Empowering the patient

Many apologies for the long, long delay in posting. Things have been very busy and the internet connection has made uploading pictures and postings a bit of a challenge. I will attempt to catch up on posting what I've been writing over the past stretch.

From 20/Jun/2009:

After two weeks of class work and an intensive introduction to the healthcare system here in India (and more than our fair share of the local, almost exclusively rice-based cuisine), we Americans were quite ready for a change of scenery/diet last weekend. We hopped on an early bus out of Vellore and headed for the small city of Pondicherry, on the eastern coast. Getting there and back was a bit of a journey, but a weekend away in this charming former French colony was entirely worth it. The bus ride was about 4.5 hours each way, winding through small roads and out through the countryside, and packing more people into that vehicle than you’d think possible (and infinitely more than anyone would deem comfortable). Safely in a seat, it was pretty enjoyable to watch the passing imagery… the bus stops oozing with frenzied commuters and hawking vendors… the sweating faces pressed against the bars on passing buses… the stoic pairs of oxen pulling their tired carts… the occasional building sprinkled in along broad stretches of dusty landscape, with giant advertisements painted on their square sides so it looks like giant cereal boxes dotting the countryside… the near-neon green squares of sprawling rice fields, stretching out toward the perfect blue sky… groves of palm trees bridging the horizon and breaking the silent tension of this chromatic brilliance…

Arriving in Pondicherry, I instantly felt like I was in a wholly different place. The first and most obvious sign was the relative cleanliness… Trash seems to be abundant everywhere in Vellore, while the streets of Pondi were lined with trash bins (effectively labeled “Use Me”), with trees and ornate little shop fronts. The French influence could be seen and felt everywhere… It reminded me a little of New Orleans (minus the booze, boobs, and beads). And there was even a beach. Well, a rocky coast… but it offered the smell of sea air I’ve been missing. We paid a visit to an Ashram during the afternoon, and saw a whole crowd of followers devoted to spiritual leader Sri Aurobindo. It was an impressively peaceful place, and I’m starting to get a sense for how/why spirituality (and the many forms it takes in this country) is such a significant component of Indian life. [ That’s a statement begging for further explanation… hm… may have to come back to that]. We had dinner at a really nice rooftop café, and the waiter had this delightful French-Indian accent (and was downright excited to exchange a quick few phrases en français). A weekend filled with croissants and seafood and wine, and an ever-elusive (in India) iced coffee. Throw in a blessing from an elephant (that’s not a euphemism for pee!)… I’d say it was a pretty nice getaway.

The Americans and the Dutch folks out for French in India...

Elephant blessing

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Getting back to Vellore… We started the first of our clinical rotations last week. This first posting was in the Low Cost Effective Care Unit (LCECU)… a small unit at a different site from the main hospital that caters (as you might imagine from the name) to the poor communities of Vellore. The unit is run by a small but remarkably committed staff of five doctors, with specialists and interns from the main hospital rotating through service here as well. Patients are entered into the LCECU system if they qualify financially, and a chart is made for them… consisting of a series of cards detailing the patient’s medical history, family information, prescription and procedure log, and a record of payments assessed and completed… All this is neatly and openly stated on 5X7” cards clipped together and, believe it or not, kept by the patients themselves. There are no medical records maintained at the LCECU… but I found it even more surprising to learn that—with the exception of the occasional house fire or flood over the years—they almost NEVER lose a chart. I can’t imagine this would ever work in the US. But patient after patient I saw would file into the Outpatient Department and dutifully produce their chart. I was amazed. The main doctor we are working with here (the inspiring Dr. Suschil) explained that this system serves not only as a highly effective record-keeping scheme, but also as a means of empowering a population of patients that is traditionally and tragically [and this can be said almost universally about the poor] underserved.

I sat in one of the small offices in the Outpatient Department with one of the junior doctors for most of the first day. This tiny area housed a desk, chair, several stools, an examining table, a blood pressure cuff, a stack of prescription pads, a flashlight, and a cash box. That’s about it. And in some of the other offices (of the same size and outfitting), there were even TWO doctors, seeing patients on either side of the desk (!). Over the course of the day, I saw a steady stream of patients come through the curtain to be seen by the doctor, pay a bill, clarify a prescription, or (as it seemed to the English-speaking medical student in the corner) make their impatient case for why they should be seen now… Many of these interactions often coincided with each other (yes, including the actual exam), with the young and surprisingly poised doctor holding court in an impressive display of multitasking/crowd-management. [I guess this is a good time to mention that the healthcare system in India doesn’t have the same practices and stringent legislation regarding patient privacy… to say the least]. It was such a constant flurry of activity that there was barely an opportunity to translate the gist of the cases as they came and went. Honestly, the average exam time was about five minutes. I followed along in the charts and was totally awe-struck by how thoroughly this facility seemed to be living up to the intentions of its name… This was a model—albeit a startlingly foreign one—in efficiency. And, as evidenced by the modest sums of rupees humbly deposited in the cashbox, extremely low-cost. Dr. Suschil explained that people all pay in accordance with their respective financial means, but generally pay at least some fraction (however small it may need to be) of the actual cost of the visit, test, or prescription. The rest? Subsidized by the revenue generated from the other paying patients… which includes funds from the entire patient pool of the big, money-generating, tertiary-care main hospital at CMC. He went on to explain that they call this the “Both-And” model, because it aims to meet the healthcare needs of both the very wealthy and the very poor… There is even a special unit (the ‘A-Block’) at the main hospital where, if folks are willing to pay for it, they can have private, AC rooms and whatever tests or specialty services they so desire. Meanwhile, half a mile away, the poorest residents of the town can receive all their necessary care at a price they can afford.

Now, before I get into the ever-controversial and oh-so-pertinent topic of universal healthcare, or start discussing things that sound dangerously like that ‘socialized medicine’ we all keep getting worked up about, I’ll offer the disclaimer that this is simply a description of one type of system at play in one small setting in rural south India. If you’re wondering… Yes, it does seem to work quite well, relatively speaking. And yes, it does make me wildly excited to see such a progressive system functioning here (considering there are so many other factors in this culture that are either quite conservative or just restrictively poor or outdated). But, of course, it’s far from perfect…

Another component of the LCECU that I was able to experience was the outreach efforts of the staff. In the US, the concept of “house calls” is all but entirely obsolete, relegated to remote locales or medical memory. Here, however, with a patient population that can’t always make their ways to a healthcare facility and thrives very much on their sense of community, the practice holds a unique importance. I accompanied Dr. Sushil on his village “walkabout,” an entirely informal but clearly regimented course through a few nearby neighborhoods… Dodging livestock and mopeds and sewer drains, we wove our way past cramped huts and crumbling buildings to pay visit to an unofficial roster of patients. Along the way, people emerged from doorways and shop fronts and alleyways and hurried to greet Dr. Sushil. He patiently interacted with them all, asking about their health and their families in a manner that was unbelievably efficient and compassionate. Many of them produced the now-familiar chart. He would quickly scan it, and make some recommendation about their medications or need to be seen in the clinic. After each of these interactions, he would share the vignette with me, sometimes asking me to remind him to tell certain, more delicate details later. I was struck by the circumstances of each of these lives… beyond anything I can hope to convey now in words (These are stories I need to digest for some time before I attempt to retell them). I was also struck by how aware this physician was of all the forces at play in the lives of so many patients—his debriefings on each individual included mention of their job, financial problems, alcohol use, diet, marital problems, family structure, psychosocial concerns, and even personality quirks… I have never seen a doctor so informed about and committed to his patients.

Some snapshots from the villages...

Dr. Sushil

I’m not sure how many hours we spent walking about through these lives… It was one of those experiences that, despite the sweltering heat, transcended the measure of a wristwatch. I am sure, however, that it was a glimpse of the human condition that will inform much of my future training as a physician.

"Doctors Are Like Gods"

From Friday, 6/12/09:

We just finished up our first unit here in Community Health. It was a busy two weeks of study that gave us a fairly comprehensive introduction to the public health infrastructure in the state of Tamil Nadu (and a bit about the whole of India as well). We took site visits to see examples of each component of the multi-tiered system… From the larger government tertiary care facilities all the way down to the tiny, one-room rural sub-centers. Each day we saw a new setting where healthcare was being delivered, learning about the services offered, staffing structures, the populations served, and the challenges faced. I’ve never been so simultaneously impressed and depressed by an experience. On the one hand, this system is a triumph of public health planning… Villages are tended to by individual nurses, who filter patients to sub-centers, who refer patients to larger facilities, who triage patients and send them to the large tertiary care centers if need be… The idea being that patients should only go as far up the chain of care (and as far away from their homes) as needed, and the health of each smaller community is managed locally by its own members. Meanwhile, primary care is delivered on a large scale at low costs, and the burden (both in terms of patient load and disease severity) is reduced at the large, expensive facilities. And the best part of this whole step-wise (or maybe web-like) system is that it’s means-adjusted… i.e. the people who can afford expensive care pay the full price tag, and the people who can’t afford anything are cared for free of charge, with a sort of sliding scale for everyone in between. I’ve oversimplified a bit here for the sake of brevity, but that’s the gist of the public health scheme here in the state of Tamil Nadu. And, in my humble opinion, it’s a pretty solid design. (I left out the part where the government also supports the integration of what we call “alternative therapies” in the US into mainstream care in India. Awesome.)


On the other hand, there are things about the reality of this potential-laden system that are unbelievably depressing. Mainly, the sheer lack of man-power to keep the whole beautiful operation going… Time and again, we went to facilities with longstanding vacancies on the staffing list, often in key care-provider positions. This means that the actual quality of care is far short of the mark. And the facilities, though carefully built by government and Rotary Club funds, are by and large not places where most Americans would feel comfortable getting a band-aid, much less a blood draw. Also, the lines (or “queues”) are unbelievably long at every service station… people wait and wait and wait, often foregoing their day’s wages. Here’s a photo outside one of the primary health centers we visited.

Another striking image from one of the urban health centers was the labor and delivery department. This woman had just given birth earlier this morning, on a modest stretcher-looking table with a small U-shaped opening at the foot. This is her recovering with the newborn in the nursery.

I guess I will forego the full analysis of the flaws of the public health system here, since that is probably left to someone with a lot more time and knowledge than myself. My main point is that there is so much to learn from the design of this system and the principles behind it… but also so much to improve about the way it is executed.

Another part of our introduction to the healthcare system involved a visit to a combined preschool-primary school. The schools are linked to the government healthcare model because they provide nutritional supplementation for children within certain age ranges, and serve as the main site of health screenings. This was by far my favorite afternoon of the whole two weeks… the kids were so excited to have visitors. And visitors with flashy digital cameras, oh my! Here’s a few of my favorite pictures…



One of my native classmates was explaining to me the culture surrounding the medical profession in Indian. I had picked up on the widespread reverence toward anyone with a stethoscope around their neck (the distinguishing feature of Indian physicians). However, I hadn’t realized just how deep this attitude ran. When she saw me more or less melting over one patient’s child outside a hospital, my classmate asked if I wanted to hold her. I thought this was odd, since the kid was comfortably secured in her mother’s arms and she was not exactly offering. But my classmate shook her head, gestured toward the child, and the mother immediately thrust the baby into my arms, smiling. I was shocked (so was the baby). She went on to explain that people here want doctors (or, I guess, lowly med students masquerading as doctors) to touch their kids because doctors are seen as all-powerful and almost divine. They actually have a saying here in Tamil that translates to something along the lines of “Doctors are like gods.” Whoa.

This would turn out to be the first of a few times that parents have gleefully offered their child into my arms. I certainly don’t object, but it’s a strange thing...


Just in case you were concerned that it’s all work and no play over here, I wanted to tell you about this darling little place where the international students congregate each Wednesday night. It’s actually called the Darling Residency (sorry, couldn’t resist…). In India, I’m learning, hotels have restaurants within them, and the words ‘hotel’ and ‘restaurant’ are used somewhat interchangeably. This one has a lovely terrace restaurant on the top floor, and really delicious food. After dinner last week, we went down to the basement level where there’s a bar. I should note that bars here (and liquor stores, or booze in general) are few and far between… and frequented only by men. If being white didn’t make us stand out already, being the only chicks at the bar definitely seals the deal. [Side note: Indians make a lot of delicious consumable goods, but I don’t think their beer merits any accolades…]

The only ladies in the place...

One week...

Hard to believe we’ve already been here in Vellore for an entire week.

Per the explicit request of a very special lady, I’m attaching a few shots of where I’m staying (small ones—hope that’s sufficient, Mom).

1) View from the middle of campus 2) The Canteen (best Dosas around) 3) Our room at the Guest House 4) Just a couple nerds on their first day of school.... 5) The Community Hospital where we'll be spending a bit of time





The campus is quiet and comfortable… you really can’t complain about AC when it’s 109 degrees outside… with uniformed guards stationed at all of the gates (they too are fond of the Wobble, every time I wave hello), so the campus feels like a world away from the loud and congested township. There’s a bit of a community here, with medical, nursing, and physical therapy students each living in separate (and gender-segregated) hostels, as well as various visiting students, college staff, and many of the actual hospital physicians also living on campus.

As for my actual purpose for arriving in Vellore… We’ve begun classes with the second year medical students here at CMC (who are, for the most part, about 19 years old because they begin medical school immediately following high school). The three of us are joining them for their two week rotation in Community Health. Interestingly, this is a mandatory unit for ALL medical students, and gives them a thorough and firsthand introduction into the key principles of public health… In the US, we’re encountering this sort of curriculum only as part of an optional, second degree program, not seen by the overwhelming majority of medical students. The things that they’re covering seem SO vital to the practice of medicine… it strikes me more than ever that this ‘extra’ public health stuff shouldn’t be extra at all.

On our first afternoon, we joined them on a field visit to a nearby village. The rickety bus climbed a winding road up through the mountains, where all 60 or so med students (plus the three white folks) spilled out into the narrow, sloping streets of this tiny rural community. The class divided up into small groups to go home to home conducting what’s called a morbidity survey… interviewing the families about each person living in the home, their age/education/health status, etc. I won’t bother explaining all the details, but it was impressive to see this kind of simple, necessary public health groundwork being conducted by students on day one. It was also amazing to see the village, while my preexisting frame of reference was still very much unshed…

I stepped into the first home and slowly took it all in (my Tamil-speaking classmates were doing the actual survey). It seemed by American standards to be extremely poor—five people living in a small, dusty, unadorned three-room dwelling—but when I asked what socioeconomic status rating this house would receive in the survey, my classmates informed me that this was somewhere in the range of middle class. They must have noticed my chin on the floor, because they hurried to qualify: Having electricity, livestock, and access to running water (from a pump outside the door, not in their actual home) meant they were much better off than many other families. We throw around the term socioeconomic status a lot in discussing public health, but this one afternoon's visit to just a few homes has significantly altered my understanding of the term...

Here's a photo Holly snapped in one of the homes we surveyed:

We also stopped by the small schoolyard in the village and chatted briefly with the teachers there (again, I wasn't doing much of the talking). Most of the students were sitting inside... not sure whether it was a sign of obedience or the heat... but this one little girl stood and stared the entire time we were there. I was so taken by this face:

Side note: The children in India are-- and yes, I'm making a strangely broad generalization-- ALL cute. I'm still partial to one little firecracker back home (Miss Ava, the reigning Cutest Kid). However, it must be noted that so far every child I've seen is adorable. And it's not just because all of their deep chocolate eyes seem to stare straight through my face and into my soul, though that may have something to do with it. I can't promise this blog won't transition into a full-fledged photo-essay on the children of India.

Charidas!

Just a few days into our stay and I’m definitely enjoying it here. We’ve made friends with a group of international students who are helping us feel very welcome. One tall Dutch guy, Tom, took us into town the other day to show us around a bit. A rickety bus picked us up at the campus gates and, for a mere two rupees (four cents!), took us in a gender-segregated, carnival-ride-like fashion into the heart of town, near the main hospital. We strolled down Ghandi Road (which was uncharacteristically quiet on account of the midday heat), where we wandered into a few of the gorgeous fabric boutiques. The store owners unfolded dozens and dozens of patterns for us to see and touch—it was a smorgasbord of the most beautiful cloth I’ve ever seen. Holly and I each chose a few sets to be made into the “charida,” which is the standard women’s day-to-day outfit here. Saris, I’m told, are considered more formal/cumbersome. Most women in the town still wear them, as well as most of the older female doctors and hospital workers, but all of the medical students wear the charidas. It consists of a long dress/shirt top, over billowy pants (for the best visual on the bottoms, kindly consult youtube for the timeless music video of ‘U Can’t Touch This’), with a matching long scarf worn across the collar bone and over both shoulders. We brought our fabrics to the tiny home shop of Tom’s favorite tailor, where we were measured quickly and chatted with the woman there. Three men sat at adjacent antique sewing tables, whizzing away the entire time we were there. Despite how it may look, they were actually very excited to have their picture taken:


We returned last night to pick up the outfits and pay the [inconceivably small] bill. I can’t say I’d rock the look for a night out in Boston, but the clothes are so, so beautifully made. And now we can at least pretend to fit in with our classmates.


I’m consistently taken aback by how inexpensive everything is here… A very few American dollars buying authentic, custom clothing just doesn’t compute with my home-based fiscal awareness. I realize, though, that it’s a part of the larger picture here… The poverty is everywhere. Overwhelmingly pervasive. Certainly, Boston panhandlers are plentiful and suffering, but I’ve never seen anything close to this. Poor people wander and sit everywhere in the narrow streets, and even those not asking for money are silently begging for something…

Other impressions… hopefully less somber… The smells in and around the town are incredible. The magnitude and variety is really something… delicious smells of simmering meats and curries, fresh cut fruits, flavored tobaccos, jasmine flowers… and the less pleasant odors of rotting garbage, livestock, diesel exhaust… I’m also struck by the rapidity with which they transition from one to another. Each smell is so strong, and then suddenly so different. Aromatic subtlety plays no role here.

Communication has been a bit of a struggle so far. Yes, English is one of the three official languages in this city (the others being Hindi, and the local dialect Tamil). However, by and large the locals seem to be what Jerry Seinfeld once dubbed “low-talkers,” in addition to seeming generally aloof. But the primary reason I’m struggling to understand them is this one particular affect I’ll call the Head Wobble. The name pretty much describes the gesture, though until you’re speaking to a local and actually see it in action, you cannot really grasp it. The Wobble, I’m told, can mean any number of things: “Yes,” “Maybe,” or “I don’t know” to name a few (though it looks an awful lot like a “no”). This would render it, by my calculations, one of the least effective forms of human body language, ever.

One thing that is communicated quite clearly is their cultural regard for skin color and sun exposure... While everyone I know in the states is zealously seeking a tanner appearance (be it through sun worship, fake-baking, or your favorite tinted lotion), the women here couldn't be different. There is a premium placed on fair skin, and the TV ads boast skin-lightening products at every commercial break (I was totally appalled). Many women carry parasols during the peak sun hours (though partly just for the heat). And they are very concerned about we Caucasian newcomers finding the shade.

Anyway, off to dinner now. I'll write more soon.

Boston to India...

Hi everybody… it’s taken me a bit to get this set up, on account of a very busy first few days in India and some highly intermittent internet connection and laptop charging. We’re working out the latter two. But here it is—the reluctant, peer-pressure induced blog of a humble American ex-pat :)

The trip was by all accounts a success. Some 43 hours after setting out from my apartment in Somerville, I arrived at my new home at the CMC campus in Vellore, India. It was a long, disorienting trip that felt simultaneously like the lucid dreams of an afternoon nap, and the most epic college all-nighter of my life. We took the train from Boston to Newark, NJ, then flew to Frankfurt, then to Delhi where we had a cozy nine hour layover. Then we hopped a domestic flight from Delhi to Chennai (after convincing some heavily-armed security guards that we were, in fact, the three obviously-American passengers booked for that flight). We were picked up in Chennai by car and brought the remaining two and a half hours to Vellore. With each leg of the trip, the hour on my watch became increasingly meaningless, while our trio became evermore the minority… Though I was thoroughly warned beforehand, I have yet to adjust to the stares.

My first impressions of India are many and scattered… honestly, I can’t seem to keep my eyes wide enough to take it all in. This place is a veritable bombardment of my human perception. From the moment we stepped off the plane in Chennai, I could see the heat and congestion pressing against the front glass of the little airport. Hundreds of people yelling, old British cars honking… the smells of tires and exhaust mingling with some amalgam of human body odors and incense ripped my nostrils into the reality that waited outside. I was nearly run down by a moped before I groggily made my way to the car, where I pretty quickly passed out.

I woke from time to time during the drive to gaze out the window. The roads from Chennai to Vellore are a site that cannot easily be described. The ‘lanes’—though well marked—are merely suggestions, and do little to guide the insane milieu of cars, buses, motorcycles, scooters, bicycles, rickshaws, autorickshaws, pedestrians, and livestock all wrestling, honking, and yelling for their share of the road. I will never again complain about Boston traffic or Jersey/New York/Connecticut drivers… the scene feels like something out of a video game. At one point, I blinked open my eyes to see an infant just inches from my window, clutching her mother on the back of a moped driven by the father, with another small child in front of him.

The human landscape alone is something to behold. So, so many people EVERYWHERE. I'll leave you with this shot out the window on a road not far from the college campus, which could be repeated over and over for miles with hundreds more people crammed into the frame…

I have lots more to write soon... that start on 'first impressions' barely scratched the surface. missing everyone back home! Much love, ~ Alicia