Classroom Reflection #3 – Comparing India to Back Home

The “tragedy of scale” in India makes for some interesting medicine. With 1 billion potential patients, the rare diseases that are “one in a million” are actually quite common. Whereas in the US we may be lucky to see and treat one case of scleroderma or malignant hyperthermia during our career, it is not uncommon for a doctor here to have seen 10 cases of each! As I mentioned in a previous post, on our first day we saw sepsis, TB, atypical pneumonia, two STEMIs, a stroke, and lung cancer. At other clinics, we have seen Leprosy, Valentino syndrome (look this one up!), congenital heart disease, and dozens of cases of rheumatic fever.  The breadth of pathology here is nothing short of impressive.

We had the pleasure of working with an ophthalmologist as he went to a rural health camp and performed cataract surgery. Even from this one experience, it was easy to see the burden to the patient and their family that something as small as a cataract can have. Blindness caused by cataract not only incapacitated the patient, but consumes the time and effort of all family members involved because the patient needs a full-time caregiver, which in turn prevents said family member from earning an income. Furthermore, the blind patient has an impact on the community which often times will band together to help them. What is even more amazing, is that a simple, 15 minute operation could literally have a life-changing impact for both the patient and their family by allowing them to return to being a productive member of society rather than a burden. In truth, I had never really thought about the impact of cataracts before my time in India and now I have a newfound respect for ophthalmologists and the influence they can have.

One of the life lessons I’ve learned from traveling abroad, is that kids are kids no matter what country you’re in. Much in the same way, sick patients are sick patients around the world. Diseases that are common at home are also common here. Because India is quickly becoming a modernize country, they are seeing a sharp rise and many of diseases that come with modernization. Things like diabetes, hypertension, cerebrovascular disease, and obesity are all much more prevalent than at any other point in the past. What once was a country largely plagued by acute maladies is now becoming one ravaged by the burden of chronic disease.

With this being said, I have been fascinated by the “obesity “epidemic in India. While it is true that people here are overweight and would technically fall into the obese category on the BMI scale, they are nowhere near as large as people in the United States. Almost jokingly, I asked one of the doctors with whom we were working about the largest patient he had ever treated. His answer……..a BMI of 35. At this point, I looked at my classmates and we simply laughed. We then proceeded to tell him that back home in Kentucky, a BMI of 35 was overwhelmingly healthy. Naturally, was shocked to hear this, and was even more shocked when we told him that patients regularly have a BMI of 45 or 55. And that we had each personally seen a patient whose BMI was pushing 100. Tales of the bariatric beds and bariatric laparoscope’s left him amazed. While there may be an obesity epidemic growing in India, it pales in comparison to the one we are facing back home. What is most unfortunate is that after living here for a month and looking at the carbohydrate laden diets and the abundance of sweets for sale at every shop in town, I can only suspect that India will only struggle more with obesity in the years to come.

The prevalence of certain diseases closely parallels social economic status but this is also changing. 30 years ago, obesity affected only the wealthy. Now, it affects all social strata as India is becoming more modernize and access to sweets, treats, and unhealthy foods is increasing. (An interesting aside – during our 4 weeks I have seen only about 5 morbidly obese people, 2 of which happened to be tourists). Education also has a huge role to play in a differential prevalence of disease.  Generally speaking, the south of India is better educated than the north. This is relevant as we have spent most of our time in the north, and I’ve seen what a lack of education, particularly in regards to healthcare, can do. Patient here have little to no health literacy. Because of this, they frequently fall prey to the scams of quacks who are selling snake oil. Old wives’ tales about pregnancy, STI’s, and HIV run rampant and patients pay the price because of this. Young women know practically nothing about pregnancy and how to care for themselves or their unborn children. What’s worse is that very few births happen in hospitals (despite being heavily incentivized by the government paying each mother 6000 rupees per child born in a hospital). Instead children are delivered by the “experienced” women of the villages, sometimes with disastrous results.

Right now, in particular, is a difficult time for India. With the recent the demonetization movement, many people are struggling for access to cash despite having money in the bank. This impacts their healthcare as it is largely cash based and many patients simply can’t afford to seek care (even if they have money in the bank, they can’t access it). Because of this, the idea of preventative care hardly exists at all. Patient seek help only after they have fallen off the proverbial cliff.

While working with a pediatrician we came to discussing vaccinations. Fortunately, India does not face the problems that we do in the US with the “anti-vaccination” movement. Instead, there is a general lack of understanding of the importance of vaccination and as such many children go unvaccinated. Additionally, cost is a huge factor in determining whether or not a child gets vaccinated. For instance, a full series of vaccinations will easily cost at least 15,000 rupees (which is a huge sum of money) and most families simply can’t afford it. The pediatrician did mention some government programs for vaccinations but I didn’t get the impression that they were very successful or widespread.

Even basic things like access to clean water, an actual house to sleep in (not just a shack by the side of the road), and having electricity all have a huge impact on the health of the patients we have seen. For instance, what good does it do to prescribe a medication that requires refrigeration if the patients don’t even have electricity yet alone a refrigerator? Things such as this that are rarely a consideration back in United States must be thought about in detail here.

So, how do these experiences translate into skills I will bring home with me? Perhaps a numbered list is the easiest way to proceed.

  1. I think many of the experiences parallel quite nicely the problems facing rural areas of Kentucky and other underserved areas of United States. Some of the same general principles such as education, access to care, and affordability of care are critical to consider.
  2. During our week in Mussoorie we got to speak with a general surgeon turned plastic surgeon who has devoted his life to NGO work. Through conversations with Dr. Bona I learned a lot about what it takes to have a career in international medicine and the struggles that are faced by many mission hospitals and NGOs. These conversations as well as the connection with a possible mentor for international medicine are perhaps the largest take home from my time in India as I have already seen many of the principles of third world medicine during other international trips.
  3. Another take home point came during our very first day in clinic. In the United States, we way over-test, over-diagnose, and over-treat our patients (particularly because it is easy to do so, protects against litigation, and the testing is so readily available). Here in India, we’ve seen a huge emphasis on clinical medicine and looking at the patient in front of you rather than relying on imaging and labs. Perhaps this will serve as a reminder of the importance of physical exam, history taking, and actually thinking about our patients rather than reflexively shot-gunning labs as is common practice in many emergency departments.
  4. On a non-medical note, I learned the value of taxation and the benefits it can have for a country. As much as we may hate paying taxes in the US we have so much to show for it. We have well maintained roads, access to public facilities, a medical safety net for the elderly and the poor, and easy access to education just to name a few benefits. India has little to none of the aforementioned things and with less than 1% of people paying taxes (take this number with a grain of salt as it came from someone we worked with and is not necessarily accurate) not much can be done about it.
  5. The idea of a social contract and pride in the cleanliness of your town/city/country. At the risk of being accused of painting with a broad brush, it would appear that the majority of people in India have little regard for the environment and those around them. Nobody thinks twice about throwing trash out on the curb (or side of an otherwise beautiful mountain), urinating on the side of the road, or burning their trash on the curb. There is little sense of social responsibility or “owing it” to other to keep things clean. We asked many people about this in an attempt to understand what we have observed and we couldn’t get a straight answer. For instance, in the US you would never get away with any of the above things without being confronted by a stranger or the police. Nor do people in the US feel like they could/should be able to do these things as there is an overwhelming majority opinion that they are wrong and not socially acceptable. It blows my mind that a similar “social contract” doesn’t seem to exist in India and makes me eternally thankful that we have one.

 

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