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This Week in The Lancet

  • Volume 377 1719 (2011)
  • May 21, 2011

Common things occur commonly. Except when you’re in India.

Many students plan their elective based on the 4 S’s: sun, sea, sand and sick people. However, it has always struck me that this period would be a great opportunity to explore areas of medicine to which we have little or no exposure during our medical training. Having studied at the University Hospital of North Staffordshire, there was one area that I was keen to expand my knowledge of – something I was unlikely ever to see firsthand in the Midlands – tropical disease.

I had accumulated reasonable experience in the field of infectious diseases through various placements, student selected components, conferences and also a research module in which I worked with malarial parasites. Throughout these experiences, the medical student mantra ‘Common things occur commonly’ has always held out, and I have more routinely seen evidence of complicated pneumonias, HIV and MRSA than Malaria, dengue and typhoid. I decided to make rarer infectious diseases the objective of my elective planning hoping to be able to work with cases I had only read about in text books. If I happened to find the other 3 S’s along the way, so be it!

A few days later my university was visited by ‘Work the World’, a company which organises electives in Africa, Asia and South America. I discussed my situation with Abby, the project co-ordinator and she told me about the options available through their company. I was immediately taken with the description of India, a place I had not thought about before because of friends who had battled against mountains of red tape to get the correct visas and the right kind of placement. However, ‘Work the World’ are well established and their agreement with the Kerala state government allows their students access to a range of hospitals and clinics. Most importantly for me, they could arrange a placement at a state-run hospital in Trivandrum that included 4 weeks of adult and 4 weeks of paediatric tropical disease. On top of this, accommodation, food and transfers from the airport were all included, and there is local staff on hand 24-7 that could support me if things didn’t go to plan. I didn’t need much convincing to sign up!

When I arrived in Trivandrum, I had 24 hours to settle in to the accommodation, orientate myself within the city and recover from jet-lag before I started work at the General Hospital, one of the few state funded hospitals in Kerala that treat people below the poverty line (the equivalent of 300 rupees/ £4.30 per month). The catchment area included not only the people dwelling in the city, but also the surrounding rural areas. It was filled beyond capacity at all times and outpatient clinics (consisting of 2 doctors) could see in excess of 400 patients in a day. When the wards did not have enough beds to accommodate all of the inpatients, people would just sleep on the floor. It was very clear that this hospital, while commendable for offering some kind of service to the poorest people in the community, was severely underfunded and under resourced.

My first day on the adult ward for infectious and tropical diseases and I was confronted by roughly 40 patients suffering from a range of diseases including Dengue, Malaria, Typhoid, Leptospirosis and TB. This was something I had wanted, but faced with such a desperate state of healthcare economics every day on the ward rounds was hard to accept. There were no side rooms or areas where infectious patients could be kept in isolation from the others, and despite hundreds of mosquitoes in the wards, the only method to prevent the spread of malaria from one infected patient to another, was the provision of mosquito nets. Although this makes sense on one level, closer inspection showed these nets were old and riddled with holes and many patients, not understanding their condition, simply removed them when they became too hot. TB patients fared no better, taking on another battle when it came to a lack of medication. Although a number of drugs were paid for by the government, the rest had to be funded by the patient. Needless to say, none of those living below the poverty line were able to afford any of these additional drugs, so all patients on the ward, regardless of their disease, were prescribed the same cocktail of crystalline penicillin, cefotaxime, ranitidine and B complex vitamins. When I asked one of the doctors if they were concerned about spreading antibiotic resistance by using the same antibiotics for every patient they simply asked, “What’s the alternative?”

Male Infectious Ward

Male Infectious Ward

Now I should probably point out that I am not so stupid as to believe that the hospitals in India would be similar to those we have in the UK. I knew I was going to a state hospital, and I had conjured up what I thought was an appropriate expectation – I wasn’t shocked that the floors were bare concrete, or that food was being cooked next to the patients’ beds. I wasn’t even that surprised that the sluice ran in a trough down the middle of the ward so that you had to jump over it to get in and out. That being said, I had not prepared myself for actually witnessing people dying as a direct result of a poorly funded healthcare system. A memory that will always stay with me is that of a 13 year old girl who was brought into the paediatric outpatient’s clinic unconscious and in a dehydrated state. Her parents reported that she had suffered 6 days of diarrhoea, and had lost consciousness during the previous night. She was admitted to the paediatric intensive care unit (PICU) and started on multiple saline infusions and a dopamine infusion in order to bring up her blood pressure (which had not been recordable on admission). On taking a detailed history from her parents, it was discovered that the episode of diarrhoea had started after she had eaten an ice-cream which they didn’t believe was made with clean water. It was decided that the girl was probably suffering from acute infective diarrhoea (AID) and was started on IV Cefotaxime. After 12 hours the girl’s hydration status had returned to normal but she had not regained consciousness. There was doubt about the causative organism of the condition, but the parents could not afford to pay for any further investigations such as a CT scan, stool or blood cultures, and these tests were not provided by the state funding. Unfortunately, the girl died after 28 hours in hospital. Post mortem revealed that she had been suffering from Shigella Encephalitis.

General HospitalGeneral Hospital, Trivandrum

Rural patients arriving at the hospital when it was too late, or when expensive treatments were the only possibility remaining, was a common problem throughout my time in Kerala. It made me realise a lack of resource by the hospital and a shortage of funds from the patient’s family were not the only problems. The healthcare system in India is hugely affected by the level of public education and although Kerala boasts nearly 100% literacy because the state provides compulsory primary education, levels of health education vary widely between the urban and rural areas. In the urbanised areas, there is a high level of awareness about common infections, what symptoms they present with and when an illness is at the stage where it requires medical intervention. This is not the same in the rural areas, where there is little knowledge of different infections, and often Ayurvedic Medicine (Indian traditional herbal medicine) is used in preference to western medicine.

Ironically, it is in the rural areas where many of the infectious agents are more prevalent, for example leptospirosis, which is spread easily amongst the workers in the rice paddy fields. There is also an ongoing problem with rabies. Over recent years there has been a change in government attitude towards the treatment of stray dogs in India and whereas before they would be culled frequently to prevent the spread of disease, the government has decided that dogs should not be killed due to widespread religious beliefs. This has unsurprisingly resulted in a rise in the incidence of rabies, which has, in turn, necessitated the provision of public health education about what to do if bitten. Whilst this information is widely known in urban areas, it is not so in rural communities and many people from those areas either do not seek medical attention at all when they are bitten or attend an Ayurvedic doctor instead. These patients then present to the state hospital in Trivandrum at a later date, once the disease has irreversibly progressed to the terminal phase. I saw one such patient who presented to the outpatients department with hydrophobia and dehydration having been bitten by a pet one month previously. He had not sought medical help prior to this point and was clearly in the terminal phase of the disease, he was admitted to one of the hospital’s ‘Rabies cells’ (darkened rooms without any stimuli to the hydrophobia). In this cell he was administered some rectal diazepam (he was not able to take it orally due to laryngospasm) to keep him relaxed. He died a day later.

Resource RoomResource Room

Aside from the medical aspect of my time in India, I was also able to see a lot of the state of Kerala and experience some of the culture. I was very fortunate to be in Trivandrum at the time of the Pongala festival. During this festival, 3 million women from around India line the streets of Trivandrum and cook dishes which they then take to the temple as an offering to the gods. While men aren’t allowed on the streets during the festival itself, in the week leading up to this day there are various parades taking place across the city which everyone can attend and I was fortunate enough to be able to see one of them. It was quite a magnificent spectacle!

Pongala FestivalPongala Festival

To finish up this article, I should probably offer some guidance to those thinking of pursuing something similar for their elective, based on my experiences. I think a few things that I would highlight are:

  • The importance of travelling with a reputable company that can give you the kind of placement that would be most rewarding
  • The idea that you cannot necessarily predict what you will see. Nor can you predict the patient’s outcome. So prepare to be shocked!
  • It can be fascinating to go in search of something you’ve never seen before.
  • UNcommon things occur commonly in India- so go and see them!

I’d like to conclude by saying that my time in India was fantastic despite some of the unfortunate cases I witnessed. I learnt a huge amount and gained a lot of experience in both tropical diseases and Indian culture and healthcare. This placement has really made me appreciate the NHS and how fortunate we are to have free healthcare for everyone, and has also inspired me to consider infectious/tropical diseases as a potential career path.

Daniel Monnery
Medical Student
daniel_monnery(a)hotmail.com

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