During the summer of 2002, I traveled to the town of Kurnool, in Andhra Pradesh, India to work as a volunteer at Kumar Nursing Home and as an intern under Dr. Radhakrishna Hari, a neurophysician and internist. The purpose of the following narrative is to share my experiences and views concerning the Indian healthcare system and to present the difficulties confronting medical practitioners and patients in India. My service work helped me to learn more about the intricacies of practicing medicine and about the personal characteristics necessary to become a successful physician. The J.W. Saxe Memorial Prize financially supported this public service project.
Overview of the Indian Healthcare System
India's healthcare system is comprised of both a public and private sector. The public sector consists mainly of government-run hospitals in urban areas and primary health centers (PHC) in rural areas, which provide an extensive range of services to the poor. Problems faced by the public sector, however, include shortages of medical drugs, and socioeconomic factors, location, and the quality of the services affect people's choices to use the public healthcare system.
The private sector is rapidly growing and is maintained by both highly proficient, trained professionals as well as untrained individuals. These private practitioners can share a culturally- and socially-based relationship with their patients. Patients bring their own medical records to each examination, and private practitioners may charge different fees depending on the financial status of the patient. In addition, poor people who may be unable to afford certain medication may rely on free samples distributed by pharmaceutical companies or their physician.
Strict laws regulate the sale of all medications but those sold over-the-counter. In many parts of the country, however, antibiotics and steroids can be purchased without a prescription. This situation allows the patient to treat him or herself, which can increase susceptibility to drug resistance.
I spent my mornings in India volunteering at Kumar Nursing Home, a small hospital that provides affordable, efficient healthcare services for underprivileged patients. As a volunteer, I had conversations with many patients about their medical histories, disorders, treatments, and lifestyles. My main duty was to educate illiterate people about basic healthcare concepts. The nurses also taught me how to administer injections, use medical technology, and dress simple wounds. Below are journal entries from a day spent at Kumar Nursing Home.
A Day at Kumar Nursing Home
~7:30 A.M.~
I see my favorite patient toddle into the nursing home wearing her usual purple skirt. She's a five-year old who is suffering from edema due to kidney troubles. Her eyes glimmer with curiosity as I prepare the equipment for the ultrasound examination of her abdomen. While Dr. Kumar performs the test, I skim through a manual about ultrasound procedures that is published by the World Health Organization.
As the doctor writes another antibiotic prescription for the girl, I ask her if she is feeling better. She proudly lifts her blouse to show me how much the swelling has decreased. I am about to leave the room when her grandmother stops me. "What should I do to keep her healthy?" she asks. I turn to the nurses for advice, but they only smile encouragingly. I begin to lecture her about well-balanced diets, when I notice how earnestly she is listening to me. I wish I have the authority and understanding of a doctor to more completely answer her questions, but I realize that my modest knowledge can also make a difference.
The family lives in a rural village without access to clean drinking water. I describe the invisible "bugs" in the water and try to persuade the elderly woman to boil it before giving it to the child. She makes excuses about "not having enough time to boil everything," and I know she does not have enough money for a water filter. When I warn that the girl may become ill again, though, she promises to boil the water for her. I silently congratulate myself on this little victory, but sigh as I contemplate the numerous villagers who could use better health educations.
~9:00 A.M. ~
A middle-aged woman is here for her endoscopy exam. I describe the procedure, emphasizing that she will not experience any pain as a long tube is inserted through her esophagus to observe her stomach. We are waiting for the doctor, when she begins speaking to me in Telugu. I have trouble understanding her particular dialect and a nurse nearby acts as an interpreter. The patient says she has come from a distant village and has sold her jewelry to pay for travel expenses.
Suddenly, her eyes well up with tears, and she whispers, "Do you think I may die?" I am confused about how to respond as she describes the symptoms of her disorder. She tells me her health began to deteriorate after the birth of her third child. "I should never have had any children," she moans. At this point, I am confident about what to say, and remind her of how much her daughters must mean to her. Then she asks about cancer. She has heard about it in her village and is almost convinced that she suffers from the disease. I correct her views on cancer and explain that in the rare case that she is suffering from it, cures are available and many patients have survived. She smiles weakly.
The exam is over and she is diagnosed with a gastric infection. As she leaves the clinic, she warmly grips my hand and thanks me. I know I will not forget her.
~1:00 P.M.~
We have been waiting in the operation theatre for half an hour, but the physician is still not here. I am considering taking an autorickshaw (Indian taxi) home for lunch and returning later, when I glimpse an assistant carrying the doctor's briefcase into the room.
The patient is moaning slightly even under the influence of anesthesia, and the stained and frayed linen sheet that covers him quivers slightly. The room, with its faded paint and large steel containers of sterilized equipment, seems inadequate for so delicate an operation. The power fails again, the comfort of air-conditioning is gone, and I feel slightly dizzy. My belief in the surgeon's ability to emerge successful in these conditions is faltering, when a comment by the anesthetist changes my perception. She says, "The patient places his entire faith in the doctor and the doctor puts all his confidence in his own abilities, the power of medicine, and God. What else can we do?" As I ponder her meaning, the inadequate operation equipment seems to disappear, and I only see the colorful, religious pictures that decorate the walls.
Certain aspects of the Indian healthcare system surprised me. For the most part, I found a high level of cleanliness at the nursing home and resourcefulness on part of the nurses. I observed that many modern medical technologies are readily available. For example, Dr. Hari, under whom I completed my internship during my evenings in India, has electroneuromyography (ENMG) and electromyography (EMG) equipment in his home clinic.
I believe public action is necessary to improve healthcare services in India. High levels of school enrollment at the primary level can ensure that people are well educated about leading a healthy lifestyle. An increase in female education can lead to an increase in child nutrition levels and a decrease in child mortality. Patients also need to be aware of the various healthcare services available and their rights to proper medical care.
I think India's healthcare problems are unique, because of the effects of socioeconomic status and culture on health. The wealthy and the impoverished live in very different conditions, and their lifestyles have a marked affect on their bodies. Some cases that demonstrate the impact of culture or religion on health involve orthodox diets or traditional lifestyles. India's healthcare system must be equipped to deal with patients of widely different cultural, economic, and social backgrounds.
Overall, I gained a greater understanding of the knowledge and personal characteristics necessary to become a successful physician and to improve public health services in developing countries through my experiences in India. I look forward to working as a public service volunteer in India after I graduate from medical school. The hospital environment increased my familiarity with medical techniques, technology, and terminology. I also learned how to communicate with people in the compassionate, yet instructive, tone of a doctor. Perhaps the most important skill I developed as a volunteer was the ability to listen. Sometimes, after listening to patients, I could offer a few words of advice and change cries to laughs and ease fear and pain. But on many occasions, I realized that by solely listening, I could perform the greatest service of all.
Himabindu is a third-year student majoring in bioengineering. She aspires to practice medicine, perform clinical research, and work as a healthcare volunteer in India.
