Global Health Placement Blog
By: Amar Seva Sangam
Coming from an athletic therapy background, when I heard about professional international travel, images of sport physiotherapists covering major games such as the Olympics filled my head. Images of treating injured athletes competing to represent their countries internationally. However, this changed the first week of my Masters in physiotherapy where one of our teachers introduced to us the topic of Global Health in our Foundations of Professional Practices class. I knew immediately that this was something I wanted to incorporate in my professional practice. That very evening, I emailed that teacher to learn about ways I could be involved in global health as chances of a global health clinical placement taking place were slim due to the ongoing and seemingly never-ending COVID pandemic. The very first opportunity he suggested was to be the School of Physical and Occupational Therapy student coordinator of the Interprofessional Global Health Course our university organized every year. Well, as much as I wanted to get myself involved in global health, this was a little like jumping into the deep end as the responsibilities for such a position were endless; find speakers for our 10 courses, advertise the course to all health programs, register and keep track of the attendance of 100+ students, etc. all with absolutely no background in global health. But as much as this scared me, I decided to challenge myself, send in my application, get selected and although A LOT of work had to be put in, I learned so much from the experience. I came out of it a lot more knowledgeable and prepared to do a global health placement. However, the COVID pandemic was still ongoing, and I had to do my clinical placements that year in my home province although I managed to do my second one in Nunavik where I worked with the local Inuit population which did have a national global health feel to it. I kept engaging in various global health opportunities my second year and was overjoyed when I found out that there was an opening for a global health placement for my very last internship!
Due to the graduation requirements to have experience in multiple scopes of practice, my last internship had to be in a context of neurological rehabilitation which fit perfectly with the clinical mission of Amar Seva Sangam (ASSA). ASSA is situated in a small village, Ayikudi, at the foothills of the Western Guats in rural Tamil Nadu, the most southern province of India. It originally was founded by in Shri. S. Ramakrishnan in 1981 and was a school of 5 children in a shed. Today, it has expanded to an entire campus with a variety of services with the overarching goal of serving those with a physical and/or intellectual disability. There is a special education school for children who have intellectual disabilities, a children’s home to house them, a mixed primary/secondary school which is adapted for both children and teachers with disabilities. There is a medical testing unit in which physiotherapists and occupational therapists see pediatric cases and stroke patients and there is also a post-acute in-patient spinal cord injury unit. These were the two areas in which I was assigned to see cases during the duration of my placement.
Beyond this, ASSA also engages in their Village Based Rehabilitation (VBR) initiative in which therapists visit children in their homes to teach early intervention strategies to their families. I had the opportunity to go on a fieldtrip one of my last weeks to observe a day of VBR which was very insightful. Their model is that the surrounding approximatively 200 villages are separated into regions which each have an early intervention center which houses rehabilitation specialists such as physiotherapists, occupational therapists, speech and language pathologists, and special educators. These rehabilitation specialists are present at the center a few days a week and spend the rest of their week visiting children and their families at their homes. These children are visited typically 2x/month by rehabilitation specialists and 1x/week by community workers. Community workers are helpers who have no previous degrees and who get trained by rehabilitation specialists (in any discipline) and who carry out the rehabilitation plan or home exercise program drafted by the rehabilitation specialists. This whole model is overseen by means of an app in which the rehabilitation specialists can chart and give updates on their patient’s progress. The app is monitored by a core team of physiotherapists at ASSA. This was particularly interesting to me as I aim to eventually work at the intersection of rehabilitation and public health to increase accessibility to rehabilitation in local and global capacities. What ASSA has done is exactly that – creating access to rehabilitation in a rural, resource-poor setting.
There were a few cultural adaptations that we had to integrate into our lifestyle at the beginning of our stay which were essential for the next two months, some of which came as a surprise. The first was that no cutlery or utensils were used at mealtimes (except for serving food) which meant we had to get used to eating with our right hand exclusively. Eating with your left hand is improper as it is used to clean oneself after going to the bathroom. The food itself was quite delicious but different as well, we quickly got used to eating idlis (UFO shaped steam rice cakes) with coconut chutney, dosas (local crepes) with sambar (vegetable-based sauce), rice at every lunch and chai (tea with lots of milk and sugar). Quite literally, a care aid would come into our afternoon session everyday and offer both therapist and patients chai, and after a quick break, we would resume our sessions. I always loved these chai breaks!
Another cultural habit that we got used to is quite frequently instead of the traditional “Hi’ or “How are you”, the local greeting is “Saptacha?” which means “Have you eaten?” and our answer invariably being “Sapte” or “Yes, I have eaten”. Another cultural adaptation was also simply the language barrier. In my previous travels, I had mostly been able to get along with good knowledge of English/French/Spanish but the vast majority of the population speaks Tamil here which resembles in no way any of the languages I had any experience in. Over the 2 months, we learnt a few words useful in everyday life and a few physiotherapy words like Vali (Pain), Oukaregel (Sit down – but politely), Nimri (Straight), … There were a few patients with a rudimentary knowledge of English in which we could communicate a little, but others had close to zero English. For these patients, gestures and facial expressions became our preferred method of communication. There was a translator on campus who was extremely helpful for these patients, but he wasn’t always there as there were three of us physio students treating at the same time in different units. In these cases, and when we really needed someone to translate, other patients, patients’ families or other therapists would attempt to translate. While sometimes funny, sometimes this became incredibly frustrating as my patients who would finally have someone to speak to in Tamil would have entire conversations that would be summarized in 3-4 words to us. I would often internally put that conversation on hold, think to myself quietly about what chance I had to be able to do this internship, and ask again once the translator was present to garner the information I was missing.
What I realized also was that “life” cultural shock is one thing, but “professional” cultural shock was another and it was the latter that affected me a lot more. During every previous internship I had done in Canada (I had previously completed a total of 6 including those in athletic therapy), our performance was always measured with how efficient we were with patients, how many could we see in a day, how fast we could chart, how positive our contribution was to the public health care system, how many resources we used, etc. However, I realized that this was not at all the same thing in India. During our observation period, we saw a “group pediatric session” in which there were maybe 25 children in the treatment room, one being evaluated by the therapist, a few in standing frames and the rest were left to their own devices. At that specific time, I think that only two or three children were seen by therapists in the time allowed for the session and I’m honestly not sure what the rest did. Right away our minds went to “How can we develop a session in which most children can be doing something productive?” but we were unsure how to approach this as we were guests here and had to measure how our input would be viewed and make sure we did not overstep our welcome.
Another example of how things work differently in India was the necessity of being okay with “going with the flow”. Once, after I had just finished my workday and scheduling different interdisciplinary meetings for my patients, the top supervisor came to us and announced that we were going to the movies with the homekids the next day. This was a cultural experience he believed that we should not miss so I spent the next minutes reorganizing the meetings I had just organized. When we asked “who will see our patients?”, we were told “No problem, no problem, they will be seen” without more detail. And the next day, we went to the movies (which was another experience in itself where approximately 50 children with different disabilities and 5-6 caretakers managed to all get up 2 flights of stairs into the movie theatre in what looked like organized chaos with wheelchairs, walkers, and all kinds of ways to get up and down stairs) and our patients had magically been seen by other therapists. Everyone was so excited for us to see the movie theatre in india! Note: the sound is so loud, I would recommend bringing earplugs!
A different professional and ethical shock was when I started working with inpatient spinal cord patients. As I was evaluating my first case, I asked my patient what his long-term rehabilitation goals were and he answered “To walk again”. This came as a surprise to me as this patient has sustained a complete T3 spinal cord injury more than 2 years ago which, for the uninitiated, essentially meant that he no longer had and would never again have sensory or motor use of his lower trunk and legs. I was wondering if he was simply in denial as I would have expected his previous medical professionals to have explained his prognosis but as I asked around, it became clear that the culture here was to simply not explain negative prognosis. In his case, he said that the doctors operated on him, said that his spinal cord was fine and sent him back home. The fear is that if they explain a negative prognosis, patients and their families will get angry at the medical core, come physically damage the medical centers, and request a second, third, or fourth medical opinion. I was not allowed to disclose his prognosis as the fear was that he would not believe us and leave the center, whereas now he was somewhere that we could work on his functional deficits to increase in ability to engage in life post-discharge and perhaps slowly and gently come to the realization that there were certain things that he would never be able to do again like walk. This became an interesting ethical dilemma because I value honesty with my patients and working with a relationship of trust which comes with an honest estimate of prognosis. However, as there are cultural intricacies that we were unable to navigate, I was not in a position to go against my supervisor’s recommendation and tell him the truth. My entire time working with him, for 2 months, I had to redirect his walking-related questions with answers like “Let’s focus on your arms right now and getting you to a point where you can transfer independently!”. That never sat comfortably with me but I never found a better solution.
Ethical challenges, communication challenges, cultural challenges, life challenges were all difficulties that we had to stretch our creativity muscles to find solutions for and situations which were annoying at worst (we would often not have water and electricity at our guest house!) and very entertaining at best (there was a scorpion once in the SCI treatment room causing havoc). However, these were all so minor compared to how much I have learnt and grown both as a person and as a physiotherapist from this internship and have made so many connections with therapists, patients, and other ASSA inhabitants. I will always remember working with one of my stroke patients who had aphasia and cognitive difficulties which made communicating with her even more challenging. I was working on stretching her spastic forearm and both of us felt her forearm release suddenly. Her face lit up, both of us were beaming and laughing together because this was such progress compared to previous days. Her mother and our translator were looking at us so confused because they couldn’t figure out what happened as we kept smiling. This, to me, in a nutshell is what global health rehabilitation is – creating connections around increasing functionality, transcending cultural and communication barriers.
All pictures taken and posted with explicit permission of the patients.