Student BMJ June 1998: Life
Mayday University Hospital,
Thornton Heath,
Surrey
William Norman experiences medicine on the move
You have no idea just how vast India is until you attempt to cross it from coast to coast. The express train took two days, and then it was a further four hours on a commuter train to reach S'Kota, a small market town about 80 km from the east coast of Andhra Pradesh. The first part of my elective was on the Lifeline Express: an operating theatre on wheels. The train is run as a well organised, self contained unit by a retired army colonel. Three converted railway carriages are crammed with theatre tables, anaesthetic machines, full sterilisation equipment, and support services. The express is run by the Impact India Foundation (a branch of the English charity Impact, set up in 1983 to prevent avoidable causes of disability). The medical team consists of visiting professors from Delhi and orthopaedic interns from Visak city, about 80 km away. Nurses are recruited from the local hospitals to look after patients in the recovery "ward."
Primary health care in India
Surgery is carried out on the train, which is driven to remote areas for a month at a time. During the first 10 days that I spent on the train the team worked with untreated polio patients, performing tendonotomies and osteotomies to reverse the tendon contractures that prevent walking. About 30 patients were assessed each morning in an outpatient tent. All were given numbers, but they still crowded round the doctors' table, vying to be seen first while at the same time listening intently to the discussions about other patients.
Although the clinic clearly stated that it was for "polio patients only," children with all kinds of conditions came anyway. A 3 year old girl who was brought in floppy had been unable to walk for three weeks after a flu-like illness. She was diagnosed as having the acute flaccid paralysis of early poliomyelitis. There was nothing we could do for her: she needed intensive physiotherapy and long term follow up, which, sadly, her family could not afford.
Patients lucky enough to be selected for surgery were operated on that afternoon. They waited silently in the recovery area before being carried into the operating theatre. They were lightly anaesthetised without muscle relaxant, to avoid a long recovery from the general anaesthetic and the risk of aspiration. Consequently, three surgical teams could work continuously, allowing two or three orthopaedic surgeons to perform 20 operations every afternoon.
People who would otherwise have been forced to sell their smallholdings travelled up to 80 km to receive free treatment in the train because they said that the local "free" government hospital charged for treatment. Thus, one function of the train was to encourage local government services to improve health facilities for people with polio. Before the train departs from a village the charity sets up a clinic for the local doctors to provide follow up care. Members of Impact return twice over the following six months to monitor the follow up.
On the right track with the Lifeline Express
For the second part of my elective I worked in a primary health clinic in Dokur, a rural Indian village 120 km south of Hyderabad city. The clinic was run by the Institute of Rural Health Studies, a local organisation working at providing basic health care with the minimum of resources. The catchment area was huge, with patients coming for treatment from up to 150 km away. Two local Indian paramedics, who had been trained by British general practitioners, ran the clinic for three days a week, and on the other days they visited nearby villages in a converted van. The paramedics ran an efficient and impressive clinic. They carried out tests on blood (erythrocyte sedimentation rate, haemoglobin measurement), sputum (acid fast bacilli), and urine (microscopy, protein, sugar).
Tuberculosis was rife in the area. However, as a chest x ray film costs up to one week's wages, the diagnosis often relied on clinical suspicion and the results of sputum microscopy. Next door to our accommodation a patient was confined to bed with spinal tuberculosis, which was completely asymptomatic, but he was at risk of becoming paraplegic if he had continued to work. Standard triple therapy lasts six months, and this inevitably leads to problems with compliance. The solution at the clinic was to ask for a deposit of 200 rupees (£4, or about a week's wage), which would be returned on completion of the course; the drugs were supplied monthly free of charge.
By contrast to S'Kota, village life in Dokur was lively, and people working in the clinic were welcomed into the community. I was there during the wedding season, and the village was full of processions taking wedding parties to the temple to pray. They were invariably led by a band playing free jazz. Even the normal temple life was beautiful, with prayers going on through the night, amplified over the tannoy system. It was such a privilege to be given the chance to live with the villagers as an equal. We ate fresh hot Andhra vegetable curries for every meal (always gorgeous), drank from the well, and slept in the schoolteacher's spare room. The beauty of India is memorable, and there are treasures everywhere in towns and cities. It was an unforgettable experience.
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