Sunday, May 1, 2016

Uttarakhand diary

Forest fires between Ramgarh Malla and Bhimtal
Smoke rises from fires near

The mountains are on fire. Literally. I was in Nainital district for a week, and smoke haze lay thick in the air. Driving up from baking hot Kathgodam last Saturday afternoon, the driver Dinesh tells me the Gaula river running past the town has been dry for some weeks now, and each year there is less and less water in it. Our destination is a village called Khansyu in Okhalkanda block in Nainital district. The normal route is past Bhimtal, but Dinesh seeks an alternative, longer route as the Bhimtal road is blocked, and there are many fires along the Bhimtal road.

I try to ease my nausea induced by the numerous hair-pin bends by lying down in the rear seat of the taxi, but it not helped by the acrid smell of wood smoke. In some places the smoke smells of pine. We drive past tree trunks charred and still burning.

The dry river bed of Gaula river near Khansyu
Khansyu is in a valley in Okhalkanda block. The Gaula river flows at the base of the valley, and is completely dry. This is the river that supplies water to Kathgodam. Nain Singh, the local co-ordinator of the project I am visiting, tells me that in the six years that he has been here, this is the first time it has run dry.

The place is beautiful, layers and layers of mountains all around. That evening, though, I see a fire creeping up the hill opposite. I cannot see other fires, but I know they are there. The next morning, the valley is full of a smoke haze.

A fire creeps up the hill near Khansyu
Smoke haze in the valley at dawn.
The reason for the fires are discussed locally - was it the locals who tried to burn the grass? Was it the dry winter with no rain at all? Is it the pine forests that help to spread this fire far and wide? Some blame the pine (an import by the British) for it all, saying it depletes ground water, does not allow other trees to grow, and that it is highly flammable.

There is a terrible water shortage in Khansyu and the villages around, and indeed all over Nainital district. Water is guarded jealously, and having your water tank emptied in the night is not unusual. During the week I was there, water was supplied twice.

Driving back to Kathgodam on Friday, we cross large tracks of mountainside that have already burnt out - blackened tree trunks (some still smoking), an eerie silence with no bird calls, no crickets chirping, and an overall bleakness. Would the earth look like this after a nuclear holocaust, I wonder - such total desolation?

Closer to Bhimtaal we see and hear fires again, and just a few kilometers before Kathgodam I spot large areas of mountainside that have been sheared clear of trees and dirt. Landslides during the monsoons last year, Dinesh tells me. They stand out as ugly white streaks many metres wide, against the brown and green of the mountainside, ending in a pile of boulders at the bottom of the valley.

The mountains are achingly beautiful, but how long can we preserve them that way?

5 pm: Just received the sad news that Nain Singh's landlord died on Saturday, trying to save people of his village when the fire threatened to engulf their homes. He sustained 80% burns and was taken to the hospital in Haldwani, but could not be saved.

Thursday, April 7, 2016

Where do we go from here?

Bicky, 9 and his sister Vaishali, 6, are children of a gardener who works for our landlady downstairs, as well as for several other house owners in this relatively better off part of Bhopal. They are both first generation learners, their parents having moved to the city to give their children a better education than they could get in their village. You can see them last year, elated with their new uniforms and ready for the new school. (They moved schools to one in the neighbourhood, when their parents moved to live in this area).

Vaishali and Bicky, 2015
Bicky is in Standard 3, and is in a Hindi medium private school. He is not able to read simple words in Hindi, nor construct a sentence. His English textbooks have been selected by the school, and have words far beyond his comprehension, telling stories that he cannot relate to. While he struggles to spell "table" and "door", his English textbook talks of the "quest" of a prince in search of the "most beautiful princess in the world" and of the beautiful girl who knocks on his palace door on a night of "torrential" rain. 
Bicky can neither spell or understand what all this is about. Yet his workbook is complete, and correctly done. 
How is this, I ask him. 
The teacher writes the answers on the blackboard, and we copy them down, he says. Then she marks them as correct. 
His parents send him to a tuition teacher each afternoon, paying the same amount as the the school fee each month. 

Vaishali is in Standard 1, and her parents put her in the English medium section of her brother's school, hoping she will have an advantage over others studying in the Hindi section. She has a problem recognizing alphabets and numbers, though her English workbooks, too, are full of words copied from the blackboard and marked as correct answers. However, her maths skills are passable, and she can do two digit addition (don't ask her to recognise and name the numbers, though). She is in a class full of upper middle class children in this neighbourhood, and is not getting the extra attention she needs to learn. 
She, too, attends the same tuition classes her brother does, and neither seems to benefit from the tuition one bit. 

When they come upstairs to study, I keep trying to make sure they learn their basics, while they are under pressure to prepare for the test the next day. I am aghast at the quality of teaching going on in their schools, and how they and their parents are being cheated. If they cannot be provided a proper primary education, where do they go? Who regulates the quality of teaching in all the small neighbourhood "private" schools that spring up like mushrooms everywhere? 

Don't we owe our next generation anything? Can we honestly look these children in the eye and say we have given them a fair chance?

Tuesday, December 29, 2015

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.

Friday, April 3, 2015

'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.

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, 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.

Tuesday, December 30, 2014

...and the follow-up

Following my blog post below, a friend brought it to the attention of officials in the Health Department who took a serious view of the matter and ordered an inquiry. All the nurses on the evening shift that day were called, and Meera's case sheet was also reviewed.

The day before the inquiry, Meera's husband received a call from a woman who said she knew they had complained, and that they should come the next day to the committee and withdraw the complaint as it was a question of possibly losing her job. Meera and her family were too scared to testify or even to stand in front of a committee to deny anything. (In fact, they had not formally complained -Meera's sister had told me about their experience as a matter of course when I asked about Meera). They did not turn up at the inquiry to identify the nurses.

The nurses (as expected), all denied that they had taken any money, alleging that the family had  complained since they did not see Meera as often as the family felt they should.

An examination of the chart revealed no entries apart from admission details a day before the delivery, and the delivery details (over 24 hours later) about the baby weight and condition. There were no notes about her progress of labour,  nor any notes about the baby and mother during the 48 hours Meera remained in hospital after the delivery. The first page does not even have the date on which she was discharged from the hospital.

All the nurses on shift that day have been transferred out of the labour room and the maternity ward, pending a more formal inquiry.

One of Meera's neighbours who recently delivered at the same hospital said she had heard someone had complained and there was an inquiry and nurses had been transferred. The ones now in the labour room had treated her very politely and no one asked for any money, she told Meera.

A good first step, sending out a message that such actions will not be condoned. One hopes that the quality of care and record keeping is also pursued with equal vigour. 

Sunday, December 7, 2014

a hospital delivery

The young woman who helps me in the kitchen was pregnant with her second child and went to one of the Government facilities in the city here in Bhopal for the delivery. She is an undernourished woman who works much more than she should. In her first delivery she bled heavily and needed three units of blood transfused. This is her second child after a gap of seven years. Let us call her Meera.

She was in hospital for three days, having had leaking of the amniotic fluid, and therefore unable to just stay at home. A doctor saw her once on the second day of her admission and told her all was well. When she was in pain and wanted to go to the labour room, the nurses repeatedly turned her away, saying they would call her when necessary. Four other women were admitted in the same room as her. Her older sister (who is also expecting her second child) stayed with her in the evenings after she finished her round of domestic work. On the second day, one of the women delivered a dead baby, which worried the remaining women. On the third day (Wednesday) Meera's pains increased in intensity and the nurses would still not examine her.

Meanwhile, the woman in the next bed (a primi - first pregnancy - who had been admitted for eight days) went to report to the nurses that she could not feel the baby move for the past hour. The nurses scolded her and sent her back to the bed. When her husband arrived in the evening, she informed him and he went and raised a ruckus at the labour room door. At this, one of the nurses came to examine the primigravida, listened for the baby's heartbeat, and then informed her that the baby was no longer alive.

Hearing this, the remaining two women in the room were taken away by their relatives to some private nursing home. Meera remained alone in her room, and when her sister arrived, told her all about this, as well as about her increasing pains. Her sister was scared now, and they did not have the means to go to a private nursing home. She went up to the labour room nurse and offered her Rs. 200, asking her to examine her sister. The nurse told her the amount was not enough. Meera's sister assured her that she would bring the rest of the money later, and the nurse told her that in that case she would also examine Meera later. The sister collected some more money and finally offered the  nurse Rs. 500, after which she allowed Meera to enter the labour room. A second nurse was standing and glaring at them, so she was given Rs. 500 as well. She was warned not to tell anyone that she had given them money, or else "acchha nahi hoga" (it won't be good for you). The delivery then proceeded, and Meera gave birth to a healthy baby boy on Wednesday night.

"That was the only expense at the hospital", Meera's sister told me yesterday when her sister was discharged  -"the hospital provided good food three times a day to my sister, and all the medicines were free. Only problem is that the nurses are very rude, and to enter the labour room we had to pay the nurses Rs. 1000. I had saved it for my own expenses during delivery, but had to spend it.You can be sure I am not going there for my delivery. I don't know where I will go but not to that Government hospital."

Saturday, November 29, 2014


i have just returned from a short trip to malkangiri district, dipping my toe there, i guess. i went to the district headquarters for a day, and spent the next three days in mathili. we chose mathili as part of a study since it happened to be the block with the highest proportion of tribal population in the district.

we drove through beautiful forest, and along a river and several streams, the road being a single road and bumpy for most of the way. once we were stopped by some BSF jawans, complete with bullet-proof vests, automatic rifles, and sniffer dog - and asked about where were coming from, where we were headed, etc. but apart from that, though we met them at various places, we were not stopped anywhere. there is a heavy presence of security forces in the district.

View from the road.
i went to the district headquarters for a meeting (huge no of vacancies there in all sectors), and to mathili block where i went to a nearby village called kosabahal, and a V4 village called puttugaon. everyone we met cautioned us to return to the main road before it turned dark, due to security reasons. our choice of village to visit was, therefore, limited by this factor too.

mathili block has had 6 maternal deaths since april this year - those are the reported ones. this is worrying. the universal complaint even in balasore  was that 102 does not respond, that janani express was much better as it was decentralized and the woman could reach the hospital at least.

The UP school at Puttugam

puttugaon lies in a shallow valley and is accessible now with the construction of a bridge and a culvert, but even so, we could only get there over a deeply rutted kutchha road - vehicles will be mired in the mud in the rainy season - all the deliveries seem to be at home since once it is dusk the ambulance refuses to come there. even in the daytime, it often takes so long that the woman delivers before the ambulance arrives. women in labour, or other sick patients have to be taken on a motorcycle, or carried the 12 kilometers to the  roadside.

everyone - men, women, adolescents - are all illiterate, they had no clue about why open defecation can be a problem or what problems unclean water can cause. the men, however said open defecation is now a problem since the forest has been cut and they have to go far for it. the women understand oriya but spoke in a dialect that we could not understand. i can see where basic communication can be a real problem. most of the men spoke oriya.

School student helpline number displayed prominently
there is a school in the village - with over a 100 children between grades 1 and 8, and three teachers. the teachers say they cannot control the students ever since they have been told they cannot strike / slap / beat the students. the students come out learning nothing - but did the beating ever result in better learning levels? but they have convinced the parents that their children's poor literacy skills is the not the their (teachers') fault. the teachers all come from far away - i am not sure how may days a month they actually turn up. and i wonder how many of them can communicate with the children in their dialect to teach them anything....

the encouraging thing here was that everyone eats the chatua (which is the supplementary food provided by the ICDS to young children and pregnant and lactating mothers)even if all members in the family share it, in contrast to balasore where no one did.  and a young 22 year old ANM, who passed out 2 years ago is living in the village. she is from malkangiri and trained in koraput. orissa took a decision a few years ago to open nursing schools in the tribal districts and take only tribal students, in an attempt to try and overcome the problem of absenteeism - it seems to be paying off. this ANM who looks more like a high school student, has conducted several deliveries in the village.