Rumour Has It

Apparently there are rumours that I am not, in fact, on a medical elective but am instead just running rampage around the country of Sri Lanka. While my blogs so far have touched little on the subject of medicine (have I even mentioned it at all...?), due to a lack of exciting pictures and things to say that I think would be of interest, I have therefore been pressurized into quelling these ugly rumours by posting this blog about my experiences of Sri Lankan medicine. To be honest, if you're all so interested I'll make you read my 3000 word elective report... yeah... I didn't think so! 

One of the key things that I have found interesting here in Sri Lanka is their primary care system, or the way they get around not having one. Unlike England, you don't register with a General Practitioner (Family Doctor) here and go and see them every time you feel tired, down-in-the-dumps or generally unwell. There are family medicine doctors that play this kind of role; but the government funded institutions are few and far between so generally patients would go for a private consultation. If you have a headache here - you might decide the best person to consult is a Consultant Neurologist; which you could do- at the right price. Therefore, lots of the initial triage, diagnosis and management that occurs within a GP practice in England doesn't take place so neurologists may be inundated with the non-serious cases while poorer people suffering from conditions requiring specialist referral may remain unseen until they are so bad they become hospitalized. 

As an individual who is hoping to get in General Practice in my future career the lack of GPs over here was an interesting thing to me. GPs play such an integral role in our health society in the UK. They are the front-line of medicine and tend to be close enough to patients and families to give advice on all sorts of issues that may arise. I'm totally in love with this system!

I mentioned that, here in Sri Lanka, they manage to get around this. And they do! In fact, their health care indicators are some of the best of the Asian world and I am thoroughly convinced that one of the reasons for this is their robust system. Never, ever, ever ask a Sri Lankan who is involved with Health care to 'briefly' describe the Public Health system. Their enthusiasm will keep you there watching their powerpoint on the matter for HOURS! 

Being from England, it's kind of a shock to me whenever I hear someone talking about a public health system in a positive way as the NHS gets so much stick. Here, when they mention England, they talk proudly about their system being based on ours and they talk of 'Western standards' which I now translate as 'clean'. (This translation occurred after an unfortunate incident where we were put up in some accommodation that was described to us as "Good. Maybe not Western standards." - we didn't stay for long.) 

Health care in Sri Lanka is divided into the 'Curative' sector and the 'Preventative' sector. As we were based in Community Medicine, our elective focused on the second of these which led us to the National Prevention Campaigns for Dengue, Filiariasis, Malaria, Cancer, Tuberculosis and Rabies. Four of these conditions, we hardly even have to consider in England but in Sri Lanka they are rife due to mosquitoes and stray/wild animals including dogs on every street.

Resources are low with a spending of only 2% of the national budget on health in comparison to the 46% in England. If you're asthmatic here you have to buy your own inhalers; or you're put on oral steroids. The resource management is kind of shocking when you hear things like that. 

The front line for health in the community (e.g. antenatal and child health) instead of being coordinated through General Practices, is coordinated by Medical Officers of Health. There are around 330 MOH areas in Sri Lanka and these units consist of one Supervising Medical Officer of Health and Medical Officer assistants (the number of which relates to the population); Public Health Inspectors; Public Health Nursing Sisters and Public Health Midwives. Different members of this team are responsible for environmental health, pregnancy care, child health (including school visits), disease surveillance, food and water safety, occupational health and other duties specific to their community. The Public Health Inspectors maintain 18 different registers and balancing all their different roles seems like an absolutely impossible task. Somehow, a lot is achieved. 

The socioeconomic environment of Sri Lanka also poses several problems for a coordinated and national health care system. In Sri Lanka some of the poorest people live on estates such as tea plantations or rubber plantations. We heard many different accounts given of the conditions that people on the estates live in. One extremely charismatic man who worked for the Plantation Human Development Trust gave us a convincing account of why we shouldn't feel sorry for such people - that they are getting houses built for them and nearly all of them can access a sanitary toilet now; and the education is so good that they even had someone from the estate go to medical school. "It is under control" was his real message. He talked about the work they are doing to provide facilities for the estates including Child Development Centres so the mothers can drop their children off from 6 months of age and go back to working on the plantation. Apparently, most of the people who benefit from the advances on the estate don't even work on the estate, he told us, visibly disgusted.

We got to visit an estate to see for ourselves what conditions were like; we visited two in fact. The picture of the ward above is an old estate hospital that is no longer used now as there is a bigger hospital nearby that has facilities for people who need more treatment than the Estate Medical Assistant (the one we met was a pharmacist who was trained in certain medical examinations- probably by the National Institute of Health Sciences who are doctors that have gone down the training route so haven't practiced clinical medicine in years so the advantages afforded by this training would have been interesting to see) could give.

On the first estate we visited (a tea estate in Ratnapura), we were taken to a Child Development Centre where the children presented us with flowers and sang "Brother John" in English and Sinhala. It was adorable and we felt awful that we hadn't been able to bring them anything as we hadn't been pre-warned about the visit.

 The homes next to the CDC were "line-rows" - the kind of housing that they are trying to eliminate in estates (but from what we saw, most people still live in them). The houses have two rooms, usually, though the people who invited us into theirs had built an extra space on the back. The kitchen and toilet were outside. We felt so embarrassed as our hosts asked us to sit down and opened a packet of biscuits and bottles of drink that they were selling in the shop that took up one of the rooms of their home. We politely nibbled at a few because we just didn't know what else to do. They were completely open, completely generous; what they had was ours to share. I've never felt more ashamed of the greed and selfishness that we seem to have in bucket loads in these so-called 'developed' countries.

To be fair to the man who had told us that the estates were getting better, the next estate we visited did have a few of the new houses which stood on their own ground and incorporated a toilet. In contrast to the line-rows it was a million times better. As that thought passed through my mind I suddenly felt so far away from home; I couldn't imagine what these lovely, humble people would think if they saw even our little flat. I hope I always remember what I saw and felt about the estates.

In Colombo, we got to see some impressive (if over-crowded) hospitals such as the Lady Ridgeway Paediatric Hospital where we were able to see a few cases of suspected Dengue.

Don't you wish I'd just stuck to blogging about elephants?