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The Rediff Special/ A V Ramani

Lakshmi And Primary Health Care

Lakshmi Karji is a thin, pale woman who has been troubled by a cough for the past eight months. She lives in Gangabada village in Orissa with her husband Bhim and has a two-year-old son, Somnath. Her child was never immunised, even though there is a subcentre in Gangabada and an ANM -- Auxiliary Nurse Midwife -- is supposed to be living there. The village also has an Anganwadi centre which is defunct. Somnath had recurrent attacks of malaria, and was anaemic and malnourished. His mother took his state of health as a matter of course, since all the children she knew were pale and had pot-bellies. When she began to feel more tired than usual and began to cough, Lakshmi did not worry.

Only when her son became lethargic and developed a cough which would not go away did she get alarmed. Mohanty, a Gram Vikas field worker, had been advising her for months to take her child to a doctor and in September Lakshmi felt it was time to do so. She and her husband climbed the 3.5 kilometres out of the valley (a climb that would daunt even the physically fit) to Champaghati and walked a further 5 km to the Gram Vikas campus at Koinpur, where I saw them.

I had no doubt that both mother and child had tuberculosis. When Lakshmi's sputum samples were negative for tuberculosis, I referred both of them to the district hospital at Parlakhemundi for an X-Ray diagnosis and treatment. This was an expedition in itself.

Mohanty went with them. The nearest bus route is 5.5 km away from Gangabada, across the border in Andhra Pradesh. The bus comes to this point only once a day; and as they missed it, they had to walk a further 4 km to the main road to get another bus, for a 2.5 hour bus ride to Parlakhemundi.

Lakshmi's first visit to the district hospital resulted in her and her child being prescribed antibiotics and tonics. Lakshmi was also prescribed "Threptin" biscuits for what the doctor described as her "debilitated state."

Lakshmi and Bhim bought what they could, which wasn't much. They were told that they could claim up to Rs 300 from the CDPO (Child Development Project Officer) for the child's medical expenses as he was severely malnourished. But neither Lakshmi nor Bhim knew how to go to the CDPO's office in Rayagada.

Besides, they could only claim the amount they had spent, so where could they find the Rs 300 to spend in the first place?

Somnath died in October. Lakshmi's fever continued, as did her cough. But now she and Bhim were busy with their bogodo or shifting cultivation, and there was no time to spare to mourn, or for matters of health: anyway, Lakshmi could do at least some work.

After the harvest, Mohanty reported that Lakshmi and Bhim were back in their village and she was still troubled by the cough. She was weaker now and could not walk far. I decided to go with her to the hospital this time.

We sent a jeep to pick her up from Gangabada -- a journey of nearly 50 km each way which took five hours on the bad mountain tracks. Lakshmi came to the campus in Koinpur one evening and the next morning we set off for Parlakhemundi.

We reached the district hospital just before 10 am. After registration and consultation with the doctor, she was asked to get a X-Ray done. The radiology technician told us that the voltage was too low to take an X-Ray, and that we would have to wait till noon for the voltage to improve.

It was now 10.45am. I got talking to the ADMO (Assistant District Medical Officer) who explained that they were short of X-Ray film: only 30% of the consignment from New Delhi had reached them and nobody knew what had happened to the rest. So they had to use the film sparingly. Only medico-legal cases and serious in-patients could get X-Rays done for free.

Everyone else had to pay for them, and since very often there was no power or the voltage was too low to run the machine, people went to private clinics to get them done. He urged me to leave Lakshmi behind as an in-patient, but she refused to get admitted for a X-Ray.

At 11.45am, the voltage had improved and we ultimately got a very poor quality film. The screen was defective, the technician explained, and what looked like a tumour in the right lung was to be ignored. In spite of the bad film, it was obvious that Lakshmi's left lung was almost totally destroyed.

The doctor saw us again at 1 pm, diagnosed tuberculosis and prescribed anti-TB drugs. I sighed with relief. Once the TB card was made, it could be transferred to the Primary Health Centre at Rayagada and someone could collect the drugs each month for her from there. She would not need to come all the way to the district headquarters hospital.

But my relief was short-lived. By this time, the pharmacist had gone home for lunch and was going to be back only by 4 pm. The ADMO urged us to wait or leave Lakshmi behind as an in-patient, but we could do either.

Lakshmi had come alone, and she had to get back home to her family. It was raining and the jeep would not be able to go up to Gangabada. We would have to leave her at Saba in Andhra Pradesh. From there, she would have to walk the 5.5 km home and get there before nightfall.

We could not afford to wait longer.

Tired and dispirited, we left the district hospital. We asked one of our staff in Parlakhemundi to collect the drugs later that evening and drove back to Saba. On the way, I tried to explain to Lakshmi why she had not been given any medicines and assured her she would get them soon.

As I saw Lakshmi start on her walk back to her village, I was acutely aware of having failed her. I could have provided Lakshmi with the anti-TB drugs myself, but she would have to pay for them and that would have been difficult. I was keen to keep the costs of the health programme at Koinpur low, to utilise the government health facilities as far as possible.

The district health authorities had assured me that there would be "no problem" in treating patients suffering from tuberculosis.

Perhaps the time and money spent for Lakshmi's diagnosis was not considered a problem? Nor the fact that the diagnosis had been delayed for several months, and had probably been responsible for her son's death? Nor that even after all this, she still had not been able to get her medicines?

I have eighteen other people, adults and children, whom I have clinically diagnosed as having TB. Can I just refer them to the government system?

Will someone there care?

A V Ramani has an MD in Community Health from the Christian Medical College, Vellore. She spent four years working for Gram Vikas, a NGO in Mohuda, Orissa, that works among tribals in the area.

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