Update: India 1
The New Delhi railway station was dark and cold at 6 am; and while sitting on a wooden bench waiting for
the train to Dehra Dun the temperature did not affect me as much as the blue-grey gloom of the poorly lit
platform. I had also been there in May 1995. An eerie realization struck me that I had been on this same
platform almost 13 years previously, the last and only time I had traveled to India. That trip was merely for
fun, to explore - a break after medical school and before starting residency. I had arrived the previous day
in Delhi and the temperature was 42 degrees Centigrade (110+ Fahrenheit). Delhi was crowded, hot, and
overwhelming. I needed to leave; and fast. I went to the railway station, asked for a ticket on the next train
out of town and was given a ticket to Jammu. At the time, I was unaware that Jammu was the southern
(winter) capital of Kashmir.
A flood of memories now reminded me of boarding the impossibly crowded train with masses of people
streaming everywhere, packages piled high up on the platform, unfamiliar languages and noises, all
blanketed by the blue-grey light. I squeezed on to the carriage and a man pushed against me. He looked
me in the eyes and asked enigmatically, “Who do you travel with?” Taken aback, I stuttered and
responded with, “M-m-myself.” He replied gravely, “Yourself - and God.”
On board the train, I met a delightful family from Srinagar who lived on a houseboat on Lake Dal. They had
traveled to Goa to sell carpets, were returning home, and asked if I wanted to accompany them for a few
days. Despite knowing about the troubles in Kashmir, I said “Yes.” (For the record, to myself, I did vaguely
question the decision – just before leaving Hong Kong and flying to Delhi, a friend had said in passing,
“And now Adam, I know you, whatever you do, don’t go to Kashmir.” I had responded with, “Don’t worry, of
course I won’t. I’m not that crazy.”)
We arrived in Jammu the following morning and boarded a bus, and after 7 hours ultimately arrived in
Srinagar – the summer capital of Kashmir. Before entering the Kashmir Valley, we passed through a one-
kilometer long tunnel from which we emerged into a large verdant bowl. Kashmir, as advertised, is
beautiful. I stayed four days on a houseboat and only once ventured into Srinagar itself. The dozens of
houseboats, long multi-room structures were a delight and formed a vast floating village. Tradesmen and
vendors would paddle around on small boats and visit the various families. I ultimately flew back to Delhi
and later to Katmandu. But that as they say…is history.
Thiik hai? (OK? – in Hindi). So now 2008.
“Few patients come to hospital when it is so cold.” This was the mantra during my first week in India. “Why
not? What happens to them?” I repeatedly asked. The responses varied but the consensus was that
during bitterly cold weather (when I first arrived it was often below freezing) the local population, who
mostly live in small villages in the mountains, just stay at home. I certainly understood not going on a long
trek into town but once again, I was faced with the realization that the actual surgical needs of these
neglected populations are unknown. I could not believe that with such abject poverty in the surrounding
population and with Herbertpur Christian Hospital (HCH), according to the 2006-7 annual report, being “the
only referral and advanced secondary care facility it the region;” no one needed an operation. My
assumption (and fear) is that many sick patients simply die.
So to explain a bit more, I am currently volunteering at HCH, a mission hospital just outside of the small
town of Herbertpur some 200 miles north of New Delhi in the state of Uttaranchal in northwestern India.
The hospital, originally founded as the Lehmann Hospital in 1936 by Dr. Geoffrey Lehmann, a British
engineer who later studied medicine to assist with the health needs of the local community, is now a unit of
the Emmanuel Hospital Association (EHA). EHA operates the largest group of mission hospitals in India
with over 20 facilities and other community health centers. HCH is a 100-bed hospital with surgery (Dr. R.
D. Singh), medicine, pediatrics, ob/gyn (Dr. Mitra – also the hospital medical director), orthopaedics (Dr.
Anshuman), and family practice (Dr. Jeff). There are two functioning operating rooms (and two others
recently constructed and almost ready for use), 24-hour emergency coverage with an emergency room, an
intensive care unit (ICU) with ventilator capabilities, and even laparoscopic surgery and a c-arm. This is no
typically isolated mission hospital.
Work-wise the last few days have been great. On Tuesday, a number of trauma patients presented who
needed acute stabilization (unfortunately, for the surgeons, none of them needed an operation). A few
other surgical patients also presented with complaints ranging from severe gastro-intestinal bleeding,
urinary retention, abscesses and other soft tissue injuries. (From the number of patients in casualty one
could tell that the weather had improved.)
On Wednesday, surgical rounds began as usual at 8 a.m. in the ICU. The 15 year old girl that had
presented over the weekend with a four-day history of abdominal pain and who had then been operated
on for a typhoid perforation of her small intestine was still not doing well. She remained on a ventilator with
deteriorating kidney function, and needing more medicines to keep her blood pressure stable. It is doubtful
that she will survive. The other ICU patients, however, were stable and we then quickly went through the
male and female wards. The wards are typical of many developing countries; about 30 beds divided into
two rows separated by a narrow central isle. The patients are all wrapped in coarse blankets and colorful
wool caps to stay warm; most have family members at their bedside. Like other developing world hospitals,
families are essential in undertaking many routine nursing functions and for providing food. Meals are not
served by the hospital.
Wednesdays and Fridays are the two surgical operating days, and that day was no exception; Out Patient
Department (OPD) for surgery is open on Monday, Tuesday, Thursday, and Saturday. Our delay in the
ICU that morning kept us from attending the Morning Prayer session when the staff gathers in the large
hospital entry that doubles as the OPD waiting room; later patients will wait in these seats to by seen by
the medical staff. Each morning at 8:30, a small group leads the staff in song, accompanied by a few
musical instruments, then a passage from the bible is read and commented upon, and prayers are said.
Afterwards, a medical handover meeting takes place and a report of the previous night’s events is given.
That day, we proceeded directly to the Operating Room. The first case was a laparoscopic
cholecystectomy (gallbladder removal). It always amazes me when facilities in resource-limited
environments are able to undertake such procedures. Often times I think that it may be a waste of
resources, however, one argument that stuck me recently, is that with the old-fashioned open technique
for removing gallbladders patients stay in the hospital almost a week and they have a much longer
recovery period. Very poor patients who are day laborers or who work in the fields may have a greater
need for a quick recovery to be able to get back to work and provide for their families. It is an interesting
perspective. I was told that rich people can afford to have a longer recovery period, poor people cannot.
The next case was an older woman who had had problems eating and passing stools on and off for many
years – after having previous old-fashioned open gallbladder surgery. X-rays showed that she had an
obstruction and needed an operation. This case I did with Prem, the 3rd year surgical resident currently
rotating at HCH. In the U.S. a 3rd year resident would mean that he is halfway through his training, here in
India the system is a bit different; their total surgical postgraduate training is only 3 years. The case was a
difficult lysis of adhesions, but Prem did most of the operating and did an excellent job. For me when
working in these resource-limited areas being able to teach is one of the highlights.
I have also been doing other teaching as well. Here at HCH there is a family medicine training program and
a rural surgery training program and I’ve given a number of lectures on trauma and other topics. We are
also working on putting together a workshop in March that would teach many of the principles developed
and promoted by the World Health Organization’s Global Initiative on Emergency and Essential Surgical
Care (GIEESC). After attending a GIEESC meeting in September in Dar es Saalam, Tanzania, I have
become more involved in this project. The efforts are to improve access to surgical care, promote
emergency and essential surgical skills in developing countries and encourage research into the Burden
of Surgical Disease. Again, this nagging question of how much surgery is needed in many of these
countries. There is data showing that almost 10,000 operations are performed every year in the U.S. for
every 100,000 persons. In the developing world, the rate can be as low as 300 per 100,000. (At HCH it is
approximately 800/100,000) Why is only 5-10% of the surgery performed in developed countries
performed in developing countries? How many more operations are needed? How many people are dying
from the lack of a simple operation? How much death and disability could be averted with a hernia repair,
an operation to stop bleeding, a caesarian section, or the proper casting of a fracture?
In trying to answer these questions, a growing number of individuals and organizations are attempting to
undertake research projects. Resolving these questions is also one of the aims of Surgeons OverSeas
(SOS), the program arm of the NY Society of International Humanitarian Surgeons (NYSIHS). (www.nysihs.
org)
Anyway, I digress. Back in the O.R. we continued with a video cystoscopy and lithotripsy for bladder
stones; the insertion of a chest drain for a 1 year old with pus around its lung; and at the end of the day
did a tracheostomy for the girl in the ICU. Again, I took Prem through that case. Achhaa (good - in Hindi)
Since Wednesday, things have slowed down again, (and yes, it is colder - again) but we did admit a man
with a bowel obstruction due to adhesions for a previous surgery. He too needed a lysis of adhesions.
So by now, some of you are probably thinking, fine, enough about the surgery, what’s it like? And what
about the food? Well for one thing, it is definitely warmer than it was. And when I say warmer, wow, do I
mean it. My first few days here it was almost unbearable. All the buildings cement and the floors are
marble; there is no insulation except that it get even colder inside than out. It was impossible to stay warm.
At night, I would wear almost all of my clothing, crawl under four blankets, have a very small heater next to
my bed and shiver until I fell asleep. It was impossible to type or even think at times it was so cold. I really
felt sorry for the local villagers and tried to picture what their existence might be like. I could not even begin
to imagine.
In terms of facilities and amenities, everything here is fine. I have my own room and bathroom. Water is
heated with an electric coiled metal bar placed in a bucket of water. It is easier now to bathe, as it is not so
cold. In the adjacent building, there is a mess hall serving breakfast, lunch and dinner, plus tea from 5 - 6
pm. The meals have been basic but good: rice, dhal, roti (flat round bread), stews and other sauces,
mostly vegetarian, and occasionally some meat. On Wednesday, people were excited because there was
chicken.
Not surprisingly, things outside the hospital are rather unhurried, but I have had a chance to head into the
near by town of Vikas Nagar for a few meals with some of the local doctors. The restaurants have certainly
not been for the faint of heart! Located down small alleys, they are mostly single rooms opening to the
outside with small tables and a large hearth and cooking place. Fresh roti is rolled and baked, and meals
of either meat in a sauce or small spicy flattened ground meat patties are served. Once I also had some
decent Tandoori chicken. The food was all very good, and let’s just say - I didn’t have any problems
afterwards. Maybe I am luckily but the food seemed fresh and made to order.
Last Saturday I also went for the day to the town of Mussoorie. It is about an hour and a half dive, past
Dehra Dun and up into the mountains. I accompanied Dr. Mitra who sees OB/GYN patients on Saturday s
at the Landour Community Hospital, another EHA facility. I spent time with Dr. Sam, the surgeon, in his
OPD. Mussoorie, at an altitude of 2000 m (6000ft), is one of the so-called “hill stations;” towns up in the
mountains that the British popularized during their rule and used as an escape from the fierce heat down
in Delhi and on the plains. In the winter, the altitude makes for an even colder experience, and not
surprisingly, there were even fewer patients than in Herbertpur. Nevertheless, it was interesting seeing the
narrow streets and shops all perched on the side of the mountains. Off in the distance the real snow-
capped mountains of the Himalayas were easily visible. We took a secondary road back to the hospital,
passing along sharp twisting turning cutbacks with sheer drops down to a river below. We occasionally
passed crazily overcrowded vehicles and individuals walking along the road. The views, despite the cloud
cover were fantastic, clearly, in the U.S., this would be a national park. Often, however, my thoughts drifted
to thinking about the locals; “How do they survive the cold?” “How many will need surgery?” “How many will
die?”
Thiik nahin hai. (Not OK)
Adam