I spent my eight week elective in Tamil Nadu, South India, splitting my time between two very different hospitals, both working to serve the poorest of their community. The main aim for my elective was to explore the possibility of working in Tamil Nadu in the future. I have worked in the state before, and have a strong desire to return in the future. I wanted to understand the structure of medical care, and the attitudes of healthcare professionals.

My first attachment was in a fairly large charity hospital on the plains of Tamil Nadu, in a town called Oddanchatram. My favourite primary care attachment at Christian Fellowship Hospital (CFH) was in the hospital setting, where primary care doctors run tuberculosis and HIV clinics. The World Health Organisation (WHO) have a well-defined programme of 'Directly Observed Therapy, Short-course', or 'DOTS', to ensure that patients with TB complete their treatment. Patient concordance with TB treatment is a challenge, due to drug side effects and a complex regime involving 4+ medications. The WHO has tackled this by advising that a standardised treatment regime is directly observed by trained community health workers, for the first two months at least. The primary care doctors at CFH recognise that this is important, but have developed a method that they feel is more empowering for patients.

When diagnosed with TB, patients are admitted for three days to teach them about the treatment regime, its importance & possible side effects. Doctors also generally counsel patients about their diagnosis, so that they take responsibility for their own health. Moreover, patients pay a deposit of Rs. 500 (about £5), which they receive back once they have successfully completed treatment. If they miss one dose (shown by labelled packaging, see Figure 1), they receive a warning from the doctors. If they miss two doses, they are fined Rs. 100. This is an added incentive to complete the treatment successfully, and be responsible for their health. I found this a unique attitude for India. My previous experiences in the country have highlighted that India is still paternalistic when it comes to Medicine. In every other department in CFH, this was very much the case, and Dr Susan's attitude towards TB management was refreshing and inspiring.

I did face some challenges with regards to ethics and patient care during this attachment. I struggled with the disinterested attitude of many doctors and what I perceive to be poor communication skills. I understand that medical training in India is still very traditional and does not focus on the patient as autonomous and in charge of their health. Coming from a modern medical school such as Peninsula, this was very different and challenging! I had some difficult discussions with consultants, particularly when they decided not to treat patients for discomfort/pain because they knew the patients would endure it. For example, patients with endotracheal tubes were never sedated, unless they were causing 'trouble' for the nurses. I was very upset to see the distress on patients' faces as they tried to be brave, gagging on a tube 24 hours a day. I believe that a patient should not have to endure distress if you have the resources to combat the cause. CFH had plenty of sedation available, but it was rarely used, which I think challenges the ethical principles of beneficence and non-maleficence.

My second attachment was in Gudalur Adivasi Hospital, in the beautiful Nilgiri mountains (see photo). The Adivasi, or aboriginal, tribes that live in this region have historically been ignored by services, including healthcare. Until the early '90s, they had no hospital to attend, no antenatal care and less than 5 per cent of children received complete immunisations. The community health programme in this area is absolutely fantastic. Although there is now a 20-bed hospital catering for inpatient care and outpatient clinics, all the work was started through a community health programme. Every tribal village in the area has been surveyed thoroughly, so it is very clear which focused interventions need to be brought to the village. For example, it might be shown that unplanned pregnancy rates are higher in a certain village, so 'health animators' will visit and provide education on family planning and contraception. The focus is very much on tribal people being trained to be health workers, which not only gives the individual high self-esteem, but means that the village is self-sufficient. The village health worker is provided with a box of simple medications, and is trained to recognise and manage simple diseases. They also know when someone needs to visit an outpatient clinic or be admitted.

The Adivasi people had a poor view of healthcare until GAH was set up. Government hospitals, which are free for those who need it, treated them as 'untouchable', and therefore Adivasis did not want to attend. The current statistics speak for themselves. After just over a decade of GAH, antenatal care has increased to 90% from under 2%, 81% of mothers now give birth in hospital and both maternal and neonatal mortality have plummeted. Eclampsia rates have dropped from 20%, to nil, and 94% of children are now completely immunised. The average cost of this healthcare system? Rs. 140, or £1.50, per person per year. I have huge respect for the people who work in the area with the Adivasis. Not only is there a comprehensive healthcare system, but other services too, including advocacy and land rights, social work, education, business & enterprise. There are too many areas to discuss fully, but if you are interested, there is a wealth of history online – search for 'Adivasi Munnetra Sangam, Gudalur'. It was a wonderful community to live and work in, and I was so pleased to have this opportunity.

There were still some challenges working in this hospital. There are limited resources, so that despite the amazing progress, patients still have to travel 2 hours for a CT scan and there are only 6 antibiotics in the pharmacy, meaning if an infection does not respond to those, there are no other options. Surprisingly, I did not find this upset me, because the tribal communities are very accepting of what life brings them. Health, illness, life and death are all to be expected, and I think that attitude affected me.

This trip to India has further encouraged my love of the country and confirmed that I could provide useful skills that I believe UK medicine has instilled in me. For example, championing patient autonomy and involvement in their care, and providing a less paternalistic framework for the doctor-patient relationship. There are doctors, such as Dr Susan at CFH and Dr Nandekumar at GAH, who are improving the small area where they work, in such simple ways – treating patients with love, respect and dignity. I found this inspiring and hope to do the same in future, whether I am in the UK, India, or somewhere else!