A month hiatus--Research experiences galore

So I didn’t notice it until now, but I took about a four week hiatus from this blog! How may I summarize the past 27 days here?

First, the Rural Study

There are definitely some American conditionings I’m deprogramming, and some I want to stauchly uphold. For example, I’ve deprogrammed the need to feel anxious when people aren’t plus or minus 10 minutes on time (it’s about +30 minutes). Instead, I become really happy having the time to meditate on being. I’m happy not because of external forces, but because I am. It’s sometime I’m still practicing, but as they say, practicing makes perfect! Yet, sometimes I get just slightly annoyed because those who are helping coordinate the patient interviews mis-record the patient study number (so it doesn’t match the actual order of being interviewed), and we all get in a slow-paced search for the correct information. I feel the attitude toward organization and accountability is lax—so some patients are discharged, and no one informs us, until the interviewer and I search the wards ourselves (or ask someone else, which takes much longer…)! Even then, the nurses cannot find the records of these patients we interviewed some weeks ago. In our survey, we have questions that can only be asked after the discharge process, and it takes 2-3 minutes (literally). To miss the discharge questions invalidates the pre-discharge questions that takes around 30 minutes! In total, we have missed 8 patients, and what’s more confusing is that the nursing staff and the registration counter does not inform us of discharged patients. I can understand—it’s probably because perhaps people just put faith in what will be will be, and it will somehow get done in some time. If we miss patients, we’ll just make up for it. In this case, there is no clear responsibility, and that’s alright, because my Indian mentors and I probably couldn’t have foreseen this. And frankly, I feel I’m more welcoming of missed subjects than the local interviewer! Last pet peeve of the rural research: the alternate interviewer flirts with the main interviewer quite obviously when we could have asked the nurses to bring the next interview subject. I’m waiting hours upon hours in totality waiting for patient subjects in a counseling room that has paper-thin plastic sliding doors, hearing the next-door counseling discussion. The people outside can make-out lots of the discussion too. I wonder how confidential this set-up truly is.

Fitting cartoon

Urban study

So I finally got to start the doctor satisfaction survey of the lab and blood bank services at Vikram Hospital. And its something I’m learning to navigate…Dr. Anjali, my mentor here, is definitely able to give directives for others (doctors, staff alike) to facilitate the completion of surveys. What am I exactly navigating at Vikram? I’m still learning the ropes for that, but there are my observations: Doctors are extremely busy, with patients crowding outside their offices, almost as a first-come first-serve basis. The nurses are the gatekeepers to office entry, and as a patient, you’ll hope they’ll remember that you were there somewhat early and let you in as soon as possible. However, there’s the doctor-card you can play, and once you mention you’re a doctor (or a doctor-student—a tip I’ve been given), you’re in before you know it. You still must wait for the consultation/what-have-you, but it’s less of a wait. Once inside I introduce myself, and sympathizing with their hectic faces I convey that it’s a quick and painless process taking 5-10 minutes. Then I hand them a sheet to tick. It’s too bad I didn’t conduct a pilot test because Dr. Anjali wants all doctors to give their responses. Obtaining surveys may sound easy, but so many factors prolong the achievement—the Dr. Anjali-designated assistant who needs to finish her lab duties by 11:30am, which quickly turns to 11:50am before we start. There’s the waiting outside the crowded office and the assistant persuasively telling the nurse to make us first priority. And of course, there’s a TEA break at the canteen, followed by the inability to catch doctors busy during peak hours. After a lunch at 2:30pm, we finish the whole survey process for that day at around 3pm or 3:30pm really, and about 7 doctors have been surveyed. I’m thinking, ”Isn’t there a faster way? Must we dumbly wait at one doctor’s office for 30 minutes?” Two weeks ago, when I started the survey, I actually came after hours 4-6:30pm and got 4 more doctor surveys completed. Because I didn’t play the doctor card, I had to wait 1.5 hours for one doctor to be available because the nurses put me as the non-priority. Finally when I saw the doctor, he actually apologized that I waited so long, and explained that the nurses here wouldn’t know any better to make me the first priority. Honestly, I didn’t know I’d be the first priority because don’t patients need to have their consultations too? “Come on, it’s India,” he replies. And I learned that I too would be better off adapting to this system if I ever wanted results done.

Not-work related events!!
In the past month, I've also
*had a cathartic Ayurvedic oil massage and detox (which was surprising great!) all for $32 including meals, accommodations, etc. I felt so envigorated when I rubbed an herbal powder onto my Ayurvedic oiled skin...my eyes widened automatically. I'd highly recommend it.
*practiced yoga at 6am with around 30 village girls laughing at me (because I look sooo different) and helping me make sure I knew the yoga moves. Surprisingly to them, I did because I took some yoga classes before.
*sped down a mountain on a moped sandwiched between two friends thinking I'd die because the bus was about to run into us (and driving on the lane divider). Hello...we're near the edge of a falling down a mountain (they call it "Chamundi Hills"). The locals who sandwiched me of course were unfazed.
*got invited to experience sunrise at a mountain near Saragur (rural town where I work), with 15-20 monkeys wanting some banana peels outside the temple devoted to Chikkadevaman goddess.

And, I am looking forward to attending a South Indian wedding on Sunday just a 3 hour train ride away from Mysore!

Around town and back

Kannada patient survey translations and scale smiley chart

How may I summarize the study's progress so far? In between waiting for random selection of patients, to waiting for patients to finish their lunch in order to be interviewed, to waiting for patients' discharge so we don't miss the survey data, I've come to accept that much of the global health research style is waiting for what-have-yous to transpire in its due time. Of course, waiting for others with no set timeline, is something to be viewed with normalcy here because it's much of the pace of health care of resource-low areas. A Dr. Dan from Canada, who is completing a global health elective here, was well-versed to reassure me that this is a part of the global health package.

Another aspect of having a translator interview patients? I absolutely love observing natives' body language--with their free-flowing bobbing heads beaming their tranquil and hearty smiles. I feel that despite some of the native's rural, impoverished lifestyles, many people exude just as much vitality, if not more than people I meet in America.

Apart from appreciating the subtleties of body language, there are myriads of exciting subtleties of the nearby town. I got a first grand tour of how to reach the local bus station from Dr. Dan, replete with avoiding stepping in what makes the zoo smell like the zoo, interspersed with returned smiles from passersby. Below are the images culminating from the trip from my camera:




Ganesha atop an awning to a shrine








Credited to Dan

Enjoying a refreshing slice near the fruit stand
(Credited to Dan for having the audacity to snap pictures of other people's children!)

Vendor arranging his fruit into mini-pyramids













Mid-afternoon street scene

Cart driver with two emaciated cattle!
(didn't notice his large smile until after uploading the pictures!)

Man herding sheep and running to his bike
(Credited to Dan, this picture was taken around the time when a herd of wayward blue-painted horned cows, each four times my size, stampeded around us! I was so scared, but these cows are pretty docile.)

The man above reunited with his bike and smiling for us!
(Credited to Dan)

On a sidenote, I also had my first food poisoning in India yesterday (with the hospital canteen's food!) Oh my gosh, what an experience! On the brighter side, my mentor for the study, Dr. Bindu Balasubramaniam, invited me to her house and offered to make a light dinner for me, some oatmeal or light dosa the next morning, and gave me some pantoprazole to take. It's great that I'm only a 2 minute walk away, and Dr. Padmaja, freely entering Dr. Bindu's house, asks me how I'm feeling and pats her palm lovingly on my head. Dr. Bindu asks how old I am, and I respond, "I'm twenty-three," and I almost sense something in her eyes become motherly toward me. To be honest, I was a little embarassed having to be taken care of, but I get the feeling that hospitality is second nature here.

Learning to eat the South Indian way...

So for the past few days now, and out of utmost respect for different cultures, I have been scrutinizing and training myself to eat like a South Indian. This is a bit hard when of course, it's not so easy to tell that no one's touching food with the left hand, or that curd (yogurt) is eaten only after sweets (if any), or that using your right hand to mix your rice and sambar (spicy veggy soup) into a clump to pop in your mouth is a precarious skill that takes a few tries.

The hospital canteen is a prime environment to learn all these survival skills, sans spoon if one is as determined like I think I am!

I'm freaking out here, mainly because the soap dispenser isn't dispensing soap, and the communal rag used to wipe your hands before taking food has been used by 20 or 30 hospital staff already. I notice that some hospital staff (even physicians) don't use soap to wash their hands after eating food (they just use water). Thus, I'm thinking: “can the spices serve as hygienic agents too? Because many spices and herbs do have antimicrobial properties...”

Enough of fear! I ignore all that because I'm not interested in starving. I have made some friends here with varying levels of English to teach me proper South Indian food etiquette.

So, below is a picture of a basic meal which I've labeled:

First, one uses only the right hand (sacred hand) to touch food, because as I later learned, the left hand (the unsacred hand) is used to serve others, clean yourself after using the toilet, and other “unsacred” activities. The left hand, however, can also touch silverware and the water pitcher, but it may never ever touch food. The reason being, if one hand is used only for the “dirty” things (left hand), then you won't ingest the “dirty” things when touching food with your right hand. This, I've come to understand, was an ancient method of hygiene—steeped in practical Hinduism. You can imagine the laughter when I used my left hand to break the chapati or papad (images above).

When no one's looking of course, I do use my left hand to eat...always forbidding using my left hand makes me feel half-disabled, half-accomplished.

The second lesson—food order:
(1) break the wheat flat bread (chapati) with your right hand in to small pieces (it's harder than it looks!) and use it to grab the sabzi (veggies), (you may dip the sabzi-chapati “mini-taco” into the soups),
(2) take out all the small stainless steel bowls from the large plate,
(3) dump rice into the large plate and the soups into the rice,
(4) knead the soupy rice mixture until satisfied,
(5) clump rice-soup with all 5 fingers to be rested on the middle, ring, and pinky fingers—pop into mouth,
(6) use the salty pickled carrot or veggie to salt the rice,
(7) break the big chip (papad) bit by bit and eat it directly (do NOT dip into rice-soup mix),
(8) finish with curd (yogurt)

I was eager to demonstrate my South Indian food etiquette at a lunch Dr. Balasubramanya (or Dr. Bala for short, one of the organization directors) invited me to, in celebration of the Hindu harvest festival yesterday (called “Sunkranti” or “Pongal”). Well, what can I say? Dr. Bala was delighted I sat on the floor and used only my hands!

It was an amazing cultural culinary experience--the traditional South Indian way! A plaintain leaf acted as the plate! On top of the large leaf was the yellowish lemon rice with maroon-skinned peanuts, rice with a hearty sambar (soup), some veggies options done tastefully and colorfully (ex. chopped cucumber with small golden nuts, and others), and pongal (a festival sweet) and of course, yogurt. Yum yum yum...lastly Dr. Bala's wife, also a physician, made a trail mix of sweets for us to take home, having used a mold to shape the sugary solution til it solidified into a bell-shape.

Of course, the festival did put the ethical review on hold and I was wandering around the hospital trying to catch Dr. Bindu (my research mentor) to discuss it, only to discover she was in her house celebrating. That's alright of course, because had we convened to “work,” I wouldn't have experienced my neighbor's homemade pongal (the special sweet), and her discourse on spiritual ascension and the purposeful ingredients of Indian food for each season.

The organization's staff here, whenever they are able, has always invited me for food or tea at their houses. I feel at home in this strange, yet familiar place...and it's great.

On Vivekananda's birthday...

Sunset in Saragur--and right outside my housing unit

A 1.5 hour drive from the city Mysore, Saragur is situated practically in the midst of sheep herders and tribal communities—the vast countryside. Swami Vivekananda Memorial Hospital, dedicated to the Nationalist spiritual leader Swami Vivekananda, is a mission hospital whose vision is “a caring and equitable society, free of deprivation and strife.” Actually, January 12 is Swami Vivekananda's birthday and the hospital staff were commemorating this in the prayer room which I unexpectedly passed. Ushering me to join the cross-legged crowd, an elderly lady sat beside me on the floor as incense and chants enveloped us. The finance officer later walked around with a fire on a plate of stainless steel, and everyone put their fingertips in the heat, following through by either wafting the heat to their faces or bringing their hands in prayer to their chests. The prayer ended with a coconut sweet for everyone to have! Caloric—yes, but I need it according to a physician there!

Vivekananda Memorial Hospital (VMH) runs India's first rural-based comprehensive HIV/AIDS program, and Karnataka (where Mysore and Saragur are located) is a high-risk state in India. Also, VMH just co-integrated HIV+ and HIV- patients in the same building—a first of its kind. This is a big deal for a country in which HIV/AIDS is highly stigmatized. Now how do I fit into this picture? (other than randomly joining a Hindu prayer?) Simple, I am conducting a patient satisfaction survey that aims to detect patients' perceptions of discrimination. Do seropositives (HIV/AIDS patients) perceive more discrimination than seronegatives (HIV- patients)? What may the hospital be overlooking in its quality of care? And how may the hospital improve their services to reduce stigma and discrimination?

The survey is being translated into Kannada as I speak! The Kannada script is bubbly, but block-like, and I'm mesmerized as I see people write in it.

Below are eye-candy (from my two road trips from the city to the rural hospital & a local school run by the same organization):

Woman leading oxen

See the hay rider?

Sheep grazing

Locals washing and sunning clothes

Yesterday, I had the opportunity to meet my first HIV+ patient in a hospital setting! I sat in on a counseling session where this semi-hollow cheeked 7 month pregnant woman came in, with her mother-in-law waiting outside the office. She was a fair-skinned, female whose eyes emitted a dimmed vitality. Here, counseling is considered part and parcel of the medical services. One receives counseling for anything really—financial counseling for medical fees (to establish a fair price—a sliding scale fee), spiritual counseling (suggestions on meditation techniques), STD/HIV counseling, etc. Of course, everything was conducted in Kannada—Karnataka's language—so I had no idea what was going on except she was pregnant. Afterwards, the counseling coordinator asked, “So, what do you think of her?” What an odd question to ask! I just told them she looked drained. Turns out, she's HIV+ and received HIV from her truckdriver husband. (In India, truckdrivers and migrant workers have been spreading HIV rapidly in rural areas.) Of their family, only husband and wife knows about their disease. Confidentiality is crucial—even the mother-in-law sitting outside had no idea what transpired in the counseling room. So, when will the rest of the family find out the couple is HIV+? The coordinator's response: “Relatives can usually guess it because of the frequency with which they obtain medicines. Eventually however, the rest of the family will know when couple cannot hide their physical conditions anymore.” However, the great news was, that the unborn child had a 99% rate of not having HIV transmitted! It just takes taking 4 tablets immediately after birth and some serum drops (if I heard correctly), and the infant can breastfeed without being infected. That is amazing!...minus the pains at which the infected feels the need to hide their status.

All in a day's (or two days) work

So, I woke up again to the hustles and bustles of Mysore—ubiquitous honking, melodious cries from vendors (I'm guessing), and the symphony of exotic chirps at dawn's crack. Quite a reliable alarm clock. It was so reliable, that after arriving at 4am and sleeping a bit, I was alert and ready to begin at 7:30am on my first day!

Finally after months of preparation with the help of many amazing mentors—Dr. Dratler, Dr. Madhivanan, and my mentors in India—Dr. Arun and Dr. Balasubramaniam, I'm here. Running around barefoot with remnants of mosquito bites in Indian garb at the Public Health Research Institute, I'm not worried at all about unforeseen delays and what-have-yous. I'm being Zen about it--acknowledging the process and calmly but intentionally effecting desired changes.

The road to Mysore from Bangalore airport was fun! I learned some Indian driving etiquette, such as: honk at anyone blocking your lane because many drive right smack dab on the dotted line. (Even the double lines are mere suggestions...) And, if others honk at you for doing the same, you kindly let them pass and give them a honk back. It's not exactly the road rage I see in America...quite the contrary! It's an acknowledgement that the road rules are fluid, so the etiquette is to accommodate once asked and if you are able. Of course, if you can't that's okay too, as there are always ways around it. For example, our tiny taxi was able to squish itself between hedges and a truck with a protrusive and monstrous bundle fastened with rope. It seemed as though the ropes could break, and those sacks of who-knows-what could come crashing on the taxi roof. But all is well, because we carefully and smoothly bypassed that disaster.

The scene from my mosquito screened window

I also made an impromptu presentation at the ethics review board at Vikram Hospital last night (and they approved of my project!). I've been forewarned innumerable times that Indian time is Indian Standard Time + x (x ranging from 15 min to infinity). Although the presentation was delayed 30 minutes, that was fine, because I gladly preoccupied myself with the hospital canteen! A glass of watermelon juice (delicious and thick!) cost me 18 Rupees ($0.37). Dr. Arun, my mentor for the urban study, personable and endowed with large enthusiastic eyes, was such a willing advocate for this project that I'm thinking, “even if delays happen, I know I'll will be in good hands.”

I'll be meeting my other mentor, Dr. Balasubramaniam, in a rural area (1 hour away from Mysore) later today. She is an OB/GYN and the director of a Community Health Centre which is dedicated to HIV/AIDS patient counseling, care, etc. Their affiliate hospital, Vivekananda Memorial Hospital, caters to the tribals too—the marginalized indigenous peoples forced to leave their forest dwellings in Saragur's environs. Anyway, the ethics board had many insightful suggestions to make. Guess I'll be doing paperwork and meet-and-greets for the rest of the day there.

The people here have been so pleasant! After gesticulating that I liked her sticker between her eyes, the house maid told me “come” and stuck a bindi on my third eye with matching colors to my garb...so sweet of her!