Sunday, December 17, 2006

De-planes are de-layed

Plan was, fly to Colombo, wait a few hours and then fly to London in time for a late breakfast at TC. In actuality, as both planes have been delayed, the plan has changed.

The one from Bangalore was delayed by 4 hours, but Arun, who has fingers in every travel pie, had specially made friends with the manager of Sri Lankan airlines who phoned him up personally to tell him of the delay, which meant that, instead of sitting at the airport for hours on upright, minimally padded metal tube chairs with only enough knee room between rows for the significantly shorter Indian thigh, I sat around with his lovely parents eating appam and sambar for supper, chatting.

The drive to the airport contained the most poetically perfect example of Indian traffic chaos to send me on my way. Despite leaving for the airport at 10.30, it wasn't long before we came upon a stationary line of traffic. My driver, who seemed to be from the more restrained part of the spectrum of Indian drivers, duly pulled up behind the car in front. We were on a two-way road with a single lane in each direction. After a couple of minutes of not much happening, I looked up and noticed that the number of lanes had expanded to 3. Courteously, the new lane makers had left enough space for a small car with no worries about losing a wing mirror or two, to get by in the other direction. But not for long. As soon it everyone else noticed how much more progress you could make by driving on the wrong side of the road, they all wanted a go. We made slower but more legal progress to the junction, where a lane divider separated the patient from the impatient drivers. A couple of the latter group made swashbuckling left turns cutting across all the legit and less legit lanes. In the midst of this swirling maelstrom was the most bemused and ineffective traffic policeman I have ever seen. He looked like a deer caught in 6 rows of headlights.

Anyway, after the first short flight, here I am, sitting gritty eyed at 3.40 am in Colombo airport listening to piped classical music, played, it would appear, on comb and paper, whilst a lot of christmas tree lights in this famously buddhist and hindu country twinkle rhythmically in plastic garlands and on trees. Occasionally, the music stops for an announcement made by someone who clearly trained at the the Karma Sutra School of Public Address. It's impossible to make out what she is saying but she sure says it in a suggestive fashion.

I hope the next (12 hour) flight is not delayed longer than the two hours they so far have promised. I don't have a very good record of getting back from India at the original scheduled time. The first trip, I was delayed by 24 hours and no-one, despite promising they would, informed Mum and Dad, who came to the airport to meet me after my being away, and at one point believed lost forever in revolutionary China, for 7 months, only to wait and wait and wait until everyone except me had got off the plane, which wasn't surprising, because I was in Dubai. The second trip to India, the plane from Calcutta was also delayed by 24 hours, but luckily, not only had I been away for less time, with no ventures into unstable war zones, I also managed to make the necessary phone call myself. This time I have managed to contact the most reliable member of my family, my Grandmother, who will disseminate the information as necessary.

I sincerely hope, however, that I don't make a hatrick of being 24 hours late.

Friday, December 15, 2006

Coming home for Christmas

Tomorrow I leave RUHSA for a last weekend in Bangalore before flying home to the UK for Christmas. I am really excited at going home and also really happy I am not leaving India for good. It’s a luxury to be able to spend enough time living in a foreign country that you get to go home for holidays, whilst knowing that you get to go home to stay eventually as well.

My suitcase is full of nothing but presents. I have packed no clothes at all, as currently I am only wearing "summer" clothes. Of course, in fact, it is winter here with a few concessional chill Christmas breezes-only somewhat cooler than the hairdryer-hot wafts of high summer. It is a lovely ambient temperature during the day, around 25 degrees, but for the average South Indian, these are arctic temperatures. The fleece and balaclava salesmen on the roadside are doing a roaring trade. Many an Indian scooter rips by with entire Indian families, of course, perched on them, all wearing vile puce coloured fleeces zipped up to the chin with a cheek-and-chin encasing balaclava hat and, if male, a lunghi. I feel like yelling out as they pass to forget the headgear, which looks ridiculous, get a pair of trousers and pair of socks on and even out the overall body temperature, but in reality, as a friend of mine pointed out, being warm-blooded animals, this whole charade should be unnecessary. My theory is that they are trying to recreate the 100% humidity and 40 degree heat of summer, inside their clothing.

Over the last few days I have been enjoying cycling up to the village to continue with my medicals. Vellore district is on the plain beyond the Deccan Plateau which spans almost the width and length of South India and makes the ride pleasant rather than arduous. The bike, like Mum’s school one, is a Hero with no gears, so despite the practically imperceptible undulation of the land, I still find it difficult for my legs to keep up with the pedals. I have attached my rickshaw hooter to the front, which affords much entertainment for both me and the school children, bus loads of men, passing rickshaws, solitary walkers and cows at whom it is a necessity to honk. Occasionally, during particularly enthusiastic knee activity, I accidentally hit the hooter for extra fun. Seeing the Indian countryside passing slowly by as I, comparatively speedily, cycle, is wonderful; the sinuous punk-headed palm trees bordering the brilliant green glistening paddy fields, where a figure with cloth-wrapped head and loins, bends tending to the young rice shoots.

As I pass by the rope-making village, I see the whole process of creating rough, strong hemp rope from insubstantial piles of brown fluff. The village consists of a row of several houses set below the road. At the extremities of the long spaces between the huts, fixed to the ground, are iron hand-winding frames with a central cog. Four hooks are evenly placed around the wheel, making a square, and rotate faster in the opposite direction.

The first strand grows magically. A woman, holding a basket of raw fibre under her right arm, keeps the rotating strand taut, feeding it the mahogany candy-floss, while walking backwards slowly away from the winding machine. Yesterday, a white-haired, slender lady, very gracefully wound the handle, never breaking pace or seeming to find it an exertion. Dotted around the work yard are huge mounds of raw hemp, on which a teenager or two lolls lazily, watching their mother and grandmother working industriously.

Once the smaller strands are formed, four of them are attached to each hook on the machine’s wheel. Another family member, far away at the edge of the village, holds all four strands attached to a hand hook which also revolves, in rhythm with the twisting of the rope, whilst the handle remains still and stable. A man, needed for his strength, winds the machine handle and all the strands dance separately yet synchronously, intertwining themselves into a recognisable single strand of perfect rope. On the road side, from the branches of the Neem trees, half-coiled like Kaa the python trying to leave his tree to snack on Mowgli, hang their finished handiwork for sale. It is a beautiful spectacle.

Arriving at the village today, I had to do a home visit. It was a little different from those I did in Kirkby or Dalton. We walked through the village on and beyond the tarmac to a sand track weaving between palm-roofed houses. Outside one, in the blazing sunlight, the old lady I came to see was seated on the ground, a sack on her lap to protect her legs from the sharp-edged, dried leaves she was weaving deftly, despite arthritic hands, into more thatch for her house. Mobility was impossible for her because she had fallen a couple of years ago, and despite probably having fractured her neck of femur, was unable to afford surgery. She has been unable to weight bear or move without being held by two people since then. She is the sole carer of her achondroplastic, staturely challenged, 40 year old son, who, having limited marriage prospects, has remained single. No new generations are available to help with the burden of care.

Home visits in India, unlike the UK, are a popular and well-attended spectator sport. Confidentiality is impossible when there are friends, relatives, neighbours unashamedly listening and contributing to the old lady’s story. Whilst they are not missing a detail of her complex medical history, they manage to find out whether the funny white doctor is married ("No." "Why?" – How do you answer that?). It has been an extraordinary experience doing these medicals, requiring quite different skills from those utilised at home. It is amazing how much of a barrier there is between a doctor and patient who can’t communicate directly. In some ways too, there are surprising moments of connection, through non-verbal means. When, via the interpreter, I asked if the lady had any problems moving her bowels, she tutted, shook her head and rubbed her knees furiously. I patted her arm and said, "I know exactly how you feel, my knees are killing me too." We laughed.

Sometimes, though, I know the interpreter hasn’t understood why I’ve asked a particular question and asks a different one. The subtlety of nuance and impression revealing important cues crucial to understanding someone’s health beliefs are mostly lost. Sometimes, the interpreter is embarrassed asking certain questions. I find it difficult not to be able to broach difficult topics delicately myself, framing and leading into the sensitively-phrased questions according to the patient’s response. Having an interpreter brutalises the consultation process.

The great bonus in doing these home visits, is that I am a walking, talking sandwich board for the project and there is a palpable interest in what is happening. By paying attention to the more usually neglected or ignored elderly, we have, I hope, elevated their status, and will encourage them to continue to engage with us. A potential problem to be overcome was the shame of someone coming to the clinic and showing the rest of the village that they were not looked after by their families. The level of interest being shown to us as we wander through the village suggests, at present at least, that people want to come and join the program. We shall see in January if that’s the case.

Back at RUHSA campus, there is a suggestion of Christmas, despite the un-seasonal weather. In the hospital yard is a huge, familiarly palm-roofed crèche, surrounded by seated saried and lunghied patients, staring inquisitively at me as I take a picture of it and the "Christmas Tree" (straggly, wilting fir branch with one star on the bowed top). On the ceiling of the outpatient clinic, where brisk-walking nurses in their regulation plain, sky-blue, crisp saris, ferry trays of equipment and notes to and fro, are strung rows and rows of coloured twisted crepe paper and tinsel. The other day, I even heard ‘Hark the Herald Angels Sing’ wafting through the coconut palms. Hindu sandalwood-striped foreheads and Muslim embroidered hats mingle easily amongst the Christian decorations.

So today, I start my journey from RUHSA’s tropical Christmas to a more familiar celebration with my family. Last night, as is my long-held, intractable habit, I was up until 4.20 am, packing and generally footling (in reality writing this posting instead of packing). I am very much looking forward to getting home, although, it would also have been an amazing experience to spend Christmas here. I can’t wait to see everyone and hear what has been happening in the four months since I left. Most especially I am looking forward to being greeted only by people who know me; no random shopkeeper or passing giggling school girl will ask me for my "good name, please, Madam". I will enjoy being anonymous and not an unintentional source of constant entertainment.

Hopefully, for the next 10 days I will be laughed with not laughed at.

Saturday, December 09, 2006

Taking their first medical history in 70 years

As mentioned, over the last two days I have been carrying out medicals on some of the elderly villagers of Keelalathur. It was a sobering experience and I am never going to tolerate people slagging off the NHS again. The people I saw are amongst the most vulnerable of the villagers and have been targeted for exactly that reason.

There are many compounding reasons for their vulnerability. Firstly, elderly people have increased morbidity, secondly, there is a concomitant loss of function which makes self-care harder. This is true of all elderly the world over, but in India there are other factors to be considered. Traditionally, people live in extended families of up to 40 people, or even more. In arrangements like this different generations live together and, apart from the expected in-fighting and petty jealousies, there is mutual support between family members. This sounds like a good, non-governmental method of creating a welfare system, but when you add a dash of poverty, the recipe changes.

Village houses vary in type, from concrete squares with 4 solid walls, a roof, windows and several rooms, to a small, low, long hut made of adobe (cow shit) covered in withering palm leaf thatch. One room serves every function from kitchen to bedroom (the loo is "open plan", ie, you shit on the road side) and there is no chimney. Cooking is usually done over a stick fire or kerosene stove. There has been some effort to utilise biogas and bottled gas, but the latter is expensive and the former, although a brilliant idea, only works where there are enough cows to provide enough crap to provide enough gas to cook a chappati on, and there aren't. As a result the huts are full of health-destroying smoke which has nowhere to go. The only filtration system is the capillary gas exchange of the many occupants' lungs.

This is just one of the multitude of health problems resulting from the villagers' lifestyle and I haven't even mentioned malnutrition, gastroenteritis, mosquito-borne disease, TB, undiagnosed cancers, leprosy (fortunately drastically reduced since I last visited, but India is still one of the 7 countries remaining worldwide not to have controlled it adequately), injury (from the total absence of health and safety measures), rising diabetes problems; and doesn't even begin to touch on the possible mental health effects of such an existence. A colleague at RUHSA conducted a study in the area and found a staggering suicide rate of 148 per 100,000, with the highest number in young girls from 10-19, as compared to a rate of 2.6 per 100,000 in the UK.

The lovely romantic notion of family members living side-by-side in mutually beneficial harmony (a difficult image to sustain once you have seen the adobe huts) is not the reality. In the villages, there is so little money to be made by staying put, that the younger generation often leaves to work in the cities and leave the older people behind. Several of our elderly people are widowed and living alone. Alternatively, if the younger generation has stayed put, living in extended families, the meagre income is prioritised to feed those family members who can generate more money. This is rarely the crooked white-haired grandmother with a ragged cotton sari and barefeet.

The government has a partial solution to this problem. Elderly people who have no sons (whose responsibility, traditionally, it is to look after the elder family members) get 200rs per month (₤2.35), which is a pitiable sum, but those who have sons get nothing. As there is not enough money for basic essentials, you can imagine what the spending is on health care. Zilch. Except in extreme emergencies, when the essentials are forgone. But even then, the elderly do not pass the criteria required to count for an extreme emergency. They are old, they are going to die anyway. Why waste money. It's the brutal end of a spectrum we are surprisingly familiar with in the UK, but we pretend we are not.

Our project is a small attempt at introducing the concept of elderly care into a culture where even to be old is an achievement. With the "greying" of the population - India has the second highest number of people aged over 60 in the world - occurring here at a faster rate than in the UK, with no provision for elderly healthcare, nor even for a consistent universal primary healthcare, it feels like a futile drop in a stormy ocean, but the ocean, too, started as a drop. And before that there was also Chaos.

Sitting in the yard of the Community Centre building, with the tamarind leaves gently dropping onto our precious note paper, watching the stooped, barely clothed people coming across to us, handsome faced and dignified, I thought of how far from my UK practice I was. We greet each identically with hands clasped in front of our faces, smiling, our heads rocking in synchrony. For each of them, the first question, through the translator, is: "Have you got any medical problems?".

It's a peculiarly difficult question to ask when there are no notes, no previous records, no knowledge of their life for the last 70 years; it seems to create an undulation of despair in them. Where can they start? Of course they have medical problems. Even the act of going to the loo, without the benefit of Occupational Therapy putting in handrails in or raising the loo seat - they have to get up and down from squatting 6 inches off the ground - causes problems for their elderly, arthritic, undernourished joints. Forget about the fact that they are trying to earn one or two rupees a day by sweeping the temple floor with a brush made of coconut fibres, requiring requires a posture akin to someone actually picking the dust up from the floor by hand.

On the first day, I met three people. None of them weighed more than 37 kilos (less than 6 stone). They all had marked kyphosis - dowager's hump - caused by osteoporosis and all of them looked bewildered at the interest we were paying them. Yesterday, I saw 5 more people. The first lady cried when I asked about any medical problems. She rattled off a long list of concerns - poor sleep, difficulty breathing, no appetite, problems swallowing, constipation, pains in her stomach, to name a few. She lived all alone, hunched and helpless. She had never been inside the community centre to see the doctor in her life. She was telling her medical history for the first time.

During the examination, it became apparent that this lady, in addition to her long list of existing chronic problems, was acutely unwell. She was pyrexial, tachycardic, tachypnoeic with a low blood pressure. It was at this point that the wonder of the NHS truly became apparent. At home, I would have sent her into hospital. I would also, probably, have known more about her than I did. The receptionist would have called an ambulance, it would have come to the surgery, picked her up and taken her into hospital, where hopefully, the source of her infection would have been investigated, she would have been treated with antibiotics and been discharged back home, with perhaps a care package to ensure she could cope at home. Now obviously, sometimes, details within the NHS let us down, but we never stop expecting it to look after our health. We take for granted that our doctor, although perhaps she (or he) can't maybe give us enough time, knows what pills we are on, what problems we had with our bowels last year, that we had a crisis of confidence at the start of a new job. We take for granted that, as women of childbearing age, we will be called for a smear test every few years; that we can go to countries where polio still exists, safe in the knowledge that we have been vaccinated against it.
And all this without having to make the choice between health and nutrition.

Staring, helplessly at the darkly wrinkled face, I weighed up the options she had. To go to hospital she would need transport, a bus, for which she needed money. To receive treatment from the hospital, she would need money. To get medication from the chemist, she would need money. She had none. She could do none of these things. There was an option of coming back to the mobile clinic in 6 days, where she could get some pills, and they would probably waive her fees, but she needed some treatment now. The best we could do was to buy her 12 paracetamol for 12 pence and hope for the best. On a little slip of paper I wrote a note to the doctor in the following week's clinic hoping that nothing disastrous happened over the next 6 days. So now, you can understand why my tolerance of people moaning about the NHS will be very very low.

Thursday, December 07, 2006

Awaiting Committee(s) Approval

Today I used a stethoscope for the first time in 3 1/2 months. I went to Keelalathur village to do medicals on the elderly people who are going to be attending our community centre. It sounds so simple, but being India of course it wasn't. Actually, today is the first day that I have been frustrated to the point of having my mood affected. Usually, a good old head wobble and a grin is enough remind me that I am a guest in this country and with a bit of luck, charm and persuasion anything is possible. However, today, the limits of possibility seemed to be visible.

I am the only person who seems to be in the least bit anxious about the project’s time scale. In one week and one day I am leaving RUHSA for Christmas. In 5 weeks, we have planned an inauguration of our community centre. Dr William Cutting, a retired paediatrician from Scotland, who was instrumental in the inception of RUHSA, is visiting for two days in January. Back when it seemed easily possible, we planned for the community centre’s "Grand Opening" to coincide with his visit, for him to cut a ribbon or two. The Grand Opening is gradually becoming less grand and there is less and less to open.

For the last month or so, I have been agitating and putting direct and indirect pressure on RUHSA’s engineer, Donald (about whom I can't say anything bad because he is responsible for the future installation) for him to get the kitchen built in time. Donald has a list of 26 jobs to do (the kitchen makes the 27th and my loo, which has snuck in through the mosquito flap, is number 28). Donald looks terrified of me and on principle says "No problem" to everything I ask, until I ask for specifics, in which case he just says "No". It is a small comfort to find builders and workmen are the same the world over. There is a fluidity of neck muscles amongst Indian workmen which is absent in their British counterparts, but the sharp intakes of breath accompanying the head movements, drawn in through clenched teeth, are identical.

On Monday, we had a frustrating but ultimately useful "site meeting". We now have a plan, which can be presented to the Committee which allows plans to become formalised and set down on paper, before the paper version can be submitted to the Committee which agrees whether this plan is ok and forwards it to the Committee which decides how much money is needed for the project before it goes on to the Committee which decides whether the amount decided is enough, blah, blah blah. As you might imagine, it is unlikely that Donald will be able to get through the 47 required Committees before the 11th January, let alone get the first brick laid. Despite this self-evident truth, always the answer is "No problem". On a side note about Committees, I am reliably informed that the CMC Hospital (of which RUHSA is a department) excels in Committeeship. It you want something done, you have to form a Committee. And if you want something not to be done, you have to form a sub Committee. To excel in Committeeship in India is an achievement indeed.

So now, we are thinking, perhaps, instead of a Grand Opening of an unbuilt kitchen, we can have an Open Day instead - an exhibition informing the community about the plans for the centre – and also start the food program. The Self Help Group women can make the food in their homes and bring it to the centre. Great idea, sounds possible even in the short time frame. Give the centre a bit of spit and polish (only 3 Committees needed to approve that) and get some furniture, benches, chairs, mats, eating utensils etc, with the money sent over from the Trustees in October. Then I discovered that the money, which is sitting in a bank account somewhere in Vellore, is not able to be spent because it needs approval from a Committee. There is a glimmer of hope. It is possible that a quick word from the Director (Dr John) to an Emergency Accounts Committee will allow some emergency funds to be released. Unfortunately, he is freezing in Denmark (without socks) for the next 2 weeks so nothing can be done until then. By the time he returns, I shall be freezing in England (with socks) eating crunchy vegetables and no curry (I hope).

Feeling a little bruised but by no means quashed (yet) after all of this, we began to plan how I would carry out the medicals. Mr Jebaraj, one of the team members, has been traipsing around the village conducting a quality of life questionnaire. The team had decided that my attendance might be detrimental so I couldn’t do the medicals at the same time. I had been promised that these would be finished two weeks ago but something has always come up. Never on first asking. No. On first asking it is always, "No problem". However, when I ask to see the finished QOL questionnaires or ask exactly how many have been completed, then the truth seeps out, reluctantly and ambiguously.

A plan was made at our Wednesday staff meeting, which is being attended by fewer people each week. Despite it being a regular weekly occurrance, people still manage to look astonished when I ask them if they are coming. I get the distinct impression people are starting to hide when they hear me coming. As I have a peepi-peepi on my bike, they get plenty of warning. Whilst sitting in the meeting, looking around at the sparse blue concrete walls and empty beige plastic chairs, I had a brainwave. Every week a mini-bus takes medical supplies and a few staff to Keelalathur where I was going the next morning to catch any of our target group who might attend the clinic. I felt a bit faint at the idea of trying to mesh my needs in with the clinic's and I thought it would be better if I could take everything I might need and not interfere with the other staff at all. So, my brilliant idea was, why don’t we take 3 chairs from the meeting room with us (knowing there are only enough to run the clinic).

You would think I had asked to borrow their own personal bedding for an orgy. For once I was told directly "No it’s not possible". Why? Well, firstly, you need to ask permission (of who?) and then get a receipt (from who?) and then ask permission of the transport department to allow them into the van and ask the clinic staff if they minded sharing the van with some renegade chairs. Feeling slightly stubborn, I said, fine, who do I ask. No direct answer. So I asked a few people who all gave me equally indirect answers and finally narrowed things down a tiny bit. Apparently the chairs in the meeting room were definitely taboo, but I could take some folding metal chairs (perfect) which were in the Community College next to the Transport Department, whose permission I still needed in order to take them to the village. Happily, I cycled off to find the various Important People to ask. I was feeling triumphant. I had Beaten the System. I was back in the world of No Problem. Every one I asked was more than happy to help. Just to be sure of my victory, I went again first thing in the morning to check that all systems were still go. They were. I waited excitedly for the clinic bus to arrive. Of course there were no chairs in it. Apparently I had got permission from everybody except the person who had the chairs (I still have no idea who that is) so all anyone was every agreeing to was the principle of transporting chairs to and from the village.

We ended up chairless at the village, the clinic started late and no-one turned up to see me. We wandered around the streets asking in all the houses trying to find our target clientele. Eventually we found 3 people. Even seeing and examining those three was a lesson in itself.

Friday, December 01, 2006

What a hoot!

Every object with more than one wheel has some mechanism for making a disproportionate amount of noise. It's mandatory. As per the instructions "Sound Horn OK" painted on each tailgate beween Shiva's third eye and garish but arresting flowers (and a slightly peculiar maxim I have yet to get to the bottom of, but apparently is a veiled reference to family planning - "We two ours one"). There is therefore stiff competition for the few molecules of sound-empty air space. Today, I contributed to the hullaballoo.

I went in search of some rickshaw hooters (in Tamil it would appear they are called peepi-peepis). It was really, considering the difficulty I had in trying to get someone, anyone, to understand about tin-openers, astonishingly easy to make myself understood. It could be something to do with the fact that there is a huge density of hooters per square metre - one indeed, a big Daddy Parper, was parked outside the first shop I asked in. Not knowing the word I needed was peepi-peepi, after a few futile minutes of me opening and closing my hand over an imaginary bulb and making farting noises being met with familiarly blank looks, I stepped neatly to one side and opened and closed my had over a real bulb and made real farting noises. The message was understood and I was directed to a shop was only a few metres away.

History will never reveal what the shopkeepers thought a white Englishwoman, who seemed inordinately amused by the sounds of the peepi-peepis, wanted with them. A new Rickshaw wallah on the scene perhaps.

The trip back through town was surprisingly unimpeded. A rickshaw came to a stop just in front of me and leant out to ask if I "wanted a ride, madam" He nearly jumped out of his skin with my reply. He had no horn to respond with. A man, not looking where he was going, nearly walked into me. There was no collision, but there may have been a ruptured eardrum.

Before I went back into the library, where I would have to curb my enthusiastic use for the peepi-peepi, I went to the tailor (of Innerwear fame) to buy some material. The One-Woman-sideshow-with-Peepi-peepi went down a storm and we spent a happy hour alternately chosing material and honking back at the traffic. Many passers-by did not know in which direction to jump. I can't wait to affix it to my bike and go cycling madly up and down the villages, parping at anyone and everyone. It's amazing how much entertainment you can get for just 50p.