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.

Dr. Claudio's One-Liners

Dr.Claudio Schuftan, runs the PHA-Exchange, an international mailing list for those interested in the People's Health Movement and working towards ensuring health as a human right. Here is a sample post containing a collection of some of his one-liners.

1. Half truths are like half bricks: you can throw them further.

2. The rich countries perpetuate the myth that expertise is the prerogative of the few.

3. If we made poverty and malnutrition contagious across the globe, their elimination would be remarkably rapid.

4. The rich like to speak of one world, but actually they are worlds apart of the realities of poverty with its ongoing HR violations.

5. When poor people are suffering and oppressed, the last thing they need is a God of docile love and meekness.

6. In international affairs (including international HR law), countries of the South most often react, but just reacting limits their choices.

7. "If I am not for myself, then who is for me? And if I am not for others who am I? And if not now, when?".

8. Stop reinventing the wheel. Start putting wheels on the wagon.

9. The future has many names: for the powerful few it is status-quo, for the bold (among the not-yet-powerful-many) it is an opportunity for needed structural changes (that will tackle HR violations at their roots).

10. Struggle is a principle of development; to be is to do.

11. Faith in the power of doing is better than doing nothing at all.

12. Either we unite, organize and cooperate closely or many more will continue dying unnecessary deaths… United, we all have an opportunity to make a difference… Divided we beg, united we demand

13. Action unites more than words; the latter usually divide.

14. "Raise hopes, don't destroy illusions".

15. We are not to preach, but to organize mass actions.

16. The name of the game is: Focus on lasting/sustainable results, not on any dogma!

17. Because men and women experience poverty differently, we need to work harder on the rights of women (and those of minorities).

18. Perhaps it is unrealistic to expect poor women to overcome deeply ingrained socio-cultural barriers just because we empower them financially through micro-credit operations and/or we train them in leadership. For their rights to be ultimately respected, more than that will be needed…

19. An economic system that has little or no use for better than half of the world's population can and must be radically transformed.

20. The world economic order works for the advantage of 20% of its population.

21. Neoliberalism globalizes poverty, not development.

22. The debt of poor countries has already been paid by ever-falling-terms-of-trade. (That is why the HR-based framework calls for debt relief for the poorest countries).

23. Money equals force in the market; therefore, those with money dominate. So world trade is a means of domination of the rich countries.

24. The laws of supply and demand can fix the market price of bread, tortillas, cassava or rice, but they do nothing to alleviate hunger as a key HR violation.

25. The invisible hand of the market has no capacity to imagine or create a decent society for all.

26. Globalization does not have a human face; it has a cynical human mask.

27. In the era of globalization, progress means inequality and for its staunch promoters, reason means self-interest.

28. There is enough for everyone's need, but not for everyone's greed.

29. In the struggle for the alleviation of poverty, the check has come back from the 'Bank of Justice' marked "insufficient funds".

30. Income for the poor is perhaps the best guarantee of health and food security.

31. It took Britain the exploitation of half the globe to be what it is today; how many globes would India need?

32. As the threat from the many HR violations we see worldwide increases, so does the cost of inaction.

33. Social justice and the universal respect of HR will not succeed if it remains the sole concern of intellectuals.

34. Death is a social disease: How often do we overlook this axiom?

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."

Free Burma!

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).

Mein Akela Nahin Hoon: The Story of Dr. Binayak Sen

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.

Can I still disagree?

I wont discuss the intricacies of the arrest of Dr. Binayak Sen, a noted paediatrician and human rights activist in Chhattisgarh. Much has already been written about it. The SaveBinayak site is an excellent starting point. The internet activist can sign petitions here and here. What is troubling for someone not involved in the local intrigues of the case is the strong statement that the Chhattisgarh State Government makes with such an action. By going after a man who strongly sided with non-violent, democratic means of countering State excesses and negligence the government is slamming shut the door to democratic activism and dissent. Taking up the line of George Bush, people can now choose to be either 'with us or against us'. The Chhattisgarh Special Public Securities Act, under which Dr. Sen is charged has sweeping powers and contains wording that can be interpreted in such a manner that a number of seemingly innocent acts can be construed as 'waging war against the State'. The Act seems to be targeted more towards so called 'Naxal sympathisers' than any armed revolutionary. Here is where the danger lies. Since the Naxal movement claims to represent and fight for the most oppressed sections of Indian society, the landless farmers and tribals, any person seen as sympathising with these people is now seen as a potential Naxal. I grew up in the heart of the democratic movement that hoped to represent the poor and the oppressed in India. Never have I heard anyone openly admire Naxalite violence or any other sort of violence for that matter. People on the ground do sometimes however, acknowledge the frustration and hopelessness that occasionally drives people to take up arms. For the first time I am witness to a new fear within the community. People are now acutely aware of the value of political correctness in an atmosphere where a single careless sentence or act can be misconstrued as supporting violence aganist the state. Overnight the community has woken up to the fact that the political support from the middle class which viewed activists as people who have taken a much respected but less beaten path has evaporated. Any sort of activism is now seen as a bunch of idealists creating a nuisance at best and at worst activism is seen as terrorism. The line between democratic and non democratic dissent is fast eroding. An environment in which you can get away with anything provided that you can create enough spin to make people believe that your enemies/victims are 'terrorists' is deeply disturbing. The vulnerableness of groups with no access to mass media and other channels where they can sufficiently and honestly portray there version of the truth is great. Skillful control of most Indian media by a nexus of businessmen, politicians and corporates contributes to this environment in which all protest has become theatre whether the script involves violence or not. Any free and just society needs to provide space where citizens can confront the government and other powerful institutions. It is imperative for concerned people to fight to maintain and expand this space for democratic, constitutional ways of disagreeing with the Powers That Be. While there is still time and space.

Phoenix blog

Its time to resurrect the blog. Again. A quick update. My long drawn out medical studies are finally over and from August 2007 I will start work at the Tribal Health Initiative in Sittilingi, Tamil Nadu as a junior doctor. I hope this change in my setting will be reflected in a change in perspective and content of this blog. I hope to delve deeper into understanding the chaos which is the Indian health system and use this blog as a platform for opinion and discussion. As of now I am using this rare free month to travel as much as I can within North India.