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The most common reaction of laymen is that of raised eyebrows when you announce that you have a degree from the west. Having been through various such acquaintances, I was shocked when a colleague of mine, at a new course I was pursing, remarked ‘what’s there in a foreign country, when there is so much to learn from your own?’ His statement got the better of me and I made sure to avoid all kinds of interaction with him during the rest of the period.

Recently, I got an opportunity to visit one of the better known slums of the state. The first visit was a stroll around the places, amidst the homes and the shops and small interactions with the residents. The scenario left me speechless.

I am constantly shopping and wondering whether to buy a Fischer price or a funskool toy to my 1 ½ year old son to play.

During my stroll in the slum, I meet a group of kids, the same age of my son playing with shredded pieces of aluminum utensils, rubber and bricks.

One of my favorite role in life is that of an architect. Since time unknown I have been planning a dream home built on acres of land, with separate rooms to fulfill my fetish for foot wear and handbags, a lovely swimming pool, a garden with exotic flowers and fruits, a customized library, a minimum of a spa and a sauna and an additional home with a beach view for the retired days.

I met few families who lived underneath the steps, in the darkest corners, places where not more than 2 could fit at once. Their dining room, the kitchen, the bedroom all had to fit in that small place.

A few specks of dirt on hands I waste no time to visit the wash, I take umpteen number of baths to ward of the sweat in the summers and I met kids who did not remember the last time they had a decent bath.

My son by the age of 15, would have studied in a high profile school, would have blindly followed all the fashion trends and would be a charismatic teenager raring to run ahead in life. I met a young boy aged 15 yrs, who had done basic schooling, was a drug addict, a chain smoker, an alcoholic and was recently beaten up by the local police. He had no plans for his future and was not sure what he would do or be in life.

When I walk into a hotel with all the mouth watering, diverse cuisines, I never look at the prices because I am confident I can afford anything. I conversed with a little girl 9 yrs old and here goes the conversation

Me: Hi, what’s Ur name?

Little girl: Hi, I’m……

Me: Did you have breakfast?

Little girl: Yes

Me: good, do you go to school?

Little girl: No, I’m at home. I clean and take care of the house

Me: Will you come with me?

Little girl: will you give me food to eat?

Me: Sure, What did you eat today morning?

Little girl: I ate rice and that was yday morning

I called up that young gentleman, whom I had not spoken for a year, apologized for my folly.

I accepted that the best lessons will be the ones that my own country will teach me .

*** Under the fans, constantly clicking keys, I thought I was changing the world, until I met a bunch of lovely women who amidst dust, scorching sun and fearless dogs, walked from one home to the other collecting information for me to work upon.

Thank you Anthu, Sujatha, Saraswathi and Leelavathi. Our job is minuscule when compared to yours.

Thank you Roopa, for heading the team in the right direction.

Congrats Thriveni, your team is doing a fantastic job.

And finally thank you Munna for persuading me to come to field, I would love to visit the field more often. For me, it was a truly humbling experience.

NB: Munna, Anthu, Sujatha, Saraswathi and Leelavathi are field staff of the urban health team at IPH, Bangalore. Roopa and Thriveni are faculty of IPH, Bangalore.

The auditorium at Tumkur was abuzz with expectation. The district and sub-district health officials from the government health services had congregated for a training session organised by Swasthya Karnataka on administrative procedures. The resource person for the day was Dr. P K Srinivasa, the lead consultant to the Government of Karnataka on implementing the National Rural Health Mission. The expectations of the participants was not so much because a senior official from the state was coming. It was because of who the resource person was; in this case, a respected and established clinician, administrator, mentor and leader within the health services.

Dr. Srinivas had started his career as a doctor trained from Karnataka’s oldest medical colleges, Mysore Medical College. He had joined the state health services early and had worked in remote primary health centres as a doctor and later in hospitals. He had risen up the long ladder stretching form a PHC medical officer to the level of a Project Director of Reproductive and Child Services for the State of Karnataka more recently. After retirement, his rich experience would not be wasted; the state continuing his services as a consultant to help implement the most important initiative these days, the NRHM. Among the lively discussions between the participants and him, was one important aspect of leadership – by example.

Dr. Srinivasa spoke of the fundamental nature of organisations; of adopting the values and principles of the leader. While most people are sincere in their work inherently, many others are fence-sitters, as he called them. They adopt the values of their leader. He also quoted from experience. It is critical for government services to produce such leaders, for in adopting these values of service and dedication, not only would they be transforming the way in which they work, but they would be transforming their entire institution.

Such is the case of the district hospital in Tumkur. The district hospital in Tumkur is an ancient one. It is one of the older large hospitals in the state of Karnataka, having been established a year after independence in 1948. By a strange quirk of fate, the then Maharaja of Mysore, Sri Jayachamarajendra Wodeyar, who was to inaugurate the hospital abruptly left the venue, for the day the hospital was inaugurated was the day that Mahatma Gandhi was assassinated. The inauguration stone that marked the occasion today lies within the walls outside the office of the District Surgeon. The hospital caters to over 2 million people in Tumkur district, and what a responsibility to manage a hospital of such a size given such a task….

Dr. Pratap Surya is the District Surgeon, the man who is at the helm of affairs at the hospital. He has indeed a mammoth task on his hands. Being the head of a large 250-bedded hospital that sees over 1000 people a day is no joke. A random sample of the patients reveals the enormous service that the hospital renders – one of the patients from Midagesi, a distant town in the taluka of Pavagada had come in search of the ENT surgeon for the chronic infection afflicting his adolescent son. He was a landless labourer from there, nowhere else to go for him; the bus charge from his place to Tumkur and back, and the wage loss resulting from a loss of one day’s work together added to quite a burden. There was another person from the town of Madhugiri, an old man who had come hoping to improve his vision by getting rid of the haze that had recently developed in his eye, a cataract. The hospital in Tumkur has an ophthalmologist and an ENT surgeon to cater to both of them. I ran into the gynaecologist, Dr. Diwakar in the corridor. He had just finished a caesarean surgery to save the life of a mother and the newborn. In this case, the newborn was positioned transversely in the mother’s uterus, thus not being able to be delivered normally; a classic indication for a caesarean section. If the mother had not reached the hospital in time from the distant village beyond Madhugiri town, the physiological process of childbirth could have been fatal for both the mother and the child. In her case, thankfully, the newly launched service of 108 had promptly brought her in time for the procedure. The woman being from a family that is below poverty line, like almost all of the patients that obtain service at the hospital had undergone the procedure completely free of cost.

The old man from Madhugiri will have his vision soon. The ophthalmologist scheduled his surgery for the upcoming batch. The ENT surgeon, who single-handedly manages the entire department will soon see the adolescent boy from Midigesi, in time for him and his father to catch the evening bus back home; he cant miss another day of daily wage. The taluka of Madhugiri could rest easy, avoiding its tryst with yet another maternal mortality, thanks to 108 and the gynaecologist at Tumkur. This was yet another routine day in the government hospital in Tumkur.

Yet, it is not automatically so. A lot of effort has gone into managing the hospital. It is but easy to target government hospitals for their poor quality of care and negligence. Easier still to say “privatise”. But, when one sees the segment of people who these hospitals cater to, we understand the importance of strengthening them; and it is not for lack of effort by the local staff that these ills plague the government system. People like the present District Surgeon, Dr. Pratap Surya are the foot soldiers of health care to the masses. Neglect and carelessness in the leader could easily have a cascading effect on the staff. But, Dr. Pratap Surya, by sending the right signals of integrity, service-mindedness and discipline – he leads by example.

Of course, there are problems. Why do poor people have to travel for such a long distance for an ENT consultation? Why wasnt the mother with a transverse lie diagnosed well in advance, so that she need not have come at the nick of time to the district hospital? Moreover, why aren’t such services available at the sub-district level itself? Why is the district hospital so overcrowded?

Thankfully, the launching of the NRHM holds promise. The priority accorded to maternal and child health and the resulting strengthening of referral units to prevent infant and maternal mortality, upgradation of neo-natal ICU’s in Tumkur district hospital, and of course the leadership by example provided by people like Dr. Pratap Surya, one can see encouraging signs of improvement. Let us hope that the efforts of several people within the system like the district surgeon or Dr. Srinivas and many others among the Tumkur district health team will result in better quality service to the poor.

On a recent visit to Chattisgarh, I had the opportunity of visiting the Jan Swasthya Sangha (JSS). This is a NGO launched by doctors in 1999. Currently there are 5 doctor couples and between them, they cover the following specialities – Medicine, Paediatrics, Surgery, Community Health, Obstetrics, ENT and Anaesthesia. Their main objective is to serve the underprivileged in the remote corners of Chattisgarh. Today, while there is a raging debate on how to motivate young doctors to serve in rural areas, it is heartening to see these 10 doctors working in the heart of tribal India, ignoring the Maoist and State violence that rages around them. Almost all of them are from urban upper middle class backgrounds, but have sacrificed this to serve the people.

Working in difficult conditions and with limited resources, they provide mind boggling services. It is customary to see patients being treated for cerebral malaria, TB empyema, intestinal volvulus, bear bites, eclampsia, acute renal failure, tracheo-esophageal fistula, … The list goes on and on. They get patients from near and far, some walking days together to reach this hospital. Other than this, the doctors have trained community health workers who provide preventive care to the far flung tribal villages. When necessary they treat patients or refer them to the hospital for further care. Other than hospital duty, most of the doctors visit the villages on a weekly basis to provide care right at the doorstep.

I have come across many such NGOs who provide services in needy places. But what makes this group different is their combination of empathy, commitment and scientific rigour. Even in this remote corner, they practice evidence based medicine, using available resources to generate local evidence. For example, they found that TB patients put on the routine RNTCP regimes returned within a year with relapses. They conducted studies and showed that the alternate day regime may not be adequate in our Indian conditions. Similarly, they were able to argue (with empirical evidence) against the Ministry of Health’s policy of witholding chloroquine prophylaxis for pregnant mothers. This matter has now reached the Planning Commission level.

Yet another activity that they are proficient in is developing low cost and appropriate technology for local problems. Patients in remote villages could not access any lab services, and so all fever cases were being empirically treated for malaria. To provide lab services, they trained their health workers to make a blood smear. This smear is then sent via the local bus and handed over to the hospital. When the bus returns back to the village, it collects the lab reports from the hospital and hands it over to the health worker. Thus the health worker is able to provide appropriate and effective treatment without resorting to shotgun therapy.

For more details about them, you can visit their website at http://www.jssbilaspur.org/ . Outlook has an article on them – http://www.outlookindia.com/article.aspx?233477

The health workers

Patients waiting to be seen at the hospital at Ganiyari

Some of the doctors

As a part of the 3rd South Asian Regional Symposium on ‘Evidence Informed Health Care’ at CMC Vellore, I had an opportunity to listen to Dr. Norman Swan, a pediatrician turned journalist, who is currently working as a health correspondent with Australian Broadcasting Corporation. The topic of his talk was  ‘use of media in public health’ with a focus on ‘why and how public health professionals (mainly doctors) shall engage with media?’. I really enjoyed his talk and herewith I am putting a few points that I gathered from his inputs.

Why Docs often avoid engaging with media?

Scared to face media?

1) They are scared of getting ‘misquoted’ by media…..
– Remember, its only you, who remember for long (and may be your employer for even longer) that you were ‘misquoted’. People at large have no interest in remembering that. For them, today’s newspaper is tomorrow’s (if not evening’s) waste paper (something to be collected for ‘pastee vala’). Remember that the average grab on television is of maximum 6 seconds!
– There is no other way to reach to millions and millions of people but using mass media.
– ‘Good journalists’ rarely ‘misquote’. It is also a result of ‘misreporting’ by us or an inherent potential of any communication (between say a doc and journalist) to get misinterpreted!
– Finally, an important (and probably only effective) way to learn to get media coverage is to keep engaging with media.

2) Media ‘sensesionalise’ issues…
– Yes, they do sensesionalise. Remember people have got hundred things to do in their daily routine and it is your job to make them realize that at given point in time, there is nothing more important than to listen/read your story! You often  literally have to grab them, shake them, and make them to listen/read to your story.
– Remember, a journalist has to strive for a not so easy daily struggle with editor to get space for his/her story.
– A good journalist will in fact sensesionalise the story by stretching the evidence to its edge (and not crossing the line! that comes only with experience).

Dr. Norman Swan

Why to engage with media?
– It is the only way to reach really large number of people. Most basic thing that we must do (and of course people have right to get to) is information. Probably it is unethical not to provide information (from your research or whatever) to large population for whom it matters most.
– To learn how it works and how you can get media coverage for issues of public interest. The question is ‘why not to engage with media?’.

How to get media coverage?
Probably 3 important things are 1) what to target? 2) How to tell a story? and most importantly 3) Understand how media works.

1) What to target?
– Remember that in a country like India (where a large segment of population can’t read), broadcasting media has potential to go beyond the reach of print media. ‘Radio’ is still an important source of information to reach ‘hard to reach’ population.
– Most broadcasting media start their story search from print media! Better to target the story strategically to an important media form and then let story spread from there, rather trying to share it to  ‘all’ and ending up with little (or ‘no’) coverage.

2) How to tell a story?

– Use personal stories or ‘case study’ to explain your phenomenon. We all are emotional!
– Use ‘numbers’ in a way that people can comprehend. Try to turn/compare numbers with things that people are more familiar with  e.g. (for Bangaloreans) In India deaths from tobacco use are so many that it is like  a couple of BMTC buses getting rammed over eavery minute with no one remaining alive!
– Use more ‘quotes’ and not a simple descriptive story.
– Use negative  rather than positive angle of the fact. It evokes stronger emotional reaction. What will make you worry most?; you benefiting hundred rupees without any effort OR you loosing a hundred rupee note!

3)Understand how media works…

– Remember! Journalists are busiest people and are not interested in coming over lunch or dinner but in a good story told over phone or a coffee table! They have few hours in a day to line up stories before editor.
– If you understand and respect this fact, they understand and respect you!
– Engage with an objective of providing information (Not being staunch advocate!)
– They identify their ‘experts’ not on very rational basis but ones who 1) are good communicators 2) are readily accessible 3) can direct them to relevant sources even if they themselves do not have needed information 4) respect their schedule and understand their demands.
– We all rely on intuitions and do not think rationally as a routine and still most of the times we get it right. Do we think of  ‘Cochran’s systematic reviews/met-analysis’ while passing through African savana and noticing a grass movement calculating  the probability of it being a tiger!!!

So Shall We Have a Media Strategy at IPH ?

The Institute of Public Health has taken on the responsibility of running a Citizens Help Desk (CHD) in the district hospitals of Bijapur and Bagalkot in North Karnataka. These CHDs are part of the innovations under the National Rural Health Mission.

The following stories are just a glimpse of life in a district hospital.

Money matters

In Bagalkot, an accident case was brought to the hospital. The person who had been hit was carrying a bag with one lakh rupees. As it was a road accident, it automatically became a police case.

When the patient came to hospital, and he was being searched to find out his identity, the money was discovered. The accompanying police constable immediately wanted to keep the money, though he was willing to share it with the others. Luckily for the victim, the CHD manager was present and with the support of the medical officer on duty was able to keep the money safe.

…And the hospital is a cleaner place

Most public places in India these days are characterised by hundreds of tiny plastic cups discarded after the ubiquitous tea has been consumed. This was also the case in both Bijapur and Bagalkot hospitals; till the time the CHDs decided that there was a need for cleaner hospitals. They simply worked with the hospital authorities and banned the chai wallah from entering the hospital premises. Henceforth, whoever wants to drink tea has to go outside to the stall and drink it. The patients get tea inside but out patients and others cannot drink inside the hospital! And the hospital is a much cleaner place.

It is possible to use the toilet now!

One can usually smell a public toilet from quite a distance. If the toilet is in a hospital, then it is much worse. One can go into the sociological reasons of why people do not use toilets the way they have to, but most of the times, it is simply because there isn’t enough water in the toilet to keep it clean.

These district hospitals were also in the same situation, not just the ones for OPD but even in the wards. So much so that the staff nurse used to refuse to sit in one of the wards due to the smell. The patients of course had no such choice.

The CHDs decided that this was yet another issue that needed to be addressed. They raised the issue with the hospital administration and they were able to restore water supply in the toilets making them usable.

And the PHC called us

It was a normal day at the CHD. The telephone rang. It was the doctor from the Jamakandi Community Health Centre calling us for assistance. He had a patient who needed a hernia operation; but the patient was a little worried about being able to manage in the hospital. So the doctor called the help desk to say that he was sending the patient to the hospital with his reports asked the team to help with further treatment. It is on days like this that team feels accepted by the government team.

And we felt helpless here…

It was the middle of the night and a patient came for delivery. She was in a serious condition and had come from far. The duty doctor simply refused to admit the patient and turned her away saying that they did not have the means to do the delivery in the government hospital. The patient’s caretakers took her away to a private hospital. The CHD volunteer tried to intervene but it did not work.

Later, it was learnt that a healthy baby was born, but at a far greater expense.

But, here we managed to help…

It was evening when a rural patient arrived; again a delivery case, again the doctor refused saying there was no blood. The CHD volunteer was better prepared this time; he called the District Surgeon who asked him to intervene and help the patient and contact the blood bank. By the time the district Surgeon arrived, the blood had been arranged for and the patient admitted. Another healthy child born.

The District Surgeon was also appreciative of the CHD work.

No change

The cost of registration at the hospital is Rs 2 and the cost of an X Ray is Rs 50. The persons at the Bijapur counter were over charging – not returning the balance from the registration and keeping the change so that the registration cost became Rs 8 or 18. For an X ray, they would charge upto Rs 100. Several patients complained to the CHD. The CHD manager took the complainants to meet with the District Surgeon who transferred those people.

Useful links:

It is no measure of health to be well adjusted to a profoundly sick society.

Jiddu Krishnamurti

Gubbi, a Taluka headquaters in Tumkur district

Gubbi is a small town in Tumkur district in Southern Karnataka. Gubbi Veeranna, one of the well-known theatre personalities from Karnataka who started the first Kannada theatre hailed from here. Historically, the town was well-known for its local markets for cotton and areca nut. As early as in 1871, Gubbi was a municipality of its own. The Imperial Gazetteer of India in 1871 talks of the monthly ‘jaatres’ or fairs which were well known for the sale of cotton cloth, blankets, rice and other articles from as far as Malnad (the mountainous monsoon-fed wetlands to the west) to the dry areas of Rayalaseema and the low hills of Arcot to the east and South. Today, Gubbi is a taluka headquarters in Tumkur district and is one of the ten talukas in the district.

Gubbi is about 20 km from Tumkur and is situated along the highway to Honnavar from Bangalore, that passes through Tumkur. The taluka hospital of Gubbi is along the highway passing through the town. The Administrative Medical Officer, the doctor in the hospital tasked with managing this hospital is Dr. NL Dani. The hospital was a Community Health Centre earlier with 30 beds being upgraded now to a 100 bedded hospital.

Dani is one of the participants of the capacity-building programme organised by IPH and its partners in Tumkur. Dani is a paediatrician by training with three decades of experience. He is today managing a 100 bedded Taluka hospital. His hospital sees over 200 patients in a day, is severely understaffed and morbidly overloaded. In these days of panchayati raj, he is answerable not only to his superiors in the hallowed chambers of the directorate in Bangalore, but also to the representatives of the people in the narrow chambers of the Gubbi Taluk Panchayat.

Gubbi Taluka Map

The hospital provides out-patient services to nearly 200 people in a day. In these days where there is a beeline towards corporate hospitals and having busy evening practices, it is heartening to see Dani and his colleagues in Gubbi hospital providing services within the constraints they face; and these are many. Dani conducted a study in his hospital to understand patient satisfaction, as it bothered him that most of the people obtaining the services at Gubbi hospital were reporting that they were not happy with the services. Was there truth to this?

Dani approached it very scientifically. He did not take this for granted. Nor did he cursorily conclude on the reasons for patient dissatisfaction. He conducted a study consisting of exit interviews of through a structured questionnaire. Patients were recruited into the study randomly. He considered the following aspects in his questionnaire:

  1. Staff availability of patients
  2. Basic amenities like toilets, drinking water, ambulance services and drug availability
  3. Patient safety in hospital – infection control, physical safety of women and children
  4. Perceptions of cost
  5. Administrative and procedural problems

The questionnaire confirmed his hunch about dissatisfaction. Presenting the results in Tumkur, Dani also shared the possible reasons for this. On an average, each doctor in his hospital sees over 70 patients in a day. Many of these, of course are specialists who are supposed to be giving a lot more time than they can to these patients that are referred from primary health centres. However, these patients needing specialist care are clouded by many others who come here for routine health problems. There is no referral system in place.

Dani in his study prepared hospital performance indicators for all departments – in-patients, specialities, CSSD etc. He identified issues in human resources, infrastructure and a few other issues as key reasons for the patient dissatisfaction. He found that staff motivation was poor. Also, he was working in a severely understaffed hospital. Recruitment to the hospital happen in Bangalore. While it is easy to upgrade the beds from 30 to 100, finding the requisite support staff and motivated doctors to work here is another story. The district is helpless to fulfill existing vacancies. In addition, he found that supervision was poor. The doctors and other senior staff could hardly devote time to supervise and hand-hold their non-clinical team. Where is the time for management of the hospital?

In addition to doctors not being available in good numbers, the amenities provided were also poor. Residential quarters were not available for all the staff. The hospital lacked good water and sanitation facilities. A reception counter itself was not there.

This was of course a small study done in a small taluka hospital, one among over a hundred taluka hospitals in the country. However, the issue Dani identified for his study, ‘patient dissatisfaction’ is a universal phenomenon in public health services in the country today. In India today, irrational health practices and expensive health care is becoming a feature rather than a problem. Government-provided health services is the lifeline for millions of poor, who depend on these, and for whom health expenditure is often catastrophic. The reasons Dani identifies through his study are also quite representative of hundreds of other taluka hospitals.

Doctors in government services work with many constraints. Staff are demotivated. There is always pressure from elected representatives, sometimes justified, and other times not. Teamwork is lacking and the work environment is not always cheerful or fulfilling. Yet, there are people such as Dani in many of the small hospitals in the country, whose toils go unheard, and whose stories go unsaid. Yet, we often see the glamour and glory that many a corporate hospital catering to a much smaller proportion of people get.

Here is a doctor who in the middle of taluka meetings, trainings, reviews and visits by superiors, also manages a busy out-patient services as a paediatrician and is expected to manage a 100-bedded hospital for a taluka. In the midst of this, he keeps his spirit alive and did a study to understand and document patient dissatisfaction. We hope that Gubbi finds more specialists and most importantly, committed people like Dani.