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.

Becoming an MFC writer

My parents wrote in the MFC journal when they were little older than I am currently. Its managed to survive all those intervening years and the latest issue carries and article by me. Ruminating about what it meant to be a slightly lonely medical student. Check it out here (Its on the last page.)

Sometimes I cant really say whether I like the style it is written in or not. Why don't you tell me?

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.

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!