Monday, March 22, 2010

rabies then, rabies now.

this was written for rediff about a patient i saw in 1992, nearly 20 years ago. nothing much has changed, it seems, apart from the fact that sarguja district is now in Chhattisgarh instead of in Madhya Pradesh.

Bitten By Dog, Bitten By Man

One evening in March, Somaru was brought to the dispensary in Bhainswar, in the western part of Surguja district in Madhya Pradesh. As was usual among the Gonds in this area of MP, Somaru had married early and at 17 was the father of a six-month-old baby. A gentle, well-built lad, he had been learning irrigation techniques from Father Alex who lived opposite the dispensary.

Now, he was quite unrecognisable: a wide-eyed, desperate boy, babbling incoherently, clutching at Father Alex's arm and asking repeatedly for water to quench his thirst.

Five months ago, on Diwali night, Somaru was bitten by a dog on his right ankle. The wound took weeks to heal. As the dog had been stoned to death immediately, there was no way of telling whether or not it was rabid. Somaru paid no heed to our pleas to get vaccinated against rabies at the Primary Health Centre in Sonhat. We worried too much, he said. Besides, he did not want to cycle 13 km through the forest to the PHC for any injections.

As the wound healed, Somaru resumed work, tending his field. Exciting things were happening in Bhainswar. For the first time, the villagers were growing a winter crop of wheat, thanks to the irrigation system they had devised which lifted water from the river that flowed past the village. Somaru had no time to worry about his ankle.

All of a sudden, he had begun to feel feverish and could not swallow water.

The evening wore on. I watched over him in the fading light with a feeling of helplessness. I knew Somaru had contracted rabies. He was, quite literally, beyond help. Nothing anyone could do would save him.

Somaru talked incessantly, begging Father Alex to save him, crying out in fear that he did not want to die. Again and again he asked for water and when we did give him some, he spat it out and turned violent.

Father Alex and I explained to Somaru's relatives that he had a serious disease and would probably die within a few days. We advised them to take him home and keep him quiet, warning them that he could turn violent. They could not accept this. How could a five-month-old dog bite cause this madness? Besides, the wound had healed completely, and he had been perfectly well till just two days ago. "He is possessed by spirits," they said.

While two of the younger men borrowed the dispensary jeep and drove 80 km into the jungles to fetch a vaid (traditional healer), Somaru's family carried him home and kept an all night vigil, chanting and praying while he tossed in his tragic delirium. By morning, Somaru's in-laws and other relatives from the surrounding villages had arrived and joined in the prayers. Then the vaid came in, took one look at poor Somaru and declared that this was not a devil he could exorcise.

Somaru died late that evening, 24 hours after he had been brought to the dispensary, in an agony of fear and thirst. When we heard the news, a wave of relief washed over me. No one should ever die such a death, and at least it was over for Somaru.

Just then, his uncle and father rushed into the dispensary, fear writ large on their faces. Somaru was very violent just before he died and when they tried to restrain him, he had bitten them both. His father and uncle, I realised, were also possibly infected.

Father Alex and I went to Sonhat to get the rabies vaccine from the PHC and bring it to Bhainswar where the nurse could administer it to the two men. This would save them from having to find a place to stay in Sonhat until they completed the course of vaccination. The vaccine available in the market cost nearly Rs 300 a dose, and the villagers could not afford that. Only the subsidised vaccine from the PHC was within their reach.

There was no vaccine available at the Sonhat PHC, so we drove a further 40 km to Baikunthpur, a large mining town. Here we were informed that the only anti-rabies serum available was at the district headquarters, Ambikapur.

Three hours and 120 km later, we were at Ambikapur. There, the district hospital authorities told us that they had no vaccine and it had to be obtained from Indore, nearly 750 km away!

In despair, we went to see the collector. Not that he could do anything, but we wanted to tell him what had happened. He was extremely sympathetic, got in touch with the hospital authorities and asked them to send someone to Indore right away to get the vaccine. He also told them to hand it over to Father Alex for transportation to Bhainswar. If the vaccine did not arrive in a few days, he told us, he would sanction funds to buy it in the market.

Over the next ten days, Father Alex returned three times to Ambikapur, to the district hospital. Each time, there was no vaccine. Finally, he went back to the collector only to find that he had been transferred out of the district. Eventually, we spent nearly Rs 1,800 each on Somaru's father and uncle for a full course of the rabies vaccine. I am happy and relieved to report that both are well.

Some weeks later, Father Alex happened to be at the Sonhat PHC and found it stocked with the rabies vaccine, supplied from the district headquarters.

"It is always available at Ambikapur," he was told. "But how did you hope to get it without bribing someone at the hospital?"

Sunday, March 21, 2010

distress migration

Two of the emergencies seen by us yesterday highlight the tragic plight of migrants - the nowhere people in our country. These are not from across the international border, though they do cross various borders in search of a living and for survival : the border between their village and the city; the one between states; the one between cultures; the one between the familiarity of one's own home and the unsure, unstable one of a new and unknown place, among new and unknown people; the nebulous line between being very vulnerable and being extremely so.

The first was an 8 year old boy brought by his parents with a history of a dog bite on his elbow eleven days ago. The parents had moved from Shahdol in MP to Kota in Bilaspur district of Chhattisgarh, to work in a brick kiln there. The contractor assured them nothing would happen, they could use some local herbs to treat the wound, which they did. They, of course, were not aware of the dangers of a dog bite and the need for anti-rabies vaccine. Now, eleven days later he reached our clinic, with frank rabies. There was nothing we could do, except explain the disease and the prognosis to the parents and urge them to keep him comfortable for the few days he has left before he dies. This for a young child who is bright and alert and in full possession of his faculties. The parents left our clinic at Ganiyari, weeping and trying to comprehend what had happened.

The second was a patient seen at one of the outreach clinics at Semariya. I
was at the clinic and a man rushed in with his wife in his arms - she must not weigh more than 25 kgs. They are from that village and had migrated to Kanpur in Uttar Pradesh to work in a brick kiln. She fell ill 10 days ago, and when he ran out of money giving her IV drips there and she did not improve, they came home. She had not been eating now for four days. She was in shock with cold hands and feet and a barely recordable BP. She had severe pneumonia and sepsis and was gasping for air. After resuscitating her and starting antibiotics for the pneumonia, I sent her to Ganiyari for admission - she is there on oxygen and under further investigation and treatment. She probably also has TB as well as sickle cell disease, apart from being severely malnourished.

Two families of migrants, two families with severe illnesses, two families whose health is no one's responsibility.

Wednesday, March 17, 2010

monkey business

from "Banian Tree, the Pride of Hindostan" by James Forbes

(James Forbes was an officer in the East India Company in Bombay, and was Collector of Dabhoi (near Baroda) )

"The Banian or Burr tree (Ficus bengalensis) is deserving of our attention: from being of the most curious and beautiful of nature's productions in that genial climate where she sports with the greatest profusion and variety. .....
....on the banks of the Nerbudda I have spent many delightful days with large parties, on rural excursions, under a tree supposed by some persons to be that described by Nearchus, and certainly not at all inferior to it.
On a shooting party under this tree, one of my friends killed a female monkey, and carried it to his tent; which was soon surrounded by forty of fifty of the tribe, who made a great noise, and in a menacing posture advanced towards it: on presenting his fowling-piece, they retreated and appeared irresolute, but one, which from his age and station in the van, seemed the head of the troop, stood his ground, chattering and menacing in a furious manner; nor could any efforts less cruel than firing drive him off: he at length approached the tent door; and when finding his threatenings were of no avail, he began a lamentable moaning, and by every token of grief and supplication, seemed to beg the body of the deceased: on this, it was given to him: with tender sorrow he took it up in his arms, embraced it with conjugal affection, and carried it off with a sort of triumph to his expecting comrades.

The artless behaviour of this poor animal wrought so powerfully on the sportsmen that they resolved never more to level a gun at one of the monkey race."