Introduction-An Identity Crisis
During the Battle of Kurukshetra in the Mahabharata, witnessing numerous lives being extinguished daily on the battlefield. One day, Arjuna experienced profound despair and intense confusion regarding the ethical justification of engaging in battle against his own brothers. Arjuna asked, “Who am I? ” Lord Sri Krishna responded by narrating a story, after which Arjuna obtained his answer. This assurance confirmed his identity as a warrior before being a brother, leading to the subsequent events recorded in history.
The Clinical Case
As an aspiring public health specialist and community physician, we often encounter scenarios in which we must determine whether to adhere strictly to our professional obligations or extend our efforts towards a broader social initiative.I encountered a comparable scenario when I encountered a 35-year-old tribal male, Ramen Tudu (pseudonym), a daily manual wage laborer from the remote village of Saltora in Bankura, admitted to our leprosy hospital (RLTRI, Bankura). He was clinically diagnosed as a case of multibacillary leprosy, had completed MDT treatment, and was suspected of having a relapse along with type 2 lepra reaction and peripheral neuropathy. Nasal swab result shows absence of M. Mycobacterium leprae and the bacteriological index in slit skin smears demonstrate an escalating pattern.
The social Case
I was assigned trainee duties on the day when a senior staff nurse requested my presence due to his distress since morning. I approached him and found him reclining on the bed in the late morning. Initially reticent in my presence, he gradually opened up as I established rapport with him. He shared details about his family, his modest village, financial struggles, and the prevailing superstitions concerning leprosy in his community. These beliefs include restrictions on family members of leprosy-affected individuals from bathing in communal pools and attending the same school. I learned that he fabricated a fictional job opportunity in a neighboring town to receive medical treatment in this village in order to protect his family from social stigmas. I was incredulous upon hearing the information given the current advancements in AI and machine learning. I pondered whether the Sustainable Development Goals will address these gaps at the grassroots level. The passage of time may provide further clarity on the matter.
A Father’s Day out-Community Physician rocks
Coming back to my story, I asked him at last, “What is the issue today, Ramen? ” He tearfully informed me that he needed a day off to visit his daughter on her 12th birthday. However, he was prohibited from doing so due to his ongoing treatment regimen that required his presence.I had the same doubt that of Arjuna in Mahabharata and I asked myself “Am I just another clinician or someone more than that”.I remembered the teaching of my gurus in the field who like Lord Krishna always guided me to see the problem from view point of a community physician who always looks into health as a multidimensional entity and not just mere absence of disease. By that time, I had decided to take on the responsibility of escorting him to his daughter. I rented a car and arrived the following morning, which came as a delightful surprise to him. Happiness manifested in his tears as we commenced our endeavor. He instructed me to maintain secrecy regarding my identity, to which I affirmed that I am acting as a friend, not a doctor, for the duration of today. We traveled a distance of 80 kilometers over the course of 2 hours, culminating in a significant moment when I was able to present the ultimate gift to my daughter on her birthday, evoking strong emotions. Tears welled up in my eyes as I envisioned my daughter embracing me upon my return home following my training.
A Clinico-social perspective
Upon meeting Ramen’s family, I had the opportunity to thoroughly investigate the clinicosocial aspects of his disease. A rudimentary dwelling consisting of a single room lacking adequate lighting, ventilation, and sanitation facilities, where open defecation is common practice, along with an outdoor kitchen and exposed food storage. They exhibited inadequate lifestyle and hygiene habits. I discovered a nearby Anganwadi center, however it was closed and I was unable to interact with the staff. I arrived at my final clinic-social diagnosis as a 34-year-old male with a manual labour occupation, belonging to socioeconomic status V according to the modified BG Prasad classification. The patient presented with fever, painful nodular lesions, and peripheral neuropathy, diagnosed with lepra reaction class 2 and suspected relapse due to an increase in bacteriological index (BI). Contributory factors include poor hygiene, housing, sanitation, lifestyle habits, inadequate knowledge and attitude towards the disease, social stigma, and superstitious practices. These factors have led to a failure in primary prevention and have contributed to morbidity and poor disease outcomes.
Preventive and Social Medicine- An unique Identity
I felt privileged today to feel the real essence of a preventive and social medicine expert, where I had the opportunity to go deep down a neglected tropical disease through a clinic-social case at individual, facility, and community levels. It allowed me to experience the versatility,humanity and multidimensionality of the field of preventive and social medicine much beyond clinical practice.
