By Professor Dr. P. Suvarna Devi, Former Professor & HOD, Department of Pediatrics, MKCG Medical College, Brahmapur, Odisha
A journey of 56 years! Many of you reading this were perhaps not born when I started my fascinating journey in this wonderful discipline. As an undergraduate I was very much attracted to surgery and also won a gold medal and prizes in the subject, so naturally decided to be a surgeon. When I first took up a job in 1965, after migrating from Andhra Pradesh, in Red cross children’s Hospital, popularly known as Sisubhavan, Cuttak, I was placed in charge of the surgical ward. Sisubhavan is a picturesque place on the banks of the Katajudi River and is cool with lots of mango trees. Dr. Kashinath Misra was the superintendent and a very able administrator. He would impose a fine on anyone who picked mangoes including doctors. It was taken over by Government and named Sardar Vallabhai Patel Institute of Pediatrics. Surprisingly it was the only Institution named after the great man in the whole of Odisha and the library hall with its wooden flooring was the place where Sardar Patel negotiated with the erstwhile Maharajas to join the Indian Union in 1947. It was a short stint and I moved to Government service and my first posting was in a cancer ward. It is surprising how some great people change the destiny of others simply by their behavior. Thus it happened when I came in contact with the late Professor Dr. Sarat Chandra Mishra, the first professor of Pediatrics, who used to come to Sisubhavan as a consultant from SCB Medical College. His simplicity, compassion, nobility, and profound knowledge impressed me greatly making him my role model. There was no entrance examination for PGs in those days and students were selected based on their undergraduate marks and I was given Pediatrics. So I moved to this delightful discipline from the cancer ward where I was working as an assistant surgeon and found myself under the kind studentship of Prof. Mishra. Another good thing about Sisubhavan was the comradery among the staff members and Prof Mishra used to say that he wished for such an atmosphere in the pediatric department of SCB Medical College too, which was sadly missing. The nurses were also excellent.
“You must become a parent before becoming a pediatrician” Prof. Misra often used to say, the wisdom of which I understood only when I became a mother, rather early in my PG studies. One becomes very patient with the queries of anxious mothers and appreciates the pain of parents seeing one’s child suffer, only when one is a parent. Common cold in the firstborn is a much bigger illness with undue anxiety, than pneumonia in the fourth child! Immunization was not so popular at that time and DPT was the only vaccine freely available. The Polio vaccine was not supplied by Government and was given only to a privileged few. I still remember the tragic case of a mother who gave smallpox vaccine to all her 5 daughters but not to her only son due to the fear of side effects and he died of smallpox. Infectious diseases were rampant and we used to have a special diarrhea ward of 30 beds which will open for the 3-4 months of diarrhea season only. Severe dehydration was very common and I became an expert in doing venesection in record time and pushing in IV fluids to save a gasping child. A sign of severe dehydration which was not mentioned in books, was the extreme softness of eyes which I named as “cotton wool eyes”. It was published as a letter to the editor in Indian Pediatrics and also presented at a National conference. ORS was not yet in vogue, but we used to dispense small packets of electrolyte powder designed by Prof ST Achar to be dissolved in water and given orally. On one occasion he came to visit Sisubhavan and advised us about as simple a thing as the seating arrangement for waiting mothers! Dr. RN.Panigrahi, who was the senior member among us was his student and instrumental in arranging his visit. He used to tell mothers jokingly, “If you are using a glass feeding bottle break it, if a plastic feeding bottle burn it, or if a silver feeding bottle give it to me”. Thus the feeding bottle became the villain. We were often told how Papua New Guinea banned feeding bottles and brought down the Infant mortality rate. We were ignorant about feeding during diarrhea and often stopped feeding during IV therapy. Antibiotic injections were also commonly given. Another disease we were happy to bid goodbye, to was tetanus in newborns and older children. A lantern was used to burn in the room instead of an electric bulb and we would talk softly to minimize the disturbance to the patients that would precipitate spasms. Immunization of pregnant mothers with TT and infants with DPT has successfully eliminated the disease.
Another preventable disease that we rarely see nowadays but common in those days was Kwashiorkor. Mothers would feel happy that the child is becoming chubby with rounded cheeks and seek medical attention only when other features like edema appear and make the child miserable. Sago and barley were the favorite infant foods and help in perpetuating the condition. There used to be a tinned protein food called Casilan which when given to these children would work like magic. Edema would disappear and the miserable child starts smiling. Smiling is often the first sign of recovery. A surprising response of some children to food deprivation is marasmus instead of kwashiorkor when a baby manages to adapt to the circumstance of limited food and becomes wasted rather than edematous, and that is why kwashiorkor is often referred to as disadaptation syndrome. A heart-wrenching condition was Xerophalmia due to vitamin A deficiency and the cornea would melt in 24 hours! Thanks to the vitamin A supplementation program by Govt of India we never see it nowadays.
The next serious disease which we often encountered was tubercular meningitis and often rows of beds were filled with these children and frequent lumbar punctures were a must! Immunization has also brought down the incidence of acute bacterial meningitis. Thus I became very skillful in doing LP also. I am proud of a little patient of mine who had TB meningitis and was in a coma for 2 months and found to be blind on regaining consciousness but regained all her faculties gradually. Now she is a normal young woman who brings her child to me for treatment. It is such miracles that make our day even while working in the midst of chronically deficient and depressingly dirty government hospitals. We need to recount those days to people who complain about the lack of development in our state. A transfer is a thing often resisted and a popular expression used is “dhora-dhori”( using one’s influence) to avoid leaving a place where one has grown roots over the years. I was transferred six times, twice each to Cuttack. Burla and Berhampur during my tenure since I didn’t use dhora-dhori!
Academics is a big attraction for those with an academic turn of mind who work in Medical colleges since students make you stay in touch with recent advances and promote learning, not to speak of the loving bond one develops with these youngsters. I am still in touch with some of my students who share their joys and problems with me. One can’t afford to be irrational under the questioning eyes of postgraduates and one gains a lot of knowledge while correcting their thesis, though I am sorry to say that thesis is often not very truthful. It is considered a mere passport to examination rather than a true work of research and the sooner they be done with it, the better. I don’t know what is the present condition and hope it is better.
As I matured in the discipline my attention was drawn to the bigger picture of Infant mortality and I used to hang my head in shame when people at national conferences referred to Odisha as a state with the highest IMR in the country. In the late 90’s IMR was an unacceptable 98 for 1000 live births! As I attended a few trainings for CSSM, NNF etc my eyes opened to the acute problem of neonatal mortality which formed 60% of IMR. I realized that lack of skill in managing neonatal problems was as important as lack of equipment as we went around the state training doctors at peripheral hospitals. Late Prof SK Giri was the first person from Odisha to be trained in neonatology at AIIMS, New Delhi and he used to cover the neonatal part of CSSM, but neonatal care never took off in a big way. As a group, we went around the state to train the doctors and a few nurses in newborn care supported by Unicef and the government of Odisha. But it was a drop in the ocean and in many places, there was not even a proper bag and mask, including Medical colleges.
It was then, that I conceived the idea of NALS ON WHEELS and submitted the project to Govt of Odisha, which was promptly binned and forgotten. Imagine my surprise when I received a phone call from Dr. Vinod Paul one fine morning, saying that a fund of 8000 dollars was available to me to carry on my dream project! It was given by one American association headed at that time by Dr. Dharmapuri Vidya Sagar, called AAPI, an American association of physicians of Indian origin. I remembered one of my Bhagavan’s teachings, that when one is sincere and intense about a desire the whole universe conspires to make it come true.
Dr. Vinod Paul and Dr. Ashok Deorari were pillars of support for these programs for newborn care and I set about doing what I loved most. I selected 3 Pediatricians who recently graduated and were my students, as yet unmarried, since marriage and family are often not conducive to such an intense mission. One of them left early to seek his fortune elsewhere but two of them, Dr. Biswaranjan Padhi and Dr. Manas Pani continued till the end of the project, and another Dr. Prafulla C. Gouda joined us for a while. This unique project would not have been possible without the support of Unicef headed by Dr. Ramani, that took care of the training and traveling expenses, and Secretary of Health Miss Meena Gupta who deputed the doctors promptly for as long as I needed.
I purchased an Ambassador car, took my team, loaded the car with the equipment necessary for teaching like an overhead projector, mannikin, bag, mask, training manuals, etc, and hit the road. We extensively traveled in the two districts of Ganjam and Gajapati, visited each and every PHC and sub-centers, and trained the doctors and nurses in basic newborn care. It was necessary to teach them at their places of work so that we realize their problems in the field. We operationalized the equipment that was available but unused and innovated when necessary. An example of innovation was a resuscitation mask made by cutting the top portion of discarded saline bottle lined with sticking plaster, to prevent injury to the delicate skin of a newborn baby and using a 200-watt bulb to prevent hypothermia. I was invited to present my work at the annual conference of the American Association of Pediatrics (AAP) in Boston, USA, in May 2000. Currently, newborn units are established in all teaching hospitals and district health centers and they are better off equipment-wise also.
The next hurdle was undergraduate education in Pediatrics. Despite the children forming 40% of the population and the fact that fresh graduates have to face the difficult situation at the periphery, undergraduates were not taught much pediatrics and there was no examination in Pediatrics. It is a fact that students will only learn that which helps them to pass the examination and big brothers in medicine, surgery, and O&G didn’t like to give us any space. However due to the tireless efforts of senior professors, ultimately Pediatrics became a separate subject in the final MBBS examination, free from the overbearing attitude of big brothers. Another event that attracted students to pediatrics was the undergraduate quiz and many students from Odisha participated in finals and often were the winners too. Later on, the quiz was introduced for postgraduates also. No other subject has so far introduced such a quiz as far as I know.
As I write this Pediatrics has become so popular that it is the first choice for students in the selection for PG courses. The IMR in Odisha which was 90 in 2001 now stands at 36 and Odisha is the state in India with the fastest decline in IMR by 39 points during 2005-2020. There are 94 First referral units with facilities for the Caesarian section in 80 0f them. Free transportation for pregnant mothers and infants is available and a transportation cost of Rs1000 is given for institutional delivery. Over 48000 ASHAS are working in the state. There are 44 special newborn care units and 482 newborn stabilization units in 530 newborn care corners in the state (SRS 2020). This is not a small achievement but there is still room for more improvement, as it is said that the road to improvement is constantly under construction. I wish and pray that Odisha should get rid of the label LPS, Low performing state.
Jai Hind!
drsuvarnadevi@gmail.com
