Community Medicine and other updates

Alright so lets start from Monday last week where I left off…

On Monday, we had a journal club about nephrotic syndrome. I presented the US guidelines for management while the registrars presented the Sri Lankan guidelines. It was different from American journal club meeting because we were told to mainly use review articles rather than critically analyzing one article. But it was an interesting discussion, and I learned a lot about nephrotic syndrome which I have not previously managed. 

On Tuesday and Wednesday, I participated in the community rotation. It is supposed to be more structured and longer than two days but that is when medical students are there too. Without medical students there is less formal learning involved. But it was still a great experience. I don’t think I have previously explained Sri Lanka’s health system so let me start there…

So Sri Lanka has free, universal health care. There are some recent private hospitals popping up but most everyone goes to the public hospitals and only the public hospitals have an emergency room and trauma area. Every testing, medication, and surgeries available at the public hospital are free. This includes things like MRIs, chemotherapy, and open heart surgery. And the smartest, most trained physicians are at these public hospitals. So despite how some of them look, it is the best care available in Sri Lanka and it is quite complete. What it lacks (for free but is available if willing to pay) are certain medications (for example ceftriaxone is not available for free but cefotaxime is), specialized lab testing (like gene testing), and certain surgeries (like bone marrow transplant). The doctors told me that if they or their children were sick then they would take them to take a public hospital, which I think speaks volumes, and is not something other countries like India can boast.  With this system they have an infant mortality rate equal to many developed countries. It also helps that >90% of the country is literate thanks to their free public school system that basically everyone goes to. Private schools are rare and many public schools are better than private. I also think that’s very impressive! 

Part of this system is a great rural health care structure. Areas in each state are divided into MOH areas that one doctor (the MOH) supervises. Within these MOH areas are multiple small clinics spread out throughout the community that different medical officers (called Demonstrators) visit each day for different clnics. For example, one day it is the antenatal and immunization clinic and another day it is a children’s clinic. This allows the locals nearly daily access to doctors without going too far. It also ensures that everyone is cared for and looked after on a regular basis. There are also smaller hospitals for about every 2-3 MOH areas. Parents can be transferred from these hospitals to one of the five or six larger tertiary care hospitals in the country if needed for free. 

Seeing how much the US has struggled in controlling health care costs, I am impressed with how the Sri Lankan system works. There is a deficiency in quality and often delays in testing, but they have the same eventual outcomes. The Sri Lankan government wants healthcare to become more privatized because they feel they are spending too much money on healthcare. I have had many discussions with the doctors here on the future of Sri Lankan healthcare. They feel excited about privatization, but I am wary of the discrepancy in care that will develop-- not just in the quality of hospitals but the doctors who work there. Right now the government doctors (which is most of them) must move to different hospitals every 4 years with doctors who are more senior having priority over where they end up. This is a way to ensure that there are doctors in rural areas. It is less than ideal for the doctors many of whom must move hours away from their family but great for the patients. It's an interesting, never ending discussion so let me go back to my community medicine rotation...

I went to a couple of the clinics, seeing primarily antenatal patients but also going into the immunization area where kids were getting necessary vaccines and having their weight and head circumference checked. It was interesting because they don’t have dopplers to listen to the fetus’s heart beat. Instead they use something called a pinard. I had a really hard time hearing anything with it and probably only heard fetal heart tones twice. Here is a picture of what they look like: http://en.wikipedia.org/wiki/Pinard_horn

One of the clinics was held at an orphanage created by an Austrian doctor. It was a very well developed and maintained orphanage. They gave me tour of the place. Most of the kids are actually there due to court sanctions to get away from abusive parents, which is super sad. But the children looked very happy and content there! Unfortunately I did not have my camera but this is the website for the orphanage: http://soschildrensvillages.lk/

On Friday, I presented a case at their Clinical Lecture Discussion. The CLD is their version of Morning Report that they have once a week. But it is much more intense because only the pediatric registrars participate. They are ones on the “hot seat” and ask all the questions and form a differential. I presented the case I presented at Chair’s Conference: the girl with Hemophagocytic Lymphohistiocytosis. It was a hard case, but they got pretty close!

This past weekend, I spent time doing some final souvenir shopping and attending a peace concert! It was held at a Japanese Buddhist temple and featured people from Europe, India, Japan, and of course Sri Lanka. The point of the concert was to promote peace and understanding through music. The Japanese Ambassador was there too! It was nicely executed in a beautiful area. Here are some pictures from the event:

 A sitar player from India

 The crowd in the area

 A view of the beautiful sunset we watched there

The pagoda light up at night!

Speaking of going tourist shopping, let me tell you about experiencing what I call the “Tourist Tax”. When traveling to a developing country, foreigners often pay more than locals for many different reasons, primarily being that the locals charge more knowing the foreigners will pay. I have been charged more for that reason but can often haggle it down to a reasonable rate  that is still more than the local rate. But I have not had people jack up the price so much as when I am traveling with Anna, our new Japanese friend! I actually met some rude Sri Lankans for the first time when trying to negotiate a bus fare! 

Relatedly, I may have mentioned that people are very curious about me being Indian and enjoy talking to me. But I don’t actually stand out too much usually unless I start talking, especially now that I have gotten darker. Most people here assume I am Sri Lankan! And I really enjoy not getting unnecessary attention. But walking around with Anna, people are constantly staring and commenting! I feel like I am experiencing a different part of Sri Lanka being around her. The Japanese government has put in a lot of money into the Sri Lanka infrastructure so they are very well respected here.

I wrote this blog post while going to pick up Dhaval from the airport on Wednesday but unfortunately am just getting around to posting it now. Pictures take so long to upload! I will provide details of the rest of the week in a different post!

This post had a lot of writing so let me end with pictures of different Sri Lankan fruit and food that I tried:

Hopper and Egg Hoppers. Super yummy and cheap. It is basically a South Indian Dosa made in a small skillet. So the edges are very crispy while the center is thicker and softer. The egg hopper just has an egg broken in the middle. It is super yummy especially with their different chutneys.

Wood apple. I really didn't like this. I thought it would be more like an apple but the name only describes the appearance. The taste is not so bad; it is very tangy. But the smell and appearance prevented me from being able to eat it.

 Our version of High Tea! We meant to go to the Fort to have high tea but kept forgetting/not getting time together. But we bought amazing tea in Hikkaduwa and some local cake and made our own high tea!. The little brown things in the back are another fruit that is also very tangy. Sorry I don't remember the name of it!