Written by Somalee Banerjee, MD PGY 2 at Kasier Permanente Oakland Internal Medicine Residency Program on global health rotation with SEWA Rural in Jhagadia, India.
The first day
The roads were incredibly smooth on the drive. They did get a bit rocky on the 10km turn into the town. But on the way in, it had the same hustle and bustle that sprang out of the dust that Uluberia had. Uluberia is the town that my father is from in Eastern India and where I spent my summers growing up. For all of its variety, India has surprisingly similarities. People watch the same hindi soap operas even though they don’t speak hindi. The streets have the same bustles and the same cows. We were shown to our rooms in an apartment building within the hospital complex, and then we went to lunch our hosts. One of them son of the two of the four founding doctors of the hospital complex SEWA rural. Lunch and dinner are at a cafeteria which consists of self serve buckets of rice, dal, a vegetable of some sort and some roti. We talked about a trial of a phone based community health worker system that he had developed here. Then we talked about sickle cell anemia and the evidence in India – whether similar treatments here were necessary because the haplotype usually comes with a more benign clinical course. All of this while dal was drying on our hands after we had licked them clean with the afternoon sun pouring in the through the windows. The simplicity and directness of the conversation was refreshing, yet it had the same give and take of any professional conversation. We spent the afternoon going through the hospital followed by a lit review on our computers in the office.
Every few hours we would hear the local mosque call to prayer. In the evening, it coincided with the temple’s bells ringing.
Hospital and OPD
The clinic set up here is similar to the clinics I have seen at public hospitals in Kolkata. Patients arrive throughout the day, wait outside, file in a few at a time, crowd around a table with a few doctors and move on after a few minutes. Its an assembly line of patients built specifically to improve the efficiency of the physician. Efficiency trumps privacy and the patients seem to be ok with the system. There are few niceties and the counseling is more so telling of do’s and dont’s and doesn’t involve explaining pathophysiology. The encounter is written in 2 sentences on a small piece of paper that the patient keeps themselves and the result is a medication of some sort written at the end of the paper along with a prescription. Then how many pills of what, how many times a day is explained with loud clarity – but no explanation of why it is prescribed. In america, we mostly assume that a pharmacist will explain the medications to a patient, we are supposed to counsel more about lifestyle practices or warning signs.
In the general medicine clinic, patients came in with a variety of complaints from sore throat to diabetes or HTN follow up. All appointments are urgent care appointments and their is not real continuity of care except flipping back through the papers that the patient has brought to see if they were seen recently. Diabetes management consists of random blood sugars done at the clinic. Patients on insulin do not have a glucometer at home to do regular blood sugar checks and thus most patients ran high – 200s, 300s. One patient was there with blood sugar readings of 400s – they inquired about abdominal pain, and the answer was no… no worry about DKA. They measured urine glucose instead of HgbA1C as a point of care test to follow glucose control. The head physician who had retired from private practice insists that he does not see the merit in a HgbA1C.
On the inpatient side, patients were in mixed wards with one bed after another, but there was more than adequate space in the wards for the number of patients. This hospital is a 100 bed hospital in total. People who were admitted were of a variety of ages on the adult wards from teenagers to the elderly who did not know how old they were. Chief complaint ranged from shortness of breath to fevers. Everyone seemed to get a CBC and creatinine checked.
Rounds are mostly an attending, a medical officer and 2 residents going around seeing patients. Here the resident didn’t do much of a presentation and the attending was supposed to remember the old patients. Attending then told the resident of his plan and she noted it down for the nurse. When the resident point out some physical findings, there was some limited discussion about it.
Sickle cell clinic is on saturdays and it is staffed by an all knowing nurse assistant and a homeopathic doctor who is interested in public health. Children and adults all come to the clinic every 3 months to have Hgb check, fetal and sickle hgb levels checked. Some are on hydroxyurea and their visits are once a month to assess for significant cytopenias. We were there to assess the flow of the clinic and see if implementation was as planned. 225 patients with sickle cell disease were enrolled in the program over the last year since its inception. There was variable follow up of course and 5 died over the course of the year. Screening of sickle cell disease was expanded to all newborns to mothers having sickle trait or disease. And now we were following them here. A 7 month old came with his mother who was diagnosed at birth – more like at 4 months because the newborn sickle cell test is a send out to another blood testing place in gujarat. He seemed to be doing well with no complications. The indian haplotype for sickle cell disease is very diversely variant – some patients have mild complications while others have severe disease. India is one of the 3 countries in the world that can claim 50% of the sickle cell disease of the world – it is very widespread in the tribal/indigenous populations, who have the poorest access to healthcare.
I have heard so much about a randomized cluster trial that they are starting over the next year at 10 villages around jhagadia to test the ability of a phone program to decrease maternal and fetal mortality. ASHA workers are part time employees – usually 2-3 hours per day, usually women because women giving health advice about babies or vaccinations is more culturally palatable. They are usually not college educated, but have some high school training. The system is present through the Indian government across the country, but their responsibilities greatly differ. In West Bengal, I have a second cousin who is an ASHA worker and her primary responsibility is polio vaccination because that is what the health department there is aiming for. Here the health organization contracted with the government to make these ASHA workers into maternal and fetal health specialists. They are provided a basic smart phone with the phone app on it which basically consists of a daily agenda of people to visit, questions specific to their needs and tells the ASHA worker how to respond. They had set me up with a Hindi speaking asha worker, Sarita, because I don’t speak gujarati to go about for the day. She studied till 10th grade and afterwards had done some training to be a Montessori school teacher before she got married. Now she had two teenage boys, lived in the next village and was the ASHA worker in charge of a few neighborhoods near the main street. She took me to her visit to a 10 day old baby. There were monthly antenatal visits and after the baby was born, the baby had a 3 day, 10 day, 14 day then monthly visits for the first year, and this applies to every single baby born in the area. It is concierge medicine like I have never seen.
We went up to the first house, a plastered, painted comparatively well to do home. The front elongated room had 6 elderly people some with black glasses on (cataract surgeries galore?) lounging about on various surfaces. We kept our shoes outside and Sarita walked right through to the back house with me following. In the kitchen, there were 3 women busy with kitchen tasks and we followed them through a maze of rooms to the back room where the new mother and baby were. It was a simple house with peeling walls, few pieces of furniture. The mother was getting a full body massage with coconut oil from the neighborhood massage woman and another sister (sister in law?) was changing the baby. After ascertaining that I was also a woman, we both walked in. Sarita brought out her smart phone and animatedly started showing me through it all while the new mother chattered animatedly about the baby completely naked aside from some panties. He was eating well, no real issues, sleeping mostly. sarita noted these in the multiple choice questions that came up on her phone one after the other. Then the app asked her to weigh the baby, enter a temperature and answer yes or no to questions about skin problems (complete with photos), distended abdomen (again complete with photo). She weighed the baby in a cloth and pull weight and used a digital thermometer to measure his temperature while the baby continued to scream bloody murder for being disturbed. The baby’s aunt was shown a video with counseling about what to expect, how to clean the baby. The massage was now done and the new mother put her clothes on. The mother then demonstrated her breastfeeding technique which Sarita chose from a multiple choice question with cartoon images of latching techniques. The last query is a photo of the baby, which they both posed for then the app reviewed if all the questions were answered. She then pressed a button to sync the information to the central server. Unfortunately, the 3G was down that day because of some hindu/muslim crashes in a nearby village, but it would be stored in her phone in the meantime. Sarita then jot down the masseuse’s phone number because she has another patient who had “arm paralysis” 2 weeks ago and she thought would benefit form an arm massage.
She accomplished an enormous amount in about 20 minutes with a lot of building trust and connections while seeing how they function daily in their own home. The home environment is crucial in the infant life and her assessment of it made her visit complete. We went to a few more home that ranged down to mud huts with all of them being educated and having a full visit through this app. In one home, a 2 year old was having a runny nose so the app had her check his respiratory rate, work of breathing and instructed her to come back in 2 days to check up on this child. If there was a fever or any other worrying signs, she would have been instructed to tell the parent to take the child to the clinic or hospital.