Some stats and some thoughts

As I follow doctors around in private clinics that treat the middle and upper class of India, I've been thinking a lot about the overall realities of healthcare in this country, the US and worldwide.  I finally looked up some stats and this is what I found:

The world health organization has ranked (in 1997) the overall health system performance of 161 countries.  The performance is based on quality, equity, efficiency of each countries health care system.  The top 10 countries are France, Italy, San Marino, Andorra and Malta, Singapore, Spain, Oman, Austria and Japan.  The United States ranks 37, Philippines 60, Mexico 61 and India 112.  Take these stats for what you will, I know they are old and critics say flawed (but what research isn't?).  I still think it gives a good rough estimate of where countries stand relative to each other.  While I'm not surprised about the US, I am surprised that India is so far down the list!

Since I am partaking in maternal and child health program here, I thought I would relate neonatal mortality statics for a few countries.  In 2011, 4/1000 neonates (birth to age 28 days) in America died.  This number is the same as such countries as Canada, Brunei, Hungry, Malta, Poland, and Serbia.  This is worse than some countries such as Sweden, Switzerland, Spain, Singapore, Slovenia, San Marino, Malaysia, Lithuania, Korea, Cuba, Greece, Iceland and Belgium.  By comparison neonatal mortality in Mexico was 7/1000, the Philippines was 12/1000 and India was 32/1000. Myanmar has a slightly better neonatal mortality rate than India at 30/1000.

Prior to coming the India, I had heard many things regarding the abject poverty that existed.  From my extremely limited point of view, it seems similar to the Philippines (which is really by best comparison), so why is the healthcare in the Philippines relatively better than India?  According to the CIA (which takes data from each of the countries and makes the statement that there are vast differences between what each country constitutes poverty), the percent of people living in poverty in India (2010) was 29.8%.  I have since read an article where the government claimed it was down to 22%.  I also read an article stating the government will revise their definition of the poverty level to Rs 27 rural and Rs 33 for urban areas, and that 70% of Indian live on less that $2/day (currently the 68 rupees - 1 dollar).  I believe you can't just convert the amount someone is making into dollars and make statements regarding their wealth without taking into account the cost of living in their country, but Rs 33/day seems very low to me.  Even 136 rupees seems ridiculously low for a poverty line.  By comparison, 26.5% of Filipinos in 2009 lived below the national poverty and 15.5% of Americans (2010).

I found the following maternal mortality rates via the CIA.  They ranked these rates with #1 being the highest and 183 being the lowest maternal deaths. Many countries in Africa unfortunately top the list with Chad having the highest maternal mortality rates at 1100 per 100,000 births.  The Philippines ranks 73 with 99 per 100,000 births, India ranks 53 with 200 per 100,000, Mexico ranks 108 with 50 per 100,000 and the US ranks 136 with 21/100,000 births.   Places like Turkey, Puerto Rico, New Zealand, UAE, Kiribati, Qatar, Slovakia, Norway and the Czech Republic have fewer maternal deaths than the US.  The country with the lowest mortality rate is Estonia with 2 per 100,000 births.

I am clearly not getting a complete picture of maternal and child healthcare in India from my time here.  It has been wonderful observing doctors here and I have learned a lot, but I am getting a narrow slice of life that only includes those that can afford private healthcare with doctors, many of whom have studied abroad.  I know part of it is the fact that I am only seeing urban healthcare, which as I have hinted at in prior posts, is FAR different than rural healthcare in India.  I have read that most of the country still lives in rural areas (though urbanization abounds).  If this is true, than I have not seen the healthcare of the majority of Indians.  While in Northern India I was able to spend a few weeks in a more rural setting and was able to see some of the differences in the access to many of the facilities that are available in the city.  I was also able to get an idea of the differences in complaints between urban and rural folk.  I would be interested in spending some more time delving into these differences, trying to figure out why there is such a health disparity in this country And if I was really motivated, I probably would've already done so.  But unfortunately I am not, which is not to say that I am not extremely interested in the topic.

I am also curious as to why so many people abroad think the United States is far more equitable than it really is.  I was discussing the percentage of Americans in poverty, the shortage of general practitioners and the disparities of rural/urban healthcare that exist in America with the doctor I shadow and he was shocked.  He was of the opinion that everyone in America got the healthcare they needed.  He is not the first one to be surprised when I talk about disparities that exist in my country.  One doctor was amazed when I said there is a large homeless population in Portland.  What has perpetuated the idea that America is so equal abroad (I ran into the same state of mind in the Philippines)?  Is it simply because it is seen as a superpower, therefore it must have it's shit together?  I remember hearing many people in the Philippines talk about how America was the best country to immigrate to.  Many times I wanted to tell them to do their homework and decide what is important to them (universal health care, low poverty rates, good education) before decided which country would be best.

Fishing Village Weekend

Last weekend I looked up beaches not too far from Pune and headed for one.  I ended up going to Shrivadhan.  Google told me it was less than 200km away and it would take 3.5 hours to drive.  I thought, no problem, it'll take 4-4.5 hours by bus and should be fun.  Well, I should have learned by now that Google is not the most reliable source when doing anything in rural areas.  It was an absolutely gorgeous drive, going by Mulshi lake and through the ghats with about 50 waterfalls that I could see from the bus, but it did not take 3.5 hours.  The roads were terrible and the bus was incapable of going above 5 mph on ground that had the slightest incline.

About 5.5 hours later I arrived at Shrivadhan.  When I first arrived I began walking to find accommodation.  I started to get nervous when I walked 10 for awhile on what appeared to be the main road only I didn't see anything that looked like a place to stay, there wasn't even a restaurant.  Finally someone noticed I was looking a little panicked and asked if they could help.  They pointed me toward the direction of the hotels, which were a little farther down and I eventually found one.  It was actually quite nice and about 5-10 minute walk to the beach.  I put down my things and ate lunch in a hotel (I was the only guest) and then headed to the beach.  When I got there, I was the only one, aside from 2 kids playing in the waves.  At the far end of the beach appeared to be a small fishing village, so I decided to head there.

By the time I made my way to the boats many of the fishermen were coming in for the day.  I waved to one fisherman who was looking in my direction and he motioned for me to come over and take pictures of them picking the net, so I did.  They were all very nice and spoke very little English (and I very little Marathi).  They brought me a chair so I could watch them work, as well as snacks of fruit and samosas.  They kept telling me to eat dinner with them when they were finished, but they were also very concerned about how I would get back to my hotel after eating dinner.  It was decided that I would take an auto and I waited for them to finish their work before we all headed to the home of the owner of the boat.  It turns out that everyone picking the net was related, the owner of the boat and his two brothers and their families all help.

In India I have heard the saying "a guest is like a god."  Essentially this means you should treat a guest like a god.  Hospitality here is the tops and the fishing family was no exception!  They were all very nice and I had a great time, even though our communication was very shallow due to the language barrier.  They had me wash my hands and feet and sit down to watch some TV and chat while we waited for the women to finish cooking fish for dinner.  They served me first and filled me so full of delicious food.  Everyone watched me eat and the cook was quick to add food on my plate as soon is it began to run low.  The chapati they made was from rice flour, not the usual wheat.  I had fried fish and a prawn curry and of course rice to finish off the meal.  After I was done, they rushed me to the auto that was waiting and we tried to figure out where I was staying.  I wasn't expecting to wander so far from my hotel and I never bothered learning the name, I knew how to get their from the beach, but not via the roads.  Eventually we found it and I went straight to bed, exhausted, full and happy. 

Note the two buses trying to pass each other on the narrow road.  It takes some pretty talented drivers to do that and not hit (it also takes about 15 minutes).

Pomfret fry and curry for lunch with some papad, chapati and rice on the side.

The walk from my hotel to the beach.

Roadside view.

Tourist attraction: ride in the carriage up and down the beach.

Shrivadhan beach.

Near the fishing village.

My wonderful hosts, getting ready to pick the net.

The bottom fish is what they fried up for me to eat.  A little mushy, but tasty.

Picking the net.

Lead line

Another boat going out to see.  Notice the logs in front of the boat, that are used to move the boat along the sand.

Catch!

Me with a fresh coconut (quite possibly the best drink ever).  Also the last picture of me with my old glasses.  I offered them up to the Arabian Sea when I took a dip and forgot to hold them.  Thank goodness I bought a new pair in Pune a couple weeks prior.

If you squint and rotate your head to the right you might be able to see the Great Hornbill hidden in the branches.

Bus ride home.

View from bus.

One of the many waterfalls seen from the bus.

Mulshi Lake and cows.

Births!!!!

I've been lamenting how I've been in here for the past 3 weeks and have yet to see a vaginal birth.  I have seen 5 cesarean sections and while all births are exciting, these are not quite the same.  I narrowly missed 2 vaginal births on separate occasions, once just last Friday!

Today I went for morning clinic and the doctor told me I missed two births over the weekend.  But then he mentioned there is a woman in the labor room who as been there since last night.  I was so excited!!  I asked if I could watch the labor instead of watch him do paperwork in his office.  The doctor told me to go in and so I did.  I arrived just before the anesthesiologist.  She is a very nice woman who specializes in epidurals.  She explained to me how the epidural works and the medications she uses.  I watched her put in the epidural.  I have seen a few spinal blocks before this, but those don't compare to the thick gauge of the epidural needle.  After it was in place the laboring mother was hooked up to a pitocin drip.  Apparently this is modus operandi  at this clinic, where they like to "augment" the labor.  The mother was significantly quieter after the epidural.

I love how the doctor's here like to throw around the word "painless."  They have "painless" vaccination injections, that are supposed to be less irritating than the whole cell vaccines.  They also have "painless" births with an epidural.   The doctor comes in and asks if they want it painless or regular.  Of course the patient is going to choose painless!! I asked the anesthesiologist how common epidurals are and she said it depends on the hospital and how good they are at convincing women to get them, but that the hospital rate is about 80% with "very good results."

After I had been watching the young mother labor for about an hour, the nurses rushed in exclaiming another mother just arrived in full dilation.  They ran around getting many things ready, seemingly forgetting about the first laboring mother.  The second mother was indeed further along than the first and the hospital staff went to work painting her with iodine in preparation.

Now, I have never seen a birth before, other than on TV, but I was a little shocked by how medical it was.  The doctor scrubbed up and put on the same gown he wears for surgeries.  He had a whole slew of instruments next to him.  They placed the green clothes they use for surgery around the mother's vagina. Apparently all of this prep work was for the episiotomy.  According to the doctor, all first time mother's get cut to avoiding tears.  He said the rate is 100% because the Indian perineum is too small and weak, not strong and long like American perineums.  I'm serious, that's what he said.  So, to avoid tearing, every single mother is cut.  Every one.

The first baby came out screaming and I didn't have time to see much of it before I was rushed into the other room for the second baby.  The same thing occurred, but the baby just hung there as the doctor cut the cord.  They hurried this baby into the room of the other mother, where they began to resuscitate it while the other mother was being sewn up.  The baby was atonic, which they knew was a risk because of the ultrasounds.  They gave the baby a few breaths and stimulated it while rubbing it's back.  Eventually he began to cry and by 5 minutes the APGAR was good.  A little while later, the pediatrician came by to check on the babies.  He comes for every birth to assess the little ones.

Traveling Domestic in India

In case you've ever thought about traveling to India and then taking a domestic flight somewhere, here is some advice:

First, if you are having a taxi pick you up at your accommodation tell them your flight is 1/2 hour earlier than it really is, that way when they arrive half an hour late, they'll really be on time.  When you get into the cab and they tell you it will only take 30 minutes to get to the airport, remember it will really take 45-1 hour, especially if you're in a major city with a lot of traffic, which you probably are if you are flying.  When chatting with the driver, keep an eye on the road to make sure they are taking you to the domestic terminal, not the international terminal (it's so easy to get confused, all of the foreigners leave eventually, don't they?!?).  Please remember to carry a hard copy of your itinerary, you will not be allowed into the airport without it.  They will make you go to a counter next to the airport and charge you at least ten times what it costs you to print in at an internet cafe.  Plus, if you didn't take the advice at the beginning of the paragraph, you are probably running late and these lines can move very slowly (remember shoving is the norm).  Once you are in the airport, don't think it will be easy to find the counter.  Luckily, they don't close the counters 45 minutes prior to departure like they do in the States, so if you miss calculated how long all of this would take and you're plane leaves in 20 minutes do not dismay!  Be sure you find a friendly airline staff person who will personally escort you through the secret passageways (aka elevators) of the airport so you can arrive safely just in time to board the airplane.  Actually, just in time to board a bus that will take you to the airplane where there may or may not be someone else assigned to your seat.  Calming explain this to the stewardess, who will tell you to just keep the seat you randomly sat down in while waiting, unless of course you prefer a window.  Lastly, enjoy the flight!

I am a Glutton for Rain

I wouldn't have thought the title for this post was true, but I'm beginning to think it must be - for I reside in Portland, OR.  Last summer I spent in the gray of the Bering Sea and now I am touring India during the monsoon season.  During my time off from visiting doctors I've developed a habit of heading toward the nearest mountains, where undoubtedly it rains even more than in the cities I have been staying in.

This weekend was no different and I headed to Mahabaleshwar, a hill station about 3 hours away from Pune.  During the monsoons Mahabaleshwar is stuck in the middle of a very large cloud.  Occasionally the wind will whip through for long enough to part the fog for a few minutes.  It is always surreal to be living in such dense air.  It's also very beautiful, though I'm afraid it doesn't lend itself to the best pictures.

I traveled to the hill station via "semi-luxury" bus, which meant there were actually seats instead of plastic covered bench seats.  I hired a taxi to take me to the many "points" around Mahabaleshwar.  We spent 5 hours the first day.  The second day I visited Pratapgardh Fort, an old fort that was at one point held by a Maharathi hero Shivaji.  It was gorgeous in the think fog.  I spent most of my time walking the wall of the fort hoping for a break in the clouds to look down at the cliffs, but alas I could never see far in front of me, though I could often hear the sound of water falling below.

On the road to Mahabaleshwar

Carabao on the road.  In this area people often paint the horns of the carabao and cattle orange.

The guide that took me to the "points" where there was no view was insistent on taking "very super photos" of me along the way.

My taxi.  We went on a 5 hour tour

Boiled salted peanuts in a cone made out of what appears to be the vendor's child's homework.

Valley view from the top of the waterfall.  The clouds were nice enough to part for at least a little bit.

Gorgeous waterfall off the edge of the plateau.  I spent about an hour wandering around this area.

River made by the waterfall.

Mini-waterfalls above the major one.  Most of the local tourists were getting knee high in the water to have their picture taken with them.

They are crazy for strawberries around here!  This is a strawberry patch.  The plants are originally from California.  Unfortunately it is not strawberry season currently, but that doesn't stop them from selling frozen strawberry d-lights!

Strawberry cream.  It has cream, strawberry ice cream, strawberry crush (a type of syrups with pieces of strawberry) and frozen strawberries on top. It lasted less than 5 minuts.

To wash down the sweetness of the strawberry cream I tried makai pakoda (corn pakora) and onion pakoda.  I was skeptical of the corn, but it was fresh and actually pretty tasty.

Monkeys!! These are the first ones I've seen sine traveling to Pune.  I missed them so.

Typical view from the many viewpoints I visited over the weekend.

After waiting about a half hour the clouds broke for about 5 minutes to offer up this view.

Monkeys huddling in the rain.

Nandi the bull.

I visited a few temples that are about 450 years old.  This was the first and had the smallest Shiva linga (phallic symbol) I have ever seen.  I chalk it up to hundreds of years of people worshiping it.

Another 450 year old temple.

This is what happens to many of the historic structures.  The old temple is preserved underneath this monstrosity.  This was my favorite temple.  It is at the site of the beginning of 5 rivers of this part of India.  Each river flows from a spring through a hole in the temple where they mix and then flow out of the mouth of a cow into a large square pool then into another cow and out of it's mouth into a square pool.  People drink from the waters of the first cow and I imagine bathe in the pools.  I would have taken pictures, but as is often the case, photography inside was prohibited.

Non-veg dinner.  I think this is the 3rd time I've eaten meat since I came to India.  I do love vegetables, I just wish the most popular one wasn't potato (which apparently counts as a veggie in India).  Between rice, chapati and potatoes I can have a 3 carbs in one meal!

Pratapgadh Fort.

Uttapad masala for breakfast.  essentially a giant pancake with, you guessed it! potato on top.

More fort.

I started playing around withe the dramatic setting on my camera.

All of the buildings are wrapped in tarps for the monsoon season.

Shivaji

Lassis for sale.  I love the ceramic mugs.  There's a bubbler in the cauldron keeping the lassis frothy.

One of the coolest downspouts ever.

Way in or out of the fort area.