Pediatric and Healthcare Systems in India by Dr. Sheetal Ajmani

1. Pediatrics and
Healthcare
Systems in India
Sheetal Ajmani, MD

2. Objectives
 To recognize the importance of global health
initiatives in pediatrics
 To understand the universality of infant and child
health and safety issues
 To recognize some of the important differences
and similarities in healthcare systems in a
developing country
 To develop increased cultural competence –
increasing numbers of international travel,
adoptions, and medical tourism

3. Physicians for Peace
 Founded by Dr. Charles Horton in 1989
 Mission: To develop sustainable programs in the
developing world based on the belief that health care
can best be improved by training health professionals
in that country, who then can continue to heal
hundreds to thousands of people there
 Programs designed by communicating with
physicians indigent to the area with regards to
educational activities they feel will most benefit their
community

4. Physicians for Peace
 NALS/PALS/nursing education
 Nagpur, Maharashtra, India
 In collaboration with Dr. Satish
Deopujari, pediatrician and co-
founder of Child’s Hospital of
Central India
 Our mission consisted of:
 Dr. Ed Karotkin,
Neonatologist
 Ms. Karen Horton, Neonatal
Nurse Educator
 Dr. Sheetal Ajmani, PGY-3

5. Physicians for Peace
 Specific Programs Completed:
 Nursing education to 125
nurses in Nagpur, India and
60 nurses at Sawangee
Medical College
 NALS reviewed with 15
pediatric residents at
Sawangee Medical College
 PALS workshop with 40
practicing pediatricians in
Nagpur
 Neonatology topic-specific
updates given to 20
practicing pediatricians in
Nagpur, as well as to 15
pediatric residents at
Sawangee Medical College

6. Child’s Hospital of Central India
(Private)

7. Child’s Hospital of Central India
(Private)

8. Sawangee Medical College Hospital
(Semi-Private)

9. Sawangee Medical College Hospital
(Semi-Private)

10. Sawangee Medical College Hospital
(Semi-Private)

11. Sawangee Medical College Hospital
(Semi-Private)

12. Resident’s Areas at Sawangee

13. Resident’s Areas at Sawangee

14. Healthcare System in India
 Subcenter: staffed by 1
female worker and 1
male worker and covers
a population of
3000-5000
 Primary Health Center:
staffed by 1-2 physicians,
and 2 or more ancillary
healthcare workers and
serves a population of
30,000
 Each PHC oversees
6-8 SCs
 Each CHC serves 3-4
PHC’s

15. Healthcare System in India
 Hospitals
 Government vs. Private (Nursing Homes)
 No good public medical transportation system
 At private hospitals, families must be actively involved
in all decision-making, since they must be able to
directly pay for care (including all lab tests, radiology,
and treatment plans)
 1 relative must stay at bedside at all times
 If a new medication is needed, the family is given the
prescription to be filled at the pharmacy and bring it
back to be administered
 No family members allowed in ICU’s

16. Healthcare System in India
 Infection control in ICU’s (hats, gowns, shoe covers)
 No incubators in NICU; only radiant warmers (and
use plastic wrap if needed)
 No consistent temperature control on the warmers in
the NICU
 Role of nurses is minimal
 Blood bank
 PALS
 No manometers on BVM
 Broselow tape
 Workshops – airway opening maneuvers

17. Antenatal Care in India
 Family planning education is lacking
 Contraception: sterilization accounts for 75%
of all contraceptive use
 60% of women child-bearing age never heard
of AIDS (2003)
 30,000 HIV+ infants born/year (by conservative
estimates)
 In 2007, 159 cases of HIV were diagnosed in
children under 13yo in the U.S.

18. Antenatal Care in India
 Since pregnancy is ‘natural,’ use of prenatal
services is considered unnecessary by many
 Government hospitals provide financial
incentive to mothers to deliver in hospital,
including transportation
 65% of deliveries are at-home
 2% of families sought medical care for mother
or child within the first 2 days
 17% sought medical care within 2 months of
delivery

19. Child and Infant Mortality
 India contributes to 25% of the 10 million
deaths under 5 years of age in the world
 Neonatal mortality rates (per 1000 live births)
 U.S. 4:1000
 India 39:1000

20. Child and Infant Mortality:
Distribution of Causes of Death <5yo
(2000)
 India U.S.
 Neonatal 45.2 56.9
 HIV/AIDS 0.7 0.1
 Diarrhea 20.3 0.1
 Measles 3.7 0
 Malaria 0.9 0
 Pneumonia 18.5 1.3
 Injuries 2.2 10.3
 Other 8.5 31.3

21. Child and Infant Mortality
 Primary causes of neonatal mortality (2004)
 Sepsis 52%
 Asphyxia 20%
 Prematurity 15%
 Others 13%
 Primary causes of infant mortality (1998)
 Diarrhea 20%
 ARI 25%
 Sepsis 26%
 Asphyxia 10%
 Prematurity 8%
 Others 11%

22. Healthcare System Comparison
 Physician to 10,000 population ratios
 U.S. 26:10,000
 India 6:10,000
 In India, 74% of physicians live in urban
areas, where only 28% of population resides

23. Himalayan Health
Exchange
 Mission: To provide medical and
dental care to the underserved
people living in remote regions
of the Indian and Nepal
Himalayas
 NGO based out of Atlanta, GA
 Founded by Ravi Singh in 1996
 Eight expeditions/year
comprised of physicians,
dentists, nurses, pharmacists,
and medical students

24. Dharamsala Expedition
 April 2008
 37 Health professionals: 7
physicians, 29 medical students, 1
RN
 Also, 1 local pharmacist, 1-2 local
physicians/each clinic site, staff of
cooks, drivers, and translators
 Provided care at 7 rural villages, and
2 monasteries
 About 2700 patients seen; ¼ of
which were pediatric
 My role: Providing medical care at
the attending level in the Pediatric
medical tent. Supervision of 5-7
medical students/day in the
Pediatrics tent

25. Dharamsala Expedition
 Triage
 3 adult medicine tents, 1 pediatrics tent, 1 ob/gyn tent
 Pharmacy (pediatrics)
 Bactrim
 Cefaclor
 Amoxicillin/Augmentin
 Cefuroxime
 Clindamycin
 Griseofulvin
 Mebendazole
 Tylenol/Ibuprofen
 Multivitamins
 Laboratory
 Hb, CBC
 BUN, Cr, LFT’s
 RF, CRP, ESR
 VDRL, ASO, HBsAg, rapid HIV, sputum for AFB, urine pregnancy,
UA

26. Dharamsala Expedition

27. Preventive Medicine
 Malnutrition
 PICA
 Sun protection
 Car seats
 Seat belts
 Helmets

28. Top 3 Pediatric Diagnoses

29. Pruritic rash affecting multiple family
members

30. Scabies
 Species: Mite Sarcoptes scabiei; females are fertilized at skin
surface, then burrow into the epidermis, traveling 2mm each day
while laying a total of 10-12 eggs, female dies in 1-2months
 Epidemiology: crowded areas, in colder and more humid
conditions (long survival on fomites)
 Transmission: person to person; direct contact; very contagious
 Clinical features: itching due to type IV delayed hypersensitivity
reaction, worse at night and out of proportion to visible
dermatologic manifestations; secondary staph infections
common

31. Scabies
 Diagnosis: History and
physical exam; family
members typically affected;
can microscopically
visualize mites from skin
scraping, but not necessary
for diagnosis

32. Scabies
 Treatment:
-First line: Permethrin 5% cream (safe in
infants; cotton mittens to prevent toxicity);
Oral Ivermectin
-Alternative Topicals: Benzyl Benzoate,
Lindane, Malathion, Sulfur in Petrolatum
-Treat all household and close contacts
-Treat secondary reactions: anti-pruritics;
secondary staph infections

33. Round lesions with associated alopecia

34. Tinea capitis
 Gray patch tinea capitis: Microsporum Canis (bright green
flourescence under Wood’s lamp); erythematous patches with
scale; may develop into kerion (boggy, tender nodules with
exudate) and/or secondary staph infection
 Black dot tinea capitis: seen more in the U.S.; Trichophyton
tonsurans; erythematous patches with “black dots” from hairs
breaking off in affected areas
 Treatment: Griseofulvin is the primary treatment choice
(20-25mg/kg/day for 6 weeks); Other treatment options include
terbinafine, itraconazole, fluconazole

35. Tinea corporis
 Circular patch with central
clearing and raised,
erythematous border
 Treatment:
-Local – topicals including
miconazole, ketoconazole,
clotrimazole
-Systemic – for widespread
infection; griseofulvin,
terbinafine, itraconazole,
fluconazole

36. “I see worms when I go to the
bathroom”

37. Pinworms
 Enterobius vermicularis
 Humans are the only host
 Most commonly affects school-age children
 Present with itchy butt, worse at night
 Female pinworms crawl out of the anus to deposit eggs
at night
 Spread by contact/fomites
 Scotch tape test – eggs will be visualized on a single
specimen 50% of the time; 90% if have 3 samples
 Treatment
 Albendazole as single dose; or, mebendazole once
and again 2 weeks later

38. Miscellaneous Cases

42. Summary
 Participation in international health electives is an
invaluable experience:
 PFP: Develop academic and professional networks
with international community of healthcare
professionals
 HHE: Gain experience practicing medicine with
limited resources, and gain insight to different
perspectives and opportunities for healthcare
 Welcome Shruti Deapujari to CHKD

43. Other Benefits of International
Electives…

50. Resources
 www.himalayanhealth.com
 www.physiciansforpeace.org
 www.uptodate.com
 www.searo.who.int/LinkFiles/
WHD_05_-
_Fact_File_India_Fact_File_in
dia.pdf