Training for Medical Officer’s – National Program for Prevention and Control of Diabetes, Cardio Vascular Diseases and Stroke
IPH, Urban Health Team is working since last six years to improve quality of care for the residents of KG Halli, ward number 30. We have conducted baseline census in 2009 and follow up survey in 2013. The findings from this study and the challenges faced by the poor people in the community to manage chronic disease (Diabetes, HYpertension, etc.,) is featured in the news paper article.
Yasmin (45), who lives in a crowded colony in Kadugondanahalli (K.G. Halli), had to have her leg amputated due to uncontrolled diabetes. The reason: she was not regular with medicines for years due to ignorance about the possible complications that could arise.
Her neighbour Husseinbi (60) has been suffering from hypertension for 12 years. She spends anywhere between Rs. 200 to Rs. 300 every month on medicines. Her husband is an auto driver.
For people from low-income families suffering diseases like hypertension and diabetes, a major component of their income goes to buying medicines. A study by the Institute of Public Health (IPH), Bengaluru, shows that many choose to forgo treatment, going to the doctor only when complications arise. The study has been published in BMC Public Health, an open access peer-reviewed journal. It covered patients in K.G. Halli from 2009 to 2015.
To read more about this article : Click here
This article originally appeared on BMJ Blogs on April 24, 2015 under the same title.
This blog is my reflection on regular field visits as part of the urban health action research project that I am currently working on. The field site for the project is a very poor neighbourhood of Bengaluru called K.G.Halli. This neighbourhood has families who earn their living as daily wageworkers to a few upper middle class families.
Let me give a brief overview of the project. It is an action research project which aims to improve access to quality healthcare especially for people with chronic conditions among the urban poor. As a project initiative, we identified three ladies from the same community and trained in providing awareness sessions for chronic conditions. These community health assistants have been working in the neighbourhood since 2009. They go door to door to deliver awareness sessions on diabetes and hypertension, to inform patients what the preventive measures are that the patient and the family can adopt on a daily basis, how diet plays an important role in managing their conditions, and the importance of regular medical check ups. These ladies are an important interface between the community and healthcare providers. Over the years they have become the “go-to” people to seek advice.
Recently I accompanied these ladies for their regular home visits. As they were walking in the lanes, familiar faces greeted them, some asked them to come and join them for a cup of coffee. These were greetings on one end of the spectrum, on the contrary we had to knock on an average of 20- 25 houses and then there would be one patient or a family who would greet us. A few passers by whom we met on the way had curious questionable looks on their faces, and a few even said: “There is no patient in the family.”
Some responses I found were very startling and some of the interesting ones, which did capture my attention, were:
“I already have the disease, how will this awareness bring about a change?”
“ I do not have a ration card, that is more important to me, awareness is not.”
“ Why don’t you give us money?”
“ It is your job as a doctor to find cure and medicines, it is not the responsibility of the patient to make any dietary changes.”
“ Why are you scaring me after me being diagnosed with the disease? I do not need this information.”
“Do you have to meet certain targets? How many houses do you have to visit like these in a day?”
Another experience cited by the health assistants was, “we are educated people, we do not need your information: you would be better off educating the poor people.”
These reactions from the community, which I worked in for almost two years, made me realize that I was wearing blinkers as a young researcher and a medical doctor. It made me realize that the training in research or medical school did not give me any skills to understand these reactions or even think which other strategy I could use to communicate effectively and motivate people.
They sought a completely different path to find out about or understand their disease. Most of the patients that we visited asked us “why aren’t you carrying a glucometer to let me know if my blood sugar levels are under control.” The patients just wanted a figurative number, which is simpler for them to understand and to reassure them that their disease is under control. They would rather not listen to the “science” but to an immediate solution to their problem.
Their voices echoed completely different priorities, such as ration cards, cheaper sources of medicines, or jobs. Another question which came to my mind was whether my chosen strategy of conducting door-to-door awareness sessions was indeed the best strategy for the community or for the researcher?
The comfort of science and research were no longer my allies in solving my dilemma, reiterating the steps to actually listen to the community and understand their priorities better than going with my priorities as a researcher. How can a young researcher like me help them in securing a ration card of any other welfare schemes? Maybe there were unexplored pathways to find a common ground which has a possibility to solve some demands of the community as well as bring in about motivation in the community for adopting a healthier lifestyle.
Written by – Mrunalini Gowda, Research Officer at the Institute of Public Health, Bengaluru.
Author: Dr Mrunalini
I am pretty well known in the country and constantly have a presence in news making headlines against the multibillion Pharmaceutical industries. I still struggle on a daily basis convincing people that I’m as good as the BIG BRANDS, and to start including me in their daily lives so to help them keep their diseases under control. This is a series of stories about me and a group of generics when we started our journey in K.G.Halli (Bangalore) through a primary care clinic in January 2014.
Every Monday, I sit there for few hours seeing people scan me with a close eye and have a skeptical look towards me and the idea of taking me home and start including me, to fight their war against the disease.
Along with me there are two doctors, two community health assistants bombarded with questions for being a generic drug, is there even a possibility of me being a generic drug?
The questions they encounter “Why is the color of the packet not green”? , Why do I have to take two medicines instead of one? , Why is it so cheap? Is it cheap because the strength is less? Do I actually help in controlling the disease? How can I be so affordable? Medicines for my disease always cost me a lot, how can the expenses suddenly be so less for a month, why are you people doing this work for the community? What do you get out of this? There are a lot of whys? There is lot of how can this be a real.
A lady sits across me , picks me up and says , this is not the same medicine for my disease, the shape is different, the cover is different, when I get two medicines in one tablet why should I take two separate tablets, will this cheap medicine help me control my disease?
The doctor sitting close by me answers with a comfortable ease and politely, that the packet color is different I agree, so is the shape. But the medicine which is required to cure your disease is inside this packet. Only the cover is different. The patient continues “but why can’t I get the combination?
Out in the community I’m an unspoken truth, or something which is never acknowledged, I’m a shadow amongst the big brands, the family physician when they see me pretend like I’m nobody. While the struggle continues, I choose to embark on a journey of my own in the community along with my dedicated team of doctors and community health assistants. I will introduce myself and promote myself that I too exist amongst the multibillion pharmaceutical industries, barring the fancy covering, huge promotion and marketing strategies.
Every journey begins with one small step, while I have embarked on this long journey, hoping it will be a successful in KG Halli.
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!’