nutrition – cooking and discussing

We travelled to a place called Chittalapakkam today, where we discussed nutrition first with very small children and then with their mothers. We met in a balwadi or creche. We discussed the importance of fruits and vegetables, drinking milk, and washing hands. After this, we went to someone’s home, which was really a hut, and made high-nutritionrotis (indian flatbread) out of wheat flour and gram flour, carrots, spinach, and other vegetables. They were made with minimal oil and and not fried. We took these back to the balwadi, distributed them to the children, and discussed them with the mothers.

It was actually interesting to see what the mothers know. Some know that carrots are high in vitamin A, which is good for the eyes. Others still think eggs aren’t good for kids who have jaundice. The level of general education is very low in these communities – among everyone but especially among the women. But the health education is somewhat reasonable in the places that are being reached by the government health centers, which speaks well for Tamil Nadu’s implementation of the national health programs.

One program that we saw here was the mid-day meal scheme. Under this scheme, children are fed a well-balanced meal, including an egg, everyday for lunch at the creche and even at the schools, up to the 7th grade, I believe. This serves two purposes: one, at least one good meal per day for the children, lowering incidence and severity of malnutrition, and two, incentive for parents to send their children to school. This is another highly successful program.

back in business

It’s been difficult to keep updates going when I haven’t had much to say, much to talk about. But I saw – and treated – my first cases today.

Rather than try to keep this as a sort of entertainment for potential readers that may or may not exist, I thought it might be nice to keep a portfolio for myself of the cases I’ve seen and the experiences I’ve had. If entertaining stories come up, great. If not, that’s fine too.

Yesterday was my first day actually seeing patients. I’m working at the Voluntary Health Services, down Old Mahabalipuram Road. It’s a dusty little place, with a few old buildings that look like old timey schoolhouses. It was frightening to sit at a desk with a patient seat in front of me. My first patient sat down, addressed me as ‘madam’ and proceeded to tell me her name. Remarkably, it was the same as mine. I thought that was kind of a cool little sign.

I saw 4 or 5 patients yesterday, all with colds and sinusitis. One woman had what I suspected to be a chronic bronchitis. She had diffuse wheeze and creps heard throughout the chest, with some bronchial breath sounds as well. She complained of 3 months duration of cough with copious sputum production. We interns all had various suggestions, such as bronchiectasis, bronchitis, even walking pneumonia. The medical officer suggested that these all may be zebras. Think simple, he said. Don’t suggest investigations you know your patients won’tundergo. So we prescribed amox for a mild LRI, cough syrup, and an aminophylline. And then we sent her home.

What a strange approach!

I wonder, what does she actually have? TB? COPD? Will she get better? Or will she keep taking short courses of antibiotics periodically prescribed by doctors who just want to get the patients to go home?

Another young woman came in and told me that she was diagnosed with “sugar”, meaning diabetes of course. She says she hasn’t taken medication for one month. Why, I ask. I had to work, she says. The problem is that for her, this is actually an answer. It is valid. If she takes time off of work to go pick up her medicines, she will lose a day’s salary. She doesn’t come to the clinic until she is too weak to work. I have pins and needles, she says. I am dizzy and weak. Fatigued. We ask her if she’s done her blood work. She tells us that she has just given blood and that the report won’t come until tomorrow. I prescribe her inj. B complex – for her satisfaction or for my own, I don’t know. I ask her to come back with her blood reports tomorrow.

I know I won’t see her again.

Medicine? For the community? Say what?

How important is it for us to really learn community medicine? Most Indian medical students consider community medicine to be the biggest waste of their time. Bigger, even, than sitting in the canteen discussing the latest movie or the new gossip about the surgery profs.
Today, for a community medicine class on polio, for which India is one of only 6 endemic areas, 29 people showed up. There are supposed to be 144 people in the class. I mean granted, major exams coming up, but still…29? The tragic thing is that even the professors subscribe to the myth that CM is only for the sake of passing the final exam which is mandated by the Medical Council of India. Today’s class was peppered with the phrases “this is important for your exam” and “this will definitely be an important question for you”, instead of “this will come in handy. Most subjects are taught that way, unfortunately, but at least with other subjects the students tend to realize that they need to know their stuff. Here, no one even dares to think that CM might actually come in handy; that we might someday need to know what the different strategies for polio eradication are.
In a country like India, where 70% of the population and only 20% of doctors are in the rural areas, it can’t be stressed enough how important it is for the average student doctor John Doe (or Karthik Subramaniam, as the case may be,) to be thoroughly well versed with the principles of public health and community medicine. So what is it going to take to bring about a change in the student population?
I don’t think the problem is one restricted to my university or even to India as a whole. The factors which manage to turn medical students away from community health and public health reform vary from place to place, population to population. Let’s take the latest controversy surrounding Indian medical education, for example.
There is talk that there is going to be a new requirement that all Indian medical students should serve two years in a rural health center after graduating, before actually receiving their degrees. This rumor was enough to cause strikes and riots all over India. Government university students proclaimed that as they come from middle class families, it is unfair to ask them to give up 2 years of solid earning potential for the sake of villagers who dont’ really need real doctors. Private university students retort that since government students pay so much less in tuition fees, they can afford to give up two years where private students cannot. Nowhere in the discussion, neither in the student dialogue nor in the media, was there a consideration given to India’s need for health care for its rural and destitute sick. It appears to be a complete nonissue for people.
There is an increasing shift of perception from healthcare as a public service to health care as a consumer product, a commodity to be evaluated with respect to economic advantage and supply-demand analysis. Of course it’s easy to put a moral spin on the whole issue and to say that we owe it to our poverty-stricken brethren and whatnot (which, for the record, is precisely what i believe). And perhaps that works in a semisocialist society like India. But how does that translate to a thoroughly capitalist system like the United States? Is it wrong to tell doctors that they shouldn’t be allowed to sell their services to the highest bidder like those who bear other skills? What is it that makes medicine different?

food for thought… I’ll be sure to bring this up again soon, perhaps with fewer questions and a few more answers from my side. Ciao for now.