I felt the minivan from the airport slow as it transitioned from cruising along the highway to struggling through inner-city avenues. Weaving through cars, trucks, motorcycles, auto-rickshaws, and even pedestrians I gained my first look at urban India and a practical appreciation for this statistic: 18% of the world’s population crammed into 2.5% of its landmass. The theme of our trip being healthcare, one of my immediate thoughts was the following: how in the world do you effectively care for so many people?
One of the basic activities of any government or administration is keeping track of its citizens and resources. But in this maelstrom of bodies it seemed like even that would be quite the challenge. It reminded me of Heisenberg’s uncertainty principle. A census might rely on the physical address of a home. However, as we walked through the warren of alleyways off of the main road near our accommodation, some of the abodes were so small I had a hard time telling when one ended and another began. How easy it would be to overlook the more modest of these. A census might incorporate some sort of official registration process (e.g., driver’s license), but what about those who lived off the grid? And how might you raise the health literacy of such a population to encourage them to seek care when needed ?– a question all the more important considering that these people would constitute the unhealthiest of citizens.
In the face of such a sea of humanity could Indian health institutions be up to the task of dealing with so many patients and their conditions? (in India in 2011 there were about 7 physicians per 10,000 people – and the same for hospital beds). My experiences in Botswana suggested not without sacrificing quality. Botswana has just a fraction of the population of India and is one of the mostly sparsely populated places on Earth. Yet, there is a troublesome lack of physicians and other providers. When one doctor takes on the responsibility for over 20 patients, elicited histories are shortened, physical exams are curtailed, and medicine takes on a rote or formulaic form; e.g., a patient with “seizure” is given anti-epileptics without enquiring what this alleged “seizure” looked like or even if it was witnessed. A student of the classics, I knew of a similar phenomenon which had occurred in the early Roman Empire. As the city of Rome became the first to reach 1 million in population around the 1st century A.D., a school of medicine known as “Methodism” rose to prominence. Unlike more traditional “Dogmatic” Hippocratic medicine it did not concern itself with individuals’ hidden causes of diseases and therefore allowed for a more streamlined medical practice – i.e., one more suited for a metropolis like Rome.
It is no wonder that 80% of outpatient care and 60% of inpatient care in India is now private due to low public financing levels for an early national system that provided most health services free to all. And yet the majority of these private services are not directed to or accessible by the poor. Our trip focuses not on public hospitals but rather private institutions. Accordingly I know that the quality of care I observe in the next few weeks, shortcomings and all, will represent examples of the best care that can be provided for Indian citizenry given the challenges faced by government facilities in the developing world, including limited funding, administrative failures, and the sheer number of patients in a country of more than 1 billion people.