Skardu

Dr. Sanam Shah

F lives in a small brickhouse along the river stream. She lives with her husband and an adolescent son. On first instance there is something truly enchanting about her surroundings; im distracted by the sky so blue, tugging at me to get away from my city, 2000 km away near the sea. This is Skardu. It is home to three famous mountain ranges namely Himalayas, Hindu Kush and Karakorum and people reside in the foothills despite the natural upheavels and unrests; enough to lure us there in an instance. Lack of engulfing high rise buildings, the city traffic and general urban craziness would make it an ideal place to retire, I thought to myself. But I am moved by something unsettling about her demeanour. She spoke fluent Balti and conveyed phrases with long pauses. I try to connect with her in Urdu, she nods in reply. However, I wait for her son to return with her bag of medicines that she has been taking for a long time.

I take a breather and admire the lovely backdrop. The clouds hang low and I could almost reach up and try to touch one and the surrounding peaks are draped in the early winter snow, glistening under the rising sun. I almost imagine moving up here in the countryside seeing people like F who have been living in this town since a very long time. A nearby river stream fills the silence.

I learnt that there is a big district hospital some distance from this place serving two districts in this town and a bunch of smaller clinics serving this town of approximately 700000-800000. The number of doctors practicing there remains short. The hardest hit are women as they are compelled to see male doctors due to few female doctors serving the area. The doctors themselves are overworked in these challenging circumstances.

So the son finally arrives with a big white plastic bag that I empty on the table before me. To my astonishment there are numerous strips of Levofloxacin that she has been consuming for the last two years that apparently has not made her any better anyways. I look up at her quizically and reconfirm her history that is clearly pointing towards asthma and allergic rhinitis. I dramaticaly ask the family to discard any remaining strips and to avoid using in the future. I write a prescription of anti asthmatics and hand the son with my number in case of any questions and concerns in the future.

This is just one family I chanced to see during my last travels and I begin to think about the other families that make up approximately 800000 population in this town. Its probably just wishful thinking but I pray about having graduate programs in these locations in context of the needs of the local population and someway of retaining health professionals here who often prefer urban centres due to myriad instances like lack of facilities; public-private partnerships that can address the health care challenges and perhaps someday see the establishment of a medical school here!

Five days later when I moved back to work I still thought about her and the numerous challenges meted out by nature both complex and multifactorial. I felt guilty of the urban comforts and started to look at life from perspective of people residing without them on less than 5 dollars a day income. Even after three months of returning, I think about them and their smiling faces and I twinge to return and serve the people and enrich my life with the real stories of life and living in the real world of rural and remote health care. Thats when I think about the neccesity of primary care in developing countries and the need to mobilise a strong workforce of ancilliary health workers besides doctors and nurses. A part of me is there that will cause to return and I would be happy to succumb as long as I can.

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Sanam Shah - Editor of the Blog Rural Health Success Stories
WONCA South Asia Region

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