Clinic Days

Ever experienced  “When the circus came to town”? Brightly painted vehicles laden down with mysterious equipment arrive to a vacant lot or open field. A cast of exotic, oddly dressed characters jump out and begin unloading large, unfamiliar items in a somewhat systematic manner. Speaking loudly to each other, moving quickly, these visitors from far away periodically pause to survey the now off kilter atmosphere of the community they have suddenly turned upside down. The locals look on with an air of anticipation and uncertainty.

We usually arrive to our next clinic destination in late afternoon, just as darkness begins to let down and everything takes on a soft focus quality. Our caravan rolls in, often flanked by yelling, waving children who then stand in clusters, whispering and pointing as we get to work. We set up and break down with a rhythm and choreographed division of labor that improves every three days, with each successive clinic site. It is a little strange that this chain of events is beginning to feel normal to me.

We pass cargo down the line, person to person, unloading the rickshaws and support vehicles. Trunks and burlap bags, metal poster stands and health education banners, plus the endless small packs and randomly acquired items such as rope, tarp, and two embroidered umbrellas that have traveled all the way from a Jodhpur street market. Our faces are usually streaked with sweat and road dust, our hair wild and windblown.

We set up clinic in school yards, hospital campus parking lots, town halls, slum centers, or temple outskirts. Depending on the site amenities available, we move chairs and tables into a configuration that has emerged as best for crowd control. Yards of dyed fabric originating from the second or third round of turbans we received from our ever gracious host communities had been unwound and now serve as a means to divide space. Patients waiting to be registered, patients waiting to be seen by doctors, here. Line for pharmacy, here. Sometimes we circle the rickshaws to block out treatment areas underneath trees, and set up the “pharmacy” by shifting around cargo in order to dispense medications out of the hatch back of our support SUV.

Anyone who has been inside a train station in India, or any such crowded free-for-all, could perhaps imagine the manner in which our waiting and determined crowd of patients approach the clinic area. A mass of waving arms and white registration papers; rows of bodies pushing and leaning against us, imploring in various ways that their ailment is most urgent. Everyone steps in front of each other to be seen by a medical provider while grinning unapologetically. The intensity of the crowd and perhaps their sheer number immediately overwhelms, wares and disorients us personal space conscious Americans. Practicing medicine the way we do, where we come from, necessitates some degree of corresponding western based order and organization.

Fully acknowledging that I am operating through my own cultural bias, I began searching for a way to rope off designated “wait behind this line until you are called” areas by the second day. Our group wide collection of turban fabric was growing abundant and actually worked quite well. I hoped that our hosts were not offended to see the good quality fabric put to work for sheer utilitarian purposes. It became a necessity that I could not afford to analyze and risk having to give up.

Tables and chairs, two doctors to each station, one American, one Indian, a table for dispensing medicines, one for vital signs and nursing care, and our mobile clinic can be ready to churn out health care on any given day. Setting up the pharmacy is always the most tedious and time consuming. Various bags and containers often had to be consolidated during re-packing, so each time we set up at another clinic site it became necessary to divide out the drugs into categories on whatever table top or surface was available: Antibiotics, Antifungals, topical creams, eye and ear drops, medicines to treat pain and control fever, medicines to treat the lungs, to control blood pressure.

All drugs were ordered and purchased in India, and so have brand names that we are still learning to recognize. Still, the process was getting easier. We no longer  looked for Tylenol and easily pulled the large PCM  jars, filling endless plastic pouches with five white tablets, a five day course of treatment for headache or ailments with associated fevers. As soon as the pharmacy is ready to go, we begin seeing patients. By this point there is usually a hefty crowd congregating around us, an equal mixture of those waiting with medical complaints, and those who pushed to the front just to hover, inspect, and partake in the entertainment that we seem to provide.

Having a local person assist in “registering” patients is key. Give a school teacher or local village leader a pen and a touch of authority with the troop of foreigners, and we can begin the process of organizing a crowd to receive medical care. Traditionally, all men would be seen first, before women and children. Once we realized this, we couldn’t help but institute process of seeing one male, one female patient. Children get automatic priority, especially the young ones, who are more vulnerable to illness. 

This is often elicits some indignant protesting from the older men, especially in the more rural communities. Fortunately, they eventually accept this bizarre insistence made by the foreigners, and adjust. They make sense of it by separating into two lines, male and female and the drop down into a squat, hips low to the ground, and shuffle forward. The line advances in one fluid motion, the way a centipede orchestrates many legs to inch and wiggle its elongated whole in a forward direction.

People are warm in receiving us, kind, often blatant in their desire to interact in some way. Old women with earlobes stretched long by heavy hoops, their faces shriveled underneath sari silk veils, grab our hands and fold them underneath their own in prayer position. They offer us the honor of the Nameskar greeting, while at the same time launching full steam in to describing every pain or physical complaint they have ever experienced in their life time. Each clinic site made special preparations for welcoming us. There have been ribbon cutting ceremonies to buildings that have been standing and operational for many years, but that for the day would serve as our mobile clinic and so must be inaugurated, chains of strung marigolds to adorn our necks, tikka and rice for our foreheads, and burning of ceremonial incense.   

The majority of patients we see have chronic ailments. Arthritic aches and pains, gastric reflux and irritation, respiratory complaints ranging from infections with or without fever requiring antibiotics,  to ongoing lung damage from years of inhaling pollution, industrial dust or chemicals, and from tobacco. Some people are told, for the first time in their life, that they have high blood pressure.

Many women shyly complain of vaginal infections and voice basic questions and concerns about parts of their bodies that remain wrapped and covered by many layers of fabric. Some agree to exams. Some request to consult with a male member of their family for this decision. Others completely refuse.

There is an abundance of skin infection, and eye and ear complaints with drainage of every color. All children with large bellies are sent home with deworming medication. Several cases of erectile dysfunction, reported by esteemed community leaders who request a private meeting with the doctors, are referred for treatment.

Some people are acutely ill, though with the abundance of hospitals in India, access to emergency and inpatient care is quite good.  Still, a few cases of progressed Thypoid, Malaria, a man with a concerning story and symptoms of spinal compression, are treated and then transferred to the nearest hospital.  

There is a constant exchange going on between the American doctors and Indian doctors, who now have been working together in rotating teams for several weeks. The process of taking a history, diagnosing and treating illness, or lack there of, becomes a vehicle in cultural exchange, as questions and different ways of practicing emerge and are sifted through. Sometimes there are nurses, or nursing students present, allowing for the same type of exchange and cross cultural relating.

Often times my exchange involves the clinic site hosts, as I interact with them with the title nurse, but also in matters of organization, triage screening, and the general need for “getting things done”. Their reaction is initially one of concern and displacement, due to my female status of course. After being asked to “just sit down” multiple times at one clinic site when a particularly large crowd swarmed the doctors tables and began pushing each other, fighting to sit down in the designated exam chairs in a rough and tumble version of musical chairs gone very bad, I politely as I could stated that no I would not sit down, in fact I was going to stay standing and moving while I reorganized the set up of this clinic. At the end of this very hectic day, it was noted that I had had some “very cute and useful ideas”. We all shook hands and smiled at eachother over our chai cups.

Each day takes on a particular rhythm with an early morning focus on crowd control and management. Sometimes we have to stop clinic and refuse to see any patients or dispense any medicines until the waiting mass maintains some semblance of a line in the designated areas. We hold up our hand to demonstrate that we can’t, or won’t, do a single thing more until our request for “eck”, as in one, person at a time, is honored. At some point we break in shifts for water, roti, and dahl. We eat with our hands and wash our fingers, stained yellow with turmeric, by pouring a scoop of water from a designated jug or basin over one hand, then the other, and vigorously rubbing them together.

The end of the day is marked by shadows elongated across the yard or field we are working in. The line of patients finally thins, the pharmacy scrapes together the last few prescription orders amidst a chaotic pile of empty pill trays. We begin to thank our hosts, who after eight hours working together, side by side, in English and Hindi, have become our friends. They shyly ask us about their own medical complaints; most want their blood pressure checked.

Sometimes, there is something extra special. Like for instance, the impromptu drumming and dancing that broke out as we packed up our supplies at sunset in the Kinshingarh slum. Some teenaged boys began drumming. No longer needing to focus on the order necessary to do our work, we let our guard down and began to smile freely, to oblidge each child in their excitement to say “hello, how are you?” and get a response from us. We shook their hands and began to dance, clapping hands and kicking feet, with no more need for translation, in fact, very little need for words at all.

I linked hands with a cluster of six to ten year olds, most with stick legs and red tinged hair, a classic marker of malnutrition, and began to spin with them in an exuberant game of ring-around-the rosy. They squealed and I laughed. My only means of extricating myself was to convince the group to fold hands and bow together towards the sinking red sun, giving one last, simultaneous “Namaste”.

Each time we break down a clinic camp, we are usually racing against darkness. We hurry to stack bags and cartons into the vehicles, shaking hands and expressing thanks as we go. We jump, one by one into the vehicles, honk horns and start engines, then caravan off, each vehicle in line. Behind us we leave scraps of paper, empty pill bottles, chai cups so graciously offered. The ground where our mobile clinic stood is flattened from foot traffic. The local host staff stand waving as we disappear. 

I venture to guess that in the day light of tomorrow, everything in these villages will return to normal, and that this health rally will exist somewhere between memory and imagined in the minds of those who will recall the day that such a medical big top event rolled through town.