"Polio vaccines have eliminated polio from most of the world and reduced early cases from hundreds of thousands yearly to only 1000 in 2001."

But that doesn't really matter if it happens to be your child with suspected polio.

Yesterday afternoon, I began my rotation with the pediatrics ward team. We were there for about three hours and it was probably the most ambivalent rush of feelings I have had in a long time. It took me sometime afterwards to process it (not sure it's fully processed) and the effort exhausted me. It was a combination of wonder, excitement, frustration, anger, and helplessness. I attended afternoon rounds... what I saw was that more than half the time was spent in discussing payment issues, idle chit chat, or concern over being busy... more on this later...

The hospital smells of formaldehyde. When Carla and I were sitting in the director's office, I turned and asked her, what IS this familiar smell that I can't place? She immediately replied "anatomy lab" and she was right on. We were told to come back in a little while because an attending was still at lunch. On rounds, for the first time since college, I wanted to be an infectious disease specialist... we saw rickettsia (i never knew it could present with skin lesions of the devastating sort that I saw), suspected polio, bilateral bronchopneumonia, multitude of gastric complaints associated with fever, salmonella, possible meningitis, suspected primary TB--all within a matter of minutes of stepping foot into the ward.

The ward made me feel like I was in a time warp. The nurses all wore white sari's with plastic nurses hats. When we entered the PICU, we had to take our shoes off and go barefoot! The attending never washed his hands... in between all these infectious disease patients! I think he heard carla point it out to me, because from then on, he was constantly washing his hands... I don't think carla or I intended for him to hear us, but its better for the patients anyhow--and in my training--i understand the well being of the patient to be the end all be all of the actions. Also, the attending pointed out that when they need to attain urine samples, if a midstream clean catch is not possible (patient too young, contaminated specimen), they routinely do a suprapubic cath! For those outside medicine, this is an invasive procedure involving piercing the lower pelvis directly into the bladder to get a urine sample. We asked, why not just do a regular in and out catheter? The attending said he is "absolutely against catheters. They will inevitable introduce infection." Hmmm. I wonder why that is. The attending was excellent about teaching points and introducing each patient's history for our benefit. At the end, he left us in "pediatric casualty" which is their ER... I saw a patient with 30% third degree burns... I worry every two minutes since I saw him about his infection risk. I feel that there is alot than can be done to improve outcomes just from what I saw in the first few hours. Not expensive changes. Just behavioral ones-the Semmelweis type.

So why the feelings of helplessness... As I was trying to make sense of my feelings yesterday, here is what I came up with. In India, you will see the poorest of the poor, walk by the sickest of the sick, everyday, on every street. This has been true in every city of India that I have ever been in. As you walk by, they will call out to you, drag their bodies, with missing limbs, up to you, with pleading, begging eyes, motioning with their hands, their desire to eat something. I recently read Kurt Vonnegut's "A Man Without A Country", where he points out America is the only country with fat poor people. In India, "scaphoid abdomen" takes on a whole new meaning, as you wonder how long the skin can possibly continue to hold in whatever is left. Sorry to be graphic. But it is very real and it is omnipresent. So, I don't know if this is everyone's immediate reaction, but mine is to put up walls. If I were to process the poverty and sickness with each person I passed, and face up to the complexity of inhumanity, limited resources, failure of government, failure of humans to take care of one another, the gross inequity between my yesterday and my today, I would not make it two feet (or 0.6 meters, depending where you are) without breaking down. And yet, my ability to walk by, is likely the same defense that humankind has in allowing this to go on.

I just kept thinking "positive thoughts". Yes, this absolutely sucks, but I am here to see what is being done about it, so I walk on passing one after another of sadness personified on the street. So you see, when I got to the wards, and heard all this talk about not ordering needed antibiotics or tests due to payment issues, turning away a child without the ability to pay even with the high likelihood of polio at the top of the differential, watching worried mother after worried mother, have to make decisions about feeding all her children, or paying for medication for her sick child, and it goes on--helplessness and frustration overwhelmed me. Many times, the doctors talk in English, make a plan, and do not even inform the parents of the plan or updates on what they think is going on. In the states, I can at least go back and talk to the families if something like this happens. But here, the pathology is beyond what I have seen in infectious disease, and I do not speak the language. I am literally useless.

And being that I am Rupa, I am ambivalent. Who am I to judge a country with such limited resources, or the doctors that dare to take on the challenge? Of course they have to worry about payment if they want the hospital to exist another day. Maybe their defense mechanism for making it through the day is to have idle chit chat to break up the reality or to take pride in the busyness, even if they approach it at their own pace. But in Rupa's idealistic mind...ability to pay should only factor into cost effective use of resources... not life or death decisions. Yes we have the ability to save your child's life. No we will not do it if you cannot pay. Don't get me wrong; do not think for a minute that health care is treated as a basic human right in the United States either... its just that the level of drastic measures that are sought are at a different level in a developed versus a developing nation. Deep Breath.

Today, we had a different attending. The child with (likely) polio ended up being admitted. We saw an excellent physical exam... with the attending assessing the child's motor movements through play, establishing herself with him, and continuing on. She would do some parent education on rounds, which helped me breath a little easier. I also went to a barium swallow for a child that has had bilious vomiting for 6 days. The pediatric surgeon refreshed my embryology with understanding volvulus and malrotation. I don't think I will ever forget it--i had never seen volvulus before. The surgeon also made me realize that I need to be reading more to keep up with my basic sciences. It has been so easy to get caught up in this love affair with the clinical efficiency of things in the past two years. A little bit of grounding is good every now and then. I have to remember the "why" behind the "what."

The attending today also pointed out that their hospital is private and the poorest of the poor never even make it through the doors. Few and far between. One of the patients I saw today is part of a family of three that lives off 200 rupees a week. That is approximately $5. It is what Carla and I spent together on lunch today. Coming back from lunch, I saw grandmothers asleep on the cool cement floor outside the ward, others eating off the floor. Practically all the mothers are barefoot. I don't know that I could handle poorest of the poor.

We had a clinical meeting at 4pm. There we heard from an American Doctor that had done a research project in Bangladesh. The basic point of his, and his research appears valid and corroborated by others--influenza in the tropics follows a very different pattern than in temerate zones--present for most of the year in moderate amounts rather than the winter peak pediatricians have come to know and "love" in the Northern Hemisphere. Interesting.

I miss Jon. Besides being a good boyfriend. He's my best friend. He's the one that I talk to about all this stuff. and there is so much stuff, but no him to take in the earful.

Well, I am still a victim of jet lag... I continue to wake up by midnight every night. I have some pictures that I have taken while out and about, but I will have to figure it out later. I'm really excited about tomorrow. I hope I can continue to say that forever.