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).
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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.
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From : Mukesh Kacker
Arpanet : g-kacker@gumby.wisc.edu
UUCP : uwvax!gumby!g-kacker