An Emerging Voice tours Europe

Graduate life at Syracuse does not really give one much time to breathe or blog so the last month was a welcome change. I was selected to be an 'Emerging Voices' through an essay competition organized by the Institute of Tropical Medicine (ITM) and got to spend two weeks with them in Antwerp, Belgium attending a workshop on building our research publication and presentation capacities and presenting my essay at the ITM Colloquium. My topic was on language barriers in healthcare settings in India, something I had started writing about on this blog quite a while ago. ITM also organised for us to go to the First Global Symposium on Health Systems Research in Montreux, Switzerland. I was selected to be one of the three Emerging Voices to present our views of the symposium at the closing plenary. We spent hours trying to collate feedback, develop a critique and fit it all into a six minute Pecha Kucha style presentation. The effort paid off when we received the only standing ovation of the symposium the next day, a moment now immortalized on YouTube.

As usual my camera travelled with me although I did not use it much during the actual workshop and symposium days. Most of the shots are from our walks around Antwerp and Sunday trips to Amsterdam and Rochers de Naye.

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.

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)

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.

Operating in Chinese

In this era of globalisation in comes as no surprise to me that the artificial icepacks we occasionally use at our hospital have been manufactured in China. However I realise that a great many linguistic and cultural barriers have yet to be crossed when the instructions on the cover read as follows.

Operation Instructions

• This element it is amazing not to have. “Store the cold foot” lowers the temperature fast to clear yp coldly and slowly.
  
• Pack and open outside, the income -10◦C ice boxes or freezes are frozen hard and reservly soon.
  
• It is insulate against heat protecting cold thing. In the case, according to protecting the cold demand, set up the quantity of good performance to pack into.
  
• In the case the damage will not be polluted seriously protect the cold thing.

The social context of Indian medicine

I'm currently posted in Chamrajnagar, a rural district in South Karnataka and am practising in a social setting that gives me a lot of food for thought ..

Indian medical practice is largely based on clinical research conducted in the West. Most of the internationally recognised standard texts are by North American or European authors. The teaching methodology used here is largely an outdated, didactical approach which was imported here in the 50’s and 60’s when a large number of medical colleges were set up post independence.

However the social context in which our system is embedded is radically different from the one on which our system is based. While the Westernised elite are more likely to demand and have access to health care it is the poor, who are in an overwhelming majority who really require good, relevant health care. This is because poverty is intrinsically linked to sickness, a large component of which is preventable or easily curable.

It is quite evident that a majority of doctors respond to this difference between theory and reality with a range of practical modifications which range from the simple and obvious to the highly sophisticated. However they still exist only at the level of individual endeavors and as yet there is no large systemic acceptance and addressal of our unique reality.

Doctors in India are also handicapped in their understanding of the social context in which they practice for two reasons: One is that since entrance to medical colleges is highly competetive and students from private schools have an enormous advantage during entrance exams, doctors as a group come predominantly from upper class, upper caste backgrounds whereas a majority of people in real need of health care come from lower class, lower caste backgrounds. The second reason is that since admission to medical college is open to students only from science streams in India, doctors complete their education with only a miniscule component in social sciences as part of their Preventive and Social Medicine syllabus which exists more for namesake than anything else. Hence they are ill equipped to analyse, research and act upon any problem that is not quantitative and out of the realm of pure science.

It is this lack of understanding of social context that has prevented modern Indian medicine from being truly relevant in rural India, where the medical need is immensely greater than in urban areas. The crying need of the day is for Indian doctors to move out of the biomedical paradigm and become anthropologists, communicators and true practioners of revelant social medicine.

Neevu Engleesh Daktara?

Language in Medicine

One wonders why the study of language is not a more integral part of the study of medicine. Especially here in South India where it is not uncommon to encounter over six to seven languages in a single morning at the OPD.

The presumption is that all Indian doctors are natural born linguists. This is true to a certain extent with most of the senior doctors who seem to be able to take a basic history in a fair number of languages. Often however the interaction merely consists of a few basic questions and recycled advice. Real conservation in which the doctor can relate to the patients is difficult and requires a fair amount of experience and skill.

The people who feel the language barrier the most are the medical students and junior doctors who suddenly find themselves in possession of a fair amount of medical knowledge and absolutely no way of adequately communicating this to the people to whom it matters the most, the patients.

In this era of globalisation the issue of language and communication is all the more relevant. Large scale migration, especially to the cities ensures that at least in the urban setting doctors will always have to deal with patients from a multitude of linguistic and cultural backgrounds.

Miscommunication is at the heart of the recent rise in the number cases of litigation against doctors by irate patients and carers who feel that there expectations and rights have been betrayed. Obviously the most glaring forms of miscommunication occurs when the doctor and patient do not share a common language and have no means of overcoming this barrier.

In this context a more organised approach to the challenge of producing multilingual doctors is the need of the hour. The assumption that doctors will pick up language 'on the job' needs to be reevaluated and alternate approaches need to be looked at.

The teaching of languages has undergone a radical transformation over the last fifty years. Most Western universities have language laboratories where new and innovative methods of acquiring language ability are being explored. The challenge is for the medical profession to incorporate these advances in its effort to provide better and more effective care.