In India, the sun always rises in the east and sets in the west; at least it has done so far. Such consistency and predictability is, however, conspicuously absent from most other aspects of life in this colourful country. It seems that the only traffic rule is that cows have universal right of way. Towers of capitalism represent India's aspirations to become a developed nation by 2020; but illness and disease still crawl in the streets below. In the field of health care, a wide variety of therapies exist for the treatment of every ill, delivered through a complex interplay of private, government, and charitable institutions, by allopathic, homeopathic, and traditional healers.
I am writing this during a 6-week visit to the Low Cost Effective Care Unit (LCECU), a charitable offshoot of the Christian Medical College and Hospital, in Vellore, Tamil Nadu. LCECU is run by Dr Sara Bhattacharji and her team. They provide cheap or free medical care to the poor people of the town, predominantly on an outpatient basis, from a clinic beside the main bus station. The unit also has a 40-bed hospital with basic facilities, so that they can provide the most comprehensive care that resources will allow.
I once heard it said that India is the richest country in the world … in diseases. Hence I decided to come here for a few weeks during my GP training so that I could learn something from India's unrivaled wealth of living pathology. It is also giving me an eye-opening opportunity to experience a different approach to primary care — one in which some features of general practice as we know it are not easily identifiable, but where the doctors are able to be true generalists, perhaps to a greater extent than is often possible in the western world.
Doctor–patient relationships in India can at times seem crude and hierarchical in comparison to the current ideals of western practice. On the whole, patients tend to defer to the doctor's authority for decision making, and their virtuosity is never questioned. The mystique of the profession may be enhanced by the use of English in professional circles, so that the language of medicine is further obscured from lay understanding. It is common practice for two or more doctors to consult simultaneously in one room, with crowds of waiting patients peering through the open doorway — and that's if they're not already in the same room. It's hard to imagine such an atmosphere as being conducive to eliciting each patient's innermost concerns.
The way that western medicine is commonly practised in India encourages a view of health as the absence of physical disease. Perhaps this is an appropriate focus of limited resources for the millions of people who struggle each day to find their most basic survival needs, but a superabundance of ‘body-ache’ hints at endemic somatisation of mental unease. I have been excited, therefore, to see evidence of more holistic attitudes taking root.
The Indian National Board of Medical Examinations has recently begun offering a Diploma in Family Medicine. Although many doctors in India work as generalists, there is as yet no requirement for formal postgraduate training in general practice (or family medicine), and the educated public often have little respect for non-specialist doctors. Nevertheless, several doctors at LCECU have now taken, or are working towards, the diploma, and their enthusiasm for the concepts it embraces is infectious. So too is their enthusiasm for medicine in the broadest sense, and the working environment here reminds me of Hippocrates' oft-quoted aphorism, ‘where the love of mankind is, there is also love of the art’.
The clinical workload is wide and varied — I have seen patients with typhoid fever, malaria, measles, acute rheumatic fever, filariasis, leprosy, and tropical pulmonary eosinophilia alongside no shortage of diabetes and hypertension. Despite such a wealth of pathology, when looking around I see many faces with smiles. There is a feeling that every face matters. Sara tells me that she has grown to feel as dependent upon her patients as they are upon her. The patients, too, seem to possess a special sense of dignified humility with which they face the lotteries of life, and despite the limits of what medicine can offer, their appreciation for the efforts made on their behalf is palpable.
- © British Journal of General Practice, 2004.
