Along with rotations in community health and different inpatient and outpatient departments at the local hospital, our time in Manipal has also offered us the opportunity to observe public health initiatives in which the medical and nursing schools participate. This week, several of us assisted with the Pulse Polio Program. The Indian government began this initiative twenty years ago with the goal of achieving 100% vaccination children under five, and have had excellent success despite the logistical challenges of such a large-scale endeavor.
Polio has been eradicated in the U.S. for so long that much of our current population has no first-hand knowledge of how frightening and debilitating a polio epidemic is, but for India, the memory is fresh. There is no cure for the disease, which is highly contagious and most commonly affects children under five. The polio virus invades the nervous system and can cause paralysis in a matter of hours, and can be fatal for patients whose respiratory muscles become immobilized. Until the early 1990s, an average of 500-1,000 Indian children were becoming paralyzed per DAY (!).
Worldwide efforts to eradicate polio have been very successful - less than 400 cases were diagnosed globally in 2014. In the past, critics argued that polio was "non-eradicable," and that India in particular could never achieve such a feat due to widespread problems with hygiene, sanitation, and public health disorganization. The nay-sayers have been proven wrong, as India has now been a polio-free country since 2011. (The U.S., for comparison, eradicated polio in 1979).
The Pulse program is an example of how effective a dedicated vaccination program can be, even in a very large, resource-poor, and technologically underdeveloped nation. Since 1995, volunteer health care workers have set up booths in public places on National Immunization Days, offering the oral vaccine to eligible children. Part of the strategy for 100% coverage involves targeting families who may be traveling during Immunization Days and thus likely to miss their dose; for this reason, the booths are often set up in busy hubs like bus and rail stations.
My group, consisting of a supervising doctor from the Community Medicine department, one intern, one pharmacist, two nursing students, and myself, was stationed at the Udupi train station; Cody, Rachel, and Laura were dropped off at nearby bus stations. We arrived around 8am and settled ourselves behind a desk on the mostly-empty platform, waiting for our chance to accost small children. The nursing students were native speakers of Kannada, the local language of our district, so they were assigned the job of approaching families and leading them back to the table. The intern would then administer the two-drop solution as the pharmacist used a permanent marker to blacken the nail of the recipient's pinkie finger, showing that he or she had been vaccinated.
The first two hours were slow. A few families with children walked by, but all of them had already been vaccinated in this installment of the Pulse. The volunteers resorted to playing Clash of Clans on their phones.
Restlessly, I paced the platform and snapped a few pictures. In the lane in front of the station a man was paused on a motorcycle, straddling his bike as he looked up something on his phone. Like most riders we've seen, he had no helmet, and wasn't wearing any protective gear or clothing. Since we arrived in Manipal we've been asking numerous health care providers about the obvious and widespread issue of road safety here; traffic flows fast, with virtually no stop lights or regard for lanes. Seat belts are absent from most vehicles, bus doors remain open for the duration of the ride, and motorcyclists ride two, three, or more to a bike, sometimes holding babies and young children. Even on highways with wide, concrete medians, an occasional motorist will cross to the other side and DRIVE DOWN THE LANE OF ONCOMING TRAFFIC, seemingly unconcerned with the possibility that drivers headed in the correct direction could hit them head-on.
The man parked in front of the station had his back to the lane where vehicles entered the drop-off zone. As I watched him, mere feet from where I was standing, a rickshaw entered my peripheral vision and came barreling towards the station to deposit a passenger. He's coming in awfully fast, I thought, as the cab made a beeline towards us.
What happened next remains a mystery - whether the driver of the rickshaw had somehow lost control of the vehicle, or whether the brakes had failed, or whether he somehow didn't see the blatantly obvious obstacle in the path ahead - with a jarring crash, the front of the vehicle collided full-speed with the back of the bike, sending the rider flying backwards through the air. His body hit the side of the rickshaw first, then the pavement; the back of his skull smacked hard against the ground. The rickshaw stopped.
I hurried to the man's side. "Are you okay?!", I blurted out, realizing the absurdity of the question as it left my mouth, since a) he clearly wasn't, and b) I don't speak Kannada. He staggered to a standing position and touched the back of his head, where a circular bloody area the size of a baseball had developed. I glanced back at my vaccine team and was shocked to see that they were all still grouped around our table; no one besides me had left their post. "Does anyone want to... look at this guy?" I asked, staring pointedly at the supervising doctor and the intern, who had told me not twenty minutes ago that he had recently completed his rotation in Casualty and aspired to be an emergency medicine doctor. Almost reluctantly, the intern came forward and glanced at the wound.
"It's just an abrasion," he said, then added something in Kannada to the victim which I understood to mean that he should go get checked out at the hospital anyway. Then, to my utter disbelief, the victim nodded and climbed INTO THE BACK OF THE DEADLY RICKSHAW that had just hit him, and the driver revved up and swung around in a wide U-turn back towards Manipal. Nonplussed, the intern wandered back to our bench, plopped himself down, and fiddled absentmindedly with his stethoscope. "Want to know a trick about listening for heart murmurs?" he said, cupping the metal diaphragm in his left palm and stroking the back of that hand with his right index finger. "If you do this, drag your finger across your hand and listen through the earpieces, it sounds like a pan-systolic murmur."
"...cool," I said.
"So you're a nurse - you ever work in Casualty?"
"No," I said. "I'm primary care. Outpatient."
"Ah. I prefer emergency. That's where cool stuff happens. We had a patient come in once with extensive lacerations of the neck and limbs. His trachea was hanging out. Turns out his son was schizophrenic and had gone off his meds, Got into a fight with the dad and attacked him with a sickle. The son was also our patient - tried to kill himself by drinking pesticides. We stabilized them both, but I don't know what their relationship was like after that."
I blinked. "I would guess not good."
"I need a snack," the intern declared.
We recruited the pharmacist for a trip to the food and beverage shop below the station, where they ordered curry and I opted for a veggie samosa. "Brave," the intern muttered after I gave my order, and I felt instant regret. As we ate we discussed differences in the U.S. and Indian healthcare systems. Feeling emboldened in the aftermath of the rickshaw incident, I tossed out questions that I have been wondering about during my time here, but which I knew might be considered culturally insensitive. I reasoned that I didn't have much to lose in the company of clinicians who had watched a serious accident unfold at their feet with what can only be described as vague disinterest.
"So what do they teach you about health care for gay, lesbian, and transgendered patients here?" I began.
"We don't have a curriculum pertaining to that," the intern said, as the pharmacist stared intently at his tea. "The incidence here is very low, so it's not necessary."
Mmmmhhhm. "How about sex reassignment surgery?"
"What?"
"Surgery for females to become males or males to become females. Does that happen here?"
"Oh, I saw a case of that actually. A child born with ambiguous genitalia. They assigned her as female and did a surgery."
"But what about adults? Like for patients who are biologically male by birth but want to transition to female, for example."
"No, nothing like that. Is it common in the USA?"
"No, not common, but it's done. Insurance generally won't cover it because it's considered elective, so it's very expensive for patients."
The intern nodded. "Right. Because that's cosmetic, not a medical concern."
I chewed the samosa to limit my commentary.
"Do you have male nurses in the USA?"
"Yes," I said. "Not as many as women, but I've worked with several male nurses. About ten percent of the students in my nurse practitioner program are men."
"Do you call them sisters?" the intern asked, referring to the old-fashioned term for nurses that is still used in India and some other countries like the UK.
"No, we call them nurses."
He nodded. "We call them brothers. Seems insulting to say sisters."
I drained my chai. "Let's see if there are any kids upstairs."
On our return there were in fact a handful of kids ready to be vaccinated. One by one the moms gently wrangled them and the intern gripped their cheeks to hold their mouths open while he squeezed two drops of the solution on their tongues.
Although they didn't seem particularly pleased with the taste of the vaccine, all of the kids stared at me with evident delight. Some of the older, braver children tentatively approached the booth, grinning as they looked from me, to their parents, and back. "They want to shake your hand," someone explained, so I crouched down and extended my hand to a little girl in a sparkly kurta, who promptly shook it and ran giggling back to her mother. Before I knew it, a small queue of children had formed in front of me, turning the vaccine table into a bizarre receiving line; two drops, ink the pinkie, handshake from the unaffiliated white girl.
"That probably made her day," the intern laughed after a kindergarten-aged girl returned for a second shake. "She's probably like, 'Mommy! I touched a Caucasian!' "
"Well, I'm just... happy to give back," I deadpanned.
Near the end of our shift, a couple with three young kids disembarked from an arriving train and crossed in front of our table. As the nursing students spoke with the mother, I studied the father's left leg, which was visibly withered in comparison to his right. He was using a crutch that was much too short for him as he made halting but deliberate progress across the platform. That guy looks like he HAS polio, I thought, just as the nursing student returned. "Those kids are all set. Their dad had it as a child, so the parents vaccinated early."
"Wow," I said. "Well... good."
By the time College Bus returned to take us home for lunch, we had vaccinated a grand total of nine children in four hours. Cody, Rachel, and Laura's sites had vaccinated between nine and twenty-nine kids in the same amount of time - not particularly impressive numbers overall, but in reality, a good indication of the effectiveness of the Pulse program, since the vast majority of the children we encountered had already gotten the fingernail marker indicating that they'd been covered.
Back on campus, the volunteers were treated to a free lunch that, to our dismay, was presented without utensils. Not wanting to be rude, we took our seats with the other clinicians and students and did our best to scoop up the messy curry and rice with the fingers of our right hands only - we've been told that in Indian culture the left hand is reserved for, ahem, bathroom business, and thus not used for eating.
Later, at dinner with our whole group (at a restaurant with forks), we recounted our polio stories.
"I was just kind of amazed that a dude who literally HAD polio happened to wander by while I was sitting there," I said. "That felt very India to me. Like only here would you be participating in this public health push to end a crippling disease that developed nations got rid of long ago, and someone saunters by right in front of you who has it. I'll probably never see another polio patient in my career back home." The group nodded contemplatively.
"I got a great picture of someone in our group literally giving the vaccine to a kid on a motorcycle," Laura contributed, passing her phone around so we could see. "The dad like, barely paused the bike, we got two drops in, and they sped off. It was literally a drive-by vaccination."
"The real question is: do you think the rickshaw driver charged the guy when he dropped him off?"
"PROBABLY."
"He wouldn't!"
"I mean."
"Hashtag India," I summarized darkly.
"Hashtag thirty rupees," Elissa joked.
The vision of a concussed man handing over his last few bills to pay the driver who almost killed him sent us over the edge. It had been a long day - it's been a long three weeks - and perhaps we were slap-happy and overtired. All at once our voices became an echo chamber of cackles and we were laughing, hard, perhaps because this story couldn't be less funny, because there's so much that needs fixing here and no easy place to start - laughing because there's nothing we can do, right now, to make things better.
Polio has been eradicated in the U.S. for so long that much of our current population has no first-hand knowledge of how frightening and debilitating a polio epidemic is, but for India, the memory is fresh. There is no cure for the disease, which is highly contagious and most commonly affects children under five. The polio virus invades the nervous system and can cause paralysis in a matter of hours, and can be fatal for patients whose respiratory muscles become immobilized. Until the early 1990s, an average of 500-1,000 Indian children were becoming paralyzed per DAY (!).
Worldwide efforts to eradicate polio have been very successful - less than 400 cases were diagnosed globally in 2014. In the past, critics argued that polio was "non-eradicable," and that India in particular could never achieve such a feat due to widespread problems with hygiene, sanitation, and public health disorganization. The nay-sayers have been proven wrong, as India has now been a polio-free country since 2011. (The U.S., for comparison, eradicated polio in 1979).
The Pulse program is an example of how effective a dedicated vaccination program can be, even in a very large, resource-poor, and technologically underdeveloped nation. Since 1995, volunteer health care workers have set up booths in public places on National Immunization Days, offering the oral vaccine to eligible children. Part of the strategy for 100% coverage involves targeting families who may be traveling during Immunization Days and thus likely to miss their dose; for this reason, the booths are often set up in busy hubs like bus and rail stations.
My group, consisting of a supervising doctor from the Community Medicine department, one intern, one pharmacist, two nursing students, and myself, was stationed at the Udupi train station; Cody, Rachel, and Laura were dropped off at nearby bus stations. We arrived around 8am and settled ourselves behind a desk on the mostly-empty platform, waiting for our chance to accost small children. The nursing students were native speakers of Kannada, the local language of our district, so they were assigned the job of approaching families and leading them back to the table. The intern would then administer the two-drop solution as the pharmacist used a permanent marker to blacken the nail of the recipient's pinkie finger, showing that he or she had been vaccinated.
 |
| Come one, come all! |
 |
| The vaccine vials are transported in this cooler, with freezer packs to keep the live viruses fresh |
 |
| Doc, doc, goose! Er, pharmacist. |
Restlessly, I paced the platform and snapped a few pictures. In the lane in front of the station a man was paused on a motorcycle, straddling his bike as he looked up something on his phone. Like most riders we've seen, he had no helmet, and wasn't wearing any protective gear or clothing. Since we arrived in Manipal we've been asking numerous health care providers about the obvious and widespread issue of road safety here; traffic flows fast, with virtually no stop lights or regard for lanes. Seat belts are absent from most vehicles, bus doors remain open for the duration of the ride, and motorcyclists ride two, three, or more to a bike, sometimes holding babies and young children. Even on highways with wide, concrete medians, an occasional motorist will cross to the other side and DRIVE DOWN THE LANE OF ONCOMING TRAFFIC, seemingly unconcerned with the possibility that drivers headed in the correct direction could hit them head-on.
The man parked in front of the station had his back to the lane where vehicles entered the drop-off zone. As I watched him, mere feet from where I was standing, a rickshaw entered my peripheral vision and came barreling towards the station to deposit a passenger. He's coming in awfully fast, I thought, as the cab made a beeline towards us.
What happened next remains a mystery - whether the driver of the rickshaw had somehow lost control of the vehicle, or whether the brakes had failed, or whether he somehow didn't see the blatantly obvious obstacle in the path ahead - with a jarring crash, the front of the vehicle collided full-speed with the back of the bike, sending the rider flying backwards through the air. His body hit the side of the rickshaw first, then the pavement; the back of his skull smacked hard against the ground. The rickshaw stopped.
I hurried to the man's side. "Are you okay?!", I blurted out, realizing the absurdity of the question as it left my mouth, since a) he clearly wasn't, and b) I don't speak Kannada. He staggered to a standing position and touched the back of his head, where a circular bloody area the size of a baseball had developed. I glanced back at my vaccine team and was shocked to see that they were all still grouped around our table; no one besides me had left their post. "Does anyone want to... look at this guy?" I asked, staring pointedly at the supervising doctor and the intern, who had told me not twenty minutes ago that he had recently completed his rotation in Casualty and aspired to be an emergency medicine doctor. Almost reluctantly, the intern came forward and glanced at the wound.
"It's just an abrasion," he said, then added something in Kannada to the victim which I understood to mean that he should go get checked out at the hospital anyway. Then, to my utter disbelief, the victim nodded and climbed INTO THE BACK OF THE DEADLY RICKSHAW that had just hit him, and the driver revved up and swung around in a wide U-turn back towards Manipal. Nonplussed, the intern wandered back to our bench, plopped himself down, and fiddled absentmindedly with his stethoscope. "Want to know a trick about listening for heart murmurs?" he said, cupping the metal diaphragm in his left palm and stroking the back of that hand with his right index finger. "If you do this, drag your finger across your hand and listen through the earpieces, it sounds like a pan-systolic murmur."
"...cool," I said.
"So you're a nurse - you ever work in Casualty?"
"No," I said. "I'm primary care. Outpatient."
"Ah. I prefer emergency. That's where cool stuff happens. We had a patient come in once with extensive lacerations of the neck and limbs. His trachea was hanging out. Turns out his son was schizophrenic and had gone off his meds, Got into a fight with the dad and attacked him with a sickle. The son was also our patient - tried to kill himself by drinking pesticides. We stabilized them both, but I don't know what their relationship was like after that."
I blinked. "I would guess not good."
"I need a snack," the intern declared.
We recruited the pharmacist for a trip to the food and beverage shop below the station, where they ordered curry and I opted for a veggie samosa. "Brave," the intern muttered after I gave my order, and I felt instant regret. As we ate we discussed differences in the U.S. and Indian healthcare systems. Feeling emboldened in the aftermath of the rickshaw incident, I tossed out questions that I have been wondering about during my time here, but which I knew might be considered culturally insensitive. I reasoned that I didn't have much to lose in the company of clinicians who had watched a serious accident unfold at their feet with what can only be described as vague disinterest.
"So what do they teach you about health care for gay, lesbian, and transgendered patients here?" I began.
"We don't have a curriculum pertaining to that," the intern said, as the pharmacist stared intently at his tea. "The incidence here is very low, so it's not necessary."
Mmmmhhhm. "How about sex reassignment surgery?"
"What?"
"Surgery for females to become males or males to become females. Does that happen here?"
"Oh, I saw a case of that actually. A child born with ambiguous genitalia. They assigned her as female and did a surgery."
"But what about adults? Like for patients who are biologically male by birth but want to transition to female, for example."
"No, nothing like that. Is it common in the USA?"
"No, not common, but it's done. Insurance generally won't cover it because it's considered elective, so it's very expensive for patients."
The intern nodded. "Right. Because that's cosmetic, not a medical concern."
I chewed the samosa to limit my commentary.
"Do you have male nurses in the USA?"
"Yes," I said. "Not as many as women, but I've worked with several male nurses. About ten percent of the students in my nurse practitioner program are men."
"Do you call them sisters?" the intern asked, referring to the old-fashioned term for nurses that is still used in India and some other countries like the UK.
"No, we call them nurses."
He nodded. "We call them brothers. Seems insulting to say sisters."
I drained my chai. "Let's see if there are any kids upstairs."
On our return there were in fact a handful of kids ready to be vaccinated. One by one the moms gently wrangled them and the intern gripped their cheeks to hold their mouths open while he squeezed two drops of the solution on their tongues.
Although they didn't seem particularly pleased with the taste of the vaccine, all of the kids stared at me with evident delight. Some of the older, braver children tentatively approached the booth, grinning as they looked from me, to their parents, and back. "They want to shake your hand," someone explained, so I crouched down and extended my hand to a little girl in a sparkly kurta, who promptly shook it and ran giggling back to her mother. Before I knew it, a small queue of children had formed in front of me, turning the vaccine table into a bizarre receiving line; two drops, ink the pinkie, handshake from the unaffiliated white girl.
"That probably made her day," the intern laughed after a kindergarten-aged girl returned for a second shake. "She's probably like, 'Mommy! I touched a Caucasian!' "
"Well, I'm just... happy to give back," I deadpanned.
 |
| The new face of polio? #posterchild #comeforthevaccines,stayforthehandshakes |
"Wow," I said. "Well... good."
By the time College Bus returned to take us home for lunch, we had vaccinated a grand total of nine children in four hours. Cody, Rachel, and Laura's sites had vaccinated between nine and twenty-nine kids in the same amount of time - not particularly impressive numbers overall, but in reality, a good indication of the effectiveness of the Pulse program, since the vast majority of the children we encountered had already gotten the fingernail marker indicating that they'd been covered.
Back on campus, the volunteers were treated to a free lunch that, to our dismay, was presented without utensils. Not wanting to be rude, we took our seats with the other clinicians and students and did our best to scoop up the messy curry and rice with the fingers of our right hands only - we've been told that in Indian culture the left hand is reserved for, ahem, bathroom business, and thus not used for eating.
 |
| Some foods should just not be eaten with one's hands and I feel like this is the definition of that food |
"I was just kind of amazed that a dude who literally HAD polio happened to wander by while I was sitting there," I said. "That felt very India to me. Like only here would you be participating in this public health push to end a crippling disease that developed nations got rid of long ago, and someone saunters by right in front of you who has it. I'll probably never see another polio patient in my career back home." The group nodded contemplatively.
"I got a great picture of someone in our group literally giving the vaccine to a kid on a motorcycle," Laura contributed, passing her phone around so we could see. "The dad like, barely paused the bike, we got two drops in, and they sped off. It was literally a drive-by vaccination."
 |
| WWJSD? (What Would Jonas Salk Do?) |
"That's wild," Elissa said, handing the phone back. "That's a great picture."
"I also have a story involving a motorcycle," I added ominously, and proceeded to recount the episode with the rickshaw and the baffling inaction of the doctors.
"I feel like that's part of the attitude you feel here," someone said when I'd finished. "There's no sense of urgency. For the most part people aren't rushing to help others. It's kind of every man for himself."
"In the years I've been coming here, I have noticed that," Elissa affirmed. "The thinking seems to be, 'oh well, you know, it's just people. There's more where that came from.' "
"I guess in a country with so many people you might have to be like that," someone else mused. "You can't afford to worry about everyone else."
"But this wasn't a case of choosing your own safety over someone else's. A guy went down in front of a cluster of people in white coats and stethoscopes and they just stood there."
"Yeah, it doesn't excuse the story. A doctor has a responsibility to assist a patient when possible. Especially for something like that, when an accident is happening right in front of him."
"Well he did help - he sent the guy back to the ER."
"In the same rickshaw though!!"
"I also have a story involving a motorcycle," I added ominously, and proceeded to recount the episode with the rickshaw and the baffling inaction of the doctors.
"I feel like that's part of the attitude you feel here," someone said when I'd finished. "There's no sense of urgency. For the most part people aren't rushing to help others. It's kind of every man for himself."
"In the years I've been coming here, I have noticed that," Elissa affirmed. "The thinking seems to be, 'oh well, you know, it's just people. There's more where that came from.' "
"I guess in a country with so many people you might have to be like that," someone else mused. "You can't afford to worry about everyone else."
"But this wasn't a case of choosing your own safety over someone else's. A guy went down in front of a cluster of people in white coats and stethoscopes and they just stood there."
"Yeah, it doesn't excuse the story. A doctor has a responsibility to assist a patient when possible. Especially for something like that, when an accident is happening right in front of him."
"Well he did help - he sent the guy back to the ER."
"In the same rickshaw though!!"
"The real question is: do you think the rickshaw driver charged the guy when he dropped him off?"
"PROBABLY."
"He wouldn't!"
"I mean."
"Hashtag India," I summarized darkly.
"Hashtag thirty rupees," Elissa joked.
The vision of a concussed man handing over his last few bills to pay the driver who almost killed him sent us over the edge. It had been a long day - it's been a long three weeks - and perhaps we were slap-happy and overtired. All at once our voices became an echo chamber of cackles and we were laughing, hard, perhaps because this story couldn't be less funny, because there's so much that needs fixing here and no easy place to start - laughing because there's nothing we can do, right now, to make things better.
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