As
Delanwadi awoke from its slumber on a crisp December morning, I entered the
gates of the village’s PHC to interview my friend and medical officer Dr
Mrudula Bhoir. In the early hours of the morning, even before crowds gathered
for the comfort of chai and poha at the local tapriwala,
eager patients awaited their doctor who was deeply engrossed in a heap of
paperwork as I entered her quarters. She had been tallying the doses of
vaccinations administered that month over a warm cup of green tea, in
preparation of a monthly administrative meeting with the taluka (block) health
officer. A typical Wednesday for Bhoir.
As part of her
usual supervision duties, I accompanied Mrudula to a sub-centre (an affiliated
health unit under the PHC) in the village of Kulkuli. The facility was
thoroughly managed by a jovial and sincere ANM (auxiliary nurse midwife),
Sister Karangame. As both of them spoke over the monthly activities of the
sub-centre, a grave expression overtook Sister Karangme as she discussed the
concerning case of Tulsi, an expectant mother, two-weeks past her delivery
date, who had refused to visit the PHC to seek care. Post-term deliveries pose
great risks to the fetus and have higher chances of resulting in maternal
death, a steadily decreasing yet serious cause of mortality in India. To
examine the baby’s health and determine the reason behind Tulsi’s reluctance to
seek medical attention, the three of us set out to visit her home in the
village of Ramtola.
Surrounded by
farmland, Ramtola was on the periphery of a slim kuccha pathway, the only
connection to the main road, which made it nearly impossible for Mrudula’s car
to progress. With Vidarbha’s punishing heat and relentless rains, making the
main road inaccessible in the monsoon, I could only imagine the struggle it
would take an ASHA worker or a pregnant mother to travel to the PHC by foot. It
would have taken at least half a day.
Besides a frail
grandmother resting on a cot in the backyard, the house was empty. There was no
sign of a pregnant woman. As we waited outside the home, Mrudula pointed to an
inscribing on the wall. Marked on the side of the house where a list of dates
on which a healthcare worker had visited Tulsi’s home. Every pregnancy, birth
and death are meticulously recorded by ANM workers, who regularly visit and
examine women to ensure a healthy progression for the mother and baby. To
encourage her to go to the PHC, Tulsi’s house was visited 13 times in the last
month of her pregnancy. This was no mean feat as I recalled our journey to
reach Ramtola.
We were startled by
the rattling noise of shifting vessels from behind the house. Our patient had
been cleaning the house. With the hem of her sari tucked at her waist and beads
of sweat trickling down her brows, it seemed Tulsi had been at work all day.
She turned to face us, and our eyes immediately locked onto the protruding
bump. Her petite frame managed to balance her immensely swollen belly
remarkably well as she swooped to pick up the washed vessels. Mrudula broke the
silence- her voice sharpened at the sight of Tulsi’s exertion. Dawakhanat
kashala nahi yet? Khup dhoka hou shakte tula ani tujha balala. Kiti vaat bagsheel? (Why
do you not come to the PHC? You and your baby could be at risk. Why are you
waiting for so long?) To which Tulsi’s only reply was mala
kahi traas nahi hote madam (I have no pain madam).
Upon Mrudula’s
persuasion, Tulsi agreed for an examination. I was surprised at Tulsi’s agility
and stamina at this stage of pregnancy as she managed to lift an entire wooden
cot for Mrudula and Sister Karangame to examine her. The frail grandmother
inched herself into the room and crouched near the door, keeping a watchful eye
over her granddaughter. Tulsi mentioned she could not feel the baby move as
much as the previous week. Mrudula and Karangame exchanged worrying glances but
did not voice their apprehension. With Tulsi lying on the cot, Mrudula examined
her belly to find the baby’s position was breached, which could cause
complications during birth. Mrudula lowered her stethoscope to examine the
baby’s heartbeat. She could not find it. Sister Karagngame took a chance by
positioning the stethoscope on the other side of Tulsi’s abdomen. She could not
find it either.
Mrudula,
looking determined, tried a third time. She listened intently, almost as though
she were in a trance to locate the rhythm of life. Sister Karangame mentioned
how women avoid seeking care during the final weeks of their pregnancy in
government facilities, out of the fear of a cesarean section. With mistrust in
the medical system mired in many rural and tribal societies, Karangame
suspected Tulsi’s family might have had the same reservations. The realization
of the medical system’s folly in neglecting to change people’s perceptions of
healthcare was quite pronounced at that moment.
I looked around the room. Five women with five different worldviews. One was a woman of old thought, three were women of science. I could only hazard a guess at what Tulsi might have been; sandwiched between tradition and modernity. We were all thinking about it. Had the medical system failed Tulsi and her child? My thoughts were disrupted by a sudden exclamation. Aahe! Heartbeat aahe! (It’s there! The heartbeat is there!) said Mrudula. Sister Karangame rushed to confirm the sound. The baby was alive but in distress. Immediate medical care at the PHC was crucial for the baby’s survival. Both Mrudula and the Sister pleaded Tusli to visit the hospital, but she avoided to meet their eye. Gharvale nahi mante (My family says no) was all she said.
Tulsi’s
husband and father-in-law entered the house during the midst of our coaxing.
They did not seem surprised to see us there, it felt as though they did not
want to acknowledge our presence. Mrudula shared the severity of Tulsi’s health
with the family and urged them to bring her to the PHC. She even offered to
conduct any procedure at a minimal cost. All the family had to do was bring
Tulsi to Delanwadi. Her persuasion was met with an unconvincing reply from her
the father-in-law. Alas, we left Tulsi’s home hoping she would make it to the
PHC or that the baby would be delivered soon.
It
took 14 visits from a dedicated health worker to an isolated home to convince a
pregnant woman to seek basic care. Only at the most fundamental level of
India’s social structure, deep in the villages of Gadchiroli, did I realize the
absolute necessity of health education, the influence of social norms on health
outcomes, and the importance of building trust between the medical community
and the people it intends to serve.
As Mrudula and I returned to her quarters at the PHC, she assured me this was a typical Wednesday. I was eager to hear more about her experiences in Delanwadi. And so, I started the interview.
Being a
medical officer is an immense responsibility. It must be a tall order to match
given you are a novice in your profession. What is it like to run the Delanwadi
PHC?
Nine
thousand eight hundred forty-seven. That’s the number of people under the
jurisdiction of this PHC. As a medical officer, I examine around 1500 patients
every month. Though, I would say seeing patients is just 20 percent of my job.
A large portion of my duties occurs outside of the clinic such as overseeing
the five sub-centres affiliated with Delanwadi, supervising field visits to
villages, managing administrative tasks, deputing staff, distributing (and
withholding) salaries, organizing surgery camps and training the thirteen ASHA
workers in my jurisdiction. And, the budget. Managing the annual budget, which
borders around 80 lakh rupees is a herculean task, for which I am grateful to
Delanwadi’s previous officer Dr Pankaj Aute…and my clerk (laughs). As part of a
national health program, I also need to consistently update my knowledge of new
medical procedures, vaccination policies, cold chain system management and the
demographic statistics of my area. Above all, my most important responsibility
as a medical officer is to be calm in the face of adversity.
What have
been your most valuable lessons?
Managing
staff who are much older to me and who address me as ‘madam’ was odd during my
initial days. But it made me realize the hierarchy within the medical system.
It was important for me to give my staff respect for their experience no matter
their social standing. However, I have not let my staff’s seniority compromise
the quality of work I expect. Being in charge of people, I also had to learn
the art of delegation rather than taking all the responsibility on myself. As a
perfectionist, I couldn’t trust others. I learnt that the world has its own
pace, and I need to try to work with it patiently. After all, I can’t expect
things to progress with the speed of Mumbai’s local trains.
You went to a prestigious
medical college, where the quality of your education was unparalleled. What
aspects of your learning and growth did college not nurture?
Empathy.
Patients were treated as a case rather than as a person. There is so much more
to a patient than their symptoms, like where they come from, what they live
through in their daily life and their perceptions of the world. This is not
something we are taught to even consider as a part of our diagnosis. In
college, patients were regarded as people with white clothes on a bed, which
never made me care about their background. In healthcare and medicine, learning
about people’s habits matters. Learning where people come from to a hospital,
matters. Being an ’outsider’ in Delanwadi, I now realize the importance of
social context in my line of work.
During
my internship, using finite resources and working within limited means was not
a priority. At KEM, our MRI and CT scan machines were running 24 by 7. These
facilities definitely made diagnosis easier, but consequently, we spent less
time understanding the patient, which made medicine seem like treating the
disease rather than a person. Running a multitude of tests on the first day of
admission for an anaemia patient, went as far as conducting a bone marrow
biopsy. Maybe this is necessary at a tertiary level because doctors don’t have
much time to invest in each patient. But many tests could have been avoided and
the diagnoses could have been narrowed down if we knew patient history better.
Again, context matters. Delanwadi is not equipped with these tests and patients
often don’t have the luxury to afford CT scans or breast exams. So, I
improvised. I developed an algorithm of diagnosing patients, where their
cultural context and habits are key indicators.
In
places like Gadchiroli, with a high rural and tribal population, infectious
diseases are a scourge for the masses. It’s not that we lack basic treatment
methods. People’s health-seeking behaviour and perception of medicine are quite
poor. People need to know what they are suffering from and need to receive
quality treatment. I’ve learnt that people’s needs are very basic, and half the
battle in treatment is being amiable to patients and lending an ear to give
them the sense that they are being heard. And honestly, medicine is not rocket
science!
Have your
ambitions and illusions changed since being a medical student?
As a
medical student, I wanted to be a ‘successful’ doctor. Success for me was to be
famous and richer than my parents. I saw myself having completed my
postgraduation and working in a hospital in Thane. As I entered college, I
noticed students had many talents apart from being good in academics. Yet
preparing for postgraduation was the most common career choice for students.
Many had aspirations to practice in the US and started solving USMLE exam
questions since the first year. There were very few people who did things apart
from studying for postgraduation, as options were quite narrow and so was
people’s ability to accept an alternative career route. I always wanted to do
something that others didn’t do. I had an element of righteous anger for
injustice and I was also quite the jugaadu (laughs). I
recall listening to Dr Rani Bang’s speech at KEM. She spoke about her work at SEARCH (Society
for Education, Action, Research in Community Health), in Gadchiroli and how
youth should strive to make their careers socially relevant. She was such a
fierce personality, it’s a trait I really admire in women. I want to be like
her! It was her speech and genuine curiosity that made me apply to SEARCH’s
youth development programme, NIRMAN.
NIRMAN ne kuch
alag hi jaadu kar diya. It disillusioned me from my previous
notions of being a ‘successful’ doctor. At NIRMAN I learnt the story of a woman
named Kaju bai,
a veteran community health worker in SEARCH’s pioneering home-based newborn
care (HBNC) program. Her story still brings tears to my eyes. She is a widow in
the lowest rung of society from the village of Ambeshivani, who may not have
studied beyond the fourth standard. Yet the life she has lived and the lives
she has saved is no short of a miracle. She has accomplished what pediatricians
can perform only after years of training. Her story showed me the power of
empowering people through education at the primary level, in inaccessible areas
where no one is willing to venture. Kaju bai’s resilience has made me
want to inculcate education with my career in medicine. I used to equate random
acts of kindness with social contribution. There is so much depth and beauty by
directly being in touch with people, which is in the nature of my profession. I
want to be the agent of social change to spread that understanding to others. I
was convinced that I would go the conventional way by doing a postgraduation. Kitna
narrow tha humara perspective…I mean mera. That’s
something else I learnt, when you are talking about yourself, don’t talk about
the world. I would have done something socially relevant, but not with the
conviction and social awareness that I got through NIRMAN and my time at
Delanwadi. Indian society is rather rigid and at times unforgiving about
achieving life’s milestones at the right age. I would have not been able to
accept my decision to come to Delanwadi had it not been for the realization of
life’s richness beyond completing graduation for the sake of prestige. This
realization gave me the confidence and freedom to live a life with purpose, on
my terms.
Didn’t you
have any apprehensions before choosing to come here?
Life
in Mumbai was certainly different than my reality at present. But I wanted to
learn about medicine, the people it impacts and government administration
beyond what KEM could teach me. So, I chose to come to Delanwadi. Where else
would I have been able to interact with the population I serve so directly? I
had no apprehensions of living alone in a village. I lived at home for the 24
years so staying outside of my comfort zone gave me an immense sense of freedom
and allowed me to take ownership of my choice to practice here. I also wanted
to learn to be more patient and communicate better with my patients, employees,
co-workers, and seniors. I would not have learnt this skillset in postgrad; I
would have been surrounded by work instead.
Living
alone does come with its set of challenges, which I previously didn’t tackle
gracefully. I found it difficult to hold it together, especially when I needed
an emotional support system. Being in Delanwadi has taught me to seek guidance
from my colleagues and seniors at KEM. I’ve learnt to share my difficulties
with mentors and keep my cool. I also feel a greater sense of contribution to
health education through my work. I have certainly faced many challenges here,
which have made me lose my patience at times. But any form of social change
requires an investment of time, patience, and perseverance.
advice would you give to MBBS
students who are uncertain about their future?
I
think to flourish as a doctor, you need to devote your heart to what you feel
content in. As unusual as it sounds, happiness and satisfaction are a crucial
part of medicine. Medical students really need to ask themselves where their
happiness lies. Part of their happiness should also lie in the well-being of
others. If you feel unsatisfied with the prospect of being a clinician, then
change your line. Work with the administration, government, or NGOs. There is a
lot more than you can do, a lot more than our health system needs beyond
clinical care.
I
would also advise students to derive a personal definition for their purpose in
life. The purpose is an internal discovery; it should not be imposed. My
purpose is to see society become more equitable through the betterment of our
health system. It is a force which drives my life.
Article and images by Jainetri Merchant. Jainetri has completed her
Bachelor of Science from the University of Toronto in Canada.
The goal of the NIRMAN program
is to contribute to the flourishing of youth in India, facilitate their search
for pro-social purpose and nurture them as social changemakers.
