Wednesday, November 30, 2011

Horrifying Parasites (part 2)

So we were up in Nagaland, the state north of Manipur, this weekend for a few days visiting some of Johns friends. One of them was a doctor, who has been practicing for decades, and he had a story about an operation he had done two weeks prior that was so gross and amazing I can’t keep it to myself.

Beware: it is not for the feint of heart.

A Burmese boy came into see him (the Indian border with Burma is so porous you can walk in and out as you please) who was about 14 years old, with a seriously swollen belly. He told the doctor that it had always been swollen but that it had gotten worse recently. Worried that it was a tumor and in constant discomfort, he had made the several day trek to get it figured out what it was and hopefully get it removed. A CT scan and ultra sound were inconclusive; they could see that the poor kids intestines had been shoved to the side and that one of his kidneys had moved down to the front of his pelvis to make room for whatever the object was but they still couldn’t tell what had done this.

They decided to operate to figure out what was going on in there and see if they could safely remove it. After cutting in through the abdominal wall they still weren’t sure what they were looking at. It didn’t look like any tumor they had seen before. It didn’t look like any kind of swollen organ or infection either. Then they saw hair.

Not believing what their eyes were telling them they cut further in. A circulatory system, collapsed, never-used bowels. A brain. This teenage Burmese kid had been walking around his entire life with his twin growing inside of him!!!

This isn’t like Big Fat Greek wedding where the aunt talks about getting a small lump on her neck biopsied and finding the dead, unborn fetus of her twin. No, this thing was living in him and had been for over a decade! It didn’t have a heart, it was attached to the boys circulatory system so it didn’t need food either, thus the collapsed bowels. I didn’t get details on the brain, like how big it was or if it was functioning at all, but good lord! And for some reason this thing had recently decided to start a growth spurt. Was it trying to made its final Alien-esque escape? Its like Kuato in Total Recall only on the inside. I’m getting the shivers just writing about it.

("Open your Miiinnddd Mr. Quaid")

Its super gross I know but I had to share. Its one of those things that seems so insane it has to be real. I mean this doctor is a very well-to-do surgeon that runs a big hospital. Very respected in the community and with no reason to lie to us. He said he had pictures but that they were at the office, and I couldn’t quite bring myself to ask him to send them to me. I mean it’s a human being that had this and it seems grotesque, though certainly not below me, to gawk. But more importantly I still want to be able to sleep at night.

Horrifying Parasites (part 1)

(Swollen stomachs are one of the most obvious signs of worms)

Intestinal parasites. Worms. 2 billion people have them. 562 million of those are kids. 300 million of that 2 billion have severe or permanent health problems because of them, and over 50% of those are school-age children. And how much does it cost to treat these sinister little invertebrates? Between $0.02 and $0.20 a year, depending on the type of worms you have.

Other than iodizing table salt this is perhaps the single cheapest, easiest and best public health investment a developing country can make. And it seems most of the table salt in northeastern India is already iodized. So if we give every PMS student (the unfortunate acronym for Partnership Ministries Society) one 400mg pill of Albendazole, with a Praziqantel if they are near a body of fresh water, once year it will decrease the total burden of the parasites on the community by 70%. To treat those 8,000+ kids will cost us around $200. Not a bad investment.

We hit on this idea while I was meeting with my boss, John, and Ronnie, the V.P of education. The topic of discussion was if there was anyway to make a vitamin campaign at the schools effective and sustainable. Not really was the answer we came up with. It would cost tons of money if we didn’t them as a donation, and even then it would be difficult to secure more than a few months supply. And a few months worth wouldn’t be enough to make any meaningful difference anyway. Ronnie brought up the idea of deworming instead, which would accomplish more than vitamins at a fraction of the cost. Vitamins are not too useful if you have a swarm of helminths wriggling through your gut and consuming half the nutrients, and if kids can start getting the full benefit of the food they eat then, in comparison, that’s almost as good as giving them a supplement.

I was pumped. This was the embodiment of that annoying business/NGO term ‘low-hanging fruit.’ Like some proverbial, ripe melon on a waist-high branch, we hardly had to expend any effort to get a big reward. So I rushed off to my computer and did one of the few tangible things my degree really taught me to do well- research. Turns out that, along with the stuff I mentioned at the top, kids that get treated for worms will make an average of 43% more as adults than those with persistent infections. And the deworming campaign in 1950s Japan is one of the reasons credited for its subsequent economic boom.

(Me and John with a dead snake, its like worm only bigger and not)

We also certainly weren’t the first group to realize the benefits of deworming. WHO gives it special mention as an integral component in reaching the UN’s Millennium Goal of universal primary education. India currently even has the largest deworming program in the world. An awesome NGO call Deworm the World (a great idea for a Christmas present if you want to make a donation in someones name that will actually make a difference) partnered with the Indian government and are now treating 17 million kids for worms in the northern state of Bihar

Putting together a Power Point to train the teachers and nurses who would be administering the drugs was next. Though fascinating, learning all the fun facts on intestinal parasites and seeing dozens of photos of worms crawling into healthy skin and out through open sores brought on a paranoia similar to classes in abnormal psych. I began wondering if my lack of weight gain, in spite of impressive consumption, might be due to more than just a fast metabolism. Could it be that on one of my third world trips I had picked up a malevolent passenger? Could it be that for the last few years I had one or two silent monsters living inside of me? That, the satisfying thought of Albendazole starving a worm of glucose till it died what I hoped was an agonizing death, and the fact that the pill is only 2 cents led me to decide it was better to be safe than sorry. Though the deworming pill definitely made me sleep easier I am still finding myself thinking twice before wearing flip-flops outside.

Now that the slide show is done, and I am confirmed worm free for at least 6 months, its time to move on to the logistics of training and drug purchase and distribution. Deworming day isn’t until early January, which should give us more than enough time.

Monday, November 21, 2011

Organized Chaos

Sielmat Christian Hospital, the site of the aforementioned week-a-thon health clinic, has only been the current 36 bed, 1 full time doctor and 20 full time nurse incarnation for a few years. Before the construction of the maternity wards, optometrist office, lab and operating theater it was little more than a mud hut. That all changed when John decided to make the hospital a central part of the ministry. Funds were raised, plans drawn up, concrete was poured and, voila! A modern (by Indian standards) hospital was raised. The freshly hired nurses and doctors began treating the sick with the newly purchased modern medical technology housed in the clean, white tiled rooms; in short the hospital was transformed. The reception and billing office however, apparently didn’t get this memo.

A week ago I was sitting at dinner with Lawm, John’s pregnant wife, when she said, “Travis the hospital’s office doesn’t run well. I want to make it more efficient. Come down tomorrow, watch how the office works and tell us what to change.” I was a little dumbstruck. I mean, one of the principal reasons I came here was to have work that was stimulating and challenging (a bill the food service industry wasn’t quite fitting), but reorganize the structure of a hospital’s reception and bookkeeping system? Despite my 2 college biology classes (one of which was marine bio) I can barely fill out medical paperwork, let alone organize an efficient way to run an entire hospital office. So of course I said yes, I’d love to, and hoped that in the next 12 hours, 8 of which I would spend sleeping, some blinding flash of organizational insight would hit.

It didn’t. After introducing myself to the staff the next morning I sat down on a stool, sweaty palmed, and observed. At first, what I was watching didn’t make any sense. So I asked one of the English speaking staff to explain it to me.

During her explanation I was reminded of an anecdote Gen. Jimmy had told me about when Soviet advisers had first arrived in India. They had promised to look around the subcontinent and present the government with a 5 year plan to modernize India. After a month of traveling the country they came back to Delhi and gave an eagerly awaiting audience of government officials their report. The Russians said, “We have no idea how your country functions. We don’t believe in God but he must be running this country because its obvious no one else is.” Then they got on a plane and went home.

Though certainly not quite as extreme, my first impression of the how the hospital office ran paralleled this pretty closely.

The hospital hadn’t changed their system since they were a 5 bed mud hut, and at that time the system had been more than adequate. Now, however, as real medical center, by any western standards it wasn’t a system; two ladies, interchangeably, gave out money for expenditures, collected receipts and gave OPDs to patients. They then handed the hospital copy of the OPD to a guy who checked the bill then stuck it an envelop with the rest of that months cases and piled it in a corner. Though this may sound overly critical, the fact that the hospital managed to continue functioning deserves the highest praise I can give its employees; they are so honest and hard working that they somehow make it work. That and they are too busy/had no experience or reason to change the way it was.

In many ways this is like a microcosm for India- they somehow derive a kind of order from chaos. I think if the world ended tomorrow and all government broke down, America would implode, but life for the average Indian probably wouldn’t change that much. While we rely on the rule of law, they follow the law of rules. While our everyday life is governed by legal institutions, theirs is governed by far more durable social institutions.

Though the system worked, it was anything but efficient. So I set to work, talking with each of the workers about what they think works and what should be done to make it run smoother. After getting their input I planned it out. I based the filing system on what I remember from visits to my optometrist and orthodontist (6 years of braces and being legally blind without corrective lenses means I spent a bit of time in both). The patient payments and expenditure reimbursements now go through separate people and with a system based on the hyper-paranoid and time-tested one anybody who has worked in a restaurant knows. Filing is now to be done chronologically and alphabetically, with each patient getting their own folder. The men’s are a subtle forest green and women’s a dark ugly pink. The goal is to make the institution strong enough that it will function well even with employees that don’t have the experience or ethics of this group.

Now, in the second week, things seem to be starting off well. A bit slow and confused at times because of the change, but it seems that the staff realizes it will make their lives easier. Of course, it still remains to be seen if this system will have any long-term staying power, but it’s a start.

Now, it’s certainly not that the hospital administration could not have come up with this, or probably a far better system. It’s that, being a charity, they are understaffed and overworked, dealing with issues like making sure life saving medicine gets in and that there is enough money to keep the hospital open. Seeing that I, with no meaningful organizational or NGO experience, can do this in less than week doesn’t speak to my ability so much as to how easy it is to make a positive difference, however small, when you decide to focus and do it.

Sunday, November 13, 2011

Ducky Wrist-Bands

“Does she have a ducky band?”
“She says she has been waiting here for a long time.”
“Does she have a ducky band?”
“She says she waited yesterday too.”
“Does she have ducky band?!”
“She says she also has abdominal pain… What to do?”
“Varte! Does she or does she not have a ducky band?!”
“No, but…”
“Then tell her she has to wait in line like everyone else!” I say with as much calm as I can muster after having this exact same conversation 8 times in the last three days.

Varte, my translator, does not want to be the bad guy. No one likes telling a 60 something lady with a swollen goiter on her neck that she has to go to the back of a line 200 people long to get reading glasses, then wait in another equally long line if she wants her neck looked at. But that’s our job. I guess it pays to have an MD when you volunteer at a once a year health clinic in northeast India. But neither me or Varte do, so we get to be the bad guys that tell old ladies, who have probably never seen a western doctor before in their life, that because they don’t have the ducky wristband that says a doctor wanted them to come back in, they can go wait in the sun for 3 hours. How did I end up here?

The trip didn’t start like this. When my parents and I arrived in steamy Calcutta, our first three days were spent at the Hope Home orphanage/school hanging out with and teaching the cutest kids I have ever met. I usually hate kids but these guys were so open, nice and genuinely excited to see you every morning that even my cold lump of a heart thawed a little. They are so different from kids in the USA. American kids are spoiled and because they have no idea how bad it can be they take their privilege for granted. These kids either grew up in about as bad as it can be, and remember it, or they see it often enough on the street outside that they take everyday in Hope Home as a blessing. When my kids are born they are coming here for a year.

Arriving in Darjeeling (unfortunately not aboard the Darjeeling Limited), our second stop, was preceded by a careening 3 hour car ride up through tea plantations dotted across 45 degree slopes on roads only wide enough for a single vechile at a time. The road ended in town crammed with Tibetan refugees and 3x the population it was designed for. The concrete and corrugated aluminum structures that line the narrow roads are built literally one on top of the other and most looked so precarious it seemed a stiff breeze would blow them right off the mountain. Though the Himalayas were not as close I thought they would be, waking up to an unobstructed view of Kanchenjunga, the third highest peak in the world, wasn’t too bad.

Next on the itinerary was the stay with Jimmy Singh, the retired Indian general with 50 years of service under his belt. This was been the part of the trip I had most looked forward to, here was a high ranking Indian military officer who had served during the entirety of the Cold War! And here I was! A fresh International Relations graduate with a diploma from the mighty Beloit College. What debates we would have! We didn’t actually the General in person until our fourth day, when we left his estate for our stay at his farm house. By this point I was practically salivating. Three days of looking at portraits and photo albums of him during his victorious campaign against Pakistan and the astonishingly large collection of ceremonial sabres that adorned his wall had only peaked my interest.

And he didn’t disappoint. In fact it quickly became a apparent that this tall, distinguished Sikh had probably forgotten more since he woke up that morning about world affairs than I had learned in what I though was four years of rigorous study. I ended by just listening, slack jawed as he told about how the world actually worked. How China gave Pakistan nuclear technology but that wind patterns on the subcontinent make using a nuke impossible without the fallout blowing back, how India had almost invaded Tibet before Mao had entrenched himself and how to negotiate with a Thai officer. These were just a few of the areas covered.

The trip from Gen. Jimmy’s idyllic farm house near the Nepalese and Bhutanese borders ended with us in the forgotten northeastern state of Manipur. Our arrival coincidental coincided with one of the areas biggest events of the year- the annual free health clinic. This clinic is held by Jewish Voices Ministries International, an incredibly efficient Zionist group that is both trying to bring Jews to Jesus and unite the lost tribes of Israel. The Benne Manasha, a Jewish tribe that lives in the hills close to Sielmat, my current home, have been genetically identified as belonging to one of these lost tribes, hence JVMI’s interest in Manipur. The hospital hosting the clinic belongs to Bibles for the World, my current employer and host. And since my actual work for John Pudiate, BFTW’s vice-president, couldn’t start until after the clinic, I find myself, pockets stuffed with multi-colored wrist bands and Sharpies, shoving old ladies to the back of a bamboo fenced line.

As I watch the poor woman angrily waddle away, I find myself thinking longingly of the possible projects I will be working on in weeks to come. Projects which, hopefully, will not involve yelling “reading glasses!?” questioningly into the uncomprehending faces of polite locals. John has given me some ideas but nothing set in stone. I could be coordinating with Doctors Without Borders, I could be organizing getting multivitamins to school children, I could be investigating a pre-pay electrical system that uses generators and solar cells, or it could end up John realizes I’m completely incompetent and has me raking leaves for 3 months, but I’m hoping for the former.

Well, that’s not for another three days, when this clinic finally ends and after my parents leave. Right now its thirty minutes until the clinic closes and I can’t even see the back of the line.