The Rediff Special/A V Ramani
Should I Have Left Her There?
Sombari and Arakhita Sabar live in Saura Hatibadi, a small hamlet in the Mahendra hill range in the Gajapati district of southern Orissa. The hamlet consists of twelve households and every one of their residents seemed to be
gathered at Sombari's hut when I got there that winter night.
I had been called by Sasikala, a field worker in Gram Vikas's Koinpur
project area, to see Sombari's baby who had fallen sick. Pratima was nine
months old and Sombari's first child. She had developed diarrhoea a few
days earlier and for the past three days was paralysed -- could not move
her limbs, nor swallow. Her parents had taken her to Goppili to a private
practitioner for treatment, but she had not improved.
I went in with Sasikala to see the baby. The room was warm with so many
people inside and was lit by a lamp made of a wick in a bottle of kerosene.
Sombari sat on the floor and invited me to examine her daughter.
I was shocked to see Pratima. I had seen her barely two weeks ago and she
was an active, healthy child then. Now she lay limp and unconscious on the
mat, her neck retracted and her eyes sunken deep into their sockets. She
was severely dehydrated, had pneumonia and was paralysed. Her parents
explained that they had taken her to the best doctor in Goppili who had
prescribed very expensive medicines; they showed me the array of tonics and
vitamin supplements and antibiotics that they had bought. But, they said,
it was of no use as Pratima could not swallow. So then they borrowed money
to do a puja, hoping that would help; but it hadn't. Only this afternoon
had they noticed that she could swallow occasionally.
Pratima was critically ill, and she probably had Guillain-Barre syndrome --
a paralysing disease which sometimes follows a viral infection. Though most
cases resolve spontaneously within a few weeks, death often occurs due to
respiratory paralysis, or a lung infection. Pratima had already developed
pneumonia and she was extremely dehydrated as she could not swallow. The
key to survival in such cases is good nursing care including feeding
through a naso-gastric tube, antibiotics to fight the infection and
respiratory support if necessary.
I asked Sombari and her husband to take Pratima to the district hospital in
Parlakhemundi, 40 km away. I would not be at Koinpur to look after the baby
even if we took her there. Besides, I thought the problems of dehydration
and infection could easily be managed at the hospital.
After consultation with their relatives and borrowing some money from me,
they got ready to go to Parlakhemundi. The ride there was slow as the road
is in terrible condition. We kept stopping every few minutes so that
Pratima could be given some 'pejo' or rice water which her mother had
brought along. Though she could swallow with difficulty, I was hopeful that
she could take in enough to survive till we reached the hospital and could
have a naso-gastric tube put in.
A Saturday night is not the best time to find doctors in the hospital, and
I found to my dismay that Dr Tripathy, the paediatrician I knew, was away
for the weekend. After a short wait, the doctor on duty examined the baby,
confirmed my findings, referred the patient to the paediatrician on call,
and vanished. The baby was meanwhile admitted into the ward.
I went in to see her, and found that she had been allotted a bed with a
filthy mattress with no sheet on it. Sombari had spread the palm-leaf mat
she had with her on the mattress, immediately incurring the wrath of the
ward nurse who scolded her for doing so. As soon as she noticed me there,
however, she hurried away and returned with a sheet, grumbling that "these
tribals" were dirty and could not keep things clean. She then asked them to
buy a rubber sheet the following day, so that the sheet on the bed would
not be soiled by the baby. When I asked whether the hospital did not
provide rubber sheets in the children's ward, the nurse looked annoyed and
told me they were all in the store which would only open on Monday.
The paediatrician on call arrived and examined Pratima cursorily. He
noticed that one of her feet was swollen a bit and declared that this was a
case of malnutrition. I tried to explain the history to him -- that she had
been perfectly well when I saw her two weeks ago, that she had developed
this paralysis after the attack of diarrhoea. When I pointed out that she
had lost head control, the doctor triumphantly said -- "I told you, it is
malnutrition: that is why she has poor muscle tone." He then prescribed
antibiotics for the child and ordered some investigations for the following
I left the hospital and Pratima's family there with some misgivings, but
consoled myself with the thought that she could at least swallow, and so
might just pull through with adequate care. I returned to Koinpur by
The following day, Sunday, was a busy one. I left for the Gangabada cluster
by 8 am and it was past 6 pm by the time I returned. I had to return to
Mohuda on Monday morning, and decided to stop at Parlakhemundi on the way
to check on Pratima.
I looked for Pratima's progress notes and did not find any. There was a
single entry stating that her haemoglobin was 9.0 gm%: that was it. I
could not believe my eyes -- this was a critically ill patient, and there
was nothing to show how she was progressing in the hospital. I asked the
nurse whether Pratima's case record had been misplaced, or mixed up with
someone else's. But it hadn't. And the nurse was getting impatient with me:
"Why do you bother?" she asked. "Anyway, they have gone."
The doctor lives just opposite the hospital, and I went to call on him to
find out what had happened. He has a house with a neat little garden and a
separate room from where he runs his private practice. As I waited for him,
I was joined by several well-dressed patients and their children. No
After 9 am, the doctor emerged to start his clinic. He saw me standing
there and promptly went back into the house. Re-emerging from another door
a few minutes later, he scolded the waiting patients, saying he could see
them only in the hospital. Of course.
I asked him how Pratima had been over the weekend. He was blank for a
moment, and then recognition dawned. "Oh, you are the one who brought that
tribal child with malnutrition! Well, you cannot expect recovery so soon. I
have asked them to buy powdered milk and some tonics. These people are so
ignorant, they do not feed their children properly."
I made a last desperate attempt to tell him why I did not think Pratima was
malnourished, but he wasn't listening. I returned to Mohuda filled with a
sense of hopelessness, wondering what had happened to Pratima.
I found out two days later. No doctor had come to see her in the hospital
over the weekend. Pratima had got steadily worse, so her parents had
decided to take her back to their village early on Monday morning. She died
in her home that same afternoon.
I am still haunted by doubts about my decision to refer her to the district
hospital. Maybe I should have taken her to Koinpur and tried to do
something with the very limited facilities we have there? Why did I not
argue and insist on what I thought was the proper treatment? Could I have
remained in the hospital to ensure proper care? I have not pursued the
matter with the hospital authorities -- should I? Is this the best we can
offer at a district level health care facility?
When my colleagues heard the story, they were furious at the treatment
meted out to Pratima. Had they been in my place, they said, they would have
hit the doctor. Why was I not more aggressive? Have the years of dealing
with this system taken the fight out of me? The thought that tomorrow I
will have to refer another patient to this same place (and maybe they will
be lucky enough to get proper care); and that I rely on this hospital to
supply anti-TB drugs to the many tuberculosis patients I diagnose each
month -- does that restrain me from being more aggressive? Is there any way
to improve things, other than starting a parallel health care system? I
have tried to work with the government system as it exists, but am I doing
justice to the patients I see? Do I tell them: "Look, this is all that your
Government provides for you, so hard luck"? The situation caused by the
pitifully inadequate facilities and supplies is worsened by the callousness
of the doctors. Do I begin to educate Sombari about her rights and
encourage her to sue the doctor?
And what if she and her husband and others like them tell me what my staff
did a few months ago: "They will only understand fear. Unless we are
violent, nothing will improve." Is violence, then, the only solution?
I can't answer the questions, but Pratima's death lies uneasy on my
A V Ramani is a MD in Community Health from the Christian Medical College,
Vellore. She spent 4 years working for Gram Vikas, a NGO in Mohuda, Orissa.
The Light of A Lantern
A death in the dispensary
This One Child
Tell us what you think of this report