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.

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.

My first time

Okay, since Brian may croak if someone doesn't post something soon, I'm stepping up to take one for the team. This is our official fifth day in Hyderabad, and third day at work. It seems like everyone's having a pretty darn good time too. Minus the constant grief I'm getting from my beloved new friends (and for those who care about me back home, it's a lot of grief!!!) I really like this city so far. Haven't spent that much time here before, as most of my time is centered in Mumbai around my family. Our first few days at Sivananda Rehabilitation Center have been pretty cool. We've been learning all about leprosy, the stigma still associated with it and all the aspects regarding treatment, rehab, etc. Our own Dr. Dumford even assisted in surgery, and can probably now be called one of America's leading surgical experts on leprosy. We also got a tour of the facility, which is huge, covering a 50 acre campus, in a very beautiful wooded area. My favorite part (and possibly the saddest) was seeing the kiddos with HIV, all of whom were orphaned by parents with HIV. They were cute as could be, and seeing two of the oldest ones sing "We shall overcome," is something I probably won't forget for awhile. All these kids were taken in from the streets, fed, provided clean water, medicines and some TLC, and have reportedly all recovered well. I guess the really sad part is knowing how many more are out there. The people who run this place were explaining too us how the budget doesn't allow for very many kids but they're trying to expand if they can.
Of course I can't leave out the social part. I think we'll all agree that we had some really good mango milkshakes today at my insistence, and the McDonald's veggie burgers are about the best thing ever. We're all eating pretty much all the time, with tea interspersed about every few hours. Whoever comes and picks me up from the airport will need a forklift. So, there, that's my first attempt at blogging. More to come.........

Arrived in Hyderabad

So here we are. The flight from Schiphol to Begumpet was pretty fun; five of us sat in a row and Sujan was close enough that he visited often. Movies were Spider-Man 3 and Dhoom 2. I had seem both before, but did enjoy the Mr. Bean episode. Had an extremely interesting conversation about service projects in the developing world. There is clearly a spectrum of enthusiasm for these among our group. It will be interesting to see if anyone's view changes in the course of the next 3 weeks. We reviewed the map of Hyderabad/Secunderabad and I pointed out the places we'll be going.

Once we arrived at Rajiv Gandhi airport in Begumpet, we were greeted by Ravinder, Sujan's cousin, and his posse. We had a caravan of three vans to Tarnaka and saw Hyderabad streets at their most desolate (it was 2:30AM). Our accommodations here are outstanding and Sujan's family has been extraordinarily welcoming. Had apples and water. Off to catch a few Z's.