From New York to New Delhi by Joshua Schulman Marcus
Joshua Schulman-Marcus, a 4th year medical student at Mount Sinai School of Medicine, New York tells us about his week in New Delhi, India, working at All India Institute of Medial Sciences’ (AIIMS) emergency ward and the Centre for Chronic Disease Control-Rhona
First day
Even as I had psychologically prepared myself before arriving in New Delhi, I could not help but be astounded by the crowds of sick people. Overflowing hallways, packed beds and stretchers, benches upon benches of patients waiting for a five minute outpatient consultation, staff in masks writing away. The crowds of voices echoed loudly across the decaying walls in All India Institute of Medial Sciences’s (AIIMS) emergency ward.
One would expect differences between the largest public hospital in India and the New York hospital in which I trained. The latter hospital does have long waits and a relatively chaotic emergency room, but it also affords the best of developed world care to the city’s immigrant population. Rather, I expected AIIMS would be similar to the public tertiary center I visited in Honduras while working on a surgical brigade last June. In that hospital’s emergency wards, what I immediately noticed was the relative silence. There were no bedside monitors clanging away, and the patients largely suffered in silence.
I walked by and could not speak a word, knowing that my presence today will provide neither solace nor a voice. The best I can offer is to be a witness. But while that is a good starting point, it is hardly enough.
After a week
The past week has afforded me the privilege of meeting with some of the leading researchers of chronic disease in India. I have spent most of my days working at the Centre for Chronic Disease Control (CCDC) in New Delhi, a local research institute. The remainder of the time I have observed clinical care at the nearby All India Institute of Medical Sciences (AIIMS), which is a massive and prestigious government hospital. The experience has been invaluable for both my personal research on heart disease in India and my education about noncommunicable diseases in a developing country.
Even though India has 1.1 billion people, many of whom are now being afflicted by cardiovascular diseases or diabetes, until recently their national epidemiology was quite unknown. Most published research had been derived from a single (generally urban) center studies and involved very small sample sizes. Epidemiological estimates have thus largely been based on regional models of disease burden, which do not permit a nuanced understanding. The CCDC and collaborators have been working to remedy this situation, undertaking rigorous national studies on nutrition, disease risk factors, and outcomes. Most of the studies are still in progress and cannot yet be commented on, though my discussions with staff here about preliminary findings were quite revealing. It is clear that chronic non-communicable diseases are imposing a substantial and growing burden across the Indian population, not just in its wealthier ranks. Sadly, it is also clear that effective prevention and treatment face enormous challenges in all regards, from the nature of doctor-patient relationships to the perception of smoking (a high percentage of educated Indian youth smoke).
My observations at AIIMS were both helpful as well as deeply moving. The hospital daily provides care to thousands of poor Indians from throughout the country, and as such is almost oppressively crowded. In the busy emergency ward, I saw two patients with acute myocardial infarction. Neither had arrived by ambulance, reflecting the relative deficiency of emergency medical services in India. Their comparatively young age was also not surprising, as major studies have shown an earlier onset of cardiac disease in Indians.
However, my observations on the inpatient cardiology service were a sobering glance at the other side of the “epidemiological transition.” I examined several young men from Bihar state, all with profound rheumatic heart disease. These men, all in their 30’s, were suffering severe heart failure symptoms owing to multi-valve involvement. The existence of this preventable disease is itself a symptom of the continuing extreme poverty in much of rural India. It’s a poverty that continuously echoes in the harsh murmurs of these mens’ hearts. Joshua Schulman-Marcus, New Delhi, India
jschumar@gmail.com