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The Rediff Special/A V Ramani

Dear Diary: What Happened To The Blood Bank?

4th May 1997

As I kneel on the floor of the dispensary, knife poised over the huge abscess on Hiramani's right hip, I have a sense of deja vu. This is Rauna all over again, only several degrees worse. Rauna, an epileptic and deaf-mute, had been brought to our dispensary three years ago by his parents, delirious due to an abscess on his thigh. The abscess had developed from an injury sustained during one of his seizures. Rauna had a slow and painful convalescence. But he recovered, is on antiepileptic medication and is a healthy, active teenager now.

Hiramani is also an epileptic. Fortunately, she is otherwise normal. She lives in Laupur village in Rayagada block in south Orissa. She has not been on antiepileptics so far. Consequently she has frequent seizures and injuries herself: falls from trees, falls while fetching water or firewood, and often in the confusion following the seizure, wanders away from home.

She lives with her mother and her stepfather -- an alcoholic who regularly beats both her mother and her. Hiramani often runs away to her grandmother's house in the neighbouring village of Kinchiling. That entire village embraced Christianity a few years ago, and Hiramani's grandmother did so too. Now, when she returns to her own home, her stepfather does not allow her to step inside as she has been to a Christian house. So Hiramani lives on the tiny verandah outside her parents's hut.

She has never been seen by a doctor at the PHC (Primary Health Centre), nor by the nurse who is supposed to visit her village every month. Indeed, no one knows who their village ANM (Auxiliary Nurse Midwife) is. The nearest primary school, sans teacher, is several kilometres away, and no one asks why Hira is not attending it.

She is nobody's concern.

Two weeks ago, Hira burned herself on her legs during a seizure. She then went wandering and was caught in a storm, came home and lay down on the verandah. She soon developed pneumonia, and badly infected burn wounds. The infection travelled in her bloodstream and caused abscesses to form in several parts of her body. Hira lay delirious, too sick to eat or move, and so developed pressure sores as well. Since she was also severely anaemic, her body began swelling up as she developed heart failure.

Laupur village gave her up for dead. When I saw her on the 3rd, they had cancelled a celebration in the village as they expected she would die, and it would be unseemly to be celebrating at such a time. Hira lay there, pale as a sheet, her breathing shallow, barely conscious. But she did not die. Her mother confessed her inability to bring her to the dispensary at Koinpur, but went over to Kinchiling and brought the grandmother to accompany Hira.

We started Hira on antibiotics last night, and kept watch over her. Now here I am, about to drain the abscesses. I am worried that she will die of heart failure before the sepsis kills her. What she needs urgently is blood -- that will give her a fighting chance at survival. Sanjukta urges me not to take the risk and operate -- she'll probably die, and everyone will feel we killed her. But the grandmother is not willing to travel still further for treatment, and waiting too long may be fatal.

I ask two of the staff to hold Hiramani while I drain the abscesses -- with the severe anaemia, I dare not give her anaesthesia. But Hira does not seem to need it -- she's barely conscious, and all her attention is on breathing. She only winces slightly when I operate. I have never seen anyone so anaemic -- she's all oedema fluid and abscesses.

5th May 1997

Antibiotics, iron, a high protein diet and a close watch -- as I keep my fingers crossed for Hira. She has lived through yesterday -- inert, but not getting worse. Her grandmother finally agrees to take Hira for a transfusion if we can go and come back in a day. I am jubilant. Now I need only persuade the doctors at the district hospital at Parlakhemundi to finish the transfusion and discharge her the same day. It should be possible if we go early in the morning. I tell Hira's grandmother I'll check with the doctor first. Hira's recovery will be much faster after a transfusion.

Hira gets high fever in the evening, though her breathing is easier. It's good that her body still has some capacity to fight the infection. Fortunately she is able to sit and eat if someone holds her up. She is still not comfortable lying down.

6th May 1997

To Parlakhemundi. I meet the CDMO (Chief District Medical Officer). I tell him I would like to bring in a child for a transfusion. He tells me they are not doing any transfusions any more -- they stopped them three months ago following a Supreme Court order. They do not have the required licence. Apparently, a blood bank is not allowed to function if it is not air-conditioned.

I am aghast. I cannot believe anyone in our country would make rules like this. What about emergencies, I ask? We refer them to Berhampur, replies the CDMO. That means any accidents with bleeds, any obstetric emergencies where the mother may need blood urgently -- all have to go to Behrampur 140 km away, a journey which takes four hours if you have your own transport and who knows how long if you go by public transport. What about fresh transfusions, without banking the blood? The CDMO shakes his head regretfully: "That is what we would like to be able to do, but since it is a Supreme Court order, we cannot do anything."

Is anyone aware how many places in our country are without electricity, or with poor voltage? Is air-conditioning the only thing we can pick on to improve our blood banks? And how many people are we condemning to death with this rule, without even an attempt to save their lives?

I return to Koinpur discouraged. It breaks my heart to see Hira still struggling to get enough oxygen into herself. At least she is able to lie down.

7th May 1997

Hira is angry with me when I do the dressing and tells me she will bite me if I do it again. What a wonderful feeling to get such a response! And what a girl, to survive against all odds! She is eating much more than she used to, says her grandmother: she must be feeling better. And she has not had a seizure.

8th May 1997

6 am. Hira has walked out of the dispensary and is sitting out in the morning sun. her face is still puffy with the anaemia and heart failure, but less so than before. She tells me she has had enough of injections, and that she wants to go home. In an attempt to be friendly, I ask if she'll come visit me in Mohuda. I'll see, she replies coolly, and I retreat abashed.

She goes back to her village this evening, and Sasikala will continue her dressings and will supervise her medication. She is also on medicines to control her seizures. I will return to Mohuda tomorrow.

9th May 1997

I call Bombay to find out more about the blood banking laws. Apparently the rule is that the bleeding room has to be air-conditioned. That rules out fresh transfusions as well. One is liable to be prosecuted by the district FDA if one violates the law. I guess one can transfuse in an emergency to save a life; but one also needs to be ready to go to court and fight it out till the Supreme Court if necessary. I don't know whether the doctors at Parlakhemundi are prepared to do that: maybe they just find it easier to refer patients away.

Hira has survived in spite of the system. In our 50th year of Independence, this poor tribal girl found herself up against the majesty and wisdom of our country's Supreme Court. Even so, while she may concede defeat later on, she has won this round.

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.

Into Despair, One Brick At A Time
Should I Have Left Her There?
The Light of A Lantern
A death in the dispensary
This One Child

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