Dr A: 'The ECG shows ST depression - she has ischaemic heart disease. You shouldn't just treat her medically, advise her on diet and excercise as well. And you too need to lose weight - why do you always ride the motorbike to the hospital? You should walk from time to time. You need to be fit so you can advise your patients on lifestyle.'
Dr B, protesting: 'Just because I'm big doesn't mean I'm unfit. I mean, look at Steffi Graf - you know, the tennis player? She's big too...'
Dr A: 'Don't use that excuse with me, Steffi Graf is big because she has an athletic build - are you an athlete?'
Both of them look at me, laughing. I smile nervously. My own body has gone to seed here, driven by a carbohydrate based diet of rice and chappatis and long afternoon naps that drift all the way from lunch to dinner. Who am I to pass comment? I remember the conversation with my new GP nearly 5 years ago when I first enrolled at medical school. 'Do you do sport?', he had said. 'You should - there are too many unfit doctors out there'.
While community based primary health care is the core philosophy of the work that the CRHP does, there are still many things to be seen in the hospital here. In a way, a visit to the hospital illustrates the main social problems in an area and Jamkhed is no exception. I have made a list of at-risk groups most likely to require hospital treatment here:
- Children
- Young women
- The elderly (male>female)
- Migrant workers
- Members of nomadic communities
- People with chronic debilitating conditions (e.g. post stroke)
There are several reasons for the above. Children are really susceptible to infections, and in the rainy season are prone to malaria, viral upper respiratory tract infections and pneumonia and mostly present with these three conditions. They are also the single most vulnerable group to one of the main causes of acute (as opposed to planned) admission to hospital here: road traffic accidents. Another main cause of acute admissions at the moment is snake bite and this tends to affect older members of the population, with quite a few cases happening after dusk or in the bushes when people can't see to protect themselves. The hands and the legs are the most commonly bitten areas. A third cause of trauma, bull gore injuries, occurs much less frequently in the working population.
I have seen a number of the classic 'exotic' conditions you expect to see in the tropics: leprosy, tuberculosis, typhoid fever, hepatitis A....these cases are generally treated with routine anti-infective prophylaxis as appropriate and tend to make a good recovery quite quickly. Particularly at risk are migrant workers due to their precarious financial situation which serves as a barrier to accessing care since they have to move to find work, making follow up, monitoring and management of chronic conditions difficult. They are also understandably reluctant to do anything that will jeopardize their jobs such as taking time off work to have an operation done. In addition, migrant groups are more likely to be marginalised from health promoting activities, making them less informed on important issues such as vaccination. As you can surmise, control over the external environment is crucial to prevention of many of these conditions, and this requires social cohesion and economic power. I wonder if this accounts for the differences I have noticed in sanitation levels which vary so greatly from one village to the next.
Another main service provided by the hospital is antenatal care and maternity services, although the bulk of antenatal visits are carried out by the village health workers in the expectant mother's village, saving her a long trip to the hospital. Only high risk pregnancies are referred for more advanced investigations like ultrasound scans. At the moment there is an issue regarding new legislation that means only government hospitals are registered to carry out emergency Caesarean sections. As the nearest hospital where C-sections can be carried out is at least 2 hours away, this presents a major risk to women in labour in this area who may need emergency C-sections for any reason completely unpredictable pre-natally: for example, prolonged labour causing maternal exhaustion, obstructed labour and cephalo-pelvic disproportion and foetal distress. Clarification is being sought on this issue at the moment, which cannot be resolved a minute too soon.
There is an increased incidence of chronic non communicable disease - diabetes, ischaemic heart disease, chronic obstructive pulmonary disease and cerebero-vascular disease - worldwide. It has been interesting to see how these blights are presenting in rural India. Along with the routine myocardial infarction, I saw my first skinny patient with type 2 diabetes, malnourished due to insulin deficiency (we are drilled into associating type 2 diabetes with obesity). She had very poorly managed cellulitis that had spread deep beyond her skin into her subcutaneous tissue, needing surgical debridement. A lot of the patients who have poorly managed chronic conditions come from villages that are not involved with the CRHP (non-project vilages as they are called here) and so do not have village health workers to take care of the immediate health needs of the vilagers. This underscores the necessity of having someone local and available to attend to basic health needs in remote rural areas; without such people, these needs are neglected until people are in too much pain to function, by which time more extensive (and expensive) work is necessary.
Some screening work done while I've been here has shown quite a number of people to have previously undiagnosed hypertension, with some systolic blood pressures being in the high 200s (levels this high are classified in textbooks as malignant hypertension or hypertensive crises, requiring urgent medical treatment). This may account for the increased number of sudden deaths and strokes being seen here (hypertension is one of the main risk factors for cerebero-vascular disease). Although stroke patients who are brought to the hospital in time get prompt and efficient treatment, the challenge does not end there. Rehabilitation and continued care after medical discharge is crucial for the continued well being of the patient, socially and medically. I saw one such patient who had previously suffered a stroke come in with diarrhoea; what was the source of the infection? Gastroenteritis due to drinking water from the local stream instead of the well? A urinary tract infection due to stasis and immobility? It's hard to tell. Community based rehabilitation for the physically disabled is something I've been thinking about a lot recently; an estimated 70-80% of India's disabled population live in rural areas.
The best thing about this hospital is that almost everyone gets what they need in the end. There's a lot of elective surgery done here: tubal ligations for contraception, hysterectomies for menstrual problems in older women, hernia repairs, cataract repairs, mastectomies for patients with breast cancer, rehabilitation surgery for patients with leprosy who have sustained deformities, and so on and so forth. Treatment is given to all without prejudice and regardless of ability to pay, yet it is not free either. Generally the hospital and the patient work something out on a sliding scale based on what the patient can afford. I would still love to see a system where all healthcare was free at the point of delivery, but within this community this system is the most humane, feasible (enabling the continued functioning of the project since most people are casually employed in the informal sector and so can't take part in insurance schemes) and works very well. The teamwork definitely fosters trust between the medical staff and the communities they serve, an indispensable requirement for maintaining good health.
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