Indian red scorpion on BMJ Jan 2011 cover

I was quite puzzled by the general lack of information and clarity over treatment of scorpion stings. A phone call from a friend requesting urgent help from a remote forested area triggered me to put together this blog on scorpion sting response.

Medical school text books are quite confusing. The ones that we hold holy are mostly US or European in origin. Although many of them are quite globalised, the specific information on “local” conditions say tick-borne fevers or insect/animal bites/stings or injuries is quite lacking. In the case of scorpion stings, what I recollect from medical school is that Indian scorpions stings are never fatal. I vaguely recollect some discussion that the venomous scorpions are from Latin America or Australia. This was not an expected question for the exams and such precision in answering this question (at that time) was not so important. Later, when I was working as a doctor in a forest area, I had to know the implications of a scorpion sting.

Scorpions are quite ancient – having been on earth around the time of the dinosaurs. They are also one of the first terrestrial predators adapting mainly to prey on insects and sometimes even small vertebrates like lizards. Of all the 20-odd lethal scorpions, the Indian red scorpion is supposed to be the most lethal. All scorpions have various types of venom which is basically a cocktail of several envymes that immobilise their prey. The venom is selected to be fast-acting. Of the few species of scorpions that are lethal to human beings, the Buthids are prominent. Buthidae is the largest family of scorpions. The Indian red scorpion is one of the Buthidae. For those who are familiar with scorpions, the red scorpion is the smaller one that is more often seen around habitation rather than the larger (greenish-blackish) Heterometrus.

Scorpions are quite well distributed across India. However, information at the species level about scorpions seems quite scares on the internet. Perhaps the only good resource on Indian scorpions is this blog maintained by Aamod Zambre. The blog gives several links and resources to scorpion biologists and a key to identification of scorpions in Eaglenest Wildlife Sanctuary in Arunachal Pradesh. Although showing many dangerous-looking scorpions, the ones that often sting humans are perhaps not these; that distinction belonging to the Indian red scorpion. For those interested in the species, its biology and taxonomy, this issue of Euscorpius may be useful.

The 1700-odd species are global in distribution are not found only in Antarctica (see this effort at developing an illustrated catalog of scorpions, of which 10 selected pages of part 1 is available for download). Of all the spceis of scorpions, only about 25 species are supposed to be venomous enough to kill human beings. Most of the others, we are told cause pain, irritation, local inflammation and some minor-major cardio-respiratory symptoms. Most scorpions being nocturnal, and preferring crevices and dark corners are likely to go unnoticed. The warm and damp surroundings in houses or the shaded crevice in a dry area are ideal places for the scorpions. Scorpion stings are quite a public health problem. Like many of the other health problems, scorpion sting victims in most rural and tribal areas usually approach the local doctor who is invariably not trained formally in medicine. Herbal and traditional remedies for stings and bites about. While serving an important role in calming the victim and allaying his fears, a little more than a placebo role may be attributed to these – especially in the case of snakebites.

Scorpion stings are very painful causing local inflammation and redness. All scorpion stings are capable of penetrating the skin. The venom spreads very fast and hence the role of scorpion anti venom has been questioned widely in international and Indian literature. The intravenous anti venom may take several hours to reach reasonable concentrations in the tissue where the scorpion sting is already acting. Milder symptoms include vomitting and sweating in addition to local pain. In more severe cases, there may be breathlessness and pink frothy sputum (because of fluid collection in the lungs), variation in blood pressure, shock and even unconsciousness. Most of these symptoms are due to massive release of chemicals called catecholamines (which play a key role as neurotransmitters as well as regulate important autonomic body functions like heart rate, blood pressure etc.) – a phenomenon termed autonomic storm.

Clinical management of Scorpion stings - Bawaskar and Bawaskar (2012)

In spite of all these dangerous sounding words, the stinging is relatively rare. Scorpions are quite shy and even when they sting, the dose of venom injected is often very small, and sometimes even dry. Contrary to the fairly bold advise by the good folks at Auroville to “sweat it out for a few hours”, medical attention to scorpion sting is important. Reducing pain using painkillers and reducing anxiety using anxiolytics is of importance, especially since the victim will be suffering from shock both due to the venom as well as his anxiety. Antivenom is manufactured by Haffkine Institute, named after Waldemar Haffkine, a Russian student of Louis Pastuer who came to India to fight Cholera with a vaccine he developed in Paris. Although the role of the anti venom has been questioned, the importance of keeping the victim under observation cannot be underscored. Monitoring of his blood pressure and watching out for pulmonary edema if any is important. A place with facility to provide intravenous fluids, BP monitoring and if needed positive pressure ventilation may be needed to avert any rare cardio-respiratory colapse or multi-organ failure due to shock. The role of a drug called Prazosin, which reverses several effects of the venom has been widely reported by HS Bawaskar and PH Bawaskar from their decades of experience treating hundreds of scorpion stings in rural Maharashtra. Admirably, they have kept detailed notes and records of these treatments that is periodically analysed and reported in medical literature. In fact, nearly all of what we know about scorpion sting follow-up from India is from this duo. With the availability of medical support and administration of prazosin wherever necessary, a mortality rate of less than 1% has been reported by them. From a case report in Nepal, Bhadani and colleagues report that adequate information about these lethal complications in scorpion stings is not present among health workers – a reason for very late referral or neglect of stings. The Bawaskars report the onset of pulmonary edema anywhere between 5 to 15 hours after the sting and suggest early initiation of treatment with Prazosin – an observation seconded by the Nepal study. In fact, it is now well accepted that the time lapse between sting and prazosin administration determines the outcome of the patient. In an article recently in January 2012 in the Journal of the Association of Physicians of India, the Bawaskars present a nice overview of what is known about the epidemiology of scorpion stings, pharmacology of its venom, local and clinical manifestations of stings, clinical findings and notes on management with details on when to administer prazosin. In addition, a brief note on prevention of scorpion stings is given.

From my experience, I find that scorpion stings are very rarely the problem of people walking or working in forest areas. It is often reported from homes where people “ambush” the scorpion in its hideout rather than in an open jungle where people walking even carelessly, give enough time for the scorpion to move away. However, awareness on the potential lethality of scorpion sting and ensuring transport to a place with the basic facilities to deal with the complications (if any) is important among people living in rural/tribal areas as well as people working there.

Beginning from early Egyptian references of tumours in the breast that are choicelessly left untouched to the golden era of surgery when the scalpel was wieleded as a panacea for any bodily growth, the book presents a few thousand years of journey towards our romance with the miracles of modern medicine and the eventual disappointment that was to come after.

Doctors often do not write, canning their life experiences into a pressure cooker that is often let off on their wives or their families. If and when they choose to let the steam out as literature (and assuming that they have what it takes), the product is often wonderful. Highly recommended for doctors, highly recommended for patients (past, present and future) and the only reason not to read it would be if it is not published in a language you can read.

I was myself reminded of a photo I took from Crossword, where his oft-quoted book on famines “Everybody loves a good drought” was (perhaps?) inadvertantly placed under “Indian Fiction”, when he spoke about the time when he was invited to talk on “Indian fiction” on one of his foreign trips which he accepted for he was an authority on the Government documents.

Sainath started in earnest with the rise in petrol prices and deftly manoevered that to a paragraph he read out from a few sheets of scribbled stuff he had brought to the podium. He reassured us that this is not what he often does – read a prepared text. It was from the budget speech of 24th July 1991, when the present prime minister, Manmohan Singh was the finance minister. We got to know this only later though because the context around which “liberalisation” was brought in still exists today….at least for most of rural India. Sainath reminded us that line “…Budgetary subsidies, with questionable social and economic impact, have been allowed to grow to an alarming extent”. Since then, how many such “subsides” have had great impacts?

It appears that such “subsidies” are available for all to see as an inconspicuous annexure to all budgets – “Statement of Revenue foregone” – here it is for 2009-10. This document lists the special tax exemptions and concessions given to individuals and corporates and calculates the revenue ‘lost’ or foregone by the central government as a result of these. The figure is somewhere near 35,000 crore rupees – Sainath reminded us that this is around the money it takes to run the entire NREGA programme for a year – yes, that is what was “foregone” – the new word for corporate subsidy which has now replaced those budgetary subsidies of pre-90s days which had questionable social impact! This foregone revenue is climbing year after year and one of its greatest components has been the custom subsidies. And for those of us who were wondering if our good government was keeping the interests of many of us in mind while it was perhaps waiving off taxes on essential drugs, here is  the list – precious stones and jewellery, mineral fuels and oils, animal or vegetable fats, machinery and electrical machinery. The first one in this list – a Rs 48,798 crore exemption on customs duty for imported jewellery in one year alone – nearly the size of our entire annual food subsidy all for the great drain robbery.

Indian has more billionaires than all Scandinavian countries put together! And this is not merely from the richest cities, we were told. Sainath described those nice weddings in rural India particularly those of Gadkari’s son held in Vidarbha – that place where farmers are killing themselves for debt. Seems a bit exaggerated right – why would farmers kill themselves in a place where 2,00,000 people attended the wedding and aircrafts replaced the usual tractors and trucks for ferrying wedding guests. And who says a village cannot get 24-hour power. No load shedding during gadkari wedding! And no party-specificity with such rich rural weddings – so is the case, Sainath reminded us of the weddings of several others from all parties. India was so shining in these areas, that it was mostly blinding for many who didnt catch the irony. So much so that mass weddings with food were understandably the best social programme in Vidarbha for a long time.

The next 45 minutes was a series of anecdoetes from the 80s and 90s. The wisdom and experience of covering real India for decades was showing – he discussed the problem of “footloose migration” – those people for example from Orissa and Jharkhand who work for a few months in Hyderabad and later in Mumbai who do not get picked up by any census. We heard about that wonderful scheme that was pooh-poohed when launched – the midday meal scheme. The farmers rally or the strike at Maruthi’s Manesar plant for better working conditions that mainstream media took so late to cover. And of course, how many “luminaries” have rubbished all this tripe about farmers’ suicides and have proven it to us by legally deleting famine from their vocabulary through a parliamentary act! More followed on the food security bill.

All in all, it was a brilliant display of wisdom, erudition, spontaneity and a sense of conscience that Sainath demonstrates. He stands today as a conscience for several self-aggrandised and charismatic civil society who forget that it takes more than values and integrity to build a country. Describing himself as a member of the “un”civil society, Sainath repeated his thoughts on the Jan Lokpal Bill from that Berkeley lecture and gave tips on feeding our billionaires. 

And for those who would rather listen to Sainath himself and trust me the talk was one of his best  (the recording is not!) – see http://dl.dropbox.com/u/2047439/sainath/data-2011-9-16-19-05-15.3gp and http://dl.dropbox.com/u/2047439/sainath/data-2011-9-16-19-59-12.3gp (Thanks to Anush)

See also

• Indian media – politically free, prisoners of profit
• Three weddings and a funeral
• Reception after reception for Gadkari’s son
• Revenue foregone, but not forgiven
• Corporate socialism’s 2G orgy and all his other articles archived on India Together

The first of its kind event, the First Global Symposium on health systems research organized by WHO sought to focus on "science to accelerate universal health coverage"

The setting? The official dinner of the First Global Symposium on Health Systems Research organized at the Montreux Casino. A photo of the dying TB patient formed the background for 20 minutes of a talk on “Why Health Systems Fail” by Atul Gawande, a surgeon and writer, to an audience obviously more interested in the wining and dining and, of course, the party that followed.

November 16 to 19 of 2010 saw the global public health giants gather in Montreux, Switzerland, for the First Global Symposium on Health Systems Research under the auspices of the World Health Organization and partners. Some of us Emerging Voices from the Global South (52 of us from 29 countries) got a unique chance to be a part of this experience by getting selected through an essay competition organized by the Institute of Tropical Medicine, Antwerp.

However, for us it was a stark lesson in the “dichotomy” in practice. On the one hand, we hear all the time about “gross injustices in the way globalization takes place” and 20-40 percent inefficiencies and waste; on the other hand, we clearly have “wasteful spending” and a “culture of entitlements” to these perks and privileges among international health technocrats themselves. We talk about the need to send the right message and then hold such global events far away from the settings being discussed, with fee structures that exclude many of the very people affected. How can well-meaning people in global health maintain that we need to organize structural solidarity and transfers for health via multilateral mechanisms, when many of these organizations waste resources at the same time?

What Message Are We Sending?

We are by no means shifting blame. A portion of it rests squarely and surely on our shoulders as well, for we were very much a part of this particular event. However, one has to agree that there is something odd in talking about “reaching the marginalized” and “those who cannot afford health care” at an “official” symposium dinner in a casino. After all, an official event organized by WHO and partners sends a strong message. What message did this particular event convey? Is it an echo of this timeless verse from ‘The Development Set’ penned by Ross Coggins?

We discuss malnutrition over steaks
And plan hunger talks during coffee breaks.
Whether Asian floods or African drought,
We face each issue with open mouth.

Perhaps, we should revisit the purposes of a conference:  sharing knowledge, networking and building collaborations. Of course the setting, dinners and gala events are all important to achieve these goals, but at what costs? Lot of networking at venues like these happens for reasons of fundraising. Sometimes, fundraising for research and pet projects becomes more important than the proclaimed overall goal: “Universal Coverage.” From that point of view, the casino event was certainly very appropriate, more along the lines of “meet the President” fund-raising dinners in the United States.

This also brought into stark contrast the World Health Report 2010, which for the first time stressed that, for decades to come, many low-income countries from Sub-Saharan Africa will need external financing support to help them on the path towards universal coverage (as they can’t do it themselves). We are essentially talking about 150 million victims of catastrophic health expenditure. Do we have the right to dishonor them or our cause by acting so callously?

As far as the WHO is concerned, we have to admit that this event was probably a bit atypical, but this double culture we are referring to seems all too obvious in many international organizations. “The Lords of Poverty,” whether multilateral or bilateral, transfer very large sums of money, which should ideally make them more accountable to the public and transparent in their dealings. Unfortunately, that is not the case. The allocation of official aid follows a set agenda and its rationale has been likened to the need for champagne: “In success you deserve it, in failure you need it.”

Are Cutbacks Only For Common People?

Incidentally, a similar paradox exists with respect to the climate challenge: there are still far too many “happy fliers” among the global health big shots, in spite of the fact that climate change could turn out to be the biggest global health threat of the 21st century. Cost cutting and limiting carbon footprints have become international buzz words, but in practice the responsibility seems to rest solely on the shoulders of common people.

Maybe, it is time to stop being such hypocrites. No matter the reality, many look up to the WHO as the face of global health and the institution that should play a key role in global health governance. Lead by example, even in the face of current adversities. That is the least we expect.

A neglected statue and a neglected message

Some things are better assumed and neglected, than acknowledged and attended to. In public health research, these often find a passing mention in “Discussion” section where findings are explained, and worse still, may be as a “contextual” element. Prime among this is corruption. Corruption in health services is nothing new. Perhaps merely a sub-set of the general corruption prevalent in administration of public services, the corruption in health is much more than merely a “contextual” element to be taken into consideration in planning and implementing health programmes. Nor is it merely a feature that may explain some of the poor health outcomes that we often find. Corruption is directly, causally linked to poor health service delivery. We KNOW this and we SEE it. Yet, when I read several reports and documents at national and global levels, there is an obvious glossing over of this feature – as if this is some minor itch that governments will eventually get to.

In writing this comment to the Lancet, I had the privilege of partnering with somebody who has led a tirade against corruption in health services in my state, Karnataka in South India. As a chairman of a government appointed committee on health care for our state, he took a bold and courageous step in putting “corruption” as the main problem that the health services ail from. As I describe in the comment, this led to a long chain of events including the strengthening of the Lokayukta, an ombudsman institution that helps uncover corruption.

Yet, this is not enough! Over a decade of very active ombudsmen in Karnataka have not achieved much beyond making corruption a public issue. It continues to parasitise the reforms and innovations that we so fondly and techincally design for health systems strengthening. Of what use is a good HR policy if people accept money for transfers? Of what benefit is drug price control orders if there is collusion among officials and companies for mutual benefit at the cost of the system?

I really do not know what it is – lack of evidence? lack of resolve? In fact, I wonder sometimes, if corruption is a feature of the system or a bug?

NB: This appeared as a guest post on the International Health Policies Blog of the Institute of Tropical Medicine, Antwerp as a part of the Emerging Voices Initiative. Thanks to Kristof Decoster and David Hercot for the help and support.

We cannot stay silent. Do your bit – raise your voice, write letters, support campaigns and make the ones in high places aware that they cannot sit quiet. Sign the online pettition or write to the president, as these people did. Write in your local languages and local press and spread the message.

A recent photo of Binayak Sen: Courtesy NDTV

Reproduced below is the statement of Jana Arogya Andolana from Karnataka.

We, the Jana Arogya Andolana Karnataka (JAAK), the Karnataka chapter of the People’s Health Movement, which is a coalition of Karnataka State level networks, organizations and persons actively working for health rights in the State, express our outrage at the verdict of the Raipur district and sessions court judgement declaring Dr Binayak Sen guilty of criminal conspiracy of sedition. Dr Sen has an illustrious record of over 25 years of selfless public service in areas of health and human rights. He has been the General Secretary of the Chhattisgarh People’s Union for Civil Liberties and Vice-President of the National PUCL and has contributed to the democratic movement in the country. He has been closely associated with the Jan Swasthya Abhiyan, the Indian chapter of the People’s Health Movement.In recognition of his work, the Christian Medical College, Vellore conferred on him the Paul Harrison Award in 2004, which is the highest award given to an alumnus for distinguished service in rural areas. He continues to be an inspiration to successive generations of students and faculty. Many of his articles based on his work have been internationally appreciated. His indictment under the draconian and undemocratic Chhattisgarh Special Public Security Act, 2006, and the Unlawful Activities (Prevention) Act, 1967 and the sentence of life imprisonment is utterly condemnable. Not only has the farcical nature of the trial been reported in the media, the charges against Dr Sen, of engaging in anti-national activities, have been widely held as baseless.This judgment is an unacceptable attempt to intimidate and vilify those who advocate for the rights of the poor and the marginalized, and reveals the indiscriminate use of state machinery to stifle democratic dissent.

JAAK believes that a great derailment of justice has been done, not only to Dr Sen but also to the democratic fabric of this country. We consider this as a typical case where the judiciary has betrayed the cause of the poor and the marginalized of this country. JAAK salutes Dr. Sen’s work, and also demands that the unjust and erroneous judgement be reviewed immediately.

Many global initiatives have brought this up. The Global Forum for Health Research popularised the now famous, 10/90 gap in research – 90 % of health research focussing on 10% of the world’s health problems. Initiatives such as the Global Fund and WHO TDR tried to shift focus to the world’s major health problems – Tuberculosis, Malaria and neglected tropical diseases. Much rhetoric and some action has gone into fight against the Pareto gap in health.

One of the most sincere of such attempts is the small and silent steps that the Institute of Tropical Medicine, Antwerp (ITM) has been taking with the support of the Belgian Government. The school, little known in India has been popularising the agenda of ‘switching the poles’ – trying to put the Southern nations in the drivers’ seat. One of the initiatives under this was the ‘Emerging Voices’ initiative – an effort to choose 52 emerging voices in health research and help break the monopoly of the usual suspects at global fora. ITM provided training in research writing, presentation skills and science communitcation during a run up to the grand WHO symposium on health systems research in Montruex, Switzerland. We, emerging voices received inputs from senior faculty at the Institute as well as language coaching from Linguapolis, the language school of the University of Antwerp. It was a brilliant idea that sought to choose researchers from the South and present new ideas at the international forum.

Emerging Voices stall at the symposium

My essay on Public-private Partnership in primary health care tried to present an arguement for using health systems research to understand the conditions under which internventions work and not go in for grand scaling up, the way things happen these days in policy making. I was indeed happy to have been chosen to speak at the event in Montreux. But, the most interesting outcome of the entire Emerging voices initiative was the fact that a school in the North made a sincere attempt to support researchers from the South and provided an environment for greater collaboration between Southern researchers.

Research in health today is dominated by researchers from the richer countries. While research institutions in the South grapple with poor research budgets, poor teaching and skills and the lack of a ‘culture’ of research, most Northern institutions have had the benefit of long years of colonisation and Western science and greater budget allocations. Even when global research grants are given, the agenda is often dominated by the richer countries. In ITM, many of us emerging voices saw a genuine commitment to shift gears.

At Montruex was waiting for us a gala event. It was a gather of over a 1000 health researchers from all over the world. It was quite a well planned symposium with sometimes over 10 parallel sessions. Ranging from methods in health systems research (complexity, action research) to small gatherings of activists from the people’s health movement, the symposium was quite a diversity of actors in international health. The venue was a bit strange of course – a symposium focussing on the problems of lack of even basic access to health care being held in Montreux, Switzerland was quite an irony – in this short piece, ‘WHO Pokerface’, Meena Daivadanam, one of the emerging voices raises this concern on a blog here. We even brought this up in our own pecha-kucha presentation at the closing plenary of the symposium, when 3 emerging voices (Lalit Narayan, Aida Zerbo and Wilfred Gurupira) presented the take-home message of the emerging voices to the entire symposium. Some uncomfortable, yet important questions to the international health research community.

A great initiative by ITM, Antwerp. I hope many more schools and institutions in the North will recognise the importance of supporting south not merely with money but with building capacity and commitment. Thanks ITM for being sincere, committed and passionate about putting Southern researchers in the drivers’ seat.

NB: Special thanks to An Applemans, David Hercot, David Hendrickx, Kristoff Decoster, Jos Assayag, Wim Van Damme and several others at the Emerging Voices Secretariat and department of public health at Institute of Tropical Medicine, Antwerp

- Douglas Adams

It was just another among many Novembers for the Head of department of Anatomy at Mysore Medical College. However, it was a special moment for the close to hundred eager minds assembled amidst the dust and echoes in the biochemistry hall. It was here on that November in 1997 that I heard the first ever words of a doctor while I was not ill. It was first day of medical training for nearly a hundred of the 1997 batch at Mysore Medical College.

We were quite a motley crew – Karnataka itself well represented from Bidar to Coorg, and the usual smattering of PM/PD candidates, mostly from the hindi-speaking belt. Beside me was a lean boy from Andhra who is now a surgeon and on the way revolutionized Mad-ads and cartoons in the college, and on the other side was an eccentric looking ‘localite’, today a psychiatrist in UK. Discussing CET ranks was quite a pre-occupation on the first few days – as if all our lives, these ranks would be the defining moments! It felt quite like the end of a struggle (for the medical seat), and we felt like winners. Little did we know the struggle for the seat was only a trailer for the action-packed movie awaiting us!

As I sit today trying to retrace this new path, I took 13 years ago; I am reminded of all the things apart from medicine, that MMC taught me. There

The surgeon and the psychiatrist among the other crazy guys that made this team

was the magazine of the batch, Doctales we called it, which did not see more than 4 issues; yet, we learnt what it is to edit articles. There was the music band, Bandwith 85, as we called it with the origins of its name shrouded in mystery. The department Q, which a few of us started for late evening quizzing and other pre-occupations had little to do with medicine. There was INFEST, a mega cultural event that drew support from many batches of students and the staff alike. I saw three of these while I was in (and later near) MMC. Loke’s tea and the discussions around him should have made him a wise man. The waterless pond and the unrepresentative sample of MMC’ians, which it drew, were a constant inspiration for hanging around the reading room. And of course the new auditorium, the gift of the alumni, thanks to which we never did have to go crawling for permission to Kalamandira.

The wonderful hostel with the Late Mare Gowda and the cobbler and the innumerable idiosyncrasies that surround each member of the hostel kitchen; the wonderful movies we watched and the arguments about life, universe and everything on the stone bench; the prefectship which signified a system or the lack thereof; and inter-batch politics – these were early preparations for the real world. I cherish all the memories of the hostel, which were indeed life skills education that no medical school could have given! The long hours of group study in 137, the eccentricities in 91 and the wall art in 122. Each room seemed to acquire a history of its predecessor as well as the character of the occupant.

Yes, I learnt medicine too. I remember the pride in showing off knowledge of ossification dates and trivia about eponymous syndromes; my pride only to be dashed by RJ Last, who asked the reader never to judge the medical competence of a man who can reproduce these eloquently for they were akin to logarithmic values that could be looked up whenever necessary. Yes, I learnt case taking and diagnostic skills as a means to an end; an end of passing examinations. Soon to discover during internship how the best of diagnostic skills would not help me connect to an injured 60-year-old farmer from Bandipur mauled by an elephant and his crop lying in a heap of waste. It would not help me communicate death to the daughter or birth to the mother. These, I had to learn by myself as most of my colleagues did. Often did I seek the Corrigan’s door (as described in that red-green-yellow companion of all interns).

Some wall grafitti from Room 122

There was plenty of opportunity to learn all of these when I went off to work in BR Hills. The real thing – where there is no ‘respondeat superior’ to fall back upon! My quest for challenging settings to work took me to Arunachal Pradesh where I helped train PHC health workers in difficult settings. I saw new health problems that were very easy to diagnose but complex to treat – poverty, illiteracy and such. My later work as a medical officer in primary health centres showed me how difficult it is to work and survive in some of these settings and that explained why only a handful of us chose to work in these settings.

The journey that began on that November in 1997 with the best batch in MMC (that is what each batch says about itself!) continues today. Indeed, it is much more for the rich diversity of experiences with my batchmates and hostelmates at MMC that I remember and thank the college for. It is after all these life skills that make my journey enjoyable to this day.

Today, I work on trying to understand and solve a paradox. It is the paradox of inequity; that in a country with nuclear power we have anaemic mothers. Is it then enough to blame it on illiteracy? Is it not the responsibility of a just society to organize such services for its people? Among many determinants of this paradox is poor district health management. A complex issue that contributes to the poor performance of health services in several places in India, and the topic of research for my PhD.

As I sit back, I know that my collective experience at MMC and the hostel was very important in my life. I wonder about my batchmates and the young minds who are right now going through the experience.

Farmer's plight is a damning reflection of how much reform has taken place

Farmer’s suicide is a silent killer being brushed aside as a marginal issue; after all, a few farmers taking their life ‘here and there’ can’t be that serious. Hmm….neither is it ‘few farmers’ (nearly 200,000 in 10 years) nor is it here and there (Karnataka, Andhra Pradesh, Maharashtra, Madhya Pradesh and Chattisgarh are just the big five!). Of course, it is not a marginal issue, stemming out of a simple lack of money to repay a loan – the phenomenon points bloody fingers at the very process of ‘economic reform’ – yes, the same reforms that makes possible the 3G in our hands, and the apple on my desk. A paradox, this….Sridhar Kadam, a farmer who incidentally trained in public health shares this poem. For hindi speakers, please neglect the effort at english translation by Werner and me.

जालियांवाले हत्याकांड आज भी होते है, जरा गौर से देखिये,
गोली के निशान नहीं, जरा मौत की वजह देखिये !

लाश के सरहाने जहर की बोतल देखकर,
सभी ने जान लिया की शायद कोई किसान था!

अब तो कपास भी शरमाता है,
किसान के खेतो में फूलने के लिए!
रोटी तो वो दे नहीं सकता,
मगर कपड़ा भी दे नहीं पाता, बदन ढकने के लिए!

वो सर पर लाद कर सब्जीया बेचती है,
अपने बेटे को पढ़ाने के लिए!
और खुद ‘सरकारी गोली’ खात्ती है,
अपना खून बढाने के लिए!

ऐ लोगो मत कहो ‘खुदखुशी’ किसान की मौत को,
वो खुद की खुशी नहीं, बनाए गए हालात थे!
अगर गौर से देखा जाये तो,
जालियांवाला हत्याकांड में भी कुछ ऐसे ही हालात थे!

इसका रोना नहीं की हमारे पूंजीपती इसके निर्माता है,
और चंद ‘विद्वान’ फिरंगी इसके निर्देशक है!
गम इस बात का है की,
हमारे माटी के पूत ही इसके तमासगीर है!

क्रांती आज भी होगी, जरा आजमा के तो देखिये,
आप हमारे बंधे हाथ, जरा खोल के तो देखिये!

Still today we see bloodbaths not unlike Jalianwala Baagh.

Stop looking for bulletholes.

Watch the cause of death and misery.

See the bodies lying clutching the bottle of poison

To inform us that the cause of death was suicide.

The cotton is embarassed

To flower in the farmer’s field.

May not give bread, this cotton,

Neither will it give the farmer a cloth to cover.

His wife still sells the load of vegetables on her head

So that her son may be lettered.

And she’s still downing sarkari goli

For ironing her blood.

O brother, don’t call this one a death by suicide.

It was not to soothe own failure that he killed himself.

Don’t say destiny created the end of the road.

Cry why!

Did not the massacre at Jalianwala Baagh

Bestow the same destiny for the unarmed?

Don’t shout that Capital was the producer of this drama.

Nor wail that the Bank was the director of this karma.

This pain cuts deeper than a minstrel show.

It took sons of our land to cut so deep.

Radical change is what we need.

Dear brothers, come together

And open up your arms.

Dr. Srinivas had started his career as a doctor trained from Karnataka’s oldest medical colleges, Mysore Medical College. He had joined the state health services early and had worked in remote primary health centres as a doctor and later in hospitals. He had risen up the long ladder stretching form a PHC medical officer to the level of a Project Director of Reproductive and Child Services for the State of Karnataka more recently. After retirement, his rich experience would not be wasted; the state continuing his services as a consultant to help implement the most important initiative these days, the NRHM. Among the lively discussions between the participants and him, was one important aspect of leadership – by example.

Dr. Srinivasa spoke of the fundamental nature of organisations; of adopting the values and principles of the leader. While most people are sincere in their work inherently, many others are fence-sitters, as he called them. They adopt the values of their leader. He also quoted from experience. It is critical for government services to produce such leaders, for in adopting these values of service and dedication, not only would they be transforming the way in which they work, but they would be transforming their entire institution.

Such is the case of the district hospital in Tumkur. The district hospital in Tumkur is an ancient one. It is one of the older large hospitals in the state of Karnataka, having been established a year after independence in 1948. By a strange quirk of fate, the then Maharaja of Mysore, Sri Jayachamarajendra Wodeyar, who was to inaugurate the hospital abruptly left the venue, for the day the hospital was inaugurated was the day that Mahatma Gandhi was assassinated. The inauguration stone that marked the occasion today lies within the walls outside the office of the District Surgeon. The hospital caters to over 2 million people in Tumkur district, and what a responsibility to manage a hospital of such a size given such a task….

Dr. Pratap Surya is the District Surgeon, the man who is at the helm of affairs at the hospital. He has indeed a mammoth task on his hands. Being the head of a large 250-bedded hospital that sees over 1000 people a day is no joke. A random sample of the patients reveals the enormous service that the hospital renders – one of the patients from Midagesi, a distant town in the taluka of Pavagada had come in search of the ENT surgeon for the chronic infection afflicting his adolescent son. He was a landless labourer from there, nowhere else to go for him; the bus charge from his place to Tumkur and back, and the wage loss resulting from a loss of one day’s work together added to quite a burden. There was another person from the town of Madhugiri, an old man who had come hoping to improve his vision by getting rid of the haze that had recently developed in his eye, a cataract. The hospital in Tumkur has an ophthalmologist and an ENT surgeon to cater to both of them. I ran into the gynaecologist, Dr. Diwakar in the corridor. He had just finished a caesarean surgery to save the life of a mother and the newborn. In this case, the newborn was positioned transversely in the mother’s uterus, thus not being able to be delivered normally; a classic indication for a caesarean section. If the mother had not reached the hospital in time from the distant village beyond Madhugiri town, the physiological process of childbirth could have been fatal for both the mother and the child. In her case, thankfully, the newly launched service of 108 had promptly brought her in time for the procedure. The woman being from a family that is below poverty line, like almost all of the patients that obtain service at the hospital had undergone the procedure completely free of cost.

The old man from Madhugiri will have his vision soon. The ophthalmologist scheduled his surgery for the upcoming batch. The ENT surgeon, who single-handedly manages the entire department will soon see the adolescent boy from Midigesi, in time for him and his father to catch the evening bus back home; he cant miss another day of daily wage. The taluka of Madhugiri could rest easy, avoiding its tryst with yet another maternal mortality, thanks to 108 and the gynaecologist at Tumkur. This was yet another routine day in the government hospital in Tumkur.

Yet, it is not automatically so. A lot of effort has gone into managing the hospital. It is but easy to target government hospitals for their poor quality of care and negligence. Easier still to say “privatise”. But, when one sees the segment of people who these hospitals cater to, we understand the importance of strengthening them; and it is not for lack of effort by the local staff that these ills plague the government system. People like the present District Surgeon, Dr. Pratap Surya are the foot soldiers of health care to the masses. Neglect and carelessness in the leader could easily have a cascading effect on the staff. But, Dr. Pratap Surya, by sending the right signals of integrity, service-mindedness and discipline – he leads by example.

Of course, there are problems. Why do poor people have to travel for such a long distance for an ENT consultation? Why wasnt the mother with a transverse lie diagnosed well in advance, so that she need not have come at the nick of time to the district hospital? Moreover, why aren’t such services available at the sub-district level itself? Why is the district hospital so overcrowded?

Thankfully, the launching of the NRHM holds promise. The priority accorded to maternal and child health and the resulting strengthening of referral units to prevent infant and maternal mortality, upgradation of neo-natal ICU’s in Tumkur district hospital, and of course the leadership by example provided by people like Dr. Pratap Surya, one can see encouraging signs of improvement. Let us hope that the efforts of several people within the system like the district surgeon or Dr. Srinivas and many others among the Tumkur district health team will result in better quality service to the poor.