Tuesday, 3 May 2016

Notes from Another Sphere - Part Two

Journal Entries from A Pre- and Post-Natal Counselor's Experience at A BBMP Hospital

Varsha Shridhar

March 17th

This time, Dr. D.M is not the senior consultant, as she is off on leave. Instead, Dr. S. T, a more junior consultant, leads the way. Something about Dr. S.T tells me that she might be a little more judgmental in her attitude than D.M. Perhaps it is her statement that “some mothers are so bad that they don’t even bring their kids to the clinic for their regular immunizations”, a statement that makes me wince a bit.
Dr. S.T has some good ideas, though. She starts off the clinic by introducing herself and the team. She tells moms the drill: get your baby weighed and measured here, get their shots there, then go visit the counselor (me) on that side of the room, and so on. She also spends a good ten minutes explaining the importance of washing hands before eating and cooking, and after using the toilet. Dr. S.T is Telugu, and speaks in Kannada. However, the majority of the clientele in this neighborhood is Tamil. How many people understand her instructions? God knows. But I appreciate her intention.
This time my group is a bit more diverse in terms of language. I find that conversing in Kannada is not as difficult as initially feared. I reiterate Dr. S.T.’s messages of hand washing with most of my patients. Then, one lady brings her baby and sits down. “Tamil or Kannada”, I carol at her. “Hindi”, she replies firmly and then launches into a stream of Urdu. I blink at her. “Huh?” I say intelligently. “Bacchan kal rath **gibberish** kha liya. Aaj polio ka daviyiyan doon?” (My kid ate **something** last night. Can I give him the polio drops?) is what I managed to understand after multiple attempts. No idea what it was that the kid ate. Was he supposed to have eaten it? Or was it some sort of garbage that he stuck into his mouth? I attempt to understand this. “Aapne khaneko diya?” (Did you give him this to eat?). “Nahin, vo apne aap kha liya” (no he ate by himself).
Okay. That didn’t get me too far. What exactly was this lady’s concern? Was it the fact that the kid had eaten something he wasn’t supposed to? (in which case, why wait till the next afternoon to ask someone about it?) Was it because she wasn’t sure if he could get an oral polio vaccine since he had something in his stomach (from last night - was she saying that he had had nothing to eat since he woke up? )? Was she asking my implicit permission to give him whatever it was that he had eaten? And how in the world was I supposed to ask all these questions if my brain couldn’t unscramble itself quickly enough for me to form any coherent sentences?
Overwhelmed, I say to her, “Aap vo doctorse pooch lo” (please ask that doctor over there).
When she leaves in a bit of a huff, I berate myself for my complete unpreparedness for a Hindi-speaking patient and spend a few minutes meditating on possible answers I could have given, wrack my brains for the right vocabulary (not too Sanskritic or Anglicized) and practice some lines in my head.
Next walks in a lady who overturns my idea of the people who use a BBMP PHC. She is attired in a frilly pink T shirt and jeans, heels on her feet, a perfectly well dressed little baby girl in her arms. We talk in English; she lives in one of the neighboring high rises; is worried about her daughter having a cold. As we chat, I notice bruises on her hands and realize that what I thought was a disfiguration on one of her cheeks is actually another bruise. “What does your husband do?, I ask, very casually. “He works too. My mother in law lives with us”, she says softly. I am not sure how to proceed. On one hand, the bruises could have a perfectly rational and harmless reason. On the other hand, why was such a well-dressed woman coming to a BBMP clinic, unless she felt this was one where probably not too many questions would be asked? On the pretext of playing with her baby, I watch her carefully. But honestly, I cannot read the situation. I have to send her on her way. How does one ask another woman, whom she has known for all of five minutes, if she is being abused by her husband?

Three women with a small baby seat themselves in front of me. “Weren’t you here a couple of weeks ago?” I ask, since the baby looks so familiar. “No, no”, they assure me. “Maybe your mother came with the baby then?”, I ask the woman in front of me. “No no”, she says. The baby is about nine months old and looks to be two months. I could swear it was the same baby from the last time I was in the clinic, the one whose grandmom ran away. But these women are firm that that is not the case. I drop the subject. Again, we talk about the baby’s weight; this time I ask more detailed questions about his development and diet. The baby has never tried to crawl, or sit, or even roll over by himself. He just keeps lying down. The mother gives him some biscuits and milk, but no vegetables or fruits or breastmilk. I talk about the importance of all this but I get the frustrating sense that I am not making much leeway. But the presence of the other two ladies gives me a false sense of security as I insist again that the baby be taken to the doctor. “Dr. S.T. is right here. Please take this baby to her. He needs help”, I say. “Yes, yes”, they all nod. I think that at least the other ladies will make the mom take the baby to the doctor.

An old Muslim lady rushes in. “Gassa ka goliya dedoji” (give me the gas tablets), she cries.
“Gassa ka goliya?”, I blink stupidly. “Kya gassa ka goliya? (What gas tablets?)”
“Vahi vo lal patte vale” (those ones in the red strip)
I dazedly gaze around the array of tablets on my table. I see Omeprazole, sodium citrate, some crocin and the like. “Vo vale”, she says pointing to the Omeprazole. I vaguely know they are related to some stomach issues, but that’s about it. “Main nahi de sakti aur main doctor nahin hoon. Aap vo doctor ke pas jao” (I can’t give you those and I am not a doctor. Go to the other doctor), I say.
“Dedona” (please give)
“Nahin ji, nahin de sakti. Vo doctor se poochlo” (no, I can’t. Ask the other doctor).
She looks a bit disgusted and disappointed and leaves.

Phew! This day has no end of surprises.

Just as I am getting up to leave, a mother walks in with a small girl and a baby in her arms and hands me the baby’s records. I look at the notes the pediatric resident has scrawled: Weight 2.1 kg (<2SD) meaning that the baby is very underweight.
We chat about the baby’s diet. Then, all of a sudden, the mom bursts into tears and sobs that she isn’t really worried about the baby, it’s her daughter who refuses to eat any food. She talks about how every mouthful has to be coerced; about every mealtime being filled with tears, frustration and rage; about the family’s collective exhaustion with this situation. The baby, she says, is fine. I ask her questions about diet: what does she give the kids, how many times do they poop and pee and so on. According to her, she gives them everything: bananas, raagi, meat, eggs, milk. Apparently the baby eats all this, but the girl does not. The girl too is very under-sized; a 3 year old who looks like she might not yet be 1.5. The mother says that she finds it difficult to bring the kids to the clinic or take them to the pediatrician in a nearby hospital. She is also afraid of going back there because she thinks the pediatrician will scold. I dismiss these concerns: no no, the doctor won’t scold. She may ask why you haven’t brought the kids to her for so long, but she’ll help, I tell her. While I explain to the mother that yelling and hitting at the kid during meal times isn’t going to get her to eat more, I know that some medical intervention is called for as well. I call the Pediatric resident, Dr. M, to evaluate the situation. Dr. M. checks the girl’s throat, asks even more detailed questions about diet (I learn that trick from her: ask what the patient has at EVERY meal, not just a general overview), asks about birth weight and so on. Dr. S.T steps into the room while this is going on and listens in. The doctors diagnose malnutrition and recommend that the lady take both her kids to Sanjay Gandhi Children’s Hospital, at least ten km away. While I agree with the diagnosis and the plan, I am taken aback by the attitude of the doctors. They are patronizing, they scold the mother for not having brought the kids to a doctor sooner (no wonder she had been procrastinating taking her kids to the other doctor! This attitude must be prevalent everywhere), they discuss her kids in front of her as though she and they weren’t present. At the end of ten minutes or so of all this, the mother takes her babies and scuttles out, not meeting anybody’s eye. I am pretty sure she’s never going to come back here again. “God, these people!”, says Dr. S.T. “They are so uneducated and backward”. Then she starts a diatribe about the backwardness, about how the husbands are useless, probably spending all the money on drink and cigarettes, about how they mistreat girl children and so on. I make “hmm… hmm” sounds as she talks, not wanting to give offense. But I feel terrible and small and more than a little lost. I think my actions today have driven away this woman and her kids without solving any of her problems, adding new ones to the mix. I hated seeing her shamed so, but I hadn’t said anything to help her out. I have no idea what I ought to have done, either.

A sobering end to my second day at the clinic.

Notes from Another Sphere - Part One

Journal Entries from A Pre- and Post-Natal Counselor's Experience at A BBMP Hospital

Varsha Shridhar

3rd March 2016

My first day at the BBMP Urban Primary Healthcare Center in Koramangala. I get there around 11am, by which time the clinic in in full swing. Babies are being measured, weighed and injected with whatever shots are deemed appropriate, mothers are chatting, the attenders in their blue sarees are ordering people about… a typical scene in a government hospital. I find my contact, Dr. D.M, inside one of the consulting rooms. She is marvelously efficient - within a few minutes, I have a spot at one corner of her clinic, a set of chairs around me, and the attender is leading in my first few patients.
I am an antenatal and postnatal counselor. This means I talk to pregnant moms and new mothers about their worries and concerns, I give them advice on nutrition, I counsel them on how to take care of themselves, their babies and their families. I speak to the family members, if they are present. I find out about their work, if they have help, if they have any ongoing issues with something, I help them problem solve. My role is to be a source of support, an elder sister of sorts.
My main source of worry on this day is my ability to communicate. I can handle Tamil, but Kannada and Hindi, I tend to falter with, despite being able to read both languages and have routine conversations. Oh well, I’ll muddle along somehow, I think.
I have done some homework for this trip. Just before leaving for the clinic, I send my various cousins a question on WhatsApp: How do you say, “don’t have unprotected sex” in Tamil, Kannada and Urdu. My cousins are highly amused and I spend the time while traveling to the clinic giggling at their increasingly improbable translations. Nonetheless, before I step into the clinic, I have my answer: Avar jothe serak mudhale nirod upayogisi (use a condom before sex). “Serodu”- to join, the colloquial euphemism for sex in Kannada and Tamil. Phew! I can embellish the rest.
My first patient brings in a baby of about three months old. As is my custom, I ask her which language she is most comfortable with, to which she replies, “Tamil”. I practically rub my hands in glee. We chat. She’s a first time mom, living with her mother, who has also accompanied her, a large capable-looking woman, who initially looks askance at my questions about diet and at my even more impertinent questions about urinations and bowel movements. But she thaws soon, once I praise her lavishly at the work she does everyday to keep her daughter and grandchild healthy. I ask my patient about her husband: does he visit, does he play with his child, does he spend the night and so on. “Never!” inserts the mother, at this point. “According to our custom, her husband will not sleep in the same room with her for the first seven months”. “Wonderful!” I assure the patient and her mother. “But in case the opportunity arises and you want to have sex, you must think about contraception”, I say, keeping my eyes fixed on my young patient. “Don’t become pregnant right away. Give some time to yourself and your baby to grow up” “And give some time to your mother”, her mother interjects, at which we all laugh. I tell her to go to Dr. D.M., who I see is relatively free at the time, and discuss options for contraception and am gratified when they head there directly afterwards. A very pleasant session indeed.
I see about 10 or 12 more patients, all Tamil, most doing relatively well. My only truly worrying case is a grandmother who has brought her 9-month-old grandson, but the child looks closer to 2 or 3 months of age. “Where’s your daughter?” I ask. “At work”, she replies. “I feed the child and take care of him. I give him cow’s milk”. Further questioning reveals that her daughter breastfeeds once or twice a day. The grandmother looks hassled, has very bad teeth, slightly blurry eyes, and difficulty understanding what I am saying. The baby is asleep. “You need to go talk to Dr. D.M. This child needs help. He doesn’t look well”, I tell her. She nods and gets up. My attention is momentarily caught by the next patient who walks in. When I look back up, she’s nowhere around.

The clinic closes at 1pm. The attenders walk us out, we get back into the ambulance that will take us to the hospital whose outreach program runs this clinic. On the way back, Dr. D.M and I discuss my experience. My most vivid impression of the two hours I have spent is of how incredibly diverse the clientele is. I have spoken to mothers who are day laborers, who work as receptionists and speak English, some who are fairly well educated and some who are illiterate. The phrase “government hospital” evokes images of lines of women carrying malnourished babies, wearing tattered sarees. In reality though, the PHC serves as a first contact for pretty much anyone living in the vicinity and this includes educated women and their families. What also stands out is that most of these babies look okay - other than the one who was clearly malnourished, most babies were decently sized, many were exclusively breastfed. What is more worrying is the standard of nutrition for the mothers. New mothers are not counseled on nutrition and most do not eat vegetables and fruits, with the result that most of them suffer from constipation; some are dehydrated.

Dr. D.M urges me to come for their antenatal clinic, since this is the time, she says, where counseling is desperately required, but no one available to provide it. I hesitate to commit because I don’t want to take on too many new commitments. I don’t want to stop going to the postnatal clinic, now that I have experienced it and feel it might be better to gain some mastery on one aspect before tackling another new one.

A good introduction, all in all, to the world of the PHC.