CMC Community and Psych - May 12-14, 17-18

Urban Health -

We finished up our community health rotation with the CMC College of Nursing Urban Health Department. We saw another impressive example of nurses and student nurses making an impact in a low-resource environment.

Among other valuable lessons, we learned how to make an economical and ecological small paper bag out of newspaper for stool specimen collection - I'm sure this will come in handy at some point in our careers!

Psychiatry

The psychiatry hospital at CMC is a truly family-centered program. On the grounds of the hospital are housing options for patient and family where families are required to stay with the patient in order to learn about their therapy and drug regimen in order to make the transition back home easier. The hospital also features an impressive family center for children with intellectual disabilities. The multidisciplinary team of doctors, nurses, occupational therapists, social workers and many others collaborate to provide comprehensive care for the patients and their family.    They also use electro-convulsive therapy (ECT), aka "shock" therapy for some patients.  Below are the drugs used during ECT, as prepared by the nurse.

May 10-11 - CONCH, CHAD and RUHSA

CONCH:

We visited a variety of sites run by the Rural Community Health Department starting bright and early Monday morning. There are a total of 20 sites, each entirely run by nurses. Nursing students from the College of Nursing spend a considerable amount of time at these sites learning assessment skills, patient education skills, and community health theory. We were guided by Mrs. Priya, a nurse-midwife with nine-years experience and a fellowship in Family Practice. She is also a tutor (lecturer/clinical instructor) at the CoN.
On Monday we visited Arapakkam, a village with a population of approximately 2,000 people. The nurse run clinic there is associated with the College of Nursing Community Health (CONCH) program. They provide care in the clinic as well as making home visits. They do home visits for antenatal patients, postnatal patients, patients with chronic illnesses (most commonly hypertension and diabetes), infants and malnourished children. We visited a government run preschool in the village, took a tour of the village, observed a home visit for an elderly women with hypertension and observed prenatal care at the clinic. Below is a shot of the medication being dispensed at the clinic.

On Tuesday we visited our second CONCH site, another rural health clinic, again accompanied by the fearless Mrs. Priya, who somehow had not run out of patience for us! The model was the same as the first with a few more programs such as a geriatric day program being conducted as well as a community health lesson for local mothers about child, home safety. Coincidentally, we also saw a young boy come in with his mother with burns from spilled hot tea which served as an anecdote during the lesson. He was given first aid and referred to the hospital for further treatment.

Of interest, the temperature hit 108F today.
CHAD:

Community Health and Development (CHAD) is a Christian Medical College (CMC) run program serving the Kanniyamvadi block. Our orientation leader, Julius, a college tutor and nurse, gave a thorough overview of the available services offered at the base hospital and the outreach services.
They offer a family centered model of care. Weekly specialist clinics include TB and HIV, high-risk antenatal care, general clinics, diabetes and leprosy. They also pride themselves on their research collaborations with CMC, NGOs and international partners. In terms of outreach services, CHAD runs doctor-run and nurse-run clinics. Both models extensively involve nurses to deliver home base care and gather vital population statistics for each village. Other outreach services include income generating activities for women, a suicidal intervention program, marriage counseling, and training and development for village health nurses.

RUHSA:

The Rural Unit for Health and Social Affairs (RUHSA) is another CMC run program serving the K.V. Kuppam block, which is composed of 100+ villages, 18 centers and approximately 100,000 (1 lakh) people. Each is managed by a rural community officer who coordinates the volunteer corps that helps run health, social development and economic development initiatives. They have an integrated model for rural development which complements government initiatives. They organize youth groups, trade co-ops, women's groups, elderly daycare centers, tribal development education programs and a community college.

Along with their community initiatives they also have a 75 bed hospital with secondary care services which serves the 100+ villages. They can perform a limited number of surgeries including tubal ligation (tubectomy) and cesarean sections. Pictured below are the labor and delivery beds and the laboratory for in-house blood tests and urinalysis.

May 8-9, Mahaballipuram

On our first weekend off we made a trip to the coastal town of Mahabalipuram, aka "Backpackistan" - famous for temples, monuments, beach resorts and of course, backpackers.

We started off at 6am in a hired car (this time with glorious AC!) and a super friendly driver - Ashok. We were deadset on heading straight to the beach, but were sidetracked by a temple in Kanchipuram.

Ekambareshvara Temple: This temple is famous for its 1,008 lingas, which represent Shiva. It was mostly constructed in the 16th and 17th c. In the middle of the temple is a mango tree which represents the marriage of Shiva and Kamakshi. What was supposed to be a 15-min sidetrip, turned into a 3-hour tour... After being sufficiently blessed, and with empty wallets, we headed back out on the road.

Mahabalipuram: We rolled into town late morning and found a little restaurant that served a nice mix of French (crepes!), British and Indian - everyone was satiated. The heat was fairly unbearable so we could think of no better way to spend the afternoon than going on a grand tour of 6 monuments - with AC in the car in between!

Monument #1: Tiger Cave and Lookout Point
Tiger Cave - Included a niche surrounded by carved tigers where kings meditated.
Lookout Point - Used to search for approaching adversaries and where our tour guide clambered up to escape the Tsunami in 2005.

Monument #2: Shore Temple

This temple is one of the oldest temples in south India, built in the early 8th c. It's design spread across south India and southeast Asia. The temple is surrounded by the bull, Nandi, and has an east and west shrine, as can be seen in the photo.

Monument #3: Five Rathas aka Panchapandava (aka Smurf Village)

These date to Narsimhavarman 1, between 630-670CE and represent the five chariots of Pandava, an Indian dynasty. The monument is composed of 5 sculptures immitating traditional temples (and looked like Smurf Village-like houses) and a lifesize elephant. The style is a model for Dravida, southern style. We were again asked to pose for many Indian family photos - its funny to think we will be included in a strangers family photo album!

Monument #4: Mahishasuramardini (Old Lighthouse Temple)This temple was placed on a high rock ledge where a modern day lighthouse has also been built. There were lots of goats and a great view all the way to the shore. The rock carving is one of the most celebrated pieces of Indian art. It portrays a battle between Mahishasura (bad guy) and the good guys (gods).

Monument #5: Krishna Mandapa

This detail of the very large, intricate bas-relief carvings at Krishna Mandapa shows Krishna milking a cow.

Monument #6: Arjuna's Penance

Another intricate bas-relief example with a life-size elephant and elephant calf. It depicts the story of Arjuna traveling to the Ganges to do penance in the hope that Shiva would part with his favorite weapon, a magic staff.

We relaxed with a stroll on the beach among the fishing boats after our long temple-touring day.

On the way home on Sunday we stopped again in Kanchipuram, again, for what we thought would be a quick trip, this time to a Sari shop, but turned into many cups of masala chai, a demonstration of silk sari making and just a few purchases...

We made it home by 8pm and went to bed soon after, in anticipation of a busy week with the College of Nursing Community Health and Psych Departments.

May 6-7, Vellore, India

May 6:

Rolled into the Sheraton like hill-billies at the Ritz, dusty, hungry, tired, and grumpy from our second overnight train ride. There was a man in the next compartment who sounded like he had TB and from the sounds of his cough, did not have a good night. Neither did we!

Note: Please take special care to read the travel advisories posted on our train in the above picture.

Then we spent three hours, that felt like ten, en route to Vellore in a hippie van, stuck in traffic, with no AC. Did we mention it was HOT?!

We arrived in Vellore and made it to the lovely oasis of the Bergen House at Christian Medical College. After some icy hours in AC and some great naps, we felt restored!

May 7, 2010
Morning started off right with yoga for some, running for others. One man down, perhaps chaat (street food) night was a bad decision. The six of us remaining hopped on the bus from our lovely Bergen guest house and headed over to the CMC College of Nursing. There, we were welcomed by Mrs. Shirley David and soon after met with the Dean of the College of Nursing/Professor and Head of the Community Health Nursing Department, Mrs. Rosaline Jayakaran. The rest of the day, we were oriented to the role of nurses at CMC and their well-established community nursing programs.

CMC History 101:
CMC’s College of Nursing was founded by Ida Sophia Scudder, an American daughter of medical missionary born in India and raised in America. On a return trip to India, she was summoned one night to help three laboring women although she had no medical knowledge. The families in need would not accept the help of her father who was a doctor because he was a man. Sadly, all three women died in childbirth that night. Traumatized by the experience, Ida decided to go home to America to study medicine. After acquiring her degree, she returned to India and transformed her home into a one bedroom hospital which has today grown into the largest hospital in Southeast Asia, with 2,622 beds.

Auto-rickshaw ride
We survived our first auto-rickshaw ride today. Along the way, we picked up a few rules of the road:
1. Honk as much as possible
2. Cram too many people into the road
3. Drive on the Left
4. Drive on the Right
5. Drive into Oncoming Traffic!
6. Brake for nothing, except for cows

Wednesday, May 5, 2010 - Thanjavore, INDIA

On our second day in Thanjavore, we met with Shayamala who is in charge of the outreach programs for ICTPH. She gave us a debriefing session in the morning regarding their different programs. They have many community health workers (CHWs) who serve as liaisons from the community members to the clinic. The CHWs are chosen from both the high and low caste areas of town giving the women an opportunity to interact with each other in group sessions. They operate on a volunteer basis and are an integral part of ICTPH's business. Each CHW is in charge of 50 households, and the CHW then manages five peer leaders who each cover ten households.

ICTPH has done three main outreach programs in different villages: water chlorination, a rangoli contest, and a queen of the kitchen contest. The chlorination project educates the community on the importance of everything from hand washing all the way to using point-of-use chlorination. ICTPH supplies the first three months of tablets and then once the people realize how easy they are to use, they then buy the rest of the tablets for thirty cents a month. This ensures that the community of Allukady will be drinking potable water.

Their second project, the rangoli education campaign, uses very intricate chalk drawings that every household draws outside of their doors. CHW teams competed with each other to have the best pictation on how to prevent certain diseases. For example, some of the pictures showed how to wash hands and how to avoid getting TB. The CHW teams then won prizes for the best rangoli.

Their third outreach program was the Queen of the Kitchen contest. Women were provided with heart healthy recipes and food beforehand, and then the women showed up to make the dishes that day. They then won prizes for best presentation at the end of the day.

We all had the opportunity in the afternoon to spend a day with one or two CHWs in their homes. We were all paired with a member of ICTPH who could translate Tamil for us. We interviewed the women regarding their motivations and how they felt being a CHW. The opportunity to go into their homes and share a cup of masala tea (chai), fresh cow milk (!), or south indian coffee with them was amazing! They were so proud to be CHWs and to show us the CHW logo on each of their bags. The logo expresses both the aspects of health and light, Nala Oli. They were excited to be advancing their knowledge and to be a community resource because some of these women never went farther than high school. One woman expressed that she was a housewife before, and now she is able to get out of the house and interact with the village. She really wanted to improve the social welfare of her community and was motivated by the social aspect of being a CHW.

That evening, Dr. Sharma invited us to attend her daughter, Hiteshi's, third birthday party. Her daughter wore a lehnga and we all ate Indian snack food and cake with rosewater frosting. We ate mysore pak which is made from chickpea flour, sugar, and ghee. Sugarfest! Her mother expressed that she was upset because her father recently shaved her hair because it has been so hot. Did we mention it is HOT?

Day 1 in Thanjavur

We took an overnight train to Thanjavur and arrived this morning at 6am. We travelled with Sapna, an ICTPH staff member, who took us under her wing and made sure we had the right bunks. We were pleasantly surprised when sheets and pillows were hand delivered to our bunks, as sleeping on blue vinyl in the heat seemed unrestful. We were tired and ready for sleep and all of us got a good night's rest. We woke up to the sunrise and a few of us stuck our heads out of the door to take in the scenery - green fields, thatch huts, sunrise, local people. Someone remarked " Now I really feel like I'm in India!"

After we put our luggage down in the ICTPH guesthouse, some of us stretched our legs after two days of riding in cars, sitting in planes and sleeping in trains. Along the way we met some of the "locals" (see photo to the right). We then cleaned up and had breakfast - typical Indian savory fare: idli (steamed rice pattie), chutney, sambar (lentil soup), wada (fried lentil donut) and Nescafe COFFEE (MUCH needed). We did a bit of shopping at a local variety shop - lots of water, towels, toilet paper - and then headed off for the day around 10:30.

First stop: We were driven in air-conditioned comfort to the rural medical health center (RMHC), run by ICTPH. It is a free clinic run by one physician and two nurse practitioners. They treat anyone who walks in the door, focusing on preventative care. Common diagnoses range from diarrhea, to symptoms of high blood pressure and coronary artery disease to tuberculosis. Families "join" the clinic and receive family identity cards which are linked to the electronic medical record (EMR) system. We received a thorough demonstration of the EMR system and witnessed some patient care. This is the pilot clinic for a larger scale ICTPH program, which will eventually provide healthcare through an insurance scheme designed to make each clinic self-sustainable and accessible to rural populations.

NOTE: In the above photo you'll notice we're wearing our Salwar-Kameez - a very breathy, 100% cotton, traditional Indian outfit.

Second stop: We then went to a Primary Health Center (PHC) run by the government. The ICTPH run RMHCs will refer some patients, including pregnant women, to these government centers. The RMHCs complement the PHCs and seek to bridge the gap between community health at the village level and the existing rural health infrastructure - the idea is for collaboration, not competition. The PHCs have laboratory facilities, birthing facilities, cold-chain storage for vaccinations and have some limited in-patient capacity.

Lunch: Sapna referred us to a local restaurant where we again enjoyed typical Indian fare - delicious as usual. Aparna continues to order for us, leading us towards the best dishes. Our new dish for today was "Gobi Manchurian", an Indian-Chinese dish involving cauliflower, masala and brown sauce. We have also become obsessed with fresh, cold, homemade lime soda - "sweet and salt". It is very refreshing in this heat - have we mentioned IT'S HOT?!

Brihadishwara Temple: We visited our first Hindu temple today! It was built in 1010 by Raja Raja, "King of Kings". We were excited to see this temple, as it was featured in the BBC documentary "The Story of India", which we watched in class before leaving the US. Families approached us while we were there to ask to take photos with us and talk to us - mostly they were interested in where we were from and what our names were. We will now be featured in family photo albums across India! We were blessed with auspicious ashes in the temple and stood in awe at the stone sculpture work which was particularly beautiful in the sunset. We also saw our first elephant at the entrance!

We ended the day with chaat, a type of Indian fast food, and of course, our "sweet and salt" fresh lime soda.

Full bellies and freshly showered, we bid poyittu varukiren (goodnight) from Thanjavur!

Overview at ICTPH

After a relaxed morning we had a wonderful introduction by the staff at ICTPH. They shared their current work and vision for the future. We are heading out to an Indian dinner before our overnight train to Tanjavoor. Everyone is excited about the train ride and to finally get to see the village health center!