An 8-year-old boy was carried by his mother into an open-air clinic in rural, mountainous India, not far from the Pakistani border. Soon, through translation and physical exam, it came to light that he had been born with severely contracted muscles in his calves, likely from cerebral palsy. A surgeon had released the boy’s Achilles tendons so they could heal with a proper length and, in theory, allow the child to walk after a period of recovery. But the boy had never walked. And his mother had always carried.
This is just one especially memorable episode I encountered in the Northern Indian state of Himachal Pradesh between my first and second years of medical school. I was traveling with the Himalayan Health Exchange (HHE), a small nonprofit organization that has been bringing Western medical care to rural areas of the Indian Himalayas for nearly two decades. A somewhat rash decision made in the depths of a Minnesota winter, I didn’t really know what I was getting myself into.
Our time was spent in the Pangi Valley, a sparsely populated slice through the Himalayas, located in the upper crescent of Himachal Pradesh. The area was only made car-accessible by a primitive road in the mid-1990s, and even those rutted paths are impassable for much of the year because of snow accumulation. HHE had never led a trip into the Pangi Valley, so our leader, Ravi Singh, wasn’t completely sure what to expect in terms of road quality or patient turnout. But over 13 days, we saw about 2,400 different patients, which gave new meaning to clinical education for a newbie med student like me.
Hamstrung, but we could help
In medical school we are trained to gather information about a patient’s problem, give a biological explanation for that problem, and then, ideally, fix the underlying cause using drugs or scalpels or patient education. In the Pangi Valley, each stage of this process was hamstrung. But more often than not, we were able to gather reliable information and give a very educated guess on the underlying cause of a problem. It was the final fix that we couldn’t provide. In most instances, that is.
Which brings us back to the boy and his mother.
After the tendons were liberated years earlier, the surgeon hadn’t explained anything about the procedure to the mother, or at least, what was explained had not been understood. Thus, she was under the assumption that her son would never walk, and had been carrying him around for all these years. He hadn’t gone to school because of the difficulty of getting there each morning, many kilometers along a dusty mountain road. And, so, he hadn’t really learned to speak.
With some physical therapy initially, he would likely have been walking just fine by the time we saw him, even if he was perhaps never going to be an Olympian. He could have gone to school. His language and social development would not have been arrested. His life, and his mother’s, would have been very different.
An explanation, and a start
So, a doctor on our team explained to the mother that her boy would, in fact, walk again with proper physical therapy — that this mother and her son could expect a brighter future. The mother looked on with a bit of confusion and then wept softly, overcome with emotion. The child was then assisted as he took the first few wobbly steps of his life, at our clinic. It will undoubtedly be an extended, difficult process before he is walking and talking as a person his age should. But that will come with time. Explaining to his mother that there was hope for him, and that she may have a normal life again, with an independent child … that was a clinical moment every young American medical student should witness.
It got me to thinking about the environment where I will likely be working. More than ever before, physicians are being asked to consider the economic consequences of how they practice medicine in America. Our medical school professors encourage us to stay aware of the economic costs, in addition to potential medical benefits and harms, when assessing the value of a diagnostic test or therapeutic intervention. As I enter this medical environment looking to tighten its belt, I will remember the care we were able to provide in Northern India, despite our lack of equipment, and in many cases, our lack of a cure.
In the end, the real value of our visits to these remote villages and towns was largely based in the education we could bring them. We drove out of their beautiful mountains, I think, having left our patients with a greater understanding of their health. With the resources we have in the United States, it is easy to give short shrift to both understanding a patient’s problem and relaying that information to him or her, in favor of jumping to an expensive conclusion without thought or explanation.
Of course, cutting-edge technology should be used when it’s available and needed. But being aware of the impact we can have without our state-of-the-art machinery will allow us to do what’s best for our patients’ health and pocketbooks. And that’s what I learned during my summer in the Himalayas.
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