India 2005 - A Review of the Last Months
Just as Susanne drew up her conclusions of the first three months of our journey a couple of days ago. Now I want to explore the vision, which led to this journey with its many impressions and draw up future perspectives.
What do we have here?
This flood of impressions, seemingly unsolvable problems and distorted dimensions of figures made my head swell.
Santiniketan had already become important during our travel preparations. The German pediatric doctor Dr. Monika Golembiewski had introduced us to this place and her project. In the past weeks Susanne and I have visited many different people, projects and medical institutions. This purely subjective and generalized assessment of the medical situation can be divided into the three levels of the Indian system: Primary Health Care, District Hospitals and Medical Colleges.
Primary Health Care
Mahatma Gandhi always again spoke of India actually being rural India and not that of the cities. Even today the largest part of the population lives in the country and often quite poorly farming under feudal rule. The average income of a family is two to three Euro per day feeding several generations of child-rich families. Average means that there are many families, who have a still tighter budget. So it is evidential that this financial situation in times of illness causes substantial problems.
However the problems already start before that. Few villagers have ever visited a school. That means not to be able to read. No to able to read a prescription or name of a medicine. Many cannot even write their names. So Primary Health Care already begins with the education. This is so essential in order to develop a basic medical understanding.
Dr. Martin Kaempchen started a school project. He initiated this school in a village of the Santals (Indian natives with their own language, culture and religion) over 20 years ago. Development is very slow. This Kirsty and Rahul had to notice too, when they wanted to form a "Society" for a small village school and none of present parents could sign their name.
So it is clear that that it is difficult to build a basic medical understanding. As an example that could lead to when a child cuts it self while playing, the mother might not see the need for treatment. But a bit of iodine ointment or a thorough cleaning with clean water could have prevented this child from having to be admitted for drainage of an abscess.
Education menas understanding and being able to draw conclusions, e.g. to eat from the same bole as animals or to drink contaminated water causes many illnesses. Monika has had to prove much patience to solve such fundamental problems in the past the ten years since she has been supporting two Santal villages medically.
Now if someone gets sick, let's say with diarrhoea, how can he or his family judge whether the patient can be treated at home or needs to go to hospital; whether the local healer, who has always been sought for advice or this modern medicine is better. Many diseases can be surely be treated excellently by a healer with his ancient knowledge. He certainly understands the socio-cultural background better than any allopathische physician. But in some cases the therapeutic attempts of the Quack leads to a progress of the illness and a delays the consultation with an allopath.
In some areas the Indian government has undertaken substantial efforts to stop these healers from treating patients, allegedly due to medical malpractice. But then the villages do not have anybody at all anymore to give them medical advice and we have lost a potential partner.
Now lets come back to our patient with diarrhoea or a frequently occurring snake bite. If he considers it necessary to go to hospital, then often a transportation pausability for the 8, 15 or more kilometers is lacking to get there. Hardly a village has a motorized vehicle and if, then the petrol will cost several daily budgets of the family.
Government and health authorities have long recognized this bad and have initiated certain measures. This really is not simply with over one billion (1.000.000.000) inhabitants in India in the meantime.
The Communist Party of Indian Marxists (CPIM) has been in political power continuously since 1977 in the parliament of West Bengalen (northeast India). Supporting the rural population always was a central point of their government program. So there are several Primary Health Care Centers in this District Birbhum/Santiniketan. But these only have one physician, who usually has not past his final exams yet. And anyway he is only present for few hours and at the weekends not at all. So villagers prefer to go directly to the hospital.
Lately the health authorities make an effort to organize Health Camps in the villages frequently in co-operation with a NGO (non government organization). Just after our arrival in Santiniketan Susanne and I were involved in such a Health Camp.
Kirsty and Rahul like Monika too, organize Eye Camps in the villages. The most frequent cause of blindness in India is catheract. Patients are examined in the villages by specialists and if necessary are operated in the hospital in Siang.
It is obvious that Primary Health Care in the villages must form the fundamental foundation of the health system. Unfortunately this is only all too frequently insufficient. As mentioned, Monika is enforcing this work. She has supported the Primary Health Care Worker "Leena" with her limited training and supplies basic medicines. So hopefully the child's small wound will not develop to an abscess and a sick patient will be transferred in to hospital early. However what is far more important and Leena stresses this again and again: "to cause awareness". To make villagers consciousness of their problems and in addition to make them aware of their right to be treated in the hospital. This however was a long way and in the other villages it needs a whole force of devoted Leenas.
Sub District Hospital in Siang, Bolpur, District Birbhum
The hospital in Siang is the only accessible medical facility for most patients in the larger area. Because of unsatisfactory administration on the one side and a tremendous patient load on the other, the hospital is hardly functional. The house has approx. 250 beds. Per year 80,000 patients are seen in the outpatient clinic (OPD) and 20,000 inpatients are treated, 4,000 births and 3,900 operations are accomplished. In the "festive season" from October to January (Durgah Puja, Diwali, Christmas, New Year...) patients do not want to undergo elective operations. So everything jams up from February to May and leads to up to four patients in a bed plus several relatives per patient, who have to care for the patient (providing meals, body-hygiene, to make sure the patient receives adequate medical attention...). It is obvious that therapy and care under these circumstances are inadequate. Outside of this high season the care is hardly better.
Apparently from the 35 Medical Officers (physicians without specialization) not even ten appear regularly to their service. In a private business these would have long been dismissed. Everybody has someone in the authorities or in the government, who protects them. Not even the Medical Superintendant can undertake something.
These political problems are particularly eminent in the state of West Bengal (Northeast India) and concern the whole public sector. For over 20 years the Communist Party of Indian Marxists (CPIM) forms the government in this federal state of India. The central government in Delhi is formed by the Congress party.
The renowned Vishna Bhati University, which was founded by Tagore, had to close its gates before the end of term, because two trade unions, one supporting the Communist, the other the Congres party, were fighting for power in the university. In the health system these kind of struggles for power substantially disturbs the daily work. And a Consultant said to me: "The administration [of the hospital] has broken down and is incapable to act."
Let's take a look at a Patinten in the Outpatient Clinic. He had big troubles manly financially, in order to get to the Siang Hospital. Probably he hesitated for such a long time, until his condition became critical. He lined up in the queue for a long time, in order to be seen by the physician. Perhaps he is the seventieth patient, whom the physician sees today. Our patient hardly has time to describe his complaints, gets some kind of orders and a prescription. We're keeping in mind that our patient canot read nor write and possibly can hardly understands the office language Bengali. It will be difficult for him to follow the advice given. Perhaps he will not be able to purchase the prescribed medicines, simply from lack of money.
Our outpatient clinic physician however must master a true flood of patient and sift out the cases seriously in need of treatment. Few patients are referred into hospital with pre examinations. So everyone is seen in the OPD, starting from a few little pains up to the perforated ulcer of the small intestine. From 80 seen patients in the general-surgical consulting hours of Dr. Takur two or three cases are actualy in need of the surgeon. Besides his surgical colleague "went and got lost" a month ago. He had to look after his own father father, who had to undergo a bypass operation after a myocardial infarction. So now Dr. Takur is on call 24 hours a day. It is not clear yet, when his colleague is going to be back. Not surprising that he is ?burned out?.
I ask him, why his colleagues let him down. "They dont have any devotion to helping. A doctor in the national health system earns approx. 20,000 Rupies (400 Euro) per month. In private practice he can easily earn a multitude of that. They would like to be able afford a nice house and a car and be able to send their children to a good school."
Actually each Indian citizen has a right to medical treatment. 1.000.000.000 people! The largest part of them live in poverty. The federal state of Bihar (north India) seen alone is under the ten poorest countries in the world! Daily medical routine is that patients are seen free by the physician and treated as inpatients however in most cases they have to by their own medicines. But frequently the money is not sufficient to even obey the doctors advice following a balanced and nourishing diet: rich in
protein and vitamins.
Back to the hospital. Our patient has been admitted. Actually he disgusted of patient wards with 50 beds and far more patients, and in addition filth and revolting toilets. Three or four nurses care for up to 100 patients. There time is tight just for giving the prescribed injections and i.v. medications. Even if they had time, they probably would not wash a patients or help him to the toilet, since he may be from a lower caste or even untouchable like the indigenous inhabitants, the Santhals.
Putting gastric tubes, catheters and i.v.-lines is actually the task of the Medical Officers. They are either not there, do not have time, or say, they do not know anymore who to do it. The non-medical helpers have taken over these tasks. At most they have attended six years of school and are employed as sweeper or the like. These medical tasks they take over with pride and devotion. A devotion, which is missing here so frequently. To study medicine or nursing is usually decided by the family and not by the own devotion to these social professions. It is a profession like any other. The primary objective is to earn money. Exactly this lack of devotion the surgeon Dr. Gupta is complaining about in his private hospital in Varanasi. He specialized in England and can well judge this grave difference.
Our patient needs to be operated. He has an acute appendicitis or a complicated fracture, with the clear indication for an operation. With high patient numbers, lacking personnel and resources doctors frequently see them selfs forced to attempt a conservative therapy. Antibiotics for the appendicitis and immobilization for the fracture. Partially that will be successful, but some develop complications.
Arriving in the operation theatre (OT), we hope for sufficient oxygen, functioning equipment and adequate hygiene. Under these bad conditions the personnel has lost its hygienic discipline: Filthy operating shoes, street clothes and repeated contamination of the sterility of the operating area. A mosquito settled on the opened seminal duct while treating an inguinal hernia.
The hospital only has one functioning plus oxymeter (equipment to mesure the oxygen saturation in the blood), which is very important for surveillance during anaesthesia. However 12 to 15 operations are accomplished daily. The other plus oxymeters are defective. The money seems to be missing to repair this equipment costing 1000 to 2000 Euro. But a technician only earns 2 euro a day. The bureaucratic obstacle to get these few Euro granted for the repair seems to be too large. Apparently there are elements in the administration who actually block any attempts. It simply is just not in their interest.
The Indian health authorities received a loan of approx. 20 million Euro from the World Bank to the improve medical care (that means 2 Euro Cent per Indian). This money was used for the acquisition of new devices and construction of new buildings and not for the creation of a lasting maintenance scheme for hospital buildings and equipment. When ordering equipment all possible spare parts need to ordered too. If these are used up or are something is missing, the equipment often comes to the end of its practical use.
There are individuals, who defy these circumstances, like the orthopedic surgeon Dr. Manash Bhattacharya. People here call him the miraculous bone healer. Patients even come from Kolkata four hours away, in order to be treated by him. Day in, day out he is untiringly caring for his patients. Important devices are missing to it like a external Fixateur (to immobilize bones) and a real time x-ray screen. It surprises me that he has not shifted to a private hospital yet. Dr. Bhattacharya told me that the "Private Nursing Homes" in the district are still more badly equipped and that he is needed here.
There are many so-called Private Nursing Homes in the area. Tiny private hospitals with a few beds as reaction to the unsatisfactory conditions in the hospital. A majority of the hospital physicians work in the afternoons, evenings or their day off in these dumps, which look friendlier and cleaner however the infrastructure is not even that of the Siang Hospital.
Like our landlords Keya and Satesh, many from the middle class complain that there is no decent medical infrastructure in the area at all, even if one dose have the money. Many from the middle class are associated with the Vishna Bhati University and have a right to be treated in the Pearsons Memorial Hospital of the university. But here too there is no sufficient infrastructure, so that severe cases have to be referred to the Siang Hospital.
I have heard several rumors that a localy renowned company has concrete plans to build a large, well equipped hospital in the Santiniketan/Bolpur area. Those, who could afford the treatment would give a sigh of relief.
However, there are further positive developments. The non-governmental organization "operation Smile", founded 1982 in the USA by plastic surgeon, held two one-week Camps in the Siang Hospital. The surgeons could treat children and adults too with different prenatal face deformities (esp. lip clefts). The achievement of international troop of surgeon was unbelievable. In the Februar 148 and in September 2005, 169 operations free of charge were accomplished at both times in five days.
I asked the surgeon Dr. Takur from Siang whether this had had a positive influence on the hospital and its personnel. He said that in the precorse the toilet flushes had at least been repaired, so that the doctors could use them. But if one would ask the emploies, why they do not achieve such performance, you would get the answer: The foreigners have dedication. And we do not have that here. What a sad realization.
Dr. Takur was posted in Kalimpong in the mountains near Darjeeling for a long time. He claims that there dedication and work moral is clearly better. There one could work properly. According to him the reason is that the people from the hills have a better moral, but that also the Christian Missionaries brought in the idea of selfless charity.
Dr. Takur supplemented an anecdote of Operation Smile: They had everything flown in, from surgical instruments up to bed sheets. All the goods were kept in the stockroom. On the first day as things should start, they could not access the material because the stock-key administrator did not have the desire to come to work. Typical.
The next hospital with a medical faculty is in Burwan (Barddhaman), 1½ hours on the way to Kolkata. This hospital surely has a better infrastructure. But the 500 beds are occupied by 5000 patients and over 1000 patients are seen per day in the outpatient clinics.
For those, which can afford it, there are several private state-of-the-art hospitals in Kolkata, like the Apollo hospital of the large Asian hospital chain. But even for the middle class they are partly unaffordable, because the patient is thoroughly checked and diagnosed, like we know it from Europe, but then he gets a bill with the individual items just like US-American manners. Only few can afford or have a sufficient health insurance or an employer, who takes care of the bill. Also in the middle class illness can mean financial ruin of a family. These hospitals are drawing an increasing number of medical tourists from Europe, here particularly from Great Britain and the USA. For them medical costs are not only a fraction of those of their native health care system but they do not have long waiting lists like the NHS (National Health Service) in Great Britain.
In summary the situation of the medical service is unsatisfactory in the greater area of Santiniketan/Bolpur for everybody. It is partially due to the shortage of money and education of most people, partly however also due to corruption and apparently lacking dedication for the community. Many further factors play a role, so that there is not "the problem" with a clear solution.
What has become of the vision?
To tell the long version again, it all began as my father read a book to me when I was seven years old about the jungle doctor Albert Schweitzer (official homepage). Since then I said that I wanted to become a doctor. As a child of an English family, that had emigrated into a Swabian village (southwest Germany), it is not to be taken as granted to receive the necessary education to be able to study medicine. But the right doors were always opened for me on my way, to now a house officer in general surgery. I think it is the experience that everything that I takle becomes a success, that gives me the confidence to start such projects as India 2005.
At the end of my study I had to ask myself, what I want to begin now with this profession. Albert Schweitzer' seeds sprouted again. In my day dreams I drew out a small hospital in a disadvantaged part of the world, perhaps in India. I had been there before in the year 2000 doing an elective period and fell in love with the country.
I hardly dare to confess openly that when I wove this dream further, I saw an Aschram, Kibbuz or a village. I was fond of the Gandhi'istc conception of an Ashram, in which people of different education, origin and work, live in a loose group together and tender for each other.
Perhaps you will object that we have that in our social free-market economy in Germany. Yes, we do. But when I was in an under privileged country the first time and I had to tell what Germany or Europe is like, I became aware that we also have totally obskure, paradox problems, which we apparently can not or do not want solve. It is difficult to explain the fact to someone in India that we have 5 million without work but can hardly finde someone willing to clean, cook or chauffer for us, what normal for the middle class Indian. "In Germany you are all so rich! And nevertheless you can not afford servants and traveling by taxi is so expensive?"
An Indian is baffled that there are no arranged weddings in Europe, however each third couple of a love wedding gets divorced. "What, half of your health costs are spent in the last two years of your? You are all insured, aren't you? How can your health care system then be a crisis?"
Generalised and brightly colored, but the essence becomes clear.
We were actually were discussing this dream of the Ashram. A small hospital, school, agriculture, like this mission of the Holy Cross Sisters in Jarkhand, that had impressed us very much or Auroville in south India. I had begun my junior house-officership at the Surgical University Clinic in Freiburg and had to find out whether this dream was only hot air or if it contained a visionary core. So Susanne and I decided to give up our employments and to travel India. I was conscious that this would probably be the unsecured and possibly stonier path. But hopefully it would be more interesting and more adventurous than to settle down in private practice or to become a senior consultant. This decision was not taken easily and now and again I still have my doubts.
Now we have been here for three months already and have seen lots saw and got many impressions. We have gone to a lot of effort to document this, above all the medical things on these web pages. By putting it onto paper (or into bits'n bites), points have become clearer, these obscure problems stand out still more and the fatalism become even more obvious.
Since meeting Monika our journey had always had been directed towards Santiniketan, with this mission in mind to build up a hospital. To the question, what we are doing here in India, I explain that we want to finde out, firstly whether we are welcome, secondly whether we are needed here and thirdly whether we are able to and if we want to invest part of our life here.
Everywhere we are received and invited with open arms. Beautiful Indian hospitality. We live in a house community with an elder better-off Indian couple from Kolkata. Mrs. Das explained to us, it would be because of the fact that in Hinduism God is in everything. Like that God also is in the guest and so he is pampered accordingly. Recently we were invited by Dr. Ghosh, a Medical Officer of the Siang Hospital, for a meal at his parents' house in a village. Susanne and I sat at the table and ate, while the extended family took care of us and watched.
Welcome to build a hospital or an outpatient clinic? I am not sure. There are a couple of people, who offered to support such a venture energetically. But I do not know at all whether it is the correct approach to place a hospital here. More to this question in a moment.
Dr. Martin Kämpchen asked quite justfully whether it needs a doctor and a nurse from Germany here. After my above report we are all certain that a drastic improvement of the medical situation is required here. Some people who I tell my idea to become quite enthusiastic.
But what actually is needed here? Surely basic school education and improvement of the financial situation would distinctly raise life and health conditions. Primary Health Care Workers in the villages, like Leena, could improve the medical situation significantly, by creating awareness, initiating early therapy and transfer into hospital if necessary. This would reduce the working load in the hospitals and could lead to an improvement of the therapy there. Allegedly the Ministry of Health wants to undertake large efforts in co-operation with British and German technical welfare organizations by reformimg this sector. Is worth mentioning the so called "German Water". Some years ago the Gesellschaft für Technische Zusammenarbeit (GTZ) installed many deep bore water wells in the cities and the smallest villages. These wells are equipped with easy to operate hand pumps, which can be used by children too. This led to a considerable reduction of water-born diseases such as diarrhoea.
Corruption in the hospitals and above all in the administrations does not only paralyse the health system. Perhaps hospitals should be run by privately and physicians should not be state servants. A phenomenon, which partial has let India ascend to the world market leaders in the last years, e.g. in the sector of information technologies (IT). A development, which is seen very reluctantly by the Communists in West Bengal. But remember, "the sellout of the state" during the Thatcher era in Great Britain had caused substantial problems.
We came to speak with Martin Kaempchen on the question "what is needed?", when Mr. And Ms. Das were visiting him. Mr. Das, a very educated engineer in the retirement, claimed "Money and Education!", Martin contradicted "Character!". People need character.
Ethics of active brotherly love is only finding its way into the Indian spirit since the last century, like Rabindranath Tagore developed it. But we westerners find it just as difficult to pursue brotherly love or Schweitzers ethics of "reverence of life" and not to chase our egoistic and greedy self. Otherwise our grandparents would not be dumped in old people's homes and our society would not be so hostile to children. There Indian moral is natural to care for the old mother until death. But here western greed is creping too. And children? Susanne is astonished time over again, how many children are here always and everywhere.
On our journey we saw the effects of our occidental moral and ethics, which were not always positive. The western influence in Ladakh with the building of schools leads to the children learning to read and write "How to make tee.", but no longer practically how to prepare Tee. Also they do not learn how to build a house or to cultivate the fields any more. The ancient culture is visibly getting lost.
In Varanasi we spoke with Mr. A. Kapoor. The carpet wholesale dealer complained that there are hardly no hand knotted carpets being made anymore. Nearly everything is manufactured by machine due to the western boycott of child labour. Many families became even poorer, because the only breadwinner of the family was the 10 or 12 year old son. The extinction of the handicraft of the carpet maker disturbed Kapoor still more. Since ancient times, this art was learned from a jung age and passed on from generation to generation. Our propagated western moral with good intentions can lead to the contrary effect in an old established socio-cultural system, which is difficulty for us to understand.
Does India need more physicians? India trains very many physicians. The education is not bad. Above all it is practically oriented and meets the needs, where diagnostic possibilities are lacking. However a large part, especially good doctors, are recruited by foreign countries, manly Great Britain, the US, Australia, south Africa and the rich Gulf States. This Brain Drain involves not only physicians but the whole health sector: nurses, paramedics, laboratory specialists, etc. It is understandable that a doctor prefers to work where he finds the necessary infrastructure to be able to fully implement his medical knowledge and besides earns a multitude. Hardly no Indian physician would voluntarily move to the countryside, in order to work in a Health Center, where the next cinema and decent restaurant are one hour by car away.
And, are the doctor and the nurse from Germany needed? Helpful people are in demand. To build up a hospital will under no circumstances solve the causes and will only improve a small part of the bad situation. But I want to do surgery! That brings us to the third question.
Do we want to and can we?
Can we and do we want to spend a part of our life here? This brings up a whole load of questions. Do we bear the summer with temperatures over 40°C? Do we want to do without decent wine and cheese? Can we feel comfortable in the Indian society long-term? Actually for me the crucial question is whether I want to try it, want to dare it, want to trust that this is the right way. The many doors, which were opened for us, seem to say yes.
But I have fear. Atypical for me. I do not want to live ten thousand kilometers far away from my family. I miss my home city Freiburg, long friendships, coffee in the Kolbencafé and Butterbrezeln for breakfast. Do I want to give that up? At the moment I do not have to (yet?).
The most important for me is to complete my internship and become a registrar. This will still take roughly 4 years. This knowledge and technical ability is essential. For this I hope to find a good Mentor at a district hospital in southwest Germany.
In the coming years I could return regularly for some weeks to deepen contacts and perhaps tp work in the hospital and get to understand the Indian better.
A good contact to the hospital in Siang could possibly lead to an improvement of the situation on a long-term. The above average medical care in the hospital of Leh, Ladakh, is partially due to the annual Super Specialist Camps, which are an engine of development. "Operation Smile" left an impression in Siang. Monika has won a neurosurgeon willing to operate a six-year boy with a hydrocephalus in Siang.
Dr. Gupta from Varanasi said that if Westerners with such ambitions come to India, then they will be supported and receive acknowledgment, since despite their comfortable life, they regard it necessary to do good here. I think that hereby people are motivated to work on these apparently unsolvable problems.
I believe that especially important is that people living and work here takle the problems themselves and that they try to solve their way. They understand the socio-cultural background. The development, which they push forward will be sustainable.
Whether I will build a hospital or a Ashram here remains open. Nevertheless, there must be a continuation.
Finally I would like to supplement in view of my rarely felt uncertainty that these views are not static. We are still travelling until Christmas this yearly and have not seen all the people and projects in Santiniketan yet either. I reserve myself revisions due to this dynamism.
Elias, Santiniketan in October 2005
Our house and transport during our stay in Santiniketan
One of many lakes, where fisch are bred and people wash them selfes
A smal "alternative" market
Rice padies at susnet
Dr. Martin Kämpchen
Mr. Snehadri Chakraborty, a good friend and help of Monika
At Rahul and Kirsty's home for dinner
At Satesh and Keya's home for dinner. A nother gest in the right. Sathes is not on the photo.
An idol of Durgah surrounded by further figures of the myth
Dr. Kausik Gosh and I
Dr. Kausiks famiy
Kaum waren wir in Santiniketan, schon fanden wir uns in einem Primary Health Camp eingebunden
Eingang zum Siang Krankenhaus
Eine von vielen langen Warteschlangen
Dr. Takur der Allgemeinchirurg am Ende eines langen Tages in der Ambulanz
Zwei Schwestern im Siang-Krankenhaus