Monday, March 30, 2015

Jan Swasthya Sahyog

Last week I visited a remarkable rural hospital, Jan Swasthya Sahyog  (JSS, "People's Health Support Group"). Naman, who is finishing his MD/PhD at UNC, has been doing a clinical elective with them for a couple months. The story of JSS is very inspiring. It was started by six doctors from AIIMS Delhi, India's most prestigious medical training institute. These young doctors including two husband-wife couples decided that they wanted to serve underserved populations. They chose rural Chhatisgarh, where most of the target population was tribal and they had no personal connections. Dr. Yogesh Jain explains that their group was always different from their other AIIMS colleagues in that they were interested in not just the "what" or technical bits, but the "why" and "how" of medicine. What affected them most was the inequality that exists in society. Says Dr. Jain, "If deprivation is the cause of illnesses, then physicians become the natural attorneys for the poor."

I flew to Raipur, then took a taxi 3 hours out to the JSS campus, 20km outside of Bilaspur. It is a rustic place. My mental picture was a somewhat manicured university-style setting cut out of the rural heartland. Instead, JSS is embedded in the landscape like it is home-grown for the area, pregnant with dark lush thick trees which Dr. Yogesh told me was the first thing they tended to when they started 15 years ago.  The hospital is a series of brick buildings connected by corridors, many of which are under construction as new wards are added. Those corridors are chock full of patients. People come from as far as Rajasthan to be treated at JSS, because it's known for honest, high-quality, comprehensive care. There's even a chemo-therapy unit. On Mondays, Wednesdays, and Fridays, the hospital sees patients, and they hand out 300 tokens per day. Sometimes your token doesn't get you to see a doctor till the next day, or your loved one is getting treated over an extended period of time. So people are just camped out all over the corridors.

The evening I arrived, Naman was showing me around the campus under a bright glimmering starry sky and he was on call. He got a call about a crashing patient, he was going into cardiac arrest. Naman raced off to see the patient. Later I caught up with him, and he told me the patient had died. I walked into the ward and saw the dead body. Earlier that day they had lost an infant.

To say that the situation with these patients is dire is an understatement. A rural doctor sees all kinds of stuff. Naman has treated bites from snakes, monkeys, dogs, and more.  One of the most common diagnosis I observed was cancer.  Chronic diseases like diabetes, sickle cell, and epilepsy are typical. Naman said that most women come in and complain of abdomen pain or pregnancy. And the diagnosis ends up often being infertility, UTI, abnormal menstruation, or cancer.

I watched a leg amputation, the first time I had ever seen a surgery live. The patient was an old kaka, who was a diabetic that was also a chronic smoker. He had already lost one leg from gangrene. The second leg's foot was amputated at the ankle and he promised the doctors he would quit smoking. But he didn't keep it and the stub got gangrene. So now JSS was going to amputate from below the knee. This poor frail kaka was getting his third leg amputation.

I entered the operating theater a bit nervous. The patient was prepped by the doctor by injecting anesthesia to numb his lower body. He injected a few shots into the man's spine. It was pretty brutal. I was looking forward to helping the surgery in some way, I got my chance when I was asked to pump an inflatable wrap to stop blood flow to the leg. Unfortunately the pump wasn't catching air and the nurse had to take over. That was the beginning and end of my surgical career.

I looked at the leg. The gangrene looked nasty and smelled nastier. The doctor put a latex glove over the stump to keep it clean, but I thought it was to cover the smell.

One of the nurses put on Hare Krishna bhajans to set the mood. Then the doctor went to work slicing this poor guy up. I watched him scalpel off the limb like a piece of meat. He's a real pro and a badass. Once the muscle was completely detached, he and the nurse took ends of a wire saw and hacked off the bone from underneath up. The frail kaka's body was jerking around, I wondered what was going through his head. It was a clean cut. The doctor held up the limb and tossed it in the trash. It was breathtaking. Later I asked the doctor what the hospital does with all the limbs and guts they collect every day. He joked that they throw it out back for the dogs. But he honestly didn't know for sure. They likely incinerate everything, but it made me wonder about the whole waste disposal complex that must exist supporting hospitals around the world. They must generate a huge amount of untenable waste.

Despite the challenging situation for many of the patients, the spirit and mood of the hospital and its staff is upbeat. JSS has a very warm, big-hearted, compassionate, yet skilled and capable group of doctors and nurses. It reminded me very much of the spirit of Aravind, where service values are intertwined with the approach to care. And there is no compromise in the quality. Many highly trained doctors come and lend time at JSS. Over lunch one day JSS' Dr. Raman Kataria, a soft-spoken powerhouse of a surgeon who Naman told me can do pediatric, thoracic, and neuro surgery, among others, was chatting with two renowned specialists who had flown in about an infant that they operated on that morning with no esophagus or anal opening. Besides Naman, a few other young doctors were doing their training or residency; one doctor couple (Vaibhav and Jyoti) had moved there to dedicate at least 3 years to JSS. They have several very smart and talented TISS grads (including Sushil who has been there for 3 years) who oversee administration. Top technical consultancy ThoughtWorks has a full-time, pro-bono project at JSS where they are implementing EMR (currenty led by Arjun). Naman is very sure he'll be back after his residency in California. They are all attracted by the real need, but also the positive, uplifting spirit of the place. The staff mess hall is regularly filled with jokes and smiles.

It begins at the top with the founding team. I was fortunate to spend significant time there with Dr. Jain. He is a true inspiration. A real master clinician who is as simple and humble as they come. One day I went with him to the Bahmni sub-center for mobile clinic, which is literally in a tribal area. There was no mobile network and limited power. For several hours, I watched him treat patient after patient. What he does seems like magic. He glances at the patient with a look that seems like he's seeing into them like an x-ray. He asks a few questions about lifestyle, background, medical history, all in his unassuming boyish humorous way. It's like he's solving a puzzle. It was a thrill to see someone who is world-class at what they do, applying their skill art in a context where it is so rare yet so needed. It's an inspiring juxtaposition. And he does all this all with humility, we sat on the ground cross-legged together to a simple village lunch on a banana leaf. He was perfectly at home, curiously asking about the cricket match being listened to on radio in the room over. Spending so much time around Yogeshsir in the flow of his work, I realized that being a physician at his level is very similar to being a teacher. Everywhere he goes, people are asking him to educate them about something or the other. A nurse with a form, a doctor with a diagnosis, a patient with their livelihood or children's future. He's just a walking fountainhead of knowledge.

One patient was a young, very pretty village girl. She had a presence about her, an air of confidence. She came to see the doctor about a urinary issue, which Dr. Jain helped her with. But he also gave her an x-ray look, and declared, "one day you will be a nurse with us. You see that sister over there? She's a nurse. Do you want to be like her? Keep studying , you will grow up and join us as a nurse." She silently took it in, with a look of tacit acknowledgement. In the moment, it felt like one of those life-altering moments where someone of great respect or authority said something small that woke you up to an idea that you always carried, but never articulated.

Throughout my two days at JSS, I asked people around the hospital what was the biggest hurdle to doing this work. Unanimously, the response was that the bottleneck is people. Well-trained, motivated medical staff will ultimately drive organizations like JSS to sustain and grow. I went there representing Awaaz.De to identify opportunities to support the work (being with and supporting orgs like JSS is why I do the work I do). We will be exploring ways to better connect patients, doctors, and staff through simple mobile tools, which has great potential to improve care and outcomes. But technology is just one part of the picture.

If you're a doctor, what can you do to address medical inequality locally or around the world? Billions of marginalized people deserve your attention.

Please consider supporting JSS with your time and/or resources. More info on how to get involved on the Friends of JSS website

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