Hi everybody,
We're all back home safe and sound after our 28 hour journey from Hyderabad's runway to Cleveland's runway. Just woke up and realized that I didn't get any mosquito bites last night or hear any of the traffic horns this morning from India's streets. There's no delicious South Indian breakfast awaiting me either. Shouldn't I have been offered Indian tea or coffee about 3 times by this time of the morning? Definitely glad to be back, but at the same time, I'm really going to miss these past several weeks in India.
The group has been simply fantastic. There's such a gel between all of the members. We've really had some great laughs. I can honestly say that everybody has probably laughed their quota for the year over the past three weeks alone. Lots of character and personality in each person - so many jokes/stories - truly spectacular! I'm very confident that we've all developed lifelong friendships as a result of this trip.
Even beyond our group, the physicians, medical staff, family, and friends that we interacted with while in India were always delightful company. It was always enlightening to learn more about each one of them and their life experiences.
Our program exposures included tremendous diversity including government hospitals, private hospitals, rural hospitals, research facilities, community outreach programs, etc. Places we ended up visiting included Sivananda Rehabilitation Home, NIMS, Osmania General Hospital, Sir Ronald Ross Institute of Tropical and Communicable Diseases (aka Fever Hospital), Mediciti Hospital, CCMB (Center for Cellular and Molecular Biology), and Kamineni Hospital.
Diseases were abundant - in addition to what has been mentioned previously throughout this blog, we went to the Fever Hospital on Friday and saw patients with Dengue, Diphtheria/Tetanus, Malaria, Measles/Mumps, TB, and a variety of acute diarrhea syndromes (these patients even had their own "acute diarrhea beds"). Hopefully, none of us breaks out with a fever in the next week - differential would be ridiculous!
On top of our daytime experiences, we explored India despite the blasts that took place while we there. List of visited sights included the Golkonda Fort and Charminar in Hyderabad as well as Gandhi's house, Hanging Gardens, Elephanta Caves, and various temples in Mumbai. We also spent our evenings and weekends simply enjoying our time together from late night chats to watching sports like Cricket to playing card games like King's Peasant to watching movies like the Godfather to playing our favorite Indian game Carrom (Wikipedia - Carrom or carroms is a family of tabletop games sharing a similarity in that their mechanics lie somewhere between billiards and table Shuffleboard. The game has various other names around the world, including carrum, carum, karam, karom, karum, and "Indian finger billiards").
Food was beyond lip smacking - favorites included chilli paneer gravy, vegetable manchurian, hot and sour soup, chicken 65, guava, aavakkai, butterscotch ice cream, idli, sambar, various chutneys, mango, pomegranate, and essentially all of the members of the potato family.
This has truly been a trip to remember - a chapter of my life that will always be a favorite to reflect upon for the rest of my life. It has broadened my horizons and given me refreshing perspective. I'm already looking forward to the potential Case India Trips - Part 2 (aka CIT 2).
Peace and love,
Vijay
10 September 2007
03 September 2007
Sunday evening
I came back to the apartment from my family's house mid-afternoon or so. Spent most of the weekend getting some sorely needed sleep. Also, I read Circus by Alistair MacLean. For probably the sixth of seventh time. It is a book that really enjoyed as a kid, but more so, it is a connection I have with my late aunt. One of the greatest highlights of every one of my visits to India, until her premature death in 1995, was spending time with her. We shared a love for certain books, the most important being the Three Musketeers. Circus was up there as well.
My cousin Bobby came over in the early evening to take me shopping for comic books for my daughter before the team came back from Mumbai. After waiting a few minutes for the drizzle to let up, I got on the back of his Honda motorcycle and we sped off on our mission. We made a left onto the Tarnaka main road, went under the flyover, turned right and worked our way through the expansive campus of Osmania University. This is not an area of the twin cities that I have frequented before this trip, and Bobby is my guide to all things Hyderabad whenever I come here. But it sounded very strange when he pointed the campus out to me. It seemed like such an obvious thing. I guess I am getting to know this place for myself.
The streets were full of the usual masses of humanity. I cannot estimate the numbers of persons one passes on the road even on a brief excursion like this one, but it must number in the thousands. I love traveling by two-wheeler in India. It is second (albeit a distant second) only to travel by rail. Car travel is convenient but too protected if you want the full Indian experience. Countless times, my knees missed by inches motorcycles, cars, autorickshaws, buses, bullock carts and people. It was not until we reached a large intersection that Bobby put on his helmet. I tried to be invisible as we passed the traffic cop, remembering an interaction two-and-a-half years ago, when we got busted for no helmets. Better luck this time, it turned out. After the intersection, we ran into a semi-impromptu parade consisting of about 30 participants, 4 or 5 musicians earnestly blowing into woodwinds and beating on drums, and an innominate deity.
We made our way down a road that I recognized from our week going to Osmania General Hospital. We proceeded to hunt for bookstores and were directed to a strip mall of sorts. We entered the first store and asked for Chandamamas in Telugu and Hindi. The guy looked at us like we were insane. "Only English, saar". I picked out some Amar Chitra Kathas and for some reason got a 10% discount. Which Bobby tried to talk down even more, using such logic as "500 is a round figure, why do you want us to pay 550?". It made sense to me. Next door, still no luck, and next to that was strike three. We got back on the motorcycle and headed back home. Passed roadside carts full of guavas, oranges, fried stuff, and corn. It was dusk now, and the coals on which the corn was being roasted looked and smelled incredible as we sped by. Saw a total of about 10 men relieving themselves on the side of the road. By the time we reached the poorly lit Osmania campus the sun had set completely. We passed another thousand people or so by the time we reached road 12-5-55 and pulled up in front of Samskruthi Heaven apartments.
My hair was coarse with dust kicked up from the road. My lungs burned from smoking the exhaust of 250 two-stroke engines. My blue pants had a rim of black at the cuffs and my back ached from maintaining my position behind Bobby on his Honda. I headed up the steps with a deep sense of contentment. After sixteen days of being here, I finally felt like I was in India.
My cousin Bobby came over in the early evening to take me shopping for comic books for my daughter before the team came back from Mumbai. After waiting a few minutes for the drizzle to let up, I got on the back of his Honda motorcycle and we sped off on our mission. We made a left onto the Tarnaka main road, went under the flyover, turned right and worked our way through the expansive campus of Osmania University. This is not an area of the twin cities that I have frequented before this trip, and Bobby is my guide to all things Hyderabad whenever I come here. But it sounded very strange when he pointed the campus out to me. It seemed like such an obvious thing. I guess I am getting to know this place for myself.
The streets were full of the usual masses of humanity. I cannot estimate the numbers of persons one passes on the road even on a brief excursion like this one, but it must number in the thousands. I love traveling by two-wheeler in India. It is second (albeit a distant second) only to travel by rail. Car travel is convenient but too protected if you want the full Indian experience. Countless times, my knees missed by inches motorcycles, cars, autorickshaws, buses, bullock carts and people. It was not until we reached a large intersection that Bobby put on his helmet. I tried to be invisible as we passed the traffic cop, remembering an interaction two-and-a-half years ago, when we got busted for no helmets. Better luck this time, it turned out. After the intersection, we ran into a semi-impromptu parade consisting of about 30 participants, 4 or 5 musicians earnestly blowing into woodwinds and beating on drums, and an innominate deity.
We made our way down a road that I recognized from our week going to Osmania General Hospital. We proceeded to hunt for bookstores and were directed to a strip mall of sorts. We entered the first store and asked for Chandamamas in Telugu and Hindi. The guy looked at us like we were insane. "Only English, saar". I picked out some Amar Chitra Kathas and for some reason got a 10% discount. Which Bobby tried to talk down even more, using such logic as "500 is a round figure, why do you want us to pay 550?". It made sense to me. Next door, still no luck, and next to that was strike three. We got back on the motorcycle and headed back home. Passed roadside carts full of guavas, oranges, fried stuff, and corn. It was dusk now, and the coals on which the corn was being roasted looked and smelled incredible as we sped by. Saw a total of about 10 men relieving themselves on the side of the road. By the time we reached the poorly lit Osmania campus the sun had set completely. We passed another thousand people or so by the time we reached road 12-5-55 and pulled up in front of Samskruthi Heaven apartments.
My hair was coarse with dust kicked up from the road. My lungs burned from smoking the exhaust of 250 two-stroke engines. My blue pants had a rim of black at the cuffs and my back ached from maintaining my position behind Bobby on his Honda. I headed up the steps with a deep sense of contentment. After sixteen days of being here, I finally felt like I was in India.
Mumbai
Well, we just came back from our Mumbai weekend which was great. While the others saw the sights and did some fine dining, I was subjected to the mercilessness of my family. Never do you feel as inadequate as when you are repeatedly asked why you aren't married and if you feel that you might be "too old." Such is the life of an Indian girl! Regardless, being with my extensive Indian family also makes me realize how lucky I am that so many people care so unconditionally and only want the best for me.
On the work perspective, I did have a little chat with some of my family members about their perspective on the HIV epidemic in India. The fact that I could talk about it with them at all was fascinating because in general they tend to be very conservative, the the terms "HIV" and "sex" couldn't even be uttered the last time I was here three years ago. I did find that their beliefs are that most people in India contract HIV through blood transfusions and unsanitary health care practices, not so much from unprotected sex. While I don't believe that's true, I'm glad that they're at least thinking about it. I was asking my younger cousins whether they had any sex education in schools and the answer was an unsurprising no. But they do believe that the times are changing here and hopefully for the better.
I also a road experience while in Mumbai; a car accident. We're all okay, however I have no idea who was at fault, and let's face it, it probably doesn't matter anyway. I'm not entirely sure there are "right of way" rules here. The way my cousin planned to resolve the situation was finding the other guy's address and throwing rocks at his car. Hmmm
Only 4 more days left, and I still haven't eaten any good, off the street, Hep A enriched food yet.....
On the work perspective, I did have a little chat with some of my family members about their perspective on the HIV epidemic in India. The fact that I could talk about it with them at all was fascinating because in general they tend to be very conservative, the the terms "HIV" and "sex" couldn't even be uttered the last time I was here three years ago. I did find that their beliefs are that most people in India contract HIV through blood transfusions and unsanitary health care practices, not so much from unprotected sex. While I don't believe that's true, I'm glad that they're at least thinking about it. I was asking my younger cousins whether they had any sex education in schools and the answer was an unsurprising no. But they do believe that the times are changing here and hopefully for the better.
I also a road experience while in Mumbai; a car accident. We're all okay, however I have no idea who was at fault, and let's face it, it probably doesn't matter anyway. I'm not entirely sure there are "right of way" rules here. The way my cousin planned to resolve the situation was finding the other guy's address and throwing rocks at his car. Hmmm
Only 4 more days left, and I still haven't eaten any good, off the street, Hep A enriched food yet.....
01 September 2007
Adherence
My exposure to clinical cases has been limited over the past two weeks, as I have spent my time more on research efforts. Among the patients that I have seen, though, there are some that will stay with me for a long time.
I saw a lady in her mid-40s who acquired HIV via a contaminated blood transfusion during the delivery of her second child, 15 years ago. Although free treatment is available for HIV through government centers, if at all a person living with HIV/AIDS can scrape together the requisite funds, they will do everything in their power to go to a private setting. There is really no insurance to speak of for the common man (up to the lower and middle middle class) so paying out-of-pocket is the only option. A typical day for a doctor at a busy government ART center involves seeing 100-150 patients between 9am and 4pm or so. The quality of the interaction is therefore suboptimal at best.
So the patient I saw was in a non-ART centre setting. She had survived 15 years by paying her way for meds and care. Now, she was failing her second line regimen and her immunity was again waning. When questioned initially about her adherence, she said (like so many of my own patients) that she was doing well. It took only minimal prodding and a look in her still 3/4 full pill blister pack to realize that her adherence was nowhere near the 95-100% we all preach to avoid the development of drug resistance. She indicated that she was stretching out the pills over several weeks because she couldn't afford them any more. What followed was a poignant and haunting exchange between doctor and patient. Her physician asked whether there really was no way she could pay for the meds. She pulled out her mangalsutra and said this is all the jewelry she had left in the world. There was no question, from her tone of voice, about whether selling that particular item was an option. So what then, were they to do when the inevitable immunological failure occurred, she was asked. Her daughter was doing well in college, her son was poised to follow, and she had told them both that mom may be here tomorrow or may not. She was ready for the inevitable and had apparently prepared her family accordingly.
This is a situation that happens all over the world hundreds, if not thousands of times a day. It is something that I was well aware of before this trip. Intellectually, at least. I am quickly finding out that hearing about it and seeing it are two different things. What I saw was a lady who was clinically relatively healthy, intelligent, devoted to her family (despite her husband's frequent suggestions that she kill herself to alleviate the financial burden on the family, including outlining specific methods to do so) and not in a situation that, in the US, would be considered end-stage at all. I have had multiple patients die in the past few years, but none of them fit the profile I saw before me. Depression, other psych problems, ongoing substance abuse, cancer, liver disease and poor social support are what have killed most of my patients. Poverty was the only thing keeping this lady from seeing her grandchildren.
I can hear certain people asking me now, so what? Are you going to save her? How about the next 150 people who come in tomorrow? I guess I won't be doing things too differently. I am not in the business of eradicating poverty. I am an HIV doc. I conclude that there is a lot of work to be done out there, if I am interested. And a lot of ways to contribute. Whatever I do, I hope that when it's my time, I can feel as proud of how I have lived my life as this patient has every right to feel, and that I can face my end with half as much dignity.
I saw a lady in her mid-40s who acquired HIV via a contaminated blood transfusion during the delivery of her second child, 15 years ago. Although free treatment is available for HIV through government centers, if at all a person living with HIV/AIDS can scrape together the requisite funds, they will do everything in their power to go to a private setting. There is really no insurance to speak of for the common man (up to the lower and middle middle class) so paying out-of-pocket is the only option. A typical day for a doctor at a busy government ART center involves seeing 100-150 patients between 9am and 4pm or so. The quality of the interaction is therefore suboptimal at best.
So the patient I saw was in a non-ART centre setting. She had survived 15 years by paying her way for meds and care. Now, she was failing her second line regimen and her immunity was again waning. When questioned initially about her adherence, she said (like so many of my own patients) that she was doing well. It took only minimal prodding and a look in her still 3/4 full pill blister pack to realize that her adherence was nowhere near the 95-100% we all preach to avoid the development of drug resistance. She indicated that she was stretching out the pills over several weeks because she couldn't afford them any more. What followed was a poignant and haunting exchange between doctor and patient. Her physician asked whether there really was no way she could pay for the meds. She pulled out her mangalsutra and said this is all the jewelry she had left in the world. There was no question, from her tone of voice, about whether selling that particular item was an option. So what then, were they to do when the inevitable immunological failure occurred, she was asked. Her daughter was doing well in college, her son was poised to follow, and she had told them both that mom may be here tomorrow or may not. She was ready for the inevitable and had apparently prepared her family accordingly.
This is a situation that happens all over the world hundreds, if not thousands of times a day. It is something that I was well aware of before this trip. Intellectually, at least. I am quickly finding out that hearing about it and seeing it are two different things. What I saw was a lady who was clinically relatively healthy, intelligent, devoted to her family (despite her husband's frequent suggestions that she kill herself to alleviate the financial burden on the family, including outlining specific methods to do so) and not in a situation that, in the US, would be considered end-stage at all. I have had multiple patients die in the past few years, but none of them fit the profile I saw before me. Depression, other psych problems, ongoing substance abuse, cancer, liver disease and poor social support are what have killed most of my patients. Poverty was the only thing keeping this lady from seeing her grandchildren.
I can hear certain people asking me now, so what? Are you going to save her? How about the next 150 people who come in tomorrow? I guess I won't be doing things too differently. I am not in the business of eradicating poverty. I am an HIV doc. I conclude that there is a lot of work to be done out there, if I am interested. And a lot of ways to contribute. Whatever I do, I hope that when it's my time, I can feel as proud of how I have lived my life as this patient has every right to feel, and that I can face my end with half as much dignity.
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