Holly writes a book OR 3144 words you won't regret reading

Location: CHTC Guest House
Written: 7/6/09, 2:45pm (started), 6:10pm (masterpiece completed)

I know, I know, I know. I’ve done a terrible job updating the blog over the past 3 weeks. This is partly due to the fact that I’ve emailed with several of you – so many of you know some of what I’ve been doing. But let’s face it – I’ve just been plain lazy! The 110 degree heat and 80% humidity tend to have that effect. Anyway, prepare yourself for the long, arduous entry ahead. I suggest gathering snacks, coffee, and maybe a pillow for a mid-entry nap. I have the afternoon free and I intend on using it to bore you all.

3 weeks ago: LCECU

We spent the first two weeks of our trip taking a Community Health course with the 2nd year medical students at CMC. Once that course ended, we began weekly rotations throughout the CMC system. My first week (6/15-19/2009) was spent in a special hospital called the Low Cost Effective Care Unit (LCECU). The LCECU is an Urban Health Center located in downtown Vellore. Unlike the government Urban Health Center that I visited during the course, the LCECU is privately funded through CMC.

This unit mainly serves as an outpatient clinic with a focus on family medicine and primary care. The unit has daily general outpatient hours that include diagnosing and treating acute illnesses. Additionally, each day there is a different specialty clinic to manage chronic conditions and prenatal care. These specialty clinics include Antenatal care, Psychiatry, Diabetes/Hypertension, and Pediatrics. The unit is equipped with a small lab, an ultrasound, about 30 inpatient beds, a pharmacy and a labor room. The unit does not perform cesarean sections. These births must be sent to the CMC main hospital (about a 15 minute journey by autorickshaw).

The LCECU treats approximately 150 outpatients each day (if not more!). Patients begin lining up around 6 am where they can expect to wait up to 6 hours before seeing a doctor. Clinic lasts from 8 am until 3 or 4pm. This work is divided between 2-3 doctors, several nurses, and some rotating interns. Each patient interaction lasts about 5 minutes. Usually the doctors do not have time to perform a thorough physical exam. Although the patients seemed happy to get the small amount of time allotted for them.

The patients at the LCECU are the poorest in Vellore. Many of the them live on less than 100 Rs (about 2 USD) per day per family. Care here is provided very cheaply with patients paying only what they can manage. The care is subsidized by the profits made in the main CMC hospital. Unfortunately, care often must be rationed here. Patients may have to raise their own money or wait for adequate funds to be available before they receive expensive treatments.

In spite of the extreme financial limitations, the LCECU is able to provide a good amount of care. They minimize expenses by having patients keep their own medical records and bring them to every appointment. This prevents the need for storage space and a records manager. A doctor told me that patients take very good care of their records (with records only being lost in the extreme case of house fires). Additionally, from 10am-noon each day the city of Vellore has a scheduled power outage. While the main hospital and many area businesses have generators, the LCECU saves money by managing without electricity during that time. As you can imagine, it was quite strange (and HOT!) to be examining patients without lights or a fan. Patients are able to purchase their medications in the pharmacy for a very low cost (for example: $2/month for Metformin, a drug for diabetes). A typical office visit may cost between 20 cents and $1. If a patient cannot be managed in the LCECU setting, they are referred to the main CMC hospital where their status as a limited-income patient is not lost. On my first day in the LCECU, I saw an incredibly scary situation where a woman was having a probable heart attack in the clinic. Keep in mind that if she had had an MI in the LCECU, there would be limited treatment options available (no EKG, no cardiac catheterization, no crash cart, etc). She was given sublingual nitroglycerin and referred to the main hospital for an EKG that would cost her only 50 Rupees ($1 USD). This kind of run-around treatment and limited access is just one example of the many problems that developing countries must deal with daily.

India has one of the highest birth rates in the world. As such, every hospital and clinic treats many, many, MANY pregnant women. One of the goals of developing nations is to increase access and utilization of prenatal care. The LCECU sees pregnant women once per week ("The battle of the bulge" according to one doctor). At least once in the pregnancy an ultrasound will be performed for gestational dating and as a general check up. In an extremely embarrassing situation, I once asked the doctor whether the mother was having a boy or a girl. As it turns out, the determination of gender prenatally is illegal in India. This law was enacted to fight infanticide of female fetuses. Since my arrival, a doctor in a neighboring state has been prosecuted for sex determination and gender-related abortions. Although gender-related abortion is illegal in India, abortions for other reasons are allowed.

Sign about the inability to determine gender in India

The best part of my week in the LCECU was going on house calls with a physician who works there. Dr. Sushil was one of the professors of the Community Health course. He spends half of his time seeing outpatients in the LCECU. The other half of his time is spent going on site visits in the various slums in and around Vellore. I would hesitate to use to word slum based on the connotation – but the connotation is exactly what I’m going for. To call the places we saw villages or neighborhoods would imply that these areas were in anyway a desirable place to live. The slums have open sewage drains that run along side the roads, water pumps that don’t reliably provide clean water, trash and flies absolutely everywhere, small houses where people live on top of each other (without any furniture, refrigeration, or privacy).

Slum in Vellore

Open drainage ditch in a Vellore slum running alongside the entrances to homes

I have added a video I recorded of Dr. Sushil speaking in our Community Health course. Even in the short clip, you can tell that he has incredible dedication to his patients. The clip begins with students guessing the cost of a typical delivery ($1=47 Rupees, average delivery in India is about $80 USD). He talks about visiting the home of a patient who gave birth to a daughter with a meningomyelocele. During one of the slum visits, I saw this patient. She lived with her daughter and husband in a makeshift hut that was about 50 square feet. This story is one example of the extreme poverty, heartache, sadness, and life-is-just-so-damn-unfair which exits in this country (and many others around the world). After my short trip here, I can’t reconcile, justify, or in anyway understand the WHY? of any of these cases. Of course I expected to see poverty and of course I didn’t expect to understand it. Still, expecting to see something and seeing that something are two very different experiences. Many Indians use the concept of karma as a means of explaining the vast extremes. While I completely respect that viewpoint, it simply doesn't work for me.

Two brothers play with stones on their front porch

A small hut rests near the site of a demolished building

We visited two slums during the week. The first slum visit was a general visit to check on the status of current patients as well as determine if any of the community members were not receiving care. Right away we could tell that the patients knew and loved Dr. Sushil. He makes these visits so frequently that the slum dwellers have gotten to know and trust him. We sat down with a man who had a chronic infection and was ultimately cured thanks to treatment at the LCECU. After treatment, the man wanted to repay the LCECU for saving his life. He now is a community activist and works to help his sick neighbors receive treatment. He does this by word of mouth education about LCECU as well as making Dr. Sushil aware of any individuals who are sick but can’t leave their homes. Over the course of the visits we saw many grateful patients. During 1st year, we spent a semester learning about “The Doctor-Patient Relationship.” I must say, that I learned quite a bit more shadowing Dr. Sushil on those 2 days than I did during a semester of lectures. I saw patients who had literally no money offer up their only food to the doctor. Certainly, relationships like that can only develop over time and can’t be learned in a classroom.

Dr. Sushil talking to a patient

The visit to the second slum was to seek out a specific patient. A woman with diabetes was developing cataracts and needed surgery. She was afraid to have the surgery because she didn’t know who would care for her. On the visit, Dr. Sushil spoke with her neighbors and encouraged them to help her recover. A few days later, the woman had decided to have the surgery. The woman lived in a rooftop shack that involved climbing some very steep stairs. I can’t imagine climbing these stairs every day with perfect vision and a healthy body. I don’t know how this elderly nearly blind woman does it every day.

The woman with cataracts lived on the roof of this building

Beautiful girls from one of our slum visits

Following my week in the LCECU, I moved into the main CMC hospital for 2 weeks.

2 weeks ago: The OG

Following the intense week at LCECU, I was excited to spend time in obstetrics and gynecology (“OG” or “Obs and GYNie (pronounced “guy-knee”) as they say here). Just to confuse this entry even more, I’ve added a passage that I wrote 2 weeks ago about my experience in the OG. See! It’s not that I haven’t been writing – I’ve just been holding out on all of you ☺.

The following was written: 6/25/09

Today I saw 2 live births!!! Before my trip, the only concrete goal that I had set for myself was to witness a delivery. I figured that the first delivery I saw should be “the old fashion way” and what better place to see it than a country with one of the highest birthrates in the world.

This week I have been rotating through the OB/GYN ward at the CMC main hospital in Vellore. Due to an annoying sore throat, I only went into the clinic on Tuesday and Thursday of this week. I spent Tuesday observing antenatal check ups for women labeled “high risk” for complicated pregnancies and deliveries. I spent the day with a lovely intern called Hilda. She was great as she let me do the check ups under her guidance. Over the course of about 4 hours we saw approximately 40 patients. If this sounds absurd to you, it should! However, in a country with so many people, there truly aren’t enough hours in the day to give patients the 15-20+ minute visits that we complain about in the US!

The main categories that put women at high risk here in India are: family history of diabetes, hypertension or multiple births, previous complicated pregnancies (including previous stillborn or neonatal death, previous cesarean section, previous baby in breech position), pregnant with multiples, consanguineous partner (common here), HIV positive, and I kid you not “elderly pregnancy”. Elderly pregnancy here begins at the ripe old age of 30.

Today, I was posted in the labor ward. There are two rooms (one for high-risk deliveries and one for low-risk deliveries). A neonatal resuscitation room separates the two delivery rooms. There was also an operating room for Cesarean sections. The labor room was somewhat of an organized three-ring circus. Each side had about 15 beds and they were both full! When a woman began active labor, a flimsy green curtain was pulled around her bed for “privacy,” that or to prevent the other women from witnessing their fate! During the delivery there were two nurses who job it was (it seemed) to tell the patient to push and help her hold her legs up in what can only be described as the most vulnerable and exposed position a woman can be in. There was also a nurse who Alicia and I lovingly call “The Catcher.” She has what I think must be the best job on the planet. Once she gets the baby and the cord is cut, she cleans the baby up, weighs and measures it, and swaddles it. She is the first person who sees the baby all spruced up and the first person to hold the baby. There is also, of course, the doctor who is running the show and helps get the baby out, and in the case of both of the deliveries I saw: performs and repairs an episiotomy. NOTE TO ALL MEN READING THIS: You don’t know pain, you will never know pain, you are not tougher than women, stronger than women, or in anyway more resilient than women. If you in anyway doubt me, YouTube “episiotomy done with surgical scissors.” Okay, feminist rant over.

I was really nervous to see the deliveries. I have been known to get queasy at the thought of blood (I know – I’m going to be a doctor blah blah blah). Up until the moment the head was crowning, I was still very nervous. But, once you could see the actual baby, my viewpoint completely changed. It sounds so corny, but everything they say in the movies about childbirth is true. It’s a beautiful, wonderful, incredible, natural, and happy event. I’m not saying watching a delivery is for everyone. But it was definitely the best moment of my trip – and way up there on the list of top 10 coolest things I’ve ever seen. Both mother’s delivered healthy baby boys. Alicia and I tried to stay calm, cool, and collected. But I was unsuccessfully holding back tears. Amazing amazing amazing.

Unfortunately, I also saw a mother go into labor at 26 weeks gestation. She gave birth to a stillborn boy. This is far enough along that attempts at resuscitation are often successful (the baby was struggling to breathe for about 5 minutes before dying). I asked a nurse why the baby was not resuscitated and got a disturbingly honest answer. The parents of the baby were very poor and would not be able to afford the care involved in treating a premature baby. The exact quote was “unfortunately in India we have to make medical decisions based on finances.”

The rest of the entry written on: 7/6/09

One week ago: Pediatrics

Last week Mike, Alicia, and I were in the Pediatrics ward. Obviously this was incredible because we got to see cute kids all day long. Our first day began with a morning bible session. Once each week, each department at CMC has a discussion about a passage in the bible and how it applies to the practice of medicine. This weeks’ conversation was about the role of the Husband (next week is the role of the Wife). There is a discussion book that has 52 discussion topics over the course of the year. This book had quotes about the husband being a provider, the head of a household, and the figure of authority. Looking forward to next week showed the wife as the caregiver and also as being subservient to the husband. Using my better judgment, I decided to nod and smile while keeping my respectful disagreement in my head!

We spent the mornings going on rounds with Dr. Rikki. She is an amazing clinician who turns out to be Dr. Sushil’s wife! We saw several interesting patients with asthma and/or respiratory infections. It was exciting to hear the rales/ronchi/wheezes that I spent so much time learning about this past year. The care in the Peds ward is extremely high quality. We also got to see several patients with congenital heart defects post surgery. They seemed to be doing very well.

We saw several babies who were suffering from malnutrition. They were so small and beginning to develop peripheral edema (Kwashiorkor). Malnutrition in infants here usually is caused when mothers don’t breastfeed their babies. This can be due to choice, lack of milk production, or HIV+ status of the mother (breastfeeding is not recommended).

On Wednesday of last week, we observed the pediatric infectious disease outpatient clinic. All the patients that we saw there were HIV+. We shadowed Dr. Valson who was absolutely incredible. He took so much time to teach us about the various stages of HIV disease as well as the limitations and challenges of treating HIV in India. In India, most HIV is contracted through heterosexual transmission. The “typical” story is a man contracts the disease through a sex worker. He then passes the disease to his current or future wife. Although legally, HIV status must be reported to all sexual partners in India – enforcement is difficult and prosecution is rare. Many women do not find out they are positive until their first prenatal check up when a rapid test is performed on all women. It took a lot of effort and self control to not be angry at the father’s of these children. As a physician, you have to learn to keep your own biases and opinions out of the office. But looking at an emaciated 12-year-old child with stage 4 disease, I definitely wanted to blame someone. I was left wondering how much the child knew about his disease and if it would be best to keep the mode of transition hidden from him or tell him the truth.

Thursday was spent in the general outpatient department. This was a great way to end the week. We saw patients who were there with tummy aches, earaches, and for general check ups. After an intense week of seeing some very heavy things, it was nice to see generally healthy and happy kids with their happy and healthy parents.

I have much more to write about, but I think if I write anymore right now I’ll lose your attention forever (or at least get a wicked case of carpal tunnel!). Coming up next: my trips to Bangalore, Chennai, Mamallapuram, and Dehli/Agra; My week at the Community health and development hospital (CHAD); my completely American July 4th celebration; and more.

For those of you who made it through the in one sitting, congrats! I’m sorry that my 3-week blog absence resulted in your eyestrain. Unfortunately, I’m not doing an ophthalmology rotation here so you’re out of luck. As a consolation prize, please accept this montage of various members of the animal kingdom that I’ve encountered in India.

Goats

Horse

Monkey family walking down the road on campus

Mommy and baby

Dog

Me being blessed by an elephant in Pondicherry

Goats doing that thing they do

Cow on the beach in Mamallapuram

We came back to this mammoth one night!

be patient

I am working on a really long, detailed, informative, excellent blog post that will answer the question of what I've been up to the past 2 and half weeks.

Will be up by Monday.

Thanks for waiting!

-Holly

I could get used to this

Location: International Student Hostel

Written: 6/16/09, 2:00pm

This past week was fairly uneventful compared to week 1. At this point, I feel like I am getting to know the little corner of India where I am staying. I am getting used to the oppressive heat and the nonstop sweating. I find myself craving the spicy food that initially I couldn’t stomach (although I am missing the fresh vegetables of home – especially sweet Indiana corn!). I am also getting used to the celebrity-like attention we get for being non-Indian. The other day I was shopping in town and a woman literally ran up to me and gave me her baby to hold. I have also been asked to pose in several pictures with children. These kinds of experiences have made me appreciate the diversity in the US in a way I hadn’t anticipated. While I am more than happy to hold babies and pose for photos, the underlying fixation with light skin is hard to ignore. Billboards rarely have Indian models and every commercial break has ads for skin-lightening cream. The seeming acceptance of these “light is better than dark” messages is both infuriating and embarrassing.

Me with a beautiful baby girl on the streets of Vellore
(photo courtesy of Alicia)

The one thing I will never get used to is the transportation in India. Lane lines are futilely drawn on some roads. The concepts of right of way, one car per lane, turn signals, driving on the correct side of the road, and keeping a respectable distance from surrounding vehicles seem to be lost (although I can’t imagine they were ever here in the first place). Cars share the road with behemoth buses, 3-wheeled autorickshaws, motorcycles, mopeds, bicycles, oxen, goats, stray dogs, and pedestrians in a pandemonium similar to the running of the bulls. I manage to survive these rides by holding on to whatever I can as tightly as I can – that combined with the occasional scream seems to be working so far!

Traffic and view of downtown Vellore

On Friday, we finished up our Community Health Program course that we took with the second year medical students. Most of last week was spent doing a “Health Planning Exercise.” My group was assigned the task of organizing from the ground up a health care initiative for the slum-dwellers of Vellore (a population of approximately 100,000 people). The problems that we addressed included: 1) finding an affordable and sustainable way to guarantee clean water access 2) fixing the human waste drainage system 3) increasing institutional deliveries in a population with low access to transportation 4) nutritional programs for children and pregnant women 5) figuring out some ways to end the cycle of poverty-poor health-unemployment. This exercise was a challenging and enjoyable way to wrap up what we had observed during the week of site visits. This week I will be rotating through the Low Cost Effective Care Unit (LCECU). This unit provides care to the poorest people in Tamil Nadu. Tomorrow, I will be visiting a slum with some physicians to provide health care in homes there. I am both excited to see the door-to-door visits and anxious about what is certain to be an overwhelmingly heartbreaking confrontation with reality.

This past weekend I went to Pondicherry with Mike, Alicia, Elwyza (a medical student from Holland), Sharron (a graduate student from Holland doing some awesome research about the stigma and quality of life of patients with HIV/AIDS in South India), and Jake (an economics graduate student at Brown). Pondicherry (or Pondy) is a former French colony that is a beautiful blend of French and Indian culture located on the Southeastern coast of India. We enjoyed spending time of the rocky beach that reminded me a lot of Maine (although the 100 + degree weather sort of throws the comparison away). We also went to a paper factory that sells gorgeous handmade paper products (I basically bought one of everything!). The factory uses recycled paper and plant products to make eco-friendly products.

Hanging out on the beach in Pondy
(Alwyza, Alicia, Me, Mike)

A man cycles in front of the French Consulate in Pondicherry

Pondy is famous for Sri Aurobindo Ashram, a center for spiritual education. The ashram was very peaceful and filled with guests meditating around beautiful gardens. We finished the evening with great French cuisine (including seafood which made all of the Bostonians very happy!). We are planning on taking several more weekend trips including a trip to Dehli and near by Agra to see the Taj Mahal.

I’m craving a samosa and some pineapple juice. Until next time, thanks for reading.

It's been one week since you looked at me...

Location: CHTC Guest House (Bagayam, Tamil Nadu, India)

Written: 6/8/09, 8:45pm

After my first week in India, it was nice to have the weekend to unwind and process my first impressions of the country. On Sunday, we went to a beautiful pool located right next to the medical school campus. It truly was a hidden oasis tucked behind the highway next to a shabby church and some deserted land. As you can see from the photos, the pool looks like it belongs in tropical St. Anywhere-but-India Island. It is surrounded by lush foliage and has views of the surrounding mountains. The day was perfect weather for tanning (Don’t worry Mom, I wore SPF 45!), throwing baseball, reading, and hanging out with the international students. They even served pizza and fries which was a lovely reminder of home!

Pool in Bagayam

Nice place to spend a Sunday afternoon (notice the mountains!)

Now I'm just boasting!

On Friday of last week, we went to visit a Primary Health Center (PHC) located about an hour outside of Vellore. India has a very decentralized health system that tends to direct care to clinics and village health centers instead of tertiary care hospitals. Only the sickest patients end up seeing specialists inside of the hospital. Each PHC serves a patient population of around 30,000 individuals. The PHCs provide the following services: daily outpatient clinic, a few inpatient beds (usually only 5-10), prenatal, delivery, and postnatal care, newborn care, immunizations, family planning (BCP, IUD insertion, condom distribution, tubal ligation, vasectomy), emergency ambulance transport, school health programs, lab services and referral services.

On the day that we visited the PHC, they were running their weekly diabetes clinic. Patients received various medication including insulin injections and information about managing blood sugar (which must be difficult considering I didn’t see a single glucose meter). In addition to the diabetes clinic, we were able to see some babies that were born the previous night and their mothers. They were so precious!

People waiting in line at the PHC

We were able to take a tour of the surgical theater (operating room). This was quite a shock for me! I have had the privilege of seeing several surgeries in the US (thanks Dad) and I’m familiar with the extreme emphasis placed on sterile technique. When entering the OR we were asked to remove our sandals and replace them with communal “surgical sandals.” The surgical instruments were sitting on a table in the open air. There wasn’t an autoclave in sight. I imagine that sterilization occurs using bleach or boiling water. I am hoping that I can watch some surgery while I am here (however, I have been told that this may not be an option for international students).

The operating theater at the PHC

The sandals that are worn when entering the OR

One thing that I find fascinating about the Indian health care system is the complete acceptance of alternative medicine. On the campus of the PHC there was a Siddha unit. Siddha is considered to be the oldest system of medicine in the world (http://en.wikipedia.org/wiki/Siddha_medicine). It utilizes completely natural remedies to treat disease. Patients are free to use Western medicine or Siddha (or a combination of the two). The incredible thing about India is that both the alternative medicine and Western medicine therapies at the PHC are free to patients. As you may imagine, there are several types of alternative medicine practices in India. Collectively these are known by the acronym AYUSH: Alternative, Yoga, Unani, Siddha, Homeopathy. There are ways for all patients to access these various practices under the umbrella of government-sponsored health care. In the US, most physicians consider “natural medicine” an oxymoron, or at the very least a crock of you-know-what. The positive benefits that these methods have for patients in terms of the mind-body-spirit connection are worth considering. The Siddha pharmacist told us that many patients like to try the natural remedies first because they do not have the same side effects that come with Western medication. If the Siddha meds don’t work, patients are usually willing to add Western practice to their treatment.

Two of the natural drugs offered at the Siddha pharmacy

Following the PHC visit, we went to see a Subcenter (SC). Each PHC is affiliated with 5 Subcenters. These SCs are located within the villages. The role of each SC is to manage the health problems of the village. The SC that we saw was a 2-roomed building. They employ a Sector Health Nurse, a health supervisor, and a social worker. Together these employees keep immunization, birth, death, and disease prevalence records. They also help run a nutritional center where children under 5 and pregnant women receive caloric supplementation daily (a ball of grains for both, folic acid and iron pills for the women). Each SC receives government funding to ensure that all villagers have access to the care they need. If a woman goes into labor in the middle of the night, money from this fund can be used to transport her to the nearest hospital (and pay for the delivery if that hospital is private).

The Indian healthcare system is nowhere near perfect. In fact, I have found myself saying (more than once) “Wow, I would never be treated there.” However, the infrastructure is quite strong. It focuses on preventative services, community education, decentralized points of care, and minimizing expenses for those who can’t afford care. The main thing missing from the system is obviously capital. This is quite different from the US. In the US we spend more on health care per capita (and have more to spend) than any country in the world. We have the best schools, doctors, and facilities, the most modern technology and we’re on the forefront of research in every field. How is it that India can provide some treatment to its poorest citizens while so many in the US go without care (or are put into tremendous amounts of debt accessing it)? This first week has certainly been an incredible learning opportunity. It has also further motivated me to advocate for and support universal access when I return to the States.

Cute children at the PHC

Holy Hindi it's HOT!

Location: CHTC Guest House (Bagayam, Tamil Nadu, India).

Time Written: 6/4/09 10pm (Assume India time unless told otherwise)

We have officially arrived in India and have settled in quite nicely. We are staying on the CMC medical school campus in Bagayam (about 15-20 minutes outside of Vellore). The campus is fairly large and filled with beautiful trees, flowers, and lots of animals (including a bat tree!). It houses the medical students (and possibly the nursing, pharmaceutical, and PT students as well), some full-time staff (senior professors), as well as 2 libraries, several dining facilities, a store, an international hostel, lecture halls, and a mental health hospital. I am staying in the CHTC guesthouse with Alicia as my roommate. We are quite lucky, as our room has A/C.

Bat Tree

Bat tree, close up

The first two weeks of our trip here are being spent in a course with the second year medical students.* The course is in Community Health. It is an intensive course (2 weeks, all day every day except Sunday). The course consists of lectures about the health care delivery system in Tamil Nadu and India as well as multiple site visits. The aims of these site visits are to gain an understanding of the interrelatedness of each components of the health system.

On Monday, we visited a small village in Vellore. The students conducted morbidity surveys in homes there. They surveyed the total number of people in each household, those who were sick and causes of illness. They also inquired about recent pregnancies and deaths. We served mostly as observers since the villagers did not speak English (Tamil is the native language in Tamil Nadu). I've posted some photos from that village.

Photos of some houses in the village near Vellore

Man with a cast walking his bike up a hill

Kitchen in one of the houses we surveyed (no running water)

On Tuesday, we were supposed to go to a different village to conduct more detailed morbidity surveying. However, due to some unexpected stomach illness, we decided to skip out on that trip. The food in Southern India is quite delicious. However, it is also quite spicy and takes some time to adjust. I think we were a little over zealous with some of our food choices. Luckily the illness seemed to last only 24 hours.

Today was the best day yet. We went to visit several different sites. First, we saw an Urban Health Center located in a predominantly Muslim part of Vellore. This health center is government sponsored and also receives support through the Rotary Club of Vellore. The clinic mostly handles the prenatal, natal, and antenatal care of this community. Additionally, they help run school health check ups, have a 3X/week outpatient clinic, participate in DOTS (direct observed therapy – short course), run STD clinics/screening, provide family planning options, and immunize the children in this community. The clinic serves a patient population of about 46,000 individuals. The amazing thing about this clinic is that all care is provided free of charge. It is paid for by the government (and also through some donations by the Rotary Club). Another thing that I found astounding is that this center (via the government) actually pays individuals below the poverty line about 6000Rs ($120 USD) to deliver there. This was enacted because many of these women were delivering without the aid of trained workers. This leads to increased risk of maternal and neonatal death.

Birthing room in the Urban Health Center

Muslim woman walking in Vellore

As nice as the clinic is – it is easy to recognize points of weakness in the system. First, this clinic that focuses on maternal health is not equipped with a laboratory, a full-time physician, or an ultrasound machine. After giving birth, a woman is given a 1 night stay in the clinic. If an episiotomy is performed, a 3 night stay is allowed. There are limited resources available for women with anemia (pretty high – especially in this region). Patients who are considered “high-risk pregnancies” are referred to hospitals that are better able to handle these cases. My question is what if a delivery is expected to be normal and midway a complication arises? The nearest hospital is about 15 km away. Given the terrible driving conditions here and the lack of access to vehicles, the chance of this woman receiving adequate care is pretty low. Nonetheless, given adequate resources, the system of public health established in India is in many ways better than the US. The care is focused in community clinics and then diverted to the hospital in complicated cases. The idea of the government actually PAYING women to deliver in a care setting is completely unheard of in the US (and may cause a politician to lose his seat!).

One of many great pictures from this day

Following the Urban Health Care Clinic, we went to visit a nearby preschool and elementary school. Members of the Urban Health Care Clinic go to the school once per week to perform health check ups on the children (height, weight, nutrition). Additionally, the government pays for nutritional supplementation every day through age 5 as well as lunch during the day. Since this program was implemented, the children have gained weight and their parents budgets are freed up. The men in this town made about 130 Rs/Day ($2.60, unskilled) and 250 Rs/Day ($5.00-skilled). Women in the same jobs make much less.

Visiting the school was a great time. The students were quite happy to see us. I imagine that this was their first time seeing foreigners. We took loads of pictures, which really pleased them. They loved to look at the camera screen after the pictures were taken. I am definitely planning on doing a 1 week rotation in Peds while I am here.

Cute toddlers from the preschool in Vellore

Following our 2 week Community Health course, we will be allowed to choose what rotations we want to complete. I am planning on doing: CHAD (Community Health and Development hospital), LCECU (Low cost effective care unit), Peds, Ob/Gyn. I suppose that I will wait to decide what my other rotations will be.

I am glad that we are able to take part in this course. In the US, we have studied public health methods and theory for about a year. However, this is my first time actually going into the field and seeing how public health is done on extremely limited resources. I find it pretty incredible that the entire medical class goes on each of these site visits. It would be amazing if US med schools implemented similar field trips. Additionally, students at CMC have a mandatory 2 year service requirement (servicing a population in need). I think that this should definitely be incorporated into the US training system (especially with our huge focus on specialization – a focus that also exists in India).

Keep the emails coming. Until next time, enjoy the photos.

* In India, medical school begins directly after high school. It is a 6 year program followed by internship. The students that we are studying with are between 19 and 20 years old.

Getting there is half the fun

Note: This entry was written on VERY VERY little sleep and after many hours of traveling. It is unedited and in its original form. For that, I am sorry. Enjoy. In case you are interested, the entire trip took 44 hours and 48 minutes.

Location: Indira Ghandi International Airport, Delhi, India

Time Written: 2:15 am Saturday May 29, 2009 (local time), 4:45pm Friday May 28 (Boston time)

I’m new to blogging (specifically, I’m currently writing my first sentence as a blogger). Please keep this in mind as well as my severe jetlag, sleepiness, and remaining travel (see itinerary), don’t expect miracles with this post. Before I talk about my travels to India (thus far) I’ll give you a bit of info about myself and my reasons to write this blog.

Who: My name is Holly. I just finished up my first year at Tufts Med. It was certainly an interesting year – and perhaps if this blog survives past the summer I’ll discuss it further. In addition to getting my MD, I am enrolled in a combined degree program in public health. When I graduate in 2012 I will have both an MD and MPH. My current trip to India is fulfilling a field experience requirement of my MPH degree.

What: This is a blog about my 7 week summer trip to Vellore, India. Vellore is home to the Christian Medical College (CMC) and its hospital (http://www.cmch-vellore.edu/t_main.asp). CMC is one of the top hospitals and medical schools in India.

Where: Vellore, Tamil Nadu, India. Southern India about 150 km southwest of Chennai (http://upload.wikimedia.org/wikipedia/commons/0/03/India_population_density_map_en.svg).

When: Now through mid July-ish (currently no return flight!)

Why: I am choosing to write this blog for a few reasons. First, to let people in the states know how I’m doing. Second, to document my trip so I can look back on the trip with specific fond memories.

Okay – that’s pretty much enough details to get you pseudo-oriented. Now let’s talk about what’s happening right now. I have been traveling for 32 hours and 52 minutes. This isn’t a joke – I started my timer when I got on the train in Boston. I am currently sitting in the Indira Ghandi International airport (Delhi). I’d take a picture of the newly powerwashed sign – but once you enter the building, you can’t leave. I’d test that theory, but there are armed guards at the entrance. My travelling companions are fellow MPHers Mike and Alicia. Since arriving, we have rotated between the following activities. Sleeping, eating, meeting young Indians and asking them about cool things to do in India (currently topping the list: houseboat in Kerala, beaches of Goa, lots and lots of shopping, Taj Mahal…) and then sleeping again.

Armed Guards at the Indira Ghandi International Airport in Delhi

I must admit, I expected to walk of the plane into 120 degree heat with 98% humidity. Surprisingly, it’s fairly comfortable temperature and the humidity isn’t so bad. Then again, it’s evening and we are in an air-conditioned building. I am certainly waiting for the endless summer of sweating to begin when we leave the airport in Chennai.

The travel thus far has been pretty painless. On both of our flights we managed to have pretty ideal seating (exit row – no chairs in front of us – thus plenty of room to stretch out). There was a slight logistical snafu in Frankfurt involving getting new boarding passes for approximately 250 passengers 30 minutes before the flight was supposed to board (think slow lines, lots of miscommunication due to a 3 way language barrier, and no time for restroom breaks between flights). But everything worked out.

Recap: lots of traveling, still not there, so far so good. Once I am rested, I will post more details about what I will be doing this summer at CMC, why public health is pretty awesome, and what I hope to get out of this summer.

Travel Itinerary from Boston to Vellore