Background:
The Christian Fellowship Hospital (CFH) was founded in the 1950s in Oddanchatram, a small village in a drought stricken rural area of south India. At that time, the area had no electricity, water supply, telephone, or school. The nearest doctor was 57km away. The founder of the hospital, Dr Tharien, still operates at the hospital at the age of 82.
Today, CFH has grown to a size of 250 beds with 42 doctors, and - due to the almost total absence of primary care services – 1,000 outpatient consultations take place each day. Its activities have spread to health education programmes, children’s homes, rehabilitation centres for people with leprosy and, more recently, to the opening of a hospice for people with HIV. Despite its rural location, the hospital’s reputation has grown to the point that junior doctors now choose to travel across the country to train there. Throughout India, patients are charged for treatment, but low fees and an intolerance of corruption have added to the success of CFH. Dr Tharien, meanwhile, has acquired something of an international profile, leading the international peace delegation to the UN, advising the WHO on medical ethics.
I spent much of my time at CFH working in the outpatient clinics. My first clinic was a shock. Literally hundreds of patients were queuing in the crowded corridors, while in a small, hot, airless room six junior doctors saw their patients within inches of one another. Maintaining patient confidentiality in this environment was impossible, and consultations were often incredibly short. That said I was very impressed by the clinical skills of the doctors who were clearly used to diagnosing and treating patients who could not afford the expense of many modern investigations and drugs. My examination and practical skills improved immeasurably under their tutorage, and as there were so many patients, there were numerous interesting and unusual cases. Some had traveled for days to reach the clinic, but were very grateful for even two minutes with a doctor that they trusted, and who prescribed a treatment that they could afford. Many had first consulted less reputable clinics or local healers who had extracted large sums of money from them for ineffective or unnecessary interventions.
For families already living in very deprived circumstances, the medical fees, and inability to work that illness could bring could force them to beg to survive. I had expected expensive interventions (such as renal dialysis) to be unavailable - I was not prepared for working in an environment in which most asthmatic patients could not afford to buy inhalers!
Community Medicine
Perhaps the most fascinating part of my elective was the time I spent working in a small community clinic in a remote village two hours drive from the hospital. Here the interaction between development, education, and disease was made very clear. The health and development of rural areas has been neglected for decades. Since colonial times, healthcare has remained highly centralised in large city teaching hospitals, while very little emphasis has been traditionally given to community medicine.
Often the only doctors who are prepared to work in rural areas are those who are unable to obtain hospital employment, so that the few rural people who can afford to consult a doctor receive a substandard service. The infant mortality rate is double that of urban areas(1) and most births are attended by an untrained traditional healer. While recent economic policy has favoured intensive development of the cities, half of India’s rural population of 716 million people are living below the poverty line (2). Malnutrition is very common (one study found that 85% of rural children are undernourished(3)), and many houses are in incredibly poor condition, so that for most families expenditure on health is a very low priority.
Part of the rationale behind founding CFH five decades ago was to encourage experienced doctors to work in rural communities, and it was in that spirit that five years ago it began a project to train village level health workers. These are always people who were born and brought up in the village in which they will work, who are given two years basic training in health promotion, basic medical skills, and obstetrics. They then return to live in their village, where they set up a simple clinic and a health promotion programme, which, in the village I visited, was concentrating on discouraging defecation near drinking water sources. The beauty of this scheme is obvious - in an area in which beliefs and cultural practices can vary dramatically between neighbouring villages, the village health worker is a local person who is well known, locally accountable, and accepted by their community. They are familiar with the particular problems of their village, and they are of invaluable assistance to the community doctor in his weekly visit. The hospital’s first community doctor has just been appointed, and he is one of the first in the area to have received accredited postgraduate specialist training in community medicine. It is hoped that the emergence of community medicine as a speciality in its own right will encourage other high caliber doctors to follow his example and bring their skills into rural areas.
Discussion
This was an exciting time to be working at the Christian Fellowship Hospital. In recent years it has been very courageous in putting such heavy emphasis on its community based programmes, and this places it at the forefront of a new trend in Indian medicine, which seeks to shift the emphasis of care away from major urban teaching hospitals.
The hospital’s innovative work in developing community medicine in rural villages provides one model by which a truly comprehensive community medical service may be brought about. My main motivation for studying in India was a desire to obtain first hand experience of medicine in a developing country, and to work with some of the diseases that are the biggest threats to global health today. I feel I achieved these aims – but in addition, I was surprised at how widely the skills I acquired in India are applicable to my future practice in Britain.
In recognising the close relationship between the economic, societal, and medical problems facing its patients and in valuing local accountability, the Christian Fellowship Hospital has much in common with many pioneering medical practices in this country. Two years ago, I was fortunate enough to receive a placement at Prince Philip House on St Matthew’s Estate in Leicester, which has used a similar model to great benefit in promoting health alongside urban regeneration. If these simple principles of medical practice can prove successful in both rural India and the British inner city, then this may be only the beginning of a truly international, comprehensive, holistic system of community based medical care.
Acknowledgements
Particular thanks goes to Dr A Kurian who coordinated my elective, and Dr A Sailo, Dr R Cijoy, and Dr S George who were each very generous with their time and expertise in making sure my elective was a success. I was also extremely grateful for the generosity of the patients and staff of the Christian Fellowship Hospital.
The Christian Fellowship Hospital (CFH) was founded in the 1950s in Oddanchatram, a small village in a drought stricken rural area of south India. At that time, the area had no electricity, water supply, telephone, or school. The nearest doctor was 57km away. The founder of the hospital, Dr Tharien, still operates at the hospital at the age of 82.
Today, CFH has grown to a size of 250 beds with 42 doctors, and - due to the almost total absence of primary care services – 1,000 outpatient consultations take place each day. Its activities have spread to health education programmes, children’s homes, rehabilitation centres for people with leprosy and, more recently, to the opening of a hospice for people with HIV. Despite its rural location, the hospital’s reputation has grown to the point that junior doctors now choose to travel across the country to train there. Throughout India, patients are charged for treatment, but low fees and an intolerance of corruption have added to the success of CFH. Dr Tharien, meanwhile, has acquired something of an international profile, leading the international peace delegation to the UN, advising the WHO on medical ethics.
I spent much of my time at CFH working in the outpatient clinics. My first clinic was a shock. Literally hundreds of patients were queuing in the crowded corridors, while in a small, hot, airless room six junior doctors saw their patients within inches of one another. Maintaining patient confidentiality in this environment was impossible, and consultations were often incredibly short. That said I was very impressed by the clinical skills of the doctors who were clearly used to diagnosing and treating patients who could not afford the expense of many modern investigations and drugs. My examination and practical skills improved immeasurably under their tutorage, and as there were so many patients, there were numerous interesting and unusual cases. Some had traveled for days to reach the clinic, but were very grateful for even two minutes with a doctor that they trusted, and who prescribed a treatment that they could afford. Many had first consulted less reputable clinics or local healers who had extracted large sums of money from them for ineffective or unnecessary interventions.
For families already living in very deprived circumstances, the medical fees, and inability to work that illness could bring could force them to beg to survive. I had expected expensive interventions (such as renal dialysis) to be unavailable - I was not prepared for working in an environment in which most asthmatic patients could not afford to buy inhalers!
Community Medicine
Perhaps the most fascinating part of my elective was the time I spent working in a small community clinic in a remote village two hours drive from the hospital. Here the interaction between development, education, and disease was made very clear. The health and development of rural areas has been neglected for decades. Since colonial times, healthcare has remained highly centralised in large city teaching hospitals, while very little emphasis has been traditionally given to community medicine.
Often the only doctors who are prepared to work in rural areas are those who are unable to obtain hospital employment, so that the few rural people who can afford to consult a doctor receive a substandard service. The infant mortality rate is double that of urban areas(1) and most births are attended by an untrained traditional healer. While recent economic policy has favoured intensive development of the cities, half of India’s rural population of 716 million people are living below the poverty line (2). Malnutrition is very common (one study found that 85% of rural children are undernourished(3)), and many houses are in incredibly poor condition, so that for most families expenditure on health is a very low priority.
Part of the rationale behind founding CFH five decades ago was to encourage experienced doctors to work in rural communities, and it was in that spirit that five years ago it began a project to train village level health workers. These are always people who were born and brought up in the village in which they will work, who are given two years basic training in health promotion, basic medical skills, and obstetrics. They then return to live in their village, where they set up a simple clinic and a health promotion programme, which, in the village I visited, was concentrating on discouraging defecation near drinking water sources. The beauty of this scheme is obvious - in an area in which beliefs and cultural practices can vary dramatically between neighbouring villages, the village health worker is a local person who is well known, locally accountable, and accepted by their community. They are familiar with the particular problems of their village, and they are of invaluable assistance to the community doctor in his weekly visit. The hospital’s first community doctor has just been appointed, and he is one of the first in the area to have received accredited postgraduate specialist training in community medicine. It is hoped that the emergence of community medicine as a speciality in its own right will encourage other high caliber doctors to follow his example and bring their skills into rural areas.
Discussion
This was an exciting time to be working at the Christian Fellowship Hospital. In recent years it has been very courageous in putting such heavy emphasis on its community based programmes, and this places it at the forefront of a new trend in Indian medicine, which seeks to shift the emphasis of care away from major urban teaching hospitals.
The hospital’s innovative work in developing community medicine in rural villages provides one model by which a truly comprehensive community medical service may be brought about. My main motivation for studying in India was a desire to obtain first hand experience of medicine in a developing country, and to work with some of the diseases that are the biggest threats to global health today. I feel I achieved these aims – but in addition, I was surprised at how widely the skills I acquired in India are applicable to my future practice in Britain.
In recognising the close relationship between the economic, societal, and medical problems facing its patients and in valuing local accountability, the Christian Fellowship Hospital has much in common with many pioneering medical practices in this country. Two years ago, I was fortunate enough to receive a placement at Prince Philip House on St Matthew’s Estate in Leicester, which has used a similar model to great benefit in promoting health alongside urban regeneration. If these simple principles of medical practice can prove successful in both rural India and the British inner city, then this may be only the beginning of a truly international, comprehensive, holistic system of community based medical care.
Acknowledgements
Particular thanks goes to Dr A Kurian who coordinated my elective, and Dr A Sailo, Dr R Cijoy, and Dr S George who were each very generous with their time and expertise in making sure my elective was a success. I was also extremely grateful for the generosity of the patients and staff of the Christian Fellowship Hospital.
