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Should I Have Left Her There? ...................................... by Dr A V Ramani

Sombari and Arakhita Sabar live in Saura Hatibadi, a small
xhamlet in the Mahendra hill range in the Gajapati district
of southern Orissa. The hamlet consists of twelve
households and every one of their residents seemed to be
gathered at Sombari's hut when I got there that winter

I had been called by Sasikala, a field worker in Gram
Vikas's Koinpur project area, to see Sombari's baby who had
fallen sick. Pratima was nine months old and Sombari's
first child. She had developed diarrhoea a few days earlier
and for the past three days was paralysed -- could not move
her limbs, nor swallow. Her parents had taken her to
Goppili to a private practitioner for treatment, but she
had not improved.

I went in with Sasikala to see the baby. The room was warm
with so many people inside and was lit by a lamp made of a
wick in a bottle of kerosene. Sombari sat on the floor and
invited me to examine her daughter.

I was shocked to see Pratima. I had seen her barely two
weeks ago and she was an active, healthy child then. Now
she lay limp and unconscious on the mat, her neck retracted
and her eyes sunken deep into their sockets. She was
severely dehydrated, had pneumonia and was paralysed. Her
parents explained that they had taken her to the best
doctor in Goppili who had prescribed very expensive
medicines; they showed me the array of tonics and vitamin
supplements and antibiotics that they had bought. But, they
said, it was of no use as Pratima could not swallow. So
then they borrowed money to do a puja, hoping that would
help; but it hadn't. Only this afternoon had they noticed
that she could swallow occasionally.

Pratima was critically ill, and she probably had
Guillain-Barre syndrome -- a paralysing disease which
sometimes follows a viral infection. Though most cases
resolve spontaneously within a few weeks, death often
occurs due to respiratory paralysis, or a lung infection.
Pratima had already developed pneumonia and she was
extremely dehydrated as she could not swallow. The key to
survival in such cases is good nursing care including
feeding through a naso-gastric tube, antibiotics to fight
the infection and respiratory support if necessary.

I asked Sombari and her husband to take Pratima to the
district hospital in Parlakhemundi, 40 km away. I would not
be at Koinpur to look after the baby even if we took her
there. Besides, I thought the problems of dehydration and
infection could easily be managed at the hospital.

After consultation with their relatives and borrowing some
money from me, they got ready to go to Parlakhemundi. The
ride there was slow as the road is in terrible condition.
We kept stopping every few minutes so that Pratima could be
given some 'pejo' or rice water which her mother had
brought along. Though she could swallow with difficulty, I
was hopeful that she could take in enough to survive till
we reached the hospital and could have a naso-gastric tube
put in.

A Saturday night is not the best time to find doctors in
the hospital, and I found to my dismay that Dr Tripathy,
the paediatrician I knew, was away for the weekend. After a
short wait, the doctor on duty examined the baby, confirmed
my findings, referred the patient to the paediatrician on
call, and vanished. The baby was meanwhile admitted into
the ward.

I went in to see her, and found that she had been allotted
a bed with a filthy mattress with no sheet on it. Sombari
had spread the palm-leaf mat she had with her on the
mattress, immediately incurring the wrath of the ward nurse
who scolded her for doing so. As soon as she noticed me
there, however, she hurried away and returned with a sheet,
grumbling that "these tribals" were dirty and could not
keep things clean. She then asked them to buy a rubber
sheet the following day, so that the sheet on the bed would
not be soiled by the baby. When I asked whether the
hospital did not provide rubber sheets in the children's
ward, the nurse looked annoyed and told me they were all in
the store which would only open on Monday.

The paediatrician on call arrived and examined Pratima
cursorily. He noticed that one of her feet was swollen a
bit and declared that this was a case of malnutrition. I
tried to explain the history to him -- that she had been
perfectly well when I saw her two weeks ago, that she had
developed this paralysis after the attack of diarrhoea.
When I pointed out that she had lost head control, the
doctor triumphantly said -- "I told you, it is
malnutrition: that is why she has poor muscle tone." He
then prescribed antibiotics for the child and ordered some
investigations for the following day.

I left the hospital and Pratima's family there with some
misgivings, but consoled myself with the thought that she
could at least swallow, and so might just pull through with
adequate care. I returned to Koinpur by midnight.

The following day, Sunday, was a busy one. I left for the
Gangabada cluster by 8 am and it was past 6 pm by the time
I returned. I had to return to Mohuda on Monday morning,
and decided to stop at Parlakhemundi on the way to check on
Pratima. I looked for Pratima's progress notes and did not
find any. There was a single entry stating that her
haemoglobin was 9.0 gm%: that was it. I could not believe
my eyes -- this was a critically ill patient, and there was
nothing to show how she was progressing in the hospital. I
asked the nurse whether Pratima's case record had been
misplaced, or mixed up with someone else's. But it hadn't.
And the nurse was getting impatient with me: "Why do you
bother?" she asked. "Anyway, they have gone."

The doctor lives just opposite the hospital, and I went to
call on him to find out what had happened. He has a house
with a neat little garden and a separate room from where he
runs his private practice. As I waited for him, I was
joined by several well-dressed patients and their children.
No tribals here.

After 9 am, the doctor emerged to start his clinic. He saw
me standing there and promptly went back into the house.
Re-emerging from another door a few minutes later, he
scolded the waiting patients, saying he could see them only
in the hospital. Of course.

I asked him how Pratima had been over the weekend. He was
blank for a moment, and then recognition dawned. "Oh, you
are the one who brought that tribal child with
malnutrition! Well, you cannot expect recovery so soon. I
have asked them to buy powdered milk and some tonics. These
people are so ignorant, they do not feed their children

I made a last desperate attempt to tell him why I did not
think Pratima was malnourished, but he wasn't listening. I
returned to Mohuda filled with a sense of hopelessness,
wondering what had happened to Pratima.

I found out two days later. No doctor had come to see her
in the hospital over the weekend. Pratima had got steadily
worse, so her parents had decided to take her back to their
village early on Monday morning. She died in her home that
same afternoon.

I am still haunted by doubts about my decision to refer her
to the district hospital. Maybe I should have taken her to
Koinpur and tried to do something with the very limited
facilities we have there? Why did I not argue and insist on
what I thought was the proper treatment? Could I have
remained in the hospital to ensure proper care? I have not
pursued the matter with the hospital authorities -- should
I? Is this the best we can offer at a district level health
care facility?

When my colleagues heard the story, they were furious at
the treatment meted out to Pratima. Had they been in my
place, they said, they would have hit the doctor. Why was I
not more aggressive? Have the years of dealing with this
system taken the fight out of me? The thought that tomorrow
I will have to refer another patient to this same place
(and maybe they will be lucky enough to get proper care);
and that I rely on this hospital to supply anti-TB drugs to
the many tuberculosis patients I diagnose each month --
does that restrain me from being more aggressive? Is there
any way to improve things, other than starting a parallel
health care system? I have tried to work with the
government system as it exists, but am I doing justice to
the patients I see? Do I tell them: "Look, this is all that
your Government provides for you, so hard luck"? The
situation caused by the pitifully inadequate facilities and
supplies is worsened by the callousness of the doctors. Do
I begin to educate Sombari about her rights and encourage
her to sue the doctor?

And what if she and her husband and others like them tell
me what my staff did a few months ago: "They will only
understand fear. Unless we are violent, nothing will
improve." Is violence, then, the only solution?

I can't answer the questions, but Pratima's death lies
uneasy on my conscience.

                                 - 30 -


Dr  A V Ramani is a MD in Community Health from the  Christian Medical
College, Vellore. She was working for Gram Vikas, a NGO in Mohuda,
Orissa, she now works for UNICEF in Bhubaneswar, Orissa

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Georges Lessard
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Mt Rolland, Quebec J0R 1G0

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