Himalayan Health ExchangeRiley Williams

Location:Himachal Pradesh

• 17 different clinic sites, including care at Tibetan Buddhist monasteries, schools, and pop-up clinics in villages.

• Pop-up clinics were collapsible tents, erected in villages identified by the Indian government.

• Team consisted of 16 medical students, 2 residents, & 2 attendings.

• Evaluated & treated over 2000 patients.

• Lodging including tents & hotels, but mostly guest houses at Tibetan Buddhist monasteries throughout the state.

Challenges to Healthcare Access in

Rural India

• 90% of Himachal Pradesh Residents live rurally1.

• Physician Shortage

– In the US, there are 2.3 physicians per 1000 citizens.2

– In Himachal Pradesh, there are 0.22 allopathic physicians per 1000 citizens.4

• Travel for care can be dangerous and time consuming.

– No public transportation

– Low rate of vehicle ownership

– Unpaved or damaged roads are the norm

– Single-lane mountain roads with steep drop-offs

• Prohibitive Costs

– Median Household Income (rural) = $625/year3

HHE Overcomes

• 8 collapsible tents

• 7 footlockers of pharmaceuticals

• 1 cargo truck

• 6 personnel vehicles

• 5 hours – typical transit time between clinic sites

• 2 trips per year (plus 5 to other sites)

An Interview with Dr. Todd Cowdery:

• “Providing medicines is great, but I think our most value

comes from reassuring patients who’ve had questions

about their health but no way to have them answered.”

• “There are languages we’re all fluent in that transcend

what’s spoken. There are subtle tricks during your physical

exam that can communicate to your patients while they

communicate to you.”

Most Profound Clinical Experience

• 56 year old male complaining of

fatigue, 15-lb weight loss, early

satiety, progressive for 8 months.

Admits to daily alcohol and

tobacco. No other PMH. Denies

pain, N/V or stool changes. PE

shows distended abdomen with

indiscernible organomegaly. Has

never had imaging. Local doctor 6

months ago said the problem was

“gastric”, has no plans for follow-

up.

• Case highlights several frustrating issues:

– Trouble translating

– Lack of follow-up

• On patient’s part; our inability

– Pt unable to afford imaging

– We are unable to provide U/S due to local

regulations

• A simple, quick point-of-care tool could help

guide our recommendations and raise

flags/reassure

• POC U/S has proven efficacy in remote &

austere settings 7,8,9

Issues with Ultrasound in India

• In 2016, HHE was permitted to bring an ECHO machine, but has been denied clearance for ultrasound machines otherwise

– Read: 20 Days in the Himalayas: A Doctor's Journey6

• In 1994, the Indian government banned ultrasound use for gender determination in pregnancy due to high rates of pregnancy termination if the child was female.5

• The rationale is that females are less able to contribute economically & move away after marriage.

• These attitudes especially prevalent in rural communities, which tend to be more conservative and reliant on manual laborers

• Law regulates the sale of U/S machines, limits use to radiologists and obstatricians completing a 6-month course

• This has had the unintended consequence of limiting the use of diagnostic POC U/S for Indian and foreign practitioners alike.

• Disproportionate impact on availability of U/S in rural areas unlikely to have consultant radiologists or providers able to leave work for 6-months of distant training, plus patients are often unable to follow-up.

• “It would be remarkable to find an ultrasound machine in our region of rural Chhattisgarh in a primary health centre (PHC) and even many community health centres (CHC).”5

Possible Solutions

2. Allow Radiologists to register machines in clinics where they are not physically located.

– Current law requires every U/S machine to be registered to a government-certified U/S provider

– Requires the training of on-site practitioners in the technical skills of obtaining an image but not in its interpretation.

– Images can be sent remotely to radiologists for review or streamed in real-time.

– Some highly-integrated Indian health systems have had success with a similar model.

– Easing regulation regarding who is allowed to purchase U/S machines could make this solution more broadly applicable.

3. “Silent Observers” required on U/S Machines

– Data-storage devices capturing all U/S images, intended for review & audit of unapproved uses.

– Has been attempted in the past, but equipment at the time was easy to circumvent.

– Requiring these on all new U/S machines purchased could pave the way for wider availability of U/S devices.

• Phutke et al. identify 3 solutions to increase U/S access5:

1. Make gov’t approved U/S training more accessible:

– With advent of portable U/S devices, create online courses for practitioners or more numerous, more local offerings

– Broached in 2016, Supreme Court ruled against as the law was not intended to adjudiate who is a qualified technician

– Remains a potential solution moving forward

Cultural Experience – Atithi Devo Bhava• Atithi Devo Bhava

– “…be one for whom the guest is God.”

• Being hosted as guests in Tibetan Buddhist monasteries…granted access to their temples, audience to their rituals, loaned their cricket bat.

• At several sites, we were greeted with a Tikka, a Khata, and a selfie. One group gave us hats!

• In 1950, the Chinese Government laid claim to Tibet and began occupying the area.

• In order to practice their culture & religion freely, more than 128,000 Tibetans have fled Tibet.10

• Himachal Pradesh is home to the largest collection of Tibetan refugees and maintains a Tibetan government-in-exile

• The spiritual and governmental leader of Tibet, HH the 27th Dalai Lama, has his home in Dharamsala/McLeod Ganj

• Norbulinka (above) is an alcove of Tibetan culture – a school whose mission is preservation of Tibetan art forms.

References1. “Cencus of India 2011.” Cencus of India 2011, Government of India, 2011,

censusindia.gov.in/2011-prov-results/paper2/data_files/punjab/3.Paper-2_pb_pop_decl_gwh_byresi.pdf.

2. "Countries Compared by Health > Physicians > Per 1,000 people. International Statistics at NationMaster.com, World Development Indicators database. Aggregates compiled by NationMaster." 1960-2005. <http://www.nationmaster.com/country-info/stats/Health/Physicians/Per-1,000-people>.

3. “Human Development in India.” Indian Human Development Society, 2005, ihds.umd.edu/sites/ihds.umd.edu/files/publications/pdf-files/02HDinIndia.pdf.

4. Punam, S, and S Sharma. “Status of Public Health Services in Himachal Pradesh.” Status of Public Health Services in Himachal Pradesh - a Case Study, 2012, www.researchgate.net/publication/314283719_STATUS_OF_PUBLIC_HEALTH_SERVICES_IN_HIMACHAL_PRADESH_A_CASE_STUDY_Impact_Factor-5414.

5. 5. Phutke, Gajanan, et al. “Ultrasound in Rural India: a Failure of the Best Intentions.” Ultrasound in Rural India: a Failure of the Best Intentions | Indian Journal of Medical Ethics, Indian Journal of Medical Ethics, 2018, ijme.in/articles/ultrasound-in-rural-india-a-failure-of-the-best-intentions/?galley=html.

6. 6. Krishnan, Sandeep. “20 Days in the Himalayas: A Doctor's Journey.” American College of Cardiology, 2016, www.acc.org/latest-in-cardiology/articles/2016/08/22/09/23/20-days-in-the-himalayas-a-doctors-journey?w_nav=LC.

7. 7. Gharahbaghian L, Anderson KL, Lobo V, Huang RW, Poffenberger CM, Nguyen PD. Point-of-Care Ultrasound in Austere Environments: A Complete Review of Its Utilization, Pitfalls, and Technique for Common Applications in Austere Settings. Emerg Med Clin North Am. 2017 May;35(2):409-41.

8. 8. Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments, I: Feasibility of field deployment. J Emerg Med. 2011 Feb;40(2):190-7.

9. 9. Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments, part II: current indications. J Emerg Med.2011 Mar;40(3):313-21.

10. 10. Press Trust of India. 127935 Tibetans Living Outside Tibet: Tibetan Survey. Hindustan Times, 2010, web.archive.org/web/20110927215516/http://www.hindustantimes.com/127935-Tibetans-living-outside-Tibet-Tibetan-survey/Article1-634405.aspx.