I had fun writing about my first experience in an Indian hospital. The mundu-clad old doctor effectively assaulting me, first with words then with a thick needle (though he got the job done); the bright stares and fascinated questions of the orderlies as they injected my pale skin with anti-tetanus serum. I found it all highly amusing even as it was happening. But why? I had a serious wound which was treated appropriately. Where's the hilarity in that?
There are a lot of reasons. The unfamiliar environment, the staff's attitudes and the coarse, anaesthetic-free treatment each added a layer of absurdity to proceedings which were not that funny in and of themselves. It was all rough edges and imprecise approximations, all jugaad, not a job well done but a job done well enough.
This persistent quality of inexactness (articulated very well here by Paris-based NRI Noopur Tiwari) is one of the most charming things about India. It puts a smile on your face whenever the vegetable vendor throws chillies into your bag in lieu of coinage, or when the man you've just met on the train calls you 'brother' and means it. But does it have a place where lives are often at stake? How much approximation can we accept in India's hospitals?
Between the facilities available and the delivery of care, I witnessed a range of combinations in quality at Indian hospitals. None was ideal.
The general ward at Thiruvananthapuram's Medical College was a hall of thin curtains and tall, unglazed windows; it held up to seventy or eighty patients at a time, each seemingly suffering from a different condition. Attention from nurses – let alone doctors – was extremely sporadic. Given the almost total absence of care and technological resources, the chief order of business for most patients on the ward was to get out, either to the comparative safety of their homes or on to the next world.
At the other end of the scale were the shiny floors and plasma screens in the lobby of Credence Hospital, a women's facility also in Thiruvananthapuram. The service at reception was swift and impressive, and wait times were less than an hour. It was easy to be impressed with what felt like a Western-standard facility just kilometres away from the dreaded hall of the damned at Medical College. Unfortunately, the delivery of care let it down: the consulting doctor treated my friend with icy detachment, as if the letters before and after her name gave her the right to look down on her patients. At Credence Hospital, the Indian pride in material gains was not paired – as it usually is – with an equivalent pride in treating the guest as one's temporary God. Indeed, the pride extended no further than the expensive, comfortable chairs occupied by self-important physicians.
Somewhere in the middle is Varkala's Sree Narayana Mission Hospital. I went there in early 2011 with an appropriately inexact complaint: I felt funny. For the previous two weeks I'd suffered increased tiredness, a slight headache and dizziness and had a few problems with memory. I put off seeing the doctor for as long as I could, partly because of my previous experiences in Indian hospitals and partly because of my own stubbornness. Thinking I might have an inner ear problem, I got an appointment to see Dr Sureshkumar, an ENT surgeon.
Sree Narayana Mission Hospital's buildings are no more impressive than those of Medical College, and certainly a world away from Credence. Each is a relic of the past century, with only a few computers and some plastic seats to modernise decades-old, functional, concrete rooms. My consultation with Dr Sureshkumar was held in one such room, with the requisite young nurses hovering at the sides. Dr Sureshkumar picked up his pen as I sat down (he had no computer). I braced myself for brusque, courtroom-style questioning.
However, this doctor was not like the others. I couldn't call him warm, or friendly, but he looked me in the eye and proceeded with straightforward questions to try and sort out what was wrong. It took a few minutes to go through symptoms, recent activities and medical history, after which he examined my ears and checked my blood pressure. Finding nothing of note, he ordered blood tests and prescribed vitamins and a tablet to improve blood flow to the brain. Finally, he requested that I return after five days to update him on progress. I thanked him, had blood taken in the laboratory (which had vials of blood in a heap on its wooden bench, alongside a pile of unused syringes) and went home. The whole process took about an hour, including wait times.
At my follow-up visit, I collected my blood results from the smiling nurses in the lab. Dr Sureshkumar looked over them and, noting no new symptoms, advised that we watch and wait for a further five days. I didn't keep the next appointment as I felt I was getting better, but the haze descended once more a week after that and I returned to Mission Hospital. He quietly and seriously scolded me for not following up with him, then ordered a CT brain scan – on which, again, there were no abnormalities. He restated the lack of anything unusual on all my tests and examinations and suggested we follow up again in another four days, at which we could consider referral to a neurologist (who only visited on Mondays). I started feeling better within three and missed that follow-up, too; a week later, I had recovered and was getting on with my life as normal.
There was no cause for laughter throughout all of this. In fact, if there was any weak link in the chain in terms of looking out for my health, it was me and my poor appointment-keeping. Dr Sureshkumar went about his work with clear-headed efficiency and genuine care. I noticed that nobody left his office frowning, or nervous, or confused; all, from wide-eyed children to stooping aunties, strode away with relative purpose to the next station of care. The nurses, meanwhile, smiled and assisted wherever necessary, and escorted patients to where they needed to be next (this seems to be a surprisingly uncommon practice in hospitals everywhere, not just in India).
My positive experience at Mission Hospital got me thinking. If Dr Sureshkumar can perform so well, and with such uncluttered directness, why can't all medical practitioners do the same?
In his book 'Better: A Surgeon's Notes On Performance', the widely read and respected American surgeon Atul Gawande wrote about the lack of coherence in rural Maharashtra hospitals. He tells remarkable stories of doctors fighting the heavy odds against them - massive patient numbers, limited space, lack of available medicines and underqualified colleagues - and successfully treating a multitude of difficult cases. Knowing full well the impossibility in such remote areas of implementing a revolution in either medical technology or knowhow, Gawande demands the government's intervention on diligence:
New laboratory science is not the key to saving lives. The infant science of improving performance – of implementing our existing know-how – is. Nowhere, though, have governments recognised this. A surgeon in much of the world therefore stands on his own, with little more than a pen, his fine fingers, and his wits, to cope with a system that barely works and an ever-growing sea of patients.
The medical community in India has mostly resigned itself to current conditions. All the surgical residents I met hoped to go into the cash-only private sector (where patients with the means increasingly seek care, given the failure of the public system) or abroad when they finished their training – as I think I would, in their shoes. Many attending surgeons were plotting their escape, too. Meanwhile, all live with compromises in the care they give that they cannot bear to tolerate.
(from Atul Gawande's 'Better: A Surgeon's Notes On Performance', pp 242-243, Metropolitan Books, 2007)
Just as they are on Indian roads, the margins in Indian hospitals are narrow and roughly approximated. Medical outcomes, from delivering a child to cancer treatment, have so many variables weighing upon them that it is often impossible to predict where a given patient will end up. However, the variables that can be controlled should be identified and carefully managed, to whatever extent possible.
In too many cases, this is not what happens. There are hundreds of stories online of medical professionals in India failing to perform adequately, such as this American couple's attempts to be treated for food poisoning and fever, or this article about widespread recycling of dirty syringes. The bottom line is, I got lucky with Dr Sureshkumar and his Mission Hospital colleagues. Even though my malaise petered out seemingly of its own accord, he demonstrated the value of methodical, thought-out care; how one man, employing a combination of understanding and diligence, can perform at his best.
As Gawande often says in his writing, the idea of doing the basics right is an old one. It's so old, in fact, that many people in important positions cast it aside, believing it irrelevant, especially when newer technologies are doing so much to improve and lengthen our lives.
The basics, of course, remain the foundation for everything else we do, and to forfeit quality and diligence in a field like medicine is to forfeit lives. There are no doubt thousands upon thousands of medical professionals in India who perform to the same standard as Dr Sureshkumar does. They need to be rewarded, and those who fail to follow their example need to be brought up to the same level. This will be an enormous task if the Indian medical community is as resigned to current conditions as Gawande says. But, unlike a cancer patient's prognosis, it is a possibility that need not be approximated.