Update: India Fall 2008
OK, so I’m a sucker when it comes to aiding a “damsel in distress.”
A few months ago I received an email from Dr. Philip, an Indian general surgeon who is also the
medical superintendent of the Lady Willingdon Hospital in Manali - a small mountain town in
Northwestern India. Through a mutual friend (and SIHS member) he heard that I sometimes work as a
surgeon in developing countries and that I might be interested in covering for him while he attended
a rural surgery conference; how could I refuse? Lady Willingdon Hospital, founded in 1935 by the
then British Vicereine of India, is a 50 bed rural mission hospital providing medical care, emergency
surgery and obstetrical care to a population of about 300,000.
I arrived a little over two weeks ago and I’ve had a wonderful time. What could be bad about a hill
station town at 6,500 feet, crisp fall days and plenty of pathology? We’ve taken care of patients with
typhoid perforations, head injuries and spinal fractures, women needing caesarean sections, multiple
TB patients and even did a few open cholecystectomies (gallbladder removals), upper endoscopies
and a colonoscopy. As the colder weather approaches, the patient load has tapered off, and it’s
certainly not the stressful work I had originally anticipated – but there are two main reasons for that:
Dr. Jacob and Dr. Mark.
Dr. Jacob is a young Indian surgeon who recently started working here at Lady Willingdon. Previously
he was on his own at other rural mission hospitals in central India for about 3 years. He is
experienced, pleasant to work with, and has readily taken over much of the work I had anticipated
worrying about myself (when Dr. Philip contacted me, I was to be the only surgeon).
Dr. Mark, also known as Mark Hardy, is a tenured Professor of Surgery at Columbia University in New
York. He’s a vascular surgeon and founded the transplant program at NY Presbyterian Hospital and
recently stepped down as the surgical residency program director (and another SIHS member). I met
Mark a few months ago and he had expressed interest in doing some international work and
developing an international rotation for Columbia surgical residents. When I agreed to come to
Manali, I asked Mark if he was interested in joining me. Both he and his wife, Ruth, agreed. It’s been
a lot of fun having the Hardys here. Mark is an excellent teacher, and surgeon, and has spent a
great deal of time in the Out Patient Department seeing patients and teaching the junior doctors
(there are three) and the visiting Australian medial students (there are also three of them). He’s easy
going, flexible and has a great sense of humor. He was also interested in seeing ‘how I do what I do.’
And it’s been interesting for me to share some of my ‘tricks of the trade’ that I’ve learned from doing
this type of work for the past 6+ years.
As for the work, we make rounds every morning after a short devotion that begins at 9:00 am and
includes one song and a short reading from the Bible, read both in Hindi and in English. The hospital
is a collection of small buildings linked by narrow walkways and outside corridors. The rooms are
small and crowded with from one to three beds; one second storey room with two beds and a sloped
ceiling I call “the Ann Frank room.” The steps up and down are narrow and rickety; the inside of the
old wooden building is green with a pungent antiseptic smell. We start in the four-bed ICU that
contains monitors and a single ventilator. The staff are competent and efficient – a testament to the
leadership of Dr. Philip and his wife, Dr. Anna, an emergency medical physician originally from
Louisiana.
We were really impressed a few nights ago, when after a vehicle crashed and careened off the road
dropping 10-15 feet (3-4 meters), four of the passengers were brought to the hospital. Mark and I
had been finishing a c-section and arrived in the emergency room to see the nurses doing chest
compressions on a patient and pumping air into his lungs with an ambu-bag. The man was
unconscious but we were able to find a pulse and one of the junior doctors quickly inserted a
breathing tube. Slowly he began to regain consciousness, but was unable to move either his arms or
legs. He had a high neck fracture and will most likely remain a quadriplegic for the remainder of his
life. The family ended up taking him to a special facility that manages these types of injuries, but the
outcome is not promising, and the costs will eventually probably become prohibitive.
We see many sad cases where patients do not receive adequate care because the families can just
not afford the specialized treatment. One 12 year old girl presented with heart failure due to a hole in
her heart (ASD). She had been diagnosed 3 years ago, but was unable to receive the necessary
therapy – in the US nowadays this is a relatively simple procedure and these children live normal
productive lives. It is now only a matter of a few months or at most a few years before this girl dies.
As Manali is at 6,500 feet (2,000 meters) we have seen numerous patients with breathing problems
(in additional to a large number of TB patients), problems that would resolve somewhat is they were
able to move down toward the lower altitudes of the plains, but the people in this area live in the
mountains, they do not have families in the plains, they know of no other life, they are resigned to
stay where they have always stayed.
For our first Sunday, Mark, Ruth and I were treated to a delightful trip to the Rohtang Pass. This pass
is part of the Manali to Leh Highway, a 485 km road billed as the second highest highway in the world
(the first being the Karakoram Highway from Northern Pakistan to Western China). We left the
hospital at 10 am and drove the 53 kilometers to the pass in a bit over 2 hours. The views, initially
through the lush pine forests at the northern end of the Kullu Valley, gradually became stark barren
outcroppings of stone and eventually steep cliffs of rock and glaciers. The road snaked back and
forth over the mountainside. There were limited guardrails and often not much of a road. Our driver,
however, was wonderful and we safely ascended to the pass and were able to gaze out over the
immense views and snowcapped peaks. (By the way, Rohtang in the local language means “pile of
dead bodies,” but we didn’t see any.)
This past Saturday, we hiked to Old Manali, a quaint cluster of old stone-roofed houses about 2.5 km
north of the hospital. There the scene is more unhurried, with numerous cows walking around the
temple of Manu. On Sunday, we visited the town of Vashisht, 3 km from the hospital on the opposite
side of the Beas River. The town is popular in the summer with backpackers but was relatively
deserted this time of year (most of the backpackers take advantage of the beach and warmer
weather in Goa). Again we hiked, but this time we had to scale the side of the valley to reach the
village. It was a glorious day, bright sunshine and warm. We had to make way for a few mules and
other livestock, but everyone, including Mark and Ruth made it to the top and we enjoyed a lovely
meal of Indian food, momo’s (Tibetan steamed dumplings) and beer.
Mark and Ruth are leaving early tomorrow morning and are heading to Beijing where he was invited
to advise on the vascular surgery program for a new “health city” located just outside of Beijing. I’ll
certainly miss going to breakfast and dinner with them. Our breakfast routine is to go to the Mount
View restaurant with what we vote as the best milk coffee in town, and dinner is either at one of the
Tibetan/Chinese restaurants or Mayur – our vote for the best Chicken Tikka Masala. Manali is a
tourist center for India, and although relatively small, there is a lively pedestrian street, “the Mall” with
numerous shops and restaurants, smells of burning fires and grilled meat, along with cows and
donkeys and dogs. It makes for an interesting stroll in the early morning or when we go for dinner.
Overall, I’m very happy with how things turned out. By us being here, Dr. Philip and Dr. Anna were
able to take a short vacation (even if it was to a conference), and we were able to take some of the
night calls to give Dr. Jacob a bit of a break. Dr. Mark learned a great deal about working in a rural
mission hospital and was frequently excited about the various “tropical” diseases which we just don’t
see in New York. He is excited about initiating a program for the Columbia residents to rotate out
here for 6 weeks, probably starting in the spring, after the snows melt and the volume of cases picks
up. Of course I always wish we could be busier, but as everyone here seems to be pleased with our
visit, I think we did a good thing. (Oh, and for those of you who might be curious, this was not a
SIHS/Surgeons OverSeas sponsored mission. The monies that Peter and I have raised for SOS will
be used in places even worse off that here – such as Sierra Leone and Malawi.)
I wish everyone a great holiday season. In the next few months I’ll be traveling to the Netherlands,
New York, Qatar and then for a week in Florida for the New Year. 2009 will kick off with a mission
back to Sierra Leone where I will be accompanied by a team of MIT Sloan School of Business
students who will be working with us (self-funded) to develop creative funding solutions to the
problem of improving surgical care in Sierra Leone. I’ll certainly keep you all updated on that one.
Namaste,
Adam
(Lumba wallah)