LETTER FROM A REMOTE VILLAGE IN ODISHA

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DR SAHADEV SWAIN

Dear readers,
I am a General Practitioner (GP) in the UK. I was born and brought up in a village called Shalianch, now in Kendrapada district of Odisha,India.

The village is situated in the middle of nowhere. The village is surrounded by cultivable lands where mostly rice is grown. in my childhood, there was an MBBS qualified private practitioner serving about 100000 population in the area. Right from my childhood I always wanted to be a doctor so that I can help of this doctor who was serving the community singlehandedly. After several decades I decided to return to the village with the intention of meeting older people and bid good bye to them, in case I am unable to travel to the village in future. Here is a brief account of my reflection.

With due deliberation I decided to live in the house I was born and meet people. I reached the village with my sister’s family. I was welcomed by my cousin’s family who lives in the house. Soon we had to get on with the work. I had my bag with basic pieces of equipment that I used for my usual consultation room. I also got a prescription pad printed with my personal details. I had collected some basic essential medications particularly if anyone was unable to buy them. We had a fixed time in the morning and in the afternoon. The people were informed and instructed to in one by one. I was ably assisted by a student nurse, an ASHA worker and my sister who is a local AYUSH doctor and her student physiotherapist son by taking turns. The patients came mostly one by one although sometimes they wanted to enter all at once. The stories unraveled one by one.IMG-20191130-WA0023

It is difficult to describe each case in detail but I will like to outland some cases in general and a few cases in specific to bring home some points of observation.

Diabetes appears to be a huge problem in the village. n a village of 150 households there were at least 40 known cases of diabetes. There were different levels of awareness about the disease Some of them were very aware and took their medication regularly. But many of them were unable to afford the expenses of buying regular medications. Some of them mentioned about taking other forms of therapy like homeopathic or Ayurvedic medications. Some of them, however, were so confident of the mercy of God that they did not feel the need for taking any medication either for diabetes or hypertension.

However, some of them did attend reputable diabetic clinics. They were given written leaflets about a detailed diet plan and other advice. I tried to organize a joint consultation morning for all the people with Diabetes. However, it was challenging. My intention was they can learn from each other about diet, exercise, medication and whom to consult. In the end, I ended up consulting them individually to give customized advice.

Musculoskeletal conditions were the next most common presenting problem. Osteoarthritis was particularly relevant to the elderly population. The involvement of knee, hips, and back were problematic for both men and women. There was difficulty in squatting for defaecation in addition to limiting the day to day activities. The men who were the main bread earners from farming activities were unable to perform their usual jobs. But it was heartening to note that some of them retained their mobility by continuing to use bicycles. However, I saw one of the most severe forms of osteoarthritis of the knee resulting in fibrosis, muscle wasting and complete lack of flexibility . as a result the person was completely bedridden. This added an additional burden of caring for the women of the house particularly when the men were out in the town to earn a livelihood.

Low vision particularly due to cataract was very common This I thought was one of the most common causes of blindness that could be prevented or cured. I did come across a woman with night blindness that was resistant to vitamin A treatment. This condition in a middle-aged woman who has been recently widowed and with interrupted electricity supply in the village and toilet outside the house adds to the plight of the woman if she has to go to the toilet in the middle of the night. I later gathered she may have retinitis pigmentosa. She was reluctant to take up my offer to go to the ophthalmologist for further diagnosis because of a lack of resources.20191119_092500

Hypertension appeared to be a common problem among the villagers. For one of them stroke was the first presenting problem. Many of them did not know they had hypertension and others did not see the importance of taking regular medication. Although this person survived the stroke the physiotherapy, medication and regular check-up in a tertiary care center are very expensive for the family. Not to forget that this middle-aged man will not be able to do farming that he used to do. Also once a stroke happened I saw how difficult it is for the family to provide aftercareIMG-20191125-WA0008

The incidence of road traffic accidents is increasing due to improving road conditions and moremotor bikes and other veicles . Some of them are fatal.accidents . The survivors are also left with a lot of physical and mental morbidities morbidity due to trauma and posttraumatic stress disorders.

There was also also delayed diagnoses of cancer due to lack of screening facilities . Eeven after the chance diagnosis proper treatment and follow up in thecancer centres were out of reach for ordinary families.

End of life care was also difficult due to the complete lack of resources. I witnessed the struggle of a family in even providing a comfortable bed to the dying. Bedsore in the shoulders are not very common but was present in the person I visited.

I did encounter acute cases of asthma. I was puzzled by higher incidence of allergic rhinitis in the village,maybe the dust, pollen or grass are the allergens!

This is in addition to the burden of communicable diseases. I did encounter cases of typhoid and tuberculosis.

My letter from the village will be incomplete without mentioning my visit to the school or me helping plantation of about one hundred trees in the village.

I enjoyed the company,curiosity and intelligent questions from the students. I was able to pay my respect to some of the surviving teachers. However, I did notice that there were still no toilets for the boys at school! There is also no computers in school!

How has it changed my life?

My encounter with abject poverty has taught me

1. Do not complain. Be grateful for what you have.
2. A liitle act of charity can change some ones life.
3. If you walk one step the world walks two steps with you. So take the first step yourself.
4. At the end there is thank you most of the time!


How is it relevant for Family medicine?


1. I feel I was able to deliver health care to everyone with the help of low tech instruments because of my training and expertise in family medicine. Therefore, the quality of postgraduate training in Family medicine is essential for the provision of universal and quality health care coverage at the ground level.
2. Besides my long experience and knowledge, my long-standing relationship with the villagers helped me to gain their trust.
3. The patience and respect by providing privacy, full attention and active listening and the dialogue with the family increased the patient’s (and doctor’s) satisfaction.
4. Family Physicians are the leaders who can be instrumental to deliver care at the village level. The Family health Centres of Kerala provided the perfect model for the rest of the country
5. Will telemedicine help for remote access? only time will tell.
6. We need “Setu” program of the Academy of the Family Physicians of India to reach out to the villages.

Now that I know so much about the village I wish I was their permanent family physician! How nice it will be if every village like mine had their own family physician? Is that not a utopia at the moment?

Thank you for your attention,
Yours sincerely
Sahadev Swain

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Dr Sahadev Swain

MD,MA,MRCOG,FRCGP
GP Partner, Biscot Group Practice
9 Blenheim Crescent
LUTON LU3 1HA
Phone 01582 404012
Hon Treasurer, RCGP Beds& Herts Faculty
Member, Board of directors, Beds& Herts LMC
Member, Board of directors, Luton GP Federation
Member Audit Committee, RCGP, London, UK