In January 2015 I am going to Samuha in the South of India to act as a preceptor for 4 amazing physiotherapy students from the University of British Columbia (UBC). I will write updates and blog posts on our work at the centre.
Here is part of a presentation that the students and I did at a Medical School in Koppal India. I started off by doing a little comparison of statistics between Canada and India.
So, here goes
You could fit 3 of India inside of Canada!
But, with an area 1/3 the size of Canada….
You would have to multiply Canada’s population by 37 to get the population of India!!!
India has the second largest population in the world today (Canada is at #37).
Forecasted Population Growth
And by 2050 India’s population is expected to surpass China’s to become the most populated country in the world
India has a population density of 386 people per square kilometre compared to Canada’s 4 people per square kilometre!!
How about life expectancy? What do you think?
88 years in Canada, 66 years in India
So, what are the leading causes of death?
All Cause Mortality
When I asked the medical students what they thought about the All Cause Mortality. (Meaning the total number of deaths relative to the population) they looked at the list above and said “That’s good! It means more money for us”!
Well, I guess that’s one way of looking at it. But, for me, it presents a huge opportunity for health care professionals in India and Canada… These conditions are preventable!! As a healthcare professional, especially one focused on exercise and prevention, these statistics get me excited! It means there is something we can do about it!
Let’s get people moving and eating healthier!!
What else can we do? Let’s help everyone have equal access to healthcare! This should be accomplished by policy and governance. But, in the meantime let’s work on Community Based Rehabilitation Programs for under-serviced areas in Canada and India
We finished the placement and our time at Samuha in Southern India at the beginning of February and after having some time to reflect on our 5 weeks there I’d like share a little bit about our experience.
The goal of our time at Samuha was to educate local Community Based Rehabilitation (CBR) workers to enhance their skills, while at the same time providing a once in a lifetime learning opportunity for the 4 UBC students. Based on the final meeting with all of the Samuha staff and individual meetings with students I am pleased to say that the project was a huge success!!
During the final meeting, staff were very thankful for the education that was provided to them. Especially the educational sessions where we covered paediatric assessment and treatment, wound care, stroke rehabilitation, surgeries available for children with cerebral palsy, and hip dysplagia. We tried to keep the sessions as interactive as possible and I will make sure to remember this in future teaching sessions that I do.
As far as suggestions for the future, the staff wanted us there longer and to focus solely on education! I love these suggestions and totally agree that a longer time commitment would be great in order to really focus on their needs and goals and have enough time to go through theory and practical sessions with CBR workers. Lucky for them they have an awesome Physiotherapist, Andrea Mendoza (www.physioandrea.com) going for 6 months next year!!
Now, let me talk about the 4 amazing students that I had the pleasure of teaching for 5 weeks! To be honest, I was a little nervous as a relatively new physiotherapist taking 4 students for my first time as a clinical instructor. But, I couldn’t have asked for 4 better students. The teamwork they displayed was incredible! Since there were 4 of them and 1 of me there were of course times when I wasn’t available to all of them. But, they were great at working together and often times solving problems as a group. At the end of the placement, I was happy to let them know that in my mind they were already physiotherapists. Canada is lucky to have such intelligent, caring, and motivated people soon to be part of their healthcare system.
One aspect of the placement that everyone seemed to really like was our nightly recaps. With these daily recaps we had a chance to talk about any clients that we saw throughout the day and talk over assessment, treatment progression, or any other questions that came up. I think the highlight of our nightly chats for me was the highs and lows. This is where the students and I would each go around saying our high and low for the day. As an example, one day my low was seeing the state of a public school where a child who had very low mobility and a severe pressure sore was placed in a classroom on the second floor where he sat on the floor in his own urine. The high for that day was seeing how all of his friends helped him get home. They would help him manage the very steep set of stairs, where they had a pink bike waiting at the bottom. The child would then get himself on the bike and his friends would wheel him home. Just an incredible sight! This is just one example of many to show how caring and helpful Indians truly are. Even at a young age, there was no judgement for this little boy. Only, friends more than happy to help.
Similarly, the people who are involved with Samuha are all in it for their love and desire to help people with a disability. The staff at Samuha work tirelessly to help people in their community and are changing the world as they do it. They work 6 (often 7) days a week and as many hours during the day that is needed to make sure that every child, person, and family member is seen to the best of their ability. Many of the staff even welcomed us into their homes and really made our time at Samuha the best experience possible! I am happy to have had the chance to meet such incredible people and look forward to planning a return trip where hopefully I will be able to contribute in a larger way. Phil
During one of our first days at SAMUHA we were each given a list of children that we would treat during home visits. The children live in various villages surrounding Koppal. The CBR workers from SAMUHA make routine visits to assess and treat these children in their homes. Often it is difficult for the children and their families to attend therapy at SAMUHA, so the home visits are a great alternative for treatment. We all get very excited for home visit days because it is an opportunity to see the children function in their home environments and to explore the small villages that we would not otherwise experience.
The day typically begins by either hoping on the back of a motorcycle with a CBR worker or cruising to the villages by jeep. The scenic drives through rice patty fields, sugar cane fields and sunflower fields are always beautiful. There are cows and buffalo to dodge in the middle of the roads and herds of hundreds of sheep blocking intersections…. there is never a dull moment in the chaotic Indian streets. When we arrive at a home we are welcomed by dozens of locals who are all curious to see the “foreigners” visiting their village. The families will lay down a blanket on the ground either indoors or outside and we will begin our therapy session. The word spreads quickly when the “foreigners“ arrive and within minutes we are surrounded by families, friends, neighbors, local villagers, and of course cattle.
The CBR workers provide us with the child’s history and information about their condition and previous treatment. We view their medical records, x-rays, and even tissue samples that they are sometimes given from the hospital. The sessions provide an excellent opportunity for us to learn from the knowledgeable CBR workers and we provide them with additional therapy suggestions. Our goal in the sessions is to share information and skills with the CBR workers and to practice therapy techniques with families so that they can continue rehab at home. We have treated children with cerebral palsy, autism, malnutrition, developmental delay, mental disability, amputees, and many more. Some of the children haven’t received medical attention until late childhood therefore; their conditions have progressed significantly. Regardless of the condition or the child’s status, the CBR workers provide therapy in hopes of helping the child reach their maximal functional capacity so they can develop and participate in their community.
We have been amazed by the generosity and welcoming nature of all of the families we have visited. Even in homes where resources are scarce, they still offer food and drinks to their guests. Most of the homes offer tea saturated with sugar during each session. When the tea is served, everything stops. It is tea time only. After visiting 7-8 homes we all surpass our sugar threshold, but we still accept the tea to be polite. Some of the families offer us endless amounts of food like rice dishes, idly (fluffy rice cakes) with coconut chutney, and fresh crispy deep-fried chilly peppers. We are always stuffed after a day of home visits. At the end of the visits we wave goodbye to the crowds of villagers and head back to SAMUHA. Home visit days are always fulfilling and provide an opportunity to connect with the children and their families in their typical environment. It is very useful to observe children in their homes to help address their functional needs in the most effective ways possible. – Sara, Josina, Madison, and Krysta (Physiotherapy Students)
Since the day we arrived here we had heard about the “Dr’s Camp” that was going to be happening while we were at the campus. January 18 – it seemed every child we had seen so far was going to come. We approached the day with a mix of excited curiosity and trepidation as we could not quite fathom how so many kids could be seen in one day. There was no official count of how many were expected and to us it seemed everyone was coming. At this point we are well acquainted with rooms crowded with children and their various family members. It’s always a little chaotic but it always some how seems to work, like many things in India.
The suspense continued to build as we waited for the doctors to arrive from Bangalore and finally, fairly late in the morning, we met the three orthopedic surgeons over a cup of tea. In typical western style, we were all wondering how we could possibly have time for tea. There were going to be at least 100 children to see! But we sat, sipped our sweet tea and got to know the surgeons, some of whom have been coming to Samuha since 1992 as part of the Bangalore Orthopedic Society. They reminisced about children they had treated and commented on the shift from primarily treating children affected by polio to the now highly prevalent Cerebral Palsy within the last 20 years. By the time we finished our tea we all felt confident in the surgeons and figured it must be time to start seeing children by now!
We were wrong. Obviously, it was the time for a welcoming ceremony and introductions. The training hall was packed full of children and their families – we could barely make our way to the front. We tried to imagine what would happen if we tried to run a clinic day like this at home with so much “wasted” time and could only picture a lot of anxiety! It was hardly wasted time as by the time the introductions and candle lighting ceremony was over we felt like a team and there was a familiarity between the professionals and the families. Something was said in Kannada, the local language, and the room emptied.
Within moments, three metal examination beds were quickly set up and the doctors were seeing children. The aim of the day was a screening clinic for children with various disabilities who would benefit from an orthopedic surgical intervention. It was under five minutes for each child and over 105 children, plus a few adults, were seen. Of those, 26 were referred for surgery. Not once did we feel that a child was unfairly assessed as much thought went into each interaction. It was impressive to see the skill and knowledge of these surgeons as they knew well what was feasible, the limits of resources and carefully considered the outcomes and risks. They consulted with each other over difficult cases and with us, creating a cooperative atmosphere and an incredible learning opportunity. Nearly every child walked away with a recommendation for physiotherapy. Before coming to India we were all pretty sure of our role as physiotherapists and the benefits of physiotherapy but after all of our experiences here, such as this surgical screening clinic, we all feel better prepared as advocates. We have seen the stark reality of what a lack of physiotherapy interventions and education looks like. At the same time, we have also seen the significant benefits of either physiotherapy as a stand-alone intervention or in conjunction with surgery.
The day was so much more than we could have ever imagined and we saw more variety of cases in one day than many practitioners will see in a year, a lifetime, really. If you can even imagine, we saw all of it in less than 3 hours. It was incredible. As students, where else can you see over 100 clients aged 6 days to well weathered and wizened with pathologies including Cerebral Palsy, congenital Osteogenesis Imperfecta, post-polio, Rickett’s, achondroplasia and pseuoarthrosis tibia.
For the 26 who were referred for surgery, meetings are held and funding arranged through various sources. So many aspects are thought of and taken care of, such as volunteers for traveling to Bangalore and care for other children who might be left at home. It was so wonderful to see the comprehensive and cooperative spirit here. The day ended with discussion about the possible underlying causes for the high rates of Cerebral Palsy and other disabilities in the area leaving us hopeful that investigation and recognition of these factors might lead to a decrease of disabilities in the future.
As we all reflected on the day we had respect for the programs here and the people running them. However, we also had even more respect for the resiliency of the adults and children living with disabilities here. They live, they adapt and they cope as well as circumstances allow and often in ways that we can’t comprehend. The day was educational, inspiring, and real.
Two years ago, Samuha’s Spinal Rehabilitation Centre (SRC) was opened a short distance away from the Early Intervention Centre campus. It is the only rehabilitation centre of it’s kind in the entire state of Karnataka. It is currently equipped to support 6 residential Spinal Cord Injured (SCI) clients for 3 month stays each. Samuha is in the process of expanding the centre to have the capacity to host 16 SCI patients at a time. The SRC is unique in its ability to host clients long term and provide effective rehabilitation throughout their stay.
Following a spinal cord injury in India, most people will spend some time in the hospital, where they may or may not receive physiotherapy treatment. Once they are discharged from the hospital, they return home, sometimes to villages hundreds of kilometers from the nearest hospital. Depending on their financial situation and mobility level, they may or may not be able to transport themselves to see a doctor for follow-up visits. Unfortunately this means that many of them end up spending much of their time lying in bed, without any mobility aids such as wheelchairs to get around in. When asked about this, the head Community Based Rehabilitation (CBR) worker at the SRC, Ayallappa, expressed concern that these patients spend most of their time sleeping and depressed in bed. What often happens when SCI clients are not well educated on their condition and do not receive the support the need, is that they end up spending too much time in certain positions and develop pressure sores. Without the proper attention, these pressure sores will worsen and likely become infected, leading to a very poor outcome.
When clients are admitted to the SRC for their 3-month stay, they are provided with a rural wheelchair (3 wheeler chair for rough terrain), a bed and 3 square meals a day. They are also able to use all the facilities on site, which include, a rehabilitation gym, accessible bathrooms, accessible laundry facilities, gardens and a learning hall. They are cared for by staff on site and are rehabilitated in the gym by CBR workers during the day. Many of them come to the SRC with pressure sores and the staff diligently clean and dress them to allow them to heal. They also often have to learn to sit independently, transfer in and out of bed into their new wheelchair and complete all the strengthening and stretching exercises they are given by Ayallappa. Over the course of their stay they become independent in their mobility and develop really strong upper bodies!
A physician from Koppal has started volunteering his time to come to the SRC every 15 days to ensure the patients are medically stable and provide them with any medications or treatment they require. He has also started teaching the CBR workers how to properly care for the pressure sores and how to monitor for signs and symptoms that might require medical attention. He is also able to provide them with professional consultation on equipment they may benefit from.
Now that you know about all the wonderful things happening at the SRC, could you imagine if they were able to address some of the missing pieces? Firstly, if they had air or water mattresses to sleep on, their incidence of pressure sores would decrease (according to the physician) by 50%. Secondly, if they were able to provide waterproof and more durable cushions for the wheelchairs this would help with longevity of the cushion and also to decrease the incident of pressure sores. Thirdly, the supplier that they get the specialized rural wheelchairs from has stopped providing those wheelchairs. Samuha is now unsure how they will be able to purchase these chairs to provide to their clients. If you know of a good supplier, please contact Phil. Lastly, since it is the only centre of it’s kind in the state, they are not able to accommodate even close to the number of people that could benefit from a stay here. Samuha has been cautious about spreading the word about SRC, because they know the demand will be so high and they won’t have the resources to provide a high quality of care to all those who could benefit. It’s unfortunate to know that some people may be stuck inside because they haven’t received the care they need post discharge from hospital. They are currently in the process of expanding, but this will only add 10 beds. So many more would benefit from this amazing centre!
During the day, we have started running group exercise classes to keep everyone engaged and they have really enjoyed being able to play their own music through our mini portable speaker. The guys also love when we get a group volleyball game going outside and you can tell the social aspect of the SRC is extremely beneficial. When asked by a prospective patient’s wife whether or not her husband should become a resident, all of the current residents raved about their experience at the SRC and how much strength, mobility and independence they have gained. We all look forward to our days spent at the SRC because the atmosphere is calm, laid back and friendly. Samuha has definitely created a great atmosphere for recovery and we’re so grateful to play a role in it.
– Krysta, Josina, Sara, & Madison (UBC Physiotherapy Candidates)
Samuha and India have been absolutely incredible so far. We arrived to Samuha on January 6th, and I can’t believe that 13 days have gone by. It feels as though we arrived yesterday. But, looking back at the amount of life changing experiences we’ve had and the amazing friends we’ve made, it seems as though we have been here for years.
Everyday is packed with clients and cases that a physiotherapist in Canada likely wouldn’t see over an entire career! Many of the clients we see are suffering with severe and complex disabilities. This places extreme pressure on families who then require one of the family members to stay home to care for the individual who has a disability. Often times it is the mother who stays home, which takes away from the family’s income. Other times it is a sibling who stays home, missing out on education.
Some of the clients we have seen with CBR workers to date include:
– Many, Many children with Cerebral Palsy (I would estimate that 80% of the children we see have been diagnosed with CP). For those of you who don’t know, CP is a blanket term for any insult to the brain in children up to 3 years of life.
Now the question is why!? Why are there so many children with CP in rural, southern Karnataka? Well, according to Hampanna, the high prevalence of CP is due to unqualified doctors who are administering oxytocin to speed up delivery. In addition to this is the high number of home deliveries and large distances to hospitals
– Children with CP aged 8-10 who have never seen a health care professional!
This has been a sad but educational experience. Often these children have developed severe contractures, have very poor trunk and head control, and are often left to lay on the hard floor. This is mainly due to a lack of awareness of normal child development as well as available treatment centres and options for families.
This has been very educational as we can see first hand how important early intervention truly is. During our evening meetings, the students often say that they now have a better understanding of the value of physiotherapy.
– Post Polio syndrome
Although India has been declared polio free, the effects are still visible in a few patients.
– Bowing of limbs due to malnutrition
– Osteogenesis Imperfecta
– Pressure sores on spinal cord injury clients, children with spina bifida, etc.
– A client who had a “spinal cord stroke” that is likely a Guillian Barre or another neurological disorder.
– Strokes (40 year old, 24 year old)
– Bone Tuberculosis
– Spinal Cord Injuries resulting from falls at work
In one instance a client was working for the government on the electrical lines, was electrocuted and fell 20-30 feet.
– Non union of tibia
– Muscular Dystrophy
– Parkinson’s Disease
– Living Conditions and school situations
The clients that we have had the opportunity to see with the CBR workers are the lucky ones that are being treated by the incredible staff at Samuha. You really start to think about how many people are not receiving the treatment they need. For instance, the Spinal Cord Injury Rehabilitation Centre (SRC) at Samuha is the only one in the state of Karnataka! The SRC can now accommodate 15 clients. The total population of Karnataka is 64 million!! That’s almost twice the population of Canada!
Another barrier to treatment that families encounter is that the Indian Health Care System is quite complex. I am in no way an expert on the health care system. But, after many talks with Hampanna physicians, surgeons, and families I have a bit of an understanding of the system and some of the opinions for and against.
Briefly, the Indian health care system included public and private hospitals. There is no universal health care in India. Consultations and medical procedures are paid for by the patient. It is recommended that individuals and families have private health insurance.
Many people in rural India are not aware of the insurance and coverage available to them. For instance, farmers are eligible to pay into a health insurance policy where they pay a relatively small sum per family member to receive medical services. But, most of the farmers around Koppal and Samuha are not aware of these programs.
Similar programs exist for children with a disability. But, again families are not aware and do not know where to seek care.
Part of Samuha’s role is to increase awareness of funding schemes and helping families and clients navigate the health care system. Another very important and needed service!
From the instant we stepped off the train onto the Koppal platform, the group of Samuha staff made us feel welcome and respected. They loaded our bags into their Jeep and us four girls got our first glimpses of Koppal from the back of motorcycles driven by the staff. The town is bigger than we were expecting, with many shops lining the streets, cows meandering around and cars, motorcycles and buses blasting their horns. We pulled into the campus, just outside of town, and relished in the calm and safe atmosphere created by the staff. After eating our breakfast with only our right hand (the left hand is the toilet hand), we settled into our room for the 5 weeks. It’s a simple and spacious room with 4 mosquito net clad single beds and our own bathroom with a squat toilet. We are sleeping just upstairs from the Early Intervention Centre (EIC), the staff offices and the kitchen and mess hall where we eat all our meals.
During the day, the calm of the campus is disrupted by the arrival of many families bringing their children, sometimes as far as 300 km, to be seen at the EIC. We quickly learnt through observation of the Community Based Rehab (CBR) worker, Prabhaker, who works in the EIC, why so many families come to him. His years of experience show in his ability to apply his depth of knowledge to each case with ease, all the while explaining everything to the child’s parents. As he works, he asks us for feedback and suggestions, even though we feel we have much more to learn from him than he does from us. Throughout the mornings, we see children with Cerebral Palsy (CP), Spina Bifida, malnutrition, and more. Prabhaker breaks only when chai is brought around and even then, he only pauses for a minute. He will work tirelessly until every child at the EIC is seen, regardless of how long it will take. The entire dedicated staff work diligently to provide the best care possible to their clients.
During our first staff meeting, we planned the schedule for our first two weeks. Through all the discussion back and forth, we were able to synthesize one main piece of information, the staff all want to learn from us. This was a daunting fact for some of us, as not all of us have completed a pediatric placement. It felt strange and remarkable that before any of the staff had seen us work, they already respected and trusted us. As much as they want to gain from our presence, they also all want to ensure we have the best experience possible. From driving us around in the Jeep, to accommodating our allergies, to showing us how to do our laundry (it involves slamming and scrubbing our clothing on a rough cement block), they never hesitate to lend a helping hand. A perfect example of this is when they took us to the local festival. 400,000 people attended the festival from surrounding villages, all traveling in overstuffed cars, piled on tractors and crammed into buses. For some of these people, we were the first Caucasian people they had ever seen. We got a lot of attention. People tried their best English to talk to us, grabbed our hands, but mostly just stared. If we stopped, they stopped and surrounded us. The Samuha staff then surrounded us, like a protective barrier, to separate us from the crowds. They must have anticipated this, but that didn’t stop them from providing us with the unforgettable experience, even though it took away from their ability to enjoy the festival.
As the days progressed and we settled into our roles as the Canadian Physiotherapy Students we continued to be humbled by the unwavering hospitality of the staff. We were also exposed to many of the CBR workers in the field and, again, were impressed by their knowledge, skill and dedication. It is clear that we will learn a lot from the staff and will be exposed to many different and unique cases. We have already experienced so much and can’t wait to see what the next four weeks have in store for us.
Krysta, Josina, Madison, Sara and I are settling in nicely at Samuha. The students bought their traditional Indian dress (selwar kameez) in Bangalore and had them tailored by a friendly man at his house they somehow found in a back alley.
That night we took the overnight train from Bangalore to Koppal and were graciously greeted by Hampanna (Assistant Director) and the Samuha staff with flowers and a hot breakfast. Samuha is a very peaceful and beautiful place. The sun is shining, the sunsets and sunrises are breathtaking, and the people are the kindest I have ever met.
Samuha is an incredible place! They have so many successful projects and initiatives that it deserves a separate post. Before coming here I heard a lot about the early intervention centre and the spinal cord injury centre. But, I have quickly come to realize that those initiatives only scratch the surface of what Samuha does and how many people they help. This includes rehabilitation, training for teachers, to helping persons with a disability find meaningful employment.
In the afternoon I was invited to attend a ceremony where Samuha received the State of Karnataka award for best centre for people with a disability. The award is extraordinary because typically in India you have to apply to receive such a prestigious award. Samuha did not apply, they were recognized by the government for the outstanding work that they do here.
Hampanna included me in the ceremony and thanked the Samuha Overseas Development Association (SODA) and all of the Physiotherapists, Occupational Therapists, Nurses, and students who have come to Samuha in the past to help make it what it is today.
After the ceremony Hampanna explained:
“It is because of all of the stakeholders that we have achieved such success. This program does not belong to one group. If all of the stakeholders take the program as their own, together we will achieve even more. Although we are separated from SODA by distance, we come together for a common goal. Send my thank you to everyone at SODA and all of the professionals and students who have come before.”
Today, we spent the day in the early intervention centre (EIS) with Prabhaker, the CBR worker in charge of the centre. We saw children with Cerebral Palsy, Developmental Delay, and Orthopaedic conditions. We feel very fortunate to be able to learn from such a competent and experienced therapist.
Upcoming posts to look forward to:
Students’ First Impressions
Shree Gavisiddeshwara Jatre Festival
Community Based Rehabilitation (CBR) Worker profiles
It’s official. I have put in my notice at work and am about to start working towards a career in Global Health.
For a few days after I quit I was in a sort of trance… I kept asking myself: “Is this really happening? Did I just quit a perfect clinical job, with great mentors, in one of the most beautiful places in Canada? This is suppose to be a big snow year! What am I doing?”
But, mixed in with all of that uncertainty is excitement – I just quit my job to go head first into what I really want to do! I can’t deny that my passion is global health. Since I first learned about community based rehabilitation and had the amazing opportunity to go on a placement to Nepal (with a fantastic PT, travel buddy, and friend, Caitlin Dubiel) I have been seeking ways to get more involved and dedicate my career to this amazing field. A field that the more I learn, the more my mind is blown, which leads me to be even more fired up about learning more and contributing in a meaningful way.
So, here’s the plan:
January 2015 – I will be going to to Samuha in India with 4 amazing physiotherapy students from the University of British Columbia to serve as their preceptor. Samuha is an incredible community based rehabilitation (CBR) project in the South of India that serves to improve rehabilitation and care for persons with a disability. Our goal will be to work with the CBR workers in paediatrics and to further develop the spinal cord injury rehabilitation unit.
The project has been supported and developed for over 20 years by Hilary Crowley and the Samuha Overseas Development Agency (SODA). Hilary is a physiotherapist who has mentored over 20 students at Samuha, she is the recipient of the 2013 Enid Graham Memorial Lecture (watch lecture here), which is the highest honour you can receive as a physiotherapist in Canada. On top of this she is an all around great person. Hilary is now serving another role – acting as my mentor in many ways.