With the community

I haven't written in a while. Today I had to write for several reasons. Mainly because I realised how my new place of work and study is influencing my mind and way of thinking. I've been asked to keep a daily log during the entire course of my fellowship in HIV medicine at SVYM, Viveka Memorial hospital, Saragur which started a week ago. I'm glad that'll make me write regularly so that I jot down the crazy amount of thoughts and learnings I'm experiencing in SVYM before I forget a few of them. Also I believe writing brings clarity and forces one to learn things in detail. So what was different that compelled me to write?
I had duty in the mobile health unit (MHU) today. This is a service 5 days a week from our hospital where a doctor and a field worker goes to around 8 haadis each day (different ones fixed each day) in a van which has drugs to treat some common ailments. It's a concept which I had previously come across even at the hospital at BR hills about which I've already written. The tribal settlements were called podus at BR hills while they are named haadis here. So this mobile health unit is an operation that sounds simple but is quite extensive and wonderfully insightful in terms of how much effort is being put by many people to bring about outcomes that are beyond treating the diseases.
Briefly this is how it works in our setup:  (I still have to learn about the logistics in detail)
A field worker is given the responsibility of few haadis.So all the people in those haadis are his/hers. He/she'll take care and know about almost everyone from their place. He visits them, gets information regarding the number of eligible couple, pregnant ladies, neonates, infants, their immunisation status, the number of TB patients whether suspected, or on treated or completed treatment. Finds out about the problems if any, that they are facing related directly or indirectly to their health and socio-economic condition. Be it their job, or getting their ration/ aadhar card. So before the MHU actually reaches their haadi on their respective days, the field worker would know who should be paid attention to by the doctor. When we go in the MHU van, a siren is played to which some people come to discuss their ailments and get treated. But there are people who would be sleeping unwell and would reveal only when we go to their home and ask "yellaru channagidira?" (meaning is everyone okay?). Like my friend who was here from the US had rightly pointed out that hospital is for the people who are willing and can approach health care facility,camps are for the people who can't approach the health care facitlity and MHU is for the people who won't seek health care. :D So we take a round and ask people randomnly about their health and try to pull in people to the van not to abduct them but just to keep them healthy.
What I realised today is -

• SVYM has and is building a bond with the community it is working with through various means and MHU is one big operation that is facilitating this, especially for the tribal community who are resistant to approaching a health care facility or personnel without that bond and trust. "With" being highlighted because this is the exact same word that one of the founders used while discussing with a well wisher  the other day. About how SVYM is not working for the people but with the people. 

• I was eager to see and was able to follow up the patients I'd seen in our hospital and keep a track of how they are doing even if they weren't coming for follow up.

Also we were taught during our community posting during UG times to take a detailed history regarding the conditions that led a person to develop a disease. But here we can witness the person in his actual living environment, in his daily routine. The water he/she is consuming, the food a mother is feeding an undernourished child daily, the kind of defecation practice one is following, in real without the need of questions. In this way we can understand why some conditions if not all, we term as "preventable events" occur.
For example, today we found a pregnant lady smiling. She basically approached the van because she was having pain in her lower abdomen since the past one week. So I asked her a basic question of how many months old was her pregnancy. She giggled and confronted that she didn't know and thought it had been 7 months and that her husband knew. Then I asked her to get her mother card suspecting that she hadn't had enough ANC visits. So she came back hiding the card in her veil. She had probably visited just once to a PHC, maybe to get the card and so only Hb , weight and blood grouping was written. Somehow she was immunised with 2 injections of TT one in the PHC and the other in our MHU itself. No scan done. Not screened for HIV/HbsAg/VDRL as every pregnant lady is. She was smiling all the while until I started probing her to tell me why she hadn't visited for Ante natal care or for ultrasonography to know the health status of her growing baby. She had tears in her eyes and told us how her husband barely has money left over after pouring it all into liqour. He is least interested to share the responsibility in taking care of his  baby or carrying wife. She had no parent and her only brother was elsewhere working. So she was completely dependent on her husband for money and care. So we gave her 50 rs asking her to take the bus this Sunday to our hospital in Saragur and give us a call so we could get the investigations and scanning done. We had to ask her to hide the money and our phone numbers safe from her husband. I know this is not a sustainable gesture but this is all I could do to get her to come to the hospital. This made me wonder how many such mothers are out there who haven't approached us because everyone wouldn't have a complaint of pain abdomen like she did but they would have a careless husband who's addicted to drinking or simply doesn't care.
Probably this is one of the background details I'll not forget the next time I'm about to shout at a lady when she approaches us in labor but with an empty mother card or with no scans or with uncontrolled BP.

So MHU concept is trying and definitely lessening this burden of shadowed people and preventing complications.

More memories

The mobile unit team 

"You'll never know unless you try"- Terese Jose 

Sweet Sumithra ma'am 

9th and 11th March ~ Jeeping into the forest

Finally we were set to go to the "podus" (which are tribal settlements) in the mobile health unit, a jeep that I've mentioned in my previous post. This travels 3 days a week to 3 podus. The idea is, there are totally 9 podus around the region among which 6 of them are pretty close to the VGKK hospital and hence tribal people from these settlements access the hospital themselves. But the remaining 3 are quite interior in the forest and hence the mobile unit travels to these places to treat the simple ailments of the people there. No other public vehicles are allowed to travel into these settlements and hence we felt lucky to see the interior of the forest, hoping we'd come across some elephants too.
We'd stop the jeep in an area where the people would come with their problems. We checked the BP of all the adults who came and found some of the readings high. They weren't known cases of hypertension, which made me think, if some kind of screening would help them to be diagnosed early and treatment started.
In one of the podus, a small boy and his sister were asked to take us to their temple "dodda sampige". The tiny boy kept running down and up the contours of the hill to take us there, forgetting to see if we could keep up to his pace. Luckily his sister, who was a little older than him was keeping a watch on us :)
They led us deep in the forest to a big tree which was their worshiping place. It was a treat to the eyes. This was a very peaceful place where all one could hear was the leaves we stepped on and the happy stream running. There were bells hanging high and low considering both adult and kids who would want to ring them, rocks which were covered in vermilion.

These were our cute little guides 

In another podu, a 2 month old baby was brought for cough and cold by it's mother and grandmother. The baby had tachypnea and chest indrawing due to difficulty in breathing and looked like it needed immediate care for pneumonia. Hence we scared them to make sure they ran to catch the bus to the hospital and were happy to see them waiting in the bus stop while we left that place.

On our way back, right when we were discussing that all we got to see of the elephant was it's turd, we found one elephant near some water, a tusker! That completed our feeling of a ride in a forest. 

That evening we went to the hills by steps because Dr. Akhil took us there. Puffing and panting, we some how made it to the top and then realised why he took us there. The sunset was amazing. It was like an orange ball falling into a green carpet. None of the photos could capture it well enough to do justice. We bet on the time the sun would take to set and it sank twice as fast to the smallest time we mentioned and thus the day ended. 

7th March ~ Tele-medicine

This day kicked off early with some exercise thanks to the little pact we made where one had to sit up from sleep as soon as the other called their name .We took the road instead of the steps up the hill to reach the temple on top. The temple was a usual one but the view on the way was a refreshing one. On the way back we got some yummy dosas that we were told about earlier.

It was my friend's turn to go to the PHC downhill, so I went to the OPD at the hospital as usual. A man was brought that day who was too weak to even walk with a history of severe headache and vomiting. Since his BP was on the lower side, we started some fluids and took a detailed history. He was operated a year or 2 ago at JSS for a tumour in his brain. Don't know the exact details of the tumour or the surgery as they had not carried any documents about the same. They said they were asked to follow up for a repeat MRI at the same hospital after 6 months but failed to do so due to financial reasons. So we thought that the current symptoms were probably due to raised ICT maybe due to a recurrence. Then we started figuring out where and how to refer them. For every option that we suggested they would have their reasons. Even when government hospitals were suggested they humbly said they'd need money to travel and stay in the hospital plus they would be prescribed medicines to be bought from outside which would again not be affordable.
That's when the medical officer there, Dr. Akhil, pointed out the potential of tele-medicine in such circumstances where the patient can't afford the travel charges and hospitalisation in a different city. What if we could have gotten the MRI done and took a neurosurgeon's opinion regarding the management through a phone call? Maybe in this particular case it would be tough to manage as the facilities were limited. But if he'd come earlier, probably the follow up could have been arranged in this way. Also there are plenty of simpler illnesses that can be taken care of at the PHC level or at a hospital like VGKK's with an extra help from an expert staying elsewhere. It's an era where all reports are just an email or what's app away.  Infact the computer there even had an ECG app which could be used to send the ECGs taken to Narayana Hrudayala for opinion.
Basically the lesson learnt that day was that there are different ways of delivering health care. When a patient finds it difficult to approach health care facilities, there are plenty of ways health care can approach him/her. One being tele-medicine. The Hospital is already using another way through "mobile health unit" about which I'll be writing in a future post.    

8th March ~ International Women's day celebration

We were asked by the high school teacher 2 days earlier if we could talk to the kids for a few minutes in kannada on the occasion of International Women's day. Not because we've achieved something great that can inspire them but because it would be from someone new for them :D 
Terese agreed to help me with the content while I agreed to talk in kannada. So we said yes and that's the last we saw of him. I don't know where he disappeared. So on 7th we spoke to that sweet teacher Sumithra who helped us schedule the event on 8th. She also suggested that we highlight a few points regarding personal hygiene, menstruation, teenage pregnancy etc.  


After a lot of web search and thinking till 8th noon, we had a small talk ready where I narrated the story of Malala Yousafzia to tell them how she had to fight for the basic right to education. And to let them know that this is just one of the rights that the women in some of the countries including ours are denied or deprived of.

We asked them to involve both the girls and the boys in the event because I remember what Emma Watson said in her inspiring UN speech campaigning for #HeforShe, "How can we affect change in the world when only half of it is invited or feel welcome to participate in the conversation?" 

We ended the talk by taking an oath I made in kannada, along with all the kids who participated. 

The translation being, 

"I'm my own master from today. I can achieve any goal I wish. I won't let anyone tell me that I can't do something. I will never discriminate people with respect to gender. If and when I come across gender discrimination, I will try my best to take action against it instead of just witnessing it". 

After which Sumithra ma'am gave an inspiring talk about the other rights that the girls have to be aware of, about female foeticide etc.  

I learnt a few things from her speech. Speeches are inspiring and effective when they are specific. She had just 3-4 points, but she made sure those points reached their mind clearly by giving them tangible day to day examples .    

The school here has lovely teachers who make the children share responsibilities and provide opportunities equally thus eliminating gender stereotypes. 

6th March ~ Uppit day

We made uppit using the induction stove. The only thing worth mentioning that day :P

Otherwise this is how we were all day!

5th March ~ The Model PHC

As told, we got ready that morning in time thanks to the sweet teacher who rescued our dosa dough by making dosas at her home for us and I went to Gumballi while Terese stayed at the OPD in VGKK.

In the bus to Gumballi, I had this different feeling of happiness. It felt like my first small adventure as a doctor. So, the PHC in Gumballi, to be precise in Uppinamole, is a NABH accredited 24X7 PHC, a model PHC, one of the many such PHCs started by Karuna Trust all over the country in association with VGKK.

I entered into the doctor’s chamber, Dr. Ramprasad, and he graciously let me take a seat and help him see the patients waiting. After a while he took off and let me experience the crowd that he probably treats everyday while hearing the drilling of teeth from the next door. Yes, there is a dental OPD as well! Next to which a new born was lying with her tired mother. She was brought for delivery that morning by an ASHA worker. Time flew as I tried my best to treat the patients and soon was having chapathis at the fine canteen there. 

 What makes this PHC so different and better compared to a regular PHC is that it provides services that are not termed Primary health care in the conventional sense. Every wedneday patients are admitted to the first floor who suffer from cataract and get operated on Thursday and reach their homes with a new sight on Friday! Just like how its done at KR hospital, Mysore which is by the way a tertiary care hospital. Heard that they will be tying up with a similar great initiative Aravind eye hospitals which will only make things better here.  

Chronic illnesses which require regular filling of drugs like epilepsy, mental illnesses, non-communicable diseases like Diabetes and Hypertension are taken care of, too. Different specialists come on various days of the week like a specialist for Diabetes on Wednesdays and ENT surgeon some other day.

 The idea of making and running such a successful PHC and catering to the many once unreached people thrilled me. It’s a Public-private parternship initiaitive which according to me is one of the reasons for its efficiency.       

I was taken back in the jeep by the driver Suresh along with the amazing headmaster who showed us stars previously. He told me stories all along the ride back to VGKK which made me search and read about the work of VGKK and Karuna Trust in 
 Community Planning and Monitoring of Health Services - Karnataka Experience.

4th March ~ Once a hut.

We had goosebumps on climbing the rocks to have a look at a tiny hut measuring around 3X3 mt in which Dr. Sudarshan Hanumappa first put up his clinic which later lead to the establishment of VGKK. 

That day we were also excited to go into the forest to reach the tribal people in the jeep called the mobile unit which works 3 days every week. The jeep had almost all basic medicines we might require in handy lockers. But the trip got cancelled because of the program that was being arranged in the school auditorium. It was arranged for felicitating 2 people in the tribal community who actually worked for their community. One of them was a student of the same school who saved up a lakh and gave it as scholarship to the students who earned it by writing good essays about Swamy Vivekananda. What caught my attention was the talk by the other lady, Mrs. Madamma, simple yet appealing. She just asked the kids to never stop learning and not bother about what the society thinks or says and serve the community. Later we had a satisfying meal proved by how much sleepy we got at the OPD that afternoon.

The hospital pharmacy was a real surprise as they had all the drugs that we thought we might need. And a huge emergency kit hanging in the OPD. The only ones that I thought were missing were injectable anti-epileptic drugs. So that afternoon passed by treating a few people who came to the OPD.

Soon we realised we weren’t getting any physical exercise and so went on a nice evening walk and on returning we were told that one of us would have to go to the PHC in Gumballi the next day. 

3rd march ~ New stars

This was the day we had to leave to Biligirirangan hills in short BR hills as it was the option me and my friend Terese chose in instead of PKTB. I chose this inspite of people trying to talk us out of the idea only because this looked like an opportunity to see what the rest of my life might be like since I always have thought that my interest lies in public health.

So we packed up all that we’d listed including an induction stove based on the funny starving stories we'd already heard from our friends and started on the 3^rd morning. Changed 2 buses via Santhemarali and Yellandur and reached the hills by 2:30pm. The first thing I noticed was how quiet and calm the environment here is. We were welcomed by the staff in VGKK (Vivekananda Girijana Kalyana Kendra) which is a huge campus standing in the middle of the forest. We were told in detail about VGKK, what it does, and what activities we can take part in, by the coordinator Arun. He made sure we had everything we needed through Murthy. Murthy is the guy who solves everyone's problems in the campus we figured out. That night ended with a nutritious meal at the dinning hall with all the school kids and by watching the lovely Ursa major constellation shown by the headmaster Ramachari.