕೊ೦ಡೆವು, ಆದ್ರೆ ಅವರು ಒಬ್ಬ೦ಟ್ಟಿಗರು ಮತ್ತು ವಿಧವೆ ಎನ್ನುವುದು ಬಿಟ್ಟರೆ ಬೇರೆ ಸಮಸ್ಯೆಗಳೇನು ಇರಲ್ಲಿಲ್ಲ. ಯಾವಾಗ ಅವರೊ೦ದಿಗಿನ ಮಾತು ಪ್ರಯೋಜನವಾಗಲ್ಲಿಲ್ಲ ಅವರ ಅಧಿಕಾರಿಗಳಿಗೆ ೨-೩ ಸಲ ಬರವಣಿಗೆಯ ಮುಲಕ ವಿಷಯ ಮುಟ್ಟಿಸಿದೆವು.ಅವರು ಸಹ ಯಾವುದೇ ಕ್ರಮ ತೆಗೆದುಕೊ೦ಡಿಲ್ಲ. ನ೦ತರ ಸಮುದಾಯದವರೊ೦ದಿಗೆ ಮಾತನಾಡಿದೆವು. ಸಮುದಾಯದವರೊ೦ದಿಗೆ ಮಾತನಾಡುವಾಗ ಮತ್ತೊ೦ದು ಹೊಸ ವಿಷಯ ಬೆಳಕಿಗೆ ಬ೦ತು, ಒಟ್ಟು ೪೦ ಹೆಣ್ಣು ಮಕ್ಕಳನ್ನು ಭಾಗ್ಯಲಕ್ಷ್ಮಿ ಸೌಲಭ್ಯದಿ೦ದ ವ೦ಚಿತರಾಗುವ೦ತೆ ಮಾಡಿದರು  ಈ ಭಾಗ್ಯಲಕ್ಷ್ಮಿ…. ಟೀಚರು. ಇದರ ಬಗ್ಗೆ ನಮ್ಮಲೇ ಚರ್ಚೆಗಳಾಯಿತು ಮತ್ತೊ೦ದು ಸಲ ಅ೦ಗನವಾಡಿ ಟೀಚರ ಹತ್ತಿರ ಮಾತನಾಡುವುದೆ೦ದು ನಿರ್ಧರಿಸಿ ಅವರಿಗೆ ಮತ್ತೊ೦ದು ಅವಕಾಶ ಕೊಟ್ಟೆವು. ಅವರು ಸುಧಾರಿಸುವ೦ತೆ ಕಾಣಲ್ಲಿಲ್ಲ ನಮಗೆ ಅದೆ ಸಮಯದಲ್ಲಿ ಅದೃಷ್ಟವಶಾತ ಹೊಸ ಶಿಶು ಯೋಜನ ಅಧಿಕಾರಿ ಬ೦ದಿದ್ದು ಅವರು ನಮ್ಮೊಬ್ಬ ಸಹೊದ್ಯೋಗಿಯ ಸ್ನೇಹಿತರಾಗಿದ್ದು ಒ೦ದು ರೀತಿಯಲ್ಲಿ ಸಮುದಯಕ್ಕೆ ಅನುಕೂಲವಾಯಿತು. ನಾವು ದಾಖಲಾತಿಯೊ೦ದಿಗೆ ಅವರನ್ನು ಭೇಟಿಯಾದೆವು, ಪರಿಸ್ಥಿತಿಯನ್ನು ಅವರೆ ಬ೦ದು ನೋಡಿ ನ೦ತರ ಕ್ರಮ ತೆಗದುಕ್ಕೊಳ್ಳಬೇಕೆ೦ದು ಅವರಿಗೆ ಹೇಳಿದೆವು.

ಹೇಳಿದ೦ತೆ ಅವರು ಅ೦ಗನವಾಡಿಗೆ ೧೦ ಗ೦ಟೆಗೆ ಬ೦ದರು. ಅವರಿಗೆ ಅ೦ಗನವಾಡಿಯು ಯಾವ ಸ್ಥಿತಿಯಲ್ಲಿದೆ ಎ೦ದು ತಿಳಿಯಿತು, ನ೦ತರ ಮಹಿಳೆಯರೊ೦ದಿಗೆ ಗ್ರೇಸ್ ಕೇ೦ದ್ರದಲ್ಲಿ ಸಭೆ ನಡೆಸಿದರು, ಸಮುದಾಯದೊ೦ದಿಗೆ ಮಾತನಾಡಿದರಿ೦ದ ಅ೦ಗನವಾಡಿ ಟೀಚರಿ೦ದ ಎನೆಲ್ಲಾ ಸಮಸ್ಯೆಗಳಾಗುತ್ತಿದೆ ಎ೦ಬುದು ಅವರಿಗೆ ತಿಳಿಯಿತು. ಎ೦ದಿನ೦ತೆ ಆ ದಿನವು ಟೀಚರ್ ೧೧ ಗ೦ಟೆಗೆ ನೇರವಾಗಿ ಸಭೆ ನಡೆಯುತ್ತಿದ್ದ ಗ್ರೇಸ್ ಕೇ೦ದ್ರಕ್ಕೆ ಬ೦ದರು. ಲೇಟಾಗಿ ಬ೦ದದ್ದಕ್ಕೆ ಅವರ ಅಧಿಕಾರಿ ಕಾರಣ ಕೇಳಿದರು ತಕ್ಷಣ ಉತ್ತರ ನೀಡದೆ ಸ್ವಲ್ಪ ಸಮಯದ ನ೦ತರ ತನಗೆ ಆರಾಮ ಇರಲ್ಲಿಲ್ಲ ಎ೦ದು ಹೇಳಿದರು (ಹುರುಳಿಲ್ಲದ ಉತ್ತರ). ಟೀಚರನ್ನು ನೋಡುತ್ತಿದ್ದಾಗೆ ಸಮುದಾಯದವರು ರೇಗಾಡಲು ಶುರು ಮಾಡಿದರು- “ಇಷ್ಟು ವರುಷಗಳಿ೦ದ ಅ೦ಗನವಾಡಿ ನಡೆಸುತ್ತಿದ್ದೀಯ ಯಾವುದಾದರು ಒ೦ದು ಮಗುವಿಗೆ ನಿನ್ನಿ೦ದ ಅನುಕೂಲವಾಗಿದೆ ಎ೦ದು ಹೇಳು ನೋಡೋಣ”? ಇದಕ್ಕೆ ಅವರ ಹತ್ತಿರ ಉತ್ತರವಿರಲಿಲ್ಲ. ಸುಮಾರು ಸಮಯ ಚರ್ಚೆಗಳಾಯಿತು, ಅ೦ಗನವಾಡಿ ಟೀಚರ್ ತಮ್ಮ ನಡವಳಿಕೆಯನ್ನು ಸಮರ್ಥಿಸಿಕ್ಕೊಳ್ಳಲು  ಸಮುದಾಯವರ ಮೇಲೆ ಗೂಬೆ ಕೂರಿಸುತ್ತಿದ್ದರು, ಆ ಸ್ಲ೦ನ್ ಲೀಡರ್ ಅವರನ್ನು “ನೀವು ಹೊರಗೆ ಹೋಗಿ ಇದು ನಮ್ಮ ಸಮಯ ನಿಮ್ಮ ಸರ್ ಹತ್ತಿರ್ ನಾವು ಮಾತನಾಡುತ್ತೇವೆ ಎ೦ದು ಹೇಳಿದರು”. ಸಮುದಾಯದವರು ಈ ಅ೦ಗನವಾಡಿ ಟೀಚರ ನಮ್ಗೆ ಬೇಡ ದಯವಿಟ್ಟು ಬೇರೆ ಟೀಚರನ್ನು ನಮಗೆ ಕೊಡಿ ಎ೦ದು ಒಮ್ಮಲೆ ಕೇಳಿಕೊ೦ಡರು.ಅದರ೦ತೆ ಆಗಲಿ  ಎ೦ದು ಅಧಿಕಾರಿಗಳು ಒಪ್ಪಿಕೊ೦ಡರು.

ಸಧ್ಯದಲ್ಲಿ ಒ೦ದು ಒಳ್ಳೆಯ ಟೀಚರನ್ನು ಕೊಟ್ಟಿದ್ದಾರೆ, ಆದರೆ ಅವರು ಡೆಪ್ಯುಟೇಷನ್ ಮೇಲೆ ಬ೦ದ್ದಿದ್ದಾರೆ, ಆದಾಗ್ಯು ನಾವು  ಈ ಅ೦ಗನವಾಡಿಗೆ ನಿರ೦ತರವಾದ ಟೀಚರ ಬೇಕೆ೦ದು ಅನುಸರಣೆ ಮಾಡುತ್ತಿದ್ದೇವೆ.ಅದಕ್ಕೆ ಅಧಿಕಾರಿಗಳು ಒಪ್ಪಿ ಮು೦ದಿನ ಅಭ್ಯರ್ಥಿಗಳ ಆಯ್ಕೆಯಲ್ಲಿ ಹೊಸ ಟೀಚರನ್ನು ಕೊಡುವುದಾಗಿ ಭರವಸೆ ನೀಡಿದ್ದಾರೆ.

ಹಿ೦ದಿನ ಟೀಚರ್ ಸ್ವಲ್ಪ ಮಟ್ಟಿಗೆ ತನ್ನ ನಡವಳಿಕೆಯಲ್ಲಿ ಬದಲಾವಣೆ ಮಾಡಿಕೊ೦ಡಿದ್ದರೆ ೪೦ ಹೆಣ್ಣು ಮಕ್ಕಳು ಭಾಗ್ಯಲಕ್ಷ್ಮಿ ಸೌಲಭ್ಯದಿ೦ದ ವ೦ಚಿತರಾಗುತ್ತಿರಲ್ಲಿಲ್ಲ…., ಕೊನೆ ಪಕ್ಷ ಈ ಸ್ಲ೦ನ್ ಮಕ್ಕಳು ಸಾಕ್ಷರರಾಗಿರುತ್ತಿದ್ದರು…. ಸ್ವಸಹಾಯ ಗು೦ಪು ಅಥವ ಸ್ತ್ರೀ ಶಕ್ತಿ ಗು೦ಪುಗಳಿ೦ದ ಹೆಚಿನ ಮಹಿಳೆಯರು ಆರ್ಥಿಕವಾಗಿ ಸಬಲರಾಗಿರುತ್ತಿದ್ದರು…..

-Munegowda C.M, Amrutha and UHP team

Adolescents’ perceptions about smokers in Karnataka,India

Prevalence of tobacco use among adolescents in India is very high. Despite many epidemiological studies exploring tobacco use among youth, there is no published data on adolescents’ perceptions about smokers in Indian society and its implications on tobacco control.

Article type Research article

Authors : Upendra M Bhojani,Maya A Ellias,Devadasan N

Journal: BMC Public Health

Submission date : 8 April 2011

Acceptance date : 14 July 2011

Publication date : 14 July 2011


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Whose life is it anyway ?

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…………..

-Roopa Devadasan