South Indian idyll
Authors: Katrina Darke
Publication date: 11 Aug 2007
Katrina Darke describes how her family spent a six month sabbatical
Our options were numerous. The aims for my husband, Tim Johnson, were broad—to experience general practice in a different cultural setting, to live somewhere culturally exciting, and to have fun. We took our three children: Barney (7), Oliver (6), and Maddy (4) whom we wanted to keep safe and away from war zones.
Although we emailed worldwide, we found few suitable positions. Eventually, however, we found a placement in Tamil Nadu, south India. It was suitable as the health centre needed GP cover for only a limited period of 10 weeks, and they were happy for me and my husband to job share (we both work in general practice in the UK), and they were also happy to accept our young family alongside ourselves.
Friends and colleagues variously thought our adventure was mad, brave, or crazy. It was with a mixture of excitement and trepidation that we left Bristol on 1 July last year and headed for India.
KCPatty is a village of 700 people situated in the western Ghat mountains of south India. The primary health centre covers the surrounding area, a rural population of roughly 17000, many of whom are “adivasis” (tribal). Most villagers live in poverty, working as landless farm labourers who find daily work for a wage of 20-30 rupees (roughly 40 pence). The medical centre is run by its consultant, Rajkumar, with the help of seven health workers, local villagers who have been trained to perform various duties such as routine observations, emergency care, radiography, counselling, and anything else as necessary. There is also a resident registrar who is training in primary care.
The fabric of KCP Health Centre comprises a huddle of concrete buildings that have been erected over recent years. There are two consulting rooms, a small ward where we could keep patients for observation, and a separate room serving as a labour suite. The on-site pharmacy stocks a large range of common drugs, reflecting a similar range to those we use in the United Kingdom. There were, however, some expensive omissions such as asthma inhalers so we used tablets instead, which we struggled to get used to.
Equipment included an x ray machine, which was donated by charity a few years ago. By its side were three plastic buckets containing solutions for developing, fixing, and rinsing films. With haphazard electricity supplies and varying voltage, radiography was an art, involving a variation of exposure with immediate voltage. Resulting films were surprisingly good. An ultrasound machine was also to be found secreted in a box in our bedroom, but unfortunately permission to use it had been refused because of fears of sex selection in pregnancy.
Laboratory facilities on site were limited to urine dipstick testing and ESR. All other blood tests had to be sent for analysis to the nearest hospital two hours away. In reality, because investigations would come at a cost to patients, this meant that we largely worked without recourse to investigations.
The medical day was divided into two parts—outpatients in the morning, and field visits in the afternoon. Outpatients was a mixture of fairly recognisable GP stuff such as hypertension, diabetes, gastritis, and febrile children, enough to give us some confidence that we knew what we were doing. There was also a fair share of the more unusual (to us), such as numerous complications of tuberculosis, rheumatic fever and its complications, and filariasis. The tribal population often marry within their community, so there was a good smattering of the genetically obscure, for example, three sisters with femoroscapulo muscular atrophy and absent femur.
Management of chronic disease in this setting demanded a more flexible approach than we were used to. Patients are reluctant to have blood tests for many reasons, perhaps the greatest of these is cost, so use of diuretics and ACE inhibitors was unmonitored. We avoided high doses of drugs because of this, and were more likely to resort to polypharmacy to achieve clinical results. Likewise, the many insulin-dependent diabetic patients under our care used insulin unmonitored. Even if we could have supplied the patients with free glucometers, the cost of strips is prohibitive for ongoing use.
The afternoon field trips to outlying villages had several aims: to follow up patients with chronic disease, case finding of new problems, and perhaps most importantly, for village health education sessions. Many villages are remote, some reached only by walking for up to nine kilometres by foot through plantations and/or jungle. These treks through banana, coffee, and pepper plantations took us through stunning fertile scenery with the loud backdrop of birdsong. Less appealing was the common experience of leeches. These treks were often tiring, particularly in the heat of the day, yet the villagers confront the same trek when attending the primary health centre with an acute illness. Many women traverse for several hours when in labour; others have walked these distances with broken limbs.
Although financial issues had an impact on delayed presentation and limited treatment of disease, varying cultural norms and myths debatably played a bigger role
Working with such an impoverished population, we often felt uncomfortable at the charge patients had to pay to see a doctor (35 rupees). The elderly population is dramatically affected by the minimal welfare provided by the state. We saw many patients daily who presented with total body pain. More often than not, these people were elderly, yet through lack of other means are forced to continue working as labourers. After years of suboptimal nutrition and heavy work it is no wonder that their bodies are grumbling. I doubt whether our provision of nutrient supplements such as calcium and iron really made much difference.
No waiting lists
Although we missed the egalitarian ethos of the NHS, we were almost daily reminded of its inefficiencies. Patients who needed referral were usually sent to missionary hospitals in the area. Care is provided at a minimal cost, but many of our patients were lucky to receive aid from local non-governmental organisations. Others went to government hospitals where care (but not ongoing drugs) is free. Either way, secondary care came with no delays. A patient with a cataract one week would be reviewed postoperatively the next. Patients with critical valvular heart disease were seen and operated on within the week. A patient who needed an MRI or CT scan would have their investigations performed later that day and would return for further advice the next.
Although financial issues had an impact on delayed presentation and limited treatment of disease, varying cultural norms and myths debatably played a bigger role. Though education is helping dispel some of these myths, there is still prejudice to some who are unwell. Seizures were generally interpreted not in medical terms, but as a visitation from the devil. Fear of the condition means that adults with epilepsy have virtually no chance of marrying—in a society where remaining unmarried is generally perceived as a failure. Suicide rates in young men with epilepsy are high.
Our experience at KCPatty was educational, fun, and life changing in ways we could not have expected. We returned home with a mixture of emotions—sadness at leaving behind such a friendly, dedicated team of health professionals who had also become friends. Yet I also came back with a renewed sense of appreciation for life here, one in which I am not discriminated against because of my gender, social status, or religion, and one in which we ultimately have so much choice, over where we live, what we eat, what we do. I also had a renewed enthusiasm for my job in the UK. Although the work at KCPatty was extremely fulfilling, I did in the end miss working in my own language. Working through a translator, however good, ultimately leads to very predictable medical consultations that miss the nuances of any other patient agenda.
I did have concern about our impact on the KCPatty team. Although they were overwhelming in their appreciation of the time we had spent, I felt guilty at the ease at which we were able to walk away. While we were there, our relative wealth and freedom was obvious. We spent our weekends away from the health centre, exploring nearby tourist sights. I wondered how these health workers felt watching us depart each weekend; several had never gone further than the nearest town.
I often wonder how our translator and our registrar look back on our philosophical conversations regarding life, marriage, and travel. Certainly all our views changed and were moulded during these discussions, but I can't help feeling that we sowed the seeds of dissatisfaction and a desire for the unattainable. Our female registrar will not defy her parents' wishes about her career and marriage—but will this be harder for her to bear knowing that millions of others make these choices for themselves? And our translator's insatiable thirst for intellectual stimulation and literature is sure to remain unsatiated while he has limited access to the resources accessible in larger Indian cities and over the internet.
The children found India variously exciting, colourful, vibrant, strange, and threatening. A predictably huge range of responses over time. After several months they started to miss what they knew from home and became increasingly stressed and irritable; there was also some increasingly odd behaviour from our oldest child. As three blonde children, they stood out from the crowd, and the constant photographs, handling, and cheek pinching took their toll. They were quite simply too young to understand these as cultural differences.
They now look back fondly on the experience, and all talk of going back. The highlight was an elephant ride through the cardamom plantations of Kerala; the tuktuks and the general colour and vibrancy of India remain at the forefront of their memories.
Would we do it again? Probably. As adults it is clear what we gained—an educational and life experience that will remain with us forever. But we'd advise others to think carefully about isolating their children from what they know. The remote setting of the health centre brought challenges over food, lifestyle, entertainment, and ultimately, because of vast cultural differences, isolated the children from others of their own age. They have settled back to life in the UK very well. Depriving them of school for several months has made them enthusiastic pupils. And still now, three months after our return, they frequently comment with appreciation on their lives here, an unusual and endearing perspective for children of their age.
Katrina Darke GP locum Bristol firstname.lastname@example.org