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.

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.