Sunday, September 1, 2013
The stolen bag of gold
The moment I stepped in the office I figured out something grave had happened. Biman was on his desk with an extremely worried face. Kanak was silently weeping in front of him as if he fell into some serious trouble. Bharat, the driver of our polio surveillance unit stood up hurriedly from his seat when he saw me making my entry into the office.
‘What happens?’ I asked them.
I was equally surprised to see Kanak back. He left for Lucknow yesterday. How come he has returned so early? Generally he comes back from Lucknow after 4 - 5 days. Why the hell the fellow is breaking in so much of tears?
‘Sir, there is a big problem.’ Biman’s comment carried a strong sense of concern.
‘What is that?’ I took my seat by that time, ‘What happens to Kanak? Why is he back so early? Is everything fine with him?’
‘Kanak has made a big blunder, Sir.’ Biman gave his reply in a hopeless voice.
Kanak was hired to transport the stool samples of the AFP (Acute Flaccid Paralysis) cases to our regional laboratory located in Lucknow.
All stool samples collected from the AFP cases are tested in the lab to know if those samples have Wild Polio Virus (WPV) or not. If WPV is detected in the stool sample, the paralysis is caused by polio, if not the paralysis is caused by diseases other than polio.
WPV is responsible for polio in children and causes permanent paralysis of their limbs. The paralysis is incurable and irreversible. The affected child becomes crippled for the rest of his/her lives. Polio is a disease without cure.
But the WPV can be eradicated which means the deadly virus can be eliminated from the earth forever. Most of the countries of the world exterminated polio from their soil but few countries including India still harbour WPV. We are putting our best efforts to eradicate polio from our country.
‘What blunder?’ I exclaimed.
‘The box having the stool container inside has been stolen from Kanak’s custody in the train.’ replied Biman in utter dejection.
I was completely shocked.
‘But how? How could Kanak be so careless?’
‘That’s what I was telling him Sir. He didn’t take proper care of the box in the train. Somebody must have picked it up taking fully the advantage of his callousness.’
Kanak, all on a sudden, started crying loudly, ‘Believe me Sir, I was always alert in the train. I was traveling in the general compartment as I didn’t have reservation and somehow managed to get a seat over there. The box was on my lap throughout. I dozed off in the journey little bit. The box was picked up during that time. When I woke up I couldn’t find it. I asked everyone in the compartment including a cop, but nobody was able to give me any clue about the box.’
‘Stop crying Kanak. I very well understand the trouble you had gone through.’ I intervened, then asked Biman, ‘How many more days we have to collect the additional samples of stool from that paralytic child? Biman, would you please find out?’
‘Sir, our bag of gold is stolen. It is an irreparable loss. I don’t think we have much time left to collect the additional stool samples. Please let me check from the case investigation report of the child.’ Biman sounded absolutely frustrated.
Bag of gold. That’s exactly what we refer to the stool samples that are collected from the paralytic children in the polio eradication project.
Polio is a disease where a child develops sudden onset paralysis of his/her lower limbs (sometimes, upper limbs as well). Interestingly the paralysis is a loose one and the crippled limb hangs from the body like a dead branch of the tree. We have a special name for this kind of paralysis – Acute Flaccid Paralysis or AFP. Polio affects mainly smaller children, but sometimes it doesn’t even spare the older lots.
The Wild Polio Virus (WPV), that we mentioned in the earlier part of the story enters into the human body through contaminated food and water, subsequently sails into the gut, multiplies in millions and finally gets out of the body through the stool. A polio affected child discharges WPV in maximum number in his/her stool during the period of the first two weeks from the onset of the paralysis. If you collect the stool samples of the paralytic child particularly during that time and test it, there is maximum chance of detecting the virus in the stool and thereafter, you can easily confirm your diagnosis of polio in the paralytic child. In case the same stool sample doesn’t show any trace of WPV in it, you can confidently say the child has developed paralysis due to some other illnesses but not due to polio.
So, timely collection of stool, that is within two weeks of the start of paralysis in the AFP-affected child is the most important thing to confirm if the child’s paralysis is caused by polio or not.
Sometimes, due to delayed reporting of the paralytic child, his/her stool sample can’t be collected within that two weeks’ deadline. That reduces the chances of detecting the virus in the stool of the paralytic child, as the excretion of virus in the stool drastically lessens after the deadline of two weeks.
The golden rule of polio eradication project says, ‘Search extensively for all the AFP affected children in the community, detect them early, preferably soon after the start of their paralysis, collect their stool samples by all means within the two weeks’ deadline, and ensure in this way that you haven’t missed to diagnose a polio affected child in your area.’
This vigilance work of detecting the AFP cases in the community is the most crucial thing in the polio eradication project. In public health terminology we call it polio surveillance. Missing an AFP affected child and subsequently failing to collect his/her stool samples during the period of first two weeks after the start of paralysis denotes you are not sufficiently alert in your AFP vigilance activities. That further means, we fail to know which AFP case is due to polio, which is not.
Without a sensitive vigilance system of timely AFP case detection and stool collection, polio eradication efforts remain weak and ineffective.
Our bags of gold were collected on 6th and 8th day of the paralytic onset of the child. We further calculated from the case history of the same child that today was actually the 11th day, and we have only 3 days left to collect the additional samples of stool to keep the case within the parameter of ‘timely reported’ category.
I cancelled all my routine activities and rushed to the village of the child to collect the stool samples. The child’s residence was in the remote village of Banmankhi block. When we reached the house a big surprise was waiting for us over there.
The child had been already transferred to her Nani’s (maternal grandmother) place in Bhawanipur block. We noted down the address of the Nani’s village and made immediate move towards the new place.
Crime, big and small is a common event in Bhawanipur block. We were repeatedly told by the block officials not to travel in the block, especially after the sunset.
But we were desperate to collect our ‘bag of gold’. We had no option left.
We reached Bhawanipur in the late afternoon. The route connecting Banmankhi with Bhawanipur blocks was tortuous with a horrific strip of road filled with innumerable pits of various sizes that consumed a lot of our precious time.
The next challenging task in Bhowanipur was to locate the exact place where child is currently residing and reach there at the earliest.
We took the help of the local Primary Health Centre (PHC) of Bhowanipur. The Medical Officer of the PHC Dr R.P.Singh was gem of a person. The moment he heard our tragic story of stolen ‘stolen gold’ he took no time to jump into our jeep to accompany us in the most daring ‘stool collection mission’. He took with us his right hand man of the PHC, Mr Arjun Mishra, one of the Health Educators. Arjun Mishra knew every nook and corner of the block like the palm of his hand. Being a seasoned local man he was also a safe guard against any possible criminal threat en route.
Thereafter, we landed into the problem number three.
Polio virus is a funny virus. It can only survive in very low temperature. Slight increase of temperature in its environment can destroy the virus in no time. After collection, the stool samples should be kept inside the frozen ice so that the virus, if present in the stool samples can remain viable there. The stool samples are sent to the lab with adequate and proper ice packing to keep the required temperature intact throughout the shipment process.
Whenever we go out to the field to collect our ‘bag of gold’ we always carry a vaccine carrier with four frozen ice-pack inside. After collection the stool containers with the stool samples inside are placed within the inner space of the vaccine carrier that is surrounded by the four ice-packs and brought to our polio field office; there after transferred immediately to the deep freezer of the office and kept till they are transported to the regional lab for testing to detect the wild polio virus in the samples.
If your air conditioning system for the ‘bag of gold’ is not proper, your gold might not remain gold till the end, channelizing all your hard efforts into the water.
It was middle of the summer. When we checked our ice-packs they were half melted. The chances of replacing them with frozen ice packs from the Bhowanipur PHC were bleak.
There is a need of uninterrupted electric supply to freeze the ice-packs adequately inside the refrigerator. But that always remained a dream in a place where power cut for hours was the most common phenomena.
Dr RP Singh had finally come out with a solution of the acute problem. We stopped the jeep at a rural ice-cream factory on the way and bought a big chunk of ice to fill up the vaccine carriers to freeze our half-melted ice-packs.
We reached the village on the verge of the sunset and somehow managed to locate the child’s house with the help of some kind hearted villagers.
Fortunately, the child was present in the Nani’s house with her mother.
‘We have to hurry up a little bit.’ Arjun Mishra put an instantaneous alert on us, ‘the place is not safe after the evening.’
And then emerged the challenge number four of the day.
The mother informed us the child has become severely constipated, so ready stool sample is very unlikely. We need to wait. But how long?
‘Give the child some milk and biscuits. That can produce some stool.’ suggested Dr RP Singh.
‘The child is not taking her food properly since her illness.’ complained the mother. She had already been giving us frequent suspicious looks by that time.
‘Why these guys are so much after my child’s stool?’
How did the poor woman know that it was not stool but the bag of gold for us?
Worries were clouding in Arjun Mishra’s face with time. He was much more concerned about our safety than collecting stool from a constipated child.
The child was given milk and biscuits but she refused them on the spot. All attempts to feed her had miserably failed.
I suddenly remembered my jeep has a flatus tube which can be used to collect stool from a constipated paralytic child. Bharat immediately brought the tube.
We told the mother that we would make the child pass stool with this tube which will be inserted in her anus. Her suspicion became deeper and she refused our proposal straightway.
‘Let me try with my little finger.’ Dr RP Singh again came forward to suggest another option to get out of this unexpected crisis.
He convinced the Nani (maternal grandmother) first and thereafter the mother and other members of the family.
When the child passed stool, it was half past eight. My happiness knew no bounds irrespective of Arjun’s Mishra’s repeated words of caution, ‘We are very much late Sir. We must leave now. This is not at all a safe area to travel at these hours.’
And we faced the fifth and final challenge of the day, on our way back to Bhawanipur PHC.
After about fifteen minutes of leaving the village with a successful ‘stool collection’ mission under our belt, when we were enjoying the bumpy ride on the uneven and constricted village road, about 10-15 masked horse-riders blocked our way. We just couldn’t figure out how and wherefrom the bandits appeared so fast to stop our jeep.
They were carrying guns, and some of them were AK 47 – our jeep’s strong headlight made them clearly visible.
‘That’s what I continuously feared about.’ I heard Arjun Mishra’s fretted voice.
‘Don’t look at their eyes when you talk to them and for God’s sake don’t argue with them if you really value your life.’ cautioned Dr Singh.
One of the horse riders waved his hand to tell us switch off the jeep’s headlight. Bharat helplessly reciprocated.
Three of the horse riders gradually neared our jeep. Their silhouettes looked no less than haunted walking spirits under the clean moonlit sky. One of them pointed his finger at us to get out of the jeep.
‘Are they going to shoot us?’ I murmured.
‘I hope not.’ Dr Singh pacified me.
When we disembarked, two of the horse riders were already on the ground from their horses. I could see their third companion targeting his gun at us on the horse. My heart almost stopped that moment.
We were very much within their firing range. It is just a matter of pressing the triggers of those deadly killing machines to put the complete full stop to our lives.
‘Who are you and where are you coming from?’ one of them asked harshly.
‘Let me handle them. None of you should respond to their queries.’ mumbled Dr Singh once again.
‘We are from the polio department. We went to the near- by village to see a paralytic child.’ he replied in extreme politeness.
‘Search the jeep. If anyone tries to play smart, don’t hesitate to shoot.’ instructed the same person to his fellows.
Two of the men got into the jeep. After sometime, they came out with the vaccine carrier which had our most valuable ‘bag of gold’ inside.
I felt I was equally worried about the most valuable stool sample which had been collected after a whole day’s inhuman efforts.
‘What is there inside this box?’ asked one of them.
‘Stool sample.’ replied Dr Singh smoothly, ‘We collected from the paralytic child.’
‘Open the box.’
Dr Singh looked at me, smiled and knelt down to open the box.
‘Please have a look inside.’ he told the bandits after he opened the vaccine carrier.
One of them switched on the torch to look into the vaccine carrier and took the stool container out.
‘What is this?’
‘This is the stool sample as I told you about.’
The man immediately dropped the container on the road. ‘Shit, its stool, damn it.’ he said in utter disgust. His fellows burst into sudden laughter.
I immediately put the container with stool sample back to the vaccine carrier. I just couldn’t afford to lose my bag of gold once again.
‘Why there is so much of ice inside your box?’ the man asked again.
Dr RP Singh gave the bandits a small but solid lecture on polio, stool sample collection, two weeks’ deadline etc etc.
They were probably not ready for a polio session like this.
‘Let them go. They are harmless polio people.’ We heard him instructing his men.
We had a big sigh of relief.
The rest of our journey was eventless except a very special comment of our good friend Mr Arjun Mishra.
‘Sir, your stool sample actually saved our lives today.’
‘Remember, we have to collect one more sample of stool after 24 hours.’ I gave him a mild reminder.
‘No problem Sir,’ Arjun got back to his usual enthusiastic mood once again, ‘We can take hundreds of those samples now. Nobody will dare to touch us anymore.’
From the story-book 'Eradicators' by Sugata Mukhopadhyay