The Doctor Will See You Now

As part of our observation of community health practices in India, Cody, Rachel, and I have spent a few days this week at the PHC, or Primary Health Center, that serves the village of houses that we've been visiting in the Hirebettu area outside Manipal. Like our primary care offices in the States, the PHC is the first line of defense against acute and chronic diseases in a local population. Unlike our offices in the States, there is often only one doctor in this setting who serves a patient population of thousands. The entire PHC is staffed by just a handful of full-time workers: one physician, one pharmacist, one receptionist, and four Female Health Workers. There are no nurses on staff in these centers.

Our ride to the PHC: College Bus's sidekick - College Van!

Retention of medical personnel is a huge problem in the Indian health care system, as doctors and nurses will often train here and then move abroad after graduation to work in high-paying countries like England, Australia, and the United Arab Emirates, causing a massive shortage of providers and especially primary care clinicians. When we've talked to students and professors here about the problem, the majority of them denied that it was an issue that needed fixing - "we are proud to send our students abroad after graduation," one nursing instructor said. "It is a mark of success in their training." In the States, our shortage of PCPs has prompted an expanded scope of practice for nurse practitioners and physician assistants, but those roles don't exist in the Indian health care system, and the nurses we've talked to here almost unanimously agree that the very hierarchical, physician-centered model here would not permit the advent of mid-level clinicians in the forseeable future.

The PHC

Front desk/patient lobby at the PHC. At right, the pharmacy window.

One of the most interesting differences between the PHC and our primary care offices back home was the pharmacy. The photo below shows the small, one-room office from which the sole pharmacist for this clinic operates. The meds, displayed in the window, are generics for common primary care problems (omeprazole for acid reflux, NSAIDs for pain, various antibiotics for bacterial infections, amlodipine for hypertension, metformin for Type II diabetes) and other drugs for problems common in the region (pills for malaria, tuberculosis, anemia, and leprosy, for example). Meds in the U.S. are carefully stored and locked to prevent theft by patients, clinicians, and others who may abuse or resell them - here, we have been informed, this is not prevalent.

The pharmacist told us he had been working at the PHC for 13 years

Pharmacist dispensing meds to a patient

Pharmacist distributing pills and tracking inventory

While we were waiting for the doctor to arrive so we could chat with her, we hung out in this room with a Female Health Worker. Historically, in rural India and more globally, untrained community members (usually women) have been the ones to provide midwifery and nursing services to pregnant women and the sick or wounded. In India, an initiative to train these people in home deliveries, basic sanitation and hygiene, administration of immunizations, and health teaching has allowed them to become extensions of the health care system. We talked to a FHW who had been working at the PHC for about two years, but had been delivering babies in the community for two decades.

This close-up of the black "Tracking Bag," into which the staff places reminders about when various children in the community are due for upcoming shots, was a little... disquieting.

At least "DIED" is empty?

In this room, lab tests are performed to test for a variety of acute and chronic conditions, including standard blood tests like hemoglobin, and local concerns like malaria and filaria (an infection that, you may recall, resulted in the enormous scrotal specimen from the anatomy museum). Water samples from local wells can also be tested here for contaminants, and if necessary, chlorine will be added to purify the supply.

Here's an exam room where prenatal care takes place. Pregnant women have to get registered at the PHC and then attend three prenatal visits before delivering the baby at a hospital or other birthing center. Prenatal care includes a tetanus vaccine, free iron and folic acid supplements, and family planning counseling. The most popular birth control methods in this area are the copper IUD (although the increased bleeding that is sometimes associated with this method can prove problematic for women who are already at risk for anemia due to iron-deficient diets), surgical sterilization (for women - vasectomies here are rare), and less commonly, condoms and birth control pills.

The wound care room:

While we were visiting we saw a patient who had been bitten by a wild dog receive a rabies shot in this room

The wound care room also contained this -

#reassuring

Other frightening items inside the clinic included these color-coded bins:

In a fit of courage I peeked inside the yellow bin. It was mercifully empty.

Next to the PHC there is also an anganwadi. Anganwadis, part of a government initiative begun in India in the 1970s to combat childhood hunger and malnutrition, are found in rural areas. They are small, two-room structures staffed by one teacher and one assistant, who supervise 30+ children between the ages of 3 and 6. In addition to functioning like a preschool (the children play together, do daily song and dance routines, practice their ABCs, and learn to recite basic information like the name of the town and district they live in), the anganwadi also provides breakfast and lunch. The teacher continually assesses each child for malnutrition by charting their height and weight against a growth chart, and if a child falls off the curve, they are given additional food at these meal times. A mere 6 rupees per child per day, or about 10 cents, pays for two meals.

The Hirebettu anganwadi

The kids with their teacher

 While we were hanging out with the kids I made the mistake of showing them the selfie feature on my phone.

They LOVED selfies

This is the most popular I will ever be in this life

The kids at the anganwadi were incredibly well-behaved when the teacher told them to sit quietly - much more attentive than the kids in any American preschool I've visited. Their rapt obedience may have been due in part to the fact that the teacher whacked a few misbehaving children with a ruler in the time we were there. We asked the children what they wanted to be when they grew up and every one of them said "an anganwadi teacher!!!". We learned that the typical salary for teachers is 2,000 rupees per month - about $30.

"Does anybody want to be a nurse?" we prompted with a smile.
"No!!!" the children yelled gleefully.

Despite appearances to the contrary, this is a not a child jail

"Namaste!!" the children screamed through the window as we slipped into our flip-flops and departed the anganwadi. Namaste, usually said with a slight bow and the hands tented together like in prayer, is a versatile salutation that can be used as a greeting and a goodbye. In Hinduism, however, the literal translation of namaste means "I bow to the divine in you."

"Namaste!" we replied, waving to the passel of children and their smiling teachers before turning back to walk the dirt path past the PHC to the lot where College Van would come to take us back to Manipal. Visiting the villages  has been our favorite part of this trip so far, for those of us who have been able to go. The hospital care here is at best a little depressing and at worst downright horrifying, but the efforts of the PHC and home health visits give off a more hopeful impression.  Life here is not easy for many people, and health care at all levels suffers from understaffing, inadequate resources, and lack of technology, but the sense of commitment to the needs of patients and their families is strong. I thought about the lone doctor at the PHC, working 6 days a week with no backup - with no other trained diagnostic professionals on-site, in fact, no one to bounce ideas off of or consult for a second opinion or laugh about the dozens of things we laugh about every day back home as we bumble through the daily adventure of medicine - and felt overwhelmed at the mere thought of so much responsibility. Nothing in my clinical observations in India bears much resemblance to the clinical rotations I've had in the U.S., but the same spirit of community, of people helping their neighbors and working hard to get them the care they need, is obvious. There is much to bow to, here.