Thank you to Marcello who has written this blog post on his experience in Kolkata. They are recruiting now if you’re keen! Contact details at bottom of piece xxx

The unrelenting heat of summer finally dissipates

The monsoon rains have just hit Kolkata, and the entire city has breathed a sigh of relief as the unrelenting heat of summer finally dissipates. This relief will be short-lived as the city sinks under a sustained assault of pouring rain that gives everything a musty damp smell for three months.

Nonetheless, there is nothing as spectacular as a wall of water thundering down: people, dogs, rats, geckos, mosquitoes all scurry for shelter. Seeking shelter from nature defines most months of the year in India. During the winter months, one shelters from the nippy winds that blow from the hinterland, seeping in through the cracks of shoddily built houses better geared for heat than cold. Whilst the wind is sufficiently piercing as to render the winter months uncomfortably chilly, it is nowhere near powerful enough to dislodge the dense smog emanating from countless small coal fired stoves and poorly maintained diesel cars. The trees and the grass turns a greyish-brown, and, at night, the air is eerily yellow. The smog finally lifts as the heat rises and residents switch their coal fires for fans and air-conditioning. For three months, India is gripped by intolerable heat that strips anyone of any dignity as they collapse in a sweat-drenched mess.
And so I reach the end of my year in Kolkata: I moved here at the tail end of the monsoon, and return to the UK as the rains batter the country again.

 

India truly embodies extremes

Much like its weather, India truly embodies extremes. Whilst it is on the cusp of economic greatness, the distribution of that greatness is seriously wanting. The burgeoning middle class, no longer concerned about the provenance of their next meal or the security of their weather-worn shelters, are afflicted with the same obesity problems that afflict Western democracies. On the flip side, up to 300 million children – or roughly 50% of all Indian children in any given year – under the age of five are stunted.

True hunger is no longer as pervasive as it was two generations ago, but India still has a massive nutrition problem at either extreme of its society. We demonstrated this recently in Liluah Bhagar, the newest slum that Calcutta Rescue started operations in: The growth curves among children are dramatically shifted to the left of WHO aggregate averages.

Indian television, advertising and cinema would have you believe that most Indians now eat too much and can switch on their air-conditioner from the other side of the country on their 4G network that puts our British connectivity to shame. Yet in Kolkata – as in many other major Indian cities – more than 50% of the population of anywhere between 14 and 17 million people is crammed into densely packed slums where residents still use the canals that criss cross the north of the city as their toilet, and where periodic outbreaks of cholera are still very much an issue. This year, a sewage pipe burst in South Kolkata, sparking an E. Coli epidemic in which dozens died: it made the news because it affected middle-class districts.

The Pavement Doctor and Calcutta Rescue

It is in this Indian world that Calcutta Rescue has worked since 1979, when Dr Jack Preger, a British doctor, sat down and started treating patients on the side-walk opposite Loreto School, the most exclusive girls’ school in Calcutta. Over the next 38 years, Calcutta Rescue grew with the support of networks in Europe and North America and now runs three fixed clinics, two schools, an arsenic mitigation project, a handicrafts vocational training unit, and two street medicine ambulances that criss cross the city’s slums. At its helm, Jaydeep Chakraborty, a genial Londoner who returned to his roots much to his parents’ complete bewilderment, is gently shaping the indefatigable work of his staff base in an effort to produce concrete numbers that accurately reflect the success and importance – and above all, continued relevance – of Calcutta Rescue’s work.
I stepped in on the heels of a work colleague and friend, Amy, who had spent the previous year in Kolkata. My brief was to continue the quality improvement work she had started, and I jumped at the opportunity to take a year out of training following a gruelling two years of core medical training in London.

In my first week, Jaydeep set me a task: to help improve the street medicine team. I spent two months observing how the street ambulance teams worked. I carried out a month long audit of consultations, which highlighted some worrying gaps in consistency and accuracy in patient care. I noted the lack of formal training amongst most healthcare workers, and, above all else, the lack of a regulatory structure that ensured staff members could be held accountable for the care they delivered.
With Jaydeep’s help, I crafted a three-pronged strategy to improve the administration, delivery of care, and training of the street medicine programme.

Achieving some quality improvement

Administrative bureaucracy in India is slow and inefficient: paper – so fragile in the aforementioned climate – is king; computer literacy is patchy at best; and statistics are, for the most part, a succession of numbers that have little meaning beyond how many patients were treated in any given day. Quality of care is often synonymous with dispensing medication, meaning patients are often treated on the basis of symptoms rather than a defined diagnosis. Doctors are uneven in their communication skills: some limit their interaction with patients to an arm’s length, and for many, shouting and reprimanding are acceptable ways of admonishing patients who have misunderstood treatment plans. Finally, the whole body of health workers with years of experience but no formal training lies idle as the doctor’s decision is king: there is little devolution of care compared to the UK.

In the second six months I spent here, I spent approximately half my time performing clinical duties – mainly trying to achieve glycaemic control in poorly controlled diabetics, and trying to fatten TB patients with BMIs in the low teens – and the other half corralling other volunteers into a teaching and training programme.

With the help of a British ICU nurse, a German pharmacist, an Austrian paediatrician, and a Swiss medical student, our crack team spent an afternoon or two a week in a rowdy classroom teaching staff about child growth measurements; recognition and onward referral of the unwell or malnourished child; and introducing the concept of ABCD to help with patient triage.

We finished our curriculum with some success: we estimate that at least 50% of our class of 28 are now independently proficient in accurate growth measurement, and another 30% are proficient in applying ABCD principles to the unwell patient.

In parallel, I worked with the Swiss Support Group to raise funds for basic infrastructure improvements for the street medicine programme to bring diagnostic tests to the field. We are negotiating purchasing a Swasthya Slate – an Indian designed, tablet-based machine that can perform up to 33 basic diagnostic tests in real time – from the Public Health Foundation of India. Next week, the street medicine teams will have a brand new observations machine to help health workers sort their patients into red, yellow and green priority groups. One of my TB nurses is secretly cursing me for enforcing monthly BMI calculations amongst our sickest TB patients, some of whom really look like concentration camp survivors.

The other half of my week I spent in the office crafting strategies with Jaydeep and other members of the management team. I was also responsible for coordinating volunteers coming from abroad, determining where their skills were needed and offering a shoulder to vent on, because Kolkata is as infuriating as it is loveable. I mistakenly mentioned I could touch-type, so I was in charge of taking minutes for most management meetings. I was an independent observer to the quarterly Governing Council – Calcutta Rescue’s board – meetings.

Lastly, I collaborated with Swayam, a NGO whose focus is to promote and protect women’s rights in West Bengal, to set up a gender-based violence programme in Calcutta Rescue. We hope that this might start alleviating the suffering endured by almost 80% of the mothers enrolled in our disability programme, who are frequently scapegoated for giving birth to children with physical or intellectual disabilities.

Epilogue

So in summary, I cannot speak highly enough of my experience in this last year. Despite the heat, the honking, the crowds, the lack of anonymity – albeit, still privileged – caused by my white skin on the metro, I wish I could stay longer. I am intensely humbled by the dedication and selflessness of Calcutta Rescue’s staff and I have developed skills and knowledge that will be invaluable to my career as a registrar. I can now confidently research and write a strategy; I can effectively win over a team of people, and lead them to move away from doing things the same way because it’s always been done that way, improve their results; and I can almost make green mango dal.

The greatest thing about Calcutta Rescue is that a volunteer like Amy and me can mould his or her experience and priorities to just about any service improvement project, and Calcutta Rescue and Jaydeep will listen and enact those changes that we deem necessary.

I hope this article whets some appetites; I would be delighted to respond to further questions via email, either on cvc@calcuttarescue.org or m.scopazzini@doctors.org.uk.