A Day in the Life

We've been in Manipal, India for a little over a week now, and although our activities change from day to day, we've settled into something of a routine. Prior to the start of this program we emailed our instructor/coordinator Elissa and described our chief clinical interests, which each of us will attempt to whittle down into a concise, compelling topic for the thesis-like Scholarly Project we must complete by the end of this semester. The School of Nursing here has drafted a schedule of rotations based on our input and the degrees we are pursuing back home, such that each day, some of us report to the hospital for observational shifts on different wards, and some of us venture out into the more rural outskirts of the community to observe home-based health care and outreach programs.

Regardless of where we're headed, each weekday begins with an 8am trip to the cafeteria. Like most of the meals in India, the cafeteria options are divided into "veg" and "non-veg," the latter describing options that contain meat, fish, or eggs. Veg breakfasts cost 40 rupees (about 66 cents), and non-veg cost 50 rupees (about 83 cents).

As per usual I have no idea what virtually any of these ingredients are. The dollop of yellow at bottom right is ghee. The savory pancake and accompanying sauces are made of vegetables and mystery.

This one appeared to be a cabbage potato mixture (at left) with fried bread (top right). No matter how carb-heavy the breakfast of the day is, white toast always accompanies the offerings. The cup contains chai tea.

One day the meal was literally nothing but three types of starches: cous cous (at left), rice pilaf (top right), and toast.

If you are feeling feisty you can get an egg.

Savory cumin fritters, toast, vegetable mystery stew, chai, boiled egg, ghee.

At breakfast, we are visited by small friends.

"Don't scoot your chair too far back," Laura warned me one morning. "There's like, a kitten behind it."

After the carbo-loading is complete we assemble in front of the School of Nursing and divide ourselves based on assignment. Since Cody, Rachel and I are in the primary care/family track back at MGH, much of our time is scheduled for observation in the outpatient community setting. Manipal's nursing students are required to complete 150 days of home visits to patients in surrounding rural areas, during which time they perform a handful of basic laboratory assessments, nutritional surveys, and health education on topics tailored to the members of each family.

While waiting outside on the first clinical day, I made a discovery that filled me with glee.

Look closely...

THE RETURN OF COLLEGE BUS!

Unfortunately, College Bus is also a daily exercise in cheating death. There are no seat belts, and the folding door by the driver's seat flaps merrily in the breeze as we hurtle down the road at 70+ mph, passing pedestrians, bikers, and other vehicles on a road that never seems quite big enough to accommodate two cars side-by-side. "If we hit a bump out here and everyone goes flying, I'm going to be the first one flung headfirst out that door," I said once to Elissa, seated beside me. "Yeah," she agreed, gazing out the window. "Oh look! Rice paddies!"

On our first day in the field we visited this house, which is home to a multi-generational family of six.

Diabetes screening is one of the basic lab tests that can be performed using equipment carried and set up on-site. We watched a nursing student lay out newspaper on the front stoop of the home, add eight drops of the patient's urine sample to a test tube containing a reactive chemical, then heat the mixture over a flame. The mixture retained its original blue color, indicating a negative test. Any change in color would have indicated an elevated level of glucose in the sample -- 0.5% for green, 1.0% for yellow, 1.5% for orange, and >2% for brick red.

I wish there was a way to just make this caption say "diabeetus testing supplies" in Wilford Brimley's voice

The student told us that they can use a similar procedure to check the level of protein in the urine (a screening test for preeclampsia), but that they didn't have any field tests to evaluate urinary tract infections, STDs, or other conditions that require urinalysis.

The family invited us inside the house to share a mid-morning snack of fresh coconuts, which grow on a tree in their front yard. Vinish, one of the nursing instructors (below, at right) showed us the proper technique for drinking the juice. I happened to be wearing a bright pink lipstick, which smeared all over the coconut surface when I pressed it to my face. The family found this HILARIOUS and we all had a grand time laughing at my folly.

This tastes nothing like Vita Coco

When we'd drained the liquid from the interior, one of the men in the family deftly hacked off the top of each coconut with a small scythe, revealing the soft white flesh lining the inner cavity. They showed us how to use a piece of the shell as a spoon to scoop up the fruit as a toddler in the family looked on with envy. "The family says he is sick with a cold, so he must not eat cold foods," one of the nursing students explained to us as the mother carried the sobbing child away. "This will make him worse."

More coconuts for me

As we walked through the community, Vinish pointed out features of the landscape and built environment. Some houses have Western-style toilets, but many others have no running water. Part of the health education for this population cautions them to avoid open defecation and encourages applications to government programs that build latrines that can be shared among families.

This well provides water to the neighborhood we walked through:

"Do you have these at home?" Vinish asked. Cody and I tried to explain that our parents' houses in Rhode Island and Michigan both utilize well water, "but they don't look like this."

"No?" said Vinish.

"Well it's all underground," we clarified. "You can't see the water. There are just pipes that go directly from the well into the house."
"You must think this is very different," said Vinish.
"Yes," we admitted, staring over the edge into the water below and noting the tiny swimming creatures around the periphery.

It is said that if you stare too long into the abyss, the abyss stares back at you. In this case it's mostly tadpoles.

More pictures of the village. Note the umbrellas, which many people carry to shade themselves from the 90-degree "winter" temps:

Coconut trees!

Piles of coconut debris are a common sight throughout southern India, as the dried husks can be burned for fuel.

Rachel and Cody

Cody's last name is DeSouza, which is Portugese in origin. Portugese immigrants settled certain parts of India, so D'Souza is a common surname here. At one D'Souza house we even met a woman with the exact same name as Cody's mother.

Some of the homes are owned by much more affluent families and look like structures that could be easily transplanted into an American suburb. Elissa explained that families who are able to send relatives to work abroad in places like Dubai benefit from the extra money that these earners send home, which allows them to buy homes furnished with elaborate details like granite floors and carved wood doors.

The home of a more prosperous family outside Manipal

Inside, a nursing student prepares for a full physical examination. The allure of the crunchy newspaper proved too irresistible to the kittens, who enjoyed its satisfying crunch under their paws and had to be shooed away several times.

I've said it before and I'll say it again: when it comes to Jesus doors, go big or go home.

Not far from the more opulent houses, though, other families are living well below the poverty line. As we approached the dwelling below, the instructor told us that it housed family of nine, including a young postpartum mother with a 15-day-old baby. The grandmother had been diagnosed with anemia, so the nursing student assigned to the site had prepared a presentation identifying the foods that the woman should add to her diet to introduce more iron. This is, of course, difficult advice for a family that can barely afford basics like rice.

"See the floor you're standing on?" the instructor said. "That's polished cow dung."

The family also had a pet dog and a tiny kitten, although it was unclear whether anyone had truly wanted them or if the animals simply appeared at the home one day and had been permitted to stay. No one seemed to be paying them much attention or providing any food; as we approached, the dog was napping on the threshold and the kitten was suckling from her, perhaps fruitlessly. Just as I was admiring the cuteness of the scene, the patriarch of the family came over and whacked the kitten three times with a small tree branch. The kitten yelped and skittered away, but continued to skirt the perimeter of the scene the whole time we were there. Later, one of the young children picked the kitten up by the ear and swung him. Cody and Rachel and I watched with discomfort; as visitors here, we aren't permitted to interact very directly with patients, and even if it were appropriate to criticize this family's treatment of their own animals, we would still require an interpreter to do so.

As a self-proclaimed animal person, witnessing the widespread disinterest and even revulsion that many Indians seem to have towards animals has been one of the hardest parts of this trip for me. Everywhere we go in both city and rural environments, hundreds of docile, affectionate stray dogs roam the streets, playing and scavenging for food, eagerly setting themselves down next to anyone who tolerates it. Pedestrians and motorists mostly ignore the dogs or shoo them away, but stray cats seem to be an object of outright disgust; on several occasions we've students jumping out of the way of adorable kittens, recoiling with the same repulsed expression I might make upon seeing a rat in my basement. Coming from a culture where cats and dogs are doted upon with as much love as children, it's difficult to see so many animals who seem to crave human attention and are so consistently denied or mistreated.

Eventually the little dog was also banished - the patriarch picked her up by her two front legs and carried her out of sight behind the house. Later she and the cat reappeared and the two of them passed the time by scavenging through a nearby garbage pile for food and chasing each other around the small side yard.

When it was time for us to leave the little dog trotted over to me and put her paws on my leg. I crouched down and petted her for a few minutes while the grandfather and a few young grandchildren watched with amazement. "You don't do this, do you?" Cody asked the family, as the dog dropped to the ground and exposed her belly for me to rub, tail wagging wildly. They shook their heads and laughed heartily, amused by such an unnecessary expenditure of kindness. I felt distinctly sad as we departed, wondering how much longer both of them, and in particular the scrawny kitten, would live in this inhospitable environment. In the days since the visit I've been consoling myself with the thought that the little kids in particular might remember the bizarre novelty of a strange white girl doting on their gentle pet, and imitate that behavior in their own interactions with her. I thought about what they might say if they knew that a day before this trip, I apologized to my own dog for my upcoming absence by buying her a bag of treats and some new toys to enjoy in my time away.

File under: dogs that wouldn't survive one day in India

After our long morning away from campus, we take College Bus home...

...and consider our options for lunch. Sometimes we end up back at the cafeteria, or "mess," for a standard-issue meal that looks suspiciously similar to breakfast.

"I think what I miss the most is texture," Rachel mused sadly one day. "I just wish I had something crunchy."

More often, we order from one of the restaurants in the second floor of the cafeteria building, which is arranged like a food court and has options for Indian, Chinese, or Italian food, plus a Subway.

Possibly paneer butter masala? I don't even know at this point.

And then the rest of the afternoon is spent on a variety of tasks that might include paperwork, errands, homework, or lectures, all the while fighting off a carb coma until dinnertime.

This has been a long post. If you made it this far, congratulations. Please enjoy this unintentionally racist-sounding line of White Beauty skincare products as your reward.

Heil Pond's?

THE END.