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?"

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.

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."

a tiger reserve in the making

the approach road from sivalkhar to sarasdol within the sanctuary has been cut across with a deep trench so that vehicles can no longer traverse it. a roundabout route through achanakmaar still did not allow access - we suddenly need a special pass from the forest officer in the block headquarters. a village we have been visiting for the past six years to support health workers providing primary health care services is now difficult to access. equally so for the villagers to reach the outside world in a case of an emergency.

meanwhile in bamhni village, six axes were confiscated this week. it is no longer allowed to cut any branches of any trees, or cut trees themselves. though the resettlement is a couple of years away at least, life is becoming difficult for people here. firewood may be gathered from what has fallen on the forest floor, but no dead logs can be split, nor can one collect wood to repair a beam of a house, or to build a hut.

returning from the shivterai clinic this afternoon, i see a forest department jeep in front of us with six confiscated pieces of slender wood, already worked on caringly to form what may become beams.

as we overtake that jeep, we are stuck behind a large truck, carrying huge logs of wood, perhaps eighty or more in that overloaded truck - tree trunks that must be at least fifty years old. each log is marked by chalk indicating the date it was logged, and its length. some more markings that i cannot understand. sold by the forest department to i am not sure who. this, of course, will not destroy the forest. what the forest dwellers need to keep alive, will.

Teejmati and baby

Teejmati Baiga, from Shantipur village. Displaced twice from her forest village, once for a dam, then again. Now to be displaced for a third time, she is not sure where, to make way for the Achanakmaar tiger reserve.

harvest

corn hanging from the roof of a hut in boiraha village, inside the achanakmaar sanctuary.

this village may not be around in a year from now, as it has been notified to be moved as now this whole area is to be a tiger reserve.

a typical clinic

dr sitaram, this one is for you.
on wednesday, 3rd february, i was one of eight doctors in the outpatient clinic of JSS at ganiyari. cases are screened and sent to concerned specialists, so i did not get most of the ob/gyn or paediatric, or surgical cases. the following patients are who i saw as a "general" physician:
a. a 35 year old woman with hive-like lesions on her face and legs for three months, with no itching but with jhunjhuni or tingling. a slit skin smear showed 3+ AFB: a case of lepromatous leprosy.
b. the second patient was a young 28 year old woman with swelling of the body for three days, a blood pressure of 210/130, heart rate of 120, a pansystolic murmur at the apex; urine albumin 4+, and a serum creatinine of 6.8. she is on a nitroglycerine drip to bring down her blood pressure, and we need to rule out a connective tissue disorder. USG showed normal sized kidneys.
c. a diabetic hypertensive alcoholic who had discontinued all medication on his own and came with bilateral cataracts. he came because his eyesight was too poor now for him to continue tailoring.
d. a 65 year old woman with blood and mucus per rectum for three months: she had carcinoma of the lower part of the rectum, which would need resection and a colostomy. she refused even a biopsy to confirm the diagnosis, and went home.
e. a 45 year old woman with ankylosing spondylitis.
f. a 40 year old man with a three month history of upper abdominal discomfort and severe weight loss. suspected carcinoma of the stomach, referred for endoscopy and biopsy
g. a 23 year old woman with an intra-uterine death and spontaneous abortion at 7 months, with retained POC, bleeding, and post-partum depression. Hb 5.3 gm%, and refused a curettage to stop the bleeding.
h.a baiga tribal woman who i had brought back from the field clinic inside the sanctuary the previous day with a history of a fall from the "machaan" (raised wooden structure built in teh field to safeguard the crops against wild animals at night). she had a fractured acetabulum with internal dislocation of the head of the femur. she is on traction now at ganiyari
g. five patients newly diagnosed as hypertensive
h. one 25 year old boy with a liver abscess.
i. about 10 non-serious patients.

all this in one clinic in a rural area in Chhattisgarh, seen by one physician. my other colleagues saw an equal number of seriously ill patients through the day, including several emergencies. there were about 240 consultations that day. this goes on three days a week, through the year. we get patients from all over bilaspur district, and from other districts too; also from neighbouring madhya pradesh.
these are poor patients, over half of them have BMIs less than 18.5. most are backward castes, or scheduled tribes and scheduled caste patients.
the clinic is a virtual gold-mine for those who want to learn medicine, and a sure indicator of the sorry state of our public health system - we have a medical college, and the district hospital within 25 km from our clinic. and two block PHCs within a radius of 20 km from ganiyari.
it speaks volumes too, about the burden of disease in the community.
would anyone like to come and help out for any length of time? we would really appreciate it. two weeks at least would be preferable, but even one week would help if you cant spare more time. you could plan it anytime during this year, so please do give it a thought.
(the picture shows patients waiting outside the laboratory for their reports. they will then be seen by the doctor for further management, no matter how late in the day)
for more information, please contact janswasthya@gmail.com, or myself at atkuri@gmail.com