August 28th and 29th: IKP Center for Technologies in Public Health (ICTPH)

Sarah, Andrea, Rachael and Alison in the lobby of our new hotel

                                  
On Monday morning, we all woke up bright and early at 6 am  on the train to start our first day at IKP Center for Technologies in Public Health  (ICTPH). We were able to easily find our driver once we arrived at the Thanjavur train station and made our way over to our new hotel. The hotel is comfortable with very kind and helpful staff. A few of us were finally able to turn our clothes over to be washed, which we have needed to do for a few days now. After settling in, we were off to meet Dr. Zeena Johar at the ICTPH headquarters. Upon arriving at ICTPH, Dr. Johar took us out to a wonderful breakfast at an authentic Indian restaurant. The menu was in Tamil and Zeena had to translate for us to tell us what was available. After breakfast we walked back to ICTPH with Dr. Johar and sat in on a meeting with different members of the staff and learned the details of how ICTPH is involved in the community healthcare of 3 nearby clinics. We were lucky enough to be observing in Thanjavur at the same time as Dr. Nachiket Mor, who is  a member of the Board of Directors at ICTPH.

An example of the household ID cards used
to identify patients and track their visits through
 computerized documentation at the ICTPH clinics

ICTPH  has three community clinics and plans to continue expanding. There are 200,000 people in a targeted area that do not have nearby access to a primary health clinic (PHC) which is the institution for government care. In this way, ICTPH is setting up an alternative (for some, the only) option for healthcare. Each clinic has a physician, a health extension worker (HEW) and community guides and services approximately 1,500- 2,000 community members.
There were several topics presented throughout Monday and Tuesday to help design protocols and other systematic aspects of the organization. The protocols are followed by the ICTPH physicians who  have a bachelor's degree in medicine or another health science field with additional training provided by ICTPH. Currently the training is about three months, but they hope to expand that to one year in the future. The topics included women's health, cardiovascular disease, nutrition and micronutrient supplementation, defining the roles of the different medical care workers, design and placement of new clinics including the furniture, computerized documentation (they are designing an entire new system for use in the clinics). The discussion was intellectually stimulating. Issues are thoroughly discussed and debated with everyone sharing their opinion, experience, and knowledge. The staff frequently cites relevant literature and identifies areas where more information is needed. We contributed to a few of the topics discussed, sharing our experiences with electronic medical records, women's health, and other areas of health care. The staff is impressive - they are passionate about the mission of the organization, intelligent, and experienced (even the many young staff members).

Our waiter beginning to make our paan

We concluded the day by getting together with the members of ICTPH for dinner and tasted a variety of delicious food including both north and south Indian and Chinese cuisines. We  continued an informal discussion of community health and learned more about India in general. Some of us had never used finger bowls and were introduced to the idea - warm water with a lemon slice used after a meal to clean the fingers and emulsify grease. We also tried paan - an extremely sweet after dinner digestive which is made by wrapping betel nuts, rose water and other seeds and spices in an areca leaf. Some of us enjoyed this as a one time experience, while others (mainly Alison) said they wouldn't mind making this a part of their daily after dinner ritual. This was a great opportunity to get to know the ICTPH staff on a more personal level. We had a wonderful time!

Alison, Rachael, Andrea and Sarah very excited to try paan

Alison and Andrea dove right in, while Rachael and Sarah
were a little more apprehensive

    

Rachael and Sarah reluctantly watching each other eat the paan

Dr. Mor said he was very impressed we swallowed it all,
 but even more impressed when Alison asked for seconds!

    

August 27th and 28th: Taj Mahal and more

Taj Mahal

Saturday, August 27th

The beautiful view from our rooftop during breakfast

We woke up today tired from our late night, but very excited to finally see the Taj Mahal. The morning started with breakfast on the roof of our hotel, which had an amazing view of the Taj Mahal. The location of our hotel turned out to be perfect with the view and being only 600 meters from the Taj Mahal East Gate. Our tour guide, Issi, picked us up at 9:30, grabbed our tickets and then led us in the Taj Mahal. We were all so excited and the Taj Mahal was even more amazing than we expected. As soon as we had the Taj in view, we started taking pictures and didn't stop until we left two hours later.
As we walked down along the empty reflection pool, our tour guide began to share with us the history of the Taj Mahal. The Taj Mahal was built by the Mughal Emperor Shah Jahan in honor of his wife, Mumtaz Mahal, who died during the birth of their fourteenth child. He was so heart broken he decided to build the Taj Mahal as a memorial and resting place for her. It took twenty two years to build, along with an estimated 22,000 laborers and 1,000 elephants.  Walking up to the beautiful mausoleum, one of the seven wonders of the world, was surreal. Once inside we got a closer look at the marble, which was extremely intricate and decorated with an array of colorful stones. Our tour guide took out a flashlight and held it against the colorful stones in the marble. Because it was so dark inside the Taj Mahal, the flashlight lit up the marble causing the stones to glow. From behind the Taj Mahal we could see a cleared area where Emperor Shah Jahan had started to build the Black Taj Mahal, but was arrested by his son for his extreme spending used to build the Taj Mahal before he could start it.

Rachael and Alison with one of the people
who asked to take a picture with them

One of the experiences we found entertaining while at the Taj Mahal were all the Indian men, women and children who asked to take pictures with us. This seems to be a common occurrence when foreigners visit the Taj Mahal, but we liked to think we were special :)

Alsion, Rachael, Sarah and Andrea in front of the beautiful Taj Mahal

Our salesman at the marble factory with some of the workers

After reluctantly leaving the Taj Mahal, our tour guide took us to a marble shop. We got to see the marble workers in action working on various pieces. After watching the workers and seeing some of beautifully finished pieces, we each purchased something special as a memory of the Taj Mahal and Agra. 

Agra Fort

We then went to Agra Fort. When Emperor Shah Jahan was imprisoned by his own son, Aurangzeb, he was sent to the fort and looked on from afar to the Taj Mahal, where his beautiful wife was buried. The Agra Fort was large and had a two tiered moat- one dry, one wet. The dry one held tigers and predators, while the wet one held crocodiles to fend off intruders. There is still an army presence at the fort and we could only explore what India has sectioned off as a historical society site. Then we went to Itimad Du  Daulah or "Baby Taj." The "Baby Taj"  looks over the River Ganges, a holy river. It was very warm in the afternoon and we looked out over the large river to see two figures waving at us,  enjoying an afternoon swim.   

Rachael, Andrea, Sarah and Alison relaxing in a doorway
at Agra Fort

Rachael, Andrea and Alison relaxing at the "Baby Taj"

Itimad Du Daulah, or "Baby Taj"

Andrea and Alison enjoying the view of the River Ganges

    













We finished up our exploration of Agra and ate on our hotel rooftop restaurant with a beautiful view of the Taj.

Our view at dinner of the Taj Mahal from our rooftop

Sunday, August 28th

Today was another one of our big travel days. We woke up early to meet our driver and start our 3-5 hour, depending on traffic, drive from Agra to New Delhi. Along the way we stopped to take a break and accidentally found the India version of Wal-Mart. We were so excited to see familiar brands and snacks, we each bought more snacks than we could fit in our bags. We arrived at the New Delhi airport, which was very large and modern, with enough time to wonder around and grab something to eat.

Within a few minutes of being inside the airport, we spotted the famous golden arches and quickly made our way to McDonald's for lunch. After trying the delicious veggie burgers, which are not available in the US, we made our way to the gate. Our flight was two and a half hours back to Chennai and on arrival we were picked up again by another driver. We met up with Marjorie after being picked up and went out for dinner at a delicious Indian restaurant and celebrated her birthday. After we ate and discussed our wonderful and eventful weekends, we got back in the car and headed for the Chennai train station.

Rachael, Sarah, Alison and Andrea getting settled in the train before bed

After searching for a few minutes, we found our sleeper car and seats. None of us, except for Marjorie, had been on a train in India before, so we were not sure what to expect. We had our own area, which was hidden by a curtain, that had two bunk-beds with sheets, pillows, and blankets supplied through the train. After our long day of traveling, we changed into more comfortable clothes and applying ear plugs and sleep masks, we got settled in and quickly fell asleep for the night.

August 26th: Community Health And Development (CHAD)

View of CHAD from the back

Our group with the St. John's masters students

Today has been a very exciting day. This morning, we took a short walk to the community hospital on the CMC campus. The hospital's name is CHAD, which stands for Community Health And Development. We met with Mrs. Suseela who took us and another group of master's nursing students, from St. John's University in  Bangalore on a tour of the facilities. Although the encounter was brief, it was great to chat with the other students. We wished we had had a little more time to swap perspectives on nursing practice and education.

One of the patient beds at CHAD

The CHAD hospital is significantly smaller than CMC's main hospital, however, it still serves a wide variety of functions for the community. On our tour we were able to see several different wards, including pediatrics, labor and delivery, specialty clinics (e.g. ENT, dental), immunization clinics, and others. At the moment there is a rotavirus vaccine program being offered that is part of a privately funded program that is optional for patients.

Instruments to be sterilized

The CHTC buildings where patient education and
workshops take place

Behind the hospital is a separate set of buildings known as CHTC - Community Health Training Center. Here the community health staff teach classes and workshops on various health topics. One program that has been successful is for newly married couples, where topics such as conception, menstruation, fertility, contraception options, and family planning (i.e. spacing pregnancies) are explained. In addition to the work they do at CHAD and CHTC, the staff also does community health outreach in local villages.

A medicinal plant with properties to help decrease symptoms of asthma.
There were many plants on CHAD's grounds

The large oxygen tanks stored at the back of CHAD

Alison and Rachael  

Sarah and Andrea

We were also able to see the theater (operating room). We ran into our new friend Dr. Anand Manuel the anesthesiologist who we met yesterday at the psychiatric department.  Although we were only scheduled for a tour of the facilities, he invited us to observe a scheduled Cesarean section. For one of us, this was the first opportunity to see a surgery, which made it even more unique. The rest of us were able to compare practices and protocol with those from the US. It was fascinating to watch the events taking place and identify the roles of all of the health professionals in the OR and see how the roles are the same or different. All in all, we have noticed often the role of the nurse is not as comprehensive or encompassing as in the US, including that of the OR scrub nurse.

Rachael, Sarah, Dr. Anand Manuel, Andrea, and Alison

Both yesterday and today, Dr. Anand was so good by taking time to explain things to us and to ask us questions to make us really think about what we were observing, the rationale behind the actions, and the relevant physiological aspects. We learned too that his wife, Jasmin, is one of the amazing nurses we met the other day - a true power couple!

As we write this, we are driving from Vellore to Chennai. We're then scheduled to fly to New Delhi and then drive from Delhi to Agra. We will arrive in Agra around 3:30 in the AM assuming there is no traffic. We have to rest up for our 9:30 tour of the Taj Mahal. It'll be a long day of travelling, but we are looking forward to our visit to Agra.

August 25th: CMC Psychiatric Department and Nambikkai Nilayam

Playground area for the children at the psychiatric department

Today was our last day at the psychiatric department/hospital. We leave for New Delhi tomorrow and are actually working out details to change our travel plans because of a hunger strike and political protests occurring in New Delhi. The hotel we planned to stay at is in the area of the protests. While right now the protests are nonviolent, the government has closed several metro stations in the area and there is a big debate tomorrow in the government. Since the nature of the protests could change at any moment, we thought it best to avoid the area entirely.

In the morning we went to the Occupational Therapy department. This department was different than the OT rehabilitative services we went to yesterday because this service is for the inpatients at the hospital. OT is very comprehensive here and seems to be the backbone of the hospital especially in regards to the schedule.

At 8am the patients (divided by gender) meet and perform simple exercises for 15-20 minutes. The exercises are especially helpful for patients taking anti-psychotic medications who experience EPS (extra-pyramidal symptoms) as a side effect and exhibit Parkinson's-like movements followed by breakfast from 8:30-10am. From 10-11am, all of the patients (including outpatients who live locally and participate in day care) meet for discussion time which includes reading a newspaper article and discussing the topic. One patient reads the article aloud, another summarizes it, and then they all discuss. There are three language groups: English, Hindi/Bengali (combined), and Tamil (the local language). Then there is general discussion about hobbies and sports. The OT said that this helps with cognitive ability as well as overcoming social phobias and practicing speaking in groups. All topics are encouraged, but, murders and suicides are not topics that are encouraged.

From 11-12pm, there is activity time and people participate in individual hobbies that are tailored to their abilities. For example, one woman was working on sewing and a man, previously a physician, is working on computers. From 12-2, patients eat lunch and rest (during the hottest time of the day). From 2-3:30, there are individual and group sessions in which stress management is addressed as well as other topics. Games are included, and there are also goal-oriented activities. From 3:30-4 is tea time followed by 4-5pm with outdoor extracurricular activity time (such as playing volleyball or badminton).

Caregivers (i.e. the patient's relatives) are encouraged to participate, especially in the beginning. The OT said that it is helpful for the relatives to observe how the physicians are interacting with the patient and the behavior can be modeled. Also, the caregivers can participate in their own stress management group. In terms of rehabilitation and re-integration into the community, the patients are encouraged to simulate activities they will participate in upon discharge. For example, one teacher with paranoid schizophrenia was unable to teach for a year, but was able to re-integrate into the community and wanted to return to teaching. She was very nervous about speaking in a group, so students were brought in to simulate a classroom setting and she felt much more confident.

Then we went to observe ECT ("shock therapy") in a seizure is therapeutically induced and helps with many types of mental disorders, including depression. One woman we observed felt a lot of guilt from
her past and could not function. Today was her last round and she received 12 rounds total in 6 weeks. She has been improving and her guilt has dissipated. The patients walk into the treatment room and lay down, then a sedative is administered followed by a muscle relaxer. One of the young men we observed today was chanting something to himself to help keep calm before the sedative took effect. The beeping was loud but he kept his chanting up and even though we were listening to the chant, it slowly faded away and his chant became the monitor beeping. One woman had to receive two shocks because the first was sub-therapeutic. The anesthesiologist was great and showed us around and grilled us with questions. Andrea was the best at answering his questions because of her background in cardiac nursing. He knew that we wanted to see, so he allowed us to get up close for observation.

ECT is not like it was many years ago - the patient is sedated and also given a muscle relaxant so the body does not convulse widely. A blood pressure cuff is used on one arm to block the muscle relaxant from going into the patient's lower right arm but the shock goes through and the M.D. can observe how long the seizure lasts (at least 20 seconds is therapeutic). This is like how it is done in the US. We also observed the recovery room. It seems like the nurse's role here is concerned mostly with the biological needs of the patient (medications, sleeping, eating) unlike in the states where nurses would lead group activities like in the OT department.

In the afternoon, we observed the child and adolescent ward. Children with autism, mental retardation, developmental delay, and cerebral palsy come here for support. The family is invited to stay for at least 3 months, and after discharge, the family checks in with CMC every few months (if they lie locally) or annually (if from the north). Parents are taught how to engage with the children as they are the main caregivers and will have to care for the child everyday. At CMC, the parents learn about positive reinforcement and how to administer the rewards (like keeping charts and then giving candy, stickers, or an activity as a reward). Psychologists are the head teachers in each room and take part in the interdisciplinary rounds each week. The patient's progress. Siblings are also brought here to help encourage sibling relationships and sibling rivalry is addressed. The families can leave on outings and are free to explore the city.

There was a separate child and adolescent OT department that we didn't see. Patients with OCD, ADHD, oppositional-defiant disorder and conduct disorder (the disorder that is correlated with antisocial personality disorder) are treated here.There are games, learning how to interact in a social environment and group activities.

August 24th: CMC Psychiatric Department

The walkway to CMC's Psychiatric Department

Today we went to the psychiatric department of CMC Hospital where there the focus is on family-centered care. Alison is a BSN/MSN Psychiatric Mental Health Nurse student and this was one of the main reasons she wanted to participate in this program. The department is actually completely physically separate from the main hospital and on the same quiet, relaxing campus as our dorm. Family centered care in this case means that a patient needs to have one (preferably two) relatives stay with him/her while at the hospital. The family helps support the patient during his stay and when he is rehabilitated back into the community. At CMC, the family helps deliver the care, learns about medication, and even helps inform the staff/physicians about the patient's personal symptoms and level of functioning. For example, if a person were to come to the hospital and was not performing at optimum functioning, but improved and the physicians were discussing discharge, then, the family would give their input and say that it is not the optimum functioning and the person needed continued support.

The Psychiatric Department is located in a picturesque area

On admission, the patient (and family) are informed and commit to generally a minimum of a four week stay at the hospital. Still, no wards in the hospital are locked, the patients discuss being discharged when they feel ready (and physicians and family discuss the possibility of
continued support if necessary) and if the patient feels it is necessary, he may leave the hospital grounds, and the hospital will call the home to check that the patient got home safely.




Apparently, this hospital is one of the only ones in India that follows the family centered model. The family even stays overnight with the patient, and helps with everyday activities. In the morning, there is occupational therapy as well as group therapy and all patients are encouraged to participate. Mid-day is relaxed, and the patients are encouraged to participate in afternoon activities.

This morning, we observed daily rounds in which the medical doctors, nurses and occupational therapists make rounds on the patients. Medical residents also participate and we listened to a very thorough and comprehensive case study of one patient who was diagnosed with bipolar disorder. The  hospital is very interdisciplinary. We were pleased that we knew answers to some of the questions that the lead physician posed to the group.

Unlike the main CMC hospital (where physical ailments are addressed), insurance does not cover mental health. So, people pay out of pocket, even the patient of the lower socioeconomic classes will pay some amount. The nurse said that it is good that the patients pay, even if it is a small fraction, so that patients understand the severity and importance of the care and she corsrelated payment with good
compliance.

Earings made by
patients at the rehababilitative center

In the afternoon, we went to the rehabilitative services, where people do not stay overnight at the hospital and instead participate in day care activities (like making earrings, candles, and paper bags out of newspapers that are then used in the college store) and then sell their products. The clients create relationships and take anger management classes and learn to identify stressors.

Coconut bowls made at the rehab center

There are four phases and by the end of the fourth phase, the client is encouraged to reenter society and hold a job. The therapists work with merchants (like grocery store owners) to help the clients get jobs, and follow
up with the clients. There is even a half way house for the clients to live in while their life is stabilizing. One downside is that a lot of the clients have chronic mental illnesses, and many of the families desert them and discontinue support, so it takes long time to create a relationship and support the client to reach the fourth phase. The program even addresses stigma of mental illness and how to approach the stigma in society in an adaptive manner.

Nurses station at the Acute Care Unit
where patients are monitored for 48hrs

As we may have mentioned before, the nursing faculty have to teach theory courses as well as clinical courses and manage their hospital jobs. Many also conduct research and are pursuing their own advanced degrees. It seems very time consuming and difficult. As students do not stay long at their clinical sites, and psychology is often not a favorite of students, it seems difficult to integrate students, and meet the patients' needs at the psychiatric hospital. Still, it seems like there is one student for a patient (we learned about some government hospitals where there are 10 students per patient) and not every patient has a student. The role for nurses at this hospital seems to be overseeing things and administering medication, not as much counseling as there is in (ideal settings) in the US.

Dinner at Dean Rosaline's House

That night we were graciously invited to Dean Rosaline's house for dinner. She, with the help of her husband, made a delicious meal of gobi (cauliflower), two types of chicken (one dry and one with gravy), chappathi, vegetable rice and the most refreshing ginger lime juice. For dessert we had fresh mangos, bananas and apples. Everything was very delicious! After eating we all gathered together to take pictures. It was a very pleasant evening.

August 23rd: CONCH in the Village of Puttuthakku

Entrance to the CMC center

Andrea, Sarah and Rachael with two CMC nursing students

Our field work today in the village was quite different from yesterday. We have a project to complete while here with a focus on nutrition, specifically pertaining to the nutritional status of children under five years of age. We arrived at the nursing school around 8:00 am and spoke with one of the community health professors about the questions we came up with to ask about nutrition and she helped us think of additional questions to focus our nutritional assessment for our target population. She was very helpful! We came up with questions to ask mothers in the village about their perception of their children's nutritional status, whether they thought their children were malnourished or well fed, and why. If they had easy access to nutritious foods and supplements and if they thought those foods were costly. We asked the mothers where they get information about cooking nutritious food. We asked if the children had any illnesses in the past, trying to ascertain if the child had ever had parasites which can effect the nutritional status of the child. We asked about the immunizations status of the children as well as if they are weighed frequently. We also asked if the children use any local government programs focusing on nutrition.

A mother holding her 1 1/2 year old son, who graciously
answered all of our questions

Children eating lunch at Balwadi

We split up into two groups each with a CMC student nurse as interpreter and visited 2-3 families. It was very interesting to gain an idea of the villagers' perception of nutrition. The mothers were very conscious of the need for a nutritious diet to the point of being worried if their children wouldn't eat the meals they prepared. One mother stated that she felt that her children were skinny and malnourished because they refused to eat anything other than sweets, biscuits and milk. Some of the families used the village government program called Balwadi. Balwadi is a government funded school for children ages 2-5. The children are able to start to learn letters, counting and rhymes, dance and songs and a nutritious lunch is provided every day. The main food given is called a Tinp Ball which is a power made of wheat, rice, grains and jaggery (a sweet plant) and is formed into a ball and cooked. We really enjoyed being with the families and seeing more of the daily life of a villager and getting to know some of their concerns as they relate to their children. We have been impressed by how caring, selfless and family/relationship oriented the Indian people are.

The Tinp Ball and grains

  

Two of the elderly villagers attending the Geriatric Club

After interviewing the families, we returned to the CMC clinic to learn about their elderly day care program. Every day except Sunday they have what they call the "Geriatric Club" where the village elders come and play games, get the newspaper read to them and can talk to each other. A volunteer from the community comes every day to help with the club. The nurses told us that the elderly are not always well taken care of by the families and often feel useless since they are no longer working and contributing to the community. We were told that before television came there was more of a sense of community in the village where the women after finishing their duties in the home would gather at people's houses and talk. Now that there is television that no longer happens and the elderly especially no longer have that time with the villagers to associate and feel part of something.

We ate lunch, after our introduction to the elderly program, at the CMC clinic. We packed a very nutritious lunch of peanut butter and nutella sandwiches. After lunch we were conversing with the nurses regarding the DOTS program, which is a directly observed treatment therapy for tuberculosis. The healthcare professional gives the patient their medication daily to make sure the patient follows the correct treatment regimen for 6-8 months, thereby preventing the patient from stopping the medication early or not taking it at all. This program is in place to help prevent the spread of TB as well as resistance to the medication caused by an incomplete treatment regimen.

While this conversation was going on, Andrea began to feel ill and had to be taken back to our hostel on the CMC campus to rest.

Children of the village primary school listening to a
 health lesson on upper respiratory illness.
Alison in the background listening along with the children.

The rest of us went to another primary school where we observed an interactive health lesson presented by the CMC nursing students. Then went back to our hostel and to the canteen for dinner.

August 22nd: College of Nursing Community Health (CONCH) in Venkatapuram



Sarah, Andrea, Mrs. Shirley, Alison, and Rachael on
the roof of the CMC College of Nursing

Today we started off at the CMC College of Nursing and had a tour of the new facilities by Mrs. Shirley, one of the assistant deans. The building was consecrated last August and is very large and welcoming. There are several courtyards with open air hallways. The school has a mock ward for simulation, many classrooms and office spaces, a continuing nurse education classroom with videoconferencing, a nutrition lab, and many other educational spaces. During their nutrition classes, the students not only learn the science of nutrition, but also how to shop for and prepare various diets so they can teach patients and their families. The nurses demonstrate how to cook meals in the home (instead of just presenting information).

We then went with a group of students and staff to a village (Venkatapuram) for community health nursing. There are many CMC faculty/staff nurses that run community clinics and the students join them during their community rotation. Each week, three days are spent in the clinics and two in are spent conducting home health visits. There is also a pre-school and primary school education component.



Nurse drawing blood from patient's finger
by applying oral suction to a pipette

The yellow school bus takes the staff and students (along with some CMC hospital nurses) and drops them off at various rural clinics in the area. We went with a group and observed today. The clinic where we observed was a four room structure, about the size of a bedroom or living room in the US if not smaller. It also serves as the village library. The community nursing in India covers a broad scope. There is generalized nursing care with taking vital signs and providing education and medications, there is prenatal care, and school education (going to the schools in the community and providing education on health and hygiene). The care is also subsidized- the nurses know the communities really well and each person pays what s/he can afford. We were able to observe several visits in the clinic and two home visits.

Family members of the
village vice-president

We went to the village vice president's home and she served us coffee and tea. They were very gracious and we spoke about one of the sister-in-laws upcoming arranged marriage. The CMC RNs are mostly Christian and the village people are both Hindu and and Christian. This family was Hindu and had a separate temple room with a separate kitchen (food and flowers are offered to please the gods).

The governing body of each village is the leader in deciding what programs are offered in each village. The president/vice president help organize getting potable water, electricity and even building the village's Hindu temple. The president also helped bring in the CMC presence. India's government is also trying to improve the overall health of the nation, such as paying Rs 6,000 to the women for giving birth in the hospital. The government also helps subsidize medication – a lot of the medications given out today were given out in kind to those who could not afford it. There is also another program, Primary Health Care (PHC), that is government run, and if the CMC clinic does not have a particular medicine, then they refer the patient to PHC. For example, today a toddler was brought in with a terrible case of Otitis media – an ear infection –and the clinic did not have the drops to prescribe so the family was referred to PHC. It is great to see the autonomy of the nurses at the clinic. The patients come in with their individual medical records (like brochures of their past checkups) and the nurses update everything in a notebook and gives out any needed medications. For the rest of the morning, we observed more nursing visits.

Andrea, Alison, Rachael, and Sarah
in Hindu temple



Sarah with a bindi on her forehead

After lunch, we wandered over to the village's recently built temple (only a few feet away from the clinic). For the whole morning, the boys/young men and an old man had been looking into the open windows and smiling at us. One group member, Rachael, wanted to see the temple and suggested we go over. All of the temples are brightly colored. The youngest boy ran to get the keys and they opened each door for us and showed us the status of their gods and insisted that we pose for pictures. Even though we shared

very few words (such as hello in both English and Tamil) and the names of the gods (but with different pronunciations) it was a lot of fun and we felt very welcomed.



Alison interacting with the school children

In the afternoon, we went to a primary school where one of the CMC students gave a health lesson. During their community health clinical rotation, the nursing students have to present projects to the primary students, and it was so much fun to see both how the school education is conducted and the children. They loved the cameras- we would take pictures and then show it to them. We were able to have basic communication with the children – for example, asking them to smile with teeth showing and reciting the colors of the rainbow in English. We had so much fun – all of us love kids.

CMC nursing student teaching
primary school children

The nurses use large educational flipcards to teach about different health topics. Today's lesson was on parasites and prevention, as well as questioning the children on what they ate for lunch (follow-up from a previous lesson on nutrition). Most of the outreach relationship between CMC and the village schools seems to focus on health education/prevention and caring for the children when they are sick (different from what Alison has been learning from her US work/research where the school children are given physical examinations and there is followup at home). 



Thatched roof hut in village; not that
of client

We then went to a thatched-roof hut and visited a woman living with Parkinson's disease who is supported by her daughter. The daughter has three children and is separated from her husband and is the sole wage earner in the family. It was an interesting juxtaposition from the vice president's house. Overall, it seems like the village is being built-up. The elderly woman was able to get her medication and the standard ration of food from government programs. Additionally, she receives 1,000 rupees a month and additional rice from the government as she is an elderly widow.



Primary school students in
uniform waving goodbye

We also learned about the government's role in providing education. In Tamil Nadu, education is free, girls are encouraged to attend, and uniforms and bicycles are provided. There is also sometimes a free midday meal.
At the end of the day, we took the school bus back to the nursing school campus, tired but excited about our full day. We are so grateful to everyone who is taking the time and energy to help us learn about India, especially the CMC faculty, staff, and students and the local community members.