Everything I've Heard about Indian Health Care is True
on Margaret Campbell's Rambles (India), 23/Dec/2009 17:40, 34 days ago
Last night Jan's ankle started puffing and by this morning it was fully swollen, angry red and very painful. We assumed it was an infection, although I teased him that it looked like gout, so off to the hospital we went. Several months ago I had lined up a doctor so if anything like this happened we would know where to go and what to do. I was able to find his card, he answered his cell phone (can you imagine an American doctor doing that?) and agreed to see Jan at the hospital in one hour. We are lucky that we live just around the corner from the district medical center, as I described in my last post, so it was fairly easy for Jan to limp there. Surprisingly no one at the hospital speaks English. I would have expected the information desk to be fluent because there are so many languages in India that either Hindi or English serves as the universal language and this is the district hospital. But we made do with my"chota chota" Odia and everyone else's pidgin English and found the doctor's room where we massed with 20 or so others in a big room with few seats and a desk. Just after our arrival the young doctor arrived and was besieged by the crowd, each flapping pink and white papers for his attention. We were there for about 30 minutes and his pen never stopped moving except when he listened carefully to his stethoscope or asked his patients questions. Exams were made in five minutes or fewer, fully clothed, and in the full company of all in the room. No such thing as medical privacy here. Prescriptions were dashed out and exam notes entered in a ledger - one line for each patient. But in spite of the incredible speed with which our doc dispatched his duties he treated each person with gentle concern. RAPID gentle concern. Dr. Padhmi took one look at Jan's ankle, asked him about whether he'd had an injury (no), what medications he is taking and then wrote"gout" on the prescription pad, also requesting a blood test and writing out a prescription for antibiotics and an anti-inflammatory - elapsed time fewer than four minutes. Although he clearly seemed to think the problem was gout he also treated what might be an infection - the poly-pharmacy approach that our in-country doc advised us was likely to occur and warned us to counter with a dose of realism: do we really want to take drugs for everthing that might have caused our distress or just what makes the most sense? Up to us. That's when the fun started. Poor Jan was in a lot of pain so I hoofed it around the hospital looking for where tests were to be done. Oh, wait. We forgot that although our sponsoring agency provided handy first aid kits with sterile syringes among other supplies, exactly for this kind of situation, we had not thought to bring one, so before we mingled Jan's body fluids with who knows whose I went home to fetch a kit. Then we set out for first one room in the hospital and were redirected to another, which turned out to be the cashier. Huh? The cashier gives blood tests? No, the cashier helpfully tells us to FIRST go to the pathology lab to find out whether they have the chemicals for the test before we pay him for services. Smart. I found the pathology building and eventually found the right lab. It was kind of like a game of Marco Polo where I kept asking others whether I was warmer or colder to my destination without knowing exactly where I was going. Eventually I determined that they did not have the chemical needed for the test (Surprised? No.) so I went back to the cashier who did not think I owed anything for services rendered and then back to the doctor who looked at me a little bit like I was an idiot , but still with RAPID gentle concern, and told me to go to a private lab for the test. Well, duh. Labs are all over Koraput and I have often thought with equal parts horror and amusement about getting my blood drawn there. In fact, I took a picture of one I walk by on my way to work, posted below. See whether that's where you'd like to share your blood, urine, sputum and potentially have others share with you… Before we left for the lab, I went to the pharmacy near the hospital to get the medications because it's the best pharmacy in Koraput and they speak good English there. As usual, a crush of people surged forward, each thrusting a prescription paper into the windows; the guys with the longest arms winning. Sadly, I always get good service there because I am white and am accorded more respect than I am due, but in situations like this, with swine flu still hitting the front pages of India's newspapers and the hawking, spitting, coughing and largely unwashed crowd pressing in on all sides and dominating the airwaves, I was glad to get the attention of the pharmacists and get the heck out of there. There were four pharmacists on duty and a constant surge of maybe 30 people vying for their attention. Behind the windows prescriptions flapped, boxes toppled over each other, scissors flew, pens scribbled charges on boxes, money slid over the counter and cries of"Arrey!" accompanied slaps on completed orders. Like a pari-mutuel betting counter? Like the NY stock exchange? No. This was a scene of coordinated chaos unlike anything I've ever seen. Rather than filling orders in sequence, the pharmacists save time by constantly prioritizing those with meds near the front of the shop, or with needs that could be filled by already open boxes on the counter, while consolidating trips to the rear. There are no bottles, no instructions, no packaging. What you get is blister packs scissored to the correct number of pills slipped into a plastic bag with a quick shout of"twice a day with food" yelled into the din. Do I prefer this to standing in line seemingly forever at CVS? In a way.. Yes. Happily, there is always a fleet of auto-rickshaws at the hospital so we were able to purchase a ride to the market a mile distant and find a lab. As with any medical system, it's good to have money. Very efficiently, they sat Jan down and, with their own syringe which they were happy to show Jan came from a sterile package, got his gouty blood and told us to return in an hour for results. After an auto-rickshaw ride home to get Jan settled with his foot iced and elevated, I walked back to the market to get the results. The genial head honcho at the pathology lab tells me: gout, and charges me 50 Rs or $1 for the news. When I returned to the hospital for advice on comfort measures, treatment options and preventive measures the doctor and all forms of life had disappeared from the hospital offices so I gave up for the day, put up my own feet up for a rest which were aching from standing and walking most of the day, and gave Jan ice and anti-inflammatories. We looked gout up on the web and it's more of a lifestyle changing thing than anything that he has to do overnight so no worries. As I said in the title of this post, everything I have read about Indian health care is true. Care is guaranteed by the government but the medical facilities are distant from rural villages and don't have supplies so patients who do reach a care center have to buy them, or do without. Treatment is poly-pharmacological because doctors aren't sure what's going on and tests are unreliable so they treat every possible cause, at least for those who can afford to pay for medication. Tests, by those who can afford them, are almost always done by private labs because the government facilities don't have the materials. Medicines are not covered, and they are not cheap (265 Rs in today's case, which is more than Jan would be receiving as a monthly old age pension of Rs 200 if he were an Indian citizen of 64). The honest doctors are skilled and caring and face a tidal wave of suffering and disease daily, as I have seen myself this morning. If you believe what I read, the dishonest doctors do not show up for duty at the hospitals but rather hold office hours at their private clinics during"work hours" for a fee, while double dipping their government salaries. In facing this onslaught, the care afforded India's citizens is probably the most efficient I could imagine. When I returned to the doctor halfway through the day to ask about how to get the gout test, he answered my question over the heads of a dozen supplicants, his pen still flying. By then another physician had joined him on the other side of the desk and her pen was flying too. He may have seen a hundred patients in half a day, and his colleague many more. Can such a care system be effective in addition to being efficient? Probably not. Although nine out of ten cases are exactly what they seem, perhaps one out of ten will not get the right treatment because it's not obvious what's going on, and even among those correctly diagnosed, many will not be able to afford the treatment prescribed. It's certainly not a system that effectively serves the poor who speak tribal languages but not Odia, Hindi or English, or can't afford transportation to medical centers, nor tests nor medicines. But with 1.2 billion potential patients, few facilities in rural areas, and a sadly small percentage of doctors who show up for work, it's an impressive show of force. Bottom line: don't get sick in India, but if you do, have plenty of money to make the best of it. If you get sick in the US go see my doctor, Cindy La Mar, in Palo Alto, California, and please tell her I sent you. She will spend an hour or three with you to make sure you get the care you need but it won't be cheap. If you have insurance you'll survive the visit financially but if you don't you'd better consider getting a job with benefits. If you have better health care options in your country please tell my president and congress what to do. They need all the help they can get to provide meaningful change.