Water maintenance, strange places, and crunch time

The past week has been a hodgepodge of exploration, some enjoyable retreats, and a heaping pile of work. It's crunch time for our initial research papers in which we discuss the background of our diseases, how they impact people in India, what resources are currently available, and what our proposed interventions are. It will be exciting to have a finished product in hand, but the pressure of producing a useful and well-researched product is palpable.

Part of the field research conducted by our gastrointestinal diseases team (and the CVD team since we happened to be along for the ride) was to visit the Ambulappatu water storage tank and witness the monthly cleaning. This was not quite as exciting as I had anticipated, but interesting nonetheless. The storage tank holds about 100,000 liters of water to be used by people in the small village, which is disbursed by pipes reaching to several public taps. We've learned that an incredible amount of contamination can occur between the tank and the taps, as cracks in the pipes are common- from natural wear and tear, or from animals/vehicles/people damaging them. This is unfortunate considering the high rates of open defecation by both people and animals, pollution from the roads, and bacteria from the sitting water in the rice paddies have easy access to the water that people drink. At the source, the water tank is emptied on a monthly basis and then refilled, and a bucket containing chlorine (just enough to kill the bacteria for a short while) is lowered into the fresh water and swished around. Once the G.I. team has access to water testing kits, samples of water at the source and at the taps will be taken to see where and what types of contamination are occurring. It will be interesting to find out!

Over the weekend I ventured out with some of the interns from ICTPH (the program I'm working with) and Mukesh, the son of the owner of the guesthouse where we stay- he was a helpful tour guide, taking us to the Thanjavur Palace- a rustic concrete building that was once home to Thanjavur Kings, up until the 19th century. It was complete with winding, steep staircases (one of which ascended into complete darkness), connecting multiple levels of open-air platforms with nice views of the surrounding town. After the palace we visited the museum and library next door to learn about the history of Thanjavur's kings and to see some of the oldest scriptures written on palm bark. An interesting day to say the least.

Yesterday our group was given a chance to present our project ideas to the president of IKP Trust (the umbrella organization for ICTPH) and all of the ICTPH staff. It was a little intimidating, but a great opportunity to get feedback from people who will be involved in the implementation of our projects, should they decide they're worthwhile. It was exciting to finally hear about what my colleagues have been learning about, since there is some segmentation between groups. After a barrage of questions and comments, we were lucky enough to be treated to a relaxing day at the Ideal River View Resort (it lives up to its name, sitting right on the bank of a lovely river), including some delicious food and several hours spent in and out of the enormous outdoor pool. It was the calm before the storm, however, as we are all engulfed in work for the next two days, anxious to finish the first piece of our work here.

(Delicious) Food for Thought

Yesterday was amazing, there is no other way to put it. We went early to Karambayam village to meet with one of the community health workers- we wanted to see how women cook in the village as part of the research for our proposed interventions, as well as just out of personal curiosity. One of our instructors, Ravi, and one of the ICTPH workers from Thanjavur accompanied us to the woman's tiny, concrete hut with a woven palm frond roof. We crouched inside and were asked to sit on a blanket at the back of the house near the 4-ft.-high back door opening. We could see right away a cooking apparatus carved from earth- 2 circular openings with space on one side for wood to be inserted for making a fire, with holes to place the pots just above the flames. A similar stove apparatus made of stone was in the woman's house as well. We were excited to watch as she prepared rice and proceeded to cut vegetables on a hook-like blade branching off of a wooden plank- she chopped mangoes (part of which we were allowed to eat, so good!), tomatoes, onions, potatoes, eggplant, and "drumstick" (a long tube-like vegetable). At the front of the same plank to which the hook-blade was fastened was a metal, ridged, spade-shaped device- I was intrigued by it and happy to see it in action as the woman proceeded to take half of a palm coconut and rub the inside against the device, creating tiny grated pieces of coconut. She was able to grate every last bit of the coconut out of its shell- a very efficient tool. Next, the woman proceeded to crush cumin, fennel, and other spices with the grated coconut, onions, and garlic, using a 10-pound stone tool resembling a fat rolling pin. She rolled the tool over the spice mix across a flat stone surface, creating a finely crushed mixture that smelled incredible. Meanwhile fresh tamarind was soaking in a bowl of water- this water was later added to the curry for extra citrusy flavoring. All of these items were mixed together with the other vegetables, oil, and heaping teaspoons of salt (we were sure to observe how much for our research) in a metal pot over the second fire pit in the stove. As we waited for the food to cook, an elderly woman accidentally let two chickens into the house, creating an entertaining commotion as they flew/climbed through my hair to get out the backdoor. We tasted some of the crushed spices and I was pleased to hear and taste that none of them contained salt- the only salt included in the meal was the iodized salt itself- and thus we knew what to measure to see how much an average meal contains. We also asked the woman how much her family of 4 consumes in a week, and were a little shocked to find the amount to be exceptionally high. But this didn't distract us from the pleasure of sharing the incredible process and flavors of a truly fresh meal. Once the rice was finished, the woman placed it on a banana leaf and brought out steaming bowl of curry to accompany it- we just had to taste it! It was the most amazing curry I have ever consumed, especially the eggplants fresh from the garden!

After this wonderful experience we were invited to meet with the secretary for some of the Karambayam self help groups- women's groups that are organized around the desire to save money for small business ventures such as tea stalls (small shops). The concept is aimed at empowering women to learn about finances and take initiative to support themselves and their families through microfinance. In the Karambayam area, there are 35 groups of around 20 women who all contribute a small amount monthly to a savings account, and then their shares are matched with government loans for individual or collective business ventures, as well as small emergencies, transportation to events, or other incidentals. The secretary of the self help groups was happy to meet with us and give us some helpful feedback about how these groups might be willing to help us raise awareness about hypertnesion management through small dietary changes- it sounded very promising. After our meeting we were directed to the back of the house to see a woman cracking crabs by hand- she insisted that we hold them and take pictures. It was comical and fun to say the least.

At the end of the day we were able to meet with the village Panchayat President (a local government leader) in Ambulapatti (a village very close by) to briefly discuss our idea and ask for her support. She expressed support for our work and invited us back to visit again.

All in all, this was my favorite field visit- both educational and inspiring, and reminding me why I am here.
Next up: a trip to see how they clean the local water supply tanks! Interesting tales to follow.

Walking around Thanjavur

To work and to play

The weekend held a number of fun adventures and learning experiences. On Friday I was determined to explore the town of Thanjavur and find out more about the place I've been living. I ventured out on my own into the heart of town, which is busy and lively and full of... well everything! People, cows, vendors, garbage, cars, motorbikes, rickshaws, fruit, flowers... there's something for everyone here. I was continually amazed at the sheer numbers of people (although it's still notably far less chaotic than Chennai) and vendors in particular- if you want sarees, there are at least 10 stores in a block. Need jewelry? Just go to one of the 50ish vendors in a half mile radius. I visited numerous shops of all kinds just to get a feel for what was out there. I wandered around admiring the seemingly ancient architecture intermingled with newer homes and vending stalls. I stumbled upon a neighborhood with a cluster of tiny stalls for what appeared to be handicrafters, metalworkers, sawyers, and other manual laborers perfecting their talents- it was incredibly intriguing to watch and admire the use of hand-powered tools and other appliances we would rarely see in the U.S.
On the work side of things, our class learned about maternal and child health, looking at the tremendous improvements that have been made in India over time, especially in the region we are in- Tamil Nadu. Infant mortality has declined significantly, and the fairly recent government-run primary health clinics that we've been visiting have played a large role in that. Women can receive incentives for delivering their babies in a medical facility, and thus fewer women are delivering at home where there is increased danger to the mother and child. There is still a fairly common problem of children being undernourished, sometimes due to the mothers being malnourished and unable to breastfeed, and for other reasons as well. Tamil Nadu overall, however, has a lot to show for the health and wellbeing of mothers and children.
Our project is moving along smoothly- my group is digging deeper to find out what foods are locally available, what people are purchasing and cooking, and what modifications may be feasible to help improve the health of people with hypertension. Tomorrow we will do a fruit and vegetable inventory of Karambayam, looking at what trees are nearby, what is being sold at the small shops, and what people have in their homes. I'm looking forward to also visiting with one or two women as they prepare a meal to see how they measure ingredients (if they do), how much salt and oil goes into the food, etc. We'll also explore what venues, if any, exist for physical activity (other than the physical labor that many people engage in for work) to see if it's feasible for people to incorporate exercise into their daily lives. While I know that lifestyle changes can be a hard sell, the feedback we have received from the village residents we've spoken with implies a willingness to adapt their lifestyles if it means better health. If nothing else, making sure that people have the information about how to take care of themselves is worth the effort. People can and will continue to make their own choices, but at least our efforts here will have contributed something to the community, however small.

Matters of the heart

This week has brought about some new insights into cardiovascular disease in southern India, specifically in Karambayam. The nuances of everyday life in a village are returning to me from my experiences in Botswana- I feel at home just getting to know people in the village, exploring small shops and even looking at garbage to get a sense of what impacts peoples' health in Karambayam. Although I know that life is far more complicated than several weeks of observation and interactions can illustrate, I am hopeful that I'll be able to contribute something useful to the people I'm working with. Yesterday's field visit was both fun and informative- we visited two households and several small shops. The first family we spoke with consisted of a husband and wife- the husband surprised us with his English-speaking abilities and the wife helped us understand how she dealt with her high blood pressure. It was really interesting to hear about her experiences interacting with the healthcare system- she travels to another town to see a doctor because she doesn't know enough about the clinics nearby; when she was diagnosed with hypertension she didn't receive any information about the condition or how she could deal with the condition except for taking the pills she was prescribed, which she claimed she didn't take regularly. She revealed that she did not know if eating differently or exercising would impact her health, but she said that if her doctor told her it would she would be willing to adjust her cooking accordingly. This story seemed to resonate with the other people we spoke to in the village- knowledge about how to manage cardiovascular risk factors by means other than medication was minimal, and willingness to adjust cooking practices for health purposes was strong. Through this information our team was able to get a better idea of what we might wish to do for our proposed intervention.

As we walked away from the first house, an elderly woman with few teeth approached us, unable to speak but making sounds and motions to indicate that she requested our company at her home. It was very sweet and we consented, taking a seat on the front stoop and greeting her middle-aged daughter who emerged from the house. The two of them were very friendly, and the older woman continuously patted my back- her daughter told me she thought I was pretty- it made my day. Sitting on the stoop having a casual conversation with complete strangers brought back so many fond memories of my experiences in Botswana- the way that life takes its own trajectory and time becomes a meaningless construct. We were able to speak with the women about their health experiences as well and received similar information to indicate that healthcare was being sought elsewhere, that doctors rarely recommended lifestyle changes but primarily prescribed medication with little explanation, and that people would be willing to make small changes to their diets for overall health.
Following this encounter, we visited a line of small shops along the main road where people can purchase a variety of foods, toys, school supplies, and tobacco. We spoke with a few of the shopkeepers and learned that the most commonly sold items were cigarettes, and that even children bought them (they were sure to change out of their school uniforms in an effort for people to not notice their ages). A variety of vegetables and grains were available, including tomatoes, garlic, onions, "drumstick" (a tube-shaped stalk with a hard outer shell and soft inside), eggplant, radishes, chillies, potatoes, okra, rice, pasta- considering the size of the shops, it was surprising to see such variety. I looked at some small packets for sale and bought one to investigate- I was told it was used in Chinese-Indian food and that it wasn't very popular- I was happy to hear it since this substance was straight-up MSG. Sold in a packet in crystals like salt, recommended for a variety of foods and said to "make food taste better." I recalled my migraine headaches and nausea resulting from food with large amounts of MSG in it- not an experience I would wish on anyone else.

There was a small bar down the road called a Tasmac- a small shop without chairs where only men can go to purchase hard liquor and beer (it is generally unacceptable for women to drink here). There were a handful of men hovering around it, and one of my instructors went to check out the scene. While there he witnessed a small boy purchasing and running off with bottles of beer, although when asked the bartender said he did not sell to children.

I tried to absorb everything from the day, but it was hard to let it all sink in- so many intricacies and complicated webs of issues surrounding health, it is hard to imagine how to even address a small part of it. And yet I am still hopeful.

Field visit 3: Karambayam

Yesterday yielded an interesting yet somewhat frustrating day in the field, in a small village known as Karambayam. As our groups further defines our projects, looking at determinants of disease and brainstorming potential ways to address them within the local context, we sought answers about what daily life is like in the villages we're visiting. This approach has inherent limitations, given that we're only here a short amount of time, our field visits are a few hours a day, and we have a very limited knowledge of the language, making communication challenging. We were fortunate enough to have a brief encounter with the SughaVazhvu guides- women living within Karambayam selected and trained to conduct household visits and assist people in accessing medical care. Although we had only a brief time to visit with them, we learned about some of the main concerns facing people in Karambayam (hypertension being one that my CVD team took note of), and how people view community health workers. It seems that these women are viewed positively and trusted within the community, improving the likelihood that people will get accurate information about their illnesses and seek help at the rural micro-health center. That being said, many key issues still exist in the community, such as high rates of tobacco and alcohol use (mostly among men) and limited physical activity, especially for women who are confined to home a lot of the time. There are overwhelming factors that contribute to heart disease, similar to those that exist in the U.S., but often more complicated by poverty and lack of knowledge about how behavior impacts health. It will definitely be challenging one specific area to focus on for our proposed intervention. Hopefully future field visits will provide more insight into how we can provide something useful and appropriate for the context.

Research aside, it was nice to be able to visit with people in the village- everyone was very welcoming and curious about us. I'm looking forward to meeting more people and spending more time in one of the villages, although we're not yet sure which area we want to focus on.

Luxury, poverty, and life in between

The rest of our weekend in Pondicherry provided an interesting exposure to another part of Tamil Nadu district and life in India in general. Here are some observations, but keep in mind- these are just my thoughts- others may have different opinions.
Pondicherry is known for its history of French colonization, still evident by from its street names (Rue de St. Louis, for example) to the grandiose European-style architecture. Pondicherry is host to tourists from a wide variety of places- we encountered people from various places in India and surrounding countries, France, Germany, the U.K., and a few other Americans. Despite the outside influence, Pondicherry still appears to maintain cultural strength, demonstrated by the dress code (women wearing saris and salwar kamees), food, and lifestyle. It was conflicting to encounter extreme poverty mingled with ritzy tourist hotels and restaurants- the contrast was stark and disheartening. While walking down a side-street, we encountered a woman and her two small children washing their clothes and dishes in a filthy water drainage area- the water was literally brown and green- and this is how many people have to survive in India. Along the way to Pondicherry we witnessed people swimming and doing laundry in the same standing water that served as a garbage dump. It is mind boggling to think about how these conditions came about and how they might be improved.
As a sharp contrast, our group celebrated Shawn's birthday last night at a fancy rooftop restaurant near the beach. We had met a few other Americans earlier in the day who joined us for dinner- one was living in Chennai, working for a Leprosy clinic; another was doing her anthropology dissertation in a small village, working with children with disabilities, and the other was volunteering at the same organization for children with disabilities. It was interesting to gain some other perspectives about life in India as a foreigner and particularly working in such unique settings. The girl from Chennai shared her stories from the clinic, as well as her trip to a factory where clothing is made for Wal Mart- she was horrified at the working conditions, with women and young girls having to work long hours with minimal pay and only one short and regimented break. I couldn't help but think about the ultimate impact that we, as Americans, have on so many people just by participating in small routine procedures, like buying a shirt from Wal Mart. Not that I haven't thought of this before, but here it seems more real, actually seeing the people who ultimately bear the brunt of our consumerism.
Besides thoughts of leprosy and exploited workers, our dinner was pleasant and a nice way to end our last evening of vacation. The trip back to Thanjavur was intriguing- we took a back-roads route through several small villages, some bearing communist flags and numerous political signs, as well as tiny rural villages with numerous billboards for fancy jewelry shops. We passed fields of cows and goats, rice paddies, and some beautiful water-scapes complete with swimmers and a crocodile sunning itself. It was comforting to see the Big Temple as we arrived back in Thanjavur, to rest and process a rejuvenating and yet conflicting weekend.

Strangers in Pondicherry

Nine of my classmates and I hired a van and driver to whisk us away to Puducherry, also known as Pondicherry, a formerly French-colonized town on the coast of the Bay of Bengal. The trip took a good 5 hours, driving past seemingly endless stretches of open land- some rice paddies, some open fields, and some grazing land for cows, sheep, and goats- occasionally interrupted by bustling towns. We passed through several toll stations and then had to get a permit to enter Puducherry- I've heard that Puducherry does not tax alcohol and other "sinful" products and therefore is a popular destination for in'n'out shopping, so the government has instituted permit fees to enter the city. We went to the permit station, but unfortunately it was closed- unfortunately the only way to get a permit was to go back a good half an hour to get a permit. It was difficult to understand the driver and a few people got concerned about what we were doing, especially since it was dark, none of us knew our way around and we were going to a remote area. We turned onto a deserted road and someone mentioned that things were getting a little creepy- but as the driver realized he had missed a turn to go under the highway to the other side, he put the car in reverse and instead of a beep beep reverse sound, Jingle Bells started playing. It was hilarious, all of us singing Jingle Bells in the dark in the middle of nowhere. Needless to say, everything worked out and we made it, tired and hungry, to Ginger- an affordable but semi-luxurious motel with a restaurant, comfortable beds, and functioning showers. I slept like a rock.

Today we ventured into the busy town, admiring the French-influence architecture, bicycle rickshaws, and occasional beach views. Although the beach is a bit dirty, it was still thrilling to see and hear crashing waves. We all put our feet in the water and felt instantly cooled against the unforgiving summer sun.

After walking all over in search of a park we'd passed on our drive on the way to the beach, we finally gave up tried to explain to rickshaw drivers where we were trying to go. We got in and drove literally around the corner, only to see the park right there. This is turning out to be a very comical trip.

Lunch at Le Dupleix- built in the 1800s as the home for the French mayor, the building was impressive and the food was delightful. A welcome reprieve from the heat of the day, followed by some time sitting on the hot rocks at the beach. An ideal day to say the least, and it's not even over yet.

The Big Temple at Thanjavur, public health training, and a trip in the works

Yesterday several members of our group, as well as our two instructors, ventured to the Big Temple in the town we're staying in, Thanjavur. The Big Temple (also known as the Brihadeeswarar Temple) is an incredible series of constructions dating back to the year 1002, although many additions have taken place since then. The highest temple tower is a sight to behold- carved stone reaching 63 meters (189 feet) high, and illustrating 16 different stories through detailed carvings. Although we were told by our tour guide that the temple was built from a single stone, I've since done my research and seen otherwise. Regardless, this is one of the most amazing structures I have ever seen and remains a World Heritage Site for a reason! As we entered the temple grounds, we were beckoned by a man with an elephant to stand nearby as the elephant put his trunk over each of our heads- it was the funniest sensation feeling the hot and smelly air blowing over my head! After that entertaining experience, we were fortunate enough to enter the temple to see how the procedures within take place, where people are presented to Shiva and receive a blessing in return- it was truly a magical experience to be at the heart of something so grand. We also entered a smaller temple on the grounds which was devoted to Ganesha, which was also an interesting and unique experience. Strands of flowers were presented to us and we were marked with red ash to symbolize life, in contrast to the white ash we had received in the other temple that represented destruction of life (or destruction of the self). Visiting the temple was a peaceful and powerful experience.

The past 2 days we have been getting down to the nitty gritty of our coursework, learning to implement basic public health strategies in the field, to be able to identify what is "normal" health and what is not. We were trained in performing basic dental/oral examinations to check for any obvious issues with the mouth, jaw, gums, and teeth- it was pretty entertaining getting to practice on our classmates. Today we discussed GI health, specifically problems associated with diarrhea since that is one of the primary causes of death in the developing world. We practiced making oral rehydration solution (ORS) to use when dehydrated, and learned how to chlorinate water in order to purify it for drinking (although this was not complicated, it was interesting to taste the chlorinated water just to get an idea of what it's like and why some people are resistant to using it). In the future we will learn other practical skills related to the other illness areas we are studying- cardiovascular health, cancer, and maternal and child health.

As for tomorrow, several of us are planning a trip to Puducherry (formerly known as Pondicherry), a region of India formerly colonized by the French and therefore having different architecture and points of interest. Pictures and stories coming soon!

More village roads

On the road to Sholapuram

Field Visit: Sholapuram, Vadakkur, and Andipatti

Pictures: Sugha Vazhvu Rural Micro Health Clinic at Andipatti; view from RMHC; peppers growing behind RMHC; inside the RMHC; inside the primary health clinic at Vadukkur; grass huts at Sholapuram; temple at Sholapuram

Today brought some helpful insights into some of the public health concerns facing rural India, as well as a chance to view some amazing scenery and meet interesting and friendly people. Our class group was divided into smaller subgroups which allowed us to visit multiple sites simultaneously and converse more easily with people. My group first visited Sholapuram, a very small and remote village about 40 minutes outside of Thanjavur. The village straddles a narrow, winding paved road, shaded by palm and Eucalyptus trees. To get there we passed by fields of rice paddies, small clusters of skinny trees and palms, numerous cows and water buffalo, and a few dried up dams. We passed through a couple of tiny villages as well, consisting of a few stores and tiny shops, people, free-roaming animals, and lines of bikes. Despite being so small, each village we passed was alive with activity.

There is no formal health facility in Sholapuram- the nearest primary health clinic (PHC, run by the government) is about 3km away- not too far. But we visited the village mostly to get a feel for how daily life is. We took a long stroll passed the primary and secondary school (combined into one), the one water tower that serves as the primary source for the village water, a fading temple, and an intersection which serves as the village bus stop. A truck sat nearby, selling betel leaves wrapped in palm-frond bundles- these are used to wrap areca nuts (referred to as betel nuts), and often tobacco, to be chewed for their stimulating effects.

We stopped to chat with some people running a small stand near the bus stop. We learned that most people in the area survived by performing agricultural work, primarily at rice paddies and growing groundnuts (peanuts), egglplant, lentils, and radishes. Even children begin helping with the work at the age of 10 or 11. Most people in the village grow food for themselves and sell whatever is leftover. There is one tiny grocery stall selling a few vegetables (brought in from Thanjavur) and packaged spices, a few cold drinks, snacks, tobacco and few household items. We spoke with a woman about when and why she would go to a clinic, and she said when she had a fever or other ailment. Preventative healthcare is still unfamiliar in these areas, and understandably given that there is not a clinic in the village itself, not to mention that even in more developed countries preventative care is a challenge. This is something we will consider when thinking about our recommendations for addressing cardiovascular health.

Next we went to the nearest primary health clinic (PHC), in Vadakkur. The clinic is a concrete building consisting of about 10 rooms, including a delivery room, and recovery room for after births and procedures, a procedure room, an injection room, a room for administering DOTS (directly observed treatment, short-course) for tuberculosis. As in many other developing countries, tuberculosis is a rampant problem and especially challenging to treat when medicines are either not administered or taken correctly, as it is easy to build resistance to them. DOTS helps to address this problem by having a nurse or physician present to witness patients taking their medication on a daily basis.

While at the clinic, one of our facilitators from ICTPH fainted, most likely from the heat- it was very unfortunate, although it did provide an opportunity for us to see the nurses in action. We discussed the services offered by the clinic which are diverse and free, but we also learned about the paper record-keeping system that does not account for patients having multiple visits- follow-up with patients is not common since no individual patient medical records are kept. This is one shortcoming that ICTPH is trying to address with their programs.

Our final stop was in Andipatti, a slightly larger village where the newest ICTPH rural micro-health center (RMHC) resides. The RMHC was a lovely facility overlooking a field of pepper and eggplant bushes, as well as numerous palms and mango trees. It was idyllic to say the least. Unfortunately we were unable to visit with the nurses working there, as there were patients there at the time, but it was nice to see the facility nonetheless. As we continue our field visits we will decide in our groups what village(s) we wish to focus our proposed interventions on.

I am trying to absorb as much information as possible, as there is so much to learn- about India's government, politics, public and private healthcare, cultures, history- it can be overwhelming, but so rewarding and interesting to be having this experience. I look forward to continuing this journey.