Sunday, 13 August 2017

The Elderly Lady and her Chicken

Dr. Etonu Joseph

It was a usual day on the ward in the rural facility I work in (kapelebyong Rural Health Center,in north eastern Uganda), as I was doing a ward round. Like other normal days it is characterised by children having malaria and usually I review them to make sure the dosages are right and they receive the right treatment.
This particular day I noticed a chicken walking through the ward and of course I was furious(given that infection control is very important) why would a chicken be moving through the ward. Then I chased it out. The African local chicken are quite fast and of course it got away.
Surprisingly after sometime I noticed the same chicken coming back to the ward. This time I asked the nurse on the ward what was wrong with the chicken.
She then revealed to me that the chicken is for one of the elderly patients on the ward. “It has even laid eggs and it must be trying to come back to lay another one”, the nurse added!!!
This made me even angrier. How can a chicken just want to lay eggs in a hospital!!!
I matched to the patient with my eyebrows up and I noticed next to her was an old sink that was not in use, with a box and about 11 eggs. The chicken had already laid 11 eggs!!! I asked her in shock, ‘’why is your chicken laying eggs in the ward?” She replied to me, I was admitted to be in hospital for 2 weeks and unfortunately I stay alone at home. This is the 3rd time my chicken is laying eggs and the 2 previous times I wasn’t home to protect it from the neighbours who stole all the eggs. I am not willing to take any chances this time so I have decided to carry the chicken to hospital with me this time, she humbly replied. I told her that unfortunately chicken are not allowed to live in the hospital next to patients because it could cause diseases and she just kept quiet. She looked at me in confusion as to why the doctor wouldn’t understand her concern.
She put me in a dilemma I couldn’t send this lady back home because we needed to monitor her meds and it was unfortunate that she stays at home alone and all her children had moved to the city, like most of the elderly women.

We ended up having to organise for her a separate empty room to be with her chicken.

I am still wondering whether it was the right decision. What would you do in the same position?

Above you can see the eggs in the broken sink!!

Above you can see the patient’s bed!! Next to the sink!! With the chicken seated on the eggs below!!


I am Dr. Etonu Joseph, Junior medical doctor from Uganda 29 years of age, I've been practicing for 2 years in a rural area in Uganda in a county called Kapelebyong county. I Started my work when I was 26 years old in the facility. Iam the only doctor there covering the health of 89,000 people. Being a very rural area very few doctors attempted to work there but so far i am the one who has lasted the longest in the facility..The people I serve are the humble indigenous rural people of Karamoja and also Kapelebyong county..I graduated in 2012 at the University of St. Petersburg Pavlov,the Russian Federation. But i started working in this rural area in late 2014. I ride a motorcycle to work because the roads are soo bad in the rains that sometimes it rains on me! BUT I LOVE MY WORK and I have learnt a lot from the people I serve.

Sunday, 2 July 2017

Its just God's miracle, we are just medium...

         Hello friends.Me Dr.Suhas and my wife Dr. Prerna are specialist by degree but generalist by choice.We both have humble rural background and upbringing.Hence after our post graduation we moved to rural set up for practice as we believe we have many dues towards society and community who helped us to be a good doctor.
        In rural peripheral setup you have a new day new challenge.There are many stories till now in one year. 
But the most interesting one is the 28 year female diagnosed with unexplained infertility for 8 long years. She was investigated & treated at several Super speciality setups at Mumbai, Pune, Nasik, Malegaon, Aurangabad. 

     She even underwent multiple times for diagnostic laparoscopy, hysteroscopy, IUI, IVF & her male partner was also treated for low sperm count in last 8 years but failed every time. Spent lacs of rupees for treatment but every time result was unsuccessful. Husband being rickshaw driver, due to mental frustration gave up hope on for not being able to  become a father. 

               Interesting fact is that the couple was none other than our hospital staff worker's son & daughter in law. 
After we started practice in rural setup, the staff told the story about her son & daughter in law. The couple meanwhile consulted us. Selective investigations were done as all the previous investigations were normal. We studied the case very thoroughly and with help of expert opinion of Dr. Prerna the patient conceived within a month. Her UPT came positive for the first time. 

           The happiness which we saw on her face was priceless. After proper care of thorough 9 months pregnancy she delivered a male child on 23/4/17. Staff worker's son literally cried with happiness. He told us that we are everything for him. And we told him its just God's miracle, we are just medium...

Dr. is Dr.Suhas Pawar is (MS Gen.Surgeon) and his wife Dr.Prerna Pawar MBBS,DGO.They run a rural hospital named Saibaba Hospital, Satana,Nashik. Both belogs to humble rural background and are passionate to provide all super speciality services to rural people in there own community.This shall reduce there trouble to cope up with city urban life.

Sunday, 21 May 2017

The police protection

Dr. Etonu Joseph 

It was a usual afternoon at Kapelebyong Health center 4,in Uganda, like everyday during my work I see all patients with different conditions.Some of them are brought by a policeman and this would be because of assault or even rape sometimes.But this day had i saw a police officer,a gentleman well built and strong sitting in the waiting area waiting to see me. As usual because I knew he had other day duties. I allowed him into my doctor's room. I expected him to be accompanying the usual cases of rape or violence but was I wrong.

Entering the room he closes the door behind him and he sat down. So i asked him "What can I do for you?" He replied it is I who needs help, "yesterday night I was attacked by my wife and she was bitting me with her teeth" He showed me all the bite marks on the hands and the back. I felt for him because 1st of all he is a Man! And also a police man. And being in the village many men usually beat their wives and sometimes they injure them so badly. But it was very humbling to notice this policeman keeping himself calm. And he did not beat his wife(Being physically strong He didnot even fight back). I advised him to get help for his wife because he was not safe living with her.

But it got me suprised that if a policeman can seek for help on the abusive nature of his wife.Then that means he loves her and it could also mean that he respects the rule of law.But it also got me thinking as we call police for help, who helps the police when they are in trouble..?


I am Dr. Etonu Joseph, Junior medical doctor from Uganda 29 years of age, I've been practicing for 2 years in a rural area in Uganda in a county called Kapelebyong county. I Started my work when I was 26 years old in the facility. Iam the only doctor there covering the health of 89,000 people. Being a very rural area very few doctors attempted to work there but so far i am the one who has lasted the longest in the facility..The people I serve are the humble indigenous rural people of Karamoja and also Kapelebyong county..I graduated in 2012 at the University of St. Petersburg Pavlov,the Russian Federation. But i started working in this rural area in late 2014. I ride a motorcycle to work because the roads are soo bad in the rains that sometimes it rains on me!  BUT I LOVE MY WORK and I have learnt a lot from the people I serve. 

Sunday, 14 May 2017


Caruaru - Mayara Floss @ruralices

Mayara Floss

I need to call Emergency.
There is an emergency in the rural unit.
"But doctor, there's no phone."

Caruaru 02/17

Mayara Floss 
Undergraduate student of medicine at Federal University of Rio Grande (FURG) - Brazil. She Co-creator of project 'Health Education League'.  She is the creator of the Rural Family Medicine Café to provide a forum to discuss Rural Health – a forum for students, young doctors and experienced professors and GPs from all world. She is the student representative of the WONCA Working Party on Rural Practice. She also co-created with Pratyush Kumar the project 'Rural Health Success Stories' and writes a weekly blog of Popular Education, Arts and Health - the Ferry Street of 10.

Sunday, 26 February 2017



        I got trained in the old school of thought as far as patient care is considered. There were several dos and don’ts that were dinned into our heads. Some of these were don’t prescribe an expensive drug when an alternative cheaper one is available. The other is don’t investigate unless absolutely necessary. Always listen to the patient then proceed to examine and always try and come to a clinical conclusion. If you have to confirm do the minimum lab and other tests. When you are in doubt get another opinion.

       These principles have stood me and my patients in good stead over the years and saved us lots of headache and money. But occasionally it has backfired to give an example or two.

         I am against routine annual medical examinations and investigations to all and sundry and with valid reasons.I consider these a waste of money. But when there is a definite indication to screen a high risk patient I do order the required tests.


        In this case the a young man’s company does many tests as a part of the employee benefit and an electrocardiogram is one of them. He knows that I am against routine screening for heart disease in low risk groups and the youngster was one such.He reluctantly came and apologetically asked me to have a look at the reports.The company and done many tests which included an ECG.

          The ECG was abnormal. Though the rhythm was alight the rate was very high. Even if one gives margin to the fear of doctors and machines many have with the resulting increase in the heart rate, this kind of increase was a cause for concern.The report just said sinus tachycardia and the physician who signed it had not bothered to see the patient. There was also a marginal increase in the levels of thyroid hormone.On talking to him I realised he had lost weight, had been having some diarrhoea and when I examined him he had a heart rate of 130 beats per minute. A repeat test for thyroid function revealed he had increased activity of thyroid gland and this was duly treated.

      Had he not done the annual tests would he have come to see me? Probably not immediately but would have because he was concerned with his loss of weight. He would have come much later when treating him may have become tougher than it did.

        Another patient this time a friend of mine, who by nature a thrifty sort of a fellow [there is a very thin line between thrifty and miser].He tries his best avoid consulting me [read paying me]. He also treats himself with some success. He had symptoms of hyper acidity a year ago and as his usual antacid failed to help he sought my attention and I advised him to take a course of different class of anti acid drugs and get back after six weeks. He got better and did not get back to see me. When I met with him on the golf course he said he was well but once in a way he has to take the medicine. This worried me as at his age one should not have recurring symptoms like this. As the golf course is not the ideal place for a professional consultation, I asked him to see me in my chambers. This he did when his wife came to see me, he sort of hitched a ride.

             I found he has been taking the medication prescribed and managing.Though there was nothing much detected on physical examination I told him to get an endoscopy done to have look at what his stomach looks like [this meant going to the hospital and getting a flexible tube thrust down the throat right up to the stomach, a not very pleasant procedure but was needed]. He said alright and went away. He did not go to the hospital. He came three months later with worsening of symptoms. I had no doubt about the diagnosis. He had cancer of the stomach and further tests including the endoscopy showed the cancer had spread all over. He does soon after.

         Looking back I feel guilty for not having insisted that he get the tests done.I could have told his wife and she would certainly have succeeded in getting the tests done.Would he have survived had the tests been done six months earlier? Yes he would have.

          There is a saying that you can take the horse to the water but you cannot make it drink it. Sometimes it is difficult to force the issue. But difficult or not I should have done it and he would have probably few more years of life. Now I am carrying this burden and it will be with me and his face will keep coming to haunt me, may be, till I die.

         Another patient and another time. This person was a medical shopper. He saw many doctors and I was one of them. He had painful sensations on the skin of his thighs extending down to the calves. Only sensory involvement of pain sensation carrying nerve fibers may be due to many causes and cancer is one of them. He was a smoker and on testing he was found to be a diabetic. I was happy because diabetic neuropathy is very common and good control of diabetes will help. He was told the diagnosis. He appeared happy that a cause was found and went with the diet sheet and prescription. For three months I did not see him. When he did come he had with him records of three other doctors, one of them a homeopath. His diabetes was under control but his neuropathy [pain] had worsened. A neurologist who had seen him had done a scan of his spine and brain with no abnormality. Now he also had weakness and loss of weight which was attributed to diabetes. What is this patient’s illness?

      I expressed my worry about cancer to the patient and told him to get a PET scan [an expensive test but will reveal cancer activity] of his whole body. After much deliberation and visit to another doctor [fortunately he too advised the same] this test was done. A tumor was found in the patient’s intestine [ceacum]!

     Though nearly six months had elapsed from the onset of pain in region far removed from the place where the cancer was, it was found to be operable. The patient lived few more years but died due to recurrence.

       Here again if we had forced him to do this test and the diagnosis had been done early, may be, he would have lived his normal span of life. All of us [many doctors whom he went to] thought that diabetes is the cause when all the time it was cancer. This episode too has remained in my memory but does not haunt me as the other one does.

       Despite this experience I stick to the principle of investigating only when necessary. But as you can guess, I have started forcing and even threatening them with dire consequences if they don’t follow my advice. Once bitten twice shy that is what I have become.

        Medicine is in many ways, a cruel profession. You may be right 99 times out of 100 but you remember the 100th because willy nilly you were responsible. And to the patient who suffered it is 100 percent.

Dr. B.C. Rao is  73 year old family doctor with varied interests.He is still in active practice though only for limited hours now.He actively guide young aspirants of family practice.

Sunday, 19 February 2017

Diabetic Mitra Insulin Bank - Making Insulin Therapy Patient friendly

Dear friends today I am introducing one of my initiative Diabetic Mitra Insulin Bank to you. It a self funded initiative by my clinic to make life of diabetic patients easy & healthy- treating them well in time, early identification of complications & prevention.

During journey of this project I realise many of my patients were afraid of using insulin as therapy option. Reasons were fear of insulin injection, dependency on same, long duration of therapy, cost & availability of easy devices like insulin pen. Keeping these difficulties in mind we thought of starting a bank where patient will get everything that requires for insulin therapy conventional and modern. This bank give patients option of pre deposit money and book requirement in advance or buy later the requisite things as per need. This move helps patients in crisis time, lack of salary, draught or flood situations. We kept this channel because when patient runs out of money he /she avoids taking proper medication and later land up in severe complications. We hope this can reduce damage to some extent.

This initiative is running on a very positive note and Mr .Manjunath is our strong support like reserve bank. Till date we have 20 plus members utilising our services. Under this initiative we also pay lot of attention to insulin therapy administration counselling. During consultation we spent lot of time with patients, try to reduce as much possible fear about therapy, teach them appropriate way of administration with finger rule.*We also encourage them for self insulin administration. With help of finger rule insulin going intramuscular chances reduces and it becomes almost pain free.

In future we are hopeful for starting patient support fund which will help needy type 1 DM, old age and poor patients who are on insulin therapy but cannot afford to get it due to financial or family problems. We also hope our work will reach to maximum population and we will succeed in spreading message Lets Live Healthy with Diabetes.

 *3 finger, 4 finger, 5 finger rule

While taking insulin over arm patient should keep 3 fingers over biceps and triceps, then remaining area is ideal for insulin administration. They can take it laterally when arm is put in supine position .This helped us to overcome the misconception of injection site-“for any injection is deltoid”. Over abdomen, we asked patient to leave 4 finger area from umbilicus. This leads to sparing of rectus sheath and facilitate administration of insulin more subcutaneously. So here patient can rotate sites easily. Over thigh we used 5 finger rule so patient spared quadriceps and hamstrings. Patient can take insulin over tenser fascia lata or adductor compartment. But here chances of absorption via intramuscular route are higher. Hence it’s not an ideal site.

Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh);  M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology  & Geriatric Med; Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA; Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders  & Geriatric Medicine; C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka; Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum


Area of practice: Sankeshwar, Dist – Belgaum,Karnataka. Epidemiology of your area in brief: It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes, hypertension, asthma, hypothyroidism etc.

Saturday, 11 February 2017

Grief and resilience on a remote Pacific Island

Dr Nini Wynn

I worked as the sole doctor for five years on one of the outer islands of the Southern Cook Islands, a Pacific Island Nation. The hospital with eight-beds had basic facilities and diagnostics only.  We could not provide advanced Cardiac Life Support because there was no Defibrillator. During my stay on the island, I met a family of five: father, mother and three children – two daughters and one son, who faced three deaths in 4 consecutive years.

The 8 year old boy became ill and when it became apparent that he was not improving he was transferred to Rarotonga, the main island, an hour’s flight away. He was found to have an abdominal lump and was referred on for further investigations and management to Auckland, New Zealand, which involved a 4 hour flight and crossing a national border. 
He was diagnosed there with Nephroblastoma (Wilm’s Tumor). Prognosis was very poor and he died at the Auckland Hospital, far from home. The whole family was devastated and shattered. His body was brought back from New Zealand to the Cook Islands to be buried. Blessings were received after this boy passed away and his mother gave birth to another son. They were all so happy to have a new member in the family. However, a year later, one of their daughters was killed in a motor vehicle accident; she fell off the moving car on the way back from school, sustained a severe head injury and was killed instantly. She was brought into the hospital with no sign of life. The parents were informed and they arrived at the hospital hoping against hope. Her mother held her tightly in her arms and said that she loved her so much - she did not even get a chance to say a few words before her daughter’s last breath. Her father was quite a strong man and we did not see him crying, but we all knew that he must have been crying in his heart.  
Bad luck came in a row to that family –the following year the father became sick. He was 54 years old at that time he presented with epigastric pain and weight loss. He had had the pain for quite a while but did not seek medical attention. Clinically, no positive findings were found and he was referred to Rarotonga for further investigation. There is plain X-ray and ultrasound at Rarotonga hospital but no complex imaging i.e no CT scan or MRI. A gastroscopy was done which showed gastric outlet obstruction and a diagnostic biopsy came back as ‘normal gastric mucosa’. However, his condition did not improve and serious discussions followed with the patient, family and the health team. The possibility was that the biopsy taken might have been insufficient and missed a pathology. There were some issues and controversies during the process of his referral, which caused delays in sending him to tertiary care. When he was finally transferred to Auckland, New Zealand he was diagnosed with inoperable carcinoma of stomach and he died six months later in NZ. He was not well enough to travel home. 
I was amazed at the wife and the mother who had faced three deaths in a row - she was so strong and she dealt with her grief with a real will, whilst taking care of the rest of the family- herself, her eldest daughter and the last born son. She had faced expected and unexpected death. She travelled twice to Auckland and spent precious time with her late son and late husband during the last days of their lives. She respected her husband’s wishes to get treatment with traditional medicine for his cancer, because he believed that it could heal him. He was in a denial stage. As the breadwinner of the family, he had a strong will that he must live on. His priority was his family. He did not want to leave his wife and two children. Even though his wife knew the reality-that her husband was living in his last days, she never argued or went against his wishes. The small community of Cook Islanders based in Auckland, gave her and the family help and support in different ways; psychological, spiritual and financial, during her difficult times. His family accompanied his body back to his home island where he was buried close to his ancestors and his daughter.

When I look back at her story, some questions arose in my mind; would there have been any difference in survival and prognosis of this man and his son if they had lived in a big city with specialist care and advanced modern medical technology? Would the man have survived if the referral had been done more urgently? Is this an example of the health inequality/disparity for people living in rural remote areas? If it is so, could there have been a huge difference to this woman’s life?

What shines through is the resilience shown by the family – the very strong sense of belonging to a place – their island - wanting to be there whether in life or death. This love of their home and their people is perhaps the most important.

About the author

My name is Nini. I live in the Cook Islands, a small Island Nation in the Pacific. My work is in the Outpatient and Emergency Department at Rarotonga Hospital. Rarotonga is the main island of the Cook Islands. Prior to that, I worked in a small hospital on one of the Outer Islands which provides primary health care for the local community.

Currently I am working in a rural hospital in NZ to complete the two six-months placement as a part of the newly established Cook Islands General Practice Training Programme. This programme started in 2014 and was developed by the Cook Islands Ministry of Health in partnership with the University of Otago and the RNZCGP. Before this doctors in the Cook Islands had no Family Practice training pathway."

My story is based on a social and cultural concept on death and dying in rural and remote community – from the time I was working on the Outer Island.