Remaining of Kolkata

This is Anmol reporting the arrival of CBID India has reached Norway and started to explore Stavanger. But , right now I am sharing the experience of our remaining of Kolkata trip other than what Hector talked in previous post.

12 August:

It was Sunday but we went back to SSKM hospital to NICU and L&D for further observations of the same stuff. We still found time for sightseeing and we visited the Victorial Memorial that was built by Britishers when Kolkata was the Capitla of the country and next we visited the Saint Paul’s Cathedral.

 Hector and Stephen in a good walking pose

 Outside The Victoria Memorial 

 The Saint Paul’s Cathedral

13 August:

Monday started with an experience to the School of tropical medicine where we accompanied Dr. Tripathi’s students to get an insight into the disease of TB and HIV. The discussion and observation was really helpful to get an overview of how TB is dealt at all the levels. Along with that we also visited the ART clinic where we met Dr. Chaudhuri who explained us the flow of patients with HIV and how is it diagnosed, counseled and treated at all the levels of healthcare.

Then we had our lunch with Dr. Tripathi’s group where we had 3 kinds of meat curries of chicken, mutton and fish.

Lunch with Dr. Tripathi’s group

The later part of day was spent at the L&D of Kolkata Medical College which has very high frequencies of delivery. The residents were really cool and a lot of challenges at the tertiary level were discussed with them. Also, since actual L&D of the hospital was under construction, so everything was not perfect in the make-shift room. Stephen will follow up with the details of Kolkata Medical College in another post.

 14 August

                               

This day was a very different experience for us as we visited a private health care provider set up of JSV innovations. We went to Salboni block of Midnapore district in West Bengal along with Dr. Saha (one of the founder of JSV), Dr. Acharya and Dr. Tripathi. On the way we stopped for breakfast where we had tandoori stuffed parantha with lots of butter (only for me) and chai.

Breakfast at the “Dhabha” with Dr. Saha

JSV innovations is working as a CSR partner with Jindal Steel Works to provide health services to the community of Salboni, where JSW is setting up a steel plant.

The business model of such kind of private health care set up seemed to be very interesting as Dr. Saha showed us some reports which mentions that every year ~ $6 billion is donated as CSR by companies in India, out of which nearly half goes into health care. The corporate, being non expert in utilization of these amounts for an impact to society, are always looking for organizations for using these amounts for betterment of society.

Road to Salboni

Resting under the tree

Salboni is kind of pilot project for JSV innovations where they have started forming database for family information and children immunization. Also, they have started distributing deworming medicines to the villagers as most of them have been exposed to hook worms because of not using sleepers/shoes for walking. All these services are being done by health assistants who are being trained as health workers in a one year program, after which they would be deployed as nurses in JSW’s hospital in the plant. Interestingly, these health assistants used galaxy tablet for storing their records.

 Health Assistant feeding the data in the tablet during the field visit

Health Assistant with a villager providing de-worming medicine

JSV innovations also run a mobile clinic and a fixed clinic everyday which is run by a team comprising of a doctor, ANM, pharmacologist and health assistants. The mobile clinic is set up in mornings once a week for a group of 5 villages together at an accessible location and in a week covers entire 25 target villages for the project.  The fixed clinic works everyday in afternoons at the JSW site. Both of these clinics acted as OPD and pharmacy and the care was provided free of cost.

Fixed clinic at the JSW site made out of goods train cart

Mobile clinic at one of the villages being run at primary school

15 August

It was the Independence Day of India, but we guys had plans for work for this day too. Hector, Michelle and I along with Dr. Tripathi visited the SHIS clinic close to the Bangladesh border while Stephen and NID team spent the day at the L&D of Kolkata medical college. We also celebrated Independence Day outside Dr. Tripathi’s residence where we had sweets and samosas.

Michelle and Hector celebrating Independence Day at Kolkata

The SHIS clinic was started back in 80s as a private setup for treating TB. The major funds for running this clinic comes from royalty earned by Dominique Lapierre’s book based on Kolkata “The city of joys”. SHIS was the pioneer of starting the DOTS strategy for TB treatment where the patients have to take their medications infront of the DOTS provider so as to prevent poor compliance due to default. The Govt. of India has now nationalized the DOTS program as protocol for TB treatment.

Thanksgivings to Dominique Lapierre written on the boundary walls of SHIS clinic 

After few years of setting up, SHIS expanded itself to general OPDs and opened primary and secondary schools for education. Also SHIS has special boat clinics in the island of Sunderbans where the boat is completely equipped with diagnostics tool and acts as a mobile clinic to reach out to the 52 islands of Sunderbans.

CBID team with SHIS team

We returned back to Kolkata in the evening to take our overnight 8 hour train to Patna. It was voluntary move to travel by trains whose result was probably a bad night sleep. This was first time that Hector, Michelle and Stephen were using the rail network of the country.

 Stephen, Hector and Michelle on their first train journey in India

16 August

We reached Patna early morning and were taken to the “Happy Home” guest house by our drivers who would accompany us for rest of Bihar trip. We met JHPIEGO Patna staff in the first half of the day to discuss on Bihar specific issues and JHPIEGO’s program in the state. Then we left for Darbhanga district which was around 4 hours drive from Patna.

Soon a lot of stuff to come from Darbhanga from the Team!! 

-Anmol

All Over Kolkata

August 10. 

Anmol at the Victoria Memorial

Last week, we ran all over Kolkata and West Bengal, but I'll focus on Kolkata for now. Before India became independent, Kolkata (previously known as Calcutta) was the British capital of India, so the heritage from the British rule over India is evident in the city’s architecture and infrastructure. Because the city used to be an economic and cultural hub, India’s most spirited, visionary, and heralded intellectuals, artists, and scholars hail from Kolkata. Dr. Arun K. Singh, director of the Neonatology Department of the Seth Sukhlal Karnani Memorial Hospital (SSKM), is no exception. His willingness to share his holistic insights about healthcare delivery were refreshing and inspiring. Three great points from our conversation with Dr. Singh stuck with me. 

1. Innovation cannot be tested in isolation - Simply put, an innovator really needs to understand  how his creation will fit into the total health care system, which goes much beyond the intended function of the device. 

2. Every detail matters - In one study, Dr. Singh discovered that the bioburden (# of bacteria) in his Neonatal Intensive Care Unit (NICU) was actually higher after the floors were mopped. Dr. Singh eventually discovered that the mops were stored in the washrooms. Go figure!

3. Would you use that on your child? - Innovation in a resource constrained setting is not about cutting corners at the cost of quality of care. In other words, if I'm not comfortable using my device on my own child at Hopkins, then it is not acceptable in a developing nation either. 

We then got to visit the SSKM NICU, where, despite the large volume of very ill babies, doctors, nurses, and staff constantly triaged, adjusted, and readjusted to deliver the top-notch care to each baby. Some people think invention comes out of necessity; well these guys live it every day. We also got to tour the soon-to-be-finished seven story building that will be completely dedicated to Neonatology and Neural Development at SSKM. It's expected to become the premier neonatology facility in the nation once it is complete. As Dr. Singh put it, Neonatology is not only about saving a child's life, but also about ensuring proper quality of life for each kid.   

August 11. 

The next day we got to meet Dr. Tripathi and his Clinical Pharmacology students at the School of Tropical Medicine, which was established by the British in 1921 to provide education to british doctors in India that was on par with that provided in England. This is the first time I heard about the burden of tuberculosis in the developing world, and most importantly the rising incidence of multi-drug (MDR) and extreme-drug (XDR) resistant strains of TB. Truly scary stuff because there is pretty much no treatment for patients suffering from XDR TB. 

After that we went to the Labor & Delivery unit at SSKM, where I almost fainted. It may have been an after effect from being scared about TB or maybe because it was the first time I've seen a woman while she's in full-fledged labor. YIKES!

Being on foot is not better than being in car in Kolkata

Finally got to ride a rickshaw! (in Delhi actually)

On a fun note, traffic in Kolkata is just as bad or maybe even worse than it was in Mumbai and Delhi. It might be because the day-time population of the city is estimated to be somewhere around 30million people! Even though each trip (no matter how short) took a least 30 buttocks-clenching minutes, thanks to Ranjen (our crazy driver) we made it in one piece!

Rasgulla. Delicious milk sweet  from Kolkata. 

Jaley FRU and Singhwara PHC

Today was split between two sight visits where we had the chance to speak directly with some of the front line health care workers in rural India. We started out at the Jaley First Referral Unit (FRU), which is a 30 bed health care center providing labor and delivery services as well as basic diagnostics and treatments. Any case that the Jaley FRU is not equipped to handle is referred to the Darbhanga Medical College Hospital, about 40 bumpy km away.  While Stephen, Anmol, Namrata, and Sharon got a break down on the labor and delivery services at Jaley; Hector, Sowmya and I had the chance to speak with 7 ASHA leaders. ASHA stands for Accredited Social Health Activist and also means Hope in Hindi. These women are community volunteers with a main functional role to counseling their community on health care matters and encouraging people to seek care at proper facilities when necessary. An individual ASHA covers a local area of about 1,000 people through home visits and weekly immunization camps and receives monetary incentives from the government when their counselling results in medical services such as antenatal care visits or institutional delivery being sought out by the villagers they cover. The ASHA uniform is a white and blue sari that is easy to spot out in the villages and the level of enthusiasm shown by the women we talked to leads me to believe they are well respected within their community. While the ASHA role is basically limited to counselling now in Bihar, these women clearly showed that the ASHAs are a crucial part of the health care system in rural India. 

After thanking our Jaley hosts for dealing with our barrage of questions, we headed over to the Singhwara Primary Health Center (PHC). PHCs are the base level government health care centers staffed by doctors in rural India. This particular center is a 6 bed facility that also provides basic medical services and serves as a labor and delivery center. With fewer staff and no specialists, the PHC only takes care of very basic cases and refers more complicated issues to the DMCH. While at the PHC we had the opportunity to speak with a very experienced Auxiliary Nurse Midwife (ANM) who was kind enough to demonstrate some neonatal resuscitation techniques with a couple tools Stephen brought along. I think she had a good time working with us and several of her colleagues were peaking around the corner trying to see what was going on. 

It was a long day, but we got to see first hand how health care is delivered out in the periphery. Transportation and volumes seem to be some of the most compelling system level issues that are continuous themes in our discussions and we've definitely experience both first hand now. Tomorrow we're heading to the Darbhunga Medical College Hospital to check out the higher level of care available out here.

Don't worry, we're also eating... Anmol has served as our food guide and has made sure Hector, Stephen and I are sampling a a wide variety of Indian food, though we had to switch to some Indochinese for a bit of a break tonight.

-Michelle

PS: Inside the fort from the steps of our temporary home at the Ganga Residence....

We're connected! And a bit of time travel...

Greetings from Darbhanga! We've been having some internet difficulties the past few days, but now we're plugged back in... After an overnight train ride from Kolkata to Patna, a brief Jhpiego office visit, and a 5 hour drive, we made it to Darbhanga last night. The city of Darbhanga is the capital of the Darbhanga district of Bihar with nearly 4 million inhabitants of which over 90% live in rural areas. It's been an adventure getting here and it seems the adventure will continue as we venture from our hotel within a fort (yes, the hotel is within the walls of a fort) out on the bumpy roads shared with all sorts of livestock to the villages for visits with various health care workers. We'll definitely update more on our visits in Bihar and last few days in Kolkata, but for now I'm going to jump back a week to our day in New Dehli at the All-India Institute of Medical Sciences (AIIMS) visiting with the guys from Stanford India Biodesign (SIB).

The SIB center is located on the first floor of the Old OT Block at AIIMS, so after a bit of a sweaty walk from our hotel to AIIMS we sat down with the SIB fellows to get an overview of the Stanford Biodesign program and their experience in visits to lower level health care facilities out in the periphery earlier this year. CBID and SIB are basically kin in the sense that both programs are focused on medical technology innovation through direct experience and a needs based approach, so their overview of the Indian health care system and their needs filtering process gave us a solid frame of reference to start with. The SIB center is located at AIIMS to give the fellows direct access to clinicians, wards and operating rooms for observation in a very similar manner to the clinical rotations us CBIDers had been immersed in at JHMI this summer. After our overview and a southern Indian lunch, the SIB fellows split us up along with another batch of visiting Stanford Biodesign fellows for a walk through of the institute. AIIMS was established back in the 1950s to serve as a center of excellence for health care and medical education. Today AIIMS is consistently ranked as the top medical college in India and manages to serve over 3 million patients a year, many of which are too poor to afford medical treatment elsewhere. Even through our visit was in the afternoon with supposedly only a fraction of the daily patient load still around, I was most struck by the shear number of people crowding the wards and halls. The daily patient load is metered by tokens distributed to patients each morning (many of whom start lining up at morning hours I still consider night time), but the numbers that are seen each day is remarkable even though a supervising nurse that was kind enough to speak with me cited patient load as the biggest challenge they face at AIIMS. Unfortunately we were not able to visit the actual wards and OTs (operating theater = operating room), but we definitely left with a better understanding of medical care at apex facilities in India and a solid set of contacts with SIB and other Stanford Biodesign fellows that I hope will lead to some kind of collaboration in the future.

We'll be back with more post on our time in Kolkata and Bihar, but here are a couple of pictures from our visits today with Agunwadis, ASHAs and ANMs... (please excuse the alphabet soup, we'll be sure to explain)

-Michelle

ASHA means HOPE

Hello again! Sorry this is a few days late, from August 9. We've been having a lot of trouble with the internet here at the hotel. Yesterday when we finished up at Stanford-India Biodesign (SIB), we headed off with Tor Garvik from Laerdal to the Qutab Complex, a bunch of beautiful buildings and ruins from one of the Mughal kings of the area a few hundred years ago. The pictures here are from the short trip there and the site itself. You can see in the last picture 6 of our 7-person team: Hector, Anmol (not present - he took off to visit home for the evening), Michelle, and me from JHU, and Namrata, Sharon, and Sowmya from NID (National Institute of Design).

Earlier today we kinda took it easy because the SIB people didn’t really have anything arranged for us to do. I had been planning on talking with the team there that worked on addressing birth asphyxia, since I also had done a design team project on that last year and wanted to collaborate. However, all the fellows who were working on the birth asphyxia project graduated out, so there wasn’t too much reason to meet up today, and I’ll talk with whoever takes it over sometime once they are settled into working on it.

So, instead we headed over to Jhpiego at 11am and met with Dr. Sood, the country director, and Dr. Somesh Kumar, the programs director for Jhpiego India. Both of them were really enthusiastic that we were there and so generous with their time. They did an overview of statistics for India, ongoing programs, new public health policy in India, and what has and hasn’t worked/progressed. That led into more detail on the programs going on, especially family planning. That’s a huge emphasis now for a couple of reasons: 1) maternal mortality is extremely closely tied to total fertility rate, as is infant mortality; 2) around 25% of women in India desire but do not receive contraception (e.g. IUCDs) or improved child spacing; 3) development of family planning can lead to improving women’s education (it’s hard to finish an education once you’re married and have a kid when you’re a teen) and empowerment; 4) the exponential growth in some states makes public health programs less effective, and education, infrastructure, and development to catch up.

Another important thing we went over was characterizing an ANM (auxiliary nurse midwife) and ASHA worker. For those who were like us a couple days ago and don’t know how the rural Indian public health system works, ASHA workers are Accredited Social Health Activists, and ASHA means “hope” in Hindi, which we all thought was so cool. ASHA workers have contributed tremendously to public health by being the bridge between government healthcare and villagers. They are local women who council and encourage women to receive services, especially maternal and child healthcare, such as vaccinations, give birth at facilities, contraception, etc. and get paid when women receive these services. They only do counseling at the moment, though. Evidently, they’ve had a huge effect on health statistics for India so far.

After Jhpiego, we headed to our flight to Kolkatta. So that’s where we are now. Today was probably the most exciting for us so far and really got us prepped for the immersion. In Kolkatta we’ll be in a good government hospital here for several days, at neonatal care and Ob/Gyn. Excited for the clinical immersion to begin!

Stephen

ACHA HAI!

No worries everyone, my growing fluency in Hindi (and other languages, but mostly Hindi) is keeping me out of trouble. So, Acha Hai! (it’s going well!). This trip has been an eye opening experience, and it will turn even more interesting when we get to go to the peripheral villages in the next few days. But for now, I figured I’d summarize some my learnings in my own travel tips.

Slums surrounding a corporate hospital. 

Tip #1. Something for everyone – India is a land of contrast, though cliché, I have no better way to describe it. India is richly diverse culturally and socio-economically. Religious depictions of Hindu, Buddhist, and other religious icons often face westernized Ballywood movie banners. More strikingly, it’s not unusual to find abject poverty in the slums right across the street from one of the most well renowned corporate hospitals, where politicians and Ballywood stars come for medical treatment. India’s health care system is just as diverse. While government medical institutions cater to the poorest of the poor at minimal or no cost, large corporate hospitals cater to the insured middle upper class and the rich. Even more interesting is the growing number of small (and not so small), private clinics (known as “nursing homes”), where the lower middle class comes mostly for outpatient visits, but also for some inpatient procedures. The dynamic of nursing homes is quite unique because top physicians, who also work in corporate hospitals, own the majority of nursing homes. So even though the facilities are not as nice, the patient still receives care from highly reputable physicians at a fraction of the cost. To put it simply, in India’s free-market healthcare system, there is something for everyone. We’ll see how this holds up outside the city.  

Elevator ride inside the Tata Memorial Hospital. 

Tip #2. Take the stairs! – (If you enjoy saunas, skip to the 5^th sentence, otherwise continue) Unless you truly enjoy thirty minutes inside of a hot and sweaty elevator, I’d suggest the stairs. On the flipside, if you do find yourself in that situation make sure to get on the elevator last. If nothing else, you will become the first person to set foot on every floor of the Tata Memorial Hospital in less than 30 minutes (I’d like to see anyone try to break my record). On a serious note, Tata is one of the busiest and most respected cancer treatment centers in India. Why is it SO crowded? For one, patients from all over India, and neighboring countries, come to Tata to get top-notch cancer treatment. The second reason is that a large number of people do not seek treatment until after the disease is very advanced, and others simply do not have access to early screening or early treatment options. As a result, these very ill patients have no other option but to seek treatment at large tertiary/quaternary centers. Lastly, Indian families are very close knit. So it’s not unusual to see a large number of family members accompanying a single patient.

The Dhobi Ghat. 

Tip #3. Things work themselves out (somehow) – Stephen mentioned this earlier, but the Dobhi Ghat in Mumbai is quite a sight. Apparently, dirty laundry is collected early in the morning from all over the city and comes to this central location, where it is washed and dried in the open. What’s amazing is that it works very well, and somehow everything returns to its owner clean and dry by the end of the day. Talk about customer service! I think this example really speaks to the integrity and efficiency of Indian people. Blood banks are a unique example of integrity, efficiency, and, most importantly, solidarity in India’s health care system. When a patient is scheduled for surgery, the clinicians typically estimate how many pints of blood the patient will need. The family/friends/neighbors are then asked to donate an equal number of pints, which is typically an easy task because patients never come alone (see Tip#2). The result is that the blood banks are ALWAYS, or almost always, well stocked.

Chhole Bhatura (Scrumptious!)

Tip #4. Don’t Overeat – While it’s undeniable that you SHOULD avoid tap water, raw vegetables, non-peelable fruits, and street food, I’ve learned that the MAJOR danger is staying away from Indian cuisine! It’s absolutely delicious, so play it safe and don’t stuff your face. Bad things can happen! I’ll spare you the muddy details, so take my word for it.

Cow in the middle of the road.
Very touristy but I could not resist. 

(Life-Saving Extra) Tip #5. It’s a jungle out there – IF you are crossing the road, and think yourself lucky because there are no cars coming, fight the urge to cross the street and look the other way. Remember that people in India drive on the OTHER side of the road. If you miraculously get to the other side of the road in less than 5 minutes, you are a survivor. Traffic in India is simply unprecedented (and I have seen some pretty bad traffic in the US and in Colombia). Let me put it this way, if you are in a car in Mumbai, it would be very possible to reach out and snatch someone’s coke from the adjacent car. Also keep an eye out for trees in the middle of the road.

 (Worry-Saving Extra) Tip #6. Bring a chain! - IF you are prone to leaving stuff behind or constantly losing your phone (like moi), you may want to have a mechanism to keep you from losing your stuff. If nothing else, it will save you from the public bashing after admitting to having lost your phone more than once in 4 days. 

A land of contrast. 

Michelle makes her first appearance on our blog. Outside of J&J India

Health care for 1.2 billion people...

After braving Mumbai rush hour traffic once again, we spent the day (well yesterday now) back at the J&J office getting an overview of the Indian health care system from Dr. Shastri, a medical director at J&J, and later a market overview from a J&J group manager. Both talks were an eye opening introduction to the structure of the Indian health care system, highlighting the dichotomy between public and private sectors and the massive burden of providing medical care to 1.2 billion people with a severe shortage of health care providers and a mostly out-of-pocket pay system. I'll spare the details of the medical system structure for now since I'm still trying to wrap my head around it all and we have to jump on a plane for New Delhi in a few hours, but I'll leave you with one of the challenges presented to us today: India has medical expertise, but often can't get those experts to patients due to shear numbers and geography, so how can their expertise get to the patients that need it?

-Michelle

PS: Some autos from the ride home -