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.