R&R

The team is off in Mumbai for the weekend. I am told they went to the Elephanta caves today, something I've always wanted to see ever since reading the associated Amar Chitra Katha as a kid. I am taking a day off myself tomorrow to spend with my family here in Hyderabad.

On the gastronomic front, now that I am back on a regular diet (more like soft mechanical with aspiration precautions) we had another dose of Indian Chinese Wednesday night. It wasn't the best, but I am definitely going to miss that stuff when we get back to Cleveland. Have also been having guavas daily. Still in search of the elusive sapota.


I spent some time today with a social scientist who has done some pretty cool work on HIV prevention. This brings my perspectives on HIV care in India to five: a government-sponsored center for antiretroviral therapy, a tertiary care, academic referral hospital where patients pay for everything before its done, a private "corporate" hospital that serves the upper middle to upper class, a non-governmental organization, and today's social scientist. Each perspective has its unique aspects, but there are some themes that cut across organizations. Everyone thinks that the HIV problem here, despite the recent reduced estimates in prevalence, is spiraling out of control. Everyone also agrees that there is a ton of money floating around, but little accountability for how it is spent. I am surprised to see the universally negative feelings toward most NGOs. The glaring exception, of course, is Sivananda. Opinions on them range from: "they are in it for the money" to "they want to convert people to Christianity" to "they are incompetent". Nobody is particularly happy with the government response either, calling it a bunch of hand-waving. For my part, I am happy to have met people both in the government service and in the private sector who are really devoted to the cause.

Another common complaint here is about the brain drain. This is an often devastating problem in Africa as well. It is interesting to see that in India, this applies disproportionately to physicians. The boom in the tech industry has led to IT people who stay here leading extremely comfortable lives. This obviously does not carry over into medicine, so a lot of people are always finding ways to go overseas. Despite this though, we have come across some incredibly intelligent clinicians.
I feel like working with these guys for a month, in a resource-limited setting where you can't just blindly order tests, would be an invaluable, required rotation in an internal medicine residency. For attendings like me too!
Finally, in answer to the query about tea, if you are only getting tea twice a day in India, you are getting shortchanged. We have had tea pretty much 4 times daily here. Plus coffee. Nice.

Rainy Saturday afternoon in Hyderabad

I figured since I hadn't posted anything for about a week that I should probably do so, even though I don't think I'm going to reinvent the wheel with my blog after reading everyone else's from this past week. As everyone else has said, we are having a great time with each other and have quickly set up what can probably best be described as a very dysfunctional family away from home. One of the attendings from NIMS (Nizam Institute for Medical Services, where Dr. Y has been spending most of his time) who had lunch with us, was quoted as saying we were "interesting" and found us amusing, which Dr. Yadavalli says she meant in a good way, but I think the jury may still be out on that one. We've had terrific Indian food all week and as Jess said are seldomly left without a cup of tea in our hands or our bellies empty(in response to Dr. Armitage, I think tea at conferences and available somewhere at 4pm would improve resident morale tremendously, if nobody else's then at leaset mine).
Currently, I'm sitting in the internet cafe downstairs from our apartment, listening to the rain falling and with every good intention to work on presentation I'm giving this upcoming Thursday on C. diff, which surprisingly is said to not be a very big problem in India. Earlier in the afternoon it was a beautiful day, but now its been raining for about the past hour. Since getting back from a morning of lectures and briefly rounding with a hematology team and discussing a few cases, we've been playing this as a typical lazy Saturday afternoon with a good deal of napping and lounging. Bindu's having the most excitement as she is (finally) Sari shopping with one of Sujan's aunts. This morning, Dr. Yadavalli gave a talk to the internal medicine department at NIMS (Nizam Institute for Medical Services) and then one of the professors in the microbiology department gave us talks on the Chikungunya and Dengue fevers.
As everyone else has said, this week has been a tremendous experience with our exposure to the Sivananda Rehab Home. I was most amazed with their coordination of medical and social services for the leprosy patients, first by treating them (antibiotics and correcting disfigurements secondary to their illness) and then providing vocational training so that they can return to their homes and be able to be provide for their families and be an active member in their community. Ultimately the best part of these services is the restoration of pride in these people who may have been shunned by those around them because of their condition as there is a great deal of social stigma in India regarding the illness.
As everyone else has said, the leprosy care is just one aspect of the work done at Sivananda. They are involved in the national TB program, which Bindu previously described and are expanding their work on HIV, including a new program dealing with reducing mother to child transmission.
The one thing I have to add to everyone else's comments from this week and I have found interesting is the difference in the differential diagnoses here. From speaking with the residents on rounds this morning and from our experience with the TB program, much of what the internist sees is infectious and their primary causative bacteria are completely different from ours (for example on rounds this morning we saw aplastic anemia secondary to what they thought was an unidentified hepatitis virus, malaria and leptospirosis). Their first thoughts to cases are often such illness as tuberculosis, malaria and chikungunya, illnesses we only have a very limited exposure to or none at all. I asked a resident this morning how often he sees cases of malaria and he said usually one to two every other day and speaking of chikungunya, this area had 8,000 cases (I think, it may have been 80,000, but I thought best to underreport) in a recent epidemic in this city of 4 million estimated. If you think about it, in our most notable insect-borne illnesses we have seen about 2000 cases of West Nile and 20,000 cases of Lyme disease per year in the entire US population, compared to just this one locale (and its outlying areas). Pleural effusions here are looked at as tuberculosis first, anything else second. Well its about 5:30 here now and we're planning on starting our evening on the town in about half an hour so I'm going to get going. Guess I'll get to working on the presentation later. Hope everyone is doing well, keep us posted on what's happening back at home. See everyone back at Case in a couple of weeks.

Tea Time

Hi Everyone.

Welcome to my first solo-blog. As the others have noted, we have spent the majority of our time at the Sivananda Rehabilitation Center during this past week. Not wanting to sound like a broken record, but what we have seen has been truly remarkable. The staff and patients are inspiring and epitomize selflessness in it's purist form in the medical profession. I have been fortunate to see similar settings of community and charity in other parts of the world, and this place is no exception of how an individual or group of people can aid marginalized populations and instill a sense of confidence and pride in them so that they can have the opportunity to flourish.

Now that the deep thoughts are out, I'd like to comment on the mundane and quirky things that I find so amusing. First, tea. I love tea and I love having tea all day. It's always an appropriate time for tea here in India. In the morning, upon arriving at the rehab center, before putting your mask on while heading into the OR, perhaps even taking a break from the OR during a case. Don has also embraced tea and will incorporate this wonderful gesture in his apartment in Cleveland.

However, the most mundane and quirky things regarding the trip, thus far, have been my travel mates. The humor is constant and the quips are being fired off at lightning speed.

Well, I'd better get going. See you next blog.

Jones

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.........

Somewhere over the Atlantic . . .(late entry from flight)

(This is from about 20 hours ago, but I couldn't post while I was in the air)
Currently between Detroit and Amsterdam on leg 2 of our outbound journey. As you all know, our final destination is the city of Hyderabad, capital of Andrha Pradesh, which along with Secunderabad is referred to as the twin cities of India. From what I hear, its an area steeped in history nd is now a booming city, partly due to its tech industry (there's actually a part of the city referred to as High Tech City). So I just woke up from a nap. Fairly smooth flight to this point, with just a couple of minutes of turbulence. I think at this point we have about 10 hours of travel left, which is okay because I've only covered 45 of my 913 songs in my iPod.
So how did I end up at this point, travelling to the Indian subcontinent? Well, your protagaonist's journey began, I guess, about 5 months ago when Jess Jones said that Gopal was setting up a trip. Knowing that it would have an infectious disease slant, I jumped at the opportunity. So we booked our flight, set up our itninerary. Over the past few months, those of us on the trip and some of our colleagues at home have been meeting and discussing different medical issues and conditions we will encounter to prepare for the trip. About six weeks ago, I med with KBA in the travel clinic and got my hepatitis A shot, my oral typhoid vaccine and my malaria prophylaxis, mefloquine (of which a side effect can be psychosis, not that you'll be able to tell the difference). In the past few weeks, I've been stocking up for the trip- I've got my 98% DEET insect repellant (my skin may fry with the 98% but at least I won't get Chikungunya fever), replaced my lost iPod, read up on my Indian history and culture. And in the few days before the flight I was just enjoying some things at home, I may not have at India like Chai tea (totally kidding, I heard you trip over two chai stands everywhere you go here) and steak (since half the population views the cow as sacred I figure I can go without for 3 weeks).
We'll be sure to keep you posted on the journey as we encounter the interesting medical conditions we encounter, the culture and cuisine of Hyderabad (looking forward to the local specialty Hyderabadi biryani), and whoever comes down with the Mughal curse (my proposed Indian name for Montezuma's revenge, cast your guess for the first afflicted traveler).
Well, its breakfast time and I want to read something nerdy like an article on arthopod-borne infections, so I'll bid adieu for now. I'd like to thank the Invanz drug rep for the excellent pen I used to jot down my blog entry since I wrote this on a pad of paper at 30,000 feet.