RUHSA (Wednesday, Jan 2007)
Whew! The bus leaves early (7:05A) and I barely made it! Thank goodness for Miss Ann D! She knew exactly where I needed to be and got me there safely! 45 min. trekking, one swap of drivers (at the halfway makr the drivers from both sites meet at a spot on the road and swap vehicles and head back to their respective origin sites) and a full bus, we arrived at RUHSA.
Taken by one of the nurses on the bus who had started some small talk with me, I was delivered to the nurse's station and the office where Mrs. Greeda waited. She and the director of RUHSA's nursing department (Mrs. Sushila John) gave me an overview of the activities performed by nurses at the site. Is a 75 bed hospital serving K.V. Kuppam--1 rural block (100 villages) which contains anywhere from 80,000 to 120,000 people. They have inpatient and outpatient (like CHAD) with some specialty clinics for outpatient: ENT (Mon.), ORTHO (1x/mo.), Child Health Clinic (Thur.), Eye clinic, DM clinic. The national day for immunizations is Wednesdays, which happens to be the day I'm here. YAY! The rural hospital has a labor room with 4 beds and an operation theater. The peripheral services--the part I'm very interested in--consist of 18 units who visit the villages in the block. These units are teams of 4: one MD, one RN, one Rural Community Officer and one Health Aide; these teams are met and completed by the Family Care volunteer who is a native to the community/village visited. These teams see all morbidity cases, Antenatals, minor ailments. They perform immunizations for mother and child, and have plans of extending care to home-visits by a family nurse practitioner (the one on RUHSA's site is Miss Irene) who has completed a post-grad, 1 year course. Finally, the important area of developmental activities completes the picture of RUHSA's impact on the rural communities.
Some of these developmental activities are done on the RUHSA hospital site: there's a community college (organized like those of U.S.) where young men who have not completed their high school education can come and learn a trade like AV/Fan/Microwave repair, 2-wheel/4-wheel vehicle repair/maintenance, welding. These courses run for various lengths, but most are 7-10mo. I asked if females were allowed to enroll. Originally it was a mixed campus, but it proved to be a problem to keep attention focused on the skills and techniques learned. The reason this kind of development was designed was to keep young men from venturing out to do things that were immoral or unhealthy (drinking--especially to extent of alcoholism--sex, violence, thievery, etc.). The program seems to be popular; only two instructors teach all of the students who are spread between several rooms with appropriate tools/machinery to the kind of training they have chosen. They also had had program of chicken raising in what is now used as a large gathering hall, but that project was less profitable (though highly developmental in its training and initiating of business) for RUHSA but has proven to be a good source of income and development for familes--moved out to smaller business from homes instead of one big corporate gain. Finally another onsite activities is collection and sorting of trash from the hospital site. Because the RUHSA campus has faculty and staff housing as well as the hospital, rubbage can collect quickly. There are women who receive Rs. ?/day for working on the separation of trash and recyclables.
Miss Irene took me out to the village developments off-campus. The first was the self-help groups for women. A program started by the Indian government, RUHSA encourages and helps facilitate within different villages the initiation of cooperative bank accounts for women. These accounts (contributed by max. 20 women) require a deposit weekly of a fixed amount set by each individual. Many of these women are coolie workers (manual laborers) who produce beedi (tobacco products) and only get paid Rs. 40/day if they complete 3000 leaf cuts, or maybe Rs. 100 if they roll 1000 in a day (a much harder task). With this joint account, women can apply for a loan which must unanimously and democratically be decided by the group to give. One of the most important criteria is that the woman/family doesn't have a loan with another place. Then the debt is repaid once/mo. for 10 months. This service and organization has helped several of the women in the group (we met the lead of this group and didn't actually get to attend a meeting) help their families build homes. Some groups also include a type of trade in which the 20 women also form a collective and try to sell their goods. This leader said that many of the women in her group already work as beedi workers and do not have the time nor interest in starting their own co-op. However, it is done by some.
We next visited a Rice Puff plant. Just like popcorn, rice will puff if heated. The cause: water inside the kernel boils and must release its energy, so it explodes the casing of the rice, cooking the insides. (This is my remake and redefine from chemistry oh-so-many years ago!) They soak the rice, and then they dry it out on the ground, using direct sun. Then they shuck away the casings of the rice, and the bit that we eat is soaked again, this time in salt water (getting flavor-infused). Then, dried again, this rice is sent through an oven heated by its own casing, and the puffed rice snack is made. I was generously allowed to photograph this process (though without flash, you couldn't see anything; with flash, photo quality was greatly reduced by dust particles capturing the light of the flash and thus captured in the photo frame! Oh well, the men working at the plant gave me a sample of the treat. Yum! Miss Irene said: "Apparently if one wants to lose weight, this is the snack to eat."
From there we visited the Milk Khoa factory operated by 5 men. Here they mixed every 5 liters milk with one ½ kg sugar and cooked it over a hot fire in a wok-like pan. After about 15 minutes of steady boiling (with constant stirring so it doesn’t burn), the milk khoa is the appropriate consistency—soft-fudge-like—and weighed to make accountable the milkman should he add water and their 200g resulting density be in upset. I was given a small taste; yum! (This is certainly NOT the food to eat should you interest in losing weight!)
We returned to the RUHSA campus for lunch, which we took and shared in Irene’s room. She showed me photos of family and friends. She is given a room to herself (M.S.c. prepared), while other nurses (staff) share. She says it gets lonely sometimes, but she’s from Vellore, so she can go home quite frequently for therapeutic boosts of family and friends.
After lunch, Irene had some duties to complete regarding the students from the College of Nursing who were there for clinic. I was curious what an immunization clinic would look like with all of the masses of moms and babies waiting in the interior garden. Sometimes my curiosity gets the best of me! My request was granted, and my ears rang with babies cries all the way home that night! Some were there as 6-week-olds, others were there for the 6-month-old set. Oral Polio Virus vaccine is given routinely—two drops by mouth, generally gently puckered open by squeezing the child’s cheeks together. Most children don’t like the taste of the OPV vaccine, so a natural pucker replaces the manipulated one from the nurse. At this point, most of the children started to get fussy. They knew this wouldn’t be pleasant. Many of the older kids, coming in at their 36 mo., had enough memory recall to identify the nurse uniform, and receptively took cue from the younger ones ahead that these blue uniforms were “out to get them”. For the mothers and grandmothers who brought them, this fussiness and crying was altogether too much. No mother wants their child to cry. Mothers here make a clicking/cricket-like tongue noise to calm their children. The fictional book Hullabaloo, by Kiran Desai, mentions this practice as “sympathetic noises with their tongues” (68). With several children crying in an all cement room, it’s obvious that the natural response would be to join them in chorus. Thankfully, each mother’s unique noise brought calm to her child.
Something I have noticed in all of CMC’s work is the systematic management of the masses of people. I mentioned transportation earlier, but for health care, the OPD at the hospital sees 4,000 people every day! Similarly I was struck with awe when I learned that RUHSA hospital oversees 500 patients a day, all from one block; and the CONCH nurses each have a population of 2,500-3,500 for which to care! With those sheer masses I have still seen nurses spend time with patients; they don’t rush from house to house on home visits or hasten the end of a visit simply to move on to the next. There is real time and care spent here in community health.
I have also seen and heard about challenges facing the nursing staff in these community settings. It was first discussed openly by a CHAD team (MD, nurse, social worker, community health worker, etc) that hand-washing in the villages can be problematic. My first thought was, but you have been doing this for a long time, why is this a problem now? I’ve realized that the sheer numbers of patients that come and the complete inconvenience of fetching water, finding a drain/place to wash, and having soap and towel can drastically slow the practitioner’s ability to attend to as many patients as are in attendance. That’s probably the main reasons, but resources and money to provide such things are not always available, room/place to pack these things safely and cleanly can also be barriers to hand-washing. Home visits often provide a little more flexibility for hand washing because every family has water nearby. However, I also feel that if the public were educated on the benefits of hand washing, they would demand that every health professional do so before touching them. Therefore, I feel as though not only is it our (community nurse) duty to demonstrate those good habits of hand washing hygiene before and after touching any patient, whether in homes or in clinics. While, at first, the interpretation of this might be rudeness, with persistent education and demonstration at every home, our clients will become members of the team keeping nurses accountable to prevention of disease transmission.
More thoughts on differences I have seen in practice but largely due to the cost factor: I observed in the immunization clinic nurses not wearing gloves for administration of injections. This, while probably safe, is not for the protection of the client, but for that of the nurse. Filter needles aren’t used when drawing from ampoules. The concern I feel is that should any glass shard be broken into the medicine being drawn, and then injected (IM/SC/IV/TD), internal laceration to vessels is likely. Though I do not speak Tamil, and often even struggle with names, I recall in one immunization clinic setting where the collection of children’s charts and the injection were completely separate, without any name verification. Cards were certainly checked to verify that patients were in the right place and for the right reasons, but a second check before administration was omitted. Reason for this omission was that mothers handed the card to the nurse to see and then she placed it on the pile. This pile was meant for documentation later. Again, the sheer numbers of patients to be seen in the time allotted limited them greatly, but we also don’t want any child to slip between the cracks and not receive appropriate vaccinations! Documentation is different, so the side and site where the injection was given was also not documented at moment of patient’s care. The nurse tried to manage this by only having the child face one direction, but when a huge line came to the door, that request was overpowered. On site for the immunization clinic there was no education about potential for adverse reactions and waiting 15 minutes post-vaccination to check for any anaphylactic problems.
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