There's nothing like a good party

I have to work backwards now, to cover the things from the past few weeks!  So please bear with me...

I'm not a big partier, but I had decided long before we came, that we should have a goodbye dinner, especially to thank Dr. Philip and his wife Dr. Anna for their generosity in hosting our group.  After some scheduling issues, we decided on Tuesday, that the party would have to be held on Thursday night.

By Wednesday evening, very little had been planned.  We still weren't entirely sure how many people were coming, but somehow the estimate had expanded from the original idea of just Philip and Anna, to a guest list of nearly 70 people!  Fortunately, Sunny and the staff are amazing, and not only said that they could cook for this many people, but that they would arrange for a DJ, mats to cover the broken concrete in the courtyard for dancing, and all the chairs, tables, and dinnerware that were needed.  Nothing like having less than 24 hours to put together a party for 70 people!!

Well I'll be damned, but I have to say that I think this was one of the best parties I have ever been to.  The food was amazing, everyone danced... even me after a consider amount of dragging and persuading!  And the students and hospital staff all seemed to have an absolutely fantastic time.  Sunny had even brought my Mom and I two beautiful salwars from his trip to Amritsar, so it was the perfect opportunity to get dressed up and show off his amazing taste in clothing (his father is one of the best tailors in Dharamsala).  He brought me a gorgeous sky blue outfit with some of the most intricate beading I have ever seen in my life.

At one point we were having so much fun that we failed to notice that a huge crowd of people had gathered outside the hotel gates and were just standing there watching what was undoubtedly quite a spectacle... 40 or 50 Indian and white people dancing together to bollywood music in the middle of a courtyard/parking lot!

Unfortunately, the students had to give their final presentations the next day, so we couldn't stay up all night partying, but we had a blast during the time we had.

I have to say, my Mom made one really interesting comment to me.  She said that she hadn't seen me like this in years, having so much fun and getting up and being so energetic (even if the energy only lasted about 10 minutes).  When I think about it, she is right.  Ever since the fibromyalgia developed when I was 16, I am really resistant to doing anything... I'm always too tired or having too much pain or feeling too sick.  I had forgotten how fun-loving I used to be.  I'm not sure what made me able to be like that once again after so many years, but whatever, it was, I have to try to channel it again in the future.

The end of part 1 has come

The students, my Mom and the other 2 professors departed last night around midnight for Delhi, after a whirlwind of plan changes and phone calls.  Most will be flying back to the States this evening.  It is hard to believe that five weeks have gone by and the program is already over!!  While it is nice to have time to think of something other than 14 undergraduates, I have to say I miss them already.

Yesterday morning I got a call saying that Srita, Sunny's friend who works for Kingfisher Airlines at Bhuntar Airport had called because she was worried about the group's flight to Delhi the next day.  The one or two flights a day had been cancelled for the past three days due to bad weather and she suspected the same would happen to ours.  Because it takes nearly 15 hours to drive to Delhi, we would have to know immediately to make other arrangements for the students not to miss their international connection back to the States.

After hours of Mili, Sunny, and I all sitting on the phone or trying to sort out things on the computer and figure out our options, we decided that we couldn't chance it with the flight - there was just way to good a chance that it would be cancelled and the group would miss their flight home.  Sunny worked his magic, yet again, and somehow managed to book four very nice taxis to drive overnight and take the group as far as Chandigarh, and then another set of taxis to take them the rest of the way to Delhi.  In order for them to make it by early this evening, they had to leave at midnight.

You have to take this within the context of India, in which nothing ever goes as planned and things are rarely what you have asked for.  But to my amazement, 4 toyota taxis rolled up promptly at midnight, the students were all fully packed and ready to go, and the drivers spoke English and were very organized and had apparently slept during the afternoon, so were ready for the drive.  Within 30 minutes, we had all 17 people and their 35 suitcases packed and loaded into the car.  The drivers had even thought to bring tarps and rope to cover the bags, knowing that it was likely to rain.

We had one final moment as we stood together in a circle and announced to Sunny that everyone had chipped in to buy him a roundtrip ticket on a deluxe A/C bus back home to Dharamsala.   We took one last group picture with Sharvan, our favorite staff member, Sunny, Kundan (Sunny's best friend and our resident comedian), Himani and Anne (my friends who are helping with the TB work) and all the students and faculty.  As the students streamed from the circle to their respective cars, each hugged me as they passed and 2 or 3 of the girls even started to cry.  The five of us who were left stood by the gate to the hotel and waved as each car drove out of the compound and disappeared down the street into the darkness.   I worried that the last car was taking too long to follow the others and walked over to see what was taking so long.  When I looked in the window of the car I saw that the driver was praying before he departed on this somewhat dangerous journey.  The drive to Delhi is long, and the first leg in particular is quite dangerous as you wind your way along the mountain ranges of the Himalayas on tiny roads that run along the edge of the cliffs.  Before they left, I asked each driver to take care of my students... please don't let anything happen to them, was all I could think.

Fortunately my Mom called this morning that they had made it safely to Chandigarh and had stopped to have tea at Mili's parent's home (one of the professors who is from Chandigarh).  I am awaiting news that they have safely reached Delhi, but I was very happy to hear that they had made it that far safely.

Himani, Anne and I spent the rest of the morning discussing the logistics for us living here in the hotel for the next two months.  While we had originally planned on all three of us staying in one room, we decided that it might be better to go for the two rooms (at only $200 more for two months).  We went to Sunny's apartment for brunch and enjoyed some delicious potato sandwiches (sounds strange, I know, but they are actually extremely tasty).  Then returned to the hotel to start the fun task of trying to clean my room, which truly looked as if a tornado had passed through.

Now here I am, trying to catch up on my blogging and anxiously awaiting for it to be late enough in the morning for me to call to the States... darn time difference is really very annoying!  

The things you see

I've spent the past few days this week in the hospital, mostly observing in the OPD (outpatient department) and Casualty (or the Emergency Room as we would call it).

It is quite interesting to see the similarities and also intense differences that exist.

The morning begins at 8:30am with a short devotion service.  I was initially very wary of this, but it actually turned out to be quite pleasant.  The service is lead by Dr. Philip and begins with songs in Hindi, followed by a brief, but meaningful sermon.

Rounds begin immediately after devotion, led by Dr. Philip, who is then tailed by a contingent of nearly 20 other doctors and students.  Rounds in this case consist of every in-patient in the hospital, so you see a wide variety of cases.

Day 1 started in the ICU (which consists of 3 beds), principally with a woman who was sadly on death's door... congestive heart failure, emphysema, and a variety of other issues (apparently she passed later that day).  The condition of the patients improved considerably as we wound our way through the patchwork of rooms and buildings that house the patients.  We reached the pediatric ward and saw two tiny babies, each only 3 weeks old, both of whom were severely dehydrated from nausea and diarrhea.  This seemed a bit odd to me, as you would expect them to be breastfeeding, but perhaps they were not doing so.  The poor things were so tiny...

We saw a number of other young children with diarrhea, fever and dehydration, but that is pretty typical around here.  Food and water sanitation can be pretty problematic in some parts of the area.

We then came to another adult ward and saw a teenage boy who was complaining of severe headaches and extreme lethargy.  My mind went to migraines, but they said they thought he had tb meningitis.  Apparently the brain scan had showed "water" by which I think they meant cerebral spinal fluid in his head.  They put him on anti-tb treatment and steroids and moved on.  He was discharged the next day...

When my Mom and I found this out we were both a bit disturbed.  She explained to me that without doing a culture, there is no way they could be sure that it was tb meningitis and not one of several other things.  They apparently discharged him because he was more alert and seemed to be doing better, but that was because they gave him a huge shot of steroids to wake him up, not because the tb meds had started working.

I am not writing this to be critical... in general, the hospital does a fantastic job in the context of limited resources, but the difference from how my Mom would have handled this type of case in the U.S. was striking.

Most of the rest of my time has been spent in the OPD with Dr. Parvesh.  A nice young Indian doc, he has decided to teach me medicine 101 in the few days I am here this week.  I told him we could swap... if he taught me medicine, I would teach him statistics.

The sheer volume of patients they see is mind-boggling, not to mention the complete lack of privacy.  Four doctors sit in a row along the length of a room at a desk and patients are quickly seen one after the other.  If they need to do an exam, they pull a curtain shut, but for the most part, everyone is basically right on top of each other.  It is in pretty stark contrast to the environment created by HIPAA and patient confidentiality in the States, but no-one here really seems to mind.  The expectations are just different.

The amount of TB and typhoid seems rather unreal.  It was like every other patient had one of the other. Also a lot of other respiratory infections, fever, and diarrhea.

There were however two patients that have stuck in mind...

The first I saw on Tuesday as I was sitting with Dr. Parvesh.  He suddenly grabbed a piece of paper and told me to calculate an equation he wrote down.  I pulled out my cell phone and started punching in numbers.  When I finished I showed him the answer and asked if it seemed reasonable.  He said no and I started to get a little red in the face.  But then we both recalculated it and got the same answer, so he realized he had written down the formula incorrectly.  He hands me the "bible of internal medicine" and told me to look it up.  Of course, I had next to no idea what it was I was looking up, as the whole conversation with the patient was in Hindi, but I eventually deciphered that it was a calculation used for chronic kidney disease.  Finally, I found the formula and recalculated the number, correctly this time.  I got a number of 14.4.

Okay, I said, here it is.  Well what are the reference values, he asked?  Well how on earth should I know, I thought!  So up came the book again (fortunately I remembered the page) and I sifted around until I found a table of reference levels.  Stage 5, it said, less than 15 equals full renal failure and dialysis required.  I looked at him and whispered, "is dialysis available here"?  I had a feeling I knew the answer...

He didn't reply.  But when the woman came back later, I caught the word Chandigarh amidst the Hindi.  I am pretty sure he was telling her that without dialysis she would die, and that the nearest place to get dialysis was Chandigarh - nearly an 8hr drive away (each way) by car.  And I looked it up later and the treatment would cost $200-400 a month, at least.  That is a lot of money here, and I suspect was totally out of the range of this family.

How are you supposed to tell a patient that they are going to die, and your sorry but there is no option.  The treatment exists, but they won't have access to it.  This happens in the States too, but a lot less frequently.  The even more striking part was the way the woman and her adult daughter responded.  There expressions never changed, they just nodded and responded Acha-cha (good, or okay, I see).  And then they left...

Death is different here.  It is seen as a natural part of the lifecycle and is accepted in a way that it rarely is in the States.  That is not to say that the woman felt ready to die, or that her family would not be upset, but it is experienced in a very different way.  I suspect part of it has to do with the belief in reincarnation.  If death isn't really the end, there is not so much to fear.  And people here are quite religious/spiritual.

Then yesterday there was another case that I did not personally see, but which I heard about and have not been able to get off my mind since.

My Mom was sitting with Dr. Anna (Dr. Philip's wife from America who is also a doctor) when a woman came in with bruises all over her face.  She claimed she had "fallen on some rocks."  Dr. Anna pointed out to my mom that there were no scratches at all, as you would see if she had actually hit her face on a rock.  It was pretty obvious that the woman had been beaten by her husband.  Apparently, this happens quite frequently and while the women may come to the hospital, they will rarely ever admit to being beaten.  Domestic violence is deeply ingrained in society along with women's subordination to men.  Of course, this is not universally true, but appears to occur with a disturbing frequency and is largely socially accepted.

The students happened to have an article on malnutrition in women for yesterday's class which was linked to domestic violence.  This produced an interesting discussion as we struggled to understand the context in which physical violence, as well as the withholding of food occurs.  I wish I understood it better.  This type of violence is in stark contrast to the India I experience and the men I know.  Yet, there is considerable consensus in the literature, and in what the hospital sees, that it is very much a common feature of society, and is often not dependent on education or socio-economic status.  It really makes me appreciate the life I have, and the opportunities and status I am afforded.  While domestic violence occurs in the U.S., it does not seem to be so rampant, and is certainly not accepted culturally.  But it also makes me wonder, how will Indians change this aspect of their society?  For I firmly believe that that change can only truly occur from within.  If India is to pull itself out of poverty on a broader scale, particularly in the rural areas, women must have a stronger position in society and such violence must not be tolerated.

Tuesday - How to Develop Health Communication Slogans in rural India

We are taking advantage of the beauty of Jibhi and how relaxing it is.  The students went swimming in the brook in the morning and took a hike to the waterfall.  In the afternoon, Rainya, the social worker, suggested that we could be helpful by developing some health communication slogans to use.  She asked us to work on the areas of malnutrition, HIV, water sanitation and hygiene (WASH), in particular.  We all sat as a group and brainstormed ideas for several hours.  We had some really interesting discussions, particularly surrounding the cultural and educational issues to talking about HIV and condom use.

More to come soon... internet access is really really sporadic here so I have a lot of catching up to do!

The Dangers of Cows and Tomatoes (Monday)

Monday morning Anne and I piled back into the van with 4 of the students and returned to Jibhi.  The drive is about 4hours each way, and we had just returned the night before, from a weekend at the clinic.  Fortunately, the landscape is beautiful and can keep you entertained for hours.
The ride turned out to be a bit adventurous, as almost every car-ride in India seems to end up being.  First we ran into a massive herd of goats. Cars were backed up waiting for the sheep to get out of the road.  Men were relieving themselves on the side of the road as we sat and idled for awhile.  Finally, our driver Sanju, decided to turn around and take another route.  After an extremely interesting 5 point turn, we headed back in the direction we had just come from, before veering onto a slightly less-traveled route.
We wound our way up the mountains on the opposite bank of the Beas River as we drove through the Kullu Valley.  As we curved left and right along the windy road filled with pot holes, we saw several men standing on the side of the road making strange arm and hand signals.  I had no idea what they were motioning about, but thankfully Sanju did.  Apparently they noticed that a cow was teetering on the edge of the cliff above us.  They waved Sanju to the other side of the road, into oncoming traffic, just in time for our van to miss being squashed by a cow.  Apparently the cow just missed us... and sadly must have died on impact as its neck snapped.  Who gets hit by a cow dropping off a cliff into mid-air and landing on the top of your moving vehicle??
I was really quite thankful that I didn't actually see what had happened, but apparently I was the only one lucky enough to have missed the gruesome image.
We continued driving, with Sanju acting as if absolutely nothing out of the ordinary had just happened.  We reached Bhuntar and decided to stop to buy Anne some clothes, since she had been recruited to come to Jibhi with me before having had the chance to buy any salwars.
We had a nice time picking out some tunics in a lovely little shop we found and were walking down the street back to the car, when I suddenly found myself in a split in the middle of the road.  I felt myself slide to the ground as something extremely slick gave way under my foot, landing with one knee hard on the asphalt.  As I looked down, I was sure I was about to find  myself in a pile of gooey cow dung, but instead I saw a lot of red.  I apparently managed to step directly onto a tomato, which had somehow made its way into the middle of the road.  Now what a single tomato was doing in the middle of the road, I cannot tell you, but there it was, now nicely squished under my shoe, resulting in a lovely red streak showing where we had slid together along the pavement.  What can I say...  I have a unique talent for impailing myself on strange objects!
The rest of the drive was largely uneventful.  We wound our way for the next 2 hours, on increasingly narrower and more beaten roads, until finally we reached the clinic at Jibhi.  The students were so excited when we arrived and they got to walk across the rushing brooke that runs beside the clinic.  The scenery here is amazing.  Huge spruce trees, babbling brookes, birds chirping...

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Meeting Dr. Philip

The students came back Saturday afternoon for lunch and then donned their salwar suits for the first time to walk over to the hospital compound for an orientation with Dr. Philip (the Medical Superintendent of the Lady Willingdon Hospital whom we have been planning everything with).

We walked over to the compound which is conveniently located within a 2-minute walk of the hotel.  Dr. Philip met us and welcomed the students and staff to the hospital.  He then gave us a tour of the hospital buildings and discussed how the hospital runs and how the student's rotations would fit in.

We saw the maternal and child health ward including the delivery room and antenatal clinic, the laboratory, the emergency room, the ICU, and the outpatient department (or OPD).  The student's eyes progressively widened further and further as they learned not only the extent of the hospital's services (which was significantly larger than many had realized), but also just how much they would be allowed to observe.  Dr. Philip explained that if they left their cell phone numbers with the nurses in the maternity ward and emergency room, they could be called to come observe whenever an accident or delivery came in.  He told them they could observe in the operating room as he performed both major and minor surgeries, in the clinic for pregnant women and immunizations for children, and to attach themselves to a doctor in the outpatient clinic and follow them throughout the course of their day.  If they were really feeling adventurous, they could even be "on call" in the evenings/overnight in the emergency room to be there as the cases came in.

We also talked about how the groups would go out into the community with the village health workers and would each live for a week in the hospital's peripheral community health clinic in the small village of Jibhi - about a three-hr drive from Manali.

The students and faculty were bowled over by how open the hospital was to having them observe and integrate into the daily life of the hospital and all of our excitement could hardly be contained.

After a bit of talk on the TB research and a nice cup of chai in the OPD, we made our way back over to the hotel.

Nathan and Jacob told me how impressed they were with Dr. Philip - how intelligent and collected he seemed, as well as how thrilled they were to get to be so hands-on and to see such a wide-variety of health issues in varying contexts.  I pulled out a chair for a rest in the courtyard and slowly almost all of the students trickled in, joining me under the table's umbrella.  We had a wonderful, spontaneous conversation about their reactions to the hospital orientation, and I was filled with happiness when they universally echoed their excitement and highly positive impressions of the hospital.

While many questions remain unanswered, after so much fretting as to just how this whole thing was going to work (and would it even really!), I felt a huge sense of relief and happiness wash over me, coupled with enormous excitement about the adventure that is surely in store for all of us over the coming month!