This was meant to be the 'Indian experience'. Seeing first hand how this vastly overpopulated and underfunded healthcare system copes with endless cases of infectious diseases and the ever increasing strain caused by the prominence of 'western' conditions such as diabetes and hypertension.

Based on the information I had submitted I was told that my experience in the UK would be incredibly useful and that I would not only be providing advice and assistance but also learning to cannulate, change IV's and perform diagnostic tests. How very exciting this all sounded..... From the information I had recieved prior to travel I had fully expected (and almost looked forward to) slumming it in terms of accomodation whilst spending the days working to exhaustion in the 35C heat. When in fact I ended up staying with a reasonable wealthy local family in a district of Faridabad, south of Delhi. That being said, the family were absolutely magnificent hosts and provided extraordinary cuisine, useful information and wonderful conversation. This was particularly true of the head of the house, Dr Prabhat. As a practioner in general medicine at the government hospital he was able to offer in depth information about the struggles faced in his practice. Most interestingly he pointed out the unbelievable levels of corruption in Indian politics that siphon off much of the healthcare funding which is all the more disheartening considering the God-fearing nature of the country.

I spent the first week in a mobile medical unit that operates out of the back of an old ambulance and offers free medical care to elderly persons in the poorer districts of the city. I use the term ambulance loosely here. Even the ambulances in use by the emergency services are little more that a small transit van with a bench in the back. The problem with this particular part of the program was that firstly, very few of the elderly population speak any english and my hindi isn't exactly fluent so offering any form of counselling advice was near impossible. The language barrier even caused problems with the doctor and pharmacist that ran the service.

Secondly, the clinic has a very limited scope of medications to prescribe from so the chance to offer (better?) alternatives is again, challenging. Furthermore, a suprising number of the medications utilised were both dated and vaguely recogniseable meaning that finally, the BNF I had lugged around for a month came in handy. Throughout India, drugs are prescribed by brand. These brands are often different to the ones used at home so finding out whats inside the bloody thing is in the first place is a nightmare. Huge numbers of drugs are combination preparations containing two or more drugs. Rather alarmingly, the dose of each drug within it is far too commonly sub-therapeutic for one and toxic for the other. For example, combinations of Paracetamol 325mg + Dicycloverine (anti-spasmodic) 20mg. The recommended dose of dicycloverine for elderly patients is only 10mg and to get an analgesic effect from the paracetamol you'd need to take three tablets, hereby taking a x6 dose of the anti-spasmodic. I wish I could say this was the exception but there are dozens of other instances where this occurs.

With no concept of queing or personal space in India the potential for clinical or dispensing errors is immediately hightened. The setup of the clinic, often just parking up on a roadside or in an open space such as a temple or public park allowed the doctor and pharmacist alike to be swamped with eager patients who would thrust paperwork and prescriptions in front of them while they tried to perform diagnostic tests or dispense medication. Here's where I started to get frustrated. None of the staff spoke particularly good English so trying to make a suggestion was like trying to cook a turkey with a lightbulb. It was blatently obvious that this system was flawed and it was simple enough to improve. Trying to suggest things like giving out a ticket to the patients so they can wait to be called or creating a loop-like system so the tests could be performed at one station so this could then be handed to the doctor, then the prescription collected at the end. There is absolutely no way anyone could concentrate to the extent that is required when 20-30 people are surrounding you and waving paperwork in your face. All the medication is dispensed weekly so that patients have to attend the clinic every week. It was obvious that the workload was far too high so I posed the question "could you perhaps have the more stable patients attend every 2 weeks to reduce the pressure?". A reasonable suggestion I felt..."no, we do it every week" was the simple response. Trying to then suggest that the 4th bloke who worked there and for the most part seemed to have no discernable use should cut up the packs of medication into strips of 7 tablets so that its easier to dispense also fell on deaf ears (i.e. if its one tablet a day, give one strip. If its two tablets a day give two strips etc. The current process was to recieve a prescription, look in a miscellaneous red tub full of loose medication, find what was needed, cut it up and give it out with the only counselling being to point at each tablet and say "BP", "sugar" or "sickness". I asked if we should utilise the many spare and empty cardboard boxes to sort the medication to make it easier to find and less likely to pick the wrong product...."no time" was the response. Peturbed, bored and concerned I said "But I'm not doing anything, I can do it for you then it will make it easier in the future"......again a frustrated "no" befell me.

According to Leeds Teaching Hospitals (exhaustive) medication policy here's a list of the dispensing errors on every single prescription. So this doesnt count the dozen or so times a day that the wrong product, dose or quantity was given out before being noticed by the patient some time later.

Ok here we go, deep breath aaannnddd........No box, no name of patient, no drug name, no quantity, no formulation, no frequency, no date, no KOOROC, no date of dispensing, no expiry date, no warning labels, no product information leafet, no duration or treatment, no batch number, product not kept within manufacturers storage requirements and finally no supplementary labels.

The following week I was based with a Dr Khan at a 'slum clinic' in southern Faridabad. These clinics provide affordable healthcare to the local population and perform basic examinations, administer IV's and minor treatments such as stitching up wounds etc. India does operate a government funded healthcare service but this covers only 10-20% of the 1.4 billion population and typically deals with emergency situations leaving the remainder as private enterprises. A 'proper' private clinic/hospital will charge around 500 rupees (about £5) as a consulation fee with additional charges for treatment and diagnostic tests. This can quickly escalate to costs of around 2000 rupees per night and with the average wage of a slum worker often flirting around the 100 rupees per day mark it is clear that much of the healthcare service is out of reach of the majority of the population. The slum clinics plug the void that is left by charging minimal consulation fees, around 30-50 rupees, and (often) subsidised medication costs by working directly with a specific pharmacy or wholesaler.

The clinic itself was incredibly small, hot and cramped with the dimensions of the whole building little more than 6 x 12 feet. There was a small desk at the front with a deckchair and a bench for the patients to sit on. Behind a semi-partitioned screen, that seemed to serve no purpose other than to impeed the natural light when stitching or cannulating patients, there were two more benches for patients to lay on as procedures were performed. When the benches were fully occupied, miscellaneous nails protruding from the clinic walls provided a secure enough hook with which to hang up IV bags for patients sat in the garden furniture at the front of the clinic.

After being taught the basics of how to cannulate and administer IM's I set about the daily tasks that usually involved taking and recording obs, changing IV's, prepping injections and some wound dressing. On a day when I arrived to a rat running over my feet I assisted the Dr with a teary twenty something male who needed his heavily infected toenail removing. With the two of us occupied there was noone to keep an eye on or change the four or five IV drips that were running at the time. But no matter, because the Dr's 14 year old brother and his 10 year old mate were more than capable of changing the bags and infusing the various additives.... Ampoules were opened with the subtle technique of bashing them across the head with a pair of scissors so that glass scattered across the clinic floor. This added a certain ambience and feng shui to the blood-stained bandages, wrappers and even un-sheathed needles that had been tossed lazily in the direction of the undersized bin in the corner.

The patient seemed to recieve a large number of injectable medicines when it seemed that an oral alternative may be just as effective. I was able to discuss this at length with the doctor who provided a very valuable insight into the system. The patients at the slum clinic simply cannot afford to pay for intrinsic diagnostic testing so identifying a specific pathogen is often not possible so cover with a broad-spectrum anti-biotic is usually given quickly and readily. If the patient can't afford testing, the only two options available to a clinician are therefore to treat or not to treat. The morals of administering potentially unnecessary treatment is obviously outweighed by the hope that medication will hopefully prevent further deterioration of the patient and further transmission of the disease to the surrounding population, who often live in crowded and unsanitary conditions, ideal for the spread of infection. Treating early and aggressively with IV's firstly achieves rapid attainment of therapeutic levels to limit further spread of the condition and secondly improves patient compliance as they must then return the next day for another dose and further assessment. Whether bringing a person with typhoid into a cramped clinic on a daily basis in a room that's rarely cleaned and full of patients with open wounds is a good idea is open to debate.

A example of this therapeutic diagnosis approach was highlighted when a man with severe chest pain arrived at the clinic. He could not even afford medication let alone the echo and potential surgery that he might need. With the goverment hospital severely under-staffed, overrun and with limited beds the chances of him recieving timely treatment were slim. In the end the clinician offered him some GTN tablets to see if that would alleviate his symptoms. Fortunately, in this case it was successful and he was sent away with a packet of tablets and a good luck.

The arguement here is that at least these clinics do provide some care and I have no doubt that many, many more people are alive today because of the work done in similar establishments. The doctors are highly skilled, as they have to be to progress through the Indian medical system that is far more competetive than that in the UK. The work always involves a high turnover of patients in stressful environments and complex moral and social issues to consider. Nevertheless, one can not help but feel that with such limited resources, more should be made of what IS available.

My final week was scheduled at private childrens hospital, unfortunately due to a rather persistant stomach bug that needs few further details I was resigned to my homestay bedroom for the majority of the week. Nevertheless I did manage to spend a couple of mornings in the neonatal intensive care unit. This was certainly an eye-opening experience. With 16 babies all cared for in a small room. Again, the techniques used were often far from ideal with vials being left open to be used repeatedly throughout the day and a frightening disregard for infection control. However different this may seem to UK standards you have to consider the level of poverty in the area. Would using a fresh clean vial or medication each time price some people out of the treatment they need? Is at least recieving something better than nothing at all?

I think overall the healthcare system in India does a valiant job at trying to provide care but due to the vastly over-population and poverty all the while dealing with the corruption and social issues involved in Indian politics. The Indian's are a hardy people and I think they cope with health and sanitation issues better than we in the west would be able to but nevertheless there is a huge difference in the prosperity and availability of care within society. I sincerely hope that this gap is plugged sooner rather than later.