Deliberate Ignorance

Another month of Rural Posting under Department of Community Medicine.
I've chosen Primary Health Centre in Handignur, an agricultural village 20 km away from Belgaum.

After working there for 3 days, I'm not sure whether to be surprised or not, to realise that those who are in charge of seeing the patients are prescribing medicines rather inadvertently.


We had more than 100 patients in the OPD today. 
The pharmacist came to help as well. And she saw patient faster than I did.
I'm not impressed. 
Why? Not because of my language barrier I see patient slower.
Because before the patients could finish telling their complaints, she already threw the medications in front of them with instructions given faster than a bullet train, and called for the next patient.
Any old patients with bodyache, joint pain, Tab. Diclofenac BD.
Anyone with pain abdomen, Tab. Dicyclomine.
One patient had a right sided abdominal pain. Before i could ask more, she threw (YES, she threw) the drugs in front of him and sent him off.
I couldn't even call him back because the whole OPD is congested. Patients kept pouring in. And they don't sit down and wait. They crowd around you!
I couldn't even get up from my seat. They just pushed their way through and pressed their OPD slips right in front of you.


I can totally understand that these villagers are illiterate, uneducated, ignorant, and sometimes stubborn. 
They come demanding for injections for every single complaint, right from fever to flu to bodyache to cuts. 
Most of the times, these injections are not required at all. Instead of explaining to them patiently about their illness, the suitable treatment given and why they do not require injection, those who are working in the OPD just give them an injection, simply a Diclofenac IM, or Cyanocobalamine IM, just to shut them up and send them away.


Yes, i know. They are uneducated. They will never understand. 
They think that injection is the miracle treatment. 
But if no one ever explain to them, sensitize them, remind them, make them understand, obviously they will never know. It is not something which can be achieved in just one day. It is a long process. 
But nobody ever seem to make an attempt. 


Blame it on the montly rotation? 
Interns work for one month and the following month next batch of intern comes. New faces every month. 
Patients try asking for injections again, and also tell you that the previous doctors used to give them injections. 
To save the trouble from spending 10 minutes explaining to them, most people choose to ask them to lie down, expose their butts, load the syringe and poke! Easy! Takes hardly 60 seconds.
Even the Boss adopts this approach. He is the only person who has been permanently working at this place. Patients know him, and they trust him. He says "Give injection", what can you say?


Fine. Injections. With safety precautions, risks of infection can be avoided. The drugs given does less harm than advantage to the patients. They are vitamin deficient anyway. It eases their pain, and also acts as a placebo. I shall say nothing.


What about prescribing antibiotics for only 3 days? Reason being, these people won't bother continuing taking their medications after they get slightly better. So why waste medicine.
So, the instruction given is : NOT MORE THAN 6 TABLETS OR CAPSULES SHOULD BE GIVEN. 
Instead of Amoxicillin 500mg TID for 5 days, BD 3 days is given.


Well, if patient is not compliant, we can't help it. But at least i think we could have tried explaining to them to create the awareness of completing full course antibiotic.
But when the doctor/pharmacist is the one who prescribe an incomplete course, it is a whole different story. We are the one responsible for causing the emerging and worsening of drug resistance.

I really thank my post graduate who have guided me while i was posted in Khasbag Urban Health Centre last month. She is one doctor whom i look up to. She warned me about Antimicrobial Resistance, which is the theme of 2011 World Health Day. She is one doctor that i see talking to the patients very patiently, telling them every detail of their illness in the simplest way they can understand. She never raises her voice at patients. She definitely makes a good Community Medicine doctor. And I think a good doctor should have these basic qualities.


How i wish i could speak the local language better, so that i can speak to them better.
Though i can manage with my broken Kannada and Hindi, majority of the villagers in Handignur speaks Marathi, as it is close to the Maharasthra border. I need to pick up another language in a short time to make myself useful for this one month. Wonder if it is even possible. But I'll try.

A professor of mine once said, "You don't need to be such a hero, to try save the lives of a hundred people and hurry through all of them, but neglected most of them. All you have to do is give your full attention to that one single patient you are attending to at a time, give him the best you can. That is suffiecient."

Negligence

Was posted to Under Five Clinic.
My job is to weigh the kids, measure their heights, plot their growth charts, ask about their diet, schedule them for immunization, ask their parents if their child is ill.
Easy job. Stress free.
Senior doctors are also there, to manage more complicated cases, which is however, hardly any.

The first child of the day came. 14-month-old. I weighed him and checked his records. His weight has been been same in his last 4 visits (months). 9kg.
I thought, something must be wrong with the bathroom weighing scale. I set it to zero and weighed again. Same. I put him on the infant weighing scale instead. It showed 8.5 kg.
Whether is it 8.5 or 9, he is definitely underweight. He should be weighing at least 11 or 12 kg. On top of that, his growth curve on the chart has been plateauing since the past 4 months. This is the earliest sign of malnutrition.
I tried to ask the mother about the childs diet, eating pattern, so that I could advice further. I was attempting with my super broken kannada. She couldn't understand me. I tried my hindi, she knows only kannada.

Feeling useless, I seek help from the community medicine postgraduate, who was posted together with me. He looked at the chart, and said, "It's ok. Nothing serious." And he sent both of them off and continue reading his newspaper.
I told him again, "Sir, his weight has not been increasing for 4 months.".
He got a little irritated, "Ya ya, it's ok."

I could do nothing. I was thinking to myself, 'Are you kidding me? What's the point of running an Under-5 Clinic, if you could detect malnutrition at the earliest but do nothing about it, just because you are to lazy to do the already very easy job.

We know many of them are uneducated, or unaware about their children's growth adequacy, nutrition, hygiene, etc. To prevent severe malnutrition which are not treated in its early stage, we do primary prevention, i.e. Growth monitoring. Even health workers are trained to pick up this skill. It is anyway nothing difficult. This it's the main aim of Under-5 clinic, Anganwadis, to tackle this problem at the so-called 'grassroot level'.

But when a qualified doctor, a soon-to-be community medicine specialist, who is sitting in a tertiary hospital, does not bother about spending a little extra time and effort to look into one child's nourishment, do you think others, especially those posted to the rural areas, won't have such similar attitude.

I feel bad for the parents who are willing to bring their children, monthly, for growth monitoring, but not only they are not told about the problem they will be facing, the doctors in whom they trust don't give a damn about them.

How do they expect improvements in healthcare when the attitude of the healthcare provider is so disappointing?