For those who read my blog two weeks ago ( CP or CP) this is the promised second part attempting to explain why theory does not translate into practice in public health. This blog is not the result of a field visit like the last one, rather, a different approach dictated by my confinement by a viral fever. So, friends, read on……..
” We are as lost as our fellow surgeons in hitting the right plane,
in public health….Or are we knife shy?”
The opportunity to investigate this question of the preventive/curative divide in the health services of our country has presented itself, and I thought why not use the technological tool of the moment and ‘google’ it? And this is what came up on typing ‘preventive/curative divide’
The Cambridge social history of Britain 1750-1950, Volume 3 (click here)
Amazing how the root of the issue came to light at the click of the button! For those who don’t want to go to the link, the fact that our public health services are conceptually distinct from our medical services go back to our colonial past when the industrial revolution, and subsequent urbanisation resulted in epidemics. A pragmatic approach to preventing disease by sanitary measures in populations (Remember John Snow?) evolved , as opposed to the treatment of the individual patient. Over time, the latter became the dominant power in the practice of medicine, and the split between the preventive and curative approaches widened steadily in the early part of the twentieth century. These approaches, along with much else were probably exported to our nation at the time of independence. They took root, despite opposition and reflection and even infiltrated medical education. And until today we are unravelling the skeins in the way our health services are planned, run and held accountable.
And for those who prefer the shortcut, Dr. Devadasan talks about the artificial divide between prevention and cure, when he looked at a visit to a doctor from the point of view of the adivasi patient. Simply stated, there is no preventive or curative role, rather a simple desire to be healed.
So what does the adivasi patient see that the doctor does not? A mind uncluttered with ideas that divide will deal with treatment of the present illness as well as information on immunisation for the baby. Every interaction between the health service and community is optimised. But if the health service is fractured by its very structure, this is difficult, if not impossible.
So what have we on the ground ?
A doctor who manages the RCH programme, but has neither the infrastructure nor support (including drugs and lab services) to handle an epilepsy or a juvenile diabetic.
A busy hospital OPD for paediatrics, with personnel who have no time to ask the mother if she would like to delay the next pregnancy.
A group of ANMs fumbling with denominators for immunisation data, because the HMIS is not streamlined.
Overburdened tertiary services, because people just don’t know where to go?
I wonder when a concept can be recognised for what it is……. an idea that may be changed even after 60 years of doing things in a particular way. Or is it like the Emperor’s new clothes where we are too afraid to face the truth and all the work that might entail?
For those who are interested in how a concept can grow a life of its own,click here
-Prevention vs Cure- which takes precedence?
And finally, a ray of hope?
Consultation on History of Health Care in India: The Past in the Present Morarji Desai National Institute of Yoga, Dept of AYUSH in collaboration with WHO Country Office for India – click here
A recent visit to the offices of the local government health offices and the tertiary level hospitals confirmed what I had suspected for ages, after working in the field of public health for over two decades. There are two key reasons why our public health system is in shambles on the ground, despite India being one of the first countries to sign the Alma Ata Declaration. Briefly, the first is the completely top down approach of the government hierarchy and mindset of medical education. The second is the colossal divide between the preventive and curative wings of our health system. This article explores the first fact, the second I leave for another day.
Permit me to outline how the first operates in translating great planning on paper to a non-functioning apparatus in the field. The experience of these visits will be used to illustrate why, even if we straighten out the “systems”; integrated, holistic, affordable care will never be available to our one billion people, while our “experts” in the field hold conferences on achieving Universal coverage in New Delhi and Geneva.
In every document that outlines how the public health systems in the rural and urban areas should function, the interface with the population of responsibility is seen as being important. Obviously, people should know who they should rely on for health care, but experience has shown that it is equally important that the health care services should be responsible to the population they serve. The balance of this translates as a spectrum of community participation- from the lowest level where people are passive recipients of care to the highest level where communities plan, monitor and evaluate the services.
We strive to the latter goal. Let me clarify who ‘we’ are. As a team of researchers, trying to bring both private and public providers onto a platform with local community leaders, we have been working for two years with the local doctors and community members in a single geographic ward of the city. Time and again we have been struck by the warm hearted welcome in the homes, particularly the poorest. The home of a patient in the community may consist of a single room, 6 feet by 10 feet, in which a family of 2 to 8 members might live. Even so, in this room, where walking is restricted by the tiny space, there is no awkwardness in rolling out a mat or putting out the single foldable chair to make one feel at home. And with this single human act of trying to make the visitor feel at home, a relationship is established which dictates the future partnership.
Contrast this with the reception our team met with in the various offices we visited last month. In an effort to meet the officers in charge of the health services in the city, we hired a taxi and went from office to office, hopeful that someone in the system might be interested in what we were attempting. And everywhere the response was the same. More often than not, a waiting of 15 -45 minutes outside the room, a cursory invitation to enter, not necessarily to sit…a brief look up from the files to hear what we had to say. And before we had launched two minutes into our story , an interruption with “ So tell me Madam, what is it you want me to do?” as we shuffled on our tired feet.
The interesting fact is, in both cases (the patient with us and then us with the officer) the only need was to be listened to. But in the first, the community member has taken the proactive step of setting the stage for listening to happen. (I remember a senior physician who taught us in Medical College saying that sometimes the most important input for an inpatient on rounds is the doctor sitting by the bedside in order to listen to him or her.) And in the latter, a power equation that invisibly translates from officialdom – top-down. The assumption on the part of these authorities is that they already know what needs to be done, so your presence in their office could only be for audience, permission or financial aid. And undoubtedly, the stroke of a pen on a file changes the response down the line. A three minute brief at the Commissioner’s office got us the desired result.
So we were honoured by the visit of the officer-in-charge to the ward, at the behest of the senior authority a day later. The visit and her interface with the community workers can be best described in their own words. “Madam, when they learn to be big doctors and officers like this, are they not taught manners?”
So I conclude that while community participation and corridors of power are identical, mutually exclusive acronyms, like all health system reforms, work must happen at both ends.
The Urban health team had planned to meet officials at government health departments and at hospital superintendents to share our KG Halli area experience and figure out ways to work together. After our first “waiting day” stint in the corridors of government offices, we decided to visit the hospital staff next day. Since our 7 month pregnant community health worker Ms Leela had a problem, we asked her to come to the same tertiary public hospital for checkup
I followed Ms Leela to the door of the OBG outpatient department, where the lady gate keeper stood blocking the way. Normally (so Leela told us) only a ten rupee note is the key, but today took her blocked hands from the door to let us in. She asked only Leela to leave her slippers outside…”Why not me?” I wondered.. “Maybe I didn’t look like poor patient!!” Next Leela went to the nurse who was deciding where the patient should go. Sister pointed towards long waiting line of pregnant women and said “Go there”. That is when I intervened and asked “Why not in the next room where doctors with hardly any patients? She grinned at me and guided me forward.
Now it was Leela’s turn to follow me, I walked towards a doctor who was sitting with another senior, introduced myself as doctor and explained Leela’s problem. After a minute she looked at me..that look was like “Why are you standing here ?”….I continued to stand …after listening to Leela, the doctor said (without looking at me): “ We will see her … The unsaid message was “Why are you still standing here you can go” . I continued to stand…after few minutes looking away she said “ you sit”…I was not sure whether she was addressing me or someone else…. but there were no one around …so I presumed she addressed it to me and decided to sit comfortably on the chair!! She gave me a dirty look when I sat on the chair .. “May be she did not mean her words, I said to myself but this chair does not belong to her you don’t get up”. The senior doctor who was sitting opposite me gave a warm smile…wow that was such a nice feeling ……someone in that outpatient department smiled for the first time!! I decided to ignore that grumpy doctor (by then I had decided that doctor was an insensitive/inhuman lady!! ) and initiate conversation with the senior doctor.
Before I could initiate talk with the senior doctor, medical representatives started coming near her one after the other, and I got no time to talk. I was just observing all the activities around me…in that next 10-15 min..this grumpy doctor had told her students many times to.. “Go see my patient who was in the examination room”…may be she was not happy to see me next to her… but for some reason I stayed put …that gave me more time to observe!! Two incidents diverted my thought process from this grumpy doctor.
A lady with fifth pregnancy requesting help was told “We do not do abortion unless you want to go for permanent sterilization, either Tubectomy or current operation (Laparoscopic sterilization). If you do not agree then you continue with pregnancy”. When she said even her fourth child was not planned, the question rose in my mind whether she had been given information about contraception methods or were the doctors forcing women to go for sterilization because it is the easy option? I know with my experience of working with the Muslim community for some, it is against their cultural belief to undergo sterilization. Only educating about contraceptive methods works for many of them..but are the doctors aware of this and do they have time and patience to explain?
Another incident was more shocking and uncomfortable to witness. The grumpy doctor shouted at a young girl who looked not more than 14-15 yrs sitting quietly in the corner, “Why are you here ? Go out.” This young girl with a dazed look started walking towards this doctor…in the mean while the post graduate student said, “ Madam, her pregnancy test is negative”. But her tummy was saying something…and she was pregnant..5 months confirmed the grumpy doctor!
The next thing was in a loud voice doctor screamed “Who has come with you..you are pregnant, what you want to do?” She turned towards the senior doctor and said “UM” (unmarried) that was the code word!! The very next moment more than 15 pair of eyes…were staring at that young girl…I was trying to read that girls mind..but I failed…may be because her expression was so cold …I felt she did not know what had happened to her. Her sister in law came inside..grumpy doctor had two “VALUABLE” suggestions to make , very matter of fact and devoid of sensitivity.
(1) Carry on with the pregnancy and then give away the baby later….as if it was as simple as giving away book or pen to someone. I asked myself ‘Does she even know what she is suggesting?’.
(2) We can abort if the girl’s guardian, preferably male can come and sign for minor girl.
The sister in law who appeared to be in her later 30’s had no right to do so. ‘Who made this rule?’ I wondered ….I guess doctors decide on case to case basis. It was sad to witness the sister in law pleading with this grumpy doctor “Madam nobody in the house knows, if they come to know it will create lot of problem in the house, I will take responsibility and you please abort.” Her words fell on deaf ears, statues who sat with white coat and stethoscope around their necks with knowledge gained from medical books but lacking common sense or humanity.
A very interesting conversation followed after the young girl and sister in law was shouted at to leave and come with someone elder while I thought ‘30+ is not minor to consider as guardian for that doctor’. The senior doctor said “We didn’t have UM cases for some time, how come suddenly we are getting many cases?” Reply from grumpy doctor was… “May be this is the season”. Then they said “We should also do like private doctors…..…I was finding it hard not to ask what private doctors do? but I said to myself ‘the grumpy doctor who was giving dirty looks now and then will show you the way out, sit quietly’.
But the conversation continued and they revealed that in the private sector if an UM ‘case’ goes, they will not even say she is pregnant…. they will continue treating for anaemia till full term and then say she needs to be operated for some stomach tumor and give away the baby without anyone in the family knowing. By now I was in semi shock! When I heard this, I thought…does this really happen?’ I heard this story for the first time and could not believe my ears. And another thought came ‘Where the medical ethics has gone…Forget about ethics, where has the humanity of the individual gone…may be it is lost in the process of becoming so called white collared DOCTORS!’
The Bharathmatha slum community is facing a Basic Problems like drinking water, drainage, sanitation, Ration card, Improper Roads, garbage. The IPH team working in the urban health project decided to conduct grievance redressal meeting, to discuss these issues and find solutions to help the community at KG halli.
The urban health team organized the grievance redressal meeting on 28th 0ctober 2011 in Bharathmatha slum at Grace Centre, with the help of Mr.Chottu Qureshi (husband of councilor Mrs Shaheena Taj).
The meeting started at 12.45pm inviting the guests Mr. Chottu Qureshi, Ms.Bhargavi (Asst Engineer PWD) and Mr.Rayappa (senior health inspector, BBMP), and around 70 community representatives. Urban health team staffs were also present. Similarly Mr. Rayappa and other guests were welcomed. The purpose of this meeting was reiterated to the community. Then we requested participants to share their problems one after the other. Women were encouraged to talk in any language, which they are comfortable with.
Community members raised issues with regard to:
Chottu Qureshi listened to all the problems and responded positively. He answered all the problems… He shared the programmes what all he has done, Community also agreed. And taken some time to solve the problems.
Overall our observation about the grievance redressal meeting in BM Slum.
The meeting was supposed to start by 11.30 am. Our team members went to the BM slum to invite the community for the meeting. But community said “we will not wait for the councilor, let him come first, and wait for us, only then we will come”. At last councilor came at 12.45 pm saying sorry for the delay. After hearing councilor’s presence community started coming one by one.
Once the meeting had begun participants started asking questions, which they are facing in their day to day life. Both team and councilor felt difficult to maintain silence among participants. Once after they were convinced, the questions poured from them to the councilor. Councilor listened to them patiently. Even though everyone were asked to raise their voice only a lady called ‘Banu’ was asking questions continuously , when we interrupted her saying that she must give chance to others to talk, she replied “ sir I am talking on behalf of our community; it is our problems, let me ask all the questions”. Finally she shared all the problems related to the community, and also let others to talk.
I am very happy for this meeting to happen because on one hand majority of them actively participated and they were able to ask questions as well challenge the councilor, on the other hand councilor also able to convince the community by giving a list of services (electricity, water connection, installing taps etc) what he had done so far to the community. Along with sharing service that he has done, he also took some time to provide solution for the other problems.
One of the objectives of the urban health project is to facilitate a process of bringing the community and government officials and elected members together on a platform. So that this type of activity will motivate the community to discuss their problems and grievances directly to the officials and elected members, which will lead to workable solutions jointly. We hope that the councilor will keep up his promise and fulfill the needs of the community at the earliest.
IPH has been working in KG Halli in order to improve quality of healthcare for people living in this ward since last 3 years.In order to achieve this, IPH aims to work with healthcare providers (government and private), authorities (councilor, health department, anganawadies, others) as well as people living in KG Halli area.
Bharathmahta slum (BM slum) is one of the sub areas of KG halli. When we are working with community we realized that the anganawadi teacher working in BM slum is irregular. Because of this the mothers from BM slum, approached IPH staff to help to run the anganawadi properly. We spoke and discussed with the teacher many times, asked her what is preventing her from coming to work regularly and on time. Every time we discussed she gave an excuse of “I am a widow nobody is there at home, I have to do all the household work, so I come late”. It sounded like she was making some excuse and trying to gain sympathy by saying I’m widow to shy away from her responsibility. Continuous support and discussion to resolve her problem from IPH staff did not bring in any change in her attitude. Then we met CDPO (Child Development and Programme Officer) who is heading anganawadi centers to discuss the issue with this anganawadi. He also warned her many times but there was no change in her irregularity.
Further we invited CDPO to Bharathmatha slum, so that he could see the actual problem and take some decision. When he visited BM slum anganawadi the teacher was not there. Then on the same day we organized the community meeting with CDPO. During the meeting participants from the community said “we don’t want this teacher in our area” and requested CDPO to transfer the anganawadi teacher. Then CDPO transferred her temporarily. The CDPO appointed a teacher for BM slum but she was under deputation. She would come to the anganawadi on alternative days. Though this gave some relief but did not solve the problem completely.
We continued meeting CDPO, to get full time teacher. After 5-6 months of persistent approach new teacher was appointed by CDPO.
New teacher is young and it is her first appointment. CDPO requested urban health project team to support her as she is new to the department. IPH team explained about roles and responsibilities of teacher and how involving community can help improve services provided by the anganawadi. Urban health project team arranged meeting with anganawadi teacher and community to introduce new teacher. During the meeting teacher showed interest to interact with the community and the community was happy to see new anganawadi teacher. The community is expecting a lot from this new teacher and we all hope she lives up to the expectation.
It is more than, two months since, I had an opportunity to stay overnight in a tertiary government hospital in Bangalore. This is the storey of what I observed that night at a labor ward. It was a night of the August 23, 2011. If the nurses and doctors had listened to the crying would-be mother that night they might have prevented the death of a child.
I arrived at the hospital around 10 pm. Dr.Upen and myself were there to play the role of family for Juliet, a young lady (rather a girl) from KG halli with risk pregnancy brought to this hospital for delivery. She had no support from her in-laws. Our worry about her risk delivery flew away as doctors assured that she would deliver normally.
As the Juliet was taken inside the labour ward, we were waiting eagerly thinking what will happen, and when will they break the news. We waited for almost three hours. Later at 12.30am a staff nurse called over mike,” who are the Juliet’s relatives? Get the cloth to wrap the child”. Upen and I ran towards labour ward with the cloth and gave it to the helper. She asked me to accompany her to sign on the form before handing over the child to us. I had never come across such situation in my life before, holding and caring the child. I happily transferred this responsibility to Upen, who accompanied the helper, singed the form, and came out with the child, I saw a male baby in his hands.
The people around us were very cooperative. Some of the women sympathized with Upen and helped him in wrapping the new born properly. The baby was very quiet and slept till morning without disturbing us. The baby was separated temporarily from the mother since the mother was given drips inside the ward that had no facility like cradle, for the baby. Beds were arranged on the either side of the ward entrance so that mothers can be put temporarily on these beds before shifting them to the post natal ward.
There are enough places for the family members to stay near the labour ward. Only women were allowed to stay near the labour ward. Every now and then helpers would chase the men away from there. But my colleague Dr. Upen was excused as the baby was happily resting on his lap.
I had nothing to do but wait till morning to ensure that both mother and the baby get shifted safely to the ward. I was observing what all was happening there. I felt I was in crowded and noisy place. Staff nurse was calling the name over the mike “who are Geetha’s relatives?”, “who are the relatives of Nagamma? “etc. Family members were running fast with the cloth to sign the paper and get the baby.
The pregnant women who were waiting to deliver were walking from one end of the hospital corridor to the other end. Some of them were inside the labour ward. Some of them were screaming loudly due to pain. In the midst of all these a pregnant woman caught my attention. I was watching her from the time I have entered the hospital. She suddenly used to come out from the labour ward, would ask for water to drink, would walk the corridor and would again go inside the labour ward. She was repeating it continuously.
I could understand her behaviour that she was trying to control crying from labour pain. She was very anxiously asking her husband, mother-in-law and mother, “Ma why I am not yet delivering? For how long I need to bear this pain? Why don’t you tell the doctor to do cesarean? I think I may die due to the pain, ma please…………………. tell the doctor”. Her mother-in-law went inside to tell the staff nurse about her daughter-in-law’s wish. But she shouted at her and asked her to go out. The helpless lady came out with unhappy face. Her situation was difficult as she was neither able to console her daughter-in-law nor convince the doctor.
Around 5.30 am this lady burst out with loud cry, as she could not tolerate the pain. One can see blood stain on her dress and she was repeatedly telling her mother-in-law about blood spot, in turn; her mother-in-law was reporting it to the nurse. But it seems to be a futile exercise by the family members as the nurse did not care to take this incidence to notice.
Meanwhile Juliet was shifted to the ward with the baby. We both (Upendra and myself) were waiting to hand over the responsibility to Nagrathna, our colleague working in KG halli. While leaving hospital by around 8.30am, I met the same family and noticed no progress in the situation I saw at night. They were so helpless and asked for help, I was thinking how to help them. Suddenly I remembered the names and phone numbers of doctor in-charge displayed on the board near labor ward. I told them that they can talk to an authority and get the work done.
Afternoon I went to meet Juliet and her family members to motivate them to stay with her on that night in the ward. At that time, I met the husband of the lady whom I was observing since last night crying out in pain. As soon as he saw me tears started rolling down from his eyes. He said – “Madam as you suggested I called the doctor. Doctor asked the duty doctor to attend immediately, they did it, and they took our signature saying there is some problem with the baby. After five minutes, doctor came out to say that we have lost the baby. If they would have listened to us, and lent an ear to my wife’s cry we would have gone back home with the live baby”. Gentleman said “I do not think the child died after five minute; maybe it was dead before seeing the world”.
How to justify the behaviour of the nurse/doctor?
Is it the power of knowledge that makes them to refuse the request made from the women or family members? It is like “I know what do, you do not know anything”?