An inspiring man

I find that my blogs related to health services in rural India have mostly told negative stories, of services not provided, of indifferent or hostile care providers,of difficulties in access and availability of basic services. I have met many cynical or jaded or dishonest health care providers, be it ANMs or doctors, ready to misuse the system, or just be indifferent and do the bare minimum possible. There are any number of excuses - some valid, some not - as to why they are not doing what they are supposed to be doing. There have been a few very good ones of course, and the effect is immediately apparent - a motivated team, or a community that is immunized or gets the services it should. And these people keep the system going.

Dr N Saxena, Civil Surgeon, Rajgarh

Last week I visited Rajgarh district in Madhya Pradesh. It borders Rajasthan and the district headquarters town of Rajgarh is dry and the landscape more akin to desert areas - in complete contrast to the southern part of the district that is forested. My colleague and I visited the district headquarters hospital which is housed in an ancient building. We met the Civil Surgeon Dr Niranjan Saxena who is in charge of the running of the hospital. In the hour we spent talking to him about facilities provided at the hospital, and constraints faced, I watched him process several files. These were of patients who needed more care than the hospital could provide - facilities that were often available only in private facilities, at a cost the patient could not afford. He was instructing his assistant about which scheme could be utilized for which patient, and what amount. For instance, there was one child who had come with headaches, who turned out to have a benign brain tumour. The family could not afford the treatment, and Dr Saxena recommended a grant of Rs. 1 lakh from the State Illness Assistance Fund.

He informed us that he uses this fund, as well as the Chief Minister's Scheme for health assistance, in addition to the Deendayal programme for financial assistance in health care. He is a surgeon by profession, and carries out all kinds of surgeries - general and orthopedic surgeries (including amputations where necessary); obstetric and gynaecological surgery when the obstetrician is on leave; and cancer surgery. They see about 20 cases of oral cancer each month, and 1-2 cases of breast cancer. Post-operative cancer patients are then referred for radiation or chemotherapy to higher centres that have these facilities. Day care for chemotherapy is provided at this hospital, once the regime has been prescribed by a higher centre.

Not many women with cancer of the uterine cervix are seen, he said, probably because too many women have their uterus removed at an early age. A sad commentary of our times.

Dr Saxena was full of energy and enthusiasm, and informed us he retires at the end of the year, when he turns 65. One would not think it, to look at him. An inspiring man and one that the health system could utilize for some more years to come.

'Acche Din' in Salumber block

Palash amidst the all-pervading brown

Salumber block of Udaipur disrtrict in Rajasthan is a study in brown. Brown hills, bare trees, brown rocks absorbing and radiating heat in the harsh sun - hardly a welcoming place at this time of the year. Bright orange Palash flowers defiantly add a splash of colour amidst all this drabness. The only greenery is are a few thorny shrubs on the roadside or the occasional palm. I have seen these same hills in the monsoon - lush green, streams flowing, fields green with crops, so I know this brown is just a passing phase. Still I put on my dark glasses for the drive from Salumber to the clinic at Ghated, half an hour away.

The road to Ghated

The Ghated clinic opened four months ago, and is staffed round the clock by three nurses, while a doctor visits once a week. Today I accompany the regular doctor to the clinic. Amidst a range of patients who attend, I meet and talk to Bhanwarlal who is 32, and suffering from tuberculosis. 

The oldest of five children, he migrated to Ahmedabad as a teenager, working at polishing granite for nearly a decade before he fell ill and developed tuberculosis of the lymph glands and of the skin nine years ago. He tried treatment with various doctors, but did not find relief. As he got weaker, he started taking on lighter work to fund his treatment but now for the past five years he has been unable to work and has come back home. Last  year he had some months of anti-TB drugs too.

Bhanwarlal at the Ghated clinic

What stands out about Bhanwar are his eyes -large and distressed, they seem to look at you with hope that he can still be healed and get well. His eyes stand out because the rest of his face, like his body, is extremely wasted. At a 170 cm, he weighs a mere 41.9 kg, which gives him a body mass index (BMI) of 14.5. A normally nourished adult has a BMI of at least 18.5.

The scars and wounds are disfiguring and Bhanwar comes to the clinic wrapped in a shawl in spite of the heat. He has been started on Anti-TB drugs but the chances that he has multi-drug resistant TB (MDR-TB) are high.

Two younger brothers are also in Ahmedabad as migrant workers  - one polishes stones; the other works as a headloader at construction sites. The youngest brother is in college, and the family hopes he will get a better paying job than a labourer does. The youngest child, a 12 year old sister, also has swellings in the lymph glands of the neck now.
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The deforested Aravalli hills: one the way to Bedawal

The next day I travel to Bedawal, to another clinic. The road to Bedawal winds through more hills, now bare and revealing half-hearted efforts at reforestation. However, these cannot hide the fact that the Aravallis have been devastated over the years through unregulated cutting of trees, and, in some places, mining for granite and marble.

Rajudi, 40, Devliya village

40 year old Rajudi of Devliya village awaits me at the clinic, with cough and breathlessness. Her husband died of TB and she herself was treated six years ago with some drugs (unsure whether correct dose or duration). She too, like Bhanwar at Ghated, is wasted, weighing only 33.2kg at a height of 153 cm (BMI 14.2). She is severely anaemic and on examination I find evidence to suggest that part of her right lung has probably collapsed. It is difficult for me to make out whether her breathlessness is due to her anaemia or her collapsed lung. Her children too, like her husband, are migrant workers in Ahmedabad.

Phuski

Phuski, 65, comes in with nausea and giddiness. She says she is not hungry. She too is severely anaemic, with a hemoglobin of 5gm%. I ask her who she lives with, what she ate the previous day. She tells me she lives alone, and ate one roti the day before. When I ask her why did not eat more, she looks away and mumbles that she is not hungry. I ask about her old age pension: she gets Rs. 500 per month, she tells me, and uses it to buy spices, some jewellery....I wonder what she is hoarding jewellery for. Again, I am not sure whether her giddiness is due to the anaemia or her hunger. I can see she is starving - weighing only 33 kg at a height of 153 cm, her BMI is below normal. She insists she is OK except for her giddiness.
The senior health worker tells me her oldest son takes away her pension each month as soon as she gets it, and the neighbours feed her, depending on what they can spare each day.



This is the context in which the AMRIT clinics function.