CHAD Continued

On Wednesday of my CHAD rotation, I was able to witness another unique aspect of the healthcare system here at CMC: nurses rounds. As I mentioned in my last post, on Tuesdays and Thursdays, doctors along with a couple nurses venture out in the community in the traveling clinic on wheels. In this scenario, patients are expected to seek attention at the traveling clinic when it comes to the village. However, some patients do not adequately follow up during these village visits or may require more frequent monitoring than once every 4-6weeks. To better serve noncompliant patients or those who require very close follow up, CMC has implemented "nurses rounds." A few days during the week, two white jeeps packed with a couple of nurses and "health aids" along with a driver visit specific communities and villages to check up on non compliant patients or follow up high-acuity problems. The nurse we rode with explained to me that every nurse employed by CHAD for community outreach is in charge of 15,000 people. I took this to mean that she is responsible for following up the care of people in a localized collection of villages. The health aid that was also along with us is apparently responsible for only 5,000 patients and is able to be more intimately involved in their care. So during the jeep ride out into the villages, the two women (health aid and nurse) discussed their common patients and decided which ones we needed to see on that particular day.

When we arrived at our first community, we were greeted by an elderly lady in an elaborate saree (all the women in all the villages wear sarees, regardless of their economic status). The nurse informed me that this village elder acts a health care liaison for the community and helps the nurse and health aid identify potential patients and monitor their progress. In the first village and throughout the day, we saw many different people with a range of reasons requiring follow up. We saw some simple post-natal visits, a woman monitored for preeclampsia, a young 28 year old bald woman receiving chemo for a ovarian germ cell tumor and a few cases of acute infections such as scabies or febrile illness. The nurses main job during the visits was to check in with the patients, offer education and advice and triage their care to decide if they needed referral to the main CMC hospital. The whole experience was an incredibly unique opportunity to see people in their communities and witness up close what their living situations are like (most people live in relative poverty, however, they seem to have tight bonds to family and community and live a peaceful existence). The system of individualized care in such a vast population is quite remarkable and was very impressive to witness personally. (Since returning to the US, I have read a wonderful National Geographic article about health care administration in India, and their description of health care structure is similar to what I have written about here. Interestingly, the article pointed out that the reason nurses and health care aides who have received some medical education and training can make such a huge difference in India, is that the majority of diseases that people die from, such as starvation, diarrhea and infections, do not require doctor intervention or even hospitals. Most death and disease can be prevented with proper education about infection prevention, breast-feeding, nutrition, home remedies and personal . I did wonder at the time I was there how these women could possibly be making much difference since they don't carry medications or perform procedures. The answer, I now know, is that even minimal community education can keep the population healthy without any need for advanced interventions.)

After having two days of such eye-opening experiences, both Stefanie and I remained in the outpatient clinic today, seeing routine patients visits with the CMC interns (although I guess it depends on your definition of routine...for example, I saw several cases of rheumatic heart disease and a couple parasitic infections, which isn't exactly routine in the US). I saw one elderly woman, about 65, with complete uterine prolapse, meaning her uterus essentially extended completely out of the vagina. It was very physically uncomfortable for her and she had delayed seeking treatment most likely due to embarrassment. After examining the patient with one of the OBGYNs, the doctor informed the patient she would require a hysterectomy and needed referral to the main CMC hospital. The woman looked very concerned with this news and spent a lot of time arguing with the intern. Later, the intern filled me in on the conversation, explaining that the woman was really resistant to having the surgery. He informed me that in India, having a hysterectomy represented loss of womanhood and femininity. In the US, it is more comparable to have a mastectomy. Even though removing the uterus has no aesthetic ramifications and despite the fact that this woman was postmenopausal and could no longer have children, the uterus still represented fecundity and helped defined a woman's role in Indian society. As I have noted in prior blog entries, I just find inextricable linkage of social norms and women's healthcare in India very fascinating, which adds a whole different dimension to administering care in this country.

Overall, the week was very interesting with a huge range of experiences packed into just a few days. I think the rotation has given me a much better sense of the Indian population and the particular challenges of caring for such poor communities with minimal resources and incredibly underdeveloped infrastructure.