A very long catch up post

Written Thursday, May 7 (Happy Anniversary K and J!), but I was not able to post it before the library closed.

It is now our fifth day in India. It has been an unique experience (or according to SB: "a great adventure"...and to SP a "a psychological test"). I'm still enjoying it, but I think every day, at least one of us momentarily loses our enthusiasm. We are definitely in rural India, during the hottest month of the year, when the rest of the country seems to have put everything on hold.

So where to start?

Maybe a bit about where we are and what were doing…

We are at a rural hospital about 2 hours from the city of Hyderabad. It is a recently opened 500-bed hospital that aims to serve the rural community in the surrounding areas. It was built about 15 years ago, but from what we understand, it has only been open for a bit over 5 years. For the first five years, the hospital provided free care to all patients, but has since had to start charging for diagnostic tests. It has all the services a large US hospital would have (a neonatal intensive care unit as a well as a pediatric ICU, surgical theaters, ophthalmology, cardiology, etc.), but – as the Indian doctors we’ve talked to have put it – it is definitely not as “posh” as US hospitals.

The hospital is at the end of a long dirt road and is surrounded by dry desert. The building itself is built to be open to the outside, with many of the hallways lacking outer walls. The wards often house 20-40 beds in each room, with a nursing station in the middle. They have screens on the open windows, but the doors are usually swung open onto the outside. There is no lack of fresh air. Though the hospital has 500-bed capacity, we have found that in most 40 bed wards, there are usually less than ten patients. Partly this is because this is a new hospital, partly because it serves a very poor and rural population that cannot afford care or even the transport necessary to take them there.

The hospital also houses a medical and nursing school, but the medical school is currently closed for vacation, which means that many of the services that cater to the 500 medical students are also closed. The building’s café is closed, the library (which has the much missed internet) keeps short hours and is not open on the weekends, and the people who would normally sell groceries or bottled water have no reason to do the two-hour drive in from town. What is open is the hospital canteen, which serves spicy Indian food for breakfast, lunch and dinner, and several chai tea stands found in the hallways, which provide yummy cups of chai for 3 rupees each.

People ask us what we are doing here, and it is a rather hard question to answer. We came to study the medical health system and specifically, to focus on treatment of alcoholism. In the process, we were also hoping to do medical rotations and learn a bit of medicine, as it is taught and done by other countries. A third (fourth?) goal of our trip was to come to this particular rural program in India, because our school is interested in establishing an exchange program with them. These goals, however, did not seem very compatible with each other, with the amount of time we had available, or with the time of year when we were able to come. The medical students are on vacation, so the hospital is far more rural and isolated than it normally is. The medical system functions differently, so medical students (even when they are here) have a much more passive role (they pre-round on the patients, round with the team in the morning until 12:30 and then go home to study). The area is so poor and rural, that alcoholism is not a significant issue, at least not when contrasted with everything else that the people must deal with.

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So we find ourselves a bit lost here, though still glad to have come. Our days begin with a spicy Indian breakfast (usually a flat bread with some curry) and chai, followed by the daily dose of malaria prophylaxis that has been upsetting my stomach. Then we set off for our meeting of the day with a department head, which lasts until 12:30 or so. They have so far been very interesting. After 12:30, we are done, and being in the middle of nowhere, with temperatures hitting well over 100F daily, we work hard to find things to occupy us in the heat. With the internet down the last few days, that has meant returning home after another spicy Indian meal for lunch and trying to stay cool. Each time we come home, we change out of our culturally appropriate clothes (slacks and shirt with short sleeves – though the women here all wear saris or pressed scrubs with buttoned white coats) into clothes we cannot be seen wearing in public (shorts or skirts and tank-tops).

Sometimes, we hide in the library a bit longer and study some medicine (parasitology has been the ongoing theme since we ran out of bottled water), but the library closes at four and the draw of tee-shirts and shorts and the fans in our rooms (or an occasional upset stomach) sends us back to our apartment. There we chat, take cold showers (SP chimes in here to say that she tries to imagine herself in a swimming pool), and spend the evening playing gin rummy (we are playing a continuous game, now well into 2000 points each, with SB in the lead).

Occasionally, our afternoon is briefly interrupted by a visit from the family who is in charge of cleaning our apartment building. They rap on our door softly, always a bit surprised to see us wearing the same scandalous clothes, but always with broad nonjudgmental smiles on their faces. They bow in deference continuously and I return the bows enthusiastically, uncomfortable with this caste system still seems to dominate all interactions in India’s rural areas. We go to dinner at 8, which is the earliest time that it is served in the canteen, and attempt to eat another spicy Indian meal before our evening game of gin rummy and bed.

We would be lying if we were to say that we have not had a hard time adjusting. The heat has been hard on SP, who hasn’t had full night of sleep since we got here, the medication we take for malaria prophylaxis has been giving me stomach upset and complete loss of appetite, and we are all having a hard time eating (very) spicy Indian food for every meal. Given our need to limit our baggage size and pack for winter and spring in Europe and summer in India (and given the cultural prohibitions that make it inappropriate for us to wear the few summer clothes we did bring), we will be wearing the same clothes for the next two weeks, washing undies and socks in the sink when necessary.

And finally, probably hardest of all, has been the need to adjust to the sanitation standards of India and to accept that it is quite possible that we will all be getting sick. When we left the States, we read about avoiding non-bottled water (even checking purchased bottles to make sure the seals weren’t broken), and not eating fresh fruits or vegetables that may have been washed with contaminated water. We learned that Indian toilets do not come equipped with toilet paper, and that the tradition has been to use a small bucket (provided in each bathroom) and one’s left hand for all the necessary toilet cleanings. (Yes, we did buy our own toilet paper!) The bathrooms sinks (even in the hospital) do not usually have soap (never towels), and some of them are just sinks, which drain onto the floor (splashing over your shoes and pants) and down the drain from there. People use their left hand for dirty activities (which has been a challenge for left-handed SB) and their right hand for clean ones, but we are not always able to decipher which is which. (For instance, they open the water tap with their left hand in order to wash their hands, but often close it with their right.) Diarrhea is a frequent experience by all and an important cause of child mortality, and amaebiasis in endemic in 20% of the population.

We ran out of bottled water on Monday (our guide thought it would be available for sale in the hospital, but since the students are gone, so are the merchants) and the hospital administrator convinced us that the hospital water was safe to drink. It is filtered by reverse osmosis, in the same way any of the water we were purchasing was. We could get the water any time of day in the water purification room, which was available to all the hospital staff, patients and their families. After much debate, we decided to drink the hospital water, our other alternative being the awkward process of asking someone who commuted to Hyderabad to purchase water for us. On our second or third visit to the humid hospital room where the water storage tank stood, we watched an elderly village man stick the mouth of his well-worn plastic water bottle directly against the spout of the water source, and thoughts of Typhoid Mary simultaneously sprung into our heads. We’ve since found a second source of water, which is near the library (and predominantly used by staff and nursing students), but every time one of us has an upset stomach or loose bowel movement, we have a worried discussion debating whether it is the food, the water, or the malaria pills.

Despite all the above, however, we are enjoying our “great adventure”, and have not lost our sense of humor. The other day, SP proposed that when we get back to the States, we host an Indian night, where we sit in dirty hot clothes covered in mosquito repellent, playing gin rummy, eating spicy Indian food and drinking water from a questionable water source. I can’t wait.


Some things we have seen and done

Now that I’ve had a chance to set the scene and give an exhaustive update of what runs through our heads in those many free hours we have during the day, I want to write about some of the awesome things we’ve had a chance to do and see.

We spent Tuesday morning visiting two local villages of Kandla Koya and Suthearaguda near Ghanpur with the MediCiti REACH team. The REACH project monitors the health of the 43,000 or so people who live in the nearby 41 villages. Each week, the team goes out to the villages and collects demographic data (births, deaths, pregnancies and marriages), provides missed immunizations, and educates mothers about the need for prenatal care. In each visit, the team contacts a community health volunteer who is responsible for gathering this information. While there, they also monitor the delivery of food and vitamins supplied by the state government to all village children under 6 years of age.

During our visit, we observed their weekly meetings, met with villagers and even got to go to a small village home and a volunteer-run preschool. The home was larger than average here, with three small rooms, cement walls, and a tile floor with a beautiful floor design. We sat in plastic patio chairs, while our guide discussed the week’s data numbers with the female health volunteer who lived there, the male head of the household looked uncomfortably at us, and his five daughters grinned, smiled and waved. I swore to myself that next time I am in such a position (hopefully I will be), I will have learned at least a few words and phrases in my host’s native language.

In the preschool, about 30 squirming children (age 2-5?) sat on little chairs against the wall, with small handheld blackboards in their laps, learning numbers and ABCs. Many were thrilled to practice "Hello Madam!" on us (some looking very surprised and happy with themselves that it produced the desired effect), though a few of the littlest ones looked quite frightened when we came in.

Sitting in Suthearaguda in 100F heat, watching children giggling at me and yelling "hello Madam" repeatedly, while an old woman sat and stared from her doorstep and men slowed down when they passed us on their mopeds, I definitely felt somewhat uncomfortable and lost. I was not able to communicate with anyone but our guide, who had a real job to do as well; and I could not really answer the curious stares of people who honestly (without any judgement) wanted to know what I was doing there. And of course really, I didn't have an explanation, or a role to play, other than (gulp) as a tourist, maybe, though not even, of a medical nature. Despite all that, however, I had multiple "pinch myself" moments, realizing that I was in India, in a rural village on the other side of the globe from home, and I felt really lucky to be there, to have that experience, even if awkwardly.

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On Wednesday morning, we had the opportunity to meet with the head of the Psychiatry department, and chatted with him about treatment of alcoholism, the practice of psychiatry in India, religion and its role in treatment of psychiatric illness, religion and spirituality in general, literature, and the difficulty of publishing in India. We then took a tour of the psychiatric ward, which had only one patient in it that day: a man admitted for depression. He had presented to the hospital with abdominal pain, which was soon found to be psychosomatic in nature, and upon talking to our psychiatrist, had admitted suicidal ideation. He was depressed because he had lost his job and could not provide for his family. He was admitted into the inpatient ward, where he has now been for over a week, and started on anti-depressants. Two women stood at his bedside when we came in (wife and daughter or sister?) and looked on while the psychiatrist presented the patient’s case to us. It is not clear when he will be able to leave, but for now, the psychiatrist says, he has not improved. In India, a doctor has the right – with the family’s consent – to keep a patient who is sick at an inpatient psychiatric facility for 90 days. We ended our talk with some hot chai tea, and exchanged email addresses with our enthusiastic teacher.

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Today, we toured the pediatric ward, neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU). Our guide was again the head of the Pediatrics department (HOD), a calm, remarkably intelligent woman who enjoys teaching too much to retire. The unit doctor and two residents who took care of the patients, showed remarkable deference to her, softly answering “Yes, Ma’am” and “No, Ma’am” to every questions, and leading a wide path for her when we walked through the halls.

The first place we saw was the NICU, which was in an air-conditioned room at the end of a hallway of rooms for the staff and family to stay. In order to enter that hallway, we had to take off our shoes and either walk in barefoot or use borrowed flip-flops. (Most doctors here wear flipflops.) There were five babies there, most premature and underweight, but one with hyperbilirubinemia and one very sick baby with what appeared to be advanced meningitis. The residents presented each baby and the HOD calmly asked them questions and offered treatment suggestions. We next moved on to the PICU, which had one patient, an 8 year old boy who had just been admitted, likely with meningitis. He had altered sensorium and a positive Bruzdzinski sign, which the HOD elicited for us to see. The HOD ordered an LP and antibiotics, which we assumed could not be done without her approval.

We last visited the pediatric ward, which had several cases, all of them unique and interesting (there seems to be much more diversity here, with infectious disease and malnutrition cases we don’t see often in the US. One patient was an 8 month old with blindness, hypotonia, and athetosis. The baby had not changed since birth, but it was not clear why the mother did not bring him earlier, though cost, lack of education, and the young age of the child could all have been reasons. The mother denied a history of hyperbilirubinemia in the baby, and her other older child had normal development. The team decided that this is likely a case of cerebral palsy, for lack of a different explanation.

Another “diagnostic mystery” we saw was a 10 year old previously healthy young girl who presented lower extremity edema and fluid in her lungs. The team ruled out renal causes and the child responded well to diuresis. Her echocardiogram did not show signs of heart failure, endocarditis, valvular or other structural abnormalities, and she seemed to recover well. Prior to discharge, she was found to have weakness in her hands and legs and Guillain-Barre syndrome is now suspected. The presentation was given by one of the most quite of the residents and we could not understand what their next diagnostic plans were going to be.

Our morning in Pediatrics ended with a Grand Rounds talk about the use of Probiotics. The first half hour was a presentation of the evidence for the use of probiotics in medical treatment (for diarrhea and many other medical ailments). The second part of the talk was a ten minute marketing video presented by the pharmaceutical company that sponsored the talk, advertising their specific lab engineered Bacillus which could be used to treat diarrhea in lieu of antibiotics. This company not only sponsored the talk, but also gave us juice and cookies, which we’re really ashamed to say we ate, since it was the first juice and non-spicy food we had had in nearly a week.

Tomorrow, I will be visiting the Internal Medicine department, while SB and SP head off to surgery. On Saturday and Sunday, we have grand plans for visiting Hyderabad, not only to see another part of India, to visit some mosques, bazaars and temples, but also to buy some bottled water, stock up on powdered drinks we can add to that bottled water, and eat some non-Indian fare.