Babies

I am being frightened, inspired, confused, and enlightened by the first year of life.

This chapter begins in risk and tragedy. The first pregnancy outcomes I saw were a 6-month-old miscarried fetus and a ruptured ectopic pregnancy. I was left to ponder the commonness of early death and the fragility of life—that is, if you even make it that far.

Thankfully, I soon scrubbed into an emergency C-section procedure with a happier ending. It began with the taut mountainous belly of a tiny village woman, opened a red wet hole in her middle, and basically just pulled out a baby...full of pink chub and beautiful screaming life. As I watched this new person breathe her first air and make her first sounds in this world, she looked like a miracle to me.

(Check out some REMEDY supplies in the surgeon's hands!)

At the same time, last week I was knee-deep in infant mortality data. I had analyzed the first 5,000 household records from a survey of the VMH patient population, and found five-times higher infant mortality rates among the tribal versus non-tribal communities. My mentor suggested that we investigate the causes of these deaths and disparity. So, in one week I wrote a proposal and designed a verbal autopsy questionnaire, got approval from the swift-working SVYM IRB committee, and started interviews.

For the past few days now, I’ve been visiting homes to learn about the events leading to infant deaths. The families we meet are generous with their lives—sharing stories, medical records, theories about illness and death, and opinions of the healthcare services available to them. There’s a lot of rich information to record and process. While I can’t follow 99% of the Kannada interviews (will have to use a translator later), I can tell that the mothers are incredibly

stoic. The average mom has accepted her child’s death (most do not think it was preventable; many report a sudden death without symptoms). This allows her to move past the tragedy. Sadly, this can also undermine the infant’s chance of survival, negate health system efforts to reduce mortality, and make cause of death determination really difficult. Looking at so many mystery deaths, it’s clear that we can’t yet understand all causes of local infant mortality. This study is, however, shaping up to be a valuable test of the door-to-door verbal autopsy method, and hopefully helping to build a bridge between the neonatal/post-neonatal period in homes and SVYM in the community. One other major finding is that infant mortality is not as high as we had thought, since many of the so-called infant deaths are actually stillbirths and miscarriages. I know it’s not great news, but it is important to know.

Down the hallway in the NICU—a tiny bed surrounded by heat lamps and stuffed with copious layers of blankets—a pair of babies is sleeping today. These twins were born here four days ago, weighing in at 1 kg and 800 g. They lie side-by-side with arms outstretched, and still don’t even touch in their bed for one newborn. Both have under-formed extremities, female genitalia, and faces. Watching over them, I imagine partial organs and branching vessels, arrested mid-process—a fatally premature system inside. And yet, I definitely see little lips pursing, symmetric lungs inflating, wide eyes opening and closing to the light—a living being outside in the world. Not a miscarriage, not a stillbirth, not an infant death…good G-d, these babies are alive! It is scary, but still there’s a lot of hope.

A baby’s future depends on so many things, a lot of which we can’t control. But the key is that we CAN optimize a lot more than we do—and seizing those opportunities in the fragile first year of life is enough to keep me busy, fulfilled, and inspired in my work these days.

Monsoon 3; Comfort, Productivity, Health 0

I would love to write here about the glories of our recent weekend in Mysore—the special palace tour that took us into locked rooms, the amazing Manchurian-style fried cauliflower (“gobi”) that we ate from a street vendor, the fun of navigating crooked alleys in search of custom-made Ganesh stickers—but the harsher reality of the rainy season looms large. Here I will tell you about three major monsoon assaults to my week.

May the games begin!

While we gallivanted around Mysore town, water leaked through the ceiling of our closed room in Kenchanahalli. We came home to a face the first blow, mold.

Just before bedtime, the mold monster reared its ugly head as black specks crawling over our pillows and, with sheets pulled aside, seeping deep into our mattresses. Then I stumbled upon a flowerbed of rainbow fuzz blooming in the soles of my slippers. With fear and hesitation, I inhaled deep. Our once airy bungalow was filled with thick, damp, putrid air. Miasma! We had almost been too tired to notice. But the situation was unsafe—one of my housemates has asthma and is allergic to mold—so, instead of settling back home after a weekend away, we quarantined clothes, shoes, and bags. We emigrated to temporary quarters in the dark and started to air the old house, and managed to sleep before the sun came up.

Monsoon 1, Comfort 0

The second blow came the next morning. I woke up tired but eager to start the day—our mold-less work space in Saragur had never sounded so good. As we walked to the bus stop I heard mumbles of “route changes” and “rain on the roads”, but thought nothing of it; it always rains, and the bus is usually late. But this time, it was REALLY late. Two hours late! We waited and waited, while the monsoon gobbled up our morning. By the time we reached Saragur breakfast was over, work meetings had been missed, and morale was low. I spent only a handful of hours getting no work done (and eating no dosa), and then it was already time to go home again. Back to the mold. Ugh.

Monsoon 1, Productivity 0

These monsoon woes got me thinking about the challenges of staying healthy when it’s impossible to stay dry. With all this rain, I couldn’t understand why the hospitals in Kenchanahalli and Saragur were so quiet (only one in three beds was occupied when I followed rounds this week.) I asked a doctor why. Her explanation puts a terrible twist in the story: rain is good for agriculture, and crops are more important than health. That means that would-be patients go to the fields instead of the hospital during the monsoon season. …Healthcare-seeking behavior declines as rain increases, regardless of healthcare needs.

Monsoon 1, Health 0

In this agricultural society where sun, water, and wind are so unreliable and so relied upon, weather dictates life and death, wealth and poverty, health and disease. The upsets and hassles of my monsoon week prove that weather really matters.

Until the relationship between a human society and these forces of nature becomes less dependent—or more dependable—secondary institutions (the bus, the hospital) may just be spectators to the natural floods and droughts of life. I know that SVYM is doing its best to be so much more than a spectator, with mobile clinics and community health workers in the field every day. Still, beds in the hospital are empty. Changing values and challenging the rain is not an easy job.

Indian HOT or NOT

If you’ve spent any time at all on trashy internet sites, you must know about “Hot or Not” (www.hotornot.com). Well, I’ve got a few remarks to make and some dichotomous categories for India. These are my votes:

Squat or Not?

• Finding a nice toilet—Squat! Why, there is a veritable village of toilets behind Saragur hospital. I just discovered this incredible sight today, as I wandered out back from the canteen and spotted a rainbow row of tiny little houses. On closer inspection, it’s a permanent exhibit of different toilet facilities that can be built in nearby villages, with price tags to show how much each installment costs. The prices are low, the colors are brilliant, the need is great—and, as awareness spreads, hopefully so too will become the demand.

• Going to the bathroom—Not! So many drapings…so few arms… Going to the bathroom makes me wish I was Ganesha. I would use my many limbs to keep pant legs from dragging, scarf ends from falling, and salwar edges from dipping. It’s hard. Going to the bathroom in this outfit requires as much practice, planning, and acrobatics as the Chinese Olympic Gymnastics Team.

Breeze or Tease?

• Finding vegetarian food—Breeze! It’s a relief to eat without ever having to check for meat first. Even better, it’s wonderful that I don’t have to strain cooks and kitchens with my unexpected and/or culturally-inappropriate demands for vegetarian food. Go veg!

• Eating said food—Tease! Basically everything is eaten without utensils and using only one hand. For my first few days, I ate like a messy baby, dropping food in my lap, smearing it into unscoopable mush on my plate, and covering my whole forearm with goo and juice. Now I can manage a meal much better, but I still don’t know how to get liquids from plate to mouth. I’ve seen it done with a swiping hand circle and quick lift to the mouth, though—quite an incredible dance of hand-mouth coordination—so I’m practicing. One thing is for sure: this baby does solids before liquids.

• Drinking beverages—Tease! Drinks are poured down the gullet from a safe distance above the lips. This is a tricky trick that can make a person quite wet, but, when done properly, the cups, pitchers, or spoons that you’re drinking from don’t have to be cleaned between users. Neat!

Trial or Smile?

• Getting dressed—Trial! In this part of rural India, women dress to keep legs, neckline, and pelvis covered at all times: billowing pants (kameez) take care of the legs; a long, wide scarf draped over the front, thrown over the shoulders, and hanging loose down the back takes care of the neckline; and a tunic-style shirt (salwar) goes past the knees and provides adequate coverage of the suggestive inseam. The first challenge was to get into town and acquire appropriate wear before my only appropriate outfit got too stinky. Now, finesse is my main clothing concern. Little by little, as I am learning to keep the scarf from slipping and remembering to lift my pant legs on muddy walks (also see “Squat or Not”), it’s getting easier.

• Using basic Kannada to make a friend—Smile! Even if you don’t speak Kannada, the situation is in the foreigner’s favor: as long as you look funny enough, you can surely develop a following of curious kids wherever you go! This morning, while waiting for the bus to Saragur, we sidelined about 20-30 children on their way to school. At first, they stopped and stared from a safe distance of 10 feet or more. After several minutes, a brave student pretended to casually walk past us, continued on for a few steps, then turned around, and returned to his friends to report on his findings. Next, the students held a mini-conference; we suspect this was to plan their conversation with us. Finally, they asked us our names. A very cute exchange ensued… We inquired after each others’ breakfasts, sang Kannada songs incorrectly and tried to teach the ending lines of the ABC’s, and mostly just stared and smiled. As school time approached, it was sad to say goodbye. They were able to tear away from us with a promise of more staring and smiling tomorrow. “Bye!” “Ciao!” “Tomorrow!” “Cheerio!” Their courageous faces glowed pure triumph.

• Going for a run—Trial! But if you can manage to run in salwar and kameez and don’t mind fighting off the wild dogs…you should have no problem. Sadly, these dogs really scare me.

2130 Time for Bed!

In the pocket of my mosquito tent, are: easy-reading Holy Cow! by Sarah MacDonald, slow-moving In Spite of the Gods by Edward Luce, delectable Monsoon Diary by Shoba Narayan, a riveting book called Eradication of Smallpox in India, and a thesis on 1930s Indian nationalism (in the Bay Area!) by a friend of a friend. I try to read, but my flashlight sucks. Anyway, I’m tired enough to sleep.

Zzz –

Looking forward to yoga in the morning.

Cool breezes and weird dreams.

– zzZ.

2000 Memorable Medicine

Maybe this is just what happens when one practically lives in a hospital, or maybe it has to do with medicine in rural India in particular—but I’m encountering unbelievable things all the time. Here are some memories that still boggle my mind at the end of the day.

Anecdote 1: As a lab tech shadow, I peered into the medical record of a 20-year-old woman being checked for sickle-cell anemia—she had a hemoglobin level of 1.8 mg/dl! I was in disbelief that she had arrived alive; generally, in the States, anything under 7 could be cause for blood transfusion. Dr. S explained that she is from one of the tribes that has very poor access to healthcare, and that she had put off coming to the hospital for as long as possible. As I scanned the list of other patients getting tests, I saw that the whole patient population is really different from what I’m used to seeing in the States (no surprise), with Hgb readings commonly under 10 mg/dl and often around 5 mg/dl.

Anecdote 2: Last week we were ushered into the patient rooms at Kenchanahalli with the words, “Come! There was an abortion! Come see the fetus!” We braced ourselves for a major scene, but on arrival everything was surprisingly calm. The patient had had a miscarriage of her 6-month-old fetus; she lay recovering behind the curtain, and the fetus was brought out for us to see. It was small and wet, curled up in a kidney-shaped metal tray. Its many congenital abnormalities were presented to us simply and without ceremony—under-formed limbs here; brain growing outside of the skull there. I realized then that a potentially traumatizing medical moment for me was underway, and yet, it was not traumatizing. On this side of the curtain, things are only as big of a deal as you make them. The tragedy of a miscarriage was made to be, this time, just a strange and surprising medical moment when I didn’t know quite what to feel.

Anecdote 3: Yesterday evening I scrubbed into an emergency surgery for a ruptured ectopic pregnancy. My first reaction was one of surprise—they scrub in with “surgery sandals”! Surprise turned to fear—they don’t sedate the patient! they only have one unit of blood! there is only one trained nurse! Fear turned to admiration—the surgery was smooth and quick, without complications, and was an incredible demonstration of how much can be done with limited resources. Two sutures tied up a fallopian tube, several points on a uterus, and two layers of abdominal wall. The team was focused and cooperative. The surgeon taught about the procedure at her every step and decision point. And, thanks to a 90% subsidy for tribal patients, the whole operation will cost the family only 600 Rs, or about 15 USD.

Distractions in Saragur

Riding in an auto-rickshaw (Mercedes Benz!)

One funky fabric, soon to be one funky saree

1745 Road & Animal Planet

Most of you know me pretty well, and most of you know that I love lists. So, it should be no surprise that I’ve been keeping lists of just about everything: lists about what I see, do, eat, want to do, need to pack, have to learn, etc. Most are obvious, obsessive, and get lost anyway. But here’s one list that is worth keeping and sharing:

List #5: What different animals do when you almost run over them

1. Monkey -- will bound like a kangaroo, dangerously right in front of the vehicle, and then lob itself right up a tree. Really looks like a kangie until it jumps so high! Seems to enjoy the sport.

2. Wild boar -- will flop down in the middle of the road as all four legs collapse under him, then scramble up on his wobbly back legs, unsuccessfully try to push off several times, and eventually hobble or roll over the side of the road just in the nick of time. I feel sorry for him!

3. Sheep -- will run fast to the other side, gather in a flock, and all piss uncontrollably. Just a bundle of nerves, poor guys. Sad, but hilarious!

4. Goats -- will run in front of the vehicle without looking either way, even if their friend just got nearly hit. Silly billy.

5. Cow -- will face you head-on and won’t budge a bit. Holy cow, it knows it’s holy.

6. Humans in an oncoming car -- will play chicken with you while honking at 0.5-3 Hz. Watch out!

7. Chickens -- amazingly, don’t know yet. And I thought they loved crossing roads…

I’ve also seen a cow sucking its own udder. Weeeeeird! Not a list; just had to tell you guys about that one.