Blame ants

By Mayara Floss

“I am standing by the shore of a swiftly flowing river and hear the cry of a drowning man. I jump into the cold waters. I fight against the strong current and force my way to the struggling man. I hold on hard and gradually pull him to shore. I lay him out on the bank and revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. I jump into the cold waters. I fight against the strong current, and swim forcefully to the struggling woman. I grab hold and gradually pull her to shore. I lift her out onto the bank beside the man and work to revive her with artificial respiration. Just when she begins to breathe, I hear another cry for help. I jump into the cold waters. Fighting again against the strong current, I force my way to the struggling man. I am getting tired, so with great effort I eventually pull him to shore. I lay him out on the bank and try to revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. Near exhaustion, it occurs to me that I'm so busy jumping in, pulling them to shore, applying artificial respiration that I have no time to see who is upstream pushing them all in....” (Adapted from a story told by Irving Zola as cited in McKinlay, John B. "A case for refocusing upstream: The political economy of illness." In Conrad and Kern, 2nd edition, 1986, The Sociology of Health and Illness: Critical Perspectives. pp. 484-498.)

I was in another busy day of consultations. Patient after patient history behind history, day after day. I started to talk with my first patient in the morning. A paediatric patient with a history of a digestive malfunction and to avoid having to perform surgery again he needed adequate food, rich in fiber and that would ensure that it defecasse frequently. In consultation you do all these explanations about eating well and guidelines. I stopped, looked to the mother and ask, "are you able to buy fruit?". She shyly shakes her head "no". I gently stopped all the medical stuff and history taking, and we started talking.

Pained history. They live in the rural zone without electricity, work hard, earn little. A lot love in the child care, even milk chocolate all day they give to children - the little transgression that financial narrowing allows. But fruits and vegetables they have tried to plant several times, papaya, carrot, apple and all. However, ants did subsequent attacks to the production. 

Also, "go to town to buy fruit?". No way, the city only once every two weeks. She says that the child love bananas, they buy a bunch of bananas once every two weeks for him to eat. No fridge neither  electricity so food is difficult to store - she tells me. This bunch of bananas is the fruit, fiber, and possibility of care.

The child is not well, it is not defecating much as it should. The mother knows and tells me resolutely: "Blame ants” and unties to speak that they will destroy the ants now, they will win the ants - the desire to be more than the ants. And after that they will plant papaya, mango, all fruits of the fruit bowl. I look at her and gives me a pain in the chest, a desire to cry. But she is strong and console me: "I know that is tough and he has to eat well, we do what we can." The plan is to exterminate the ants. For now they have found out where the nest is.

I'll be back to talk to my preceptor, "the orientation of the fruit will not works ..." – I said. We opted for a medication that helps the child to defecate, and he will return more frequently - and we covered the sun with a sieve. But what medicine can do about ants?

It's like the parable of the river, people appearing downstream, here are like ants. But the fault is not of the ants. The fault is the lack of access to adequate food, electricity, sanitation, and all the blame, my dear, is far beyond the ants - it is an economic guilt, political and social. It is a struggle of the blame for human rights and lack of access to basic rights such as food quality.

But while we can not solve the major faults, I awaiting the return and the outcome of the ants.

Link to the original one (in Portuguese): http://balsa10.blogspot.com.br/2016/03/a-culpa-e-das-formigas.html

My rural health experience

Dr. Sanam Shah

Two and a half years of my residency in Family Medicine drew close and I looked forward to embark on my rural journey as part of my rural health rotation. The stark contrast in the rural urban divide in almost everything including healthcare was no surprise due to my own rural heritage. However, the healthcare experiences first hand were a real eye opener to mobilize a paradigm shift in my own perspectives. There is no one event that I could focus on right now but a composite of my entire rotation as well as other opportunities thereafter to attend to rural communities that have helped build me professionally as well as a person and contributed immensely to give due attention to this area of practice. 

So I was off to a small region tucked away in a remote northern area of Chitral, the high mountains towering above circumferentially. The nearest secondary and tertiary care centers were an hour and a half drive from there provided there were no roadblocks due to landslides and inclement weather conditions. There were two doctors and a midwife attending to the local community and I was an extra pair of hands to elaborate their provision of care as well as my practice in this low resource setting. We saw the usual common ailments from communicable diseases like pneumonia, gastroenteritis, enteric fever, viral infections to the more prevalent conditions like diabetes, hypertension, asthma,COPD as well as a high burden of depression and somatoform disorders. On the other end of the spectrum were emergencies that we had to manage as well as we could despite lack of basic medical facilities sometimes. 

It brings to memory a young boy accompanied by his male relatives, in a state of severe dehydration and decreased consciousness. He was diagnosed type 1 diabetes mellitus and was on insulin later found be expired. Lack of insulin at our own facility drove us in frantic efforts to resuscitate him with IV fluids and empiric antibiotic followed by transfer to the closest well equipped centre more than an hour away compounded by the dangers of night time travel in the difficult terrain. 

Communication with the rest of the world was limited to an hour a day of net connectivity, sometimes none and intermittent access to wireless phones which was a problem if specialist colleagues had to be approached for any queries. However, they were quite eager to help us there sharing the latest evidence from infective endocarditis to severe pregnancy induced hypertension, when hydralazine was the only drug available and we were looking up whatever limited literature to decide between IV infusion and bolus therapies.

Insight into local cultural practices was equally important. Losing a patient to “kala pathar” poisoning, a common component mixed with henna for hair dye, that too cheap and easily available , underscored the importance of community education for such problems. Another common practice was the high intake of salty tea as well as butter tea and its association with cardiovascular diseases.

The situation in the rural South is not much different. The lack of sufficient primary and preventive health services has translated into a high burden of preventable diseases. The lack of good specialists in the area has also compounded the problem. The appeals of a mother of a child with cerebral palsy from birth asphyxia to prescribe something to cure him, to a young lady, unaccompanied, who went into a seizure episode when no sedative was available in the clinic and the presence of  inexperienced staff to provide first aid, all highlight lack of empowerment of the local populace and general medical unawareness. 

Basic understanding of the local area language was imperative and from the limited basic exchanges it was almost clear that the rural population has strong faith despite adversity. The ruggedness of their local areas and resilience in the face of inaccessibility is reflected in their enduring interiors.

Rural health is certainly on the list of priority areas for my attention and I hope this small piece as well as more upcoming stories could empower us to motivate others to look beyond the challenges and serve the communities there.

Last but not the least, the opportunity to explore the untouched beauty nature has to offer from the roof of the world surrounded by snow capped peaks to basking in the pure surroundings of the agrarian regions, one can certainly make a lasting connection with this area of practice.

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Dr. Sanam Shah

Current association: Associate Consultant, Family Medicine Department, The Indus Hospital, Karachi - Pakistan

Ruptured Ectopic Pregnancy with Shock with Severe Anemia in Rural Nepal, Managed By GP

Dr. Bikash Gauchan

This is a real story from the rural The Far Western Region of Nepal in Achham District which is often considered the remotest and poorest region in whole South Asia.

20 years old female presented with Abdominal Pain for the last 7 days at Bayalpata Hospital in Achham District of Nepal. The Clinical Team of Bayalpata Hospital is lead by General Practitioner. The female described her abdominal pain to be diffuse, constant, and severe. She also developed multiple episodes of vomiting. She just married two months ago and she was having regular menstruation cycles two months ago after which she started to have irregular flow and the amount of flow was reduced. When I evaluated her she was in severe pain. Her abdomen was severely tender. She was pale. We performed ultrasound and found there is fluid collection intra-abdominally suggestive of blood and her urine for pregnancy test came to be positive. We finally came to the conclusion that she had Ruptured Ectopic Pregnancy. The next level of hospital from Bayalpata Hospital is 10 hours jeep ride and the lady did not have that many hours is she was referred to higher center.

There was dilemma what to do and what not to do. Dr. Santosh Kumar Dhungana and I decided to proceed for Exploratory Laparotomy at our own facility, Bayalpaya Hospital. We arranged blood donors for her as she is O positive. Luckily we were able to find some donors from our own staffs and from the armed police force. People in this part of hilly region do not want to give blood and our blood bank lacks necessary blood all the time and we always have hard time explaining people why blood donation is important to save lives.

Dr. Santosh gave general anesthesia and worked very closely with one of our staff nurses. Another staff nurse scrubbed with me. I proceeded with the surgery. When I opened the peritoneum, gush of blood came out of her abdomen and nearly 40 % of scrub nurse and my body were wet by the blood. We calculated the intra – abdominal collection to be more than 2 litre. We drained all the blood. The ectopic pregnancy was located on the right fallopian tube at Ampulla and there was small site of perforation from where blood was continuously oozing. We performed right tubectomy. And inserted Right Abdominal Drain. We started blood transfusion for her. After 2 hours of surgery and one hour of close monitoring she was transferred to ward to close monitoring.

One the 4th Post operative day, we were able to remove her abdominal drain and she was discharged home on 8th day of operation. Bayalapata Hospital has two GPs and they feel very proud to save this lady.

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Dr. Bikash Gauchan  MBBS, MD  Medical Director Bayalpata Hospital - Nepal