Chhattisgarh sterilisation: Why medical camps will continue to claim lives
he practice of holding camps away from well-equipped hospitals and in makeshift arrangements to achieve targets for some national health programme is so common in the state that the death of 11 persons at a Bilaspur sterilisation camp does not surprise those familiar with the functioning of the healthcare system here.
Raipur: So long as you meet the target, some deaths here and there or some permanent physical damage to the patients is perfectly acceptable —this seems to be the logic behind medical camps held regularly in Chhattisgarh. The practice of holding camps away from well-equipped hospitals and in makeshift arrangements to achieve targets for some national health programme is so common in the state that the death of 11 persons at a Bilaspur sterilisation camp does not surprise those familiar with the functioning of the healthcare system here. Curiously, the camp culture finds little worthwhile mention in the ongoing debate over the recent deaths in the media.
On the positive side, the camps bring healthcare facility closer to the rural and urban poor. It becomes easier for health personnel to motivate and mobilise a bigger number of targeted people. Given most of the latter are poor and cannot afford the cost travel to district hospitals - which can be more than 200 km from villages in some cases - the camps serve a purpose. But that's all. The negatives far outweigh the positives.
Here is how:
Beds in peripheral hospitals:
The standard operating procedure demands that there must be proper beds for patients in a hospital. In rural India, hospitals away from the district headquarters are designated Community Health Centers (CHC). These normally are 20-bed hospitals. The Primary Health Centers (PHC) have even less beds, six. Many of these beds are occupied by routine patients when the operations take place. At an average in a CHC there are a 100 child births every month. The mothers are invariably found occupying beds when the camps are held at a CHC.
Even if all the existing patients are kicked out to make way for the Laparoscopic Tubectomy (LT) camp patients, it is not possible to provide beds to all the operated upon patients. In a CHC it is not uncommon to find patients made to share beds or at least the space on the floor between the beds. This exposes the patients – both the new ones brought from the OT and the old ones who were admitted earlier for different reasons – to poor sanitation and cross-infection. The district hospitals are not only better equipped, there are more beds which can be made available to the patients according to the norms.
The standard operating procedure issued by the Government of India puts a cap on the number of operations at a camp in a single day. The number is 30. It is not unusual for a district to get a target of around 15,000 cases of operations in a year. It is not unusual either for a district to have just one laparoscopic surgeon in the district to do this. This target is divided amongst the CHCs and the PHCs who then compete with each other in holding more camps than the other with just one team between them to perform surgery.
The effective span at the disposal of the peripheral hospitals to get to this target is normally five months in a year – from October to February. To help hospitals achieve it the surgeon often hops from one camp to another in a day. To expect the surgeon to stick to the daily limit of 30 cases is, well, impractical.
A solution to this could be shifting the scene to a bigger district hospital. It would cut short the surgeon’s travel time and improve efficiency and importantly, chances of reaching close to the target with the minimal risk. But the camp culture is not amenable to the idea.
Exposing infants and children to risk:
The normal target age group for female sterilization in India ranges in from 22 to 32. Most of the women are lactating mothers when they opt (or are forced to) for the surgery. In fact, the government encourages the women to undergo LT operations immediately after the delivery. Under the New Family Planning Enhanced Scheme – 2014 issued by the Union government last month, there is an incentive for the mother undergoing an operation within a week of the delivery: of Rs 200.
This effectively means the young mother lands in the camp with an infant in her arms and a child or two tagging along. The infant with siblings and the father and the mother-in-law and other attendants add to the population of a ward during a camp. This floating and uninvited population especially of the infants, with dubious resistance levels face serious risk of exposure to infection.
Again, the district hospitals are a solution. The distance and cost of travelling discourages unwanted people from trooping into the hospital with the patient.
Taking the average number of attendants with a patient to be three, in a camp where 100 operations are done, the floating population of at least 400 persons gets added to the existing crowd in a hospital ward. Even in those CHCs where the number of toilets is more, the number of sweepers in the roll is never more than one. Up to a maximum of four ward boys are there to lord over him. This staff is expected to take care of manual upkeep of hygiene in OT, the CHC premises, the wards and the toilets. Inability to do so only adds to the risk of infection.
Pathology: Risking HIV spread
Arguably the most serious risk the poor rural women are exposed to is the chance of her getting the HIV infection. The system knows about this possibility but the patient is never informed. Basic pathology tests like routine tests of urine and blood can be and are generally done in a CHC level camp. But the facility to test HIV is not there. To insert laparoscope into the body, the LT surgeon uses an instrument to puncture the abdominal skin and to make space for the laparoscope to follow. It is called trocar, a pen shaped instrument with sharp edge.
It is used along with a canula which works as shaft for the trocar to pass through. He then puts these instruments into an antiseptic liquid. He needs this instrument again after 2-3 minutes to bore another abdomen. These instruments which come in direct contact with the blood of the first patient hardly get 2-3 minutes to remain dipped in the antiseptic solution before being called to duty again by the LT surgeon.
The solution itself is nothing more than eyewash. Even if the instruments remain dipped in the solution for the whole day it is not enough to kill the HIV virus. For this the instruments are required to be boiled at a temperature of 103 degree Fahrenheit for more than 30 minutes before it is hoped to turn ‘safe’ to use it.
The hospitals at the district level provide facility for HIV test and positive cases can be segregated from the rest.
Chaos due to cultural habits:
Cultural habits in different parts of the country add very crucially to the risks a patient is exposed to. More rural the hospital is in nature, more strong the dominance of these habits in the hospital discipline is. In Chhattisgarh for example, attendants, especially old lady attendants, rush in to put oil in the hair followed by a good massage of the patient as soon as she is taken out of the OT. Some ladies are brought especially from the village for this purpose. There is never ever enough staff in a small CHC to enforce discipline and to stop these attendants, from adding to the chaos and inadvertently increasing the risks of infection.
The normal sight in an average ward immediately after a LT operation is of ladies lying down half conscious with an infant in her arms being fed, mother- in- law at the head end busy with her head, other children occupying the remaining space of the bed with the husband struggling with the crowd, jumping over the patients and pushing himself through to reach this group. To expect the doctor to reach to the patient is expecting too much.
The cost of transporting such specialist attendants to a district hospital would deter them from accompanying the party and thereby making things better for the patient and the hospital.
Risk of the patient going into hypotension:
The targeted women are brought to the camp sites early in the morning and are kept empty stomach in the hope of qualifying for the surgery and making it to the day’s list. A camp generally accommodates 100 to 120 patients and the late comers stand to lose the chance of getting into the list of the day. The paramedics or the motivators, who stand to get their share of money after the operation, also insist on remaining empty stomach till the operation is done. In most of the operating days a surgeon conducts two camps in a day. Due to the overload he often reaches the second camp late in the afternoon and early evening. By the time the turn of the women kept empty stomach since morning comes, many of them go into hypotension – that is low blood pressure.
Number of doctors:
An average PHC or a CHC has one or two doctors on its staff. During a camp this or these doctors are expected to take care of the pre and post operative care of the patient, conduct pathological tests and check blood pressures (India is one of the few countries where this job is performed by a doctor and not a trained nurse), besides attending to his normal duties of taking care of (completing the heavy paper work), medico-legal cases, indoor rounds, emergency and routine outpatient clinic.
In a district hospital the picture is better if not exactly rosy. Attracted by better residential and educational facilities for their children and over all better living conditions the doctors by choice and efforts gravitate to the district hospitals. The bench strength is always better at a district hospital.
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