Final Thoughts and Farewells

After a few months back home, I have had time to process my experiences in India and have a few stories that reflect some insights.  After being home for only one day, my wife and I were invited to stay at the beach with one of her friends and the friend’s mother.  We had not been at the hotel for more than an hour before the mother started letting us know everything that was wrong with the room.  The A/C did not work well enough, house keeping did not come around often enough and did not clean sufficiently while there, breakfast was too expensive, the elevators were too slow, etc.  In the hotel room, I was thinking back to what one of the doctor’s in India had told me just a week or so before.  He mentioned that Indians are happy with very little.  Given a small handful of food and their family around them, an Indian person would be completely satisfied.  This is in stark contrast to my experience in the hotel.  Another family in the hotel that we had met in the elevator looked really unhappy.  It was unusual that they seemed unhappy, since they were heading down with their entire luggage.  One would assume that they were going home, and a vacation usually helps people relax, so their agitated energy seemed misplaced.  It turns out, though, that they were only heading down to request a room change since they had found a cockroach in their room.  They had just arrived that day, and this was the SECOND time they were changing rooms.  Our friend’s mom had plenty of dissatisfaction to share with this other family.  You don’t go to the beach for the hotel; you go for the beach!  Every time I had an interaction like this, the people expressing their disappointment seemed more and more ungrateful and unhappy.  Granted, they had not just travelled in a place where you see people living in shacks made of coconut leaves and where you’re lucky if your hotel has a showerhead.  Still, this was all in contrast to the appreciation and optimism I saw in people who had much less.

Another thing I have come to see is how seriously we all take everything.  In my Food Purchasing class, we learned about standards in the US in which food is to be kept at least six inches off the ground when in storage to prevent pests and moisture from spoiling the food.  In India, the storerooms I saw at BHC had food thrown on shelves and on the ground open to the outdoors with no refrigeration.  I definitely saw pests in there.  There should be appreciation for the sanitation standards that we have, but the degree of anal-retentiveness of our food safety standards reflects how much Americans often try to totally control things. 

Not everything I have to say puts Americans in bad light, but there is one more negative thing I would like to mention.  Students and workers in India have high respect for their professors and superiors.  Blind obedience can get people into a lot of trouble (people have used Stanley Milgram’s work to say this was largely the cause of the Holocaust), but there is something to be said of respecting others.  Professors at BHC could tell students to do something that did not help them academically, like taking Jess and me on a market and temple tour, and they would do it.  One of my professors, who I am friends with, told me a story of a student in her Basic Food Science lab who started tossing eggs back and forth with another student in the middle of lab!  They ended up dropping several eggs to make a splattered mess.  I have seen coworkers at a landscaping company I work for waste time to do things like hammer the owner’s name in nails on telephone poles across the property or do a mediocre job since they were only there part-time.  I cannot think of this happening in Trichy.  Of course people in that city are not 100% obedient and respectful all of the time, they are all human, after all; but, people respected each other and tried their very best.  I did not see anyone working at anything but 110%.  This was partly out of necessity: with over a billion people, you have to distinguish yourself to get a good job.  Still, I saw people doing either physically or mentally grueling work in 100-degree heat without complaining.  I came to appreciate that respect and diligence. 

The things I appreciate most after coming home are safety, cleanliness, privacy and infrastructure.  I can walk down a well-maintained side-walk that is flat without any cracks or holes without worrying about being confronted or hit by an animal or scooter/bus.  I assume that due to emissions and littering laws, the roads and public spaces feel much cleaner and are easier to breathe in.  Public spaces have things like trashcans, benches, and bathrooms always readily available.  Hotels definitely will have clean drinking water, showerheads, and some kind of food on hand.   While some of these things are luxuries, being able to walk in public without fear of being hit and killed or being able to be in a public space and have access to clean water are examples of how our laws and culture ensure a sense of safety that was not as common in India.  Public safety laws requiring workers to wash their hands and serve food with utensils is another example of the sense of safety and cleanliness not required in India.  In one of my previous posts, I discuss the food vendor who picked up a piece of foods with his hands, dropped it on the ground, and nearly put it back on the table.  With the state of most public bathrooms I saw, there was probably no soap available, and he would not have to use it even if there was.  As another example, some areas of the US have poor relations between the police and the public, and response times can be poor.  However, if we have a fire or a safety concern, we can reasonably expect professionals to arrive in a short time to help.  In India, the car accidents I saw were dealt with personally without a call to the police.  Natives told me that police response times were frequently more than an hour, and in some cases help never came.  Lastly, privacy is legally and publically expected here.  Public buses on India became grossly overcrowded.  Besides the people sleeping in the aisles and the cages of chickens loaded in any free space, people packed like sardines in every space.  After all of the seats had three to five people in them, and after all of the aisle spaces were taken, people crowded and sat on the floor around the feet of the bus driver.  In this example, the sense of personal space was much smaller.  When men I got to know held my hand all of a sudden, it was not unusual.  If I gave my phone to someone to show him or her a picture, they would start scrolling through everything on it if I didn’t stop them.  When travelling in public, especially when entering or leaving a new city, police or military could come onto the bus to count people and search bags.  Police set up roadblocks at city limits to slow traffic so that it was easier to control the flow and the persons entering the city.  If police entered buses and started searching bags here, the people could probably sue based on, whether real or fabricated, discrimination based on race, gender, age, disability, religion, etc.  While not true in all cases, public areas and roads are cleaner and safer, your personal space and privacy are larger, and all types of infrastructure, including roads, public spaces and buildings, residences, etc. are more well maintained. 

I now have a greater appreciation for all of those things we take for granted.  We have easy access to safe water, and Wi-Fi is everywhere.  These things are becoming more and more precious as water becomes scarcer and education continues to evolve using the Internet, but those things were scarce in India.  Having lived without many of the pervasive necessities that are constantly available to most of those living in the US, I value them more greatly.  There are still villages where people are living in coconut leaf shacks without electricity.  There are large schools and cities where most students and citizens do not have access to the Internet.  It seems that, while the people I met lead a richer family life and were more rooted to their beliefs and those around them, we have more freedom and resources.  Change is never easy, but connecting more closely to my family is a mere phone call or drive away, while Indians cannot just pick up the phone and have access to clean water. 

Since this is my last blog post I intend to post for a while, I wanted to reach out to anyone who wants to study abroad and thinks that they cannot for any reason, be it concerns of scheduling, budgeting, inexperience, etc.  If you want to study abroad, feel free to comment on my blog or to email me.  I also wanted to thank everyone who helped me along the way.  First of all, Dr. Jones, you were a tremendous help.  You prepared us in every possible way, from looking at Indian culture to giving us safety tips and overall being a continuous fountain of good advice.  Also, I wanted to thank all of the family and friends who supported my travels.  I know many of you were at home reading my blog posts, which made it much more fun to write when you knew someone was going to be reading about your experience.  Also, thank you family and friends for donating to my gofundme page or for sending me spending money for while I was there.  Thank you Haley, for being supportive of my travels, just a short time after we got married.  And lastly, I wanted to say thanks to all of the organizations that offered and awarded me scholarships for my trip.  Without all of you, it would not have been possible.  To the Benjamin A. Gilman International Scholarship Program, I wanted to thank you for not only the funds, but the straightforward application and continued help along the way, including requiring me to enroll in safety programs and to view various safety videos.  Thank you ACCESS for the Study Abroad Scholarship and the Passport Scholarship and for all of you advisors supporting me throughout the application and follow on service project.  Christine Dave, your efforts in preparing Indian Food for my project was greatly appreciated by me and everyone who tried it.  Additionally, Adam, thank you for letting me speak with your class about studying abroad.  Also, the Appalachian Honors College provided yet another scholarship that made my travels possible, so thank you, too.  OIED also provided the T. Marvin Williamsen Scholarship in addition to all of the advising they provided before I left.  Additionally, a few folks, especially Maria Anastasiou, helped me with my follow-on service project for Gilman, so I thank you for your time and effort.  Lastly, I thank the Goodwin Meissner Family Foundation for your contribution to my travels.  All of you made this possible for me, and it has changed my life.  Thank you. 

Travelling Home

The mind is a powerful thing.  For about three weeks, I watched a woman who had been in a car accident and fractured bones all over her body, who had been admitted unconscious with a brain stem contusion, and who could not eat anything for two weeks, gradually improve.  After the first week and extensive surgery, she was moved to the IMCU.  Later on, she was transferred to the general wards.  She was eating, moving, and speaking.  Her tube feeding was removed. She was getting better and could have probably gone home in the next week or two.  Then, she found out that she had accidently and tragically killed her son in the car accident that put her in the hospital.  By my second to last day, she had become so depressed that she had ceased all eating.  She dropped so much weight that she was placed back into critical condition and is now laying dead-faced in the ICU.  She is receiving IV fluids again.  The prescribed diet is a soft diet with mild foods like milk, idly, rice, soup, and juice.  I will not be there to see it, but if she continues on like this, she will be placed back on nutrition support.  For two to three weeks, before the depression fully set in, this woman’s body knew what to do to heal itself.  Physically, she was recovering just fine.  When she fully realized what had happened, her mind took over her brain, and she is in critical condition, again.  This is amazing to me.  You can teach nutrition students all of the theories, guidelines, disease states, advanced nutrition sciences, among any other topic, but handling patients’ psychological needs is something not taught in school.  For me, this is too difficult.  The hospital to me became a symbol of disease and sadness.  I love to talk with the dietitians, and we have become friends by now, my last day.  However, the job of any hospital worker includes being around people who are suffering, crying out, coughing, spitting, screaming, and gasping for breath.  In many cases, they are totally dependent on you. In cases where they are not, they often do not listen.  Additionally, I know that I love food science.  I love watching Madhan make the breakfasts and dinners (I am not here for lunch to watch him make it).  I love trying new fruits and vegetables and hearing the dietitians explain why you eat certain foods in which ways.  I love reading research articles.  I also love looking at the body and how it works, including in hospital care.  However, the hospital environment is wrong for me.  It is good to find this out now. 

The only other patient I wish to mention that I saw is one who I have also seen everyday for the last two weeks.  He was admitted after a traffic accident and had a bad head injury.  At first, his diet was hugely artificial.  He was receiving 28.5 kilocalories and 2.1 grams of protein per kilogram of bodyweight, much higher than the necessary 23 kilocalories and 0.8 grams of protein to maintain a healthy human.  Despite this high input, the patient was admitted with a BMI of 22 kg/m² and ended up at 16.8 kg/m².  This means he dropped from a healthy weight to being malnourished.  He is now receiving 40 kilocalories per kilogram of bodyweight and the same amount of protein as before.  Besides milk and porridge, his diet is 100% artificial.  He is being given three different supplements several times each day to maintain a high intake of energy and protein.  There are two reasons for his drop in weight.  After having been moved to the wards, his food intake was not monitored as regularly as in the ICU.  So, he was not receiving enough energy.  Additionally, he continued to develop minor infections, so his body was expending huge amounts of energy to fight these on top of having to rebuild after a head injury.  He developed hypoxia and could no longer efficiently use the food he was taking.  Now, he will remain in the ICU until the hospital can boost his weight.  In the USA, there would be a major investigation to discover why a patient was allowed to become malnourished after admission.  Many times, US dietitians document patient condition heavily when they are admitted to ensure that there is no malnutrition present beforehand.  The hospital and dietitians would be liable to a lawsuit for mistreatment.  I am not sure if there will be an investigation here, but it seemed like Gayathiri was not worried about it. 

The hospital was checking the oxygen lines in all of the critical units today.  Because the oxygen lines run behind the beds of the patients, the staff moved, literally, every single patient from these units to these super cramped, makeshift critical care rooms.  The difference was shocking.   The makeshift rooms were very crowded, super hot without any air conditioning, and really loud.  Workmen were removing and replacing tiles on the walls (which is pretty much an everyday occurrence all over the entire hospital), so there were all sorts of noises.  Also, there was hardly any equipment.  In the ICU, there are clean tables, several medical machines, filing cabinets, etc.  In the makeshift rooms, there were dirty tables, and that was about it.  Normally, these patients receive very careful care and attention in their units, but these rooms were awful.  I have also noticed that the power goes out more frequently, here.  It only happened on two days while I was at the hospital, but it continued happening during the length of the whole day.  Hospital workers have to deal with a lot of unfortunate external problems; infrastructure does not support them.

Technically, yesterday was my last day of training at the hospital.  At the end of the day, the dietitians brought out a cake, we took many selfies, and we all wished each other the best.  Today, I went back just to hang out.  I was only there for about three and a half hours compared to the usual six.  At any point, one of the dietitians stayed in the office with me to chitchat.  Gayathiri made a lot of jewelry for my wife as a gift to me as I go.   During these three hours, she spent two of them working on finishing all of the jewelry.  Some she had made during the last week, like the four really nice, deep red bangles.  Today, she made several pairs of super cool earrings out of only glue and paper.  It sounds silly, but they look really awesome.

Now that I have finished everything, we are going to celebrate our last night in India!  I do not think I have mentioned it, but another student from Appalachian State randomly showed up in the mess hall this week.  He is a botany student, and is totally new to India, like Jess and I were four weeks ago.  We are going out tonight to show him around, shop, and party!  I cannot believe the past four weeks are already gone.  It blows me away.  

One last thing I want to mention, which I am sure I will mention again in my last remaining blog posts to come in the next week, is that the culture is so different here.  People know English, but it is a different English.  I was asking one of the dietitians who is married about what her husband does.  He is an accountant with four years of experience, making 15,000 rupees ($230) each month.  This dietitian, though, does not speak English well.  I asked her in four different ways about her husband’s salary (sometimes I do not ask people, but she was open with me about her own salary).  I asked “Does your husband make a lot?,” “Are you guys well off?,” “Does his job pay well?,” etc.  English here is very specific; some things are only said in one way.  Before I asked in the only way I figured she would know what I was talking about, I hesitated because the question could be construed very differently back home. Finally, I asked “Does your husband have a large package?”  Her eyes lit up with understanding, and she reported about his 15,000 rupees.  I felt so awkward asking that in a room full of women in a country where women have fewer societal rights where they are much more prude.  However, the only thing any of them heard was “how much money does he make?” in an innocent way. 

Patient Care

The mind is a powerful thing.  For about three weeks, I watched a woman who had been in a car accident and fractured bones all over her body, who had been admitted unconscious with a brain stem contusion, and who could not eat anything for two weeks, gradually improve.  After the first week and extensive surgery, she was moved to the IMCU.  Later on, she was transferred to the general wards.  She was eating, moving, and speaking.  Her tube feeding was removed. She was getting better and could have probably gone home in the next week or two.  Then, she found out that she had accidently and tragically killed her son in the car accident that put her in the hospital.  By my second to last day, she had become so depressed that she had ceased all eating.  She dropped so much weight that she was placed back into critical condition and is now laying dead-faced in the ICU.  She is receiving IV fluids again.  The prescribed diet is a soft diet with mild foods like milk, idly, rice, soup, and juice.  I will not be there to see it, but if she continues on like this, she will be placed back on nutrition support.  For two to three weeks, before the depression fully set in, this woman’s body knew what to do to heal itself.  Physically, she was recovering just fine.  When she fully realized what had happened, her mind took over her brain, and she is in critical condition, again.  This is amazing to me.  You can teach nutrition students all of the theories, guidelines, disease states, advanced nutrition sciences, among any other topic, but handling patients’ psychological needs is something not taught in school.  For me, this is too difficult.  The hospital to me became a symbol of disease and sadness.  I love to talk with the dietitians, and we have become friends by now, my last day.  However, the job of any hospital worker includes being around people who are suffering, crying out, coughing, spitting, screaming, and gasping for breath.  In many cases, they are totally dependent on you. In cases where they are not, they often do not listen.  Additionally, I know that I love food science.  I love watching Madhan make the breakfasts and dinners (I am not here for lunch to watch him make it).  I love trying new fruits and vegetables and hearing the dietitians explain why you eat certain foods in which ways.  I love reading research articles.  I also love looking at the body and how it works, including in hospital care.  However, the hospital environment is wrong for me.  It is good to find this out now. 

The only other patient I wish to mention that I saw is one who I have also seen everyday for the last two weeks.  He was admitted after a traffic accident and had a bad head injury.  At first, his diet was hugely artificial.  He was receiving 28.5 kilocalories and 2.1 grams of protein per kilogram of bodyweight, much higher than the necessary 23 kilocalories and 0.8 grams of protein to maintain a healthy human.  Despite this high input, the patient was admitted with a BMI of 22 kg/m² and ended up at 16.8 kg/m².  This means he dropped from a healthy weight to being malnourished.  He is now receiving 40 kilocalories per kilogram of bodyweight and the same amount of protein as before.  Besides milk and porridge, his diet is 100% artificial.  He is being given three different supplements several times each day to maintain a high intake of energy and protein.  There are two reasons for his drop in weight.  After having been moved to the wards, his food intake was not monitored as regularly as in the ICU.  So, he was not receiving enough energy.  Additionally, he continued to develop minor infections, so his body was expending huge amounts of energy to fight these on top of having to rebuild after a head injury.  He developed hypoxia and could no longer efficiently use the food he was taking.  Now, he will remain in the ICU until the hospital can boost his weight.  In the USA, there would be a major investigation to discover why a patient was allowed to become malnourished after admission.  Many times, US dietitians document patient condition heavily when they are admitted to ensure that there is no malnutrition present beforehand.  The hospital and dietitians would be liable to a lawsuit for mistreatment.  I am not sure if there will be an investigation here, but it seemed like Gayathiri was not worried about it. 

The hospital was checking the oxygen lines in all of the critical units today.  Because the oxygen lines run behind the beds of the patients, the staff moved, literally, every single patient from these units to these super cramped, makeshift critical care rooms.  The difference was shocking.   The makeshift rooms were very crowded, super hot without any air conditioning, and really loud.  Workmen were removing and replacing tiles on the walls (which is pretty much an everyday occurrence all over the entire hospital), so there were all sorts of noises.  Also, there was hardly any equipment.  In the ICU, there are clean tables, several medical machines, filing cabinets, etc.  In the makeshift rooms, there were dirty tables, and that was about it.  Normally, these patients receive very careful care and attention in their units, but these rooms were awful.  I have also noticed that the power goes out more frequently, here.  It only happened on two days while I was at the hospital, but it continued happening during the length of the whole day.  Hospital workers have to deal with a lot of unfortunate external problems; infrastructure does not support them.

Technically, yesterday was my last day of training at the hospital.  At the end of the day, the dietitians brought out a cake, we took many selfies, and we all wished each other the best.  Today, I went back just to hang out.  I was only there for about three and a half hours compared to the usual six.  At any point, one of the dietitians stayed in the office with me to chitchat.  Gayathiri made a lot of jewelry for my wife as a gift to me as I go.   During these three hours, she spent two of them working on finishing all of the jewelry.  Some she had made during the last week, like the four really nice, deep red bangles.  Today, she made several pairs of super cool earrings out of only glue and paper.  It sounds silly, but they look really awesome.

Now that I have finished everything, we are going to celebrate our last night in India!  I do not think I have mentioned it, but another student from Appalachian State randomly showed up in the mess hall this week.  He is a botany student, and is totally new to India, like Jess and I were four weeks ago.  We are going out tonight to show him around, shop, and party!  I cannot believe the past four weeks are already gone.  It blows me away.  

One last thing I want to mention, which I am sure I will mention again in my last remaining blog posts to come in the next week, is that the culture is so different here.  People know English, but it is a different English.  I was asking one of the dietitians who is married about what her husband does.  He is an accountant with four years of experience, making 15,000 rupees ($230) each month.  This dietitian, though, does not speak English well.  I asked her in four different ways about her husband’s salary (sometimes I do not ask people, but she was open with me about her own salary).  I asked “Does your husband make a lot?,” “Are you guys well off?,” “Does his job pay well?,” etc.  English here is very specific; some things are only said in one way.  Before I asked in the only way I figured she would know what I was talking about, I hesitated because the question could be construed very differently back home. Finally, I asked “Does your husband have a large package?”  Her eyes lit up with understanding, and she reported about his 15,000 rupees.  I felt so awkward asking that in a room full of women in a country where women have fewer societal rights where they are much more prude.  However, the only thing any of them heard was “how much money does he make?” in an innocent way. 

CCU and Step Down CCU

Today, I shadowed a dietitian who has only worked at KMC for two months.  She mentioned to me that her pay is about 7,000 rupees per month.  This is so crazy to me, still! I make 7,000 rupees in a day or two, and I do not even have a degree, yet! Apparently, the head dietitian makes around 10,000-15,000 rupees each month.  One admirable thing that this dietitian told me is that she has only two months of experience in a multispecialty hospital because she used to work at a gym focusing on weight loss and gain.  She was actually paid more at that position, getting 12,000 rupees per month.  However, she was bored!  She said she was not learning anything, so she came to KMC despite the fact that her pay would be cut in half.  I would really have to be bored and hate my job to move to another job with half the pay.  It is wonderful that she moved in the pursuit of knowledge and contentment.  Anyways, considering the fact that KMC just hired a new dietitian last week and that they are implementing a hospital kitchen soon, it seems like they are drastically expanding the nutrition program, which is good news!  Unfortunately for me, the dietitian I shadowed today speaks very little English. It is unbelievably lucky that the country I was born in has citizens who speak a language taught all over the world, but it is learned to varying degrees!  This dietitian did things that were very different from the head dietitian, Gayathiri.  There were two problems with this for me: I was in the CCU, which I rarely visit, and this dietitian is very inexperienced.  Combined with her present, yet poor, English skills, I was left confused frequently.  Despite this, I will now report to you the common threads between each cardiac patient.  In general, these patients are served only liquid or soft diets, are prescribed much lower calorie and protein allowances than I would expect, have fluid restrictions, and take food orally with few tube feedings.  An extreme example of the limited food prescribed is one patient with cardiovascular disease who had a heart attack.  She was given 18 kilocalories and 0.6 grams of protein per kilogram of bodyweight.  The standard values for anyone are 23 kilocalories and 0.8 grams of protein.  I have no idea why these values are lower than I would ever expect.  One explanation given to me before is that most cardiac patients are overweight because the same diet that produces heart problems usually causes overweight or obesity.  Macronutrients will, therefore, be restricted to promote weight loss.  However, malnutrition is very common in hospitals here, and this is dangerous even for patients who are overweight.  I need to ask more about this. 

Something I saw today, which I have not seen before, was an Acitrom diet.  Acitrom is a blood thinner, and a special diet goes along with it.  Vitamin K and fat rich foods were to be avoided.  The patient was not served cauliflower, cabbage, any other green leafy vegetable, or coconut. 

After lunch, we visited the “Step Down CCU.”  This is where cardiac patients are moved to after their condition improves.  This ward acts as the intermediary between the CCU and general wards.  The most interesting patient I saw had a BMI of 41 kg/m² (the cutoff for obesity is 30 g/m²).  He had an aortic aneurism and left leg cellulitis.  He was to eat a normal soft diet today, but tomorrow he would begin a high protein diet because he required surgery on his left knee.  His leg was HUGE.  He had a high BMI in addition to the cellulitis.  His skin was peeling and he had ulcers all over.  The dietitian was unsure about what to do with the doctor’s orders.  They prescribed a high protein diet post-surgery, but the man had a urea value of 141 mg/dL and creatinine level of 3.80 mg/dL.  The normal ranges for these blood components are 7-20 mg/dL and 0.6-1.2 mg/dL, respectively.  These values are very high, and excess protein is often broken down, producing ammonia that is turned into urea.  With high urea levels, and with a high protein diet needed to support recovery after surgery, what is a dietitian to prescribe?  She stuck with the high protein diet, but I need to ask Gayathiri more about this tomorrow. 

The last thing to mention about today is that I finally learned to make tea, the South Indian way.  I watched Madhan, our chef, as he prepared tea.  The process goes as follows.  First, you bring milk to a boil over low heat.  This takes about three minutes.  You then add tea powder, one spoonful per cup, and allow it to simmer for a minute or two.  You then turn the heat up and down three times.  Each time, the milk will slowly boil up, nearly coming out of the pot.  Right before this happens, you turn the heat way down low and allow the milk to simmer down.  In a separate cup, you add two spoons of sugar for each cup of tea that you are making.  After the third time that you allow the milk to boil down, you pour it through a strainer into the cup with the sugar.  You proceed to pour this back and fourth between two cups to thoroughly mix the freshly brewed tea and sugar.  The result is a frothy, delicious cup of tea.  It really was more of an art than simply brewing tea.  I will have to practice many times before I can do it nearly as well as Madhan.  Tomorrow morning, he will show me how to make sambar!