# Bridging Worlds, Bridging Care Gaps

Treating patients who have recently immigrated, especially elderly individuals, often presents unique challenges and rewards. As Dr. Sharma, a urologist practicing in a diverse community, I've learned the importance of navigating not just language barriers, but also deeply ingrained cultural perspectives on health, illness, and medication. What's considered routine or easily accessible in one country can be strictly regulated or viewed very differently in another. Understanding these disparities is key to providing safe and effective care.


# A Worrisome Decline

Mr. Rao, a gentleman of eighty years, had recently arrived from India to live with his son, Anjay, and his family. Anjay brought his father to see me, deeply concerned. "Doctor," Anjay explained, translating for his father who spoke limited English, "Dad has been having these spells. He gets very dizzy, almost fell twice last week. He seems more tired than usual, sometimes a bit confused. We're worried it might be his heart, or maybe his dementia is getting worse."

Mr. Rao had a history of mild hypertension and well-controlled type 2 diabetes, both managed with medications prescribed by his new local GP. Nothing in his current, locally prescribed regimen seemed to explain this acute change. I performed a thorough physical exam, which was largely unremarkable for his age, apart from his obvious frailty.

# The "Indian Viagra" Revelation

As I delved deeper into his history, asking Anjay about all medications his father might be taking, including anything brought from India, a crucial piece of the puzzle emerged. Anjay looked uncomfortable. "Well," he admitted, "Dad sometimes takes... well, back in India, he called it his 'blue pill' or 'Indian Viagra.' He used to get it easily from the chemist or order it online."

I gently questioned Mr. Rao directly, with Anjay facilitating. Mr. Rao, with a shy smile, confirmed this. For years, he'd managed his erectile dysfunction by purchasing [Suhagra online](https://www.imedix.com/drugs/suhagra/) from Indian websites or simply buying it over-the-counter from local pharmacies in his hometown. He explained it was very common, made by a well-known Indian company, Cipla, and he never considered it "serious" medicine that required a doctor's oversight, especially not here in the US. He'd had his relatives ship him a supply when he moved, and also found some online Indian pharmacies that would still send it to his US address. He'd been taking it as needed, typically the 100mg strength, without mentioning it to his US doctors because it was just "his usual."

# The Dangers of Unsupervised Use in a New Context

The picture became alarmingly clear. An elderly man, now in a new country with a new baseline of health (even mild, controlled conditions add to overall frailty), potentially different diet, and new prescribed medications, was continuing his long-standing habit of using high-dose, unsupervised sildenafil.

"Anjay, Mr. Rao," I explained carefully, ensuring my words were translated accurately and empathetically, "the symptoms your father is experiencing – the severe dizziness, the falls, the confusion – are very likely caused by the Suhagra. Sildenafil, the drug in Suhagra, lowers blood pressure. While your father may have tolerated it in India, his circumstances here are different."

I elaborated, "His age, his existing medications for blood pressure and diabetes (even if well-controlled), perhaps slight dehydration from the move or changes in routine, all make him much more susceptible to the blood-pressure-lowering effects of a 100mg dose of sildenafil. The falls are almost certainly due to hypotensive episodes – sudden drops in blood pressure when the Suhagra takes effect."

I stressed the difference in regulatory environments. "While Suhagra made by Cipla might be readily and safely available under Indian regulations and medical practices, here in the US, sildenafil at that strength requires a doctor's prescription and careful evaluation. This is precisely to prevent situations like this, ensuring the dose is appropriate for the individual's current health status and other medications. Continuing to use it unsupervised, especially now with his age and other conditions, is very risky."

# Adjusting to New Realities, Ensuring Safety

Both Mr. Rao and Anjay looked shocked, then deeply concerned. They hadn't connected the "harmless" Suhagra, so easily obtained online and familiar from home, with his father's recent, frightening decline. The cultural acceptance and ease of access in India had created a dangerous blind spot in his new American healthcare context.

"The first and most important step," I instructed, "is for Mr. Rao to stop taking the Suhagra immediately. We need to let his system clear and his blood pressure stabilize without its influence."

Once the immediate danger was addressed, we discussed Mr. Rao's actual needs. Did he still wish to treat ED? If so, we would need to do it safely. This involved a full re-evaluation, starting with a much, much lower dose of legitimate, FDA-approved sildenafil, prescribed by me, obtained from a US pharmacy, and with very close monitoring of his blood pressure and overall response.

Anjay assured me he would manage his father's medications carefully going forward and dispose of the remaining Suhagra. Mr. Rao, understanding the connection to his falls, readily agreed. Over the next few weeks, without the Suhagra, his dizziness and confusion resolved. His energy levels improved.

# Reflection: Cultural Bridges and Medication Safety

Mr. Rao's case was a poignant reminder of the vital importance of culturally competent care and extremely thorough medication reconciliation, especially for elderly immigrant patients. Practices and perceptions around medication from a patient's home country – like the easy availability of Suhagra online or over-the-counter – don't always translate safely to a new healthcare system with different regulations and oversight. It highlighted how ingrained habits, perceived safety based on familiar brands like Cipla, and lack of awareness about differing national drug laws can lead to significant, preventable health risks. Bridging these cultural and regulatory gaps through clear communication, education, and vigilant medical oversight is essential to ensure the well-being of all our patients, regardless of where they, or their medications, originated.