The last couple days we have been going to the Urban Health Training Center and the Rural Health Training Center as part of our community medicine posting- we are finally getting to see patients all day every day (and no lectures) : )
Here are just a few of the cases we have seen to give you an idea of the patient population and the health problems they face. Note that most treatment given at these outreach centers is just symptomatic and not necessarily curative.
On Friday at the RHTC I was able to see two elderly women suffering from chikungunya (don’t feel bad if you have no idea what that is- I didn’t until I got here). Chikungunya is a virus which is spread by mosquitoes (similar to how malaria is spread)- the disease was first described in Africa and was very rare until recently. In 2005-2006 there was a widespread outbreak of chikungunya in southern India- after heavy rains and flooding (think standing water and mosquitoes). The virus is generally not fatal although some deaths have been attributed to it. Patients suffering from chikungunya generally present with fever, rash of the limbs and trunk, and arthritic symptoms in multiple joints- can be debilitating. The women I saw both had swollen joints and decreased mobility. The physicians said that the crippling joint pain is the most common and pronounced symptom. The fever generally subsides after a day or two while other symptoms, mainly the joint pain, can last up to weeks or even months (generally longer in older patients). There is no specific treatment for chikungunya- at the RHTC treatment is given for relief of the painful joints- anti inflammatory treatment. (The physicians said that in some clinics steroids are being given.)
A mother and her two sons came to the RHTC- all were patients. The mother had malaria and was given quinine tablets for treatment- she presented with fever and chills for days. Her 3 year old son had a terrible case of scabies and an upper respiratory tract infection. He was given antibiotics, skin cream for the scabies, and advised to take an antiseptic bathe. Her 13 year old son was unable to walk or sit in a chair without assistance. This was the first time he had been brought to the clinic- the mother wanted to know what was wrong and what could be done. After a very brief physical exam and patient history the physician suspected muscular dystrophy. The mother reported that her son developed normally until the age of 7- after which he just got worse. Aside from his physical disability his mental function is normal. He is the product of a consanguineous marriage. The family was referred to SDM hospital- orthopedic department for further care. However, the physician was skeptical as to whether or not they would actually take their son to the hospital (due to a lack of transportation, money, etc.).
Side note- in the past few days I have asked a few physicians about consanguineous marriages in India and why they appear to be so common. Here is what I was told… primarily people don’t understand the medical problems that can result in children that come from a consanguineous marriage (congenital abnormalities). They reported however that the number of consanguineous marriages has decreased to about 50% overall- definitely more common in the villages and rural areas than in urban settings (this is down from about 60-70% 10-15 years ago- the result of education about these congenital abnormalities). The reasons given for arranging a marriage between family members were as follows. Since most parents arrange the marriage and since children generally take care of their parents in old age- parents figure that if both members of the couple are family both have some personal stake in taking care of the parents in old age… thus, the parents are guaranteeing that they will be taken care of in the future. Also, if both members of the couple are individually related to the parents this makes certain that any inheritance will be kept within the family. When the parents die whoever (husband or wife) inherits their land, money, or other property is sure to be family.
Maybe the most disheartening case was one I saw at the UHTC. A 19 year old female came in complaining of loss of energy and fatigue. The patient was clearly anemic and malnourished. In taking the patient’s history this is what the physician found out… the woman had recently lost an infant and complained that her in-laws (whom she lives with- it is customary for the daughter-in-law to move in with her husband’s parents) were giving her a hard time about being an unfit mother. She reported that the family was not giving her any food- she said she had eaten dirt she was so hungry. She said her child died because the family was not giving her enough food to produce sufficient milk for the infant. She said her husband, who works in the field during the day, is not sympathetic and sides with his parents. The physician treated her with antidepressants, nutrition supplements, and advice on free feeding programs in the area.
Along with the above cases there was a woman who presented with fatigue and appeared anemic. After a blood test she was found to have a hemoglobin of 5 (should be around 14). There were countless children with skin infections (the result of poor hygiene)… most of them had scabies and due to scratching the skin had been broken, increasing the risk for secondary infections- which most had (presenting as skin boils averaging 1-2 cm in diameter). Oh and a family of 5 all suffering from gastroenteritis- mother, 7 year old son, 3 year old son, 2 year old daughter, and 7 month old daughter. The physician treated them with antibiotics, oral rehydration solution, and a stress on personal hygiene. And on a more positive note today a 98 year old woman came in to the RHTC, after walking 2 km from the neighboring village, to inquire about getting some new glasses. She had broken hers and wasn’t able to see very well with the old pair she had found at home. Aside from the glasses request she was healthy (and probably the cutest old lady I’ve seen- Eva and I took her picture) : )
Our days spent at the UHTC and RHTC have been an amazing opportunity to learn about medicine, about healthcare in India, about treating a patient population with limited resources, and most importantly about compassion. I feel fortunate to have been able to see and learn from patient cases that are not likely to appear at the University of Iowa Hospitals and Clinics.
Tuesday, July 10, 2007
Sunday, July 8, 2007
Just a few thoughts…
So… this post is just going to be lots of things about our summer here in India and a little bit about our posting in community medicine (more to come later).
I knew coming to India that most Indian marriages are arranged… however I was totally unaware of the process behind arranging a marriage. While times are changing and more and more young people in India are meeting their mates in their own way- opting for “love” marriages (especially in the large urban areas) – here in southern India the majority of marriages are still arranged. Eva’s aunt and uncle are currently helping their nephew interview prospective brides. This past week Auntie and Uncle, as well as, mother and father have traveled three separate days to cities around Dharward to interview girls and the girls’ families. We inquired about the process and this is what I have found out….
First the parents of the man consult a matchmaker to learn of possible brides. They then set up meetings with these girls and the girls’ families for a sort of interview process. There are generally multiple meetings before a decision is made. If the families agree that the couple is a good match they then consult a fortune teller. The fortune teller must check the horoscope of both parties and give the union an “all clear” before the couple can be married. In some cases dowries are still given in the form of money, gold, a car, etc. (of course all situations are a bit different… this is just what I have gathered thus far). If it is decided that the couple is a good match it is at this time that the future bride and groom are able to communicate- get to know each other (alone).
Eva’s uncle explained that not only must the woman and man be a good match (caste, horoscopes, height, beliefs, future plans, etc.) but the families must fit together. Generally, after the couple is married the wife will move in with the groom’s family (most homes here are multiple family dwellings). She will assume the household tasks given to her by her mother-in-law. I don’t know a lot of details about the actually marriage ceremony (it is supposed to be quite the production- generally between 1,000- 2,000 guests)… Eva and I have been invited to attend the wedding reception of one of the physicians from the hospital. The doctor is in forensic medicine and will be getting married this Sunday. It should be an interesting event- we will be wearing saris to the reception.
Now I mentioned above that part of a couple being a good match is being members of the same caste. The caste system is the basic social structure of Hindu society and although it is not as strong today as it once was… it is definitely still present. For example, here at the house there is a girl, about 12 years old, named Lakshmi who helps Auntie with the house work. She is actually the daughter of the family who farms the land owned by Eva’s family (if that makes sense). Lakshmi lives here at the house and attends school in Dharward (which is a better school than the one she would attend growing up on the farm)- she helps cook and clean in exchange for room and board you could say. Even though the family likes her very much, she is a member of a lower caste and thus eats off of different dishes than we do and sleeps on the floor near the stairwell (even though there are about 6 empty beds in the house). Our driver, who takes us to and from the college everyday, is also a member of a lower caste and thus takes his tea out of different cups than we do. It is all very strange to me.
I, being totally unfamiliar with the details of this system, did a little reading in Lonely Planet… here is what I found out. In Hindu society there are 4 castes and below these 4 main castes are the Untouchables or Dalits (menial laborers- sweepers or latrine cleaners). The castes, from top to bottom, are as follows- Brahmin (priets and teachers), Kshatriya (warriors), Vaishya (merchants), and Shudra (laborers). It is thought that if one lives a moral life it is more probable that one will be reborn into a higher caste with better circumstances. Again, in India today the caste system is definitely weakened and far less rigid… but its presence can still be felt.
Eva and I have been enjoying Indian television in the evenings… there are about 3 channels in English. The channels actually broadcast some descent shows… Seinfeld, Friends, Scrubs, Arrested Development and some alright movies. However, more fascinating than the shows are the commercials. It is interesting all that can be learned from a society’s advertisements. For example, there is a commercial (which airs repeatedly) for men’s face wash… and what makes this face wash special is that it whitens your skin. It is called Nivea White for Men (sp?). So…. while Americans are spending loads of money trying to achieve that sun kissed summer glow… Indians are spending money on face soap that will make their skin whiter. There are similar advertisements for women’s face wash. Whiter skin is desirable because it says something about your social status- if your face is light you must work indoors and make more money than the dark skinned man who works in the sun as a laborer.
Onto the next topic… Eva and I have noticed a difference in the maturity level of the second year medical students here at SDM and the second year medical students at the U of I. For instance, the other day we sat down the in a classroom in the Department of Pediatrics with the batch of second year students we were posted with. Eva and I sat in the middle of the second row. Instantly all of the students moved their chairs behind us and one another so that they would be in the back of the classroom, farthest from the professor. Come to find out the medical education system is a bit different here in India… making the age of the students a bit different. In the States, after completing 12th grade, one must earn a bachelors degree (4 years), then attend medical school (4 years), and then complete a residency program in a particular specialty (minimum 3 years)… after this you are a full fledged doctor. In India, after completing 10th grade, one must attend college-11th and 12th grade-(2 years), and then medical school to earn a bachelors degree in medicine (5.5 years including internship)… after this you can practice medicine. There is the option in India to do a postgraduate degree in order to become a specialist (three years). What this basically all means is that at age 23 (my age), I would be practicing medicine already in India, rather than having at least 6 more years to go in the States. At home we must attend 11 years of education (minimum) after 12th grade to become a doctor. Here in India it is just five and a half years after 12th grade. So our fellow 2nd year medical students at SDM are on average 18-19 years old… this would explain the boys punching each other in the arm while the girls are trying to interview a patient : )
We are nearing the end of our time here in Dharward and are in our last posting- community medicine. While it has been a bit of a struggle conveying to the department that we want to spend as much time seeing patients as possible (and as little time in lecture as possible- the Head of Department designed a two week lecture schedule for Eva and I specifically) the posting has been very interesting so far. The Medical Council of India requires that all medical schools in India provide an opportunity for their students to learn about community medicine by establishing and staffing an Urban Health Training Center (UHTC) and a Rural Health Training Center (RHTC). These centers are basically outreach clinics which provide extremely affordable healthcare to the citizens of the lowest socioeconomic class. Patients pay 10 Rupees a month (a quarter) for unlimited treatment at the UHTC and 5 Rupees a month at the RHTC. While the clinics are by no means all encompassing facilities… they do both have 2-3 exam rooms, a small lab (to do blood and urine tests), a pharmacy (all meds are free after the monthly fee has been paid), and immunization programs. If a patient requires further care and is unable to afford the services of SDM Hospital (it is a private facility) they are referred to the free government hospital in Hubli. Each center is staffed by about 15 people (5 doctors) and serves a population of about 30,000 people. The centers are open from 9 AM – 1 PM (6 days a week) during which on average between 80 and 120 patients are seen. The UHTC is located near the slums around Dharward. The RHTC is located in Wayadad, a village of about 3,200 people about 40 minutes drive from Dharward.
Our last day at SDM will be Thursday, July 12th. On Friday Eva and I will take the train to Bangalore. We will be spending the weekend with her uncle in Bangalore… and possibly taking a day trip to Mysore. On Monday, July 16th we will fly to Delhi for a North India Highlights tour (visiting Delhi, Varanasi, Agra, Jaipur, Jodhpur, and Udiapur). The tour will end in Mumbai on July 26th. We will then do some sightseeing in Mumbai (hopefully take in a Bollywood movie or two) before flying home the night of July 31st. I am not sure what the internet access will be like at our various destinations… and seeing as we are moving cities almost every other day… I can’t guarantee updates on my Blog… but I will try : )
I knew coming to India that most Indian marriages are arranged… however I was totally unaware of the process behind arranging a marriage. While times are changing and more and more young people in India are meeting their mates in their own way- opting for “love” marriages (especially in the large urban areas) – here in southern India the majority of marriages are still arranged. Eva’s aunt and uncle are currently helping their nephew interview prospective brides. This past week Auntie and Uncle, as well as, mother and father have traveled three separate days to cities around Dharward to interview girls and the girls’ families. We inquired about the process and this is what I have found out….
First the parents of the man consult a matchmaker to learn of possible brides. They then set up meetings with these girls and the girls’ families for a sort of interview process. There are generally multiple meetings before a decision is made. If the families agree that the couple is a good match they then consult a fortune teller. The fortune teller must check the horoscope of both parties and give the union an “all clear” before the couple can be married. In some cases dowries are still given in the form of money, gold, a car, etc. (of course all situations are a bit different… this is just what I have gathered thus far). If it is decided that the couple is a good match it is at this time that the future bride and groom are able to communicate- get to know each other (alone).
Eva’s uncle explained that not only must the woman and man be a good match (caste, horoscopes, height, beliefs, future plans, etc.) but the families must fit together. Generally, after the couple is married the wife will move in with the groom’s family (most homes here are multiple family dwellings). She will assume the household tasks given to her by her mother-in-law. I don’t know a lot of details about the actually marriage ceremony (it is supposed to be quite the production- generally between 1,000- 2,000 guests)… Eva and I have been invited to attend the wedding reception of one of the physicians from the hospital. The doctor is in forensic medicine and will be getting married this Sunday. It should be an interesting event- we will be wearing saris to the reception.
Now I mentioned above that part of a couple being a good match is being members of the same caste. The caste system is the basic social structure of Hindu society and although it is not as strong today as it once was… it is definitely still present. For example, here at the house there is a girl, about 12 years old, named Lakshmi who helps Auntie with the house work. She is actually the daughter of the family who farms the land owned by Eva’s family (if that makes sense). Lakshmi lives here at the house and attends school in Dharward (which is a better school than the one she would attend growing up on the farm)- she helps cook and clean in exchange for room and board you could say. Even though the family likes her very much, she is a member of a lower caste and thus eats off of different dishes than we do and sleeps on the floor near the stairwell (even though there are about 6 empty beds in the house). Our driver, who takes us to and from the college everyday, is also a member of a lower caste and thus takes his tea out of different cups than we do. It is all very strange to me.
I, being totally unfamiliar with the details of this system, did a little reading in Lonely Planet… here is what I found out. In Hindu society there are 4 castes and below these 4 main castes are the Untouchables or Dalits (menial laborers- sweepers or latrine cleaners). The castes, from top to bottom, are as follows- Brahmin (priets and teachers), Kshatriya (warriors), Vaishya (merchants), and Shudra (laborers). It is thought that if one lives a moral life it is more probable that one will be reborn into a higher caste with better circumstances. Again, in India today the caste system is definitely weakened and far less rigid… but its presence can still be felt.
Eva and I have been enjoying Indian television in the evenings… there are about 3 channels in English. The channels actually broadcast some descent shows… Seinfeld, Friends, Scrubs, Arrested Development and some alright movies. However, more fascinating than the shows are the commercials. It is interesting all that can be learned from a society’s advertisements. For example, there is a commercial (which airs repeatedly) for men’s face wash… and what makes this face wash special is that it whitens your skin. It is called Nivea White for Men (sp?). So…. while Americans are spending loads of money trying to achieve that sun kissed summer glow… Indians are spending money on face soap that will make their skin whiter. There are similar advertisements for women’s face wash. Whiter skin is desirable because it says something about your social status- if your face is light you must work indoors and make more money than the dark skinned man who works in the sun as a laborer.
Onto the next topic… Eva and I have noticed a difference in the maturity level of the second year medical students here at SDM and the second year medical students at the U of I. For instance, the other day we sat down the in a classroom in the Department of Pediatrics with the batch of second year students we were posted with. Eva and I sat in the middle of the second row. Instantly all of the students moved their chairs behind us and one another so that they would be in the back of the classroom, farthest from the professor. Come to find out the medical education system is a bit different here in India… making the age of the students a bit different. In the States, after completing 12th grade, one must earn a bachelors degree (4 years), then attend medical school (4 years), and then complete a residency program in a particular specialty (minimum 3 years)… after this you are a full fledged doctor. In India, after completing 10th grade, one must attend college-11th and 12th grade-(2 years), and then medical school to earn a bachelors degree in medicine (5.5 years including internship)… after this you can practice medicine. There is the option in India to do a postgraduate degree in order to become a specialist (three years). What this basically all means is that at age 23 (my age), I would be practicing medicine already in India, rather than having at least 6 more years to go in the States. At home we must attend 11 years of education (minimum) after 12th grade to become a doctor. Here in India it is just five and a half years after 12th grade. So our fellow 2nd year medical students at SDM are on average 18-19 years old… this would explain the boys punching each other in the arm while the girls are trying to interview a patient : )
We are nearing the end of our time here in Dharward and are in our last posting- community medicine. While it has been a bit of a struggle conveying to the department that we want to spend as much time seeing patients as possible (and as little time in lecture as possible- the Head of Department designed a two week lecture schedule for Eva and I specifically) the posting has been very interesting so far. The Medical Council of India requires that all medical schools in India provide an opportunity for their students to learn about community medicine by establishing and staffing an Urban Health Training Center (UHTC) and a Rural Health Training Center (RHTC). These centers are basically outreach clinics which provide extremely affordable healthcare to the citizens of the lowest socioeconomic class. Patients pay 10 Rupees a month (a quarter) for unlimited treatment at the UHTC and 5 Rupees a month at the RHTC. While the clinics are by no means all encompassing facilities… they do both have 2-3 exam rooms, a small lab (to do blood and urine tests), a pharmacy (all meds are free after the monthly fee has been paid), and immunization programs. If a patient requires further care and is unable to afford the services of SDM Hospital (it is a private facility) they are referred to the free government hospital in Hubli. Each center is staffed by about 15 people (5 doctors) and serves a population of about 30,000 people. The centers are open from 9 AM – 1 PM (6 days a week) during which on average between 80 and 120 patients are seen. The UHTC is located near the slums around Dharward. The RHTC is located in Wayadad, a village of about 3,200 people about 40 minutes drive from Dharward.
Our last day at SDM will be Thursday, July 12th. On Friday Eva and I will take the train to Bangalore. We will be spending the weekend with her uncle in Bangalore… and possibly taking a day trip to Mysore. On Monday, July 16th we will fly to Delhi for a North India Highlights tour (visiting Delhi, Varanasi, Agra, Jaipur, Jodhpur, and Udiapur). The tour will end in Mumbai on July 26th. We will then do some sightseeing in Mumbai (hopefully take in a Bollywood movie or two) before flying home the night of July 31st. I am not sure what the internet access will be like at our various destinations… and seeing as we are moving cities almost every other day… I can’t guarantee updates on my Blog… but I will try : )
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