One June morning, I walked through the corridors of the Shaheed Hospital in Dalli-Rajhara, Chhattisgarh. I have been in overcrowded hospitals before, but even so, this one was an eye-opener. Narrow to begin with, the corridors were lined on both sides with patients lying on narrow mattresses. Several were asleep, others lying awake or sitting up, rousing themselves for the day.
Some had relatives with them. Some had tall metal stands beside them, two plastic drip bottles hanging from the arm on top and trailing down to different patients. Sometimes I saw a patient walking about, carrying his stand. What happened to the other patient’s drip, I wondered. I had my answer when a young man walked into the sonography room carrying his bottle. His neighbour in the corridor must have gone walking with the stand.
Shaheed Hospital began operations in 1981; one of its early recruits was Binayak Sen, who joined about ten years after graduating from CMC and spent over four years here. Dr Saibal Jana, a small-framed, mild-mannered man now in his mid-fifties, joined at the same time and has become the medical face of the hospital; he is its senior-most and longest-serving doctor.
The doctor is in
I wanted to spend time watching Jana at work, watching the hospital function. I wanted to understand what motivates men like him and Sen. I have been in plenty of hospitals – by middle-age, who hasn’t? – but there is still something different about hospitals like Shaheed. Something about the constant crush of patients, overworked doctors, the kinds of complaints, the pressures on doctors' families – and through it all, the commitment to the work.
This is why I sat in Jana’s OPD room on the evening I met the woman who had been burned, watching him at work. On average, about 250 patients a day come to the OPD, many from several dozen kilometres away. It was clear, they were not as poor as patients I had seen in other rural hospitals, in Chhattisgarh and elsewhere. Was that a legacy of years of union activity, because of which most people in the area earned a reasonable salary?
The evening OPD sessions were usually less full than in the mornings. The days I visited, it was usually just Jana in the OPD, and the work tired him. He got home well past 8.30 each evening, even though the OPD clinic officially closed at 7.30. Even after that, the nurses on duty often called him in for some emergency or the other. The pressure on him and his family is unmistakable and intense.
The evening I sat in the OPD, this was how one forty- five-minute span went:
A man and his son brought in the younger son, who had suffered an injury under and behind his right ear. It happened when he was bumped about in a bullock cart. The boy was not crying, but looked morose and weary. Jana removed the bandage, moved his head around and felt his jaw. A village doctor had prescribed Cefix, an oral suspension of the antibiotic cefixime, for the boy.
Jana told them he only needed to take paracetamol; there was no need to take Cefix. A little puzzled by this advice, a little relieved too, the three got up and left. Jana turned to me and said, “They do that here,” meaning the doctors who routinely prescribe antibiotics.
An old couple walked in slowly, the man supporting the woman. Her face was twisted in an indescribably strange way, the planes of her jaws at an unfamiliar angle. But that was not her complaint. The man took off her pallu and pointed to her sternum. There was a dark brown scar there, almost as if someone had pulled parts of her skin together and tied them into a knot.
Jana touched it and said, “It’s a keloid,” which is an excessive growth of scar tissue at the site of a wound. What kind of wound, I wondered fleetingly, did she suffer on her sternum? Jana asked her to get her urine and blood tested, and depending on the results, she might need an injection. He told the couple to get it done that evening, while the hospital technicians were still at work. “But if we do this now, we won’t get transport to go home!” exclaimed the husband. Jana repeated, firmly, that they should get the tests done right then. “Do it quickly, you will be ok and you’ll get your bus.”
The next patient was a ten-year-old boy wearing a checked dhoti, accompanied by his mother. Shyly, he unwrapped the dhoti and I saw a bandage around his penis. Trying to respect his privacy, I turned away and waited for Jana to finish with him.
This is when I noticed that I was drenched in sweat, even though a fan whirled at top speed right above where I was sitting. It was blazing hot outside. Under this high ceiling, surrounded by these whitewashed walls, I remembered school science lessons about air that heats up, collects at the top of a room, and is then blown straight down by a fan. No wonder I was sweating, as was Dr Jana. Also, this must be why the waiting hall outside had a false ceiling made of thatch and was noticeably cooler. The hot air must stay trapped above the panels of thatch.
After the boy came a handsome woman wearing a dull orange sari, her pallu draped over her head. She had a soft bump on her head, about the size of a rupee coin. Jana reached out and examined it with his thumb, slightly disturbing the line of sindoor in her hair, and told me, “I can’t tell if it is connected to the bone.”
Her husband produced a couple of X-rays of her skull. “Nothing on the X-ray,” said Jana. He thought it might be a dermoid cyst, a new phrase to me. “It’s usually benign. If it is not connected to the bone, it can be removed.” He recommended a CT scan. “How much will it cost?” asked the husband, looking dismayed when Jana said it would be about Rs 2500 or 3000.
The boy who entered next had his left arm in a cast, and wore his shirt so only the right sleeve was filled. There were bruises on his nose, jaw and chin. He must have been in some kind of accident. His X-ray showed the arm bones at a bizarre angle to each other. “Will it mend on its own?” I asked. Jana nodded: “Just a matter of time.”
Medical history
There was a gap before the next patient. Jana told me that in the early days of the hospital, more doctors used to work in the OPD clinics, and there were enough that they could split the incoming patients by complaint and doctors’ expertise. But things had changed in a quarter-century. Getting doctors, and especially younger ones, to work here was increasingly difficult. This is a problem common to the other rural health institutions I’ve visited or know about. And when they find recruits, they don’t work regular hours.
Jana and I kept returning to this conversation in my time at the Shaheed Hospital. Walking with him on his rounds the next day, he told me that the hospital needs doctors who will “give time, think of the patients”. In the early days, doctors had what he called a “political mindset’, both by temperament and as a result of their training. What he meant was that many doctors in those days saw this as a calling: to work among the poor, in urban slums, in rural hinterlands. They developed an “emotional attachment” to the cause of hospitals like Shaheed, to their unique circumstances and their place in the community.
Before they built the Shaheed Hospital, miners in this area had no access to medical facilities of any kind. They built it without even knowing if there would be doctors willing to work here. As it turned out, Sen and Jana were willing and joined the hospital. It was by no means financial opportunity that attracted them. Instead it was the work, the conditions, the chance to build something to last. Things have changed in a quarter century, for sure. Motivations have. But in the early days, it was also an appreciation for the situation of the miners, of their determination to better their lives on their own, that mattered to doctors like Jana and Sen.
… As I understand it, this is where the phrase “community health” comes from. It means health care must necessarily take into account, and is even a reflection of, the community it serves. Today, says Jana, the mindset of graduating young doctors – perhaps of the country itself – has changed. For example, they rarely work in slums as part of their training. They are interested in and motivated by the chance to make money. They come to Shaheed for two or three years at the most, then move on. Work like this is rarely a career option any more; it is a merely temporary halt on the route to a glitzier somewhere else.
It’s not that there are no good doctors graduating from our colleges, says Jana. On the contrary, they are efficient, they are good at their work and are trained in the latest technologies. That applies to his team at Shaheed as well. But in general, today’s doctors don’t have the same emotional attachment, the kind of orientation or even the sense of mission that an earlier generation did. There must be some who do, of course, but they are not easily found. The result is a looming crisis for places such as this. What happens when doctors like Jana, now middle-aged, retire? Where are the younger doctors, fired with the same purpose and desire that Jana’s generation had, twenty-five years ago?
Back in the OPD, someone called Jana out to the hall. I looked around the whitewashed room. There was a chart listing the normal values of various blood metrics: HB, TC, DC, ESR, sugar, urea and creatinin. Another sheet of paper had several instructions, in Hindi, about physiotherapy. Behind me was an examination bed, under which lay several large plastic boxes filled with drugs. On the desk were two stethoscopes, an ophthalmoscope, a TV remote, medical trays, tongue suppressors, a blood pressure instrument and a copy of the Journal of Dermatological Treatment, besides assorted inkpads and staplers and pens.
Just an ordinary desk in an ordinary OPD room, its doctor tending to what must be a relatively routine set of OPD patients. And yet Jana had known several of the patients today, often asking them about their circumstances and earlier complaints before they could tell him.
When Jana came back in, a young woman in a green sari with a nose ring was right behind him. She complained of something and he examined her, but she was not really the patient. A minute after her, her mother entered, wearing an olive-green sari and weeping steadily. She wept as Jana greeted her, wept as he checked her blood pressure, wept as he listened to her heart and looked into her throat. It wasn’t that there was anything seriously the matter with her, but: “Please speak to her,” said the daughter. “The whole day she cries, and she doesn’t eat anything.” The mother tried to fall at Jana’s feet. He lifted her up, saying, “You must eat.”
“Her husband died a month ago,” Jana said to me after mother and daughter had left. “He was a heart patient.” Out of the blue, I remembered an Outlook article I had just read about a rural health clinic in Ganiyari, a few hours’ journey from Dalli if you take the recently-completed rail link. The report ended with these words: “[O]ver 300 of their patients … suffer from life-sapping rheumatic heart disease – for [which] there is no affordable surgery available in Chhattisgarh.’
As Jana and I walked back after he had tended to the last OPD patient, I reflected again: the patients and their cases I had encountered that day were not significantly different from others I had seen at other hospitals. But my time in Shaheed served to flesh out a few more details of a picture that, nevertheless, always remains incomplete: what constitutes rural health care in this country.
Excerpted with permission from The Curious Case of Binayak Sen, Dilip D’Souza, Harper Collins, 2012.
