Jhilam Biswas '05

December 26, 2003

Dickey Fellowship Follow-up Report

Experiencing Kolkata: Learning the Principles of Health Care in the Diversity of its Definition

Proposing a question can be a difficult task when one is completely unaware of the context in which to propose the question. I tried to do this a couple terms back when designing a project that would expose me to the healthcare system in West Bengal, India. I started working at R.G. Kar Medical College in Kolkata (Calcutta) helping with an HIV/AIDS Sentinel Surveillance program, and I came back with a better understanding of the diversity of public health's world wide definition. However, within such diversity, I found certain principles of healthcare and of life ring true in all circumstances. I learned that any type of absolute power results in corruption and that challenge and struggle is the true motivation of innovation. I also learned that exposure and education is the fastest path toward advancement.

The first half of my internship was focused on my main project, the West Bengal HIV/AIDS Sentinel Surveillance program. The HIV Surveillance is an annual survey sponsored by the UNAIDS Organization that asks medical colleges around the world to conduct anonymous tests on blood samples from STD patients and pregnant women in order to monitor trends and make a rough determination of the epidemic's geographical spread. The results that we collected from our patients were sent to the West Bengal State AIDS Prevention and Control Society who then use the information to provide estimates and future projections involving the disease's impact in India. The conclusions from the surveillance are also used to assess proper implementation of HIV prevention methods, mobilize the national, political, and social leaders as well as generate external support for the program. Thus, there is a long pipeline in conducting this project. My concentration dealt with observing the sampling and testing phases.

I organized the tallies of patient samples we had received from various clinics across the state and went to clinics to help with the testing and recording of patient information. After the samples had been collected, we would go back to the microbiological laboratory to run the Micro-Elisa Test, an in-vitro qualitative enzyme immunoassay for the detection of antibodies to HIV-1 and/or HIV-2 in human serum or plasma. This is the same test medical technicians use to diagnose HIV carrying patients. During this internship, I spent time in various wards in the hospital. Often, I was overwhelmed by the sheer number of people that the nurses and doctors worked with. Sometimes in the pediatric ward, I would watch doctors handling close to 75 patients an hour. Often, lines to see the doctor would go outside the building.

During this project, my advisors and I felt it was a great opportunity to run a sociological survey of the patients we were testing. We thought that perhaps we could get a better understanding of the cultural factors related to West Bengal's struggle with the epidemic. I prepared a survey questioning the patients' socio-economic background, lifestyle, education and basic understanding of the AIDS virus and safe sex practices. After running close to thirty interviews, I decided to terminate the project. I realized that my survey was not answering my proposed question of whether lifestyle and educational factors affected the spread of the virus. The way the questions were thrown predetermined most of the patients' answers. The issues discussed in the survey were of a personal nature. Thus, the patients, most of whom have never been interviewed before, answered what they thought the doctor in the room would want to hear. Perhaps if I was surveying for any other disease, I would have received valid results more easily. In India, as well as many parts of the world, AIDS continues to have a very deep rooted stigma attached to it. The cultural implications can be immense if one admits to carrying the disease. Therefore, many people resist being tested or choose not to be educated about it. I did not want to let go of this project, but I felt it was better to drop it than to give invalid results that others may possibly take as truth.

As I became more adjusted at the medical college, I began to get closer to the microbiology staff, faculty and students. This was perhaps my great fortune, for I got to see Kolkata's everyday issues with healthcare through native eyes. The state of West Bengal is under the governance of the Communist Marxist Party within the democratic country of India. This is a singular position indeed. Talking to students, the elderly, journalists, healthcare workers, and even politicians, most feel that this is an extreme detriment to the state. In addition, the tremendous population growth is a huge problem for the state. Once the affluent capital of the nation, Kolkata's economic and social condition has deteriorated drastically. I witnessed the effects of the government and the population in the sphere of health. The state suffers from corrupted politics and a decentralized government that makes most simple projects an impossible endeavor. Although the government controls all the public hospitals, the administrative power is so removed from the medical field that healthcare workers have little means of conducting a pertinent project or financing areas that need money. Doctors, as they graduate from medical school, are ordered to a particular specialty and posted at any hospital the government chooses. The educated youth, the region's largest asset, are often disenfranchised and at the mercy of complicated bureaucracy and poor infrastructure. The working conditions can be so frustrating that many either migrate elsewhere or lose their motivation to make significant progress. Thus, the original issues get lost amidst a tangled web of squabbling, squandering and politics. I found that there must be checks and balances to power or it inevitably leads to corruption.

I had started my internship focusing on the AIDS issue in India, but my interest shifted significantly as I started understanding the situation the region is facing. I found that the leading causes of death were tuberculosis and nutrition related diseases; AIDS, on the other hand, was much lower on the list of immediate concerns. These problems are all preventable, yet multitudes are constantly suffering. Huge non-governmental organizations and corporations are pouring money toward medical relief, but why are people in developing countries suffering from highly preventable diseases? I realized that it is not merely the scarcity of money that is causing poverty and untimely deaths. I spent the rest of my time in India researching how officials in India are using their resources to bring healthcare all the way down to the grassroots.

NGO's and large corporations are highly visible enterprises that need to work through the government of a developing country. They cannot penetrate the deepest layers of a healthcare issue, which is often embedded within the infrastructure of the system. Because of the lack of exposure, there is a lack of follow-up to the proper allocation of funds. This is the main issue. No one can be held responsible, so the money is not directed to the source of the problem. What's the point in putting tons of money in medicine, where overuse may decrease its potency anyway? Improving the sanitation system, drainage and water sources will solve the problem in the long-term. Healthcare is about infrastructure and lifestyle just as much as about medicine, yet not many tend to look at it that way.

I could see the region I was working in needed non-governmental options to survive. For the remainder of my internship, I had meetings to discuss possibilities of further research with the West Bengal Regional Director of CARE (Cooperative for American Relief Everywhere), Gayatri Oleti. Together, we planned outings to villages in West Bengal to see how non-governmental operations were running relief programs. This was of interest to me, because I learned of innovative programs created by people who realized the need to find alternatives to better their current condition. The Student Health Home, an extraordinarily effective program which self-sufficiently lends health care and resources to West Bengal students, is well connected to doctors at RG KAR and other hospitals. Over 200,000 students are enrolled for an extremely small annual fee. However, with the help of volunteer doctors and outside funding, this program is thriving and helping students all over the state. I had the good fortune of being invited to see the roots of revolutionary technology at a hospital in the southern part of India. At the Hrudayala Hospital and the Rabindranath Tagore Cardiac Institute in Bangalore, they have begun conducting medical visits to villages in many states in India through tele-medical technology. With the use of satellites and computer technology, specialized doctors are able to diagnose and treat patients all over the country and many parts of the world. Thus, patients who have little means of getting advanced healthcare treatments are able to receive world class medical resources. Today, as Ms. Oleti and I discovered, the process is still somewhat idealistic. Often, new technology is a very difficult thing to integrate into a society with no means to operate it. Many villages that we had been informed had telemedicine had not heard of such technology. Nevertheless, the idea is exciting, and we must allow it time to properly adjust to the world at large.

At times my experience in Kolkata was shocking and difficult and at times marvelously spiritual and enlightening. I developed an understanding of this city, named by Mother Teresa "The City of Joy," that helped me drop my frustrations and gain appreciation for the essence of the human spirit's spontaneous activity. I learned to love the process of doing a particular task and forgot the meaning of time. If I never had been exposed to the culture directly, I never would have understood its value. I grew from every challenge I faced, and each time I got became more flexible to change. From my experience, I believe that exposure and interest toward anything new initiates both personal and societal growth. My understanding has led me to create a program at Dartmouth that allows students to experience personal growth in a global atmosphere. The Dartmouth Coalition for Global Health, comprised of students, faculty and alumni, realizes the importance of looking at health as a total social entity, and encourages Dartmouth students to develop a global perspective. Medical philosophy cannot be isolated in scope; it is affected by everything outside of it. Public health is beyond the realm of medical sciences; it concerns us all. We are a part of a complete system of cause and effect and when we become the observers, we can begin to treat any issue at its root.

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Jhilam Biswas '05 is a sociology major from Norwell, Massachusetts. Last fall, in 2003, she spent a semester in Kolkata, India working at R.G.Kar Medical College on a AIDS survey conducted by the UNAIDS organization. The year before this experience, she had spent a sememster working for the Boston Healthcare for the Homeless Program. Both of these internships led her to create and currently direct the Dartmouth Coalition for Global Health which is now sponsored by the Dickey Center for International Understanding. Outside of her interests in global health, she is part of the Rockapellas, an acapella group on campus that has toured around the country singing songs for social justice. She has plans to head to medical school in a few years after graduation, but wants to study natural healing methods in India before she goes.