My (Brief) Firsthand Experience With the Indian Health Care System

Get ready for a long entry! Before today's blog, above is a photo of Monday's visit to the Sahara Center for transgender individuals and men who have sex with men (MSM). Several of them are positive for HIV, and as you can see, they have a lot of life left to live.

Today we were at St. Stephens Hospital for morning ward rounds with Dr. Arpit Jain (just like two days ago). The second half of the day, which I’m currently missing, is an HIV clinic and skills building session for people living with HIV/AIDS (PLWHA). The reason I missed it is that while in a patient’s room (with nothing at all alarming going on) I decided to have a fainting episode. If you’re thinking of the rainforest last year, when the same thing happened (although that was a little more understandable, I was watching a medical procedure), then, well, yeah, I now have a history of fainting in places of health care administration. Oops.

First of all, while St. Stephens is no Apollo Hospital (it focuses on quality, affordable care for everyone who needs it rather than luxury care for the few elite), I could not be more impressed with the physicians, nurses and orderlies who looked after me during that brief period. I wasn’t afraid of what was going on, especially after the first few seconds when I realized what had happened. But the health professionals took excellent care of me, as good if not better than in the U.S. For one thing, I felt that they were all more affectionate. As a patient, I appreciated that beyond words. There is something to be learned here.

Now on to the troubling realization that this pre-med student (how long am I going to be pre-med???) has a knack for fainting in her future place of work? Emma, Sejal, Paul and I were sitting around my hospital bed talking about how some people just can’t stand blood and guts. Of course, recent events left me somewhat sensitive to my own limitations in this area. But I stick by what I’ve learned from past experience: you can overcome just about anything with practice and dedication. You can get used to some surprising things when you push yourself to do so. The question is, should I? As it turns out, it’s not a very profound question in my case, because I don’t like to freak myself out by overthinking things. I’m just going to persist in what I know I want to do, and if in the future it becomes clear that I’m meant to be on the patient side of the health care system, and not the doctor side, I’ll deal with that when it becomes apparent to me.

I really wanted to go to the 2-hour HIV clinic this afternoon, not just to see the HIV patients because we’ve seen several already, but to attend the skills building workshop that teaches PLWHA how to manage their disease while preserving their quality of life. Dr. Jain insisted that I go home, so here I am, feeling completely fine (aside from a little annoyed with myself!). Hopefully the rest of the crew will have some insight and photos to share. Check out Sej’s blog and Emma’s to see what I missed out on.

I did have the chance to talk to Shalini, our CFHI coordinator who rescued me from the hospital and took me home this afternoon. She works with an organization called SPYM, a society for the empowerment of youth and mothers. My little drama had caused her to miss a WHO training session devoted to planning literacy classes for drug users. In the Delhi traffic, it would have taken her 2 hours to get back to work, so she was forced to take the afternoon off (she could not have been more gracious, despite the fact that I could not have been more of an imposition). But she hung out with me for awhile, so I got to ask her lots of questions about the status of Indian health care and its biggest challenges. Her thoughts were interesting:

HIV/AIDS is one of the most pressing issues in India right now, as any global health expert would tell you. However, the answer to rising HIV infection rates is multi-pronged, and requires a lot of funding and stewardship (read: management skills). While funding agencies do provide ARVs for the country, they don’t provide enough drugs to cover the population, and they don’t focus on infrastructure that sustains change. They also generally only provide first-line treatment, which is not enough for so many sufferers. These third-party funding agency limitations are transferred to the Indian government, which is severely strapped for funds. Any public health benefit for the Indian citizen has to be multiplied by one billion, a daunting task for any country, developing or not. Shalini says that mother-to-child transmission (MTCT) is a secondary worry in India (despite all the Western literature). Because of the lack of sanitary water and mother’s ignorance, a baby of an HIV positive mother is more likely to die (and sooner) of diarrhea than of HIV. Thus, all mothers, even HIV positive mothers, are actually encouraged to breastfeed and not to bottle-feed.

Shalini’s answer to all this is to focus on infrastructure. She stresses that funding agencies must increase their support for bringing ARVs to the population. But equally important or more important is the focus on managing the health care system and social empowerment programs. When people are so poor, they may stop taking their drugs and sell them off for food or other necessities. What good are life-saving drugs if you have no livelihood? People need to learn how to read, and then they need jobs. For high risk populations like MSM, commercial sex workers (CSWs), and women and men living in poverty, learning to read also means being able to read WHO pamphlets explaining what HIV is, how it is spread, and how to protect oneself.

Another problem Shalini pointed out is the low status of the girl child. Female foeticide and infanticide are a big problem in the villages, where 70-75% of the population lives. The girl child is severely devalued, and in many cases mothers don’t bother to feed their daughters and may even let them die. This is actually occurring. I ask her about the government’s recent commitment to provide free education for girls. Isn’t this having a positive impact? She says no. Again, the problem is infrastructure. Free schooling fine in the cities, where schools already exist. What about in the villages where there are no schools? It’s useless to provide girls with free education where there is nowhere to go for it.

Today, I’m left stimulated by the above discussion, and touched by the kindness and hospitality of the people whose help I totally relied on today. As a future physician (God willing--today’s tragicomedy hasn’t frazzled me) I think there’s a lot to learn from what I experienced at St. Stephen’s today. I probably won’t even fully appreciate it until later on, but it’s been a good day.

Community Outreach in Nandnargh

Today we spent the day in Nandnargh, a slum community in east Delhi. The air was so thick there that I could hardly breathe, but kids, vendors and elderly workers seemed to be doing just fine. We got to the Community Outreach Clinic, which is run by St. Stephens Hospital's profits (see earlier blog), around 9 am. We woke up at 5 am in order to get there on time! That's how bad Delhi traffic is.

For the first part of the day, we learned about how the clinic got started in 1992. It serves 90,000 people (yes, 90,000) and has programs as varied as DOTS (directly observed treatment short-term) for tuberculosis (TB) and child-to-child education, where elder students teach a variety of things to younger children. These programs are successful, yet there are some failures. For instance, multi-drug resistant TB cases are found; the doctor showed us the extensive paperwork for two cases. Some people who fail the first treatment approach are called "defaulters" because they don't show up to get their medications. These people are candidates for Paul Farmer's method of finding a patient advocate who ensures that the patient takes his or her TB medication in a timely manner. Dr. Robin, the physician who spent the most time with us, mentioned that it is rarely a family member who is appointed as a patient advocate, because relatives are likely to sympathize with the patient rather than enforce their treatment regimen. Instead, neighbors are used.

Dr. Robin also acquainted us with the clinic's efforts to empower women and youngsters to operate small businesses. He told us of the challenges to encourage young boys to fry snacks and sell them on the street. They were getting harrassed or were not selling well because they didn't know how to bargain, and because they had little variety of snack foods. Their lack of variety led customers to believe they had stolen a few goods from a legitimate vendor to sell them off and make a small profit. Expanding the selection of goods is a current challenge. The girls are now being taught to make jewelry, and already make burlap bags with simple embroidery designs and other embellishments. We were able to visit their small store, and even saw them practicing their sewing skills on newspapers. Women are also involved in making and selling spices. All of these budding entrepreneurs are coached so that they learn how to buy the raw materials, make their product, market it and sell it for a competitive price.

We also met Dr. John, an arthritis sufferer whose dedication to the community is unwavering. She showed us the CRECHE, the day-care center for children living in poverty from broken homes. Many of the kids suffered from "child bashing," but Dr. John reports that some of the children seem happier after coming to the center, because at least they experience moments of love, affection and companionship. They were such exhuberant kids. We pulled out our cameras and showed them the photos we took of them. They were so excited. I really felt like I connected with them, and almost wanted to stay there and be their "didi" (sister), as they respectfully called me.

Mid-day, we listened to a presentation on malnutrition given by Dr. Vinita Gupta. She outlined major challenges in micronutrition in India, including deficiencies in vitamin A, iodine, iron and folate. There were several physicians in the room, one of which was a prominent figure in Indian medicine whose name now escapes me. He argued that micronutrition is not so important to discuss as macronutrition. The sentiment of these physicians is that while the extensive, expensive research being done on these trace elements is impressive, what could we accomplish in the field in terms of combating malnutrition if those research dollars were earmarked for a more practical cause? Researchers come out with different, often conflicting opinions on diet all the time--even in India. It is confusing to the public and confounds common sense. Emphasizing a balanced diet, and focusing on getting impoverished communities enough calories, is what's really important.

After a delicious vegetarian meal that cost 20 rupees (roughly 50 cents), Sejal, Emma, Paul and I spent the second half of our day at the center at the malnutrition clinic, where malnourished babies are tended to. One of the babies we saw had pica--due to a deficiency of minerals, he was eating dirt and ice. Like many (most) of the children there, he also needed to be dewormed every six months. The prescriptions written at the clinic are free; while most women dress in lively colors and wear ample jewelry, they live at or below the poverty line. In most cases, the jewelry they wear is all that they own from the dowry their parents scraped together for their marriage.

It was another awesome day!

First Day on the Job!

Today was our first day of the four week CFHI program in Delhi on HIV/AIDS and Public Health Challenges. It was quite a day!

In the morning we got acquainted with St. Stephens Hospital, a non-governmental hospital that serves citizens regardless of ability to pay. Of course, there are rooms with AC and TV, and those with no advanced amenities. Rooms are about 1500 rupees per night, or roughly $40 (very expensive for the average Indian).

We saw three HIV cases, a typhoid patient, a TB patient, and several other cases, all of which were very interesting and educational. The HIV patients had it the worst, with opportunistic infections and long histories of various health problems. To make it worse, two of them had failing first line treatments. One was on his way to death, and the other had to switch to a second line amid complicated allergies and facing the fact that the government doesn't cover second line treatments. He was a 24 year old boy who had received multiple blood transfusions after a liver abscess as a child, through which he contracted the infection. Another HIV patient, the one nearing death, was a transgender patient with a very low CD4 count, tuberculosis, and a host of other problems including a fractured mandible which could not be operated upon due to his low Hb level and generally precarious situation. The doctor was not hopeful.

The second part of our day was spent at Sahara, a drop-in center for men who have sex with men and transgender individuals. Both groups are commercial sex workers. We got to speak with the health worker who began the program with so much dedication. He had to fight a lot to prove to the population that he was different from the numerous other health workers who drifted in and out of this community's existence without making any beneficial changes. But through dedication and responsiveness, the director, Ajay, was able to win the trust of these individuals, many of whom suffer from HIV and who are injected drug users.

The best part of the afternoon was the question and answer session we were able to have with the MSM and transgender individuals. We sat together and got to ask them questions about their lives and their daily struggles. The transgender population in India is very well-delineated, with hijras (the female role), eunuchs (castrated men), and a host of other culture-specific titles. Transgender men make their money two ways: 1) by dancing at festivals and parties (weddings and baby celebrations) and 2) commercial sex work. Hired dancing can earn them thousands of rupees, whereas commercial sex work, their daily jobs, earn them anywhere from 100-800 rupees.

We asked about harrassment from the police, and found that beatings and other forms of harrassment were common occurrences. As poor marginalized people they have no legal recourse. They are often faced with violence from customers, too; one worker mentioned that a customer may take the worker to a room where five men are waiting to be served. The worker is then subject to violence and forced sexual acts.

There is so much more to write about, even though this is the first day. Yesterday something very eye-opening happened. We had a meeting with all the CFHI students and the cordinators of the program. They are all devoted individuals and we are so lucky to be under their tutelage here in Delhi. The doctor in charge of the program, Dr. Raina, asked us, "Now, I've explained what you will gain. What do you have to give back to the people you will meet?"

Stupidly, I immediately thought of funds. Money that could buy more ARVs, or school books for kids, or whatever else may be needed.

Dr. Raina, on the other hand, was thinking much more simply and much more from the heart. He suggested we put on a skit to teach the community members in our outreach trips to villages and disadvantaged populations how HIV is transmitted (or some other useful topic). He advised us to make it lively and entertaining, but also ifnormative. He suggested we bring toys or little candies for the children, to build a rapport. The word rapport has been used so many times since we started the program that I'm beginning to see just how important it is to use whatever means you can to befriend the population you're hoping to help (or as Dr. Shahi sometimes says, "your victims").

Something as little as a candy or a rubber sling, or a polaroid picture can make the difference between your making a difference, or falling flat on your face as a health professional doing outreach to those who need it most. Seeing how much sincere dedication it took for Ajay, director of the Sahara program, to win the trust of the transgendered population, makes me realize that I have SO much to learn. I'm just glad I have this opportunity to do so, and pray I make the best of it.