finishing the course

we finished our one-month course yesterday, and received marigold, rose and jasmine garlands, so that "the fragrance of the flowers can spread like our service," and a scarf "for scholarship." we dressed in our saris and received certificates. then a group of thirty women from andra pradesh [who had accosted me more than a few times that morning, insisting that my sari was not put on properly (despite my very good attempt at putting it on myself after training sessions from, not one but, two women who work at CRHP) - i declined their help out of frustration and vowed to burn the damn thing because of the hours i've wasted trying to put it on] shook each of our hands and congratulated us, then took pictures with us for two hours in the screaming heat and the discomfort of my (admittedly poorly-put-on) sari.

today, saturday, we booked it to pune, rinske (a dutch medical student), kate (an australian social worker) and i. after a five hour journey in the maharashtra state bus - quite a trip, i must tell you, but adventure is not so glamorous, my friends - we arrived, only to be duped by a rickshaw driver. after we arrived at the bus station just outside pune, we walked up to a rickshaw driver and clearly stated that we wanted to go to the center of pune, a maximum five minute ride. ten minutes later we screamed at him over the traffic that we should not be getting on the mumbai highway, and, without turning off the meter, he said, as though shocked (though not convincingly), "pune center?" [despite the fact that he had repeated it confidently when we first asked him to take us there] and turned the vehicle around. When we arrived at our intended destination, he told us that the cost of the ride was 150 Rupees (the cost of the trip out of the city, back in, and to our destination). We told him we were giving him 50 Rupees, even more than the intended trip would have cost, and that was that. But he followed us to our hotel, smirking somewhat and not threatening, because we both knew that he was just trying to rip us off. Rinske started yelling at him, because she was even more frustrated than i, and when we told those at the hotel front desk what had happened, they told him to go away and he did.

afterwards, we realized that we had been fighting over two dollars, and felt stupid. ah well - it was the principle of the matter!

tonight we are at a high-speed internet cafe, which is a lovely treat after the very slow and inconsistent dial-up connection we have in Jamkhed (broadband has not yet reached that village). tomorrow we intend to go shopping and take it easy, then go back to jamkhed. monday morning i begin rotations in the hospital with dr. shobha.

i've been a bit homesick, partly because i've been nauseous the past few days and just crave my own bed in those moments of illness, but also because at this time of transition (the course ending and the rotation about to begin), it's easy to think of home and allow the desire for the comforts and familiarity of home to invade my thoughts. three more weeks, though - and i'm sure i'll be sad to leave because this experience has been just the renewer of spirit that i needed to confirm my choice of going to medical school, and created the images of patients that will motivate me through the next year of pathophysiology and pharmacology.

on that note, i'm off to experience some indo-chinese food and good company with kate and rinske. til next time...

In Memory of Muktabai Pol

Today was a sad day. A life had been lost before I even woke up, and it was several hours (until this afternoon) that I found that Muktabai Pol – a village health worker for over 25 years, who had improved the health landscape of her community and trained dozens of other health workers – had taken her own life.

We saw Muktabai in the hospital in our first days here, sitting on a bed, listless, a weak smile for us standing at the foot of her bed to say hello as we toured the hospital. We had read about her on the website and in the book on how The Comprehensive Rural Health Project (CRHP) at Jamkhed was started, and were all surprised to see her in the hospital. Dr. Shobha told us that she had issues with depression, and had been admitted periodically for her debilitating bouts of sadness. We saw her again in our second week, asleep, and in the third, when there was no glimmer of her legendary personality in her eyes, or even a forced smile for us and the new students with us. She managed to sit up, using her pillow to prop herself up off of her stomach where she had been lying, but she stared at the floor. She had gone home to her village at some point in the last week.

I say legendary personality because she was one of the first nine village health workers who, over the past 25 years, carried out the work of improving women’s status, decreasing child illness and mortality, assisting women in childbirth, and removing the stigma of leprosy and tuberculosis so that marginalized people in the community were once again accepted. All the village health workers accomplished these feats, but Muktabai must have been special, because when CRHP pooled a team to present at a World Health Organization event, they asked Muktabai to speak. This is what happened (from the book, Jamkhed: A Comprehensive Rural Health Project, by Drs. Raj and Mabelle Arole):

In a huge conference hall in Washington DC, over a thousand participants listen with rapt attention to Muktabai Pol, a village health worker from Jamkhed, India. The listeners include officials from WHO and UNICEF, ministers of health, health professionals and representatives of universities from many parts of the world. Muktabai shares her experience of providing primary health care in a remote Indian village. She concludes her speech by pointing to the glittering lights in the hall. “This is a beautiful hall, and the shining chandeliers are a treat to watch,” she says. “One has to travel thousands of miles to come to see their beauty. The doctors are like these chandeliers, beautiful and exquisite, but expensive and inaccessible.” She then pulls out two wick lamps from her purse. She lights one. “This lamp is inexpensive and simple, but unlike the chandeliers, it can transfer its light to another lamp.” She lights the other wick lamp with the first. Holding up both lamps in her outstretched hands, she says, “I am like this lamp, lighting the lamp of better health. Workers like me can light another and another and thus encircle the whole earth. This is Health for All.” The audience rises to its feet in a standing ovation.

This afternoon, I was unaware that anything was out of the ordinary, until I saw Shobha, the daughter of the founders of CRHP and Medical Director, leaving the hospital and saying, “we are having a ceremony. There has been a sad death of one of the VHWs” [Village Health Workers]. I asked who it was, and Alex, another student, replied, “Muktabai.” I immediately pictured her sad, tired eyes, but then envisioned this humble, illiterate woman in her clean but well-worn sari, lighting a candle in front of a hall full of doctors and public health officials. She was trained to do so much to impact the health of her community despite her simple background that she became a well-respected healthcare provider – a member of an elite and exclusive class – by a room full of “experts,” not to mention the hundreds in her village whose lives she saved or whose babies she welcomed safely into her hands and the world over all those years.

Members of the CRHP community gathered around as a van pulled up with a group of people from Muktabai’s village, including her husband, teary-eyed. They climbed out, then pulled a stretcher out with Muktabai on it, wrapped in a white shroud with her face and hair exposed, her eyes closed and her face relaxed and soft. They carried her lovingly into the garden of Dr. Arole’s house, where Shobha said a few words:

“Muktabai was a very special woman who loved the Lord. She had tried to commit suicide before, and last night she went home to her Father.”

All in attendance said a quick prayer with bowed heads, then lined up to place fistfuls of marigolds and rose petals on her resting body. I saw her husband then, lip quivering, eyes glassy, muttering, almost humming, in distress and pain. The women rubbed his arm and covered their hair with the ends of their saris. We lined up and, in a procession that wrapped around her, we each placed our offering of gold and red petals on Muktabai’s peaceful remains.

It is difficult to explain why I – a stranger to both the country and to Muktabai – can feel so moved by her passing and by the pain that those close to her are feeling. She, and all of these women, are so extraordinary in their contribution. But it is more the tragedy of her depression and the taking of her own life. When she did so much good, how could she have felt so sad? Today, though, she did seem at peace and encircled by those who love her, and by that I am comforted.

sites, a c-section and a sari

last week was fantastic. we explored child health and women’s status in class, then prepared to go to ellora and pune for the weekend.

on saturday morning, we left at 6 am to go to the ellora caves, which are spectacular hindu, jain, and buddhist temples and schools cut into a mountain. these are not spelunking caves, my friends. these are spectacular, cathedral-sized caves cut from the top down without scaffolding, thus they are cut from solid rock – not in pieces. the most amazing was a buddhist gathering hall with 50 foot high ceilings, all made of stone. our tour guide went behind the giant buddha stupa and starting chanting, and the sound reverberated throughout the entire temple. i could feel the vibrations.

after being hassled by vendors, i bought a beautiful garnet-colored beaded necklace for 100 rupees (2.50 USD). we piled into our jeep and went to the bus station to go to pune.

pune would be a major city if mumbai (bombay) weren’t four hours away. it has a population of 4 million people, universities, a banking center, malls and everything else that, coming from the rural areas, is shocking to see. of course there are beggars galore, and they are the most aggressive i have yet seen in india. they grab your arm if you ignore them, and i simply don’t tolerate that. even if you give them money, they continue asking for more, and many of them are professional beggars. it is clear that those who need alms most are those who are disabled or mothers with children, but those who are most in need aren’t as aggressive as those who beg professionally. i had to whip around once because a woman grabbed my arm tightly. another student with me in the course speaks hindi, and understood when a professional beggar woman said “i curse you” to her. we were able to buy some food to give to a woman and her children, and we did give to some of the poor and disabled, but it’s so difficult to think that 1) it doesn’t make much of a difference and 2) if you do give, twenty more beggars materialize.

we went to a german bakery and had masala chai and apple danishes. then we visited a broadband internet café, which was a relief after working on the spotty dial-up in jamkhed. rinske, the dutch medical student who i have befriended, and i split from the group to explore for the afternoon and had a fantastic time weaving through the streets and markets. the following morning, sunday, we went to have a half-hour ayurvedic massage. we stripped down to our underwear and got on the bed under a towel, thinking that they would fold the towel down to expose our backs. they pulled a curtain between our two beds, and each attendant took one of us. mine pulled the towel down as expected, but then pulled my underwear down in one quick motion and began kneading my buttocks!! i didn’t know what to do, so i just enjoyed the massage, which – soon after – moved up to my back and re-covered my pale and previously unhandled derriere. the massage was wonderful, though, and rinske and i jumped into an autorickshaw to hurry back to our hotel to check out.

the autorickshaws in india are basically motorcycles with a cover and a double seat behind the driver, so that you sit side-by-side with your fellow passenger. rinske and i sat there smiling as bollywood music blasted from the speakers installed behind our heads (the equivalent of the shelf-like area in a sedan under the back windshield). a ride across town costs less than a dollar.
that afternoon i presented my research proposal to the maharashtra association of anthropological sciences ethich committee. as at mount sinai, it didn’t get passed, but once the course finishes, i will work with dr. shobha in the outpatient department and in the hospital, and will document how alternative therapies are used in the hospital in a very informal way. it should be wonderful, and at least i had the enlightening experience of presenting to an indian ethics board!

today, i gave a presentation on taboo and superstition as barriers to healthcare. i focused on pregnancy, delivery, and childhood, and got to interview some village women about their experiences. one interesting belief is that women who die during childbirth do not go to heaven or hell, but become owls and watch over new babies and mothers in the hopes of cursing them because they were not able to have a child. in an effort to stay out of the sight of an owl, mothers and children stay in a hut built especially for childbirth for 12-40 days after delivery and all possessions of both mother and child do not see the light of day because the owl might take them and use pieces of their belongings in a spell to curse them. this view is no longer common due to the counseling of CRHP in these areas, and of course some degree of modernization; how isolated these villages are should not be underestimated, however. i am continuously surprised by how closed and cut off from society these communities can be.

we have been talking about water-borne illnesses and other communicable diseases over the past week, which has been really stimulating. last night i got to attend a c-section. the poor mother, 25 years old, had a high-risk pregnancy with high blood pressure and protein (albumin) in her urine, which indicates some kidney problems. after many hours of labor, the baby’s head was too big for her cervix, so they went into surgery. a beautiful baby boy came out after 3 minutes, then they closed her up and all was well. she had a seizure at 7:30 this morning – a complication of her previously high blood pressure, and was close to comatose when we checked in on her at 10:30 am. dr. shobha gave her a 50/50 chance of surviving. but we received word that she woke up and was breastfeeding this afternoon and looks as though she’s in the clear.

it's pretty incredible to be privy to these people’s lives in the hospital, and to see the successes of medical interventions. in the OR, i felt again the rush i have gotten before partaking – even passively, as i was last night – in the surgery. perhaps, despite thoughts of a public health career, i do belong in clinical medicine. the interactions with people here in the hospital have been overwhelmingly positive, and the simple things a doctor can do – things i understand after even one year of medical school – can change lives.

i have been thinking since i began medical school and opened the cadaver gifted to me and my classmates how little the average person knows about how our bodies work: what’s inside them, how they function, how they malfunction. here we have spoken much about education of village health workers, who in turn educate their fellow village people on simple remedies and diagnostics so that they can be in charge of their own health. i have been thinking about the lack of education about our health in schools and how only part of tenth grade biology actually covers biological systems. i think a national curriculum should be developed to teach about health in every school (along with my old idea and strong view that foreign language should be required in american schools starting in first grade).

this weekend, i will pick up the blousepiece that was made for me at the tailor’s; it is the belly-bearing shirt worn under a sari. the rest of the weekend i anticipate will be spent attempting to put a sari on, as it truly is an art. i'll let you know how it goes…

the everyday in india

i realized that i haven't really talked about what a daily schedule is like. i'll start with the food.

we eat at 8 am, 1 pm, and 7 pm, and most days the cuisine is the same for each, except breakfast has fewer vegetables and the occasional pancake from a western mix. we usually have the following:

dhal - lentils, which here are a yellow variety put into a bit of a watery stew with mustard seeds and eaten over rice
rice - white rice like that you get in chinese restaurants, but less sticky
chapati - basically a wheat tortilla that you tear and use as a potholder to eat the other food, especially the vegetables in sauce, but even the rice and dhal
squash - a type of "gourd," as they say, in a curry sauce
greens - sauteed or pureed, but never spicy
drumstick - a bizarre vegetable they serve in a curry sauce, which looks like celery but with a very fibrous husk around it. you cut it in half lengthwise and scrape the inside meat - which tastes like squash - off with your teeth and discard the fibrous strands of the outside
beans - green beans that are a bit less tender, usually in a spicy sauce

we've also been given hamburgers, beef stew, and chicken dishes - so much for the vegetarian stereotype. apparently, despite their holiness to hindus, cows (beef) are really cheap for meat. i guess the muslims rigged that deal!

here's a picture of us eating in our suite. you can see the chapatis in the foreground!

as for the rest of the daily activities, we usually have class from 10 to 1, break from 1 to 3:30, then have class again from 3:30 to 5:30 or 6. we have an hour to hang out or walk to a nearby lake, through some farms, and then we go to dr. shobha's house for dinner.

i have to mention that there are wonderful fruits here. papaya and banana are amazing, but what is out of this world is the mango. one ugly surprise was a beetle that had someone grown up inside the mango, but i swear there were no burrowing holes in the skin of the fruit. we even examined another one from the batch after that incident, and peeled it carefully to find another invader inside that one. i don't understand how it could have gotten inside unless it was in the fruit for the life of the fruit. please ponder and get back to me...

this weekend we are going to pune, the closest city, and to the ellora caves - hindu, buddhist and jain paintings inside these rock-cut caves. it should be fantastic.

i haven’t updated for a week because so much has been happening and because i got sick. first, i'll tell about the illness: i was not well until i stopped taking malarone – the anti-malarial that i was taking. now i feel great, and i will start taking chloroquine this weekend. that’s all there is to say about that without grossing you all out :)

now for the past week. oh, it’s been wonderful. last thursday, we went to ramayeshwar, a waterfall 15 minutes from CRHP that was supposedly formed when the god ram shot his arrow into the countryside. then he stayed there for fourteen years or so with his consort, sita. at the site where their table was is now a temple. we walked down 1000 or so stairs into the valley, over the pool under the waterfall and into the temple. it was magical.

the rain started to fall heavily as we climbed back up the stairs and eased as we looked out over the misty valley that looked almost rainforest-like, though it is drought-prone plateau in the middle of monsoon season in subtropical india! here’s rinske, david and june at the top on the look-out over the landscape.

last saturday, we went to the hospital to see patients with dr. shobha. sunday, as are all sundays here, was a day of rest, and that evening three students from SUNY downstate arrived – alex (who was the arole fellow last year), samar (pronounced summer; a bombayite who has lived all over the world and holds an MSc in computer science and a PhD in neuroscience), and ozzie (a quirky iranian-american with great stories and a reverence for che guevara’s commitment to his ideals). we began the course on monday.

we spent time talking about the social structure of india, including the caste system and the treatment of women; determinants of health; our expectations of the course; our values and beliefs; alma ata and primary health care; and more. but the wonder comes from the village visits. on our first morning, we piled into the CRHP bus and went to a village called patoda where sarubai, a village health worker, has been working for over 15 years. here she is with another village woman.

we were instructed to wander around in groups of two with a translator (i went with rinske, the dutch student, and pushba – our marathi teacher) and learn about the town. we walked through the homes of two families – one hindu, one muslim – who had businesses selling goats and grains, respectively. their homes were simple, made of brick and straw and mud, and their smiles were beautiful. in most homes live the mother, father, sons, daughters-in-law and the grandchildren. many other village children (and some adults) look on curiously, but smile when a smile is offered. the children continue to run up and say “hallo!” and shake our hands.
we left the homes of the families, and walked down a narrow road to a village well, where we met nani. she touched my face and said how fair i was and wanted a picture with me.

then she took us to her home and gave us tea and sang for us. while we were there, a woman came in who said she felt the spirit of lakshmi, a goddess, in her. she hooted and waved her arms around, joined at the wrists above her head, her whole body moving like a butter churner propelled by an invisible force. but she began laughing when she tried to do it in front of us, so i have to say respectfully that i’m not sure how possessed she actually was!

we discussed our village visit and many other topics over the ensuing days, heard more about village health workers’ lives, and got to know each other better, too. today we went to the cattle market in town, where villagers come from all over to sell cattle, goats and buffalo every saturday. then we went to the fruit and vegetable market and the hindu temple in town, where there were brightly colored sculptures of gods and goddesses that matched the electric hues and scents of the market surrounding them. There were mango, pomegranate and bitter squash vendors; men making fried sweets in steel pans filled with oil; straw baskets filled with fluorescent spices – orange, red, pink, green – under a blue tarp-covered stall; and snack mix stands attended by cross-legged women, sitting on top of the wagon on which all of their goods were stacked in unstable-looking pyramids. it was amazing.

today a preschool teacher and public health student from australia arrives, who will be here for the next month and will share my room. her name is kate. i’ll keep you posted on my new roommate and upcoming adventures.

on a parting note, a few things i’d like to share that are unique to India but have already become everyday to me:

- nodding yes consists of wobbling from side to side, not up and downone takes shoes off before

- entering a home, temple, or storeone eats with the right hand, as the left hand is used for washing

- limbupaani, or lemon water with salt and sugar, is a fantastic oral rehydration solution**
**[take from this last nugget what you will about what becomes a part of daily existence here!!]

with love,
zoe