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.

Notes from Another Sphere: Record-keeping

March 24^th 2016

The garbage dump outside the clinic is growing. This clinic is in a pretty poor part of town, in what doesn’t look like a slum, but for all practical purposes, is. Narrow roads (one main reason why I can’t call this area a slum- which slum has roads in it that you can drive a car or an ambulance on?) upon which the BBMP civil engineers, in their unfailing enthusiasm, have placed tall speed-breakers (and breakers of back, neck and every type of bone) every 5 meters, criss-cross the neighborhood. There are no trees; small garbage heaps make a colorful patch every few yards. Large garbage dumps mark the really important locations. The BBMP PHC has the most gigantic garbage dump that I have seen. 

This time, as I enter the clinic, one of the attenders tells me to enter my patient details and my plan of care in one of the registers. I’m quite excited- this would be a good way of keeping track of my patients. I peek into the earlier entries in the register. I see many different handwritings, corresponding to many different doctors. Most have scribbled the patient’s first name, followed by chief complaint and medications prescribed during the visit. I can do this, I think to myself.

I see patient after patient after patient. Sometimes, I have to stop them from launching into their story as soon as they sit down, while I scribble down my notes. I miss a lot of details in the hurried note-taking. At the end of the 2.5 hours, I count the number of notes I have jotted down: 19 mothers/ families with babies or children, and nearly all of them for low weight. My notes about interventions done nearly all read “counseled on diet and nutrition”. 

Most breastfeed their infants. But I think that the point where the greatest confusion occurs is during the introduction of solid foods. Lots of mothers give their kids biscuits and idlis. But they shun fresh fruits, mashed vegetables, even rice, or ragi, or wheat. Many refuse to add ghee to the child’s meals for fear that the kid will somehow fall sick. 

Writing this down, I wonder if what might be really useful is to make a few handouts to give mothers, lots of pictures explaining what to give a child and when. 

At the end of today, I feel really energized. Writing down notes on my patients really added an entire dimension to my experience here. 19 patients! Underweight kids! Suddenly I have a handle on this population, I’m beginning to understand them.

Note from Another Sphere: Overwhelmed

March 17^th.

This time, Dr.D.M is not the senior consultant, as she is off on leave. Instead, Dr.S. T, a more junior consultant, leads the way. Something about Dr.S.T tells me that she might be a little more judgemental in her attitude than D.M. Perhaps it is her statement that “some mothers are so bad that they don’t even bring their kids to the clinic for their regular immunizations”, something that makes me wince a bit, since I frequently tend to be one of those mothers.

Dr.S.T has some good ideas, though. She starts off the clinic by introducing herself and the team. She tells moms the drill: get your baby weighed and measured here, get their shots there, then go visit the counseler (me) on that side of the room, and so on. She also spends a good 10 minutes explaining the importance of washing hands before eating and cooking, and after using the toilet. Dr.S.T is Telugu, and speaks in Kannada. However, the majority of the clientele in this neighborhood is Tamil. How many people understand her instructions? God knows. But I appreciate her intention.

This time my group is a bit more diverse in terms of language. I find that conversing in Kannada is not as difficult as initially feared. I reiterate Dr.S.T.’s messages of hand washing with most of my patients. Then, one lady brings her baby and sits down. “Tamil or Kannada”, I carol at her. “Hindi”, she replies firmly and then launches into a stream of Urdu. I blink at her. “Huh?” I say intelligently. “Bacchan kal rath **gibberish** kha liya. Aaj polio ka daviyiyan doon?” (My kid ate **something** last night. Can I give him the polio drops?) is what  I managed to understand after multiple attempts. No idea what it was that the kid ate. Was he supposed to have eaten it? Or was it some sort of garbage that he stuck into his mouth? I attempt to understand this. “Aapne khaneko diya?” (Did you give him this to eat?). “Nahin, vo apne aap kha liya” (No he ate by himself).

Okay. That didn’t get me too far. What exactly was this lady’s concern? Was it the fact that the kid had eaten something he wasn’t supposed to? (in which case, why wait till the next afternoon to ask someone about it?) Was it because she wasn’t sure if he could get an oral polio vaccine since he had something in his stomach (from last night- was she saying that he had had nothing to eat since he woke up? )? Was she asking my implicit permission to give him whatever it was that he had eaten?  And how in the world was I supposed to ask all these questions if my brain couldn’t unscramble itself quickly enough for me to form any coherent sentences?

Overwhelmed, I say to her, “Aap vo doctorse pooch lo” (please ask that doctor over there).

When she leaves with a bit of a huff, I berate myself for my complete unpreparedness for a Hindi-speaking patient and spend a few minutes meditating on possible answers I could have given, wrack my brains for the right vocabulary (not too Sanskritic or Anglicized) and practice some lines in my head.

Next walks in a lady who overturns my idea of the people who use a BBMP PHC. She is attired in a frilly pink T shirt and jeans, heels on her feet, a perfectly well dressed little baby girl in her arms.  We talk in English; she lives in one of the neighboring high rises; is worried about her daughter having a cold. As we chat, I notice bruises on her hands and realize that what I thought was a disfiguration on one of her cheeks is actually another bruise. “What does your husband do?”, I ask, very casually. “He works too. My mother in law lives with us”, she says softly. I am not sure how to proceed. On one hand, the bruises could have a perfectly rational and harmless reason. On the other hand, why was such a well-dressed woman coming to a BBMP clinic, unless she felt this was one where probably not too many questions would be asked? On the pretext of playing with her baby, I watch her carefully. But honestly, I cannot read the situation. I have to send her on her way. How does one ask another woman, whom she has known for all of five minutes, if she is being abused by her husband?

I put this question to my husband, much later in the day. He says, “Well, you can’t ask her that. Instead, give her your card and reassure her that if she ever needs help, she should call”. Hmm… good to know. Though, if she does call, what would I do? Offer her protection? In my house with my two kids? Call the police? It’s very difficult to figure out the right steps.

Three women with a small baby seat themselves in front of me. “Weren’t you here a couple of weeks ago?” I ask, since the baby looks so familiar. “No, no”, they assure me. “Maybe your mother came with the baby then?”, I ask the woman in front of me. “No no”, she says. The baby is about 9 months old and looks to be 2 months. I could swear it was the same baby from the last time I was in the clinic, the one whose grandmom ran away. But these women are firm that that is not the case. I drop the subject. Again, we talk about the baby’s weight; this time I ask more detailed questions about his development and diet. The baby has never tried to crawl, or sit, or even roll over by himself. He just keeps lying down. The mother gives him some biscuits and milk, but no vegetables or fruits or breastmilk. I talk about the importance of all this but I get the frustrating sense that I am not making much leeway. But the presence of the other two ladies gives me a false sense of security as I insist again that the baby be taken to the doctor. “Dr. S.T. is right here. Please take this baby to her. He needs help”, I say. “Yes, yes”, they all nod. I think that at least the other ladies will make the mom take the baby to the doctor.

An old Muslim lady rushes in. “Gassa ka goliya dedoji” (give me the gas tablets), she cries.

“Gassa ka goliya?”, I blink stupidly. “Kya gassa ka goliya? (What gas tablets?)”

“Vahi vo lal patte vale” (those ones in the red strip)

I dazedly gaze around the array of tablets on my table. I see Omeprazole, sodium citrate, some crocin and the like. “Vo vale”, she says pointing to the Omeprazole. I vaguely know they are related to some stomach issues, but that’s about it. “Main nahi de sakti aur main doctor nahin hoon. Aap vo doctor ke pas jao” (I can’t give you those and I am not a doctor. Go to the other doctor), I say.

“Dedona” (please give)

“Nahin ji, nahin de sakti. Vo doctor se poochlo” (no, I can’t. Ask the other doctor).

She gives me a disappointed look and leaves.

Phew! This day has no end of surprises.

Just as I am getting up to leave, a mother walks in with a small girl and a baby in her arms and hands me the baby’s records. I look at the notes the pediatric resident has scrawled: Weight 2.1 kg (<2sd baby="" is="" meaning="" p="" that="" the="" underweight.="" very="">

We chat about the baby’s diet. Then, all of a sudden, the mom bursts into tears and sobs that she isn’t really worried about the baby, it’s her daughter who refuses to eat any food. She talks about how every mouthful has to be coerced; about every mealtime being filled with tears, frustration and rage; about the family’s collective exhaustion with this situation. The baby, she says, is fine. I ask her questions about diet: what does she give the kids, how many times do they poop and pee and so on. According to her, she gives them everything: bananas, raagi, meat, eggs, milk. Apparently the baby eats all this, but the girl does not. The girl too is very under-sized; a 3 year old who looks like she might not yet be 1.5. The mother says that she finds it difficult to bring the kids to the clinic or take them to the pediatrician in a nearby hospital. She is also afraid of going back there because she thinks the pediatrician will scold. I dismiss these concerns: no no, the doctor won’t scold. She may ask why you haven’t brought the kids to her for so long, but she’ll help, I tell her. While I explain to the mother that yelling and hitting at the kid during meal times isn’t going to get her to eat more, I know that some medical intervention is called for as well. I call the Pediatric resident, Dr.M, to evaluate the situation.
Dr.M. checks the girl’s throat, asks even more detailed questions about diet (I learn that trick from her: ask what the patient has at EVERY meal, not just a general overview), asks about birth weight and so on. Dr.S.T steps into the room while this is going on and listens in. The doctors diagnose malnutrition and recommend that the lady take both her kids to Indira Gandhi Children’s Hospital, at least 10 km away. While I agree with the diagnosis and the plan, I am taken aback by the attitude of the doctors. They are patronizing, they scold the mother for not having brought the kids to a doctor sooner (no wonder she had been procrastinating taking her kids to the other doctor! This attitude must be prevalent everywhere), they discuss her kids in front of her as though she and they weren’t present. At the end of 10 minutes or so of all this, the mother takes her babies and scuttles out, not meeting anybody’s eye. I am pretty sure she’s never going to come back here again.  “God, these people!”, says Dr.S.T. “They are so uneducated and backward”. Then she starts a diatribe about the backwardness, about how the husbands are useless, probably spending all the money on drink and cigarettes, about how they mistreat girl children and so on. I make “hmm… hmm” sounds as she talks, not wanting to give offense. But I feel terrible and small and more than a little lost. I think my actions today have driven away this woman and her kids without solving any of her problems, adding new ones to the mix. I hated seeing her shamed so, but I hadn’t said anything to help her out. I have no idea what I ought to have done, either.

A sobering end to my second day at the clinic.

Notes from Another Sphere- Opening my Eyes

3^rd March 2016

My first day at the BBMP Urban Primary Healthcare Center in Koramangala. I get there around 11am, by which time the clinic is in full swing. Babies are being measured, weighed and injected with whatever shots are deemed appropriate, mothers are chatting, the attenders in their blue sarees are ordering people about… a typical scene in a government hospital. I find my contact, Dr.D.M, inside one of the consulting rooms. She is marvelously efficient- within a few minutes, I have a spot at one corner of her clinic, a set of chairs around me, and the attender is leading in my first few patients.

I am an antenatal and postnatal counseler. This means I talk to pregnant moms and new mothers about their worries and concerns, I give them advice on nutrition, I counsel them on how to take care of themselves, their babies and their families. I speak to the family members, if they are present. I find out about their work, if they have help, if they have any ongoing issues with something, I help them problem solve. My role is to be a source of support, an elder sister of sorts.

My main source of worry on this day is my ability to communicate. I can handle Tamil, but Kannada and Hindi, I tend to falter with, despite being able to read both languages and have routine conversations. Oh well, I’ll muddle along somehow, I think.

I have done some homework for this trip. Just before leaving for the clinic, I send my various cousins a question on WhatsApp: How do you say, “don’t have unprotected sex” in Tamil, Kannada and Urdu. My cousins are highly amused and I spend the time while traveling to the clinic giggling at their increasingly improbable translations. Nonetheless, before I step into the clinic, I have my answer: Avar jothe serak mudhale nirod upayogisi (use a condom before sex). “Serodu”- to join, the colloquial euphemism for sex in Kannada and Tamil. Phew! I can embellish the rest.

My first patient brings in a baby of about 3 months old. As is my custom, I ask her which language she is most comfortable with, to which she replies, “Tamil”.  I practically rub my hands in glee. We chat. She’s a first time mom, living with her mother, who has also accompanied her, a large capable-looking woman, who initially looks askance at my questions about diet and at my even more impertinent questions about urinations and bowel movements. But she thaws soon, once I praise her lavishly at the work she does everyday to keep her daughter and grandchild healthy.  I ask my patient about her husband: does he visit, does he play with his child, does he spend the night and so on. “Never!” inserts the mother, at this point. “According to our custom, her husband will not sleep in the same room with her for the first seven months”. “Wonderful!” I assure the patient and her mother. “But in case the opportunity arises and you want to have sex, you must think about contraception”, I say, keeping my eyes fixed on my young patient. “Don’t become pregnant right away. Give some time to yourself and your baby to grow up” “And give some time to your mother”, her mother interjects, at which we all laugh. I tell her to go to Dr.D.M., whom I see is relatively free at the time, and discuss options for contraception and am gratified when they head there directly afterwards. A very pleasant session indeed.

I see about 10 or 12 more patients, all Tamil, most doing relatively well. My onlytruly worrying case is a grandmother who has brought her 9-month-old grandson, but the child looks closer to 2 or 3 months of age. “Where’s your daughter?” I ask. “At work”, she replies. “I feed the child and take care of him. I give him cow’s milk”. Further questioning reveals that her daughter breastfeeds once or twice a day. The grandmother looks hassled, has very bad teeth, slightly blurry eyes, and difficulty understanding what I am saying. The baby is asleep. “You need to go talk to Dr.D.M. This child needs help. He doesn’t look well”, I tell her. She nods and gets up. My attention is momentarily caught by the next patient who walks in. When I look back up, she’s nowhere around.

The clinic closes at 1pm. The attenders walk us out, we get back into the ambulance that will take us to the hospital whose outreach program runs this clinic. On the way back, Dr.D.M and I discuss my experience. My most vivid impression of the two hours I have spent is of how incredibly diverse the clientele is. I have spoken to mothers who are day laborers, who work as receptionists and speak English, some who are fairly well educated and some who are illiterate. The phrase “government hospital” evokes images of lines of women carrying malnourished babies, wearing tattered sarees. In reality though, the PHC serves as a first contact for pretty much anyone living in the vicinity and this includes educated women and their families. What also stands out is that most of these babies look okay- other than the one who was clearly malnourished, most babies were decently sized, many were exclusively breastfed. What is more worrying is the standard of nutrition for the mothers. New mothers are not counseled on nutrition and most do not eat vegetables and fruits, with the result that most of them suffer from constipation; some are dehydrated.

I learn something from Dr.D.M that makes me hit my head in self-irritation. The hospital that provides the service at this government hospital is Catholic, and as such, their doctors are not allowed to provide contraception. “Gaah!” I scold myself for having forgotten this basic rule of any service: never forget the funder. I recall all those women to whom I happily advocated contraception, asking them to meet with Dr.D.M. for further instructions, and cringe.

Dr.D.M urges me to come for their antenatal clinic, since this is the time, she says, where counseling is desperately required, but no one available to provide it. I hesitate to commit because I don’t want to take on too many new commitments. I don’t want to stop going to the postnatal clinic, now that I have experienced it and feel it might be better to gain some mastery on one aspect before tackling another new one.

A good learning experience and an unforgettable introduction to the world of the government run PHC.