Medical and Surgical Placement at a Mission Hospital in Bihar, India
James Peerless went on elective from August to October 2007 and describes his experiences here
From the beginning I wanted an elective experience that would challenge me and be unforgettable. I wanted to experience a culture completely different from that of the UK, and to see parts of a country that a guidebook couldn’t describe. All those boxes had been ticked within just a few hours of arriving at Duncan Hospital in Raxaul.
It was by chance that I had arranged my medical elective to a Christian mission hospital in the Indian state of Bihar, just as it made world headlines as one of the areas worst affected by this year’s flooding in southeast Asia. However, it gave me the unique opportunity to experience first-hand both the direct and indirect effects that this natural disaster had on an already deprived area of India and its people, and how the hospital responded to the situation.
The Floods
The floods caused havoc in rural communities. Heavy rains and rising water levels ruined crops and housing. People moved to the limited areas of higher ground, and were soon followed by snakes. The fear of snake bites meant that people defecated close to their homes, contaminating water supplies. In my first few weeks, the main presentations to the hospital were cases of severe gastroenteritis, including some isolated cases of cholera, and viral encephalitis in malnourished children. Patients brought in with snake bites often arrived too late for the toxins to be reversed. The snake venom in North India is mostly neurotoxic and causes breathing difficulties after twelve hours. The six-bedded intensive care unit (ICU) at the hospital was worse equipped than a general ward in the UK and the absence of ventilators meant that relatives had to bag the patient continuously. As such, the survival rate was close to zero.
As the water levels subsided, I was able to visit some villages with the community project teams. We set up mobile medical clinics in areas worst affected by the floods and where people could not reach the hospital. Due to staff shortages one day, I ran a clinic myself, and with the help of student nurses who translated for me and dispensed the medications, we saw 167 patients. It was a real challenge and a daunting task as I had no seniors to consult, but together we saw everyone who attended.
Clinical work
My days in the hospital started at 8 o’clock with a ward round on the ICU - all the doctors attended to discuss the patients together - which was very useful, and illustrated a real sense of unity between the different departments. This was followed by separate departmental ward rounds. Following this, the doctors spent the remainder of the day in outpatient clinics, from which they would be regularly called out to the ER, or to carry out emergency Caesarian sections.
For the first month, it was oppressively hot, and the monsoon rains flooded the hospital on a regular basis. It was a rather surreal experience wading through hospital corridors with fish accompanying us to ward rounds!
The isolated location of the hospital meant that it had to take on a very general role in its provision of care. I spent a week in each of obstetrics & gynaecology, paediatrics, ophthalmology and community medicine, and two weeks in both medicine and surgery. I was welcomed as a member of the hospital team and had the opportunity to perform many clinical and surgical skills, including delivering babies.
In addition to the normal running of the hospital during the flooding, the community team set up the distribution of relief packages to those villages worst affected by the floods. Our evenings were occupied by making up the bags - with rice, dhal, flour, salt, soap, candles and matches - enough to supply a family for a week. During my eight weeks, 11000 packages were distributed to the villages by boat and jeep - a staggering number. As I came to leave, the focus changed to providing nutritional packs to pregnant women, children and the elderly. As all the crops had been ruined by the flood water, the initial emergency packages helped to keep families alive, but there was a real fear that malnutrition would manifest itself over the forthcoming months after the water had disappeared.
The hospital and the community
The Duncan Hospital was established in 1930, and is now part of the Emmanuel Hospital Association - a “fellowship of institutions and individuals that exists to transform communities through caring, with primary focus on the poor and marginalized.” (1). It was established by a Scottish doctor who realised the need for provision of healthcare to the local people and across the border in neighbouring Nepal. Patients pay small amounts for treatment and time in hospital, but if a family cannot afford treatment then they are never turned away.
At present, Duncan Hospital in Raxaul, a town lying on the border with Nepal, has 200 beds and 20 doctors, and provides secondary healthcare services to potentially 11 million people in the rural areas North Bihar and southern Nepal. (2)
Although Bihar has a plentiful supply of natural resources and boasts a rich history (Prince Siddharta Gautama received enlightenment there and later became the Buddha), corruption and crime is endemic, and extreme poverty combined with poor education makes this the most backward state in India. The majority of people were poorly educated, lived in hand-built accommodation and lived by farming the land. To get medical attention, they may have had to travel large distances by foot; and due to financial concerns about treatment, patients presented with their symptoms late and were often very ill. The resources of the hospital were very limited, but the poor education, the distance and beliefs of the local people compounded the problem. People would consult witchdoctors for advice before seeking medical advice, and so presented to the hospital with their disease too far advanced for help. This gave the hospital a bad reputation as many patients arrived and died on the wards, leading other people to believe that the hospital could not help them - seen only as a place that took their money and killed them.
Whilst I was there, I found life much simpler. Showers were cold (a blessing in the hot weather!); I ate with my fingers and had to wash my clothes in a bucket. Power cuts occurred continually throughout the day at least twice an hour (but luckily the hospital had its own generator which took over after about a minute).
Conclusion and reflection
The days out working in the villages were an unbelievable experience - I got a real feel for the difficulties the locals experienced on a day-to-day basis, and my confidence in dealing with clinical situations and communication skills increased.
It was a real privilege to work with these doctors in a place so incredibly different from the United Kingdom; they welcomed me into the hospital and made me part of the team.
My aims of the elective were to experience medical practice in a totally different setting, and I couldn’t have asked for a more fulfilling experience, with or without the floods!
James Peerless
Final Year Medical Student
University of Leeds
james.peerless@hotmail.com
For further information see:
http://www.eha-health.org/aboutus.html
http://www.eha-health.org/hospitals_duncan.html