Saturday, December 09, 2006

Taking their first medical history in 70 years

As mentioned, over the last two days I have been carrying out medicals on some of the elderly villagers of Keelalathur. It was a sobering experience and I am never going to tolerate people slagging off the NHS again. The people I saw are amongst the most vulnerable of the villagers and have been targeted for exactly that reason.

There are many compounding reasons for their vulnerability. Firstly, elderly people have increased morbidity, secondly, there is a concomitant loss of function which makes self-care harder. This is true of all elderly the world over, but in India there are other factors to be considered. Traditionally, people live in extended families of up to 40 people, or even more. In arrangements like this different generations live together and, apart from the expected in-fighting and petty jealousies, there is mutual support between family members. This sounds like a good, non-governmental method of creating a welfare system, but when you add a dash of poverty, the recipe changes.

Village houses vary in type, from concrete squares with 4 solid walls, a roof, windows and several rooms, to a small, low, long hut made of adobe (cow shit) covered in withering palm leaf thatch. One room serves every function from kitchen to bedroom (the loo is "open plan", ie, you shit on the road side) and there is no chimney. Cooking is usually done over a stick fire or kerosene stove. There has been some effort to utilise biogas and bottled gas, but the latter is expensive and the former, although a brilliant idea, only works where there are enough cows to provide enough crap to provide enough gas to cook a chappati on, and there aren't. As a result the huts are full of health-destroying smoke which has nowhere to go. The only filtration system is the capillary gas exchange of the many occupants' lungs.

This is just one of the multitude of health problems resulting from the villagers' lifestyle and I haven't even mentioned malnutrition, gastroenteritis, mosquito-borne disease, TB, undiagnosed cancers, leprosy (fortunately drastically reduced since I last visited, but India is still one of the 7 countries remaining worldwide not to have controlled it adequately), injury (from the total absence of health and safety measures), rising diabetes problems; and doesn't even begin to touch on the possible mental health effects of such an existence. A colleague at RUHSA conducted a study in the area and found a staggering suicide rate of 148 per 100,000, with the highest number in young girls from 10-19, as compared to a rate of 2.6 per 100,000 in the UK.

The lovely romantic notion of family members living side-by-side in mutually beneficial harmony (a difficult image to sustain once you have seen the adobe huts) is not the reality. In the villages, there is so little money to be made by staying put, that the younger generation often leaves to work in the cities and leave the older people behind. Several of our elderly people are widowed and living alone. Alternatively, if the younger generation has stayed put, living in extended families, the meagre income is prioritised to feed those family members who can generate more money. This is rarely the crooked white-haired grandmother with a ragged cotton sari and barefeet.

The government has a partial solution to this problem. Elderly people who have no sons (whose responsibility, traditionally, it is to look after the elder family members) get 200rs per month (₤2.35), which is a pitiable sum, but those who have sons get nothing. As there is not enough money for basic essentials, you can imagine what the spending is on health care. Zilch. Except in extreme emergencies, when the essentials are forgone. But even then, the elderly do not pass the criteria required to count for an extreme emergency. They are old, they are going to die anyway. Why waste money. It's the brutal end of a spectrum we are surprisingly familiar with in the UK, but we pretend we are not.

Our project is a small attempt at introducing the concept of elderly care into a culture where even to be old is an achievement. With the "greying" of the population - India has the second highest number of people aged over 60 in the world - occurring here at a faster rate than in the UK, with no provision for elderly healthcare, nor even for a consistent universal primary healthcare, it feels like a futile drop in a stormy ocean, but the ocean, too, started as a drop. And before that there was also Chaos.

Sitting in the yard of the Community Centre building, with the tamarind leaves gently dropping onto our precious note paper, watching the stooped, barely clothed people coming across to us, handsome faced and dignified, I thought of how far from my UK practice I was. We greet each identically with hands clasped in front of our faces, smiling, our heads rocking in synchrony. For each of them, the first question, through the translator, is: "Have you got any medical problems?".

It's a peculiarly difficult question to ask when there are no notes, no previous records, no knowledge of their life for the last 70 years; it seems to create an undulation of despair in them. Where can they start? Of course they have medical problems. Even the act of going to the loo, without the benefit of Occupational Therapy putting in handrails in or raising the loo seat - they have to get up and down from squatting 6 inches off the ground - causes problems for their elderly, arthritic, undernourished joints. Forget about the fact that they are trying to earn one or two rupees a day by sweeping the temple floor with a brush made of coconut fibres, requiring requires a posture akin to someone actually picking the dust up from the floor by hand.

On the first day, I met three people. None of them weighed more than 37 kilos (less than 6 stone). They all had marked kyphosis - dowager's hump - caused by osteoporosis and all of them looked bewildered at the interest we were paying them. Yesterday, I saw 5 more people. The first lady cried when I asked about any medical problems. She rattled off a long list of concerns - poor sleep, difficulty breathing, no appetite, problems swallowing, constipation, pains in her stomach, to name a few. She lived all alone, hunched and helpless. She had never been inside the community centre to see the doctor in her life. She was telling her medical history for the first time.

During the examination, it became apparent that this lady, in addition to her long list of existing chronic problems, was acutely unwell. She was pyrexial, tachycardic, tachypnoeic with a low blood pressure. It was at this point that the wonder of the NHS truly became apparent. At home, I would have sent her into hospital. I would also, probably, have known more about her than I did. The receptionist would have called an ambulance, it would have come to the surgery, picked her up and taken her into hospital, where hopefully, the source of her infection would have been investigated, she would have been treated with antibiotics and been discharged back home, with perhaps a care package to ensure she could cope at home. Now obviously, sometimes, details within the NHS let us down, but we never stop expecting it to look after our health. We take for granted that our doctor, although perhaps she (or he) can't maybe give us enough time, knows what pills we are on, what problems we had with our bowels last year, that we had a crisis of confidence at the start of a new job. We take for granted that, as women of childbearing age, we will be called for a smear test every few years; that we can go to countries where polio still exists, safe in the knowledge that we have been vaccinated against it.
And all this without having to make the choice between health and nutrition.

Staring, helplessly at the darkly wrinkled face, I weighed up the options she had. To go to hospital she would need transport, a bus, for which she needed money. To receive treatment from the hospital, she would need money. To get medication from the chemist, she would need money. She had none. She could do none of these things. There was an option of coming back to the mobile clinic in 6 days, where she could get some pills, and they would probably waive her fees, but she needed some treatment now. The best we could do was to buy her 12 paracetamol for 12 pence and hope for the best. On a little slip of paper I wrote a note to the doctor in the following week's clinic hoping that nothing disastrous happened over the next 6 days. So now, you can understand why my tolerance of people moaning about the NHS will be very very low.


Anonymous said...

I was going to wait until I'd caught up and read all the Blog (have still got to read November) before I took (for me) the high tech step of posting a comment. However, having read this last entry I feel compelled to type something. I was feeling rather preoccupied with a dozen niggling stresses this morning (many of them Christmas induced)and you've really pulled me up short. I will no doubt still spend the rest of the day stressing about all the same things but you have reminded me that I am very lucky to have the luxury of being able to worry about exactly what I should cook on Christmas day and what if it's too late to order a turkey.
One point I will make though is that failings in the Indian health system ahouldn't stop us trying to remedy failings in our own health system even if they are not so catastrophic as in places like India.
Keep blogging and I'm chuffed to be friends with s.o who is at least trying to do something as oppose to sitting on the sofa swearing at the newspapers.

Anonymous said...

Might print out this last entry and give a copy to the next scrounging personality disorder that walks into my morning surgery...