In recent years India has embarked on a media campaign blitz under the tagline Incredible India to attract attention, and more importantly desperately needed investment, to exciting changes which have been gripping the country. Economic liberalization and political reforms have unleashed amazing growth in many industries including Healthcare (especially if you were unlucky enough to witness India throughout the 70″s to 90′s stagnation, the so-called Hindu rate of growth). Fortunately for this increasingly impressive country teaming with entrepreneurial spirit, repressed by consecutive decades of corrupt governments there finally is tremendous potential for a substantial reduction in poverty and never before seen incremental improvements in the well being of the general population. The government’s role is to continue to facilitate economics conditions favourable for growth and allow private enterprise to flourish. The availability of private sector employment opportunities for the masses, the ability to educate one’s children so they are prepared for those newly minted jobs; these should be the priorities.
Along with economic liberalization, and not to be discouraged or shunned, is the entry of massive foreign investment into Healthcare looking to make a profit. This is not an evil thing executed by coldhearted selfish capitalists. Ok maybe it is executed by selfish capitalists but hopefully not cold hearted and definitely not evil. Any enterprise looking to invest into an emerging market will segment the market and target those who can pay in order to maximize the probability of a positive ROI. India requires a sustainable growing healthcare system and not one dependent on charity. Access for all will improve in time only if the healthcare infrastructure is first built on a sustainable basis and the poor are allowed to earn out of poverty with dignity. After a thriving healthcare system for the middle and upper classes has been built, governments could allocate income taxes on thriving profitable healthcare or other institutions to subsidize the provision of healthcare infrastructure in remote or underserved areas. We all know or suspect what the patient and provider treatment experience would be like in one of these institutions. If not, please see video on Medical Tourism in India in the sidebar.
Unfortunately, Slumdog India is not so Incredible India. For a better idea of the patient and provider experience on this side of the spectrum I have taken the liberty of sampling from a blog linked here called CaseIndiaTrips 3.
CaseIndiaTrips (â€CITâ€) is a one-month elective sponsored by the Residency program in the Department of Medicine at Case Western Reserve University. In 2007 and 2008, residents from the department (and the occasional medical student) have spent a month in south India observing healthcare-related activities in a wide range of settings.
The personal anecdotes of these physicians are an INCREDIBLE insight into the human experience for the vast majority of Indians and we are grateful to them for publishing their experiences for all to see.
By Puja
Last 3 weeks seem a blur tonight. Each day as if we were in a time machine being transported to the 20th century and then back to the 21st. Each day our emotions went on a roller coaster ride. Feelings of helplessness and sorrow changed to joy and amazement on a daily basis. Here are the images and memories of CIT3
The Patients
As we enter the Leprosy wing at SRH patients start gathering around us. From little boys not old enough to cross the street by themselves, to men and women with wrinkled faces. They looked as though each one secretly hoping that they would be subject of our teaching case. A young boy falls victim to my newly acquired practical leprosy knowledge. He seems to know what exams I should be doing to test his deficit even before I have a chance to ask him to move his fingers a certain way . I point to the camera and ask with my hands if he would let me take his picture. Before I know it, both the affected and the unaffected hand is up in the air, and a shy smile behind them.
We enter the HIV ward at SRH and predictably enough the patients get up out of bed, as though they were all standardized patients. “No 281†corrects a patient with HIV after the attending doctor presents his case to us and miss quotes the CD4 count.
We enter the doctor’s office, 2 large windows fill the room with light and cool breeze gently caresses the flower print curtains framing each window. We all find chairs, some tables to sit on. There are 6 of us, squeezed in the Outpatient oncology clinic of Dr. Rao. One after another patients come into the room, sometimes more than one patient at the same time. They all have one thing in common, a plastic bag full of a lifetime’s worth of medical records, files, notebooks, hardcopies of xrays, CT scans, ultrasound. And I can’t even get my clinic patients to bring their medication lists.
Scores of blank faces riddled with hopelessness sitting, standing or leaning against walls in various lines at government hospitals.
The Doctors
Just like anywhere else, the entire spectrum can be found here. There are doctors who refuse to treat people with HIV, even if they present with ruptured thoracic aneurysm. There are doctors who prey on poor people and treat them with medications that has about as much chance working as Penicillin does for Influenza. Then there are doctors who not only restore your faith in humanity but make you ashamed of your own worthless life. There is Dr. Rao who works the system everyday to be able to provide care to his poor cancer patients. He is an unassuming man with a restrained demeanor. His words are limited, as though on loan. But when any one of his hundreds of patients walks through the door, he seems to know everything there is to know about them. First class? Second class? Third class? is usually his first question, trying to gauge how the patient is doing on the sick spectrum. He is not pushing notebooks around, he is talking to them about their schools, jobs, cancer, chemo, and death all at the same time. There is also Dr. Laxmi, who has her finger on the pulse of every microorganism and its host coming in and out of her hospital. You can see the fatigue on her face at times, and just when you think the system will get the best of her she tells you a story of how someone’s life has been changed for the better because of her lab and you are reassured that people like her cannot be beat. Amazing doctors are working here 24/7, when they talk its as though Harrison’s is being radioed to them through a secret microphone. They are passionate about their work and they love these patients. These doctors work under conditions that we cannot even imagine. Every single decision is a struggle. A CBC is not just a CBC, it may represent lack of food on someone’s table for a week. As Dr. Rao said “Life is not ideal, in real life are many compromisesâ€. Standard of care is a luxury to many here.
The Illness
One would need a daily M&M to talk about the amount of pathology that exists here. The fever hospital is full of diseases that we only read about in medical school like tetanus, diphtheria, malaria. Even the cancers here are different. Head and neck, cervical, gastric and gallbladder cancers cause a big chunk of mortality and morbidity. HIV is rampant, so is TB. And then there is what ails us all, diabetes, HTN and heart disease. As you have already learned from Nora’s post, nosocomial infections and multi drug resistant microorganisms are not strictly a problem of developed countries.
The Setting
There is something for everyone in this country. All levels of care exist here, from the neighborhood pharmacists to government hospitals that provide free of cost care, to hospitals like Apollo where rooms in the International wing would give five star hotels a run for their money. The treatment of you as a person, and your particular illness is directly related to how many rupees are in your pocket. You may be waiting for hours to see a doctor for 5 minutes, or you may purchase “a package†that includes an echo without an indication. The healthcare system often runs thin on resources, not on patients. The sheer number of people is overwhelming.
The society
It is often said this is the land of contradictions. Just when you think the hospitality and warmth of these people cannot be matched you look at a sign posted in the hospital that discourages people from giving bribes. Is the care really free in the government hospitals? People leave their doors and windows open for the majority of the day, welcoming the sights and sounds of the neighborhood. But go out on the streets and nobody will be willing to give you even a car length worth of space. Kids, no matter how sick or poor, always seem to have an infectious smile on their faces. Adults making their living on the streets are so emaciated from poverty that they could be confused for terminally ill. The decision to go see the doctor starts from how much will I miss in daily wages to what will be cost of travel. When your needs are as basic as food, shelter and clothing, health takes a back seat. Every problem here seems to stem from poverty and ever growing population.
These 3 weeks conclude a lesson in disparities in health care. To say that the course objective was met would be an understatement.
By Christina Trillis
Today is my last official day in India. Our flight leaves at 1am tomorrow morning. I am just beginning to get used to the sounds, smell, and the pace of life here, and now it is all going to be coming to an end.
As I reflect back over the time I have spent here, I have had many amazing experiences. Our last day was sepent at Siravananda Rehabilitation Home, which was the perfect ending to our clinical experiences. When we spent the first week at Siravananda, I had nothing to compare it to. I did not notice that there were screens on many of the windows, I did not notice the cleanliness in which the buildings were kept, or the extent of the organization that was involved in our every visit there. Only after traveling to multiple government hospitals and smaller community centers, I was able to appreciate Siravananda so much more.
During our last day at Siravananda we toured the HIV ward, and also a smaller ward where HIV patients who were co-infected with TB stayed. The doctor who showed us around knew each of the patients personal stories very well, and explained how each person’s condition had already improved from the time of presentation. The patients were also very informed about their medical condition, and were even correcting the physician when she told us their CD4 counts. Each patient had their own bed that was in a small room that was shared with ~5 other people. The bedsheets appeared clean, there were no bugs, and the chaos of the other hospitals was non-existant.
Additionally, we saw a new hospital which as has just recently been opened in the past 3 months that sits on the same property as Siravananda. This hospital is under new management, and is offering free medical care to the people who present there. They emphasized that they are trying to focus on quality medical care as opposed to investing their resources to make their facility look flashy and attractive. Finally it seemed like there was a middle ground. We had just visited the Fever Hospital and Apollo the day before which were 2 drastically different institutions.
The fever hospital seved the poorest of the poor, and treated for the most part all vaccine preventable illnesses. The outpatient facility was bursting to the seams with patients. Our tour guide told us the day before there had been ~2,000 people packed into one of the rooms where rougly 4 doctors were seeing patients waiting to be examined. Minimal tests are done here, and a lot of the treatment is emperic. The pharmacy consisted of a few people with boxes of medications trying to serve the hundreds of people who were sticking their heads and hands past a metal grate waving their prescriptions.
In stark contrast Apollo seemed like a building that almost did not belong here. The floors and walls were all beautiful granite, and they have special wards that cater to non-resident patients who are coming there to receive their care. The rooms are enormous and one forgets that they are even in a patient room with the flat screen TV with HBO, and the lush bed and granite counter tops in the bathrooms. Here you get care by purchasing ‘packages’. You can literally get any test that you want. If you wanted to get an echo and MRI of your body, there is a package for that. I wonder how many incedentalomas are found there….
Back at this new hospital at Siravananda, there finally seemed to be a compromise. The facility was clean, the female patients whom had just delivered had private rooms with a basinet for their child and seemed truely happy. Other preganant women were there getting their pre-natal care, and there was even a ‘major and minor theatre’ where operations were performed. There seemed to be organization here, and the patients seemed as if they were getting quality care. I hope that this institution will not become over run with the crowds of people that will likely come once the word of this place gets out.
I have truely seen a range of extremes since I have been here. I have been to slums and seen lush hotels and fancy hospitals. In India the people with endless riches truely do live down the street from the most extreme poverty. I have met many individuals who are devoting so much of themselves to making a change here, which is the most important thing. Even though there are many flaws and inherent problems in how some of the medical is delivered, it is a start, and hopefully it will only continue to improve.
By S. Shobha
There is immense suffering and extreme poverty in India. Pediatric oncology is a tough field of medicine, but pediatric oncology in INDIA is medically challenging and emotionally draining. Despite dramatic improvement in mortality of a child with ALL in the rest of the world, survival rate remains <1% in a government hospital we visited today in Redhills, Hyderabad. We observed about 20-25 children with skeletal structures having neck masses, distended abdomen, limb masses, proptosis, skull lesions etc. all co-inhabiting a single ward with 14 steel flat beds, a foot apart from the next with white covers. There are is nothing uplifting about the surroundings with dingy and flaky walls, some parents inside, others outside on the floor trying to collect whatever food they have to provide for their sick child.
The ward is full of AML, ALL, Wilms’s Ewing’s, Hodgkin’s, Non-Hodgkin’s, neuroblastoma, langerhans histocytosis, unknown diagnoses and the list goes on. Dr. Sinha sits on the corner as one by one a child accompanied by a parent makes her/his way on to the stool. Some are to get a cycle of chemotherapy, some need a transfusion if mucosa is too pale, some to get platelets if have petichiae, some on empiric broad-spectrum antibiotics for fever, some morphine for pain. Work- up is negligible and treatment assigned solely on a very limited physical exam as none of the parents can afford to pay for tests unless absolutely necessaryy. All are to be seen by social worker who stands behind the counter, so they can get some sort of assistance in getting today’s assigned treatment. Some children are actually handed a needle with a cap to take to the laboratory if blood needs to be drawn and return with the report. No there is no phlebotomist. Even the ward was non-existent until 6 months ago when Dr. Sinha finally was able to get staff together and convince the need for it to the administration.
Dr. Sinha herself is a US trained ADULT oncologist, learning pediatric medicine on the job. She is fully aware of evidence based medicine and novel treatments that change the outcome from 60 to 80% to 90% but it stops there as she is battling herself with the limited resources. She continues to apply for grants, contacting experts at St. Jude’s hospital in US for protocols, making worksheets to better document, empowering the nurses and parents at the same time to improve childcare.
Before we know it, we quickly swift through the adult inpatient ward and off to the outpatient around the corner. There again, Dr. Sinha went through mounds of chart one by one seeing around 50 patients in all in 2 hours. Patients named were called out loud, they made their way inside, barefoot, some chose to stand only or sat on the stool for 2-3 minutes as the history was quickly reviewed and treatment assigned – either a cycle of chemotherapy, transfusion, palliative care or surgical referral. There is no patient confidentiality as one patient elbows the other out of the way – they all want to be seen and cured.
We eventually head out to look for our taxi. On they way, we pass a number of people with meager belongings, who have come from far villages, now living outside on the premises of the hospital, hallways, streets, under the shade of a temple to receive radiation treatment. They will stay outside until treatment is finished, tolerated or afforded. With today’s monsoon’s pouring down heavily, I wonder where they must have gone.
