cs525-2@puff.UUCP (Mukesh Kacker) (03/22/86)
Following is the reproduction of an article published in the April 1986 issue of DISCOVER magazine .It is authored by Ms Perri Class ,a fourth year medical student at Harvard Medical School.She has described her impressions and reactions to a stint of medical training in an alien land (in India). ------------------------------------------------------------------------------ The people look different.The examining room is crowded with children and their parents,gathered hopefully around the doctor's desk,jockeying for position.Everyone seems to believe,if the doctor gets close to *my* child ,everything will be OK.A small group of Indian medical students is also present, leaning forward to hear their profesor's explanations as they watch one particular child walk across the far end of the room .I stand on my toes, straining to see the intervening heads so I,too , can watch this patient walk.I can see her face,intent, bright dark eyes,lips pinched in concentration.She's about ten years old.I can see her sleek black head,the two long black braids pinned up in circles over her ears in the style we used to call doughnuts.All she's wearing is a long loose shirt,so her legs can be seen,as with great difficulty she wobbles across the floor.At the professor's direction she sits down on the floor and then tries to get up again;she needs to use her arm to push her body up. I'm confused.The patient looks like a child with absolutely clas- sic muscular dystrophy,but muscular dystrophy is a genetic disease carried on the X chromosome,like haemophilia.It therefore absolutely never occurs in girls.Can this be one of those one-in-a-trillion situations ? Or is it a more unusual form of muscle disease,one that isn't sex-linked in inheritance? Finally the child succeeds in getting up on her feet,and her parents come forward to help her dress.They pull her over near to where I'm standing, and as they're helping with the clothing,the long shirt slides up over the child's hips.No, this isn't one of those one-in-a-trillion cases.I've been watching a ten-year-old boy with muscular dystrophy;he comes from a Sikh family,and Sikh males don't cut their hair.Adults wear turbans,but young boys often have their hair braided and pinned up in two knots. Recently I spent some time in India,working in the pedriatric department of an important New Delhi hospital.I wanted to learn about medicine outside the U.S., to work in pedriatric clinic in the Third World,and I suppose I also wanted to test my own medical education,to find out whether my newly acquired skills are in fact transferable to any place where their are human beings,with human bodies,subject to their range of ills and evils. But it wasn't just a question of my medical knowledge.In India,I found that my cultural limitations often prevented me from thinking clearly about patients.Everyone looked different, and I was unable to pick up any clues from their appearance.This is a family of Afghan Refugees.This family is from south of India.This child is a child from a very poor family.This child has a Nepalese name.All the clues I use at home to help me evaluate patients,clues ranging from what neighbor- hood they live in to what ethnic origin their names suggest, were hid- den from me in India. The people just don't look different on the outside,ofcourse.It might be more accurate to say that the population is different.The gene pool for example:there are some genetic diseases that are much more common here than there,cystic fibrosis say,which you have to keep in mind when evaluating patients in Boston,but which which would be showoffy and highly unlikely diagnosis-out-of-the-book for a medical student to suggest in New Delhi(I know--- in my innocence I suggested it). And all of this in the end,really reflects human diveresity,though admittedly it's reflected in the strange warped mir- ror of the medical profession;it's hard to exult in the variety of human genetic defects,or even in variety of human culture,when you are looking at it as a tool for examining a sick child.Still I can accept the implications of the world full of different people,different popu- lations. The diseases are different. The patient is seven-year-old boy whose father says that over the past week and a half he has become progressively more tired,less active ,and lately he doesn't seem to understand everything going on around him.Courteously, the senior doc- tor turns to me,asks what my assessment is.He asks this in a tone that suggests that the diagnosis is obvious,and as a guest I'm invited to pronounce it.The diagnosis,whatever it is, is certainly not obvious to me.I can think of couple of infections that might look like this,but no single answer.The senior doctor sees my difficulty, and offers a maxim,one that I've heard many times back in Boston.Gently ,slightly reprovingly he tells me, "Common things occur commonly. There are many possibilities,of course,but I think it is safe to say that it is almost certainly tuberculous meningitis." Tuberculous Meningitis ? Common things occur commonly ? Somewhere in my brain (and somewhere in my lecture notes)"the complications of tuberculosis" are filed away and,yes,I suppose it can affect the cen- tral nervous system, just as I vaguely remember it can affect the stomach,and the skeletal system... To tell the truth,I've never even seen a case of straightforward tuberculosis of the lungs in a small child,let alone what I would have thought of as a rare complication. And hell,it's worse than that.I've done a fair amount of pedia- trics back in Boston,but there are an awful lot of things I've never seen. When I'm invited to give an opinion on a child's rash,I come up with a creative list of tropical diseases,because guess what ? I've never seen a child with measles before.In the U.S. ,all children are vaccinated against measles,mumps, and rubella at the age of one year.There are occasional outbreaks of measles among college students,some of whom didn't get vaccinated 20 years ago, but the disease is very rare in small children.("Love this Harvard medical student. Can't recognize tuberculous meningitis.Can't recognize mea- sles or mumps.What the hell do you think they teach them over there in pediatrics?"). And this, of course is one of the main medical student reasons for going to study abroad,the chance to see diseases you wouldn't see at home.The pathology ,we call it,as in "I got to see some amazing pathology while I was in India." It's embarassing to find yourself suddenly ignorant,but it is interesting to learn about a new range of diagnoses,symptoms,treatments,all things you might have learnt from a textbook and then immediately forgotten as totally outside your own experience. The difficult thing is that these differences don't in any way,however tortured,reflect the glory of human variation.They reflect instead the sad partitioning of the species,because they're almost all preventable diseases, and their prevalence is a product of poverty,of lack of vaccinations,of malnutrition and poor sanitation.And therefore,though it's all very educational for the medical student (and I'm by now more or less used to parasitizing my education off human suffering), this isn't a difference to be accepted without outrage. The expectations are different.Their child is a seven-month-old girl with diarrhea.She has been losing weight for a couple of weeeks,she won't eat or drink,she just lies in her grandmother's arms.The grandmother explains:one of her other grandchildren has just died from very severe diarrhea,and this little girl's older brother died last year,not of diarrhea but of chest infection... I look at the grandmother's face,at the face of the bab's mother and father,who death,the chance that the child will not live to grow up.They've all seen many children die.These parent's lost a boy last year,and they know that they may lose their daughter. The four have trvelled for almost sixteen hours to come to this hospital, because after the son died last year , they no longer have faith in the village doctor. They are prepared to stay in Delhi while she's hospitalised, the father and grandmother may well sleep on the hospital grounds. They've brought food ,cooking pots, warm shawls because it's January and it gets cold at night. They're tough, and they are hopeful, but they believe in the possiblity of death. Back home, in Boston, I've heard bewildered parents say, essen- tially, "Who would have beleived in 1980s a child could just die like that ?". Even parents with terminally ill children, children who spent months or years getting sicker and sicker , sometimes have great dif- ficulty accepting all the art and machinery of modern medicine is com- pletely helpless. They expect every child to live to grow up. In India , it isn't that the parents are necessarily resigned, and certainly not that they love their children less. They may not want to accept the dangers, but poor people, people living in poor villages or in urban slums, know the possiblity is there. If anything , they may be even more terrified than american parents just because they are picturing the death of some other loved child,imagining this living child going the way of that dead one. I don't know.This is a gap I can't cross.I can laugh at my own ability to interpret the signals of a different culture,and I can read and ask questions and slowly begin to learn a little about the people I'm trying to help care for. I can blush at my ignorance of diseases uncommon in my home territory,study up in text books, and deplore ine- qualities that allow preventable diseases to ravage some unfortunate populations while others are protected.I can try to become more discriminating in my appreciation of medical technology and its uses,understanding that the best hospital isn't the one that does the most tests.But I can't draw my lessons from this grandmother,these parents,this sick little girl .I can't imagine their awareness,their accomodations of what they know.I can't understand how they live with it.I can't accept their acceptance.My medical training has taken place in a world where all children are supposed to grow up,and the excep- tions to this rule are rare horrible diseases,disastrous accidents.That is the attitude,the expectation,I demand from patients.I'm left most disturbed not by the fact of children dying,not by the differences in the medical care they receive,but by the way their parents look at me,at my profession.Perhaps it's only in this that that I allow myself to take it all personally. ----------------------------------------------------------------------------- From : Mukesh Kacker Arpanet : g-kacker@gumby.wisc.edu UUCP : uwvax!gumby!g-kacker