Observing Rural Healthcare in Villages (Part I)

Our day at SEARCH, a healthcare facility in Shodgram (Maharashtra), was our best opportunity to understand village life in India and the problems that exist within the scope of healthcare.

We started the day with a tour of the facility. This site was constructed in 1986 by Drs. Abhay Bang and Rani Bang, with the goal of providing health services to rural and tribal people in the Gadchiroli district. Our first stop on the tour was a small temple near the entrance of the compound for villagers to pray upon entry. As we soon learned, the entire hospital was designed to provide a comfortable setting for villagers and tribal people. From low roofs instead of the more common multi-floor hospitals found in cities to the names of each building based on religious goddesses that were chosen by village leaders, each detail was carefully planned. There were also multiple buildings constructed for families of patients to stay in during treatment periods or for a pregnant woman to remain close to the hospital when she was expected to deliver soon.

We were shown the two operating rooms that are used on rare occasions. Here, there are very few surgeons available in the area so instead, the hospital has implemented health camp programs. Throughout the year, the hospital coordinates transportation for villagers to come to the facility and receive treatment from Mumbai-based specialists who fly in for a month. Depending on the needs of patients, these specialists can come from fields of spine surgery, dentistry, hernia repair, and urology.

Then we had a chance to meet with Dr. Abhay Bang, the founder of the facility. He was raised in Sevagram and his philosophies and practices at SEARCH draw deeply from Ghandi’s teachings. He explained how he wanted to construct a facility in line with Ghandi’s famous quote, “India lives in her villages”. That is why SEARCH is based in Shodhgram, surrounded by the communities and villages it has served over the past three decades.

He also provided some insight and reflection on the research practices of the United States compared to that in India. He remarked, “here, you can pick up a stone, throw it, and you will find a huge problem to work on.” It is most definitely true, in India there is no shortage of challenging and rewarding problems to dedicate your life’s work to. At many universities within the US, students will spends months or years looking for a particular question within a subfield that they will work on in their pursuit of a PhD. It was an interesting comment, especially coming from Dr. Bang who received an MPH from the Hopkins’ Bloomberg School of Public Health.

We also met with Yogesh, a researcher and neurologist that was trained in both India and the United States. He jumped around from Immunology to Neurology and finally returned to India to work at SEARCH with a focus on Public Health. His research primarily deals with non-communicable diseases such as hypertension and diabetes. These conditions have become more prevalent within India and require attention because they can often place a burden on the economic health of families in villages. Hypertension treatment for a year can cost about 6% of their annual income and diabetes may cost up to 12% of their earnings. He explained that in most patients other interactions with healthcare, they usually have a fever, take medication, and are soon fully cured. Instead, he is used to hearing things like, “I took medicine for 2 months, why do I need to take more?” So he is working on education platforms and looking for devices that can help patients manage their condition and understand that their disease requires concern and attention for the entirety of their life.

Before separating, he shared some surprising facts about the state of neurological care in India. Within the entire country, there are only 1100 neurologists; stated otherwise, there is 1 neurologist available per 850,000 people. The major concerns he asked us to consider were debilitating headaches, epilepsy, and stroke. At the end of our discussion he added, “changes will come faster, maybe if they came in 30 years, now they will come in 10”, reflecting his own expectations for the next generation that often looks toward the West for influence and innovation.

(please follow along with Part II, which will be posted soon…)

(The following is a description of events during my two week observational period of healthcare practices in India)

The patient was sitting in a chair in the doctor’s office. He was a young male, who had fallen ill and made it to Sevagram’s MGIMS hospital in order to receive treatment. The doctor grabbed his arm and asked, “Do you have a fever?”, feeling his wrist to perform her own assessment. He nodded affirmatively as she verbally confirmed, “Yes, you seem a little bit feverish.”

The patient also reported a headache but no chills or other severe symptoms. He had been lethargic for the past 1-2 days and had a suppressed appetite. After some bed rest, he had developed a fever and went to a friend, also a doctor, to see what care he should seek out. Here in Sevagram, in the district of Maharashtra, malaria is a huge concern and one initial symptom is fever; meaning that any fever is always assumed to be malaria and tested as such. The patient’s friend immediately called up a practicing doctor in the area to ensure a prompt appointment to get his blood tested. Twenty minutes later, the patient was already being evaluated.

Here in India, it is quite common to call up a doctor you know and walk into their office to receive treatment. In contrast, patients from rural areas may travel from up to 15km away to be seen (after waiting sometimes 6 hours) by some of the most talented and skilled specialists in the region. Luckily, this patient had a personal connection and was able to receive prompt care, something taken for granted in the United States thanks to the 2000 emergency departments located throughout the country.

The doctor explained to the patient that she wanted to run some blood tests for malaria and dengue fever. She reassured the patient, “I don’t think it’s malaria, but we will do blood tests to confirm. It will only take 30 minutes.” The nurse then entered the room with the same kind of kit seen in blood labs throughout the US. She tied the rubber tourniquet around his arm, asked him to make a fist, and inserted the needle into his left arm, just opposite the elbow. No hesitation, no struggle, no “let’s try again because that vein is bad”. Pretty high quality healthcare. Twenty seconds later she had the vial filled with 5mL of blood, withdrew the needle, and handed him an alcohol-soaked white cotton ball to keep pressure on the punctured skin. Simple. Quick. Safe. How much more can you ask for in this region where income per capita is about $1700 per year?

For those that may not have realized yet, the patient experience described above was my own. While the blood was being tested in the pathology lab (which usually closes at 5pm but stayed open to run my sample), I went with my fellow CBID classmates to the referring doctor’s home for a traditional Indian dinner. Two ibuprofen and an hour of rest in a guest room with the AC on full power had done wonders for me and my fever. As I woke up and ate what remained of dinner, the doctor informed me that the lab had called: tests came back negative for both dengue fever and malaria. Just a quick hesitation on my part in understanding what she meant before she added, “you are all good.”

Between that news and biting into some fresh Naan bread (prepared specifically at my request two days prior), I finally felt the best I had in days. My appetite slowly returned as I made my way through most of the Indian dishes that sat in front of me. During the rest of the dinner conversation, she shared stories of her past. There were stories about reflection such as working in Saudi Arabia compared to India, stories about family involving her mother and how she relates to her daughters today, and also plenty of laughs and smiles spread around the table. Not sure I could have asked for a better night or place to spend my recovery.

Being sick is never a fun experience but there is something to be said about my opportunity to explore health care in a “non-traditional” way. My classmates would joke before leaving Baltimore about trying to feign illness to discover how patients are treated and assessed but my acting skills were not even necessary during this visit. I would like to extend a special thanks to Dr. Poonam at MGIMS and her staff of nurses and pathologists for taking care of me in my time of need. I will always remember the wonderful care and attention they gave me while I was sick in Sevagram.

Being Indian and having been to India multiple times to visit relatives, I didn't expect there to be much that I would see that would really shock me in terms of the way Indians work, think, and go about their every day lives. And for the most part I was right. The dirty roads and living conditions, the animals roaming around with free rein, the spicy and heavy food. It was as familiar and comforting as I had remembered it to be.

But the medical system in India, particularly in rural India, was something I had never witnessed before. And honestly, I didn't think I would be too shocked by what I saw there either. Of course they would reuse disposable equipment, of course the rooms and beds would be dirty, of course there would always be a never ending stream of people filing into the hospital. Even having two patients being operated on simultaneously in the same OR wasn't too shocking. Just another example of people trying to do the best they can with what they have.

What was shocking to me was how some of the patients were treated. Women in labor were pushed, pulled, shoved, slapped, shouted at. "Why are you taking so long to push this baby out! Do you want to stay in here forever?" Doctors would climb up onto the delivery bed and push on the mother's stomach from above. Pain medication, though found on the equipment tray, was rarely administered even though episiotomies were so common they were not even considered to be complications during childbirth. It was completely jarring after having seen how the obstetric department is run in the US. Every mother has her own room, full of monitoring equipment for her and her baby and medications to make the delivery as fluid as possible. Patients are constantly updated on the health of their child, how they are progressing, asked if they would like anything to make them more comfortable. A midwife or nurse stays by the mother's side during the delivery to offer words of encouragement or praise. What I always considered to be standard care for a woman in labor seemed to be a luxury that would be unheard of here.

What really made the experience even more heart wrenching was the game of "what ifs" I couldn't stop playing. What if my parents hadn't moved to the US? What if my mother gave birth in a hospital like this? What if she was treated like this? How would she have been cared for if there was a complication? What if I had been born in a facility like this? It was all too easy to imagine and imagining was all I could do for the rest of the day.

And it's not as if you can necessarily put the blame on the doctors. When you have women in labor scattered down the hallway floor because there aren't enough beds for everyone, when you have to deal with classes and clinic and projects and presentations and going home to a husband or wife and taking care of the house on top of your hospital shifts, when you haven't had time to eat or sleep or take a break, when you're performing your 11th cesarean section of the day. When no matter how many deliveries you perform and how many complications you deal with during a case, there are always 10 more women to take the last woman's place. Is it possible to always stay cheerful and polite and kind? Of course, there are many doctors I met who are this way, always smiling, always joking. Treating their patients with respect and kindness. But it really feels like the whole system has to change in order for things to get better. There needs to be more manpower and better infrastructure to handle the large masses of people who visit a hospital in a given day. More importantly, there needs to be a way to make it so that time is not such a rare commodity that a patient can't even be treated with basic manners and respect.

Aug 9th-11th, 2014:
Expecting to only take a tour around the institution on our first day, Kimber and I were quite spontaneously shuffled into the women changing room to get ready for our first surgical experience in Sevagram. We were able to observed a hysteroscopy, an ex lap diagnostics, and an emergency C-section.

It was almost as if they had a 10-minute rule here in the Sevegram's OT.

C-section

1:58PM - 1st incision ... 2:00PM - Gained access to uterus ... 2:03PM - Baby cried

Hysteroscopy

12:33PM - Inserted hysteroscope ... 12:41PM - Removed hysteroscope, procedure completed

Ex Lap

12:47PM - Inserted trocar and laparoscope ... 12:56PM - Removed laparoscope and trocar, procedure completed

Having observed 5 different surgeries by different surgeons so far, we noticed that efficiency is the key in surgeries here at MGIMS. Many of the common practices, not only in the OT but also in the institution as a whole, are motivated by time and cost-efficiency.

First, surgeons here are forced to be as time efficient as possible in order to accommodate the volume of patients who arrive to seek care. We learned later from several OB/GYN physicians that 60% of the surgeries in the OB/GYN department are emergency cases; rarely do patients arrive with scheduled appointments. A GYNAE OT may have to handle 10-13 C-sections per day in addition to other gynecological operations.

Second, surgeries must be kept as cost-effective as possible in a setting where patients have to pay for every single stitch being applied to them out of pocket. Here at the MGIMS, disposable supplies are reused 30 times before getting disposed. This is one of the key factor that enables this institution to accommodate a wide range of surgeries from C-section to laparoscopic surgeries and microsurgeries. The harmonic scalpel is only affordable because the tip is reused 30 times before a new one has to be opened. In fact, a laparoscopic surgeon pinpointed cost-effectiveness as the biggest challenge in practicing MIS in resource-limited settings. Although basic equipments are provided by the institutions, surgeons bring their own specialized equipments to make their surgeries faster and safer.

An important point for us to always keep in mind is that physicians here are well aware of what they are not doing that is being done in places like the Johns Hopkins Hospital. MGMIS has developed its own best surgical practice guidelines by taking into consideration the context it is in and making appropriate adjustments to other published guidelines in developed countries.

Kimber and I will continue to observe more surgeries and speak to more stakeholders who are connected to the OT practices in the coming week. At this point, it seems as though MGIMS is the JHH of the resource-limited world. We look forward to learning a lot more from these highly motivated and hard-working faculty members, residents, and medical students here in Sevagram.

Today was a great day. It started like most days I have had in the past two months: wake up, eat food, talk to people, learn about healthcare, and reflect on the day’s experiences. But today I got to fit in something more before dozing off to sleep.

It began by approaching a group of Indian kids near a soccer field.  They urged me in Hindi for a minute before getting fed up and simply acting out that I had to climb under the barbed wire to reach the field. After managing through the fence, we grouped into a circle and passed the soccer ball around, transitioning to a game of monkey in the middle, with one boy trying to take the ball from the rest of us. Here I was, thousands of miles from home, doing the same exact thing I had practiced and learned to do almost 20 years ago. They say “football” is a common language that can be understood around the globe, that statement seems more and more true every day.

I found some Indian boys who spoke English and they explained that the field next to us was for the older, more experienced soccer players. I looked over and saw some Barcelona and Real Madrid jerseys, a common sight most anywhere in the world. After gaining some confidence in my own abilities through our little warm up, I asked them to help me get in on the shirts v skins match which had about 14 players total.

I walked awkwardly onto the dirt field, waving hello to anyone that made eye contact. I was greeted warmly; the “skins” telling me to take off my shirt, and the “shirts” telling me to keep it on. I tried explaining, “I’m really not that good”, but it was hard to tell if anyone understood or cared. Ultimately, I lined up with the shirts and picked a spot in the left midfield, just hoping not to embarrass myself. A few headers and carefully placed ground passes later, I was in. One pass slammed against my head but I simply played on, I knew I could deal with the pain over the next few days and just wanted to enjoy the moment. Some high fives, smiles, and apologies later got me feeling like I was back in the US, just playing a pickup game with strangers that love soccer.

Finally, after five flights, eight nights straining to fall sleep, tens of meals with food I could hardly pronounce, and countless conversations beyond my comprehension, I was comfortable. I was in my element. Back to something familiar and pleasant. If I had time to take a selfie, it would have been one of the biggest smiles I could manage. But instead I spent my time playing “give and go”s with teammates, taking shots on goal, and chasing the ball down whenever it ended up in the bushes surrounding the field.

It got dark as we played and I began straining to see the ball move around on the dark, dirt field. Two lights on one end of the field turned on and we simply played through the darkness. We switched sides and passed around some more. At one point, the ball went behind the goal and I ran to grab it, a simple duty of whoever is closest when the ball goes out-of-bounds. But then I heard shouting from behind me. I turned around confused as one kid ran past me, grabbed the ball and said , “snakes”, motioning with his arms as if there was some international hand symbol for snakes that I was never taught.

Eventually it became too dark to continue. It was only 7:30pm and I could tell everyone else wanted to continue. Instead, we settled for some conversation at the lit up end of the field (opposite from the snakes). Here, I explained that I was from the USA and lived near New York City. I received the expected excitement and statements like, “I hope to go to the USA”. What I did not expect was everything else. Their English was fantastic, a simple his/her slip up every now and then but they were all so willing to share. “Are there IT [information Technology] jobs in the US?” After laughing a bit to myself due to the various stereotypes of the IT industry within the United States I responded probably more confidently than I should have. “Yes, there are always lots of IT jobs for people that are smart and willing to work hard. Plus, it’s a good job because you will always have air conditioning.” That seemed like a relevant add-on considering my heavily sweat- and dirt-stained shirt. We spoke a bit about Spain, where I performed a basic poll for the ongoing Messi v Ronaldo battle and learned how out of tune they truly were with soccer, with only one brilliant kid voting along with me and recognizing Messi as the greatest player, the rest picking Ronaldo.

But the conversation changed back to academics. One boy was a mechanical engineer. Another an electrical engineer. A bunch of them were in their final year of studies and simply wanted to move on from Sevagram. They asked about my background and wanted to know what a biomedical engineer was doing at the hospital. So many of them hoped to end up in the United States and raise families there. Here I am for two weeks, living in their home, and learning that their greatest desire is to come and live where I call home. It is still early for me to appreciate moments like this. I need more experiences and more conversations to understand my new friends. I look forward to the rest of my time here and plan to spend many more hours playing soccer and trading stories with all of them.

Ultimately, it grew dark and we were all exhausted. We walked off the field with plans for the future. I told them I was here for two weeks and they asked me to come back and play. After they told me I played well, how can I refuse? Usually in the US, when I play soccer I get laughed at by all my friends who have been training on teams for 10+ years. But now I have a chance to make a decisive pass or goal, in India, with about 20 new friends. That is definitely something to look forward to. Soccer, football, keep away; whatever you call it, it’s just plain good fun all around. Even if you refuse to call “football” a language, it sure can be quite the icebreaker.

   

We spotted some Laerdal posters!

August 9th: After getting a full night's sleep to recover from jetlag, we got up nice and early to begin our tour of the facilities at MGIMS. Our first stop was to the Labor Ward to meet up with Dr. Poonam Shivkumar, head of the OBGYN department. We chatted with her in her office about the background of the MGIMS facility and she gave us a taste of what sorts of practices the hospital followed. One of the most interesting things she told us about was the Aakanksha, or the adoption center that was part of the hospital. Unwanted babies, for reasons varying from rape to premarital sex, are delivered at the hospital and put up for adoption for couples who are unable to conceive. The women who give up their babies are also taught income generating skills, such as sewing, to help empower them.

  

One (of many innovations) at the hospital is to hang

IV drips from a ceiling line (as you can see on the left)

when there aren't enough IV poles for every patient.

Afterwards, we took a walking tour of the facility, starting with the OB department. The department is set up with different rooms for different conditions that pregnant women present with. There's a Heart Disease room, a Post Eclampsia room, a Day Care room (not for taking care of children but for monitoring patients over a 24 hour period), an Observation room (for women in the first stage of labor), a Labor room. The entire hallway is broken down by condition or stage of pregnancy to help with workflow. The patients are also segregated based on whether or not they have sepsis.

The neonatal resuscitation unit in the labor ward.

Next we went to the newly constructed surgical unit. This area had a much more open floor plan but still felt crowded from the masses of patients and relatives that were walking around. Dr. Shivkumar mentioned that one of the most tiring parts of her job was talking to all the relatives who came to visit a single and keeping them up to date on the patients condition.

Nikki and Kimber went to the OT (which stands for Operating Theater) to observe some procedures and David and I headed back to the guest house for a well deserved lunch and nap.

Aug 8th, 2014:
After more than 24 hours of traveling, we (and our luggage) landed at the Nagpur Airport at 8:30AM. We reunited with Cyndi from Jhpiego and got on the rides that would take us to the Mahatma Gandhi Institute of Medical Sciences (M.G.I.M.S.). Through hazy, jet-lagged eyes and fuzzy car windows, we experienced our first taste of India during this one and a half hour ride.

It didn't take long before the cars took us away from the city and enter the countryside. Small, 1-storey houses with Zinc roofing were a common sight before greens took over both sides of the roads. Potato, corn, sugar cane, banana, papaya and rice fields stretched across our field of view. A large stretch of what used to be potato fields was actually up for sales. Cow seemed to be a common farming animal in this area as we saw many of them on the fields.

The roads were rather empty during that time of the day but we saw many people walking along the sidewalks. Students walking to school in groups, men walking their cows along the fields, and women in their colorful dresses along the sidewalks carrying something on their back. After crossing over a train track, we started to see more small shops lining the streets. They were selling anything from fruits and vegetable to sunglasses. At one point, we passed a big well in front of a small hut. The sign read 'Raw Water Pumping Station' (yes, in English). I hope we will get to find out later on where the water comes from and how it is processed before use in the houses and the hospital. Not too far from the well, a big sign board was put up for a 'Super Specialty Home Care' campaign. Again, hopefully we will find out later what this is all about.

At around 10AM, we arrived at the guest house where we will be staying for the next two weeks. We stopped by the institute to get registered for our stay. At the entrance of the institutes, we discovered our first resource-limited-analogue-of-US-infrastructure in the form of a 'Distance Air Cooler'. 'Distance' for being able to cool air 50 feet away from the actual machine. We will share pictures and more details about this air-cooling box later!

Tomorrow we will be visiting the OB/GYN department at the institute. It will be our first chance to observe the healthcare here in Sevagram as well as talk to some of th medical students and residents at the institute. We might also get a chance to visit the solar cell facility nearby!