So I'm back at Penn, not quite ready to get back into the grind, and without baggage thanks to the incompetence of the baggage crew in India who neglected to get about 75 passengers' bags onto our plane. We arrived in JFK an hour early, so I'm probably not going to buy the excuse that there wasn't enough time or incentive to get all those bags on the plane. Oh well, it's a small matter, especially relative to all the hardship I've seen on my trip.
I kind of skipped out on writing about some of the work days because of time. But from reading these entries, I hope all of you have been able to get a good perspective about our work, both its achievements and its limitations, which I think are equally important to understand.
I would recommend starting at the beginning of the blog if you haven't read it yet, for a couple reasons. First, I think the quality of my writing was better at the beginning and got progressively superficial (and probably worse) because of time, and second, I think you'll get the full effect of the trip from starting at the beginning and will be able to follow the evolving thinking of myself and my group in the context of our overall mission. It's easier to use the tabs on the right to jump to each post rather than scrolling through.
I hope you all enjoyed this view into my life the past couple weeks. Thanks for reading.
All the best,
Ritwik
Thursday, January 14, 2010
A More Diverse Patient Population
On one of the last medical days, we set up right next to a mandir, or Hindu temple (talk about using religion to get people mobilized). The area was not in the heart of the slums as our previous medical camps were, but still high numbers of people showed up. It seems that word of our organization has really gotten around, not only because of constant high turnout but also we have been getting many requests to serve areas around Kolkata. We noticed that this particular crowd did have many impoverished individuals, but there were also a good number from lower-middle class households. We could tell this was true a few different ways:
They were definitely more well-nourished than many of the patients we had seen thus far; some of the young and middle-aged were even pre-hypertensive or hypertensive, overweight or obese, mirroring many of the problems we see in the U.S. today, probably due to relatively easy access to commercially available high glucose and high sodium foods, which these people could afford. We also had a handful of teenage girls come in with high anxiety, very little appetite, dizziness and insomnia, and when we questioned them further it seemed that this was due to approaching entrance exams (the doctor I was working with called it "exam-o-phobia" and proceeded to prescribe some vitamins and calcium while laughing at his own terrible joke). So clearly they were financially comfortable enough to stay in school, whereas many of the slum children simply cannot afford to go to school because of family pressures or the pull of domestic work once they reach a certain age. Finally many of them were coming in with previous hospital records, which very few of the really poor individuals had, and many were anxious about their blood pressure readings. In the poorest slum regions, many did not know what was a good level or even what the blood pressure implies. Finally, the doctor I was working with put down his work phone number, so that patients could come to him in the future, ostensibly to pay for his services this time rather than receiving them for free this time. I had worked with this doctor before and had never seen him do this with poorer individuals.
Even though we may have sacrificed reaching some poorer individuals in North Kolkata, it was interesting for me to get exposure to a different class of patients who were experiencing a different class of health problems.
That said, we did see a few really interesting cases. One older gentleman had a heart murmur, which was cool to listen for. This patient's heart sounds were not the typical "lub-dub" but had an extra sound to it, which is due to a heart problem emanating from old age, infection, or disease. Another 18 month old infant had an encephalocele, which is a rare congenital defect during the neural tube development characterized by protrusion of the brain and membranes that cover it through openings of the skull. Basically, the outer covering of the boy's brain was jutting through the skull because of a developmental defect that occurred while he was in his mother's womb. If allowed to get worse, the boy's physical and cognitive development could be severely impaired, not to mention the increased chance of infection of the brain (encephalitis). Pretty crazy stuff. We decided to fund his surgery and set it up with a neurosurgeon at a local government hospital before we left. It's nice to be able to use Pratit funds not only for primary care diagnosis but for changing the life of one individual who is suffering.
They were definitely more well-nourished than many of the patients we had seen thus far; some of the young and middle-aged were even pre-hypertensive or hypertensive, overweight or obese, mirroring many of the problems we see in the U.S. today, probably due to relatively easy access to commercially available high glucose and high sodium foods, which these people could afford. We also had a handful of teenage girls come in with high anxiety, very little appetite, dizziness and insomnia, and when we questioned them further it seemed that this was due to approaching entrance exams (the doctor I was working with called it "exam-o-phobia" and proceeded to prescribe some vitamins and calcium while laughing at his own terrible joke). So clearly they were financially comfortable enough to stay in school, whereas many of the slum children simply cannot afford to go to school because of family pressures or the pull of domestic work once they reach a certain age. Finally many of them were coming in with previous hospital records, which very few of the really poor individuals had, and many were anxious about their blood pressure readings. In the poorest slum regions, many did not know what was a good level or even what the blood pressure implies. Finally, the doctor I was working with put down his work phone number, so that patients could come to him in the future, ostensibly to pay for his services this time rather than receiving them for free this time. I had worked with this doctor before and had never seen him do this with poorer individuals.
Even though we may have sacrificed reaching some poorer individuals in North Kolkata, it was interesting for me to get exposure to a different class of patients who were experiencing a different class of health problems.
That said, we did see a few really interesting cases. One older gentleman had a heart murmur, which was cool to listen for. This patient's heart sounds were not the typical "lub-dub" but had an extra sound to it, which is due to a heart problem emanating from old age, infection, or disease. Another 18 month old infant had an encephalocele, which is a rare congenital defect during the neural tube development characterized by protrusion of the brain and membranes that cover it through openings of the skull. Basically, the outer covering of the boy's brain was jutting through the skull because of a developmental defect that occurred while he was in his mother's womb. If allowed to get worse, the boy's physical and cognitive development could be severely impaired, not to mention the increased chance of infection of the brain (encephalitis). Pretty crazy stuff. We decided to fund his surgery and set it up with a neurosurgeon at a local government hospital before we left. It's nice to be able to use Pratit funds not only for primary care diagnosis but for changing the life of one individual who is suffering.
Monday, January 11, 2010
Second Day in Rajabagan
We began our second week of work in the same general slum area that we started out in (Rajabagan) , but in a separate section of the slum across the road. This way we could give aid to some of the patients we missed out on the first day as promised, but also expand our program to a new neighborhood.
I was first struck by the narrow, dense nature of this slum as compared to the area where we did our first camp in Rajabagan, which was right next to a highway and was much more organized and spread out. We were greeted by a crowd of people that had been gathering near the tent/clubhouse area and we commenced registration almost immediately. This was the most chaotic crowd we had experienced yet and we were turning more people away this time after we had signed up the first 80. The atmosphere was very disorganized and if anything, got more chaotic rather than less as the night progressed.
The clubhouse was probably a fourth of the size of the first slum's clubhouse so we could only barely fit two doctors' tables inside. We had to put two outside, which encouraged the crowds outside to be even more rowdy. Nonetheless, we were relatively experienced now so we got through our patients pretty quickly. I was working with Collin today with a new doctor who gave us significant freedom with our questioning and physical examinations. At the same time, he was very attentive and made sure we were learning from him as he was prescribing. One patient was spitting out blood and had complained of other respiratory problems, so the doctor suspected the patient may have tuberculosis. There was no way of confirming it though, since we did not have the proper diagnostic tools at our disposal. There were also a few cases in the beginning of mothers complaining that children were itching their heads and developing a minor rash after they put oil on their head. Clearly the mothers were aware of the cause, but weren't stopping putting oil. I just told them to stop putting the oil on the children's heads. Hopefully they'll listen. Sometimes hearing it from a perceived "authority" (which was a rare position for me) is what makes you act.
I enjoyed seeing one family of a mother and three sweet girls ranging from about 5 to 11 years old- Mili, Buni, and Bulti Mahali were their names. They all were suffering from worms in their stool (probably from the polluted water they are drinking) and were underweight. When I asked the mother if there was anything else was wrong with the children, she lovingly described Mili, the youngest, as being "susti" or lazy, and Buni, the eldest, as not eating enough and never feeling hungry. When we completed the childrens' diagnoses, we took the clinical history of the mother, who was complaining of menstrual cramps and other aches and pains. Meanwhile the children were playing with the weighing machine and as Collin and the doc were finishing up, I decided to talk to the girls. I asked if they went to school, and they said they went everyday from 10-2. I asked them what they ate, what activities they did. I also told Buni that she should eat more because it's good for her. She laughed with her sister after I said that, but I made sure to get an assurance from her that she would follow our instructions. She gave the characteristic shy, acquiescing Indian head nod and then told me that I was very good and that I should come back another time. Though I didn't do or say anything particularly special, having a person you are trying to help give you that kind of approval for the work you are doing is a moment I won't forget from this trip.
Ironically enough, I later learned that many members of the slum were not happy with us for taking in too many members of the same family especially when some families did not get any sort of "representation" in our camp. They particularly referenced the Mahali family I detailed above, but to be really honest I'm not sure that's an entirely fair grievance to file against us. I see where they are coming from, but in the chaos of the moment it is very difficult to deny a registration slip to people who come and a mother who tries to register all her children, especially when it is first come first serve and there are enough slots open for her to do so. We could theoretically go from house to house and get one or two patients each, but I'm not sure that's worth it. I would much rather treat based on severity of illness or leave it as is than try to conform to an idea of fairness I don't really agree with. If the slum wants it to be by family, then it should be up to the leaders of the slum to pre-register those patients for us to see. That's my thinking now, but it's subject to change I'm sure.
I was first struck by the narrow, dense nature of this slum as compared to the area where we did our first camp in Rajabagan, which was right next to a highway and was much more organized and spread out. We were greeted by a crowd of people that had been gathering near the tent/clubhouse area and we commenced registration almost immediately. This was the most chaotic crowd we had experienced yet and we were turning more people away this time after we had signed up the first 80. The atmosphere was very disorganized and if anything, got more chaotic rather than less as the night progressed.
The clubhouse was probably a fourth of the size of the first slum's clubhouse so we could only barely fit two doctors' tables inside. We had to put two outside, which encouraged the crowds outside to be even more rowdy. Nonetheless, we were relatively experienced now so we got through our patients pretty quickly. I was working with Collin today with a new doctor who gave us significant freedom with our questioning and physical examinations. At the same time, he was very attentive and made sure we were learning from him as he was prescribing. One patient was spitting out blood and had complained of other respiratory problems, so the doctor suspected the patient may have tuberculosis. There was no way of confirming it though, since we did not have the proper diagnostic tools at our disposal. There were also a few cases in the beginning of mothers complaining that children were itching their heads and developing a minor rash after they put oil on their head. Clearly the mothers were aware of the cause, but weren't stopping putting oil. I just told them to stop putting the oil on the children's heads. Hopefully they'll listen. Sometimes hearing it from a perceived "authority" (which was a rare position for me) is what makes you act.
I enjoyed seeing one family of a mother and three sweet girls ranging from about 5 to 11 years old- Mili, Buni, and Bulti Mahali were their names. They all were suffering from worms in their stool (probably from the polluted water they are drinking) and were underweight. When I asked the mother if there was anything else was wrong with the children, she lovingly described Mili, the youngest, as being "susti" or lazy, and Buni, the eldest, as not eating enough and never feeling hungry. When we completed the childrens' diagnoses, we took the clinical history of the mother, who was complaining of menstrual cramps and other aches and pains. Meanwhile the children were playing with the weighing machine and as Collin and the doc were finishing up, I decided to talk to the girls. I asked if they went to school, and they said they went everyday from 10-2. I asked them what they ate, what activities they did. I also told Buni that she should eat more because it's good for her. She laughed with her sister after I said that, but I made sure to get an assurance from her that she would follow our instructions. She gave the characteristic shy, acquiescing Indian head nod and then told me that I was very good and that I should come back another time. Though I didn't do or say anything particularly special, having a person you are trying to help give you that kind of approval for the work you are doing is a moment I won't forget from this trip.
Ironically enough, I later learned that many members of the slum were not happy with us for taking in too many members of the same family especially when some families did not get any sort of "representation" in our camp. They particularly referenced the Mahali family I detailed above, but to be really honest I'm not sure that's an entirely fair grievance to file against us. I see where they are coming from, but in the chaos of the moment it is very difficult to deny a registration slip to people who come and a mother who tries to register all her children, especially when it is first come first serve and there are enough slots open for her to do so. We could theoretically go from house to house and get one or two patients each, but I'm not sure that's worth it. I would much rather treat based on severity of illness or leave it as is than try to conform to an idea of fairness I don't really agree with. If the slum wants it to be by family, then it should be up to the leaders of the slum to pre-register those patients for us to see. That's my thinking now, but it's subject to change I'm sure.
Wednesday, January 6, 2010
American Consul for Political Affairs in Kolkata Visits Pratit Education
Today we set out our most ambitious educational program yet. Collin first gave a talk on germ theory of disease and biological cells in general. Even though this is advanced material, we figured we'd try it out on these kids who had not ceased to impress us thus far. Of course we kept it at a simple level, using a demonstration where six Pratit members formed a circle to simulate the selectively permeable cell membrane. We had two of the children be germs, which the circle/membrane would not let penetrate the cell, and we had two children be the "food" which the cells did let inside. We emphasized that germs did get into cells in many cases, causing a variety of diseases. We then transitioned into the importance of hand hygiene- so that these bacteria would be washed away from our skin and reduce the possibility of it entering our body to cause havoc. The students seemed receptive as ever. For a break, we went outside to play duck duck goose and Indian chief. When we came back in we showed them "1h2O" a silent 20 minute version of the critically acclaimed film "One Water" that showcased the importance of preserving clean sources of water. We quizzed the children on both the movie and the importance of water in their own lives. Finally we showed them a first aid kit and demonstrated to them them different situations in their own lives when it would be useful. We presented this comprehensive first aid kit to the schoolhouse for use in the future. At this point, Mr. Matthew Asada (Penn '02), American Consul for Political and Economic Affairs in Kolkata had just arrived. With him there, we also presented a Rs 10,000 donation to the school that would go towards renovating the school floors, the roof, providing learning supplies, and paying teachers salaries. We then proceeded to take a tour of the slums where our students lived. This experience was mind blowing for all parties for both us and Asada. The scene was right out of "Born into Brothels" or "Slumdog Millionaire" with a maze of squadder settlements housing 500 people in tight quarters that I could barely go into without feeling extremely claustrophobic. To think they live and survive in such conditions is unreal. The most poignant moment of the day was when we went into one of the girls' homes and saw the green flosser we gave out to each of the children on the first day hanging beside her mirror. It was the lone colorful piece in that dark, downtrodden room, hanging idly on a nail but clearly our lesson made an impression on the girl.
Going back to Asada, it was pretty incredible to have a Penn alumni in Kolkata in such a high position of power so interested in our work and willingly giving us advice on how to improve our program and spread our word on campus. Let's hope both the University and the Consulate can support our programs beyond this first visit.
Going back to Asada, it was pretty incredible to have a Penn alumni in Kolkata in such a high position of power so interested in our work and willingly giving us advice on how to improve our program and spread our word on campus. Let's hope both the University and the Consulate can support our programs beyond this first visit.
Putting our own illness into perspective
I had a stomach infection the last few days that caused me a high fever and frequent diarrhea (yes, i know, TMI). I don’t know whether this is because of something I ate or what. But what if I contracted the illness at the slum? All I know is that at the end of the day, no matter how much pain I was in, I was able to recover in my grandparents comfortable apartment building, sleep for 15 hours in many blankets, given antibiotics, many doses of paracetemol (what they call tylenol here), and adequate food and clean water, which is a lot more than my slum counterparts could have imagined on a regular day even with Pratit services around.
Challenges becoming more evident in medical arena
12/31
- Today, our work brought us to Baranagar, also in North Kolkata. We started work as soon as we got there at 2. The room today was much more well ventilated and larger than the room at our last medical camp. It is going to be a new schoolhouse for the children of workers at the jute mill. This time, each person had a slip so we did not have to do any pre registration. This environment proved to be much more challenging with lack of translators, but Sandeep and I were managing as the two other stations were held up by Kal and Turja, respectively. Community leaders were so eager to help us in any way they could. One local around our age (wearing a ManU jersey) had a certain way with the elder patients as he was directing them to the different stations. Today, doctors were not next to us but at a central table. I think that worked well in terms of efficiency, but they spent even less time per patient- about 30 seconds per, glancing over the chart, and prescribing something. Certainly many of these malnourished needed the vitamins (especially B and Calcium) and many suffering from pain could certainly use the paracetemol. But I could not help but think that the doctors were using our supply of medicines as a way of circumventing a full diagnosis. Could I blame them? Probably not. The doctor patient relationship was basically non existent and I think that it was left to us medical assistants to carry this out. Because of this, today I took it upon myself to take the patient to every station, making sure that the doctor was not ignoring any of my notes or being too hasty with his prescriptions and ensuring that the patient was being instructed on their medications properly. Another side note: these patients were extremely patient with me. They let me struggle a little bit with the BP cuffs, let me struggle with my mediocre knowledge of Hindi. Had I been working like this in the US, I think I would have been promptly replaced. Here is the first ethical question: If we are not deemed certified to carry out such work in our own country, can we do so in another whose resources do not match that of our own and whose need is greater, provided we are somewhat trained? I think the answer is an overwhelming yes.
The other problem I was struggling with is how we should prioritize our long term research goals. While we are not doing any actual hard analysis on this trip, we have put ourselves in a position to do some once we return. We have copied (almost) every patient's records which contain information such as their pulse, bp, weight/height, chief complaints, and what medicines we prescribed to them. Height and Weight, used to calculate BMI, is a particularly important piece of information we hope to gather, along with the different types of illnesses/associated medicines are most prevalent. But why are we doing this? First of all, having hard data is something that prospective corporate donors and other grant providing organizations love because it provides a measure of tangible outcomes. Second, if we compile records then maybe we can better understand what the population needs most so we can direct our efforts that way, yada yada But is our work going to produce tangible outcomes in the future? After all, aren't most of the problems we are seeing a result of systemic issues such as lack of clean water and access to sufficient nutritional food sources? At this point, I see our efforts of providing much needed vitamins, and medications, as a stop-gap. While this fact is what disturbs me most, I suppose stop gaps are common in the practice of medicine and we are at least preventing continual suffering. I hope Pratit will eventually become an organization that truly is able to change lives permanently, but a lot of this depends on our funding, how much time we can all commit, and whether we adhere to long term goals that will make us sustainable. For now, I am happy with the experience I have had, but at best cautiously optimistic about what we can achieve. Going back to balancing research goals, there were times when the patient demand was so high that we simply could not jot down everything and the doctors were just telling us to forget about height/weight, bp and get down to what the person was suffering from most and prescribing necessary medications. Furthermore, we also could not ask our survey questions related to the public health situation such as what the patients thought of their water supply, how many children the women had, what problem they thought could be most improved (education, clean water, healthcare) in their slum. These are important questions but when we asked them we were spending more time per patient and risked not giving humanitarian aid to as many patients as possible. We also ran out of the pads and carbon paper was flying everywhere, so not all patient records were copied. While this is not ideal (one may even call it a shame that a handful of patient records were not recorded. I, for one, was being very anal about all of this probably at the expense of being more efficient with my patients. At one point, I was even frantically copying information from a patient’s chart that we did not have a carbon copy of). All of this brings us back to another central question, which I will borrow from my colleague Collin’s blog: When time, materials and personnel are limited and the patient demand is overwhelming, should long-term research ambitions, which hopefully will contribute to the long-term health of the community, be dismissed in favor of providing as much immediate humanitarian aid as possible? I, for one, am more sceptical about whether our research ambitions will lead to improvements in the long term health, and am a little less worried about how we balance our goals. I think we've put ourselves in a good position with our diagnostic records and research about their medical condition, but our research about their personal lives and way of living from a public health standpoint needs more work. Maybe doing a few interviews could give us a good representative idea of what needs to be improved most on a macro scale? This way, we aren’t spending time per patient…
One man, about 28 years old, Ajay Sankar came to me at the end. He was healthy (I did not see a need to weigh him especially given our time constraint. Hmm I guess I wasn’t as anal as I initially thought. Shouldn’t I have weighed him for research thoroughness?) and had a look on his face like no other patient I had seen before. I sensed he was here not because he felt he was sick- he told me he had a cough but attributed to the cold weather and clearly understood it would get better with time-but to experience our clinic for what it was. Here was a fellow who I could see had the ability to form insights unlike many of his peers, albeit with an inherently youthful, cheeky nature which resonated with me. I suppose the best word to describe him is one I will borrow from my mothertongue: “chalak” So I brought him over to Collin and I was proven right. We learned so much about the community’s history from him.
Another incident from the day that causes me much inner turmoil: There was a man suffering from asthma, whose inhaler ran out of its dosage. As part of our medication supply, we did not have any albueterol or extra inhalers. What do we do with a patient like this, whose need is not immediately met by any medications we have? The decision was made (though I was not consulted) to give him money to buy an inhaler. A community person was instructed to take him there. At first, I was annoyed when I heard this. Why should we trust them to buy medicine with the money we gave? Who is to say they won’t buy something else with that money? Shouldn’t we be the ones who go and buy the necessary medications? I still don’t know the answer. But I do know that this whole project assumes some degree of trust in the patient. We do trust the patient to take the necessary medications we prescribe them anyway. Who is to say they won’t sell those medications too? There is only so much we can do, but from a human standpoint we must assume some degree of trust.
- Today, our work brought us to Baranagar, also in North Kolkata. We started work as soon as we got there at 2. The room today was much more well ventilated and larger than the room at our last medical camp. It is going to be a new schoolhouse for the children of workers at the jute mill. This time, each person had a slip so we did not have to do any pre registration. This environment proved to be much more challenging with lack of translators, but Sandeep and I were managing as the two other stations were held up by Kal and Turja, respectively. Community leaders were so eager to help us in any way they could. One local around our age (wearing a ManU jersey) had a certain way with the elder patients as he was directing them to the different stations. Today, doctors were not next to us but at a central table. I think that worked well in terms of efficiency, but they spent even less time per patient- about 30 seconds per, glancing over the chart, and prescribing something. Certainly many of these malnourished needed the vitamins (especially B and Calcium) and many suffering from pain could certainly use the paracetemol. But I could not help but think that the doctors were using our supply of medicines as a way of circumventing a full diagnosis. Could I blame them? Probably not. The doctor patient relationship was basically non existent and I think that it was left to us medical assistants to carry this out. Because of this, today I took it upon myself to take the patient to every station, making sure that the doctor was not ignoring any of my notes or being too hasty with his prescriptions and ensuring that the patient was being instructed on their medications properly. Another side note: these patients were extremely patient with me. They let me struggle a little bit with the BP cuffs, let me struggle with my mediocre knowledge of Hindi. Had I been working like this in the US, I think I would have been promptly replaced. Here is the first ethical question: If we are not deemed certified to carry out such work in our own country, can we do so in another whose resources do not match that of our own and whose need is greater, provided we are somewhat trained? I think the answer is an overwhelming yes.
The other problem I was struggling with is how we should prioritize our long term research goals. While we are not doing any actual hard analysis on this trip, we have put ourselves in a position to do some once we return. We have copied (almost) every patient's records which contain information such as their pulse, bp, weight/height, chief complaints, and what medicines we prescribed to them. Height and Weight, used to calculate BMI, is a particularly important piece of information we hope to gather, along with the different types of illnesses/associated medicines are most prevalent. But why are we doing this? First of all, having hard data is something that prospective corporate donors and other grant providing organizations love because it provides a measure of tangible outcomes. Second, if we compile records then maybe we can better understand what the population needs most so we can direct our efforts that way, yada yada But is our work going to produce tangible outcomes in the future? After all, aren't most of the problems we are seeing a result of systemic issues such as lack of clean water and access to sufficient nutritional food sources? At this point, I see our efforts of providing much needed vitamins, and medications, as a stop-gap. While this fact is what disturbs me most, I suppose stop gaps are common in the practice of medicine and we are at least preventing continual suffering. I hope Pratit will eventually become an organization that truly is able to change lives permanently, but a lot of this depends on our funding, how much time we can all commit, and whether we adhere to long term goals that will make us sustainable. For now, I am happy with the experience I have had, but at best cautiously optimistic about what we can achieve. Going back to balancing research goals, there were times when the patient demand was so high that we simply could not jot down everything and the doctors were just telling us to forget about height/weight, bp and get down to what the person was suffering from most and prescribing necessary medications. Furthermore, we also could not ask our survey questions related to the public health situation such as what the patients thought of their water supply, how many children the women had, what problem they thought could be most improved (education, clean water, healthcare) in their slum. These are important questions but when we asked them we were spending more time per patient and risked not giving humanitarian aid to as many patients as possible. We also ran out of the pads and carbon paper was flying everywhere, so not all patient records were copied. While this is not ideal (one may even call it a shame that a handful of patient records were not recorded. I, for one, was being very anal about all of this probably at the expense of being more efficient with my patients. At one point, I was even frantically copying information from a patient’s chart that we did not have a carbon copy of). All of this brings us back to another central question, which I will borrow from my colleague Collin’s blog: When time, materials and personnel are limited and the patient demand is overwhelming, should long-term research ambitions, which hopefully will contribute to the long-term health of the community, be dismissed in favor of providing as much immediate humanitarian aid as possible? I, for one, am more sceptical about whether our research ambitions will lead to improvements in the long term health, and am a little less worried about how we balance our goals. I think we've put ourselves in a good position with our diagnostic records and research about their medical condition, but our research about their personal lives and way of living from a public health standpoint needs more work. Maybe doing a few interviews could give us a good representative idea of what needs to be improved most on a macro scale? This way, we aren’t spending time per patient…
One man, about 28 years old, Ajay Sankar came to me at the end. He was healthy (I did not see a need to weigh him especially given our time constraint. Hmm I guess I wasn’t as anal as I initially thought. Shouldn’t I have weighed him for research thoroughness?) and had a look on his face like no other patient I had seen before. I sensed he was here not because he felt he was sick- he told me he had a cough but attributed to the cold weather and clearly understood it would get better with time-but to experience our clinic for what it was. Here was a fellow who I could see had the ability to form insights unlike many of his peers, albeit with an inherently youthful, cheeky nature which resonated with me. I suppose the best word to describe him is one I will borrow from my mothertongue: “chalak” So I brought him over to Collin and I was proven right. We learned so much about the community’s history from him.
Another incident from the day that causes me much inner turmoil: There was a man suffering from asthma, whose inhaler ran out of its dosage. As part of our medication supply, we did not have any albueterol or extra inhalers. What do we do with a patient like this, whose need is not immediately met by any medications we have? The decision was made (though I was not consulted) to give him money to buy an inhaler. A community person was instructed to take him there. At first, I was annoyed when I heard this. Why should we trust them to buy medicine with the money we gave? Who is to say they won’t buy something else with that money? Shouldn’t we be the ones who go and buy the necessary medications? I still don’t know the answer. But I do know that this whole project assumes some degree of trust in the patient. We do trust the patient to take the necessary medications we prescribe them anyway. Who is to say they won’t sell those medications too? There is only so much we can do, but from a human standpoint we must assume some degree of trust.
Educating about Dental Hygiene
12-30.
Today we had our first education day, during which we emphasized dental hygiene. The beginning of the day was spent scrambling for supplies (and searching for Collin) in the Big Bazaar near our apartment. Although much of the time was admittedly spent fooling around with Ankit and Sandeep we ended up getting 30 toothbrushes for 15 rupees each (30 cents), toothpaste, a cricket bat, and hand sanitizer. Believe it or not, I ran into one of Didu’s old friends at the Big Bazaar from about 10 years ago in the Vedanta Center in Boston! For some reason I spoke to her in my broken Bengali when I realized later that English would have probably sufficed. What a small world….
When we arrived to the classroom in the slum (which was actually a small hut), I was struck by the lack of physical light entering the dark room and also the gravel and brick-laden floors. At the same time, I also had never seen such excitement and eagerness to learn from children in my life. It's too bad they are given so little opportunity to succeed, but hopefully we can plant some seeds for a future rise out of their current conditions. Each of the students stood up and said their name and age proudly in English, and some of them even recited poems and nursery rhymes they had been taught. To break the ice further, we went outside and played some physical games outside with the kids. Here we were able to really bond with the children. Many of the girls immediately gravitated to Niyoshi and were clinging on to her. Collin and Ankit provided some entertainment to everyone with their pseudo-sumo/ape wrestling followed by Collin’s Chad OchoCinco touchdown celebration while playing “dog and the bone” which is a simple version of capture the flag. We went back inside and started our lesson on dental hygiene. We came well equipped with Western supplies and Western knowledge that we were adamant about imparting on to our students. First we gave them kind of an informational lesson on the importance of brushing and what happens if you do not brush (accumulation of plaque and bacteria which the students called insects in Bengali). We then split up into groups of two-three Pratit members each and about 8 kids each to dive into some more interactive lessons that we planned before coming here. Our first activity was a flossing lesson, where one of us put on a rubber glove and doused it with peanut butter, where our fingers represent the teeth and the peanut butter represents bacteria in your mouth. The other member demonstrated how to get rid of this "bacteria" by using his finger as a brush to get as much of the "bacteria" off of the "teeth". As you can imagine, peanut butter got stuck between our fingers even after the brushing so we got a string to get the stuff between our fingers. Here we demonstrate the importance of flossing, since the string collected a lot of the peanut butter/bacteria. The kids were absolutely fascinated by this, and even more so when they tried it on their own teeth with the flossers we provided them. We continued with a demonstration of how to use the Listerine product Agent Cool Blue. Basically you rinse your mouth with this stuff and it turns your teeth blue where there are supposed to be bacteria. Who knows if it's actually legit but I guess it proved the point. Hopefully their mothers won't be too upset when they see their kids with blue teeth. Finally we gave the kids each a toothbrush and toothpaste, and a flosser, and called it a day. I'm glad we're coming back to continue all our education programs here.
Today we had our first education day, during which we emphasized dental hygiene. The beginning of the day was spent scrambling for supplies (and searching for Collin) in the Big Bazaar near our apartment. Although much of the time was admittedly spent fooling around with Ankit and Sandeep we ended up getting 30 toothbrushes for 15 rupees each (30 cents), toothpaste, a cricket bat, and hand sanitizer. Believe it or not, I ran into one of Didu’s old friends at the Big Bazaar from about 10 years ago in the Vedanta Center in Boston! For some reason I spoke to her in my broken Bengali when I realized later that English would have probably sufficed. What a small world….
When we arrived to the classroom in the slum (which was actually a small hut), I was struck by the lack of physical light entering the dark room and also the gravel and brick-laden floors. At the same time, I also had never seen such excitement and eagerness to learn from children in my life. It's too bad they are given so little opportunity to succeed, but hopefully we can plant some seeds for a future rise out of their current conditions. Each of the students stood up and said their name and age proudly in English, and some of them even recited poems and nursery rhymes they had been taught. To break the ice further, we went outside and played some physical games outside with the kids. Here we were able to really bond with the children. Many of the girls immediately gravitated to Niyoshi and were clinging on to her. Collin and Ankit provided some entertainment to everyone with their pseudo-sumo/ape wrestling followed by Collin’s Chad OchoCinco touchdown celebration while playing “dog and the bone” which is a simple version of capture the flag. We went back inside and started our lesson on dental hygiene. We came well equipped with Western supplies and Western knowledge that we were adamant about imparting on to our students. First we gave them kind of an informational lesson on the importance of brushing and what happens if you do not brush (accumulation of plaque and bacteria which the students called insects in Bengali). We then split up into groups of two-three Pratit members each and about 8 kids each to dive into some more interactive lessons that we planned before coming here. Our first activity was a flossing lesson, where one of us put on a rubber glove and doused it with peanut butter, where our fingers represent the teeth and the peanut butter represents bacteria in your mouth. The other member demonstrated how to get rid of this "bacteria" by using his finger as a brush to get as much of the "bacteria" off of the "teeth". As you can imagine, peanut butter got stuck between our fingers even after the brushing so we got a string to get the stuff between our fingers. Here we demonstrate the importance of flossing, since the string collected a lot of the peanut butter/bacteria. The kids were absolutely fascinated by this, and even more so when they tried it on their own teeth with the flossers we provided them. We continued with a demonstration of how to use the Listerine product Agent Cool Blue. Basically you rinse your mouth with this stuff and it turns your teeth blue where there are supposed to be bacteria. Who knows if it's actually legit but I guess it proved the point. Hopefully their mothers won't be too upset when they see their kids with blue teeth. Finally we gave the kids each a toothbrush and toothpaste, and a flosser, and called it a day. I'm glad we're coming back to continue all our education programs here.
The Work Commences
12/29
Finally, our work was to begin after a full day of rest. But first we had to get to the slum, situated in the far reaches of North Kolkata. Our journey was not without characteristic delays of Kolkata. We were halted in traffic in the middle of a highway for at least 30 minutes because of a protest. I don’t know what it was about, but I’m sure Mamata Banerjee, railway queen and controversial leader of the opposition to West Bengal’s ruling communist government, played some role in it. From the back of our ambulance as we were stopped, we could see drivers stepping out of their car, chatting, stretching, and cleaning their dashboards (as if that would do anything to prevent the dust particles from returning immediately from the polluted air). We saw no signs of exasperation on their faces, as if they knew all of this was coming and they were perfectly fine with this kind of delay. What would happen if a group of protestors went on I-95 (or insert local highway) and exercised their First Amendment rights to a degree that would halt traffic in such a prolonged manner?
After guiding through the roads of Kolkata with the help of our ambulance siren, and stopping briefly at Turja’s paternal house for some refreshments, we finally arrived at Rajabagan Basti (slum). Situated near the sacred Dakshineswar Kali Temple and Ganges River, this is one of North Kolkata’s most diverse and dense slums.
When we stepped off the ambulance, the tension was palpable. Some of us were snapping photos immediately, others (including myself) were taking the environment in through simple observation; on the other side, the slum residents were looking at us quizzically even though you could tell they were expecting us for some time. At the same time, neither of us knew the other party’s next move. We were finally here to do what we came for, but frankly, I’m not sure we were in the state of mind to get to work right at that moment. Thankfully, the initial confusion was settled promptly as community leaders gave us a much needed tour that would acclimate us to our new environment nicely. As we walked through what was the main thoroughfare of the slum, most of the residents paused their activity, whether it was a simple game of dice or daily collection of water from the local pipe, to stare at us. The community leaders made it a point for us to enter the mosque, and seemed to have no problem with us interrupting the lesson of the children that was going on in the madrassa (but no shoes allowed, Mike Karp!). About 100 meters from the site of the mosque stood a Hindu temple! If you know me, this sort of juxtaposition gets me going. My hesitancy with both my mothertongue languages went out the window and I scampered over to the community leaders and fired away my questions in whatever broken Hindi and Bengali I could manage. I learned that the slum had a very mixed population of Biharis (from the state of Bihar) and Bengalis, and a Hindu-Muslim ratio of about 1:1. They lived together, however, and were not as segregated as I had anticipated. Behind the temple stood what was the public bathroom and latrine, which looked like a pond of green muck.
After our tour, it was time to work. We set up shop in what’s known as the slum “clubhouse” which was actually a dark room 15x15 with a small photo of Netaji at the back of the wall. We gave tickets to the first 80 patients who showed up seeking medical attention, telling them to come back at 5 pm. We recorded their name, sex, age, and reason for visit on our fancy Mac computers. After the tables and chairs and the doctors arrived, we set everything up and got going. We had three tables inside equipped with 2 medical assistants (us), a translator, and a doctor each. Outside we had two Pratit members giving out medications that the doctors were prescribing and another member with the laptop checking off each patient and making sure they had the registration slip we gave out earlier (surprisingly they all kept their slips!). At the medication table, we also had a supply of food packets, consisting of bananas, cake, and an egg, which we gave to the patients at the end of their visit. I was with Kalyan and Dr. Banerjee for most of the evening, who is the doctor out of the three with an expertise in clinical research. At first, I thought he was being too lax, prescribing whatever medicines matched the symptoms the patients were reporting, but I quickly realized that this was a function of his experience working in such high density settings and not of a lack of expertise in diagnosis. As medical assistants, our job was two-fold: doing clinical questioning and conducting a thorough physical examination based on chief complaints. The physical examination was a challenge for me mainly because I was not sure whether doing a thorough exam was even necessary given our time crunch. Doing the clinical questioning while Kal was doing the physical exam gave me more power and opportunity to learn from Dr. Banerjee regarding what he was prescribing for the patients’ ailments. We saw a lot of patients with nutritional deficiencies, which Banerjee gauged from the BMI using the height and weight of the patient we measured initially. Many of the elder patients had cataracts and skin disease such as scalp psoriasis and fungal and bacterial infections due to lack of clean water, while many of the children were malnourished. One girl came in with a retinal disorder that resulted in partial blindness and converging of the pupils. All Dr. Banerjee could prescribe was vitamins to help her wiry frame, but we could do nothing for her main problem. Towards the end of the day, an old man came in with a cataract and also high blood pressure (around 170/110). Given the eye problem and high blood pressure, here was someone who could have been a diabetic. We administered the blood glucose test but his reading was 89mg/dL which is within normal. Turns out the cataract was just due to senility. This was my first chance to experience the diagnostic process to its fullest. Our three hours were up, and it was already dark outside. The doctors had to leave and we proceeded shortly. We said our goodbyes and said would be there next week. As we were leaving, an old woman with a deformed foot was pleading that I help her now, but we simply did not have the means or the time, so I hope my promise that we would come back next week sufficed. Next time, I think we should make sure that the patients of most need are seen first.
Finally, our work was to begin after a full day of rest. But first we had to get to the slum, situated in the far reaches of North Kolkata. Our journey was not without characteristic delays of Kolkata. We were halted in traffic in the middle of a highway for at least 30 minutes because of a protest. I don’t know what it was about, but I’m sure Mamata Banerjee, railway queen and controversial leader of the opposition to West Bengal’s ruling communist government, played some role in it. From the back of our ambulance as we were stopped, we could see drivers stepping out of their car, chatting, stretching, and cleaning their dashboards (as if that would do anything to prevent the dust particles from returning immediately from the polluted air). We saw no signs of exasperation on their faces, as if they knew all of this was coming and they were perfectly fine with this kind of delay. What would happen if a group of protestors went on I-95 (or insert local highway) and exercised their First Amendment rights to a degree that would halt traffic in such a prolonged manner?
After guiding through the roads of Kolkata with the help of our ambulance siren, and stopping briefly at Turja’s paternal house for some refreshments, we finally arrived at Rajabagan Basti (slum). Situated near the sacred Dakshineswar Kali Temple and Ganges River, this is one of North Kolkata’s most diverse and dense slums.
When we stepped off the ambulance, the tension was palpable. Some of us were snapping photos immediately, others (including myself) were taking the environment in through simple observation; on the other side, the slum residents were looking at us quizzically even though you could tell they were expecting us for some time. At the same time, neither of us knew the other party’s next move. We were finally here to do what we came for, but frankly, I’m not sure we were in the state of mind to get to work right at that moment. Thankfully, the initial confusion was settled promptly as community leaders gave us a much needed tour that would acclimate us to our new environment nicely. As we walked through what was the main thoroughfare of the slum, most of the residents paused their activity, whether it was a simple game of dice or daily collection of water from the local pipe, to stare at us. The community leaders made it a point for us to enter the mosque, and seemed to have no problem with us interrupting the lesson of the children that was going on in the madrassa (but no shoes allowed, Mike Karp!). About 100 meters from the site of the mosque stood a Hindu temple! If you know me, this sort of juxtaposition gets me going. My hesitancy with both my mothertongue languages went out the window and I scampered over to the community leaders and fired away my questions in whatever broken Hindi and Bengali I could manage. I learned that the slum had a very mixed population of Biharis (from the state of Bihar) and Bengalis, and a Hindu-Muslim ratio of about 1:1. They lived together, however, and were not as segregated as I had anticipated. Behind the temple stood what was the public bathroom and latrine, which looked like a pond of green muck.
After our tour, it was time to work. We set up shop in what’s known as the slum “clubhouse” which was actually a dark room 15x15 with a small photo of Netaji at the back of the wall. We gave tickets to the first 80 patients who showed up seeking medical attention, telling them to come back at 5 pm. We recorded their name, sex, age, and reason for visit on our fancy Mac computers. After the tables and chairs and the doctors arrived, we set everything up and got going. We had three tables inside equipped with 2 medical assistants (us), a translator, and a doctor each. Outside we had two Pratit members giving out medications that the doctors were prescribing and another member with the laptop checking off each patient and making sure they had the registration slip we gave out earlier (surprisingly they all kept their slips!). At the medication table, we also had a supply of food packets, consisting of bananas, cake, and an egg, which we gave to the patients at the end of their visit. I was with Kalyan and Dr. Banerjee for most of the evening, who is the doctor out of the three with an expertise in clinical research. At first, I thought he was being too lax, prescribing whatever medicines matched the symptoms the patients were reporting, but I quickly realized that this was a function of his experience working in such high density settings and not of a lack of expertise in diagnosis. As medical assistants, our job was two-fold: doing clinical questioning and conducting a thorough physical examination based on chief complaints. The physical examination was a challenge for me mainly because I was not sure whether doing a thorough exam was even necessary given our time crunch. Doing the clinical questioning while Kal was doing the physical exam gave me more power and opportunity to learn from Dr. Banerjee regarding what he was prescribing for the patients’ ailments. We saw a lot of patients with nutritional deficiencies, which Banerjee gauged from the BMI using the height and weight of the patient we measured initially. Many of the elder patients had cataracts and skin disease such as scalp psoriasis and fungal and bacterial infections due to lack of clean water, while many of the children were malnourished. One girl came in with a retinal disorder that resulted in partial blindness and converging of the pupils. All Dr. Banerjee could prescribe was vitamins to help her wiry frame, but we could do nothing for her main problem. Towards the end of the day, an old man came in with a cataract and also high blood pressure (around 170/110). Given the eye problem and high blood pressure, here was someone who could have been a diabetic. We administered the blood glucose test but his reading was 89mg/dL which is within normal. Turns out the cataract was just due to senility. This was my first chance to experience the diagnostic process to its fullest. Our three hours were up, and it was already dark outside. The doctors had to leave and we proceeded shortly. We said our goodbyes and said would be there next week. As we were leaving, an old woman with a deformed foot was pleading that I help her now, but we simply did not have the means or the time, so I hope my promise that we would come back next week sufficed. Next time, I think we should make sure that the patients of most need are seen first.
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