March 16, 2021: Posted by One Surgery Admin
The following is the first in an exclusive three part series of extracts from the book, “My Kinwat Days”, written by Dr Arun Gadre, a gynecologist that has spent twenty years of his career serving the draught-prone rural population in Maharashtra, India. Dr Gadre is also an award winning author in the Marathi language, with 14 published books. In 1986, early in his career, he ventured to Kinwat, a village in India to set up a surgical service for the poor along with his wife, Jyoti, a practicing anaesthetist. In 1987, he left the project, feeling he had failed. “My Kinwat Days” are his memoirs, recalling his experiences there, and offers valuable lessons for the modern day global surgery movement.
Foreword (by Saqib Noor): I had the good fortune of discovering My Kinwat Days just under two months ago, and was delighted when Dr Gadre replied when I reached out to him. I was excited to meet a fellow healthcare professional, like myself, who wrote, during their times of strife with their heart on their sleeves. He sent me the English translation of his beautiful memoirs, describing a time as a surgeon over 35 years ago in rural India. Although the literal English translation from Marathi does not do his deeply moving writings justice, I have tried my best to edit the direct grammatical translation throughout this three part extract series, whilst maintaining the fluidity and evocative style of Dr Gadre’s writings. It is saddening to know stories from 35 years ago still resonate with the current situation in the world today and therefore, it is writings like these that truly highlight the desperate need for access to improved surgical care worldwide. I would like to personally thank Dr Gadre for being kind enough to share his wonderful writings and stories with us on the One.Surgery blog.
My well-equipped hospital, the dying patient and the difference of four dollars
It is Sunday. It is a bazaar day, the day of the week reserved for commerce. It is the day when sellers gather to sell and buyers come from nearby villages to buy.
For a person living in a city, every day is a bazaar day. In the village however, it is one of seven days and always occurs without any compromise, whether it is a cold and chilly day or a hot and brazen day. And the bazaar day is the best business day for doctors.
People bring five separate rupees (one-tenth of a dollar) for a doctor. It is in their weekly budget: Tobacco, petrol, clothes, a bucket, cell for a transistor, a rupee for a movie, a 40 page notebook for a child, a rupee for sweets, and similarly, five rupees for one injection from the doctor.
And the doctors wait eagerly for their customers, 20 to 30 syringes are ready, having boiled them thoroughly and the needles are all ready too. The medical shops (dispensaries) are filled to the brim, no time to breathe, not even for lunch.
Nobody, even patients, will wait for anybody. Never! They are in a hurry as they have to catch the next bus back to their village. They will not wait long, will stretch standing erect and will go away to the next medical shop in their long strides. To take an injection nicknamed as ‘The Needle’, only from the doctors who are moneylenders for their patients too, there is no alternative. There, the patients will wait, if compelled to and will wait endlessly.
Outside the medical shop people chat with tobacco on their palms. Women clutter, converse among themselves with infants to the breasts. Men talk about politics, endlessly. Locals squat on the floor. Maybe, one lights a Bidi (a locally made cigarette), another often handles that priceless five rupee note. From the infant of four days old to the 90 years old senior, everybody wants that magic needle.
And the doctors too are ready with everything from the secondary unauthorized market – Vitamin B complex injections, tetracycline injections, and of course, that magical intravenous dextrose! For those weighty fellows, who have brought 50 rupees cash, the IV is waiting for them. Today, the collection at the medical shop will be in the hundreds and so, thus, it is this Bazaar day! The most valued Bazaar day! The Sunday!
Crowd filled roads. Women are moving eagerly. The children are following their mothers. The large and stout men are walking effortlessly. The noise is surrounding the crowd. The red turbans, the sweating black faces with shining crisscrossed lines. The astute stare. Smell of sweat, tobacco and cigarettes. Sharp calls, the bubbling laughter, quarrels, and shouts! Not even an ant can move on the road now. There is no pavement on the road. Along the border of the road, the women sellers are busy gathering their stuff. And what a wonderful collection they have! The pepper — the sweets — mangoes — chilly — the cloths – the bangles — the steel plates costing a rupee or two — the saucers. And what a surprise! Somebody has raised the tent somewhere. In that, there are many mirrors. Some are concave and some are convex and a funny show is offered. The loud speaker is crying hoarse!
And on the corner, there is one super specialist sitting with his magical Ayurvedic drugs (ancient Indian way of treatment). The so-called special ancient Indian drugs are being offered by a petty quack! The roots, the leaves, the super power drugs! The specialist has smeared his forehead with white ash. The smell of burning sandalwood is overhanging around. He is from the tribes. And yes! He claims that he can communicate with spirits too, but of course for a fee of some rupees! The cost of the treatment over there is little more than at my dispensary. But the treatment offered there is a permanent one.
Oh! Yes. He can cure piles!
Everyone from the police officer to the district administrator come to him. He can produce the culprit, the piles, within five minutes, and that too he can do without modern surgery, without anesthesia, without pain.
The qualified doctors like us comment that it is not the piles which he produces, it is just the bronchial pipe of the hen! Anyway, we modern qualified doctor would say so! After all, it is our business being affected. And yes, he has a confident treatment for jaundice too.
He applies a torn cloth over the wrist of the patient with jaundice. And look – the white cloth turns its color in to a dark yellow one – A confident treatment for jaundice! He has medicine for abortions. And one for sterility too. In spite of the presence of such a super specialist around the corner, it is the great miracle that patients also turn to me!
On that particular Sunday, I have had 20 patients! Really a miracle!
By now, it is three in the afternoon. Cooked lunch is waiting in the solar cooker back at home and we are about to leave.
Suddenly a group of villagers steadies itself at the door of my dispensary.
“Hallow!” they cry.
“Good morning!”, I reply.
“You are the one — from Bombay?”
“Yes”
“Are you around?”
“For half an hour.”
“The condition of our lady is very bad!”
“Is she pregnant?”, I ask.
“She has delivered four days back.”
“Where is she?”
“Coming — in a bullock cart.”
“Have a seat”, I usher them in.
“What do you charge for examining a patient?”, they ask.
“Three rupees”
Hearing my answer, they all look to each other and appear relieved, whatever they have heard about me has proved correct.
They all sit on a bench, quite worried.
“Which village you are from?” I ask.
“Oh! — From that XYZ”
I do the calculation: Forty-five plus twenty equals sixty-five. They are coming from a village 65 kilometers away.
“So?” I ask.
“We have tried so many doctors! Taken needles worth hundreds of rupees. Yesterday, the teacher in our village told us about you. He said that doctor from Bombay would give us a really powerful needle.”
I am frustrated. After all this — a powerful needle! An injection! Again and again –that bloody injection!
One old woman that has all bones and no flesh comes up to the door. She has just one short cloth on her body. Shrunken hands, hollow mouth, hair on her scalp like that of a doll!
“Oh! My son! Save my daughter!”
She starts crying. Others shout at her. She keeps tongue-tied. Tears are in her eyes. Hope on her face. The bullock cart arrives.
Ten people come with the woman. Hurriedly, the bullocks are detached from the cart. The woman is brought in.
Around 25 persons gather around the examination table.
“Out — all of you out!”, I shout.
The woman is hardly a teenager. Definitely, she is not more than 16 years old. She is primi, meaning a first time pregnant patient. She has delivered four days back. A quick examination reveals the moving chest, frank white coloured skin due to lack of blood. She is drenched of energy. There is no blouse over her chest and there is a specific reason for it, her right breast has an abscess. A large right breast is the size of a watermelon, the pus must be about four to five litres! One small opening is evident, a mixture of milk, blood and pus is oozing out of it.
Fever — 104 Fahrenheit. Pulse — 160. — B.P. — low. — A frank case of peritonitis too along with the breast abscess. A severe agonizing pain is evident on her face.
Jyoti examines her per vaginally. There is a tear in the perineum. The anus and the vagina have become one. Pus is oozing out of that opening too.
She gives a history of convulsions. The liver is palpable. There is no need of any great intelligence to form a diagnosis. It is a frank case of septicemia with peritonitis and a large breast abscess.
Treatment?
Well Sir! — Antibiotics, fluids, incision and drainage of the breast abscess under general anesthesia.
Prognosis?
—Excellent with modern facilities.
Jyoti and I come out of the examination room.
All are eager.
“We have to operate.”
“– — — –“
“Will have to open the abscess under general anesthesia.”
“– — — –“
“Will have to admit for at least four days.”
“– — — –“
All are speechless. I keep mum too.
A hushed discussion follows.
“Cost?”
I take a deep breath.
“It’s not much. Let us see, Including the four days stay, anesthesia charges and operative charges,” I wait for a moment, as usual there is no point in giving details, and they are interested in actual cost. “Well! My charges will be 50 RS.” I sum up,” the medicines will cost around two hundred and fifty RS. So, the total will be three hundred rupees”
The old woman comes forward. Pressing her fingers on my cheek, she urges, “She is just like your sister! — Please do a favor!”
I glance at Jyoti, Jyoti looks to me.
Only one point for all of us to ponder upon.
‘If we operate, she will live. Hundred percent. If we do not operate, she will die. Hundred percent.’
“Okay.” Say I.
Jyoti is tense.
“I will not charge my own fee. Just bring the medicines.”
Jyoti sighs.
But there is still two hundred and fifty Rupees (5 dollars) to consider.
“Oh! My dear! We are all very poor. And those doctors have squeezed us by now.” The oldie tries her last pleading.
I am curt. “Bring the medicines, I will operate.”
All are quiet. Discussions ensue in whispers.
“Just give one powerful needle! Injection, say up to 50 rupees.”, one of the crowd suggests.
I am dumb-founded. Jyoti’s eyes are locked in that girl’s stare that is being carried away to the bullock cart. They have not paid my 3 rupee consultation charges and I do not insist to.
No. They are not going to the civil hospital in the district place, that city is hundred and fifty kilometers away, the transport to it costs the same amount.
“And they don’t really look after the poor over there!” another one comments.
The mob vanishes. I close the door, we both return back to home on the motorcycle.
Our loan amount (to set up our hospital) is distressing me, 90,000 RS. ($2000). There is my hospital. I have made it well equipped. I have done posts in general surgery, along with my specialty, obstetrics and gynaecology. Jyoti is an anesthetist. One servant is sleeping in that empty hospital. He takes home 300 rupees salary for doing nothing! And this patient is going away! This was the beginning of our defeat.
After many days, one person from the village visits us.
“What happened? Did you take her to the civil hospital?” I inquire.
“No! From where should we bring money? Taking name of the God, our barber incised the breast with the razor! Anyway, she died three days afterwards.”
So it is the rift of only 200 Rupees ($4) between her death and in my hospital, between one life and death.
And this difference of 200 Rupees has one more aspect too. It is the question put forward to me by the expert in the ivory tower who represented the international funding agency when I first proposed my project.
I gave an interview to an international funding agency where I had applied for the assistance to run my hospital in Kinwat. I was rejected. I could not answer their only important question.
It was, “Don’t tell us about your operation theater. Just tell us about your plans in preventive medicine!”
Of course, I had none. So, I was refused any help. For that international funding agency, there was no merit in saving a life.
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