Sunday, April 26, 2009

Swimming in sweat and sunscreen, attempting to deal with heat delirium

Today it reached 115 degrees Fahrenheit. Yesterday it was cool at around 98 degrees. For the past week it has consistently been over 105 degrees. It is a different kind of heat then I am used to, as it is not humid but simply direct from the cloudless sky and constant all day and night. It is debilitating heat, where you have to work to get through it. Resting makes it worse so you must work to try and ignore it but it always seems to be a losing battle. It is quite amazing how much less productive the heat can make you. There are no air conditioners except in some rooms, where at times we huddle together to keep cool and find ourselves getting five times more work done.


If you walk around at one o’clock in the afternoon, you typically find one of two sights: either men lying down under a tree taking a nap or women working in the middle of a farm working. Both acts at 1pm are amazing. The farmer is amazing for being able to work in the heat in the middle of the day, wearing pants or a cotton saree. The napper is laudable for being able to simply sleep more than fifteen minutes. Some days I try to make it through a whole day without taking a nap but rarely last past three o’clock before being drained. However, taking a nap leaves me swimming in my own sweat after fifteen minutes, searching on my bed or chair for a dry spot, trying to ignore how I am more delirious now than before I slept.


A byproduct of the heat are snakes, which have been appearing in high numbers for the past couple weeks. They usually appear in the early morning, around 6am to 7am, when they search for food or a cooler area to spend the day. One morning I was sitting outside my room reading when I heard a rustling behind me. Looking back, I saw nothing. Ten seconds later I heard the rustling again with a hissing sound. Coming around the corner towards my bench was a five foot rat snake, squirming its way quickly. I jumped up and followed it as it made its way right in front of my room, bumping its head against my door. After yelling out “sapa” [snake], a staff member came out of his room with two sticks, handing one to me. On the concrete the snake had great difficulty moving and we were able to handle the snake with little problem. The next day there was another snake outside the staff housing, and three days later a king cobra was found in the evening. I only saw it after it had been badly wounded by the guard who fancies himself a snake-charmer, but the sight of it fully upright was awesome.


The hospital has thus seen an increase in snakebites, complications ranging from two little marks on the ankle from a non-poisenous snake (like a rat snake) to a hemotoxic bite (most due to vipers) causing necrosis and kidney damage to paralysis from a neurotoxic bite (most due to cobras). One patient in the hospital now has swollen hands, paralysis and kidney problems caused by the crate, the most dangerous snake in the area. In addition to snakebites, more patients with severe diarrhea have been presenting in the hospital. It is unclear exactly what has caused the increase but logic seems to say that people are drinking dirtier water since there is less of it. Finally, the heat gives a lot of trouble to pregnant women, especially if they are actively working. They lose water at a rapid pace yet need it more. The doctors are working hard to educate the pregnant women as to the risk factors of working in this heat.


Every year from April to early June, everything seems to just stop around one o’clock in the afternoon. Patients increase in the mornings and afternoons, but mid-day there is a lull, and even the doctors try to catch little naps to reenergize. Farmers have much less work in the fields and are at home more, and kids are off from school and usually running around CRHP throwing stones to knock down almonds from the tree or riding adult bikes too big for them. The women still work very hard, getting water and taking care of the house and kids, cooking and sometimes even tending to the farms. While it has been difficult to get through, understanding how Jamkhed and CRHP make it through these months each year is also an educating experience.

Friday, April 17, 2009

Paint-covered snake-bite patients make great hosts

I wanted to share three findings:

Interesting Hospital Observations: Working in a hospital brings patients, diseases and complications not ordinarily viewed in daily life. Working in a hospital in a rural village of India breaks the door even further, bringing in patients and infections rarely seen even in the U.S. Over the past eight months, patients with rather interesting histories have walked through the hospital door. Many leprosy patients have come at different stages of complication. One man stands out in particular, as the tissue in his arm had died so that maggots had been living inside and needed to be pulled out. Maggots can be beneficial when eating dead skin but in this case served no good purpose.

Also coming into the hospital was a case of mumps (MMR is not given in India), many patients with typhoid, diabetic feet, lip cancer (due to tobacco), snake bites from cobras to vipers, women and children with second & third degree burns, and large goiters. The most striking case was a child who was delivered and died within three minutes. The baby would not have lived long, though. It was born with a huge abdomen but a chest the width of a baseball, it had no penis but enlarged testicles, and at the end of shriveled arms and legs, each foot and hand had six fingers and toes. The complications were congenital, although the exact cause we did not know.

Would you like extra sugar with your tea? The humility and graciousness of Indian families has humbled me since arriving in India and continues to quiet me to this day. Never have I consistently seen such caring hosts. Families who work on the farm to feed three children and send them to school immediately stop what they are doing when I enter their house to offer me tea and biscuits. Further, they insist we put extra sugar in our tea, a sign of respect and good status for the family. Also customary is on the anniversary of the death of a family member, their memory is honored by inviting guests from the village for dinner and eating to their hearts content. Additionally, the first time I visited a friend’s house for lunch, I was seated and we were both served until we could eat no more. Then I was presented with a coconut, a scarf, a bindi and a farmer’s cap as a sign of welcome. There was no hesitation at all from my friend or from any of the houses I visit, as there seems to be true appreciation in their actions.

It does feel uncomfortable as the family is far from rich and offering you lunch and tea with extra sugar. However, it is only more complicated and ungracious to not accept. It is equally uncomfortable to eat dinner and end up simply being served, mostly by women. Often I sit and eat with the men as the women prepare the food and then serve it. When we are finished, the plates are taken, a water bowl is brought for our hands to wash, and then the wife cleans the dishes before sitting and eating her own meal. This routine is so consistent that it seems to be a sign of a good host. Their actions seem filled with graciousness and placing values over material things. It constantly challenges me to think about my own hospitality and possessiveness, often at the expense of relationships and my own values.

Just don’t let them cover you in the silver paint: In mid-March, the festival of Holi was celebrated. It is a holiday commemorating the burning of Holika, who was burned to death to protect Prahlada, the son of Hiranyakashipu (King of Demons), who was a devotee of Lord Vishnu. The day is richly celebrated by covering others from head to toe in paint. The morning is spent buying the paint powder and mixing it in water bottles with a hole in the cap for spraying. The next eight hours are then spent roaming and searching for friends to spray and color. It was not a choice of whether you wanted to have paint on you or not; rather, it was a choice of how much paint. Even then, those who protested the most were usually sprayed the most.

The fantastic thing about Holi was the universal playful attitude. Those who do not want to be sprayed may protest but eventually they will be sprayed, and when they did they simply smiled. Even today when you walk around Jamkhed, women will wear sarees and men will wear shirts and pants with paint marks covering the back and sides. But I did not see one person who was truly upset about being covered in paint even after protesting for minutes about being colored. That ease made the day very friendly and familial. By the end of the day, after hours of playing, I was unrecognizable – walking through Jamkhed afterwards, I was covered in paint to the extent that people could not tell who I was.

Thursday, April 9, 2009

The goal is not an increase in patient numbers but patient care

Since 1970, CRHP has been a leader in primary health care (PHC) and village level empowerment, especially of women. It has trained over 20,000 people from across the world on its model of equity, integration and empowerment in the hopes of spreading the message of locally-based PHC. By starting at the level of the neediest villager, CRHP has been able to collectively raise the status of the whole village while simultaneously breaking down caste barriers, long-held destructive traditions and the low status of women.


The key player in this primary health program at Jamkhed is the village health worker. She is a woman selected by her villagers to raise not only the health of the village but also its capacity to handle its own problems. At the outset, many of these women were dalits (untouchable caste) and illiterate. She was not accepted, trusted or supported in her village and the knowledge she was had was often overlooked by higher caste villagers. It was not until problems arose that the VHW was given her chance to break through the barriers.


Many of these problems were referred to the hospital, including complicated deliveries, snakebites, and pneumonia. The hospital served not only to care for the referred patients but also to support the village health worker in her decision. Questions asked by the patient’s family would be referred to the VHW, who would give the correct answer and then be supported by the doctor. When a patient was referred, the VHW would be recognized for her work. When complications arose, villagers saw that the doctor taught the VHW and trusted her. The hospital provided an invaluable service in supporting and encouraging the VHW, assisting her to be accepted and recognized in the village. Soon enough, the VHW was allowed into houses, was performing deliveries in high caste homes, and was listened to when speaking on leprosy, snakebites and other health issues.


The secondary care component of CRHP is essential to the success of its primary health program. When a flow chart is constructed of the CRHP model, two adjacent circles are connected by a horizontal line. In one circle is the village & VHW, in the other is the hospital, and in between is the mobile health team. CRHP is known for its PHC program and village work, but its ability to provide low-cost, honest hospital care is invaluable. How effective would the VHW be if she referred cesareans to a government hospital where it cost 10-15,000 rupees ($200-$300) and placed the family in lifetime debt, rather than to CRHP’s hospital for 5000 rupees ($100)? Or to a private clinician who charged extra for leprosy medications rather than to CRHP where the meds were covered by a leprosy fund? Or to a hospital where the staff treated you like an animal, versus CRHP where you were not only respected but you and the village health worker were taught?


The secondary care component, in addition to supporting the VHW and her efforts, provides low-cost hospital care, supports a non-intimidating environment, and allows the villager to learn about medicine, thus breaking down unfounded beliefs. Each year about 26,000 outpatients receive treatment, 350 deliveries take place (usually for high-risk patients), and 500 surgical procedures are performed. Family members are allowed into the operating theater during the procedure and family is expected to care for the patient as a nurse would.


On Sunday, a new 50-bed hospital was opened with a bang at CRHP. Plans have been three years in the making and construction has taken the past year. The hospital is not only bigger but better built. While the old hospital was built thirty years past with tin roofing and one floor, the new hospital is reinforced with plaster and bricks and has two floors with plenty of space, also permitting a much cooler atmosphere in the hot summer months. The larger wards and consulting rooms will allow for better care of patients and the updated surgery rooms (including one for laparoscopy) will make it easier for doctors to operate. Private rooms will provide safety and comfort to patients with burns and smelly wounds. And the building will provide a long-term hospital solution, as the last hospital (while full of character) was not built to last as long as it did.


While CRHP has in many ways set the mould for an effective primary health program, a major focus now is to become a leader in creating low-cost secondary care. Protocols for patient care, drug therapy and operations will accompany the change in space to streamline and improve access and cost. Villagers with little hospital experience but tons of real life experience will be trained to provide patient care. Doctors will hopefully be attracted to the rural setting to provide services to the neediest of Indians – in eye care, dentistry, surgery and pediatrics. The goal for the new hospital is not an increase in patient numbers but rather an improvement and standardization in patient care, something reiterated throughout Sunday’s opening. The opening of the new hospital represents the hope that CRHP will continue to be at the forefront of change in the health sector throughout India and other developing countries.