Philosophy with the Kids

Durga and Ani go to the same school. Durga goes to Nursery and Ani goes to 1st std. He has tests and homework and all the rigmarole that goes hand in hand with school. She has play time and story time. Needless to say, Durga desperately, DESPERATELY wants to be in 1st std.

This is the context of the conversation overhead between them, paraphrased below to the best of my abilities. It is equally amusing, fascinating and a bit horrifying.

D: Ani, I want to be in 1st std. And also, I want you to be in Nursery.
A: Durga, I was 3 when you were still a baby. Even when you come to 1st std, I'll already be in 4th.
D: But I want to be in 1st!
A (the quintessential problem-solver): So, for that to happen, first we have to die, then maybe you will come back before me, then you will be older and I will be younger.
D: Oh. So can I die tomorrow?
A: And even then, your mummy may not be the same as mine. We may not even have the same mummy as we have now.
D: So can I die tomorrow?
A: No. First you have to grow big, and live up to a 100 years old. Then I will die, and then you will. See, right now, small Ajji [that's my grand mom who lives with us] is 90 years old. So you also have to live till then, then when you are 101 you can die.
D: So I can't go to 1st std tomorrow?
A: No. Anyway, you don't even know your numbers yet. And you can't even write your own name.

Savan Durga

Wildflowers lining muddy paths to the Savan Durga foothills

We went to the Savan Durga hillock some weeks back. SD is supposed to be the largest granite monolith in South Asia. RK has been traveling there from the time he was a child because there's a temple to Narasimha,  who is the family deity on his mother's side. Even just 40-50 years ago, you could only reach the place by a bullock cart trip that lasted a few days, while praying that tigers didn't try to leap on you.

The tigers are non-existent now, and the forests severely cut back. But the place still retains a rural, isolated air, despite the concrete roads and the large number of shiny cars racing up and down.

We went there for hiking and birding. I thought the monolith would be great fun to climb, having some memories of traveling there soon after my wedding, and trying to climb the rock in my pattu padavai (silk saree). I was sure the kids would love it.

However, some earlier this year, some love-lorn couple committed suicide by throwing themselves off the rock and since then, all hiking and trekking activities around the monolith have been suspended. In a way, it's a good thing- fewer cars, small amounts of trash, fewer people. Not good for the local economy, of course.

But fortune favors the bold and we found many treasures in the foothill forests, crumbling walls of long lost temples and the smaller rocks scattered at the foot of the monolith.

Location of Savan Durga

Ani enjoying the monolith from his vantage point

Interspersed between the rocky facades are grassy niches like this one, fed by hidden rain water streams. They form the home for many small animals and pastures for grazing goats. 

Inside that thick crop of trees lining the foot of the monolith live a multitude of spectacular birds, including those that are found nowhere else on the planet. 

On the road to SD itself are lots of beautiful birds, but of course, given the traffic, it is hard to stand in one place and view them. Among the birds we saw on the way to SD were the coppersmith barbet (barbets are birds that I have not seen in the US. These are about the size of a myna, but green in color, quite difficult to distinguish within the foliage of the trees they usually hang about in. If you have spent any time at all in an urban park in India, I can assure you that you would have heard a barbet many many times). The coppersmith barbet leaps into view when it shows you its head. The rest of the body blends into its leafy surroundings perfectly, but stare into the tree long enough and there! You'll see a flash of red and yellow, gone before you can process it.
Another bird we noticed was the crow pheasant, also a very common denizen of urban parks. Check out the devilish eyes!

Crow pheasant or the Greater Coucal.
It's crow! It's an upside-down myna!
No! Itttt's crow pheasant! 

Coppersmith barbet. Pic from
 http://www.besgroup.org/2009/05/08/nesting-of-the-coppersmith-barbet/

The Yellow Throated Bulbul: on the endangered species list. Seen in Savan Durga.
Picture from http://orientalbirdimages.org/images/data/ytb.jpg

A couple more birds I have never seen before:

The tawny bellied babbler.
Pic from:
http://www.flickriver.com/photos/tags/tawnybelliedbabbler/

The Small Minivet- look at those colors!
Pic from : http://www.birds.iitk.ac.in/wiki/small-minivet

List of birds, insects and animals seen at Savan Durga:

Crow pheasant

Coppersmith (crimson throated barbette)

Yellow throated bulbul

Red whiskered bulbul

Red vented bulbul

Indian make robin

Pied bushchat

Sparrow hawk

Babbler?

Tawny bellied babbler

Kingfisher 

Small minivet 

Sunbird: purple and purple rumped

Malcoha 

White eye

Jungle crow

Jungle mynah

Indian mynah

Brahmini starling

Monkeys

Three striped squirrel 

White cheeked barbette 

Snails and water skaters

Fish

Mongoose 

Mosquitoes 

Ashy prinia 

Ladybird 

Cows

Bulls

Horse

Caterpillar

Water skaters

Durga atop a tree

Ani and RK atop a rock

An old pond by an older temple

Watching the antics of water skaters

All in all, a beautiful day in a beautiful place!

Time and Life

We live longer today than ever before in human history.

Yet why is it that we feel we have less time to do anything? Why do we push our kids into school at earlier and earlier stages, why do we prod them into achieving various milestones at a younger age? What are we in such a hurry for?

Memorable Patient Encounters 2

There are good days and not-so-great days. Last month, I got a bit of a shock when two of the mothers I had counseled admitted their kids to the Neonatal ICU (NICU) for dehydration, hyperbilirubinemia and excessive weight loss. Of course, all these are direct causes of inadequate breastfeeding.

I had seen one of them once briefly and the second one, about whom this post is about, I had counseled extensively and multiple times, along with her whole family. To say that I was dismayed to see her in the NICU with a sick baby would be an understatement.

Sometimes issues with language, understanding, culture etc are vast, or they seem so. This lady came from a very poor family. That per se doesn't mean anything. Intelligent, capable women are found everywhere, regardless of their family situation.The language of communication was Hindi, not my strong point; the differences in education, financial situation, family stability etc were of course clearly present. But these I have been able to overcome before, but somehow was not able to do so in this case. There was no rapport. Usually, if I find it difficult to communicate with the patient, I turn to her mother since she will be the one who's helping the new mom. Speaking to this patient's mom was just as difficult. There was a brother as well, and he was actually easier to talk to. Very interested in his sister's ability to breastfeed and the suckling ability of the baby. Usually when a male family member interests himself in the breastfeeding process, it's the father of the new mother or the father of the baby. Having a brother so keenly asking questions was surprising, but who am I to judge? I actually was grateful that someone in the family seemed to understand and respond to what I was saying. Many times I wondered if I was getting through to them, despite the head nods and the smiles, but then I dismissed my concerns, assuming that everything would be fine. She had an inverted nipple, but was feeding the baby through a nipple shield. She seemed comfortable, the baby appeared to be feeding well, was peeing well and there was a slight weight gain by the time she and the kid were discharged.

And then of course, a week later, she turned up with her little baby to the NICU.

Anyway, counseled her again in the NICU; she was defensive, not willing to think that there was a problem; and then all of a sudden, burst into tears about her father... she sobbed and spoke through her tears. I was unable to understand if her father had recently died or had abandoned them, or if all these events were in the past which she was still grieving over. At the back of my mind were all these questions: where was her husband? What was the brother's role? What was going on?!
Very confusing. And it happened right in the middle of the NICU; all the sisters stopped, stared, exchanged bemused glances, whispered among themselves and I was trying to console this lady and was wondering what I had said that set her off.

After some time, and a lot of coaxing and fake cheerful-talking, things returned to normal, or as normal as they could get. Turned out she wasn't eating properly- they were keeping her on rice and dal because she had had a cesarean section (were they punishing her or were they simply misinformed? Usually maternal diet after childbirth forms a pretty key part of my standard spiel... did I somehow miss talking about this with these guys?), she was not eating or drinking properly. Imagine- 3 meals of just rice and dal; not even with ghee. Restricted water. How is anyone to survive on this nonsense, let alone make enough milk to feed a newborn?

Later I found her brother in the vicinity and questioned him. And he said, "Yes doctor, you had told us about what to give her and what she should eat" (ok. good. so at least I hadn't missed that) and then I reiterated again about what she should be eating and how important that was.

God knows what happened after her discharge from the NICU. I hope she doesn't turn up again at the NICU and that baby grows a bit and this whole breastfeeding thing resolves without any more issues.

Ideally, I should have asked her to come meet me on an OPD basis to follow up with the lactation. But I was frankly very reluctant. I am a simple lactation counselor, that too with no qualifications other than an LCCE, a bit of experience and a true desire to do this stuff. All the psychiatric stuff, the financial stuff (they might feel obligated to come see me, but may not be able to afford the OPD fees), and most importantly, the getting-through-to-them stuff was too overwhelming for me. So I gave her my card with my number on it and asked her to get in touch in case of any issues, but didn't set a time.

Reading this account over makes me realize how out of control I felt. Most of my decisions were made based on a desire to get out of the situation rather than meet it head on. This is something I will probably come across again. So I must learn to become more aware of these obstacles. I must talk to Rk and other doctors about how they handle difficult cases.

Spousal relations

Does anybody else ever wonder how the rest of the married couples in the world seem to get along just fine? Barring the "clearly unhappy to be together" couples, most reasonably happy pairs seem to have figured out how to communicate.

Despite RK and me being fairly articulate, proactive, decent communicators in every other sphere of life, there are times when we clearly have no idea what the other is saying. I could be speaking in Swahili for all that it mattered. And he would be spouting words that make sense by themselves but have no meaning when strung together. And even if the words make sense, their meaning is sometimes shrouded in mystery. And many times the meaning that makes sense is only the most superficial and there are layers and layers of nuances buried underneath that are to be unraveled.
How the heck do other couples manage this? How do they figure it out or fight it out?

That's the other thing I'm grappling with. Now that our kids are old enough to understand many things that I sometimes wish they wouldn't, I'm trying to become more circumspect about arguing with RK. No more yelling, screaming, crying, throwing things, stamping feet, threatening bodily harm... you get the gist. Now it is all saved for the car after the kids go to school. Even then, traffic in Bangalore being what it is, one is never more than a foot away from the deeply interested observers gazing from behind their auto rickshaws or motorcycles. This means that while you are hissing threats or abusing your spouse's intelligence, you have make sure to keep a smile on your face.
And forget about having a good loud argument at home... you might as well just shout it out on a loudspeaker to the whole neighbourhood.

Come to think of it, if there's one thing I miss about Pittsburgh, it's my house and the utter privacy of it. Yelling at kids, yelling at spouse, yelling just for the heck of it... you could do it all and be assured that not one word would escape your four walls.

I've been watching other Indian couples and how they interact and I can't say that it fills me with much hope that RK and I will magically figure out how to communicate flawlessly. Either one partner gives in to save face, or the argument flares and dies down very quickly. There's no drawn-out, let's-really-dig-into-this-matter-and-unearth-every-single aspect-that-needs-to-be -changed-in-the-history-of-this-relationship kind of an argument that other people (for instance, yours truly) seem to enjoy.

God knows I tried to change myself so we wouldn't stick out among all these couples. I did the "let the man talk and I will listen quietly and leave" method and the "let's say this and get out quickly" method, both of which confused and indeed, offended, RK no end, with the result that we circled back to our usual formula of argue, fight, vent, rant, tears (on my part, since I really turn on the waterworks), ending with long monologue (on RK's part, since he is the monologue champion), laughter and a promise to try better next time (on both our parts). Phew! It's a real emotional wringer of session, which is why I try to avoid it as much as possible, even though many times I know it's going to blow up in my face.

What I need to find is a couple where one partner is high maintenance, doesn't like to do much work around the house, is fairly involved in whatever they think is important and that's it. I might find my role model.

Article on Respectful Obstetric Care

My article on respectful obstetric care is now online on Perspectivo Mag!!

Comments and suggestions are welcome!

Memorable Encounters- I

I used to read James Herriot many years ago. He had expressed a thought frequently in his many books, the truth of which I am realizing in my own life now. He said that he would have seen many, many patients, but a few always stay in the mind, who stand out clearly in the nebulous seas of memory.

Among the people I recall are two ladies: a daughter and her mother.
The daughter had just given birth and was suffering from engorgement of breasts, which was why she had been referred to me. This patient was in her mid-twenties; the baby who was born was a "precious baby". Of course all babies are precious, but this phrase is used to describe any baby who is born after many trials, miscarriages and so on. This lady had had a stillborn some years previously, multiple miscarriages, abortions etc and who was thrilled to finally have a live, healthy baby in her hands. Her mother had been making her drink garlic milk for a few weeks before the childbirth to increase her milk production. She felt that that was the reason why her breasts were so hard and painful.

So we chatted, I told her all the usual steps to decrease the engorgement, such as warm compresses on the breasts, frequent hand expression of milk, frozen cabbage leaves (!) and paracetemol for the pain. Just as I was about to leave, her mom said, "Doctor, can we try jasmine?"

I blinked and said, "Okay, why?"

She said, "Why, to decrease the milk flow, of course"

I frankly admitted that I had never heard of jasmine having an effect on breast milk and then she said,

"It's a very common thing in our tradition. Every time the mother needs to decrease her milk, especially in case she no longer has to feed the baby, we tie a garland of jasmine flowers around her breasts and by next day, her breasts will be empty"

"Really?" I ask. "What if she wants to get the milk again?"

"Then she just has to start breastfeeding and drink a lot of garlic milk", said the mother.

Later that evening, I googled this up and sure enough, there were a couple of papers that talked about jasmine flowers affecting prolactin, the hormone that stimulates milk flow. I also spoke to a very experienced pediatrician who agreed that this really worked. What is unclear to me, however, is how long-lasting the effects are and if they can truly be reversed with substances like garlic, which are known to stimulate milk, and how long the reversal process takes. 

Weeks later, someone else told me that jasmine flowers are never given to a new mother, for this same fear. Jasmines are not even kept in the same room, apparently.

Interesting, right?

A Muslim family told me that they feed the mother the udder of a mother-goat. Apparently it looks a bit like paneer inside and one chops it up, roasts it and makes it into soup. And a couple of days later, milk starts leaking out of the breasts like water from a tap!

The things you don't learn from a text book.... :)

A Picture Worth Your Time

What a stunningly powerful picture.

I saw it on the Washington Post. Copyright belongs to Johnathan Bachman/Reuters

The caption is pretty brief: A demonstrator protesting the shooting death of Alton Sterling is detained by law enforcement near the headquarters of the Baton Rouge Police Department in Baton Rouge, La.

Flavours and Personalities

Ahem. Kindly note the added 'u' after the 'o' in the heading above- an added sign that I'm becoming truly re-Indianized. This, of course, means that I can no longer take comfort in 'diarrhea', but will have to switch the unwieldy 'diarrhoea'... Not that I suffer from either, at least not currently anyway. But in case I did and for some reason, needed to write about it to someone, I can no longer zip off the shorter version (of the word, not the deed) without feeling like I was somehow cheating.

Anyway, I was impelled to write this blog (that too on my phone) after visiting a patient. Have I mentioned how much I love meeting patients? There's of course the obvious attraction of sounding oh so important when you can throw around the phrase 'need to see my patient'- do doctors still retain that kick out of saying it after years and years of doing so?- but to me, a basic bench scientist for donkey's years, there's the sense of astonishment and boot licking gratitude that I actually am seeing and talking to so many different people every SINGLE day!! To think that I spent more than a decade huddled under sterile hoods and hunching over lab counters, desperate to escape and resigned to never actually escaping, this freedom to wear something other than jeans and shirts and shoes that cover every inch of foot skin, to touch something without wearing gloves at work(!!), it's indescribable. If I had to try to describe it, I'd say it's like that feeling of well-being, you know, long-lasting relief that you get when you empty out your bowels after waiting a long time to do so.

Anyway, the main point of this entry was to reflect on the various personalities one comes across. Postpartum periods are funny- women are simultaneously stressed out and happy; they have a sense of completion (or sometimes, accomplishment) that the labour part of it is over and they are now anxious about how to get this kid to feed. So it's always interesting to see how women handle this period in so many different ways.m

More about this in the next post... My phone is dying.

School in India

To be sung to the tune of "We Didn't Start the Fire"

Brown paper wrapping

Sello-tape, label-sticking

Uniform buying

Tie, belt and badge hunting.

Early morning prayers

We worship all Gods,

(Some Gods more than others)

Religious tolerance in action.

Waiting outside school gate

Fine for coming late

Shoes not sparkling white

Go hide out of sight.

(We didn’t start the fire)

This is school in India

There is no complaining, only early waking.

School bag packed with books

Weighing at least 10 kgs

Who says it breaks kids’ backs?

We believe in weight lifting.

Lunch in steel box

“No plastics” bandbox

Where is my steel thermos?

Is plastic basket allowed?

PT, langdi, running race, kabbadi

Annual Day, Sports Day (JFK blown away, what else do I have to say?)

This is how we celebrate!

(We didn’t start the fire)

This is school in India

There is no complaining, only early waking.

NfAS: 5. The need for advertising: even in a government hospital where you’re offering free services.

April 24^th 2016

Today, the hospital ambulance that takes us to the PHC is not around. I volunteer to drive everybody in my (new) car. It takes some effort to get the car out of its parking spot, where two other cars have parked neatly and very closely in front of and behind it, but I somehow manage without bumping anything or anybody. We drive to the clinic. The garbage dump outside the clinic has grown to truly monumental proportions, overflowing fully on to the street, with an equally compelling smell. It is its own ecosystem, with gangs of dogs, rowdy goats and lazy cows sitting on it. One especially sleepy cow meanders to the middle of the heap and stands there, eyes gazing into some distant future, completely blocking the road/ garbage pile upon which I am to drive. I honk, more people behind me honk, but to no avail. Soon I realize that the people are honking at me- apparently, I am to go forth despite the bovine obstruction. I gingerly let go of the brake and loose my grip on the clutch. The car is inches away from the cow. Should I bump it gently? Or would that be considered sacrilege by the denizens of this place? I tell the family medicine resident to hit it. She is a small girl and her thumps on the bovine backside are met with no reaction from its owner. Finally she removes her ID badge from around her neck and hits the cow with the neck tie and the good cow condescends to move a bit. We cheer and drive inside the compound to park.

The postnatal clinic is full. It had been closed the previous week for the Tamil New Year, so a lot of people have turned up. I go to my little room and wait. While I wait, I download the WHO growth charts for boys and girls 0-5 years old on my phone. I’ve been doing a lot of reading about these charts in the recent past, ever since our new pediatrician informed us that our daughter was low weight (what is it with this country and low weight kids? How do even reasonably healthy kids in the US suddenly end up low weight over here, I had ranted to my husband). So I had checked up his charts (yes, I can be a bit overbearing as a mom. What to do? Kindly bear with me) and realized he was using the CDC scale which has age and weight on the axes, whereas, according to the WHO scale, which has weight and height on the axes, she is perfectly normal.  “Since we are not Americans or Caucasians, why should we go by the CDC charts?” I ask my long-suffering husband. So from long sleepless nights where I wondered how I could safely and consistently increase the weight of my baby, I swung to extreme relief, even jubilation. Thus am I a slave to numbers and charts. 

Anyway, all this mental overload with growth charts means that I now want to bring those here to the PHC. How wonderful if I could show a worried mother that hey, her kid isn’t doing too badly after all! Even more wonderful would be if I could chart the kid’s progress over time, but that requires far more infrastructure than I have.

I wait. And wait. No patients. What is going on? I decide enough is enough. I go over to every attender I see in the clinic and schmooze. And remind them to send the mothers and their kids to me, as soon as the kids have received their shots. A slow trickle of patients begins. Life in a PHC is not so different from that in a hospital or in a laboratory, after all. If you want something, be nice to the attenders, the nurses, the lab technicians.

A couple walks in, day laborers at a nearby construction site, with their kids. For once, the father seems more concerned about the children’s food intake. I am surprised and pleased and I tell him so.  It is highly unusual for men to visit the clinic on postnatal day and this man actually accompanied his wife! I congratulate him on his forward thinking. They are worried that the kids are low weight, but I suspect that the kids are fine. I whip out my growth charts, we estimate the heights of the kids (note to self: bring a tape measure next time), we check the weights (approximate, since the weighing machine doesn’t work too well) and I figure out the percentiles. Both kids are around the 10^th percentile. I mentally run through the conversation where I would try to explain what a percentile is, and then decide not to embark upon it. Instead I tell them that the kids can do better and we then spend a pleasant 15 minutes or so discussing various diets. Fun times.

Altogether I see about a dozen people in my time there- better than the previous session, but only about half of what I had seen in my earlier visits. I should continue the schmoozing sessions and also bring in a few more chairs into the room, so I can ask patients to be seated while they are waiting for me. I should also bring a couple of crayons and paper for the kids to use during the wait.

On our drive back, we are waylaid by the garbage dump again, this time by goats and lambs gamboling about in blithe oblivion. This time my fellow-passengers are better prepared. They roar and clap their hands and click their tongues and the goats make way. “Wonderful!” I cry. “You guys are the best!” 

Something doesn’t seem right with the car on the drive back. It isn’t till a week later that I realize that I have punctured one of the tires. That garbage dump had the final say after all.

NfAS: The Day I Learn About Worms

April 7^th 2016

Only 5 patients today. Why? What happened to my high numbers? I sit in my little office, reading a novel on my iPhone, occasionally standing forlornly by the door hoping for someone to walk in. It doesn’t help to see the pediatrics resident inundated in patients. 

A woman walks in, smiling at me. She looks awfully familiar. Hey, didn’t I see you a few weeks back, I ask her. Yes doctor, she says. I came back to talk to you again. 

I am thrilled. Someone actually likes me enough to return! Then I tell myself to get a grip and not to be so needy. She thinks her one year old has worms because his tummy looks big. She says she has been trying to get him to have a flatter tummy for months now, but always, it looks like he has a “thondi” (pot belly). Oh yeah… worms… I’d totally forgotten about them, coming from my decade-long American background. I’d been dewormed multiple times as a child and that thought triggers multiple memories. “Does his bum itch?” I ask. “Does he keep wanting to eat weird things, such as paint or erasers?” Have his bowel movements changed? Does he keep wanting to eat continuously?” 

No, no and no, she says. He’s totally normal that way.
Okay, does he play in the mud?
Yes.
Do you wash his hands afterward?
Yes.

I tell her to talk to the pediatrician for albendazole, though it doesn’t seem like the kid has worms. I reassure her on the pot-belliness of infant bellies and explain about stomach muscles and how they tighten over time. I end by asking her detailed questions about the baby’s diet and praise her for a good job done.

Soon after, we get up to leave and I catch hold of the pediatrics resident and ask her to tell me all about worms. 

All these weeks, all these kids in their dirt-stained clothes and mud-stained hands and their low weights, and I never thought about worms before. A bulb just switched on in my head.