The New Anthropologist and Johnny Lever's Hospital

On February 1st, I joined a UCL-BALM research unit in Chennai as a research assistant studying stigma and mental health. This transition is an exciting one for me, since it marks the beginning of my work as an anthropologist. In the introduction of his book Global Health, Mark Nichter, a public health anthropologist who has worked extensively in Tamil Nadu writes about the problems of translating his profession into Tamil and solves this difficultly by calling his discipline 'anubhav shashtra', the 'science of experience'. This is very close to my own idea of what an anthropologist does. I aim to transition from a clinician who is an expert at experiencing patients to a hospital ethnographer who is an expert in experiencing clinicians and clinical care. I hope to look critically at how knowledge and understanding is created in the clinic by different members who inhabit it. I especially hope to explore how non-English speaking patients construct an understanding of 'English Medicine'. All this will involve me look at intimately familiar environments with a fresh eye and I start this endeavor with a reference to someone else who seems to have wonderfully fresh take on the Indian hospital. Presenting the comic genius of Johnny Lever.

Snapshots of a doctor in rural Tamil Nadu

A few days ago the our health minister announced that that doctors will get better pay and 10% extra marks in competitive postgraduate entrance exams for every year spent working in a rural areas up to a maximum of 3 years. The proposal may not address to problem of the severe shortage of healthcare personnel in rural areas completely but it is indeed welcome news.

But what does working in a rural area actually mean? I spent two years working and taking pictures at the Tribal Health Initiative in Sittilingi in the Dharmapuri district of Tamil Nadu. Here are some snapshots.

Rural Tamil Nadu is beautiful.

This is the view from the kitchen window of the cottage I stayed in while working for two years at Tribal Health Initiative in Sittilingi, Dharmapuri District, Tamil Nadu as part of my rural service. Students from St. John's Medical College in Bangalore have to spend the first two years after graduation in one of the college's 400 recognised rural bond centres or pay Rs. 3,00,000 (Rs. 6,00,000 for the current batch).

The work is rewarding.

Apart from the three doctors and a couple of technical staff Tribal Health Initiative is run exclusively by people from the local community. Here is one of our health workers the day after the birth of her son. She was delivered by fellow health workers all of whom have grown up in the villages surrounding the hospital.  She had her baby in the sun when I came for morning rounds and we all shared her joy.

You might just get to live in your dream house.

I lived on the hospital campus at the edge of reserved forest land with a small stream a few metres away. My cottage had a small kitchenette, a shower and a high speed internet connection. (thanks to BSNL WLL technology). More than I could have asked for. Meals were in a common mess for all staff who stayed on campus.

You get chances to do surgery.

I learnt more in the two years I spent working with Dr. Regi and Dr. Lalitha than in all six years at college. One of the advantages of working in a rural hospital is that senior doctors have the time and patience to teach you unlike the competitive, hierarchical atmosphere of a city hospital.

You get chances to visit patients at home.

 

Every doctor should try this. If you visit your patients occasionally at home then you immediately understand what is making them sick and you realise that many conventional remedies are quite foolish to say the least. Practicing medicine also becomes a challenge when you realise that most patients can't read time, read labels or even begin to understand the nature of the medicines you prescribe.

You work with a dedicated, highly skilled team.

The health workers at Sittilingi are all drawn from the local villages and are predominantly from the Malavasi tribal community. I have never seen more competence and dedication. Our neonatal unit has a high success rate only because of the energy put in by our health workers in 24x7 one on one care of sick babies.

Things get scary occasionally.

A city boy like me had to get used to the occasionally enormous, allegedly poisonous spiders that used to sit nonchalantly on my cupboard door. My room was closest to the forest and a sort of immigration desk for snakes, scorpions, spiders and suchlike.

You learn about a different culture.

 

Living in Sittilingi meant I also saw a part of India I missed in the city. Pongal is one such amazing festival with anticipation building up for months before the actual date and the actual festivities being dissected for months thereafter.

You become family.

Being on duty 24x7 for a month at a stretch means you really get to bond with your staff. We worked, lived, ate and joked together and there was never a time when my inexperience and bad Tamil got them visibly  impatient. Here they pose with the newborn of another fellow health worker they helped deliver. Their pride in their work is obvious.

Miscarriage

A curtain of rain separates
My verandah from the hospital.
On any other day a hundred
Silent patients would pass through
The OP clinic. Each of them
Allowing us doctors to listen
Feel, touch and question them.
The warmth of their fever would
Make us uncomfortably hot.

Today the air is chilled downpour wet.
Water roars in the stony river.
Five nurses, Gi and I sloshed
Through muddy puddles to witness
Our stream in full spate.
Only one desperate couple managed
To make it on the early bus.
Wanting an abortion.

Kutti Thambi Chinna Doctor

He died five hours ago.
A small boy of three.
Looked so still and limp.
His family wailed.

His house is a few fields away.
His aunt works in our hospital.
He was born here.
He died at home.

He had a fever.
He vomited for three days.
His mother took him to a
Local traditional practitioner.

Our ambulance was called.
He stopped breathing before it came.
Tha held the mother.
And both were disconsolate.

His name is not tomorrow.

Blood toads

We deliver babies here
In a spew of blood and amniotic fluid
That splashes on our feet
Seeps into our cuts and crevices
And does daily battle with immunoglobulins
Yet the worry of contracting Hep B or HIV
Does not seem to worry the blood toads
Fat amphibians of the labour cot drain hole
Whose eyes shine at the most recent surge
Of human fluid.

Will today bring a rare gush of O Negative blood?
Will it send them scampering over the floor?
Student nurses in vain set after them
Scattering carefully stacked urine sample bottles
And a patient’s husband rushes to Salem
To buy injections that cost him two months earnings.

At night the new mother dreams
Expensive Anti D Ig courses her veins
Tiny lips suckle her breast
A multitude of pale green toads
Spawn nourished on her blood
Invade the ward hungry for more
A fresh red river flows from her uterus
Which is lax in terror.
She awakes screaming.

The junior night duty nurse runs
She awakens a thin tired doctor
The patient is shifted to the labour cot
Methergine soon flows into her veins
The now contracting uterus
Pushes out a kidney tray full of blood
Half a litre of gelatinous clots
More nourishment for the blood toads.

Teaching renal failure

Teachers help students believe in patterns in the real world. In any discipline everything seems so chaotic and impossible to understand at first. The descriptions of patterns in our textbooks seem sterile and nothing like what we have seen in the real world. A desperate, breathless man with a wailing entourage looks nothing like what a textbook patient with end stage kidney failure is supposed to look like. My reading on poverty, class and caste conflicts wont let him breathe easy. Wont let me breathe easy. At Sittilingi I've had two patients like this already. One died holding my hand after twelve hours of struggling to breathe as fluid irreversibly poured into his lungs for the last time. One went home after being successfully pumped with diuretics. He will come another day to die.

Why do people die of kidney failure? Its a long complex story involving chronic NSAID abuse, undiagnosed hypertension, drugs prescribed by unqualified local 'doctors' and blinding ignorance of methods of prevention. Add to that poverty, exploitation and a historical tendency to screw over tribal communities.

What do the current pundits of community health have to say about managing people with kidney failure in the community. Precious little. There is a huge difference between those who do things and those who write about things. The doers are brilliantly innovative yet deathly silent. Amazingly innovative ways of managing such situations do not leave the local context where they are practiced. There exists no peer review journal, no website/blog, no conscious effort to put suchlike into current textbooks. On the other side we have the suave publishers. Toting degrees from posh institutions that inculcate snobbery they fly around collecting data and creating analysis that serves them well. However they act like they never met a poor, dying man ever. Never shared his pain.

I realize that my previous paragraph is harsh. I am in danger of putting myself on a pedestal. But I write because of frustration. Because I lack good teachers. Because my textbooks are nothing like the real world. The chapters on renal failure make no sense because they don't talk about patients. I know how to manage a rising blood urea level better than I know how to manage people dying. I cant prevent death because of the silence maintained on the people causing renal failure. By selling dangerous medicines and by their failure to create a working system people of my community cause people to die stupid deaths.

Its time we saw a chapter on renal failure that reflects reality.

Dear Doctor

We work shoulder to shoulder with quite a few informal medical practitioners in the Sittilingi valley. Most of them have learnt the trade by careful observation of other practitioners and supplement or substitute theory with a common folk understanding of the body. Occasionally they refer cases to us and then we get reference letters like the following.

To
The Medical Officer
Tripal Hospital
Chitling

Respected Madam & Sir
This certified that passant name Mr. M_________ dring the poisan so the recomtet the blood seckap to passant.

xxxx
MHMS, DY&N, RAMP, FRHS, MF(Homeo-Nigeria)

Carpenter fixed my leg

A rural surgeon in Assam, an urologist by training has come up with an ingenious way of making up for his lack of expertise fixing complex fractures by internal fixation. He opens up the fracture site, then calls in the local carpenter whom he has taught the basics of surgical sepsis. The carpenter is quite adept at using standard orthopaedic drills, screws, metal plates, bolts and nuts to repair bones just as if they were delicate pieces of furniture. The urologist then repairs any vascular or nerve injuries and closes up. I guess the results would be comparable to that of the average Ortho registrar with only a few surgeries under his belt and in the absence of tertiary level orthopaedic care far better than leaving such cases untouched.

Public policy quacks

Another interesting presentation at ARSICON 2007 was one by Dr. Meenakshi Gautham on her study on the treatment of reproductive tract infections by informal medical practioners in the Tehri Gharwal region. I won’t attempt to summarise her findings here. I will only concentrate on the finding that almost all the practioners had no concept of the infectious etiology of urethral and vaginal discharge yet almost all prescribed antibiotics for such symptoms. When the actual rate of infection was calculated among symptomatic patients who were prescribed antibiotics it was found to be quite low (3-5% if I remember right). Most patients who got antibiotics did not need them.

These practioners were using a different theoretical framework, a traditional humoral understanding of the body to explain their patient’s symptoms. However they then proceeded to use antibiotics which have been developed using a modern biomedical framework. Since a formal medical education was inaccessible to them due to reason of money and language they had no means understanding this biomedical framework and this in turn made their prescription practice excessive and dangerous. Although it was not brought out in the study, they were possibly also aware of the fact that prescribing more antibiotics meant more profits and more incentives from pharmaceutical reps.

The traditional humoral understanding of the body is common sense knowledge in the region where they lived and worked. Most informal medical practioners learn what drugs to prescribe by careful observation of other doctors and it is hence not unnatural that they attempt to fit such observations into the theoretical framework in which is most familiar to them. They invest antibiotics which properties of ‘heat’ and ‘cold’ just like traditional medicines.

What I found interesting was the parallels that can be drawn between such a scenario and that of doctors writing health policy at state and national level. A large number of doctors in government committees are super-specialist clinicians with years of experience operating within the modern biomedical framework. Modern medical education ensures that even those who have spent years seeing patients from poorer, rural communities have no theoretical basis for understanding the social, cultural, economic and political realities of their patients. Those with post graduate degrees in Community Medicine don’t fare much better. It is quite likely that the surgeon mentioned in my previous blog entry might sit on a committee looking into ‘Tribal Health in India’.

Most assumptions on which policy is then based stem from common sense and years of observation. We have already seen how this can be a dangerous practice, since a large number of observations do not automatically mean that one has even begun to understand even the basics of the underlying phenomena. Indeed the resultant policy prescriptions produce results that seem similar to those of informal practioners. A lot of money gets spent, a few people get better and a large majority remain as they are.

If we are to ensure that policy decisions are made on rational grounds then we need to ensure that those making such decisions have both a deep theoretical and practical understanding of the social and political reality they are attempting to affect. Given the choice we would not entrust our bodies to a surgeon if we realised that he either didn’t have the necessary theoretical understanding of the human body or the requisite amount of practical experience. Policy interventions which affect the lives of millions of people deserve no less.

Speaking of tribal communities

I recently attended ARSICON 2007, the annual conference of a dedicated group of rural surgeons in India who form the Association of Rural Surgeons of India. The association is probably the only group of clinicians I have known who deeply and pragmatically care about the spiraling costs and increasing inaccessibility of basic surgical and medical care in India . For someone who spent five years as an undergraduate becoming increasing disillusioned with the rampant commercialisation at my Catholic institution their company was indeed uplifting.

Over three days I watched videos of extraordinary surgery aimed at minimalising costs for the patient, listened to a number of experienced speakers and generally became more absorbed in the art of surgery than at any given time during my years at medical college.

There was only one presentation that got a standing ovation and it is this presentation that disturbed me the most. A senior surgeon attempted to sum up ‘Tribal Health in India’ by presenting a few pictures of semi-clad forest dwellers, marsamic children and bloody bear attacks. All the pictures were 20 years old and in quite a few the person displaying tribal weapons was another rural surgeon, a fact that was not mentioned anywhere in the presentation. Tribals were portrayed as having ’No gods, no religion and only superstitious beliefs.’ No where was the actual name of the tribe portrayed mentioned. There were no statistics, no indication as to the reasons why tribal communities have been denied access to modern health care.. Scheduled Tribes constitute around 7% of the Indian population and actually are an extremely heterogeneous group. Such an incredibly simplistic representation did them an injustice to say the least.

What concerns me is that barring one or two surgeons, not a single person picked up the fact that the picture painted was crude and inaccurate. Here was a group of people who were not safely cocooned in an elite urban clinical practice yet after all their years in rural service they had no concept of what constituted a fair and representative description of tribal communities and what did not.

Like many other health systems, the Indian system is characterised by the fact that a majority of doctors come predominantly upper class, forward caste communities. A quick eyeballing of the ARSICON participant list will confirm this. If such doctors are truly desirous of understanding poorer, less privileged communities in order to help them then they need a basic theoretical framework in which to situate their understanding, This would be similar to the framework of anatomy, physiology, pathology and pharmacology which helps them understand surgical problems and techniques. Such a framework would include elements of basic sociology, anthropology, economics and political science and would help doctors navigate through the complex socio-political landscapes in which their patients are located.

Adding more theory to the MBBS course may seen to be an unfair demand at first. A quick review of the existing curriculum would reveal however that medical students are anyway burdened with a lot of complex biomedical theory which they have no use for. Why would anyone need to know the exact steps of the Kreb’s Cycle? Or the molecular structure of aminogylcosides? My suggestion is to replace this with basic social science theory instead.

Practicing here in Sittilingi it is ironical that when a young tribal woman is brought in after consuming poisonous plants containing cardiac glycosides I can elegantly describe the exact effect of the toxin on Na-K- ATPase cellular pumps but fumble when attempting to explain the social factors that caused her to attempt suicide in the first place. Neither can I fully explain the fact that pharmaceutical companies have decided that the specific antidote (digoxin Fab fragments) need not be marketed in India, a country where there is a large incidence of such poisonings. Such social and economic understanding would enable me to intervene much more effectively at both the individual and population level instead of merely being able to impotently explain the exact physiology behind her cardiac arrhythmias as she dies before my eyes.

Getting my priorities right

This month we are conducting an intensive campaign in the 21 villages of our health outreach programme to detect new cases of TB following a spurt in the incidence of the disease among newly returned migrant workers. This however sometimes adds a little surreality to my life.

Picture a bearded lab technician, a thin young doctor and an elderly Malavasi woman who is the local health auxiliary driving through the Avalur valley on a motorcycle. We stop at a house where the health auxiliary says she swears the man coughs a lot. He is not at home but has gone out with his goats. So the health auxiliary sets off down the road calling you his name while we sputter along behind her on the bike. Suddenly there is an answering call from up ahead. Soon an elderly man comes into view.

"Do you cough a lot, Aiya?", I ask as I dismount the bike. "Not really", he says, "But I occasionally have shooting pains down the side of my leg." "No cough? No fever? No weight loss?", I persist. "No, just leg pain", he replies. "He does cough", says the health auxiliary testily, possibly upset that her find is no longer allowing her prove that she has indeed surveyed the village for people with possible symptoms of TB. "Well, I occasionally cough at night", he finally admits. He soon finds himself sitting side-saddle on our motorcycle which is parked on the middle of the road while I auscultate his chest. The lab technician mutters darkly about the value of time. "Can you give us some sputum to test?", I ask. "I don't want a plastic cup", he says, viewing the proffered sputum cup suspiciously, "But if you have medicines for my leg pain I will surely take that."

Jesus has them too

I guess that even evangelists occasionally manage to slip up. Especially when introducing a new convert to Christian culture and foreign sounding Christian names. So it happened that a few days ago a heavily pregnant Jesus walked into our labour ward providing me with ample opportunity to scream at the top of my voice "Push, Jesus, Push" and generally blaspheme in bad Tamil as she delivered a perfectly cute baby into my hands. Not many doctors from Catholic medical colleges get to say that two months after graduating they were already good enough to successfully deliver Jesus (smirk).

Return to Slow Medicine

Today I walked in on a scene in our labour ward that would have been unusual in almost any other hospital I have known. We have two beds for women in the first stage of labour and Dr. R., the other junior doctor at Tribal Hospital was sprawled out on one of them, fast asleep. His hand however, reached out towards the other bed where it was grasped lightly in the hand of a sleeping woman exhausted by her prolonged labour. Both had been up for the last twelve hours, ever since the woman stepped into the ward. Dr. R., whose inclination for working with obstetric cases I must admit far surpasses mine, had spent a good bit of the preceding hours talking to the patient, massaging her back and generally coaxing her through a difficult, prolonged labour.

The idea of a doctor and patient falling asleep together while holding hands has the potential to cause a variety of responses amongst those in the medical field ranging from disapproval to alarm to dismissal as something that can occur only when a doctor has absolutely no other demands on her time. All these responses stem from the fact that as doctors we are trained to see patients as clinical cases first and as scared and suffering neighbours second. Right through my medical education at a big city hospital I had to imagine the situations and surroundings from which my patients came from and what it would like to be one of my patient's neighbours. None of my actual neighbours was ever seen by me since we were only allowed to practice our skill on the poorer patients in the general wards.

Working at Tribal Hospital in a re-education of sorts. There is no need to imagine my patients as neighbours. They are in fact my neighbours, working and living in the same environment as me. Almost all the staff except the doctors are women from the adjoining villages. Patients are no longer a row of bodies clothed in identical hospital garb. Instead most of them are personally known or related to the ward sisters. If you work here for a few months you would have visited a good number of the villages from most of our patients come from. I no longer send discharged patients to imaginary places but to streets I may have walked down myself.

The reason we spend time with our patients is simply because in such an environment ignoring someone who is sick or frightened is plain rude.