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.

1730 Road & Culture

Last week, as we rumbled home from Saragur in the ambulance (our personal commuter vehicle!), a white person was spotted in the road. The driver pointed and asked—Is she your friend? We laughed, and denied any relation. Next it was my turn to point and ask—Kannada dalé “white person”? How do you say “white person” in Kannada? To me, a person who has been called “la blanche” and “mzungu” more times that I can count, it was strange to not know my racial identifier in Kannada. Of course the fact that I am white is obvious to people here, but no one has said it to my face in over two weeks.

This has inspired my idea for a new and simple metric of cultural reservedness: number of minutes, hours, days, or weeks for a foreigner to hear and learn her foreigner identifier in the local language. On this scale, Karnataka is most diffident—about a thousand times more-so than Kisumu in Kenya, and a million times more-so than Yaoundé in Cameroon—and I’m still counting! I will let you know when I finally get to the bottom of Karnataka’s reserve.

1400 Work Projects

My current projects are many and varied, but I’ll be spending a lot of time on these two:

Infant death verbal autopsy: Tribal* populations have a much higher infant mortality rate than non-tribal populations, verifiably in the VMH catchment area and probably also nationwide, and we’d like to find out why. I am developing a questionnaire to elicit cause of death information from local families that have lost an infant in the last year, and hopefully (IRB fingers crossed!) I will be able to travel from house to house with community health workers and translators to speak with them. Everything about the project sounds daunting—from the goal of getting IRB approval within the week, to the logistics of traveling to so many villages, to the emotional content of every interview—but I’m excited to devote a lot of work to one project, and this one sounds insanely interesting and important.

Gestational diabetes risk assessment: One of the other students and I are putting together a manual for health worker training in the clinical aspects of GDM risk assessment—blood pressure measurement, blood glucose monitoring, BMI calculation, and diet recommendations. I’m most excited for the nutritional component, in which we will work with a nutritionist to estimate the nutritive value of local dishes. Food + math + micronutrients? = Sign me up!

*The word “tribal” is commonly used here to talk about the traditionally forest-dwelling communities that live in small villages, generally in remote areas, who for the most part have been displaced from their original habitats by dam construction projects and/or animal preservation laws. I recognize that “tribal” may have negative connotations to my readers, but it is used at SVYM without judgment or condescension. Still—this tribal designation has a complex meaning. It evokes a history of discrimination and neglect from the government, distrust of the medical system (likely founded in truth), and a lifestyle not well integrated into modern Indian society. Please try to read it that way in this blog.

1030 Hospital

We work at two different SVYM sites throughout the week: Kenchanahalli, a small rural hospital that we also call home; and Saragur, a 70-bed hospital in the town about 30 km away.

Kenchanahalli, with its lush garden, fruit trees, and bungalow-style homes for staff and visitors, feels just as much like a resort as it does like a hospital. It is a nice place to work for many reasons. I enjoy the leisurely morning that it allows, the convenience of working so close to home, and the friendly and familiar staff. When we’re working here, most of the attention is on Ayurveda medicine preparation and documentation. In between stirring pots of herbs and in periods of quiet, I read books on the front porch, where the monsoon breezes flutter my pages and the rains mist all around…before chasing me inside.

The best thing about working at Saragur is that it has everything that Kenchanahalli doesn’t! There are more patients, more staff, and more cases to see; there is a near-constant supply of electricity and internet access; and, while the hospital canteen serves good and fairly diverse meals with coffee, Saragur town is just down the road and provides exciting distractions in food and fabric. Dr. S, our mentor at Saragur, keeps us busy with three or four projects apiece and shadowing opportunities arranged in addition. We take breaks over tea and email.

Photos of Vivekananda Memorial Hospital and other SVYM activities

0930 Road & Population

When I learned that Kenchanahalli was a village of about 100 households, I expected it to be remote and low-density. Sometimes, this seems to be the case. The view from our house is of rolling green farms and distant forest, with the rare brightly colored brushstroke that I know is a field worker. Likewise the clinic campus is usually calm, with only a handful of staff and patients at any given time.

But it only takes a few minutes of driving along the road on a weekday morning to change this feeling. From the window of the bus that we ride to Saragur Hospital, I watch a population story unfold. The road fills with crowds of running schoolchildren, men lugging sacks of grain, and women toting babies and plastic urns of water. The bus stops to jam on ten more passengers, then swerves to pass a pick-up with fifteen in the rear. We pass by a schoolyard where 200 children are lining up for morning call. We stop again to pick up and drop off more people. A mile or so down the road, we pass another school with just as many kids. LOTS OF KIDS! Stop, more people move on and off. Another school. SO MANY KIDS! More people. Another. UNBELIEVABLE NUMBERS OF KIDS! More… I think to myself, “Okay, wow, this is high-density”.

While the rural population may be low-density in residence, it begins to feel quite crowded when people aggregate around the major local throughways and public institutions. Similarly, the villages feel remote and self-contained—at Kenchanahalli, it’s easy to feel like we are alone in the world—and yet there are other villages within walking distance in all directions. Geographic segmentation makes it possible to lose sight of the whole. The morning commute reminds me that India is indeed a highly populated country.

0830 Breakfast

You’re not supposed to eat or bathe in the 30 minutes after yoga, so I use this time to dress and wait at the canteen for breakfast (as long as action is greater than intent, this does not count as eating!). Breakfast (“thindi”) is most varied meal of day, since lunch and dinner (both called “uta”) always consist of palia and chappati followed by rice and sambar. I look forward to seeing what the kitchen will turn out. Once breakfast has been served, we sit on the porch with our savory coconut and saffron rice, or cous-cous with raisins and peanuts, or spicy rice pudding and tamarind sauce, and read the Mysore Deacon Herald.

The local paper offers a set of eyes through which to build some local perspective, and I enjoy this leisurely and informative start to the day. The Deacon covers mostly Karnataka state affairs with some national and sparse international news, except for a considerable amount of paper devoted to Michael Jackson’s recent death. Other big news has been the late monsoon rains, which threatened to bring down agriculture and power supply across the state. (Thankfully, as of July 9^th, the rains have come and returned water levels to normal!). Some notable news stories from the past couple of weeks are:

• Early July: The Minister of Energy does not plan to buy power, and has confidence in the rain gods to provide monsoon rains soon. Citizens are not required to pray for rain, but they may do so (with implicit encouragement from the government). Recently, a wedding of frogs—FROGS!—was conducted as a gift to the gods. Hundreds attended.
• A woman is accused of her husband’s suicide. My interpretation: sexism is more suspect than the woman.
• The national court has ruled that gay sex is not a crime. Related to this, many reports on street celebrations and touching personal stories have been published.
• There is mounting Hindu/Muslim tension in the historically non-violent city of Mysore. It all began over a week ago when a decapitated pig carcass was left at an abandoned Muslim holy site, leading to three deaths. Subsequent riots killed three or four more. The protests are sporadic and unpredictable, so it’s not clear when it will end—but the last week in Mysore has been relatively peaceful, and we didn’t have any problems when we were there last Thursday.
• On World Population Day, longer hours of electricity and better late-night television were promoted as population control measures. They must have some really good soap operas and reality TV shows, if those are to prevent young couples from having sex!

A food-centric society will make itself so known through its cuisine and conversation, and this part of Karnataka certainly does. Throughout the morning hours, you can hear people greeting each other with “Thindi aita?”, meaning “Have you had breakfast?” This is just as good as any salutation, except better. First, as a foreigner, it can win you points for “doing as the Romans”. Second, for anyone, it shows that you have the same priorities as everyone else. Concerns about and pleasures from food are some of the most basic human experiences—a natural bond—as well as a great measure of one’s well-being. Therefore, if you can only learn one phrase in Kannada, I suggest learning “Thindi aita?”* It packs the most power for the punch…or, please accept, the most local flavor for the bite.

*”Uta aita?” works equally well for lunch and dinner.

0630 Yoga

The alarm rings at 6:30 AM . On a perfect day I actually hear it, and we wake up and do yoga for an hour.

The yoga taught here is much different from the ab-crunching, back-bending, room-heating versions you can find in the United States: it’s just a series of “sun salutations” (Surya Namaskara) and coordinated breathing and body movements directed to the rising sun. At first, the motions felt awkward and ineffective. But now, the more I do, the easier and harder it gets. The easier part comes as the motions begin to feel more natural, more fluid, and as I become stronger. The harder part comes as it takes all my attention just to blend body and breath. Often now I emerge from ten or fifteen cycles, not realizing how hard I have been working—I am surprised to feel hot sweat on my brow and the rush of air going urgently, deeply, into my belly.

The other day, as I was ending the session in the most restful but morbidly-named “corpse pose” (Shavasana), I kept being distracted by a nagging hunger. I tried to focus on my breaths, but the hunger screamed at me. I tried to send my mind to my toes, but the hunger yanked it back to my abdomen instead. Exasperated, I gave in and focused on the distraction at play. But as I went wandering through the cavities and entrails of my digestive system, the hunger just…disappeared. It was not a pain in my stomach; it was not a contraction of my pylorus; no, it was not a hormone called ghrelin circulating in my veins. Whenever I challenged the hunger to show itself as a real, identifiable, localizable thing, it diffused out of existence. With my mind thus guarding the hunger, the next five minutes of Shavasana were peaceful.

This confrontation with hunger led me to a realization: I can control internally-generated problems, perhaps both real and imaginary, with mental focus. Set to work on bigger and more disabling worries—like self-doubt and self-criticism—mental control could become one’s greatest enabler. …But this is a huge project for a longer time. As I opened my eyes and rolled out of Shavasana, my focus waned and hunger returned. Relaxed, awake, and excited by my new experience, my tummy rumbled and I was ready for breakfast!

July 1st: Happy Doctors’ Day!

Today is National Doctors’ Day. For the first time I met with Dr. S, our mentor who is stationed at the local hospital, so that we could discuss our projects so far. The other girls have been here ten days longer than I have, so I’m mostly just observing, listening, and imagining right now. I’ve gotten a little involved in late stages of one project, where we are documenting Ayurvedic preparations and procedures and compiling them in a training program manual. My skills of observation may have come too late, but I can still get my hands in the work of editing and formatting! Check the program blog, where we will be posting some of those preparation recipes. I have not tried all of the medications, but the coconut one is really delightful. It is used to soothe all manner of upset stomach, but I am concerned that it won’t work that well; if anything, it has me wanting to develop stomach pains just so that I can eat more.

Another activity today was the sorting of medical supplies, which we all brought from San Francisco in 4 big suitcases. Everything was donated to us by MedShare, an organization that sorts and ships catered packages of supplies to clinics around the world (the clinic raises money to pay for shipping and some overhead, and MedShare covers the rest). We were able to hand-pick all the items at the warehouse that MedShare just opened in the East Bay, for free, as made possible by the special relationship that MedShare has with a group of UCSF medical students. We run an organization called REMEDY, which collects unused materials from the floors of Moffitt Hospital, and then hand them over to MedShare for their wider and more specialized distribution. It's a good little system with big returns...

The amount of supplies that REMEDY is able to recycle in each week’s collection is astounding. To give you some idea of how things add up, inpatient rooms are totally cleaned out for each new resident, so the cupboards from one patient’s stay can fill a garbage bin. – All those unopened packets of gauze, syringes, and cleaning solution can be used here. Surgical floors do not autoclave their tools, so in order to keep everything sterile, all the scissors and hemostats from an operating room are discarded when the procedure ends. – With three giant autoclaves on the surgical floor here at Saragur hospital, the metal instruments will be used over and over again. Even opened packets of gauze can be made usable through a wash in the autoclave.

I am attaching a photo of the final, sorted supplies that we were able to donate to the Swami Vivekananda Youth Movement (SVYM) hospitals. As we plowed through piles of gauze, built small pyramids with boxes of gloves, and admired the silver shine and clean swish-snap of perfectly functional scissors, someone told a joke: “You know what they say? The best thing for global health would be if all the tertiary hospitals in the G-8 countries shut down!” Today’s transfer of goods was not nearly as big (or apocalyptic) as that, but it did feel like a pretty good international celebration of National Doctors’ Day.

Time machine

Oops, I’m behind on news! Please excuse the lateness and pretend with me that it’s July 1^st.

Program blog

http://ghframework.blogspot.com/

The Global Health Framework Program is the interdisciplinary program that has sent me to India with three awesome other students from UCSF/UCB this summer. The India posts on this website are from us, either individually or as a group.

You will also see people writing from Tanzania and Kenya (where two other student groups are working), but that's not to be confused with India, sweet India, where we are!

Recipe: Aloo G’day & Cadla Bele Sambar (Potato and Yellow Lentil Vegetable Stew)

Intro:

Sambar, or vegetable stew, is a staple dish served with the staplest of staples (ana, or rice). Together, sambar and ana are pure classic. When we’re lucky, delicious dairy in the form of moosaru (yogurt or buttermilk curds) is also spooned onto the plate for mixing in. The dairy condiments are great for cutting the spice of hot sambar.

Sambar varies in color from light yellow to deep red, and runs the gamut of brown. The base vegetables are pretty much unchanging, with lentils or squash added in or taken out, but the flavor and level of spicy heat varies a lot. Occasionally fun little things like jackfruit seeds are thrown in to add flavor while cooking, and these may turn up on your plate! Here is a pretty basic recipe.

Ingredients:

Lots of water

2 cups lentils

Veggies: 20 green beans, 4 potatoes, 10 small tomatoes, 3 carrots, 2 small daikon or 4 red radishes

1 cup oil

1 red onion

Few dried chillies (approx. 3)

Salt

Seeds (not mustard) called “sas-vey”

Directions:

Boil a big pot of water and lentils

Throw in chopped vegetables, boil until everything is soft (approx. 45 minutes)

Fry oil, pop in seeds, sauté chopped onion and chillies, then pour in sambar

Salt and spice to taste

Serve:

Served sambar is more broth than vegetable. It is ladled into a pit that you dig into the center of your mound of rice, and then all mushed up together with the right hand. The wet rice is then transported plate-to-mouth, hopefully without too much dripping, between the thumb and three big fingers of the right hand. No matter how messy you get, don’t give up, grab a spoon, or lick your fingers – just keep shoveling! At the end of the meal, you can rinse off your hand with water.

Recipe: Cadla Bele, Cozu, & Tengina Cai Palia (Yellow Lentil, Cabbage, & Coconut Cooked Salad)

Intro:

Palia is as regular as the sun. No, it is more regular than the sun. This is true now more than ever before, because finally the monsoon season has begun. After a painfully slow start, the rains are upon us, and a few days have passed without the slightest glimpse of sun. (Food producers, food consumers, electricity users, and well just about everybody is relieved by this drip-dropping turn of events.) Palia, on the other hand, appears on our plates two times daily without fail. The first palia is for lunch, and the second is for dinner.

Palia is one of my favorite parts of every day’s menu, because it’s always changing. The chunkiness and serving size is constant, but the main vegetable can be anything from beets to okra. This one is a pretty mild version. I’ll try to capture the recipes for some more colorful and/or spicier palias soon!

Ingredients:

2 cups water

1 cup dry lentils

1 whole cabbage

5 red onions

Loose handful dried chillies (approx. 10)

1 cup oil

1 coconut

Salt

Mystery seeds (not mustard, but they look like it) called “sas-vey”

Directions:

Boil water and lentils until lentils are slightly softened, but still firm, about 10 minutes

Add one whole cabbage, chopped, and boil for 30-45 minutes, then drain

Heat the oil, add the seeds (should make a popping sound), then add onions and chillies to fry

Mix in cabbage and lentil mixture, grated coconut, and salt to taste

Serve:

Palia is served with chappati (round flat wheat bread), upina cai (pickled young mango), and sometimes a happala (crunchy round thing, like pappadam). Sometimes a hard-boiled egg is included…and then the neat arrangement really reminds me of a seder plate! When the palia plate is finished, rice is heaped on and served with sambar (vegetable stew). Logically both lunch and dinner are called “utta”, because they are composed of exactly the same parts.

Recipe: Tea (Tea)

Intro:

Sweet, milky chai is served several times a day here. Generally it’s available after a meal (never with food) and sometimes between meals. The traditional vessel is a small stainless steel cup, not much larger than a shot glass, which holds enough to last through 5 or 10 minutes of very tiny sips and great lengths of passionate conversation.

Ingredients:

1 liter water

1 pouch milk

1 small bowl sugar

3 heaping teaspoons black tea powder

Directions:

Heat milk and water to near boiling

Add sugar and tea

Stir, cover, and cook for another 5 minutes (don’t boil)

Serve!

Recipes

I've started collecting recipes, and hopefully I'll be able to post new ones frequently. Here are some classics...

Just a regular morning, you know, with the paper and monkeys

This morning I woke up without an alarm, read by the sunlight streaming through the window, bathed, had breakfast, drank sweet tea with milk, and read the paper. Now, I’m relaxing on the porch outside our guest house and alternating between computer and book. The wind blows through my hair, and verdant green is all around. People pass in and out of my periphery; I see them, and we nod. Even the monkeys are moving silently this morning. Everything is serene, and I feel as though I am being carried along by my natural morning rhythm. Then again, how can I have a rhythm when I’ve only been here for 3 days (my circadian clock is still 9 hours off!)? It’s amazing how quickly we can latch on to comfortable things in an unfamiliar place, and find a way to feel at home.

So far

Day 1: Sorted, heated, crushed, and mixed over a dozen herbs for a Ayurveda concoction. The cinnamon smelled so delicious! Met with professors from Mysore about the development of a questionnaire that will estimate a person’s prakruti; this project was met with reserved enthusiasm, since it is a complex and subjective assessment that may not easily be translated into formula. Ate lunch at the clinic director’s home; appreciated the neat layout of salt and spice on a banana leaf, and how my arrangement got the messiest over the course of our multi-part meal. More herbs work. Fell asleep before I could enjoy tea and dinner!

Day 2: Visited rural hospital in Kerala that runs a formidable sickle cell anemia program. They have genotyped nearly 80% of the indigenous populations for sickle cell anemia, developed a specialized prevention and treatment program for sickle cell crises, and counsel carriers and affected individuals on how to avoid passing on the disease (don’t marry another carrier or affected person). Not surprisingly, counseling against disease-producing marriages has been largely unsuccessful and created a lot of stigma, especially for young females with the diagnosis. On the bright side, the treatment program is running well. Also, their screening activities and community awareness programs are chipping away at the stigma and disease burden – hopefully.

Day 3: Off. Slept, ate, read, chased after internet during sporadic flashes of electricity. Very exciting!

Riding into India

My taxi driver picked me up at the Bangalore airport at 3:30 AM this morning, with a big grin on his face and a brisk jog to the car. Thankfully, he had enough energy to balance my exhaustion. As he swerved in and out of traffic, I dozed in and out of sleep. Under heavy eyelids, I saw milk tankers, brave bicyclists, and lorries carrying boxes of food and cages of birds to market. We played chicken with colorful painted trucks toting people or cargo on back, auto rickshaws, and SUVs. The modes of transport that coexist here are more varied than anything I’ve ever seen. And by that, I mean: The number of different kinds of vehicle that could have collided with us, or types of animals that we nearly hit and killed, is really impressive.

We slid through the sleeping city center of Bangalore, with fewer tall buildings and more run-down market stalls than I had expected (but that’s just what I saw). Then on to Mysore, the princely home of Maharaja’s Palace, with wide boulevards and crumbling majestic homes. With the kind of big heart that I’m beginning to associate almost-always and almost-exclusively with poor people in poor countries, my taxi driver invited me to see his house and meet his family. So we stopped in Mysore for my first cup of warm milk and lesson in Kannada. A conversation with his daughter brought up the importance and expense of higher education, such that a poor driver making Rs.200 per day (70,000 per year) easily spends 80% of his salary (Rs.40,000 and 11,000) on tuition fees for two kids. A fumbling conversation with his wife, in which we mostly communicated through demur smiles and profuse reciprocal “thank yous”, led me to promise a return visit with enough time to eat her delicious cuisine.

At 10 AM, I arrived in Kenchanahalli, ready for bed… Of course, that’s just when we had breakfast and started Day 1!

P.S. Bangalore is a bursting city of nearly 6 million, so clearly I only saw one dark street of it. Will have to go back for a better look, e.g. not early on a Sunday morning.