BY DOCTOR BISWANATH GOUDA
I never understood it when people used to say that it’s easier to make rational decisions when you are not part of the problem you are trying to understand. Not until April 2004. That summer, after graduating with a Masters in Public Health from Tulane I stumbled upon the AID website and was thus accidentally introduced to AID and its work. Since then I have tried to be an active volunteer given my work and time constraints and supporting the Bhopal campaign has been one of the consistent projects that attracts my attention. To be honest, until 2004 my level of awareness about the Bhopal gas tragedy was very vague. I knew something had happened in the year 1984 while I was in my second/third standard school in Bombay. And I remained as vague for the next 20 years during which I left India and went to study in New Orleans.
When we used to hold events at different temples, garba, dandiya/ poojas or social gatherings in US cities, I used to wonder why a significant part of the Indian community couldn’t identify with or support our petitions. But the reason was a similar lack of awareness and proper knowledge of facts/events that occurred in 1984 and the way things have evolved for the communities since. I have encountered two polarized views so far about the Bhopal disaster. One was while helping man a booth in San Diego for AID last year. An American lady came to us inquiring why we were raising the issue after two decades when everything was resolved – hadn’t the company compensated the affected people? We weren’t surprised to be asked this question and after sharing the facts and telling her about the present condition of the survivors and the reason for our display of posters, she willingly signed the petition and said she hoped those people would get proper compensation. I was glad that she at least signed, unlike some of our own Indian folks who, even after hearing the details and facts, refused to sign because they strongly believed that Bhopal was a lost cause.
The other incident occurred in Bhopal. I was on my way to the Sambhavna Clinic in a rickshaw and casually asked the driver what he thought of the gas-peedith (victims) people and if anything needed to be done for their benefit. First of all, he didn’t want to discuss the issue, stating that it was an old story and there was no point going back to the past. He was more interested in describing different tourist destinations in and around Bhopal and the town’s new shopping areas and markets – which is understandable given the evident globalization in most cities/towns of India. He seemed aloof from the Bhopal issue although born and living in that same town. I asked myself, what makes me one of those who are supporting that same cause? I am sure he has his reasons for his opinions and I will find mine.
Reaching the Clinic was not much of a problem except the rickshaw driver was surprised to know that such a hospital existed in the interior of the community as opposed to being on a major road or street. I would say the clinic is a ‘state of art’ piece of architecture, blends very well with the surrounding locality, smartly chosen colors, beautifully landscaped and cross ventilated structure gives it an airy feel in each and every room and hall of the clinic. The structure details of the clinic can be found at: http://www.bhopal.org/sambhavnaclinic.html
I had never been to Bhopal before and hence never visited the Clinic. So this was my first visit to the city as well as to the Clinic. I had planned to be there from Tuesday through Saturday and return back to Mumbai on Sunday. After being accommodated at the volunteers’ residence and discussing with Rachna the possible roles I could play during my stay as part of ‘shramdaan’, I agreed to attend the clinic with Dr Kaisar, who is the sole allopathic physician and offered to provide my services to the clinic patients. Since I enjoyed spending most time in the clinic, my observations below pertain to the allopathic services provided in the clinic.
· The clinic draws a huge patient population that includes not only disaster survivors but also patients from nearby neighborhoods and distant localities. I encountered an elderly women suffering from malnourishment and asthma, who had come to the clinic riding a bus for an hour one way! Around 150-200 patients are seen everyday who come seeking allopathic, ayurvedic, yoga/ massage therapy, diet, pediatric or gynecological services. A warm and friendly person, Dr Kaisar, the sole allopathic (modern medicine) doctor, sees around 60-80 patients regularly in the span of 5 hours.
· The majority of patients suffer from breathing disorders (asthma, bronchitis, lung tuberculosis, restrictive lung disorders), malnourishment, diabetes, heart disease, hypertension, obesity, alcohol and drug abuse related ailments.
· Cancer is also prevalent, mostly lung, esophagus, uterine and cervical cancers. I was astonished to see an operated case of transverse colon cancer, that’s more widely found in Western countries where reduced fibre intake is a common cause unlike in India and that too in an interior community of Bhopal.
· Diabetes is a huge problem and it is clubbed with obesity at Sambhavana Clinic. On a regular day, we saw at least 40-45% of the patients who were diabetic, either on multiple oral medicines or on insulin injections.
· The Clinic opens at 8 in the morning and functions till 3 in the afternoon with one-hour lunch break around noon. There is an evident smooth coordination between the staff workers, clinicians, health workers, interns and patients, which is a striking feature of its work.
· The in-house blood work lab and medicine-dispensing facility reflect the farsighted vision of the Clinic and are an added advantage not only to the patients but also for the treating physicians.
· The majority of the patients are Muslim and the staff members and physicians are well versed with their cultural and traditional mores, which helps the Clinic create good rapport and trust with patients.
· An in house kitchen provides food and breakfast at an economic price both to the Clinic staff and patient, thus saving time in seeking afternoon meals from venturing outside the complex.
· The Clinic provides ample space for patient waiting/ registration in the corridors and lawn.
· Housing alternative therapies like ayurveda, yoga, massage and dietician services provides a ‘one step destination’ for patients who need to seek multiple referrals to cure their ailments.
· The services are offered at a nominal service based fee structure, which is less than any hospital/clinic around Sambhavna.
I have tried to analyze each disorder as a single entity. My recommendations are based on my observations as stated below:
· Lung Disorders: As there is a huge patient population with lung ailments, most of them requiring steam/steroid inhalation with nebuliser, the Clinic needs an additional two nebulisers to meet the need. One should be solely reserved for pediatric patients. The clinic should also stock ample quantities of breathing masks. Pediatric masks should not be used for adults. Best practice would be to identify those patients who seek nebuliser every week and either ask/ provide them with an individual mask to reduce cross infection with other patients.
· Pulmonary function test/ Lung function tests should be done at affordable intervals to assess the improvement of treatment. Since it’s a costly test, some sort of collaboration should be made with nearby investigative labs to get the test done at a discounted rate for Sambhavna patients.
· An in house TB-Tuberculosis Center supported by the Central Health Govt. can be proposed to help subjects with tuberculosis. This can reduce the traveling distance for the patients and also would increase the compliance for treatment. Another suggestion would be to collaborate with the nearby Public Health Centers and make sure the patients referred are followed up for complete duration of therapy.
· Patients suffering from lung ailments seemed to be malnourished, more so protein deficient. Dietician should study the local food and commonly obtained food items and formulate a diet intake focusing on increasing protein intake, keeping the cost and culture in mind.
· Obesity: Obesity is a huge problem nationwide and seems more prevalent in Bhopal. As in India obesity is often seen as a sign of economic prosperity, this link needs to be broken by creating awareness of the diseases related to obesity – namely diabetes, high blood pressure, high cholesterol, breathing problems, knee and joint pains and few organ cancers. Physicians and dieticians should stress the importance of ideal weight, weight loss for obese patients and keeping a strict chart of weight, height and waist measurement at each visit for such obese people. Awareness camps/ lectures at the clinic, building educational materials for dissemination and healthy diet marketing should be stressed upon.
· Alcohol/ Drug Abuse: I was shocked to see a 12 year old male child with end stage liver failure due to alcohol intake and another 8 years old male child consuming some sort of whitener for snorting and his elder brother consuming some “white” powders. Dr Kaisar informed me that drug use was an important yet challenging health problem in kids in some localities. Both alcohol and drug use needs a multi pronged effort and cannot be treated in the Clinics unless the community is made aware and the parents are made responsible and aware to the ill effects of these drugs. Here Sambhavna should take a lead in raising community awareness, making local government take severe steps against those who peddle/supply such drugs to children and youngsters. Alcoholics Anonymous group meetings should be promoted in the Clinic campus to help such alcoholic patients.
· Cancer: I was informed that cancer was equally widely seen among the patient population. Incurable cancer patients or terminally ill patients due to cancer should be provided appropriate palliative care more so focusing on reducing pain at such late stages. The clinic staff and members should be educated to be empathetic and various ways to reduce pain in terminally ill cancer subjects. In house cancer registry should be maintained to help provide details of type, trend and history of various cancer for educational and research purpose.
· Diabetes: The clinic draws a huge diabetic population and I think it’s the case with any primary health care in India today, as we are heading to be the world’s Diabetes Capital in the next 20 years. In Bhopal, diabetes is more seen in the adult group and its mostly type 2 diabetes, which can be controlled with weight loss, diet and oral medicines. But I saw a large number of diabetics who were poorly controlled and overweight and most of them were post prandial (after intake of food) glucose raised. Some had severe form of vascular and foot disorders related to diabetes. The picture was even more complicated in those with high blood pressure and heart disorders with obesity. I suggest that the Clinic should strictly follow “ABC”. A: Hba1c should be done every 2 months or at least 4/5 months to see how tightly the glucose is maintained as it’s the most important and valid indicator for blood glucose treatment. Tighter and radical steps should be followed to achieve ideal glucose levels and the same should be stressed to the patients during education or dietary class and more so should come from the treating physician. B: A good measure of blood pressure and treating even mild hypertension in diabetics is good. C: Cholesterol check and medicines to reduce raised cholesterol should be promoted in addition to dietary changes. These three steps should be followed in each and every diabetic. Preventive steps to reduce the risk of complications due to diabetes like yearly eye examinations by fundoscope or eye doctor, annual kidney tests and monthly feet examinations to detect changes in sensation or color of feet should be widely promoted.
· Six monthly or annual diabetic special camps should be conducted by inviting a local eye doctor, kidney specialist and cardiologist as a team to assist the in house physicians. One or two days of the week should be named as “diabetes clinic’ so that doctor can give better care and attention to diabetic patients.
· A chart recording details about the onset of diabetes, regular weight and waist measurements, blood sugar levels done on various days, and eye examinations should be carried by the patient during each visit – it could be called “My Sugar Book”.
· Diabetes education classes should be held either by the health educator or dietician, in the communities and clinic premises to promote education and awareness of complications due to diabetes. Each diabetic patient should be well informed of his disease and should be equally prepared to handle any emergency state due to low/high blood glucose levels.
· Insulin intake/ injection behavior seems to be widely misunderstood. One lady was delighted to have insulin injections after being educated and taught how to take the injection. She had been flatly refusing to get started on insulin as she thought it was going to be painful and cause her more discomfort and she preferred to continue with oral medicines. But her diabetes was not under control, hence she needed to start on insulin. Friendly and proper training about insulin injections should be given at awareness lectures or meetings.
· Support Groups: I think starting support groups among alcoholics, diabetics, asthmatics and cancer patients should be encouraged to infuse a friendly and healthy behavior among such groups.
· The clinic needs a minor surgical room to attend to cuts, bruises, boils or suturing/ dressings, to carry out the physicians’ wishes.
· The Clinic is well designed to handle and accommodate volunteers. Volunteers should document interesting cases, form patient charts, and maintain blood sugar/ pressure measurements, height and weight charts and data collection and data input. Attention should be given to take pictures of such interesting cases and archive them in the library for future reference including the therapy.
· I would recommend that the Clinic should try to present their case series, patient data on prevalence of diabetes, problems of residing closer to the Union Carbide factory and similar health outcomes at national/ international meets and medical conferences, write articles and scientific papers to similar journals. This would propel the Clinic and the cause behind it to a wider and different group.
The above recommendations might not seem essential to the Clinic organizers, hence it’s totally up to their discretion. I also understand that to implement some of the above recommendations, funds and hiring additional manpower has to be met. But once the above steps are implemented, Sambhavna Clinic would proudly emerge as an ‘Ideal Primary health Care Clinic’ giving excellent standard of care treatment for chronic disorders like diabetes, hypertension and lung disorders.
I couldn’t have completed this visit report without describing my time spent in the company of AID JeevanSaathi, Rachna Dhingra.
An individual with immense energy to fight for the rights of the marginalized sections of the community, that includes the Bhopal disaster survivors. She is a dedicated, hard working and never compromising female who is not only supporting the cause but living among the survivors communities. AIDers who have been supporting the Bhopal campaign are very well aware that she was working for Dow Chemicals in US after graduating from Univ. of Michigan and now she is currently self-employed whole heartedly towards the cause. She has definitely set a fine example of sacrifice and selfless service towards a cause that she feels her contribution is worth and without which, she would might not be happy. The few days that I was at Sambhavna, I failed to see a single day where she wasn’t actively involved at any second of the time. She was either busy making sure the clinic was running as per the protocol, supervising & cooking for breakfast and lunch in the kitchen, responding to her emails, drafting letters, writing press releases or coordinating with local supporters and guiding the next possible step. I don’t feel we would have accomplished to find any other person who would have been so honest and dedicated in supporting Bhopal campaign as Rachna. She has been instrumental in conducting AID wide awareness for Bhopal campaign, coordinating with ‘Students for Bhopal’ to polarize students from various universities globally, going on indefinite hunger strikes since last two years, walking on feet from Bhopal to Delhi and has also been jailed for her never failing conviction. I would agree with Ravi, co-founder of AID, who has rightly described her as “beacon of AID”, in one of his email communications. We, the AID family, are proud having Rachna Dingra as one of our JeevanSaathis and it is apt to honor her as the ‘keynote speaker’ at the upcoming AID-US conference.
I was inundated with incidents and stories of Mr. Sathyu Sarangi, the force behind the development of Sambhavna, who was traveling overseas during my visit, but plan to meet up with him during my upcoming future visit to Bhopal.
Biswanath Gouda MD, MPH. Born in India, educated in Nair Hospital (Mumbai), graduated majoring in Clinical Epidemiology from Tulane University ( New Orleans, US) and recently completed fellowship in advanced laparoscopic surgery from Scripps Clinic ( San Diego, US). He has been an active AID volunteer since 2004 and was instrumental in starting AID-New Orleans Chapter. He also serves on the Executive Board and is the current Co-Chair on South Asian Public Health Association (SAPHA), a South Asian health advocacy group based in US.