An Indian dilemma

Abstract

Raj, a 4-day-old baby, has not urinated since birth. Dr Jha gently refers his distraught mother to a paediatrician. Nina is 21 years old and has a breast abscess. Dr Jha tells her he will operate on the abscess in the morning, notices her blanched look, rightly guesses her fear, and reassures her that it is not cancer. I suddenly notice an old schoolfriend sitting across the room from me. She unwraps her scarf to reveal a large dressing on her neck. A recently drained tuberculous abscess discharges pus. While Dr Jha examines her wound, our eyes meet. I am embarrassed to meet her under such conditions and leave the room. On returning, I ask Dr Jha whether clean and well-nourished people can get tuberculosis; the sight of a schoolfriend with tuberculosis has shaken me, as if I expected all those who I know to be free from disease. He replies that tuberculosis is very common throughout India and no one is spared. One of the theatre staff arrives to tell Dr Jha that the theatre is ready for Mr Lal’s cholecystectomy. The rest of the throng outside must wait, most of whom have travelled long distances, many on foot, to seek treatment here. Word has spread far about Dr Jha, who, after finishing at the top of his medical class, went to the UK for specialist training and then returned to India. He cares for his own people. At least half the waiting patients will have a non-surgical complaint, but in India there is no medical system to channel patients to appropriate specialists. Dr Jha is first a general practitioner and then a surgeon, as well as physician, paediatrician, obstetrician, and gynaecologist when needed. Dr Jha rolls up his trousers and shirt sleeves, discards his tie, scrubs up, dons a sterile gown and gloves, and walks into theatre. There is a combination of clean and unclean, qualified and unqualified in the theatre. Although the surgeon wears a sterile gown and uses autoclaved equipment, there are six other people present in civilian clothing. The ward is next to the theatre and the attendants walk freely between the two areas. The theatre door is wide open and one of the ubiquitous houseflies finds its way in; someone reaches quickly for the Baygon spray, filling the room with its intolerable smell. The anaesthetist has been working in this clinic for the past 3 years. Before his arrival, a man with no medical background, personally trained by Dr Jha, carried out all anaesthetic duties, and he still assists when the anaesthetist is unavailable. The other attendants, all without medical training, are familiar with different antibiotic regimens, the various intravenous solutions used, and the general care of patients. This clinic works 365 days a year. Thousands of patients go through its doors, and they share between them just three medically qualified practitioners. Bhagalpur, Bihar, India 2200 h, Dec 4, 1996 I stand by the bedside, holding his hand as he writhes in pain. In the dim candle-light, I notice his bare feet, hardened by years of walking unprotected through sun and rain, his hands callused, scarred, and capped by black nails, his dirty torn kurta, and old khaki pants. I take in the agonised look on his face, the trickle of blood at the corner of his mouth where he has just bitten his lip. I am in the private clinic of Dr Jha, on an elective in India at the end of my fifth year of medical school at Monash University, Melbourne, Australia. Dr Jha is still working in his office so we sit down for a chat. That is when Mr Lal is carried in by his wife and brother. In whispered conversation with his wife, she tells me how Mr Lal was pulling his rickshaw when he suddenly felt a pain in his abdomen. Fortunately, he had been close enough to return home, where he collapsed. His brother and wife had taken him by rickshaw to the local hospital, only to find that the power supply had been cut off, there was a shortage of medications and equipment, and at that time of night help was unavailable. It is now 3 hours since the pain began. Dr Jha diagnoses acute cholecystitits, prescribes analgesia, and admits Mr Lal to the clinic for a cholecystectomy.