Monday, January 10, 2011

Days 10-12 - Villages with Mobile Hospital

Each of these days we visited a different village.  The 12 nodal villages provide services for 96 villages in all.  I saw little of the first village except the school where we held the clinics.  The uniformed children had their lessons that day under trees behind the school buildings.  I spent some time walking around the second village, which surrounded the school so was easy to access.  It was picturesque in a rural way, with women talking together while they drew water at the communal pump, old people sitting in open doorways, women on porches preparing food.  Today's clinic was in a school facility outside the village, which is the more modern way of building schools, but means I saw nothing of the village itself.

Village buildings here tend to be build of concrete as there is little wood available on the Deccan Plateau, which is where we are.  Many have thatched roofs.  Utility poles are concrete and fences tend to be slabs of concrete or stone set upright like a line of tombstones.  Travel is by motor rickshaw and I saw almost no cars.  The schools are bare concrete, drab and in poor condition, but they may have stone floors.  The children sit on long metal benches attached to long metal tables.  The central square usually contains a shrine and is unpaved.  The streets tend to be packed dirt, but there is very little trash around, refreshing for India.  (The trash problem is of course serious and well known.  Even the doctors will toss trash out the window rather than get up to put it in the trash bin.  There needs to be a national campaign.)  The area is richly endowed with communication towers and surprising numbers of people have mobile phones.  Some people may have TVs.  As I've mentioned, both Muslims and Hindus live in these villages, but we have been told that the groups seldom socialize together.  All the children are adorable, full of energy and curiosity, run around all over the place, peek in at the clinic windows, and smile readily.  The little girls are giggly and shy.  While there are some small trees and shrubs, the women's saris provide most of the color in the villages, something else to be said in favor of this mode of dress.  As Rhoda pointed out, you never see the same sari twice.  There are scruffy dogs all over (in Puttaparthi too, along with fruit bats and monkeys) that do not seem to belong to anyone.  You would not want to touch them, but you are advised not to do so because they have fleas and worse.  Curiously, all the dogs look alike.  They are medium sized, trim, beige, with long tails.  Perhaps there is inbreeding going on.  There are occasional sounds of bellowing oxen, wooden ox carts being the chief means of moving goods from place to place.

My job all three days was to keep track of PAP smear slides and biopsies.  This was a step up from washing the equipment.  I would make sure the doctors completed the reports for the pathologist.  Then I would wrap up the slides with proper identification, label the biopsy bottles, and place matching reports and samples into little zip lock bags destined for the pathologist, an amazing man who donates days and evenings to the mobile hospital.  We did a lot of smears and biopsies, so this kept me reasonably busy.  The first day was a little chaotic until we developed a system, which from my perspective involved bothering people until I got what I needed to fill up the little bags.  Dr. Rhoda of course taught the five trainee doctors about VIA, cryo and LEEP.  We did 2 cryos and 2 LEEPS I believe.  We saw many women, but I don't yet have the total.  Sadly, we found one tiny 68 year old woman with cervical cancer, and I was invited to look through the speculum to see what it looks like.  Quite disturbing.  This woman had never been screened.  The insidiousness of the disease is that it is asymptomatic until it's too late, which is why screening is so critical.  We told this woman to go to the hospital, but she is just as likely to go home and die. We also saw a woman with a completely prolapsed uterus, which means it had inverted through the vagina and was hanging down outside her body.  You could push it back in, but it would just fall out again.  This must be very uncomfortable for her, to say the least.  She was of course referred to the hospital too, for reconstructive surgery.  One woman fainted after her procedure, but was ok again within minutes. 

There was a very moving moment on day 11 when a young woman who had had a LEEP procedure come to the clinic to personally thank Dr. Rhoda for saving her life.  She brought her daughter and introduced us to her.  If there is one memory that will epitomize for me the good we are doing, it was this moment, when the young woman took hold of both of Rhoda's hands and wouldn't let go. 

There is some wealth in the villages.  We saw one 22 year old woman who wanted to be examined for infertility.  Her mother brought her in.  She was beautiful and had quite a bit of gold around her neck, and about 10 gold bangles on each wrist.  She definitely stood out.  We had a lunch in the home of the head of one of the villages.  The front of the house was indistinguishable from all the other cracked concrete structures.  A third of the front room was full of sacks of rice to be sold.  There was little furniture or modern conveniences.  There were, however, several rooms, whereas most of the houses look quite small, maybe a room or two. 

I had a chat with the Hyderabad pediatrician on duty and learned that village children do not wear diapers, ever.  Nor are they wiped.  As a result they get frequent urinary track infections.  At least they are not creating landfill problems.  Many kids have mottled teach, perhaps from the excess fluoride I previously referred to.  There is a lot of anemia.

I previously reported that birth control consists of two children followed by tubal ligation.  Of course, it's not that simple.  Mother Theresa, a good Catholic, opposed family planning and was quite influential in India, so that's part of the challenge.  However, there have been inroads in some of the villages.  In her area Muslim men are allowed to have up to four wives.  Each of those wives may have 10 children, for a total of 40.  She saw one 40 year old woman who had 22 kids, and only stopped because her husband died (one wonders why he went first).  Mother in laws have a lot of power, and if she wants her daughter in law to have more children, the woman probably will.  She sees a lot of children with birth defects, not clear why.  It could have to do with consanguinity among marriages in villages. 

Rhoda was asked to address the cervical cancer vaccine several times.  India tried it a few years ago and there were six deaths of women who had been vaccinated.  All of those deaths were for documented reasons other than the vaccine.  Nevertheless, it caused the program to come to a halt.  It will probably be reintroduced, but with better outreach and education. (Reminds me a bit of the uproar in California over smart meters.)  It is not a complete shield, however, so screening will still be necessary.  Also, it won't be of much use to the millions of older women who are the main victims of this disease.  Deborah


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