India : Elective Experience from Oddanchatram

written by Abigail Vooght

Elective Destination: Christian Fellowship Hospital, Oddanchatram, Tamilnadu, INDIA

My Aims for the Elective:

o to learn to recognise clinical signs
o to study anatomy
o to compare Christian medical practice with secular
o to investigate the role of rural healthcare

Summary of Healthcare System

The Indian Healthcare system is divided into the private sector, the government sector, and charitable organisations. There being no primary healthcare system, patients self-present, selecting an institution according to wealth, convenience and other factors. I learnt that government hospitals have low standards of health outcome and cleanliness, though acceptable to the poor since some treatments eg. for TB and cancer, are funded by the government. Private hospitals are essentially businesses seeking maximum profits, frequently resulting in unethical practice, though the standard of care is generally high. A common example of this practice was administration of steroids to a boy presenting with epigastric pain, providing symptomatic relief, but resulting in delayed diagnosis of typhoid fever. Charitable organisations operate using low patient charges and funds from abroad. Christian Fellowship Hospital fits in the third category, but refuses to accept donations from abroad while still charging minimal fees (eg. equiv. to £20 for consultation examination & prescription) and offering concessions to those in need. This modus operandum demonstrates God's provision for this thriving hospital and prevents the corruption that frequently arises with abundance of funds.

Reflections on the Hospital and Elective Experience

Oddanchatram has the following population statistics:

Infant Mortality: 43 per 1000
Birth Rate: 16 per 1000 population/year
Death Rate: 8.4 per 1000 population/year
Life Expectancy: ~65yrs
Literacy: Male 65%, Female 30%
Leprosy prevalence: 2%
Tuberculosis prevalence: 1%

The Hospital is the equivalent of a district hospital in England, with all departments including psychiatry, a laboratory and a pharmacy, and the additional burden of primary care. In a typical day, 1000 outpatients will be seen. Medical Outpatients was the busiest, with about 350 patients to be seen daily by 5 doctors, frequently working 8am to 8pm. Staff are 86 doctors, 115 nurses, 61 paramedical, 194 students and trainees, and 75 others. The hospital believes in the principle that all are equal in God's sight, and seeks to provide an equal salary for all its workers. It has so far achieved a salary ratio of 1:4 from lowest sweeper to most qualified doctor. This stands in stark contrast to the caste system, in which the sweepers have a status equal to a street dog, and are paid accordingly. Doctors draw a salary approximately 1/3rd of the market rate, frequently re-investing 'spare' money in the hospital and living simply. One doctor explained his sacrificial involvement in his work as a God-given opportunity to serve God and people. Unless you have a sure motivation, it would be difficult to maintain that sort of lifestyle. Thus, comparision was made between Christian and secular medical practice

The concept of the 'iceberg of disease' is even more pronounced in India than in England. An Oddanchatram working class man may earn 100 Rupees per day (Rs/60 for women), sufficient for the renting of a mud hut, food and his childrens' educational needs. Healthcare is given very low priority, with preference given to weddings and festivals. In order to access healthcare, one must be able to:

o afford a day's absence from work
o travel to the hospital, there being almost no local primary healthcare facilities
o pay the consultation fee plus expenses of medication and/or investigations

Investigating the Role of Rural Healthcare..

The poorest communities, mainly in villages, did not access medical care. This was an unsatisfactory state of affairs to a hospital who sought to serve those in greatest need. In response, 70 rural projects have been set up in the region to date, providing appropriate medical care and disease prevention. A local person is trained from each village to be a 'Village Level Health Worker', who may diagnose and treat several common illnesses by following protocol. The 'Middle Level Health Worker' is a qualified nurse who serves 10 villages, and is involved in disease prevention: monitoring chronic disease; regular screening for the under 5s and the elderly; administration of vaccines and health education. A doctor makes a weekly visit to each village, holding a clinic and advising the health workers. All patients unable to be managed in the community, or in the 1-bed ward, are referred to a larger centre. The team continually evaluates and seeks to meet local health needs.

We were able to attend a hypertension meeting in clinic in the Nilgiri hills, 2 hours from CFH, to which 26 known hypertensives were invited, and 24 attended. It was an interactive educational session, using drama, a poster demonstrating the effects of uncontrolled hypertension, and a short talk by a doctor. The villagers responded well to a local speaking in their dialect at a level they could understand. This is an essential part of changing health-seeking behaviour. Vaccination schemes were similarly effective, achieving a 99% vaccination rate. These are examples of secondary and primary disease prevention, respectively.

The AIDS hospice we had the privilege of visiting was a tertiary prevention strategy, seeking to treat the opportunistic infections of the immunocompromised and provide palliative care with dignity. One doctor explained to me a cultural factor in the spread of HIV. In the villages, there is a big stigma attached to being a single woman, as it was in the past in England. Some men use this to their advantage by having several wives in different villages. The women may even be aware of the arrangement, but accept it in preference to being single. If the man contracts HIV, he may rapidly spread it to his wives. Although the disease is highly stigmatised, the family will care for the sufferers until they can no longer support them, usually for financial reasons. This is the point at which AIDS sufferers are admitted to the hospice, founded by an Englishwoman, and staffed by committed live-in nurses. Divided into single sex rooms, the husband and wife live in the same building, and their children may be housed on-site and schooled. The inpatients are cared for free of charge with unsurpassed love and respect. The most startling aspect of the care for me was the attention to the needs of the patient and creative thinking by the overseers. This is illustrated by the recognition that a human being living entirely on the charity of another has little self-worth, hence the provision of achievable work of tending orchards. This generates capital for the hospice, making it nearly self-sufficient. This type of work is a practical demonstration of God's love.

Visiting these rural clinics was the most rewarding part of my time at CFH. It was exciting to witness local ownership of appropriate healthcare for the needy. The doctors' and nurses' hospitality towards us was touching.

Other Learning Outcomes..

The elective was an excellent opportunity to learn to recognise clinical signs due to the florid presentation of a wide variety of disease. Consultations took place in Tamil, the local language, though the doctors communicated with us in English. The doctor would mostly summarise the history and demonstrate the examination, explaining signs to me, and giving me opportunity to practice. I learnt to recognise the following:

o Surgery. Inguinal hernias, palpation of greatly enlarged liver, haemorrhoids visualised directly through proctoscope (held by doctor), goitres (with some differentiation between cancerous/ non-cancerous)
o Orthopaedic Surgery. Ulnar nerve palsy (Hansen's neuritis), congential talipes equinus.
o Obstetrics and Gynaecology. Obstetric Palpation of fundal height, lie, presentation and position, though still unable to determine engagement and fetal heart rate using Pinard stethoscope; characteristic spectroscopy appearance of some STDs.
o Medicine. Loud heart murmurs and thrills, some differentiation between types of murmur, though much learning needed in this area; clubbing, abnormal breath sounds.
o Dermatology. Polymorphic light eruption, lichen planus, dermatitis

The rotation I enjoyed the most was surgery, mainly due to the kindness the surgeons showed to me and eachother. This created an atmosphere in which I was comfortable to ask questions and motivated to learn. In addition to reading up on cases seen in outpatients, I was able to learn the following areas of anatomy by visualisation during surgery: lower abdominal (ingiunal herniorraphy, appendectomy), pelvic (gynecological surgery), hand (release of finger contractures), superficial thoracic & axillary (MRM). This was followed by reading the appropriate section in an anatomy textbook. I hope to retain this knowledge!

Medicine teaching was excellent, providing ample cases to examine and subjects to look up. I regularly attended two evening teaching sessions per week, covering many topics in detail.

It is difficult to know what benefit I was to CFH. The RLUH kindly provided me with several laryngoscopes and other pieces of equipment to take to India, which were received gratefully. In response to the kindness of the staff, and my interest in the medical conditions seen, I was a keen and enthusiastic student. My role in the hospital was merely observational, and interaction with patients minimal due to the language barrier, so I did not contribute to the care provided to the patient.

The standard of medical care offered in CFH was equivalent to that of the UK in the context of the resources available. Comparison is difficult since there are few cultural and economic similarities, but the 'gold standard', we decided, was whether we would be happy to be treated there. I concluded that I would, though I would be concerned by the infrequency of hand-washing and the low monitoring of the intensive care unit. The language barrier was such that little of the history could be gleaned, so I did not ascertain the standard of history-taking by the doctors. Communication skills of the patients were noticably lacking in my opinion, though some of the older doctors felt comfortable placing a reassuring hand on the patient, and all listened if the patient became upset. When I brought this up with an Indian doctor, he said that there was just not time for communication skills due to the sheer volume of patients. Communication, in many cases is non-verbal and non-time-consuming, such as a smile and greeting of the patient on arrival, and the use of eye-contact. In addition, explaining the findings of the examination would have probably been beneficial to the patient. In most consultations, the patients did feel comfortable asking questions. Again, comparison is difficult since a smile and greeting is not often seen in Tamilnadu except between friends, the doctor-patient relationship being very formal. Generally, the consultation was paternalistic, which was acceptable to the patient since he knew the doctor was trustworthy, though not ideal.

The elective was a time of accelerated learning and widening of my experience, that I am really grateful for. In addition, some doctors have become role models for my future practice in the kindness shown to other staff, and sacrifice of personal comfort for the gain of the patients. It is interesting to note the deep influence of cultural values on Indian medicine, and to start to consider corresponding influences on British practice.