“Bihar is officially the worst state in India!” or so the TV news in Delhi helpfully informed us the day before we were due to take the 28 hour train journey half way across the Indian subcontinent. The news didn't exactly come as a huge surprise; on reporting the finalised the location of the elective to anyone who knows anything about India we inevitably met the same reaction, namely “Why?!” It didn't seem to matter if it was restaurant waiters in Southampton, Professors of Law in Mumbai or random taxi drivers in Delhi – descriptions of Bihar unanimously included the words “backward,” “poor,” “corrupt,” “dangerous” and so on and so forth. In fact, one well meaning local in Delhi told me that “We have a saying: 'you go to Bihar, you get robbed….'” I waited politely for a punch-line but it turned out that was it. Never mind.
To reassure the reader I feel I should point out that after spending nearly two months in Bihar that a) we survived it ok without any incident and b) its reputation is probably only half deserved… The state of Bihar is located in the north east of the main Indian landmass, bordering Nepal (see map) and is often affectionately known as the 'armpit of India.' Whether or not the people are all “thieves and robbers” according to the popular stereotype, what certainly is true is that most of the inhabitants live in extreme poverty, and many of the health and social difficulties we encountered during the elective can be traced back to this fundamental problem.
My main objective for the elective, however, was precisely to experience the practice of medicine in a third world context, as well as to gain some cultural insights and apply knowledge and skills acquired in the 3rd Year.
The poverty of the area meant that often patients really couldn't afford to come to hospital and pay for treatment, especially when taking into account lost earnings (which in many cases translated directly into food) for the patient as well as any other relatives which came too. The general reluctance to present often works out worse for them in the long run. I recall a man I saw who sustained a nasty compound fracture following a road traffic accident. The well meaning locals simply patched it up with a rudimentary cast/splint made out of traditional materials largely comprising mud and cow dung. Needless to say when he actually presented to the orthopaedic surgeon sometime later his case was somewhat more complicated to manage.
Another example was an elderly lady who sustained a relatively minor injury when head butted in the arm by a baby goat. Unfortunately the wound became infected and resulted ultimately in her developing acute renal failure. It took several days before the medics could stabilise her, after which she required a rather extensive debridement.
Disease patterns tend to be seasonal. The monsoon season lasts roughly from June to October and provides the agriculture with enough rainfall to last through the rest of the year. (You may recall the flooding crisis in Bihar in June.) Consequently the monsoon season tends to give rise to a lot of water borne diseases; at this time of year the medical wards were full of gastroenteritis, although encephalitis was also common, as were snake bites. The picture below illustrates some of the dramatic monsoon cloud formations.
The hospital itself was first set up in 1930 by Scottish Surgeon Dr. Cecil Duncan. Strategically located right on the border of Nepal, it seeks to help the poor and marginalised in both the northern districts of Bihar and the southern districts of Nepal. Since 1930 it has grown from 30 to over 200 hundred beds and now offers clinical services in medicine, surgery, orthopaedics, ophthalmology, obstetrics, gynaecology, paediatrics, dentistry, clinical psychology, physiotherapy and rehabilitation. It is affiliated to the Emmanuel Hospital Association (see www.eha-health.org.uk)
Teaching quality was generally very good. One of the biggest obstacles in my ability to comprehend the medicine (especially in clinics) was the language barrier. The doctors all trained in English so that wasn't a problem, but it made it impossible to either take histories from patients or listen in to the advice they were subsequently given by the doctor. Translation doubles the time of a consultation and everyone was so flat out anyway it tended not to happen, and perhaps reasonably so. Sometimes I was able to participate more - I remember once seeing a boy in Out Patients one morning who had an ear infection so I was asked by the doctor to perform Rinne's test, which I did. The child was under instructions to put his hand in the air when he couldn't hear the tuning fork's sweet 256 Hz tone any longer. However in his zeal to comply he thrust his arm in the air with such enthusiastic vigour he knocked the fork clean out of my hand and sent sliding it half way across the room, which made me smile.
A definite highlight was the opportunities to go out into the local villages both to visit literacy and education programmes, and with the ophthalmology team to run clinics in the community. (See following page for photos.)
It would be virtually impossible to fully explore the rich diversity I discovered during my experience in the Indian culture; however I shall briefly mention a few key differences that come to mind. One obvious difference was the lack of “the individual” which we in western society have become accustomed to in our obsession with the pursuit of personal autonomy. In Asia there's no real concept of privacy, which can be infuriating, amusing or somewhere in between. Anyone's business is everyone else's by default. Being one of the five white men (all foreigners working in the hospital) in the surrounding district, I constantly attracted a lot of stares whenever I went anywhere in the town, but you got used to and eventually came to ignore it. On one occasion the dentists gave me an X-ray of my jaw because I was having some wisdom teeth issues. The whole X-ray unit is rather open plan (i.e. there aren't any doors) and my experience drew quite a sizable crowd of curious Indian onlookers. Fortunately this scored more on the amusing than the distressing end of the scale.
I came across similar phenomena in practically all clinical settings I worked in. In clinic I could often catch sight of people in the waiting room peering in the through the curtain that separated the consulting room from the waiting area. Sometimes random people would brazenly accompany patients into the room just out of curiosities sake, though usually in this case (generally to their surprise) they'd be thrown out. The funny thing is that whereas in our society such breaches of privacy and confidentiality fly in the face of practically every professional guideline that exists, in Asia no one seemed to mind. That's just the way they operate.
It was an occasion when a young woman came into casualty having just had a horrific accident involving both her arms being pulled into a rice crusher. She urgently needed a blood transfusion and as the hospital doesn't have a blood bank on site she had to be taken to the nearest by ambulance. The transfer of the patient from the emergency room to the ambulance in the courtyard involved traversing the outpatients waiting room, which literally emptied as the crowd of men women and children all followed the stretcher to the ambulance outside to have a good look at what was going on!
There were certainly lots of positive effects of this 'lack of the individual' especially within the role of the family. A trip to hospital for one person inevitably meant that their entire extended family accompanied them. In fact, this was the cultural expectation to the extent that the hospitals don't actually provide any catering or food for their in-patients as the family is expected to cook for them. It was often pleasant to wander through the hospital courtyards in the evening and watch all the clusters of women crouched around a portable gas burner cooking up big vats of fresh rice, dhal and curry for the family. Naturally accommodation isn't provided for the families, so people just sleep in the courtyards, which seems to work.
Certainly another thing that struck me was the importance of, and subtly involved in communication generally, and with patients specifically. The patients we were seeing day in day out were generally very poor, probably illiterate, villagers from Bihar. They spoke a rough local dialect based on Hindi. The northern language of Hindi is a language most of the Indian doctors only speak as a second language, given that most of them come from the wealthier and more sophisticated and educated South. If Indian-Doctor to Indian-Patient communication was sometimes strained, the chances of white-English-medical-student effectively communicating with patients was pretty slim. On reflection, the relevance of this to my future practise of medicine becomes apparent as I realise just how little useful medicine one can actually get done without the ability to effectively listen and communicate. I'm not even just talking about tick-box history taking; the culture is so different that all the 'normal' by which I mean culturally appropriate to us) subtleties, (e.g. body language, intonation, social customs and expectations and so on), which we so often unconsciously rely on are completely eclipsed and rendered culturally irrelevant. To me this highlights some of the art involved in taking a history, diagnosing and communicating with patients, rather than just impersonal science.
There were limited opportunities for non-academic activities as we were generally confined to the hospital compound during the evenings for security reasons. We planned to travel into Nepal one weekend but it transpired that the political climate was too unstable. On the compound there were football and basketball facilities, a reasonably sized library complete with two computers with a satellite based internet connection, available to use at a small charge. There were good opportunities to socialise with the other ex-patriots in the hospital, as well as with the Indian junior doctors. I spent a lot of my spare time drinking a lot of chi (a very sweet Indian tea) chatting with the doctors in the Doctors' Mess, as well as discussing recipes with the chef. He didn't really speak any English so we often communicated via his 10 year old son who translated. Later he took me to the market and we bought some authentic Indian cooking utensils to allow me to practise what I'd learnt when I go back to England. Initial experiments have proved encouraging…
On the way to Bihar we travelled around India for a bit, spending time in Mumbai, Pune, Delhi, Agra, and it was well worth taking the opportunity to do a little tourism. Internal travel and accommodation was generally very reasonable.
A genuine cross cultural experience can be truly enlightening for many reasons, but in my opinions one of the most valuable aspects is the opportunity to reassess your home culture from a genuinely different stance. It's only when we completely remove ourselves from all the subconscious assumptions of the way things 'should' be done that those assumptions can come suddenly come into focus, as we view them through the lens of another cultural worldview. With this in mind, I would thoroughly recommend anyone considering an elective to take the opportunity to get as far away from the familiar and comfortable as possible, as ultimately such experiences are the most profoundly rewarding.