Field Notes II
An AKU doctor involved in relief efforts in flood-stricken areas of northern Sindh shares her experiences
August 20, 2010
Day 3 in Sukkur and Larkaro Camps
Yesterday’s meeting with the Lady Health Workers (LHWs) has started showing early results. The LHWs from the field gave calls for pregnant women and children in need of dire attention. Since I had given out my number, they contacted me directly and I directed them to ambulances and the EDO office. This healthcare workforce is very competent.
Later, I met around 25 lady doctors of the Khairpur home team to discuss the problems they will face once a load of high-risk patients is in the hospital. It was emphasised that nothing would be charged from PTS and their medication and treatment would be absolutely free, as the Government of Sindh will provide the funding. For a blood emergency, the masjid Imam would be directed to make announcements, due to which O negative blood will always be in hand, whenever needed. Once again, I reinforced the policy of IUCD, after appropriate consent; baby out, IUCD in.
Next stop Larkaro: a two-hour drive from Khairpur, though the roads and highways were broken, the lush green fields were a treat for the eyes. Dr Shahida Sheikh from Shaheed Mohaterma Benazir Medical University was waiting with her team at the Sheikh Zayed Hospital, so that we could have a brief meeting with the
university stakeholders, midwives, doctors and administration for shouldering the additional burden.
Larkaro city had 37 camps as most of people from the affected areas had gone off to their relatives. The new bus station camp was one of the most thickly populated camps, with more than 1,500 people occupying it. PPHI medical support was already there with the medicines. They were looking at routine health problems. Pregnant women were unfortunately not on the priority list. To their utter surprise, I told them that I was not there as a visitor but to work. I told that that we needed to see pregnant women and screen high-risk patients, who will then be looked after by Dr Shahida. In a hurry, they rounded up as many as 16 pregnant patients and promised many more on an informed visit.
I yet again ran into the same stories of the same women, living with the same miserable fate but with different faces. I asked one of the women named Wazirah how old she is, to which she said “punj” (5 years). I later realised that this 30-plus woman is 5 years old because that is the only number she probably knows. These women are ageless: they are born, they get married, they have children and somewhere in between the whole process, they perish. What is the importance of age in their life?
Then I asked Wazirah how many children she has, to which she replied “no children”, which was both suspicious and unbelievable. She then elaborated that although she had given birth to five children, she lost all of them during labour. This patient had a bad obstetrical history and required a caesarean for her current pregnancy. She was handed over to tertiary care for immediate action as she was already at term.
Then, there was Noor Khatoon, who increased my obstetrical vocabulary when she mentioned a four-month pregnancy with ‘paap’ (sin). Of course that didn’t mean sinful pregnancy. Seeing a lost look on my face she explained that when a woman bleeds during pregnancy, it is paap. It was then that the expert OBGYN realised that the woman was talking about a miscarriage threat and so was referred for a viability scan.
We also came across a group of women completely distressed as their men folk were still stranded in Austamohammad town. An SOS call was given to the DCO who urgently released his DPO revenue to resolve the issue.
My humble role in all this is to just establish a link between the different workforces. As a health care person, my goals are more preventive with long lasting effects beyond the myopic vision of emergency flood management.
Malnourished and stunted growth children are constantly on my mind and so when I came across a reasonable paediatrician, I asked him what can be done for this population? How can we improve the health of these sick children? His answer was very simple, ' “improve the health of mothers”, keeping the burden of responsibility on OBGYN community which was again much easily said than done.
With that and many new lessons learnt, we moved to Sukkur. The famous Sukkur Bridge is holding out against all odds. The waters are dangerously high, at the cost of telling you my age I haven’t seen high waters this high in the last 40 years and Sukkur to me is like home, as it is the twin city of Khairpur. It is housing more than 200,000 to 300,000 IDPs at the moment. The administration is on its toes as the Chief Minister has been in Sukkur for the last 15 days. He refuses to let go as the fate of Sindh and Sindhis seems to be attached to this once mighty Sukkur Bridge. He is monitoring everything himself with immediate actions.
In Sukkur, our first stop was Mehr Medical College, where we met with the principal and the Ob-Gyn incharge. I later asked the EDO Sukkur to link us with the LHWs and LHVs as I had positive results with their work in Khairpur. He scheduled a meeting with all health stakeholders the next morning, the agenda of which would be simple: mother and child health and hygiene, prevention and treatment.
Islamia College Sukkur Camp, adopted by the Mehr Medical College had a male doctor on duty. He seemed shy of female patients in general and pregnant patients in particular. I enlightened him with one of my favourite Dr Shershah quotes: “A doctor is a doctor, he is not male or female,” (meaning think beyond gender).
Here I also met a distressed father who wanted to buy formula milk for his 6- month-old daughter. He said his wife was very weak; had had four miscarriages, one dead baby and could only keep one alive. She has no milk to feed this only alive precious child who was severely growth restricted. The doctor had prescribed formula milk costing Rs400. “Where do I get Rs400 from?” he asked. Although we gave him money for the same, we learnt yet another precious lesson, prescribing is easy and we do that all the time without thinking how it will be possible for the patient to afford it.
Tomorrow: meetings with DCOs and health stakeholders to link workforces both in Khairpur and Sukkur.
Day 4 in Khairpur and Sukkur Camps
The morning meeting at the DCO office Khairpur was on a sober note. Children especially in crowded, heavily populated camps have started to die. The mortality countdown had started, more so in the age group for zero to five years. All stake holders including, EDO-Health, Civil Surgeon, PPHI and DPO Revenue were present. It was thought; that Khairpur has an acute shortage of paediatricians in particular therefore there is a high mortality rate. This is of course not true, since we all know that diarrhoea would kill the weakest of weak especially when mothers and the child’s environment are un-hygienic. Paediatricians and medical specialist could do little in such an apathetic situation. It was again stressed that a number of sweepers, hygienic intervention and health education are the solutions to the problem and need to be targeted at war footing.
Since all the schools are occupied by IDPs, the education in Sind is badly suffering. But what is un-comprehensible is why teachers and sweepers are on a long leave? The teachers can still give some education to the children and even to the parents to keep them occupied. The sweepers need to work overtime. In addition, people in the camps should be instructed to keep the place clean.
We requested for insecticide sprays. While evaluating health indicators, I was surprised to see all therapeutic indicators and there were hardly any preventive ones. I requested adequate calorie nutrition, health education and birth spacing as preventive indicators.
I had a similar meeting with EDO Sukkur, and categorically requested that LHWs/LHVs should be in the field, not to dish out medicines but to educate the people. We emphasized the same strategy as worked upon in Khairpur and the good thing is that the team replacing me has a public health person.
The road from Sukkur airport has tent camps on both sides. These are large camps housing a population of three to four thousand. There was a MNCH camp with volunteer doctors from Karachi. A lady doctor looking after the problems of the women was also present. There were two pregnant ladies who required urgent attention, one with seven months pregnancy and dehydration due to gastroenteritis and other one with early pregnancy and bleeding PV. The camp doctors had maintained Intravenous infusion and attached it to a tree branch since there was no pole. While screening rest of the women, I noticed that few were in wet clothes. Upon inquiry, they told me that they take bath with their clothes on, as they just had that one suit, and in this way both the women and the suit get washed?
Feeling sorry for one child without clothes, I gave him some money. A little while later the mother took aside three more children, took off their clothes and brought them to me. An important question or challenge arises, how to break the cycle of beggary?
For people who wish to work, do not over burden the already burdened administration. The Sukkur EDO told me “work doesn't bother me, what bothers me is the protocol, they sent me a hundred doctors from Karachi who want VIP accommodation and then I have to sit hours at the airport waiting for dignitaries”. This is a sheer waste of time and energy, especially in a crisis situation.
More sweepers and sanitation people are required, so it would be better to hire the occupants. This may increase their self-esteem as they can now earn, and may also help to break the cycle of beggary. We can think of more ways of income generation as well.
Lots of medics may be required but more importantly health educators are necessary since we want them to go back as slightly more informed and privileged.
Do not dish out colourful medicines as they don't know how to use them and are completely unaware regarding the side effects. Iron, calcium and ORS are within safer margins.
Women feel very happy and are enthusiastic about the physical examination.
Growth retardation of children will not go away with haematinics but will require long term nutrition supplements. Again think in terms of maternal health if we want to have healthy children.
Heath is not a lone intervention. Rather it is linked to education and poverty alleviation.
If I could have one wish it would be educate all children. This is the only route to survival with dignity. There are no short cuts.