Perspective changes with time and experience. My first time in India, I was twenty years old- a second year college student on the pre-med track—visiting Calcutta, working in the hospice that Mother Teresa started, volunteering at orphanages, learning about Hinduism and world religions-- all in hopes of expanding my world views and learning to care for the underserved. It is that international experience that affirmed my decision to enter into medicine and shaped my desire to care for those in need as a physician. Fast forward 8 years later—I am now a second year family medicine resident in India’s dense metropolitan capital city, Delhi, for a medical elective learning about public health, obstetrics, and internal medicine.
The difference I note in myself is more surprising than uncomfortable, because when I was twenty, I had quite the romanticized view of India, and travel in general, even after I returned to the United States. Witnessing that kind of poverty first-hand was quite formative and left me with a sense of responsibility to the international community. Now as a practicing resident-physician, I feel my perspective has matured -as I see the same needs and struggles more clearly here in the U.S. While my attachment to the international community remains strong, it is compassion towards humanity that allows me to return back to my work gladly, knowing I have a responsibility to care for my patients here at home as well as abroad.
Regardless of country or culture, we as a society and as a medical community face the same task and challenge: to care for the marginalized, high-risk populations, amid socio-economic injustices and imbalances, pathologic diseases, cultural paradigms, and so forth. India’s challenge of providing the highest quality care by western standards, arises in the setting of being a newly independent country, with longstanding culture and traditional ways of living, impacted by a dense population with limited resources and infrastructure.
It led me to reflect on barriers to health-care. Perhaps the most obvious barrier for me in providing care in India was understanding language and cultural contexts. I spent a week sitting in with an obstetrician, Dr. Sharma at Aakash hospital, picking-up medical terminology for outpatient obstetrics. As for health-care-access and screening for women in India, much of the barriers lie within cultural paradigms. From what I observed, the family unit in India is very strong; most women are accompanied by a husband and father-in-law, or some male authoritative figure who makes many of the medical decisions. Childbearing is highly encouraged and expected, but to be pregnant out of wed-lock is not socially acceptable. So much so, that most if not all unwed mothers will have abortions (or so I was told). Additionally, sexually-transmitted infections though common, are not openly spoken about or screened for due to social stigma. Though admittedly, this reflection may be an oversimplification of the complex topic of women's health and rights based on one snapshot in time. Despite the cultural challenges in mind, there are many physicians there who are working towards overcoming these barriers to women's health by increasing public education on reproductive health and improving health-care access.
I spent the following week afterwards in Chandigarh, north of Delhi, with public health workers and physicians who are actively working towards decreasing neonatal mortality by encouraging institutionalized hospital births over traditional home births. In fact, the Indian government incentivizes births by paying families a lump sum to deliver in the hospital, making the financial barrier easier to overcome. That being said, patients still have cultural reasons for delivering at home even if distance and financial hurdles are negated.
The public health workers in Chandigarh also focused on providing counseling and STD testing to female sex-workers. The sex-working industry, though illegal and stigmatized, is still very present in India. I entered the homes of women in the slums who were involved in sex-work and had a Q&A time to understand the barriers to health-care. All of those we spoke to entered sex-work for financial reasons: some had husbands who were deceased, and those husbands who were alive struggled to make ends meet financially and suffered from alcoholism. Many of these women were also victims of domestic violence. An average sexual encounter costs Rs 300-Rs1000 an act (that’s about $5-$15). And while not an easy lifestyle, the money was easy to make in comparison to working for longer hours for the same pay. Faced with the reality that the sex-work industry is difficult to leave due to financial constraints, the public health program focused their efforts on making the industry as safe as possible by providing health education, medications, free condoms, STD testing, and other medical resources. Overall they have been very successful at their interventions, and all the women we spoke to endorse using protection for intercourse consistently (a significant feat for a culture that is discrete about even the purchase of condoms!).
My final week I worked in internal medicine at Apollo hospital. The barrier of limited resources for those in poverty, evidenced by poor water sanitation and the slums, extended even into the hospitals. How precious a commodity a unit of packed-red blood cells is! In Delhi, the blood supply is limited and the patient receiving blood must find someone from his family or friends to donate the same amount he received in return. Organ donation is hampered in part by religious and cultural views on the sacredness of the body. Physicians I worked with are currently working at the grass-roots level to raise awareness and debunk myths of organ donation.
I came away from my time in India grateful for the experience and humbled again at the ample resources available to those in the United States. These barriers to medical care in India impress upon me the importance of patient education incumbent upon the physician in order to improve health-care outcomes. Of course, in order to enact societal change, it is paramount to maintain respect for any culture you work in and cultivate an understanding of societal and systemic barriers.
Going forward, I remain eager to continue medical work abroad, now with a stronger social construct that will aid in caring for people within my own country and around the world. It is with this I conclude my reflections, until my next international elective….
Thank you the faculty and staff at VCMC, FMed, CFHI and to all who supported this endeavor!