CMC - Day Sixteen

Amartya Sen is one of India's most famous academics, having one the Nobel Prize for Economics in 1998. His current professorship at Harvard University followed many years as a Master at Trinity College, Cambridge. In his most recent book, The Argumentative India, he expounds on many things, including the profundity of Indian loquaciousness. He points out, as a representative example, that the longest speech ever delivered at the United Nations, at 9 hours, came from the mouth of Krishna Menon, leader of the Indian delegation in the 1950s.

I was treated to a similar display this morning by a Mr. Ranjit, an administrator at the Community Health and Development (CHAD) hospital that sits at the southern end of the undergraduate CMC campus, to which I moved from the city this weekend. He spoke for three hours without break on all things CMC and the three of us who sat before him were absolutely rapt. I've spent the rest of the day pondering how I might share as much of what he told us without requiring that you spend all day at your computer. (I think I might have failed in that mission.) CMC's hospital would stand alongside some of the most advanced hospitals in the world, such is their capability to provide the latest care in all subspecialties. However, I am more impressed about what CMC has accomplished in the communities that surround Vellore. I'll share with you why.

First, some background. Ida Scudder was the daughter of an American missionary and physician in Vellore in the late 19th century. She was driven to leave her home and to study medicine in America after events which signaled to her – signs from god, she believed – the desperate need for women's healthcare in India.

Ranjit shared with us the story of the night she was approached by three different fathers requesting her help in their wives' deliveries. Ida, 17 at the time, said that she would alert her father, who would attend to the labouring women. The men refused in turn, prevented by culture from allowing a man to help in labour, and left. Without qualification, Ida would not go on her own.

In India, the beating of drums in the mornings means one of three things: a festival is taking place; a couple is to be married; or a death has occurred. Ida awoke the next morning to, what was to her, the ominous sound of drum beats. She asked her butler to find out what was happening and he returned with the news that three women had died in labour in the night. From this she found the motivation that would carry her through medical training at Cornell University, which would help her to start the first all-female medical and nursing college in India and, subsequently, one of Asia's most impressive medical institutions.

Dr. Ida Scudder had two convictions. First, she would train female doctors and nurses to care for all but to guarantee care to women. Second, this care would take place in the community and therefore she would not build a hospital. Her logic was simple: if good care is provided in the community there should be no need for a hospital. Obviously, this latter goal was successful in its failure to be realized (or was it? – more on that later), and I won't go into detail about how a one-room two-bed ward that was deemed a necessity became a 2,300 bed inpatient facility with over 5000 outpatients seen daily, and all supported by a renowned coeducational undergraduate medical college.

CMCs CHAD program began in the 1950s, in order to better serve the community. They realized at some point that, at the same time the hospital and its sub specialist care was growing, the villages that surrounded the hospital were growing successfully and illness rates were relatively low. Physicians and nurses from CMC, mindful of Dr. Scudder's wishes, went out into the community to learn what was going on. Villages in this part of India, if not others, have by tradition one women who serves as a birthing attendant. She is always the wife of the senior member of the caste of barbers – it may or may not be coincidental that the first surgeons were barbers. The daughter in law – who becomes a part of the family in marriage – was trained in succession. The health care workers who witnessed her work relayed to their CMC colleagues that these women were capable midwives, providing excellent obstetric care. They immediately allied themselves with these women, and started to support their work through CMC. The other providers of care were, they found, men of less rigorous training and more lofty perceptions of their own ability, snake charmers. They distanced themselves (and the patients) from these by (falsely) expressing their admiration for them, acknowledging how busy they must be, and informing them that, as a result, they'd consult them only when absolutely necessary. Probable relief on both ends. They only changed one practice of the barber's wives, who traditionally cut the umbilical cord with any old kitchen knife and then packed the wounds with cow dung. Despite the surprising lack of infection that resulted, CMC provided each women with a sterilized birth kit with gloves, half a razor blade and sterile clamps. That was a great success. The "pitchu" (from Part Time Community Health Worker) can be found in every village pointing out the hundreds (or thousands) of children that she helped deliver. And despite the fact that the government mandates that all births take place in hospitals - because of the continued risk of female infanticide and high-risk births - these women still serve a valuable role.

Being community minded, the physicians and nurses at CMC wanted to keep track of the results of all this and asked the traditional birth attendants to keep records. Being illiterate, most of them, this was an impossible task. So CMC hired and trained health aids, who can be recognized by their pink saris and who track health data for a cluster of 3 villages. There is one nurse to three health aids, one doctor to three nurses and three doctors to cover the entire 69 villages that comprise the CHAD catchment area. Here it is by the numbers: The average village has 1500 people, so each "pichu" covers that many; health aids cover 4-5000 people; nurses ~15,000; physicians 45000. Between three physicians they cover approximately 150,000 people. Remarkable! As is how they keep track. Each individual in this catchment area is given a number, based on their age, and on their village, street and home number. The GPS coordinates for each household are kept by CHAD and, in this way, they can track, using digital technology, the spread of disease in the case of an outbreak. Ranjit told us of a recent case in which a "pitchu" and health aid identified a new diarrheal case in one village. Other reports soon came in and they used the GPS technology to plot a map, starting with the first (index) case, of the spread of diarrhea. They were able to recognize that the illness followed the course of a drain. In the village they found that the water pipe ran through the drain and had developed a leak. They contracted to have the water pipe elevated above the drain and repaired. The diarrhea stopped. This is basic new technology used on a large scale with wonderful results. I wonder if the American public would allow their homes to be plotted on GPS and their health monitored so closely. It feels a bit like Big Brother. But in a country where privacy is a non-issue, such things can contribute greatly to the general welfare, and without a fuss.

Ranjit asked us, when discussing the size of the hospital today, its large patient population, and dedicated physicians of every specialty and "superspecialty" (as they say here), if CMC was a success. It was an open question and he wouldn't say what he believed. The most obvious answer would be yes. However, as Ranjit pointed out, CMC would, perhaps, be a much greater success if it was able to provide the type of care - preventative care - in the community that could keep so many of these people out of the hospital in the first place. "If we were really succeeding in our mission," he asked, "might we not need any hospital at all?" I admire the sort of idealism that his question presupposes.

What he is asking is if it is possible to do the job of preventing illness so well that we are hardly needed at all. Do we have the will, the courage, the selflessness to attempt such a thing?

justin