[Read Part 1 here]

Hospitals – for more specialists

My first experience as a patient of a hospital in India came at a nice, small private hospital in Delhi. After struggling for a day, an Indian Aunty forced me into the ER. I was immediately put on an IV, and two hours later I was sent packing with a list of medicines. All paid for out-of-pocket, no questions asked. The snobby American in me wondered, “If this were the best hospital in Delhi, why there were flies everywhere, or why there was hardly any privacy (to my Westernized expectations), or even worse of me – why was the cost so cheap!” To my skewed perspective it seemed as though, insurance or not, going directly to the ER was affordable for most expats, middle, and upper class Indians.

Returning to my ear infection story, my appointment with the newest ENT took place in the hospital, where some specialists hold regular appointments. I knew, in the hospital, having an Indian Aunty as an advocate was key; clearly without my Masi, I would have been lost. When we walked into the large, upscale, tertiary hospital initially through what I will call “the Octagon” entrance, I was stupidly unprepared for the crowd. The entrance was an eight-sided whirlwind of registration windows and pathways to the hospital. My aunt immediately went to the middle and starting having me fill out a registration form, then took it to a registration window (having lines are more of a guideline than actual rules). At the registration window, we pre-paid for all appointment and service fees, and received the pay stubs to the appointments. As it was my first time in the hospital, I was also forced into buying a “hospital identification card” for all future visits.

She knew exactly what to do and who to talk to – and I followed like the five year old I have admitted I am! Arriving to re-register for the appointment in the correct wing of the hospital involved my aunt knocking (read: opening) doors to speak to the right person before waiting to be called (can’t avoid waiting rooms). The ENT specialist, surrounded by five female assistants (while they too are doctors and nurses, they are referred to as assistants), did not lack in confidence. After my aunt’s explanation of our referral, it seemed as though the doctor was only addressing my aunt directly instead of me as he explained his diagnosis at a quick glance. Soon, he had me on the patient bed inspecting my ear, painfully digging and clearing it out with a metal rod-like device as he showed my aunt what was wrong with my ear. My presence, aside from my ear, felt irrelevant! A surprise to me, I was then sent to get various tests and CT scans, and unsurprisingly given another list of medicines, nasal drops, and different ear drops. As it is in the US, the process involved more forms, buildings, and TIME waiting. An Indian Aunty can only get you around so much. What could have lasted through the night, or returning the next day, turned into an all-day affair thanks to my Masi. Luckily, she was able to ensure my tests were done on the same day and was able to schedule the follow-up for the same week.

Five Random observations that struck me:

1. Organization of medical files (what they give you and what Indians have for themselves). See the above pictures.
2. Reimbursement of Tests: At the report pick-up window, I learned that my culture reports turned out negative and as a result, I qualified for reimbursement for that test.
3. Submitting pee: You go into a small bathroom with your cup, do your business, and leave it on a tray in the bathroom with all the other samples from the day’s patients.
4. Certain test results that that are supposed to be reported a day or two after the doctor analyzes them, can be received if your Indian Aunty requests the doctor to look at it immediately and give the verbal report in-person.
5. Advocates in the room: I touched upon this before, but, you can take as many Indian Aunties (or anyone for that matter) into the room for the doctor’s appointment. One time I saw seven people (family members? friends? community leaders?) join one patient into the doctor’s office. What was that about Privacy?

The result of my tests and follow-up? According to the doctor — Surgery! The next step, of course, was to delve deeper into the network in Mumbai and abroad of all caring Indian family members to get other opinions. For a second opinion in-person, I went to another specialist the Indian Aunty Network afforded me. The private practice, on the opposite side of town, seemingly had people from all walks of life waiting long stretches to see the doctor. I couldn’t understand how the place operated – first come first serve, arbitrary picking names out of a hat, or actual appointments. I couldn’t escape hours of waiting – terrible/crazy doctor’s waiting rooms must be a universal constant. The ENT was calm and patient, answered all of my questions, confirmed surgery, and of course, prescribed different medicine and ear drops. He was kind enough to let me take my time discussing options with my concerned family and their friends, before returning for a final follow-up to schedule surgery. The only experience I can compare scheduling my ear surgery to would be the simple wisdom teeth extraction, so I didn’t realize the extent of matching schedules of the doctor, anesthesiologists, and everyone involved plus all the tests I was required to take before surgery.

I’ll admit to a day or two’s worth of minor paranoia (blame bad movies or horror stories) but it also felt natural to worry about the worst case scenario, especially when you don’t know what is happening to your body, and dealing with it in a foreign environment. Although I may be annoyed at the familial worrying (Indian people think that worrying is a trait dominated by Indian parents, but it is obviously universal), I know I should never take their caring for granted. I do appreciate it and maybe this blog is my indirect way of admitting it. It has reaffirmed how lucky I am to afford and have access to such treatment (and in a country with renowned doctors). And how, in the grand scheme of things much worse and more important in the world, my period of ear pain and deafness isn’t a big deal. This story is long because it has dominated my November and December. For the record, I am feeling good and it hasn’t fully stopped me from this adventure in India!

So what?

What did I learn? What is the point of my rambling journey? First, I now have sympathy for people that are deaf or slightly deaf. Also, ear drops falling out of your ear probably isn’t the sexiest when you are meeting Priyanka Chopra. Seriously, though, navigating the affluent side of the health care system here brought perspective – to my work and my interactions with the facilities, professionals, and services aimed at improving the public health for the “bottom of the pyramid” population in India.

I don’t have answers, but like most of my time in India, I have more questions. Curious about the vague generalizations that I’m constantly coming across and how that is reflected in my specific and more detailed interactions. In their own bubbles, I can see the issues with the richest and poorest of systems.

A common theme in public health projects is to “promote health-seeking behavior” in marginalized populations, and generally improve access. What do those terms really mean? Does that mean that the affluent societies have health-seeking behavior and good access?

Whether I’m in India or in the US, I’m only seeking out a doctor when I’m forced to – do I have good health-seeking behavior? In India, at best/least, the advocacy of simply washing hands BEFORE eating has stayed with me. In Mumbai, we may pay a lot of money for certain services, but in another rural location with a public health project, everything is subsidized. How does that system stay afloat financially, or how is it sustainable? The issues of healthcare costs are worldwide – think about the debate surrounding the Affordable Healthcare Act in the US, and how a law aimed at improving coverage and access sparked serious concerns of burden of payment. In India, the public hospitals in the cities can be overcrowded without enough beds for patients, while public hospitals in rural locations might not be fully functional or have attending staff on-site. The mere promotion of cost-effective services is important because people don’t choose to get treatment (financial concerns, stigma, culture), or simply don’t have access. Despite being a country known to produce doctors, there is a dearth of health professionals considering India’s population and needs.

But isn’t every system unequal? Doesn’t everyone need advocates? Who will be advocates for the marginalized populations? Is it the government’s responsibility, the individuals, civil society, or the wealthy? As my Public Health professor drilled into us, I know there is no magic bullet. I can’t fully wrap my head around all of these questions, so in the process of writing them out, I’m asking myself – what do I want to learn? The preventative approach to public health – how can we better do that? Is the ultimate goal of health-seeking behavior to evolve towards the preventative approach?

Often, in Mumbai, we feel terribly guilty of working in a service-oriented project, while living an upper class lifestyle. I recognize status and how lucky I am. The experiences I have written about do not represent the access granted to most of India. Guilt aside, I should constantly be motivated by this towards my goals of improving health systems and access in India. Health care, one of the most basic of human rights, is a complex issue from the richest to the poorest, and our systems should always be working towards improvement. In addition to addressing issues of access to services and care, everyone in India needs advocates at facilities and in communities to promote and ensure functional delivery. I can use all the “buzz words” over and over, but what really matters? If you are lucky, you will find yourself an Indian Aunty!