Medic in Mysore
By Reena Aggarwal
As a long term ashtangi and medical student, I chose to do my medical elective in the city of Mysore in July and August 2006. I combined early morning practice at AYRI with a day’s work at CSI Memorial Holdsworth Hospital in Mandi Mohala, a fifteen-minute rickshaw ride from Gokalum.
At the time I was a medical student at the University of Cambridge and like all medical students in Britain was given the opportunity to experience medicine in a different country for up to six weeks. During my time in Mysore, I wrote a blog chronicling both yoga and medicine (http://blogs.ashtangi.net/medicinmysore). However, in this piece, I have chosen to focus on the medical aspect of my time in India because this is my unique perspective. This is an account of what I did, what I saw and what I thought during my time at the hospital.
CSI Memorial Holdsworth Hospital, Mysore
Mysore (population ~3 million) is the second largest city in the Indian state of Karnataka. English is widely spoken, but Kannada, a Dravidian language, is the main language. The CSI Memorial Holdsworth Hospital (colloquially known as Mission Hospital) is one of the oldest in Mysore, set up in 1906 by Methodist Missionaries with a view to serve the women and children who were without proper medical care in the poorer outskirts of the city. Today it has 325 beds which include 94 beds in a private block. They have about 40 doctors who work with a range of specialities from general medicine, Intensive care, cardiology, surgery, orthopaedics, urology, ENT (ear, nose and throat), opthalmology, psychiatry, obstetrics and gynaecology, nephrology (with a three bed dialysis unit), neurology and neurosurgery and paediatrics. The hospital has radiology services (X-ray and ultrasound only – for CT and MRI, patients are sent to local private hospitals), pathology facilities, a blood bank and a pharmacy service. The language of medical discussion amongst the doctors in the hospital is English, but to the patients and amongst themselves, it is mainly Kannada. During my five weeks at the hospital, I spent three weeks in Obstetrics and Gynecology, one week in general medicine and ICU (intensive care unit) and one week in general surgery.
The hospital is affiliated to the Church of South India (CSI) and patients pay a subsidised sum for all the services provided. There are three types of wards – general, semi-private and private. Patients pay the lowest rates for the general wards and rates increase for the other wards. 97% of the hospital’s income comes from patients’ fees so it cannot afford to offer free medical treatment to many patients (exceptions include students, employees of the hospital and leprosy sufferers). Nonetheless, the hospital is sympathetic to those who cannot afford healthcare. Some patients are known as BP line (i.e. below poverty line) and are funded by the sums collected from the private wards. I was told about a patient who had attempted suicide by taking organophosphates, as he was unable to pay a debt of 10,000 rupees. The man recovered, but in the meantime had racked up a bill of 70,000 rupees. The hospital wrote off this bill. The doctors take into account patient financial circumstances and choose investigative procedures accordingly. Some patients do not buy every item on their prescription: medicines perceived by patients to be ‘non-essential’ are frequently not purchased.
Obstetrics and Gynaecology
In India, this is primarily a female specialty. The hospital team consisted of seven female doctors – the senior consultant, three junior consultants and three resident doctors who were all working toward their postgraduate diploma in Obstetrics and Gynaecology. I had the opportunity to observe the casemix of patients – pre- and post-natal mothers, pre- and post-operative gynaecological patients and any referrals from the surgeons or physicians.
Outpatient clinics were not divided into antenatal and gynaecological as in Britain. Patients simply attend clinic and doctors deal with them appropriately. Most of the antenatal patients were Muslim women from poor communities ranging in age from 19 to 35. They looked much older than their years, due perhaps to poverty, early marriage, frequent childbearing and manual work. Women are expected to attend antenatal clinic monthly until 32 weeks and then every 15 days until delivery (anything from 37 weeks to 40 weeks is taken as full term). Yet women will still turn up at almost full term with massive life-threatening problems because of flaws in the community midwifery structure. In conformance with a vague government policy of two children per household, doctors often encourage women to have sterilisations at the time of delivery in the case of third or fourth pregnancy. The weight of many of these women was striking: it was normal to see women weighing less than 50kg during pregnancy; some weighed as little as 39kg. Compare this to the average woman in the west, weighing between 50-60kg before pregnancy and would expect to gain about 10kg during pregnancy.
While vaginal delivery was preferred, doctors in the labour room were quite interventionalist (e.g. an episiotomy– a surgical incision of the perineum made to increase the diameter of the vulval outlet – was often performed at first delivery). In the 1970s, 90% of women would have had these, but the World Health Organisation recommends that this should only occur in 10% of women and only when there is a specific reason. When I questioned the seemingly routine nature of episiotomies for first time mothers, the doctors explained they felt it was better to have a surgical incision rather than a traumatic tear. The caesarean rate was about 10% (comparable to Britain) and they used the same criteria as in Britain. Women did not have the benefit of nitrous oxide (laughing gas) during labour. Strong painkillers such as pethidine were available though not always given. Women were expected to “suffer” through labour to a much greater extent than in Britain.
The doctors often encountered family and cultural problems when trying to care for their patients. An example was a 35-week pregnant woman admitted with eclampsia (a potentially fatal condition characterised by convulsions and coma due to raised blood pressure during pregnancy – the only cure is delivery of the baby). Naturally, the doctors wanted to induce delivery. However, her husband and in-laws wanted her to return to their home in Mumbai for the delivery – given her condition, a perilous journey for both her and her baby. The consultant tried to reason with her, but the woman felt she had to bow to her husband’s wishes, and discharged herself.
Hysterectomies were performed both abdominally and laparascopically (telescopically) often on women only in their mid-forties, for indications such as menorrhagia (heavy bleeding during periods). The doctors justified this by pointing out that women have their families young, and by their forties these organs were “not so useful”. Cervical cancer is the most common cancer in South Indian women and is predominantly a problem of the poorer strata, related to education, income, multiple partners (male promiscuity is given as the main contributor to the spread of the virus Human Papilloma Virus – HPV- a major cause of cervical cancer) and sexual exposure prior to the age of 18 years (the main causal factor and a consequence of the early marriage age). In Britain, screening has practically eradicated this disease, but in India the majority of women at risk live in villages where preventive health care is very patchy.
The medical team was all male. In the intensive care unit, I saw some very distressing cases - things that I would rarely encounter in Britain. For example, I saw many men who had tried to commit suicide by taking organophosphate pesticides leading to muscle paralysis, one man who had tried to hang himself, and most distressing of all a woman in her 50s who had poured a can of kerosene over herself and set herself alight in order to spare her family the economic burden of supporting her.
There were a wide range of tropical diseases on the wards including malaria, dengue fever and even a few cases of ictero-haemorrhagic fever (Weil’s disease). One young man with encephalitis (inflammation of the brain) was being ventilated. I asked if the cause was Herpes Simplex Virus (the most common cause). I was told “We don’t know that. But if we test for HSV this will cost 2000Rs and if we treat for that it will cost the family 4000Rs and they cannot afford that.” Instead they prescribed broad-spectrum antibiotics and treated for tuberculosis – the man did not live.
On the wards, many patients had been admitted with a non-specific fever. This could have been due to a variety of causes, but a relatively rare viral disease called “chicken gunia” was sweeping across three states of India including Karnataka during the summer. Symptoms included a high fever, rash and joint pain. It is a self–limiting disease responding to a few days of rest and supportive therapy such as paracetamol and fluids. It is caused by a virus transmitted through the bite of the Aedes aegypti mosquito (also responsible for dengue fever), which bites during the day, rather than at night. It was difficult to know the exact numbers affected in the hospital – serological testing had to be sent to a specialist laboratory, which was deemed too expensive. Hence, every case of fever was treated as a suspected case of chicken gunia.
The surgical team was also all male. I had the opportunity to assist in different operations – appendectomies, hernia repairs, and small procedures under local anaesthetic. The theatres are well equipped but, as they have fewer resources, the theatre clothes (scrubs, masks and hats) were quite old. There is less of a disposable culture in India, so where in Britain we use plastic and paper, they use cloth and re-sterilise.
Once again, I saw quite different sets of cases in the hospital. For example, in the Surgical Intensive Care Unit (SICU) I met a 19-year-old boy who had been working as a cook in a kitchen. The stove had exploded while he was working which left him with 40% burns - he was lying on a plantain leaf, which had been doused in potassium permanganate, to keep him cool and prevent the fragile surface of his skin sticking to the bed sheets and causing further damage. I was told that one of the surgeons in the hospital uses mashed papaya pulp directly on burns: apparently papaya, plentiful and cheap in India, contains enzymes which break down dead tissue and even act as an antibiotic.
“The diabetic foot” was a common finding on the surgical ward rounds. One patient particularly stuck in my mind – a diabetic woman in her 70s who had been “beaked” by a hen on the top of her foot. She had ignored the original injury and the family had not sought medical help for a month (the late presentation of cases to the hospital were often due to financial pressures on patient and family). When she arrived, most of the foot was gangrenous and infected. Some of the other patients I met included young male victims of road traffic accidents – mainly on motorbikes. The surgeons described them as “blood boiling boys” as they rode their motorbikes too fast and risked terrible injury. A snake had bitten another man on his leg – the wound had become infected so the surgeons intervened and drained the site of pus. I was told that there are four poisonous snakes in India – cobra, viper, sea snake and krait. These are mainly found in the jungle and not, thankfully, in the streets of Mysore.
Experiencing South Indian medicine was challenging. The medical culture was very hierarchical and consultants expected to be addressed as Madam or Sir. As a student, I was expected to be passive and silent during teaching or medical rounds. I was told not to consult books during rounds or in front of patients as medical staff were not expected to look “ignorant” before the patients. I observed the way junior doctors expected to be humiliated by their seniors in the name of education and career.
Nevertheless, I found that doctors possessed skills and knowledge equivalent to those in the British system, but did not necessarily have the resources and infrastructure that we take for granted. Doctors were less reliant on the results of investigations and used their clinical judgment to make diagnoses. They often had to consider the financial circumstances of patients and treat as best they could, though this might mean that patients would not complete a full course of treatment. Overall, I came away with an admiration for the way the doctors attempted to do their best for patients despite limited resources.
Reena Aggarwal started practising ashtanga in London in 2002 when working as a pharmacist and lecturer at the University of London. In 2003, she decided to follow her dream to become a doctor and moved to Cambridge to study on the University’s Graduate Medicine Course. During the intensive four yeas of the degree, Reena continued to practice ashtanga with Louise Palmer (Camyoga) and coordinated a small self practice group in her college. In 2006, she combined six weeks of practice at AYRI with medical studies in a local hospital. She qualified as a doctor in 2007 and now works at St. James’ University Hospital in Leeds, West Yorkshire, and practices yoga as medical rotas and on-calls allow. She can be contacted at raggarwal73 at doctors dot org dot uk.
Photos courtesy Reena Aggarwal. To view more, visit our flickr gallery at www.livingmysore.com.