Almost immediately after reaching my AIF Clinton Fellowship placement site in Puducherry, India, I contracted pneumonia. So, when considering what experience to draw upon for this first post, I kept coming back to falling sick. A country’s emergency care system is perhaps one of those things you don’t think about until you have to. And once I had to, I couldn’t really worry about much else. To better understand how I landed in the perfect storm to catch pneumonia, it is helpful to know a little bit about my strange and wonderful new home in India: Puducherry.
A semi-urban city on the South-Eastern coast of India, Puducherry is most commonly cited for its beautiful beaches, the famous Sri Aurobindo meditation ashram, and French cafes. All of these contribute to it being a tourist hotspot for foreigners and locals alike.
If I’ve made you envious of my placement site during a year of serving the underserved, just wait—I’m getting to the pneumonia part soon.
Obviously, daily life here is not about eating croissants for breakfast or sipping a cocktail on the beach. Though I am neither really tourist nor local here, I’ve already discovered some oddities in this little town. When I first felt nasal congestion, I went out looking for tissues or handkerchiefs. I searched every shop on the main Mahatma Gandhi road to no avail. The next Sunday, I ventured back to the same street, only to discover an onslaught of new vendors. There is a significant uptick in products and services sold in here on weekends because of the tourist inflow. Ironically, it was not tourist stuff—which you can find any day in the windowsills along Promenade Beach—but everyday items. Suddenly, I had shop owners waving packets of handkerchiefs in my face for nearly ¼ of the price I had paid for three extremely fancy ones in the mall. I bought enough to last me many weeks and was no longer worried about their scarcity to dispose of them.
Getting Back to Emergency Care
What does my handkerchief expedition have to do with the state of emergency aid in India? Not having to worry when you get a little sick is a privilege. I ignored my symptoms for the first few weeks, thinking it was probably just a little cold. The underlying assumption in making that choice was that if it turned out to be more than a cold, I could easily get medical care. It turned out I could not even easily find a tissue.
Having an efficient, reliable, and high-quality emergency response system is an infrastructure guarantee I took for granted by growing up in the United States. As far as Maslow’s Hierarchy of Needs (Fig 1), I’ve spent all my life comfortably in the top three rungs, concerned with my emotional, professional, or philosophical needs. The fears I had as I got sicker kept me hovering in the bottom two rungs, a terrifying reality so much of the world never escapes from.
Without a doubt, some of the challenges I faced were because I am new here. But I suspect there is also a broader systemic issue in the Indian healthcare system. I couldn’t find much on the situation in Puducherry specifically, but I decided to dig deeper to understand what options most Indians have when they fall sick.
A Globally Broken System
I had not yet been diagnosed with pneumonia when I woke up in my hostel room at 4 am one night with a raging fever, nausea, and dizziness. I thought to myself with alarm, who do I even call if I need help right away?
At home in the U.S., the answer is almost a reflex: 911. Within 10 minutes, police officers, firefighters, and an ambulance are dispatched to your location (Julie Fritz, 2019). In my hometown of San Francisco, the average response time is 5.46 minutes, the nationwide record (Halpin, 2019). This is a luxury most of the world cannot rely on.
However, the American healthcare system is far from the ideal. While you can get a quick response from a 911 call, there is notoriously a difference between black and white Americans’ relationship with the police (an important issue that requires its own post/platform). Suffice to say, however, that minority communities are more fearful to use the 911 service than white Americans (Grabar and Stern, 2018). The U.S. healthcare system also has its own slew of very troubling concerns, including the exploding cost of medical care, pharmaceutical companies inflating the cost of medication and, in my opinion the most sinister of all, racial bias. Like issues in India, these failures disproportionately affect systematically marginalized, oppressed, or poorer communities in the U.S.–primarily black and Hispanic communities–from getting the same standard of medical care as their white counterparts. This happens to both poor and wealthy people of color because of unconscious bias (Kristan Foden-Vencil, 2019). Their care is compromised when paramedics take minorities patients to safety-net hospitals even when they are farther away, or when ER physicians discredit a black patient’s complaint of pain, assuming they have a drug habit. Given the failures of the American system, I am certainly not suggesting the U.S. does it better and India ought to follow suit.
The Healthcare Gap Between Urban and Rural India
Not only am I not advocating for India to replicate the U.S. emergency response model, but it also cannot be done for practical reasons. Emergency care must be India-specific because the challenges facing this country are unique. While India does have a burgeoning emergency care system that has expanded and improved tremendously in the past few years, there are many operational hurdles to servicing a billion people, more than 80% of whom do not have health insurance, across varying geographies (Singh, 2016).
The equivalent of 911 in India is 108 or 102; in major cities such as Chennai, Bangalore, or Mumbai, it is fairly well known and used (Das & Desai, 2017). Big cities have invested a lot of money into better road infrastructure and awareness campaigns to shift how the public reacts to emergencies. Bystanders were often afraid to assist in road accidents or medical emergencies because of the red-tape they would have to suffer through from police officers and court cases, but in 2015 the central government passed Good Samaritan protections that have improved bystander intervention (Das & Desai, 2017). In big cities, there are also many corporations, NGOs, and private hospitals which sponsor their own ambulances to supplement the government ones (Das & Desai, 2017). These centers have invested in better facilities and training for the responding ER physicians, improving patient outcomes and public trust in the 108 system (Das & Desai, 2017). But in rural or semi-rural regions, these services are woefully under-resourced and operationally stunted. A villager, for example, still travels on average 20 km (12.4 miles) for emergency hospital care (Singh, 2016).
There are many factors that contribute to the large divides between urban/semi-urban and rural India emergency care. There are fewer ambulances, well-trained doctors, and clean facilities with reliable power in these areas. Public awareness is a big issue: both about existing ER systems, and the Good Samaritan protections (Das & Desai, 2017). Infrastructure presents another significant hurdle. Many semi-urban and rural areas lack reliable roads and a good sewage system. India is also routinely one of the most polluted countries on Earth (The Economist 2018). Affording life-saving hospital care presents an enormous financial burden to lower and middle class Indians, though as previously mentioned, the absurd cost of healthcare is not a problem unique to India (Singh, 2016). Operational hurdles such as these exist not only in off-the-grid remote areas, but semi-urban ones such as Puducherry as well. Some of challenges I encountered myself showed up routinely in my research, suggesting what I experienced is perhaps not all that uncommon, even for someone not totally lost and new to the area, and with resources available through a structured Fellowship program.
It would be impossible and irresponsible to generalize medical care in India, some of which is world-class. In fact, among the rising health care costs in the U.S., many Americans opt to seek medical care in India (Block, 2018). India is among the Top 3 medical tourism destinations worldwide (Suri, 2019). This dichotomy between the standards of medical skill and care available in India, and what many lower-to-middle class Indian citizens might experience is the gap I am most concerned with as a development professional.
I want to be clear that my observations stemmed largely from my one experience and the little research I’ve done. It shouldn’t and would be inaccurate to be taken as a sweeping indictment against the India’s healthcare system as a whole. Rather, learning about this complicated, broken, yet also improving system of medical care gave me greater insight and empathy over the community I am working with this year on menstrual hygiene education and women’s health awareness as part of my Fellowship project. It was also encouraging and useful to educate myself on all the quality resources that are available, which I was just unaware of. I am infinitely grateful to have the resources provided to me by AIF and my family that carried me through those worrisome moments, but most people do not have this safety net. Ultimately my situation turned out to be less alarming than it felt at 4 am alone, but for too many people in all parts of the world, the fear of falling sick is perpetual and medical emergencies are life-altering.
And if there is a universal point to all of this, it’s this: it is a truly awful feeling to fear for your health and safety. To wonder where to turn for help, if it will come in time, and (though this was thankfully not the position I was in) if you can afford to save yourself or a loved one. It probably doesn’t matter if you’ve lived with this fear every day or were thrown into it after 24 years of bliss; it doesn’t get less scary over time. While the triumphs of the system in India are commendable, and the challenges left are immense, getting everyone past Maslow’s first two rungs, allowing them to feel safe enough that they can for once focus on love, self-esteem and becoming the most they can be, seems to me the point of doing this work at all.
- Block, Daniel (2018, January 2). “India’s Hospitals Are Filling Up with Desperate Americans.” Foreign Policy: Link to Article
- Das, Subroto, and Roochita Desai. (2017). “Emergence of EMS in India.” Journal of Emergency Medical Services (4.42). Link to Article
- Foden-Vencil, Kristian (2019, January 3). “Emergency Medical Responders Confront Racial Bias.” NPR Morning Edition: Link to Article
- Fritz, Julie (2019, September 6). “What Is The Average Police Response Time In The U.S.?” Safe Smart Living: Link to Article
- Grabar, Henry and Stern, Mark Joseph (2018, May 10). “The Privilege of 911.” Slate: Link to Article
- Halpin, Matt. (2019, January 29). “Police Response Time in US Cities.” A Secure Life: Link to Article
- Hanchate, Amresh, et at (2019, September 6). “Association of Race/Ethnicity with Emergency Department Destination of Emergency Medical Services Transport.” JAMA (2.9): Link to Article
- Kristan Foden-Vencil (2019, January 3). “Emergency Medical Responders Confront Racial Bias.” NPR: Link to Article
- McLeod, Saul. (2018). “Maslow’s Hierarchy of Needs.” Simply Psychology: Link to Article
- Respaut, Robin, and Chad Terhune (2019, January 22). “U.S. Insulin Costs per Patient Nearly Doubled from 2012 to 2016: Study.” Reuters: Link to Article
- Singh, Mahendra. (2016, April 23). “80 % of Indian Population Not Covered under Any Health Insurance.” The Times of India: Link to Article
- Suri, Manveena (2019, February 15).”India Wants to Make Medical Tourism a $9 Billion Industry by 2020.” CNN: Link to Article