Don’t Worry, Be Hampi :)

January 28th, 2014

The incredible city of Hampi is a sprawling site of ruins and structures that made up the elaborate Telugu empire existing over 600 years ago. Quoting the history from the Lonely Planet:

“By the 16th century, the greater metropolitan region of Vijayanagar, surrounded by seven lines of fortification, covered 650 sq km and had a population of about 500, 000. Vijayanagar’s busy bazaars were centres of international commerce, brimming with precious stones and merchants from faraway lands. This all came to a sudden end in 1565 when the city was ransacked by a confederacy of Deccan sultanates; it subsequently went into terminal decline.”

With flat rice paddies uniformly sprouting green grasses from the rice grains under the mud juxtaposed on puzzling boulder formations towering above, Hampi is surely one of the most beautiful places on earth.

The main travellers’ strip of Hampi Bazaar has changed tremendously since my last visit in 2011. As Hampi is aiming to gain World Heritage status, the government has ousted many of the shops and businesses that once lined the main pathway to the Virupaxshi temple. Piles of rubble now replace restaurants and shops however a small shopping and living district still exists closer to the river. This time, we (5 of us Canadians and 4 of the German volunteers) chose to stay across the river in a much more relaxed area called Virapapur Gaddi. Goan Corner Guesthouse really was in its own corner: we had to walk through a rice paddy to reach our multi-hut guesthouse (complete with a minihorse-sized canine) with a beautiful backdrop of popular bouldering sites.

Friday evening was spent relaxing and having a few casual beers, followed by an easygoing morning swinging on the hammocks outside our rooms and deciding how to spend our day. We ended up congregating on Rishimuk Plateau, a collection of 27 crags on freestanding boulders. Kailen and Marcia took the lead as the experienced climbers and everyone had a great time trying different problems and conquering each crux!

Photo credit: Leon (one of the German volunteers) – danke!

Photo Cred: Leon

Maegan and I explored a bit on our own and did some bouldering too:

We caught the picturesque sunset on our own private rock with no one around: 

Major photo credit for this perfectly staged shot! Thanks Leon!

Buuuuuttttt what goes down must come up (?) and unfortunately we all ended up getting some form of food poisoning, ranging from immediate violent gastrointestinal distress in the wee hours of the morning with intense malaise and limited will to live (yikes Marcia and Ben!), to moderate lingering nausea, loss of appetite, and hot flashes over 36 hours later. For the better of two days most of us were out of commission: Sunday was the peak for several crew members – the then-healthy ones (only to fall ill a day later!) were able to do the beautiful walk along the river to the Vittala Temple containing the stone chariot. 

We just made it to another site before its closing time and saw the Lotus Mahal and the former Elephant Stables – two beautiful works of architecture. We’ve wrapped up another Tuesday here at Samuha and are back in business. After taking a vacation from our vacation, most of us feel 90% healthy and we were all able to spend another day working with families. Only 1.5 weeks left!

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Chapatti… Chaparti… Cha-parrrrtay!

Where can you find honking horns, flying dates and bananas, tinny Indian music blaring through low-quality speakers, and 300,000 people? At the Koppal Jathra, of course!

On Saturday January 18th, after a long day of teaching the local workers about autonomic dysreflexia (taught by Hilary) and blood pressure (taught by Kailen), we gathered our energy to head to the annual local festival. The five German volunteers and the six of us Canadians planned to meet the many local workers and some of their family members. On the way there, we waited on the side of the road for our ride and witnessed some of the most cramped transport… ever.

We walked down the main road weaving in and out of groups of young men holding hands or arms draped around each other (men are extremely touchy with their friends), gaggles of girls with flowers pinned in their braids, and full families wearing their Sunday best, many of them travelling hours from the surrounding villages to be a part of the excitement. Very quickly we became a spectacle and had people (usually men) taking many photos of us as they walked alongside us.

We waited for the main event – a massive stone cart lit up with flashing Christmas lights would be pulled about 250m to the fairgrounds by hundreds of men tugging two long ropes. Once the chariot started moving, we were given dried dates to throw as offerings (which was about 200m away… we barely could throw it across the road on which we stood; I’m quite sure we ended up just nailing a few people in the head). The chariot reached its destination at a large boulder in the centre of the field, and that concluded the main event. And that was that – we headed away from the centre along with about 100,000 others leaving early and made our way back to campus.

Another big reason to cha-parti and eat chapatti is a birthday. As in many cultures, another year completed is cause for a celebration. We’ve been fortunate to enjoy two birthdays thus far: Bhagya (the daughter of the two orthotic technicians) turned seven on January 12th, and our very own MPT student Danielle Boyd turned a whopping 26 on January 15th. Bhagya wore a crown of dainty bright orange flowers while a fancy candle burned while singing ‘Happy Birthday’. Bhagya cut the cake and as per Indian tradition, she fed each person present a bite of cake and they returned the favour – she must have eaten equivalent to 1/4 of her cake!

Through quiet planning and recruitment of the German boys Leander and Ben, we ordered Dani a double-hearted chocolate cake, complete with the singing candle. The local worker Tahera gifted Dani with a gorgeous vibrant blue, purple and orange sari that Tahera (luckily) helped her put on. It didn’t look easy to manoeuvre ten metres worth of fabric! Dani looked so elegant and was overwhelmed when about 25 of the campus staff were there to sing her ‘Happy Birthday’ on  the evening of the 15th.

This coming Friday the five of us girls and four Germans are headed to one of my favourite places in the world – Hampi. On Sunday, Hilary and perhaps a couple other staff members will meet us our there for the day.  I’m sure we’ll have a few opportunities to cha-party!

Same Same, But Oh-So Different

Being open-minded has been crucial to maximizing our experience here at Samuha in rural South India. We’re so used to living and working in the Western World that we sometimes forget  how vastly different therapeutic environments can be around the world, and the challenges that come with practicing outside of our familiar workplaces. Through our observations, we have compiled a table to compare and contrast the therapy practices, culture, and environment between Canada (specifically an urban centre like Vancouver) and India.

Canada	India
Full confidentiality for client information, private treatment rooms, high value for patient dignity (full effort to drape exposed body parts, use curtains to separate patients etc)	Maximum capacity in treatment room, all families and patients watch and listen to the others’ sessions. All treatments happen in the same room in front of everyone, there aren’t any curtains, children are changed freely
Strong emphasis on therapist body mechanics,  safety, and health; lots of equipment available to facilitate therapist comfort (ex. high-low beds, sitting stools, no-lift policies which require ceiling lifts)	Therapy on floor, therapist body mechanics are not a priority. Mechanical lifts are rare
There is a piece of equipment or a gadget for everything (ankle-foot maximizer, K-Tape, theraband, grip strengthener, toe separators, off-the-shelf orthotics, multiple measurement tools such as goniometers, blood pressure cuffs, disposable gloves)	Minimal equipment, rare disposable supplies like tape or gloves. This is improving slowly but often the equipment isn’t available in rural centres and if it is, the organizations don’t have the financial means to purchase these items
High level of general health knowledge, often taught from very young age. Media frequently has articles regarding positive exercise, diet, and lifestyle habits	Much of the health knowledge is based on old wives tales; but slowly increasing health education in schools
Although many smaller workplaces foster workplace friendships, some therapists compartmentalize work and personal lives. Many therapists change jobs multiple times throughout their career	High focus on inter-work friendships, the staff here stay in one workplace for many years, they are like a family (go to community events together, celebrate birthdays, etc)
High value on objective outcome measures and  evidence-based practice	Infrequent use of outcome measures. Not common to initiate further research for difficult cases or  unknown topics
High focus on client-centred care. Decisions for a patient are often made as a group (patient, family, physician, allied health). Multiple treatment options are explained to patient to allow him/her to make an informed decision about his/her care	Goals and treatment plans are often determined by health care professionals (paternalistic management). We have seen patients coming from other health care professionals with strict recommendations without detailed explanations or other options (ex. a physiotherapist in a nearby town told a family that their child MUST get a back brace and cannot come back for treatment without one. We assessed the child and found that he didn’t need one and that regular exercise would be a much better option)
Ready access to diagnosing processes (MRIs, blood work, and particularly genetic testing)	Blanket diagnoses of either ‘developmental delay’ or ‘cerebral palsy’
Easy and high access to high quality health care professionals and multiple others for second opinions etc	High quality surgeons and doctors are rare in rural areas. Families have to travel far to seek care
It is inappropriate to eat during a treatment session and in front of the client	Chai and tea biscuits are almost always served during sessions
When something breaks we often replace or if we want a new piece of equipment we order/buy it.	Workers are very resourceful and creative, are able to build, modify, fix and design equipment. Nothing goes to waste
Usually fixed/limited treatment sessions (ex. 30 minutes). Therapists often wish we had more time to complete a thorough assessment/treatment	Unlimited time with each client, can do as much treatment as necessary; no set appointment times. Families are more than happy to wait all day to be seen

But it’s important to note that therapists in Canada and India certainly have one major thing in common: We are all passionate about caring for our patients and doing whatever we can to improve the quality of life for each and every patient we interact with.

Using the Peanut Ball in Canada and India

Planes, Trains… and Auto-Rickshaws

January 16, 2014

There have been several opportunities for us to head into Koppal town, whether it’s to visit a client in their home or to buy some treasured fruit. We wanted to share some of the methods used to transport people, food, goats, wheat, and anything else you can possibly  think of.

On the way to Koppal, we took the overnight train with convertible sleeping bunks:

Another day, we were given the luxury of taking the Samuha jeep to go into town, cramming 11 people into a 7-seater. This was actually less than capacity as nobody was hanging out open doors nor sitting on the roof.

Here’s a bullock cart, one of the most common forms of transport. The two bullocks below are decorated with ribbons and paint in preparation for the upcoming Jathra (festival) tomorrow.

Taking up the majority of a narrow and crowded street barrels a modern city bus, complete with a scrolling route display:

Bikes are also common, seems like they like to teach the young’ns early here:

MINI HORSE!!!! 

It’s encouraging to see that adapted forms of mobility are becoming more readily available in rural India. Maegan snapped this photo of the clients at the Spinal Cord Rehabilitation Centre:

What better way to travel home from school than a tractor-towed trailer bed?

How many bodies can you squeeze onto a motorbike?

…or in the most popular form of Indian transportation, the auto-rickshaw!

As you’ve seen, Indian people are resourceful and creative with transportation methods, and have little to no personal bubble. And safety? Pfff.

Empowerment

January 15, 2014

Leading up to this trip, many friends and colleagues inquired about the kind of work that we would be doing over the five weeks. I replied with the obvious: we’ll be providing physiotherapy assessment, treatment, and consultation for special needs children in the Koppal District.

What I wasn’t able to include in my elevator pitch were a few other key tasks. After surveying the local workers, Hampanna (the director) passed on a few requests for physio-related topics that our team has been researching in order to provide continuing education to the workers. In total, we’ll be doing four full days of presentations on topics ranging from bowel and bladder function in spinal cord injury, to feeding issues in very low functioning children, to interpretation of medical reports.

Additionally, while providing hands-on treatment to our clients, we’re aiming to EDUCATE and EMPOWER the family and other caregivers with background information, handling techniques, and exercise ideas so the family can continue to provide the much-needed therapy long after we leave.

Over the past week we’ve been interacting with one of the hardest working kids and most dedicated mothers that we have ever met.

Akshay is a super sweet 4-year-old boy with mild spastic quadriplegic cerebral palsy (all four limbs affected). Since learning of Samuha and their services several months ago, Akshay’s mother has been bringing him (and his two very busy siblings) to the Early Intervention Centre. They are often the first to arrive at 9:30am and leave close to 4:00pm, doing multiple 45 minute sessions throughout the day, alternating with early childhood education lessons to make him as successful as possible prior to entering school.

We compiled a list of exercises that we implemented and then taught to Akshay’s mother.  Within minutes she requested to try assisting Akshay herself. As we observed and made minor suggestions, we realized that she was extremely observant and had a natural talent for hand placement to spot Akshay during the exercises, and she also had the skill to set up each activity and modify it to be most suitable for Akshay.

We showed her how to practice sit-to-stand to strengthen Akshay’s quadricep muscles:

We also used the peanut ball to practice reaching and placing stacker puzzles to work on his core activation and upper limb function:

We also showed his mother how to facilitate weight-shifting using the wobble board and specific hand placement:

She reported that only one month ago, Akshay was not walking nor climbing steps into the home. Today, he walked 20 wobbly steps independently down the hallway. Akshay’s mother also said that he starting stepping up the stairs with assistance into the home just three days ago. We truly believe that his successes are directly correlated to his obedient nature and his mother’s persistence and true commitment to doing everything possible to help Akshay out. Marcia has taken Akshay onto her caseload so she’ll be providing him with more specific exercises to address his poor balance, weak core, and decreased pelvic stability. We can’t wait to see what other achievements he’ll make in the next 3 weeks!!

Our Home Away From Home

January 14, 2014

Since my last visit in 2011, the Samuha campus has undergone multiple changes to further improve the efficiency of the services it provides. Here’s a tour of our crib for the next 3.5 weeks…

The Samuha Samarthya campus is a fabulous space with multiple working and living areas. Several of the staff live in distant villages and therefore bunk here during the majority of the year, travelling home on holidays or long weekends.

We spend at least three times of the day in the mess hall for meals. Usually our meals consist of chapati or roti with spiced cooked vegetables, followed by white rice and sambar (the South India version of dhal, lentil soup). Breakfast is usually a spicy rice dish as well.

Here’s the kitchen where all the magic happens:

The night watchman often lends a hand with preparing some of our food:

The workshop is where orthotists Muttanna and Kahmalla work to create seating systems and all sorts of orthoses.

The Early Intervention Centre is the newest addition to this campus, and that space was only created about 2.5 years ago. It was formerly an office, but special fundraising efforts were made to transform this room into a kid-friendly area where families can meet and children under 6 can receive regular therapy.

Here’s the rooftop (aka our workout area) for our time here. The bench and cement blocks facilitate circuit training and bodyweight exercises to keep us healthy and happy! Some of the staff often join in with us for morning exercise.

This is our the humble abode with our mosquito protection, our laundry line and necessary bathing station and porcelain throne.

And this, ladies and gentlemen, is our precious water heater:

Lastly, here’s Maegan working hard in the laundry area:

The Spinal Cord Rehab Centre is off-campus at another location, stay tuned for a guest post from one of the other students for more information about this amazing new facility – apparently the only one of it’s kind in Southern India!!

So far we’ve felt really comfortable and at-home here, with so many of the regular staff members present to create the family feel… but I think we’d be lying if we said we didn’t miss our fluffy down duvets and hot showers!

Cultural Impacts on Health in rural India

January 13, 2014

We are now starting our second week at Samuha, and have had a good chance to interact with the local workers, staff, and families. We’re starting to realize that health issues in this part of the world are more complex than simply diagnosing ailments, diet, and medications. Cultural norms have an incredible impact on the prevalence of conditions, and often solutions that would be considered ‘simple’ in the western world are certainly not-so.

Many people believe that only doctors, injections and other medications can help their child, and rehabilitation or exercise is not a widely known concept. Parents will spend thousands of rupees looking for a cure or quick fix.

Toilets are non-existent in villages, so there is often resistance to installing one in a home despite the tremendous need of a person with disabilities. There aren’t any plumbing systems therefore the community would have to create a system just for that family.  Things are changing though: there was a recent court case where a woman left her husband because he refused to install a toilet in their home. The court ruled that he had to install one within 150 days or pay a fine.

Co-sanguineous (aka within-family) marriages are common, with more than 50% of families having this set-up.  The most known pairing is that a girl will be set to marry her mother’s brother. Many of the children that we’ve seen come through the clinic have very young mothers (between 15 and 20) and a much much older father.  Another common marriage set-up is between first cousins. The age gap is much less but the bloodline is still close. For those who haven’t taken genetics courses in university, reproduction that occurs within similar bloodlines increases the chance of recessive traits being expressed – in layman’s terms, many conditions are seen in co-sanguineous marriages that would not otherwise be seen with a mixing of totally different genes.

There is still a difference in the level of social acceptance of male versus female. Women here have an abundance of responsibilities: they farm, clean, cook, shop, and take care of the children.  Despite this, the females will eat after the males have finished in some households, and therefore are malnourished. An unhealthy woman will then have difficulty producing nutrient-rich breast-milk, leading to a malnourished baby.

 

In general, mental or physical disabilities are taboo and these people are often neglected – those with special needs often stay at home, don’t seek therapy and as a result suffer consequences of their disability (contractures etc). There are some positive changes happening – the government recently passed an act that disabled children who attend a public school will receive financial support, starting at 700 rupees/month. This is a great step in the right direction, but even if these children attend public school, they won’t have adapted equipment or individualized education plans as we do in Canada.

It’s important for us to realize that we can’t come to Samuha and change the culture. We’re here to share our knowledge and create positive changes where we can, learn about commonly-seen issues and improve our hands-on skills from the local workers, and we’re encouraged to hear that health policies and general attitudes toward disabilities are improving everyday.