2013 PFIG Recipient Shefali Hegde
College of Arts& Sciences
Cognitive Science and Neuroscience Major
2014 Graduation Year
Internship: Community Health Program, Christian Medical College
My deep interest in medicine and international healthcare has brought me to Tamil Nadu this summer, where I will work for two months at CMC Hospital, one of the top medical centers in India. I will accompany CMC endocrinologists as they make rounds through the main hospital in Vellore and the rural diabetes clinics in the Kaniyambadi and Anaicut village blocks.
In addition to my work in the clinics, I have two main side-projects this summer. The first involves organizing a diabetes education and outreach campaign in the villages. As part of this, I will visit primary and secondary schools and conduct educational workshops aimed at diabetes awareness and prevention.
My second project is my own research on diabetes management in developing areas, supervised by the Head of Endocrinology, Dr. Nihal Thomas. My fieldwork will build upon the hundreds of interviews I will conduct with diabetes patients, ultimately informing the direction of my fourth-year honors thesis.
Notes on the first week
On a rickety sleeper train bound for Vellore, I stared from my bunk at the small steel Ganesha figurine dangling from the wall beside me. Ganesha, with his elephant head and protruding belly, had long been my favorite character in the stories my grandma told me, years ago, on the balcony of my ancestral home. Ganesha is known as the Remover of Obstacles, the Patron of Arts and Sciences, the Deva of Wisdom, and the Lord of Beginnings. I was not very religious, but who better to bow my head to in hope that the next two months would be a success?
My first day at the hospital was unlike anything I had prepared for. The outpatient clinic was pure chaos, with patients and their families laying claim to all free space on the floors, tables, and chairs. The lines outside were at least a half-kilometer long. (A note: the 2,695-bed hospital serves a local population of approximately 400,000 and even more referrals from other states in India.) After a week at the hospital, though, I began to realize how organized the chaos really was. I saw that the patients dealt not only with their physicians, but a whole team comprising of nurses, social workers, therapists, and medical students. All patients were seen and able to discuss their individual problems with the doctor.
In my first week, I observed at least 40 consultations of these endocrinologists and social workers with patients and their families. During the high-risk eye clinic, the ophthalmologist allowed me to use her ophthaloscope and pinpoint the blood vessels that signaled diabetic retinopathy (near-blindness). At the foot clinic the next day, I witnessed one of the most serious complications of diabetes: a foot so severely infected that it needed amputation.
Unfortunately, many of these traumatic complications were completely avoidable with proper preventative behaviors and education, which these patients lacked. Thus, I had decided to focus my research project on measuring the self-care behaviors of Indian diabetics, and identifying the barriers and risk factors that lead to poor disease management. I hoped that my research could provide this essential (and hugely lacking) information, and identify patients most in need of intervention.
Conducting patient interviews and assisting with diabetes education proved to be the most gratifying part of my internship. I was able to hear the unbelievable life stories of these patients. The auto-rickshaw driver who took his insulin injections between shifts. The young mother who had developed diabetes during pregnancy. A teenager whose diabetes was undiagnosed until he nearly fell into a ketoacidotic coma at age 10.
Through these interviews, I noticed that the majority of patients couldn't name the type of diabetes they had. Many simply called it "the sugar disease." Dozens of patients, particularly in the rural areas, did not know that diabetes could cause complications in other organs. I was beginning to notice threads between these stories that I hoped to eventually frame in a cohesive narrative.
Still, I was daunted by the prospect of structuring my own research for the first time. I had spent months prior to arriving in Vellore planning the details of my research design. I had secured approval for my 60-page IRB proposal, which explained and defended my methodology. I knew what my objective was, but still felt overwhelmed by the hospital and its endless stream of activity. I questioned whether I could accomplish all that I had hoped in a short two months.
The biggest barrier to my research, however, was linguistic. Though I had 3 years worth of Hindi classes, these proved entirely useless in south India, where the dominant spoken language is the state language (in Vellore, this is Tamil). Luckily, I had a huge team of doctors and advisors willing to help me at every step. My 4-page survey had been translated to Tamil as soon as I arrived, thanks to a kind nurse. The social workers helped to translate whenever I encountered a patient who was not literate.
On the clinical side, I have followed doctors and nurses from the department into slum, urban and village clinics in Tamil Nadu. Six days a week, I am witnessing the skills necessary to educate and practice in a setting that lacks many technological advances. The dedication, compassion, and professionalism that all these doctors, nurses, and volunteers bring to their important work each day has been my motivating source this summer and will continue to be as I venture further into my career.
In my final weeks at Vellore, I lost track of time. I began to feel so comfortable and in sync with the new city, so absorbed in the culture of the hospital, that I lost all need for a clock. I made friends with the locals and the shopkeepers. I knew where to find the tastiest biryani, the cheapest Bisleri, and the most beautiful mountain peaks.
I was learning, slowly, some essential Tamil phrases and relied less and less on a translator. I could counsel Tamil-speaking patients on their "unavu" (diet) and "utarpayirci" (exercise) when they arrived at the clinic.
One of the most salient results of the internship was completing my research project and gathering a huge amount of data on diabetes self-management, awareness, and education. The project, which I had initially viewed with such despair, yielded strong results - though not without a few sleepless nights!
Because I only had a few short weeks to gather all the data, I spent much of my time interviewing patient after patient. I also collected information about each patient's blood sugar level and glycosylated hemoglobin level, or Hba1c, which can be used as a marker to measure how well diabetes is controlled. On my final day in the hospital, I had interviewed over 230 patients, collected in-depth information about their self-care behaviors and demographics, and consulted each patients' medical record on the hospital database for other essential information.
On the Tuesday before my departure from Vellore, I met with 14 of the head doctors in the Endocrinology department to discuss the (preliminary) results of my research project and their implications. I gave a half-hour presentation of my data to the doctors, highlighting which areas of the patient population most struggled to care for themselves and were lacking in essential medical knowledge. Later in the day, I repeated the presentation for the diabetes nurse educators, who could directly utilize the results of the study.
One of the shocking results of my data was that only 12.5% of patients achieved good glycemic control, as measured by their A1C. The majority of patients failed to follow a proper diet or a proper exercise plan.
Foot care behaviors and self-monitoring of blood glucose were also considered 'inadequate' by international standards. The results were indeed shocking to the nurses and doctors, and highlight the need for a tailored educational intervention for high-risk patients. The situation is bleak in India - where diabetes is at epidemic levels in both rural and urban areas.
Even after working in India for 8 weeks, I feel I need to spend a few decades at CMC to truly appreciate the complexities of the Indian medical system and the difficulties of administering health services and education to a low-income population. Much of what I saw was gristly and devastating. (In the village hospital, for instance, I witnessed surgeries -without anesthesia- on dozens of children who had developed abscesses after being given shots by a phony village doctor.)
Finally, I must thank the Parent's Committee for their generous support of my internship this summer. I am extremely fortunate to have been afforded this rare academic opportunity as an undergraduate. I am eager to incorporate all I have learned this summer about global and community health into my own medical career. After this experience at CMC, I seriously hope to work in the developing world or with under-served communities following graduation.
My advice to all those looking for internships next year is simply this: Choose something risky and out of your comfort zone. (I am proud to say I didn't make a single photocopy this summer.) Contact your intellectual heroes, voice your passions, ask to work alongside them.
You won't regret it.