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 day.

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 midnight.

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 tribals here.

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 conscience.

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.

EARLIER FEATURES: The Light of A Lantern
A death in the dispensary
This One Child

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