Stopping in the Middle East

So I woke up at 6am yesterday to a knocking on our hotel door in Chennai. It was our taxi driver, frantic, "we must leave right away!!". That is always a great way to start the day. At first I thought maybe I overslept, but he then explained that it is Republic Day in India (sort of like our Fourth of July), and the streets would soon close for preparations for a parade and making it to the airport would be difficult. I through on the worst outfit because I only wanted to open the suitcase just from the side since it had been carefully packed - so I just grabbed whatever came out which was a stretchy gray shirt. I had to cover up, it is India and stretchy shirts are a nono, so I threw on this black cotton thingy. It was hilarious, but we got in the van and sped to the airport. I kind of felt like I was being rescued from India in th middle of the night or something. Once we arrived, 45 minutes to drive about 4 miles, the lines were long. I was glad we had gotten there so early because by the time we got to the gate (through customs, passport control, multiple security lines) we only had about 30 min before boarding.

I always forget this part of traveling is so traumatic, from the traffic, the lines, being labeled "economy class", the frisking, and the tension filled waiting time for boarding as everyone wants to be first to avoid having to check their carry-on. But it is an adventure nonetheless.

We had a nice flight to Dubai, around four hours. I noticed when booking our hotel that the whole city was near capacity for rooms. Come to find out I have conveniently masterminded our stop in Dubai at the start of the International Shopping Festival, people come here from all over the world for great shopping "deals". I think the cost of the plane ticket would easily negate the savings and this is all a marketing gimmick, but nonetheless we are here.

Today Paul, Rachel and I will go on a camel safari and be the ultimate tourists. It includes a bbq and hand painting, along with pictures in traditional style clothing. It is quite cliche but we can't pass it up. More pictures soon!

Rebecca

Goodbye Sweet India

Me and my new friend Kristen at the beach in Mamallapurum, old temple in the background.















I was asked to make a speech by someone from the tourism department regarding their International Dance Festival. The background is a rock carving from 400AD. Random weird stuff like this speech has happened frequently. I made a joke that they must have had good forsight in carving the wall just for this dance festival. Nobody laughed, there is quite a language barrier.

The bane of my existence here, the malaria harboring mosquito on a flower during MY lunch.

Baby Biswas, an 11yo F with cerebral palsy, I gave her my livestrong bracelet (see left arm). If I go into pediatric PM&R it is because of patients like her.

Well, the time has come for me to pack my things (which required the purchase of an additional suitcase). I still have plenty to blog about so I plan to continue relaying my past experiences as they come to me. I have loved my time here. Not in a vacation way, but in a "broadening my horizons" way I suppose. I have seen things here I never saw in three and half years of education in San Antonio. I have seen Wilson's disease twice, tuberculosis meningitis, leprosy, and many other things very rare back home - things I only thought I could see in a textbook. The environment seems to have brought out the better student in me. Feeling free from pending evaluations and studying for a test, I asked questions like there was no tomorrow and found many people willing to teach me and sacrifice their own time. I feel guilty in that I have not added much of anything to this place, really just taken up time from schedules and a chair in the patient examining room. Perhaps that will lead me back here one day to repay this beloved debt to CMC. The doctors aren't paid much more than the nurses, and housing options are scant at best and this makes for quite a genuine and humble experience that I am proud to have participated in.

That said, I do miss home quite a bit and will be happy to see my sleepnumber bed again. David has let Boston back on the bed, we were trying to train him to sleep in his pod during the night, but I suppose we will cave in. I hope the Spurs are doing okay and I hope my family has recovered from the Cowboys loss. We will be on our way to Chennai tomorrow, then a few nights in Dubai and back home by Tuesday afternoon. I plan to post on my rehabilitation experience and final thoughts sometime this weekend.

Leprosy

Staff bus at Karigiri.

Patient cured from leprosy, lives and works at Karigiri producing ceramics. He is deaf and mute with minimal vision. I bought two of his "magic pots".

The feet are numb due to nerve damage from leprosy. The feet are disfigured because they were numb and underwent repeated damage.

Dr. Brand was a pioneer in leprosy research and used his own ingenuity to help unravel this disease that destroyed lives and harbored a stigma like no other. He is now one of my personal heroes. His wife, Margaret, worked as an opthalmologist and also conducted work that led to the discovery of how leprosy causes blindness.

Leprosy is diagnosed by a skin scraping, they are the little red dots. I am very proud of this picture because it is hard to take pictures through the lens of a microscope. My mother in law will be so proud!

I am finally prepared to share my experiences at Karigiri, a nearby Leprosy hospital. As part of my class participation in discussing a tropical disease, I will also discuss some history and medical points with my own narration from this trip. I apologize if it is a little disorganized.

Leprosy (or Hansen's Diseas) has been around for a while, noted many times in the Bible - those afflicted with this disease have a horrid history of being shunned by society. In medieval times lepers (now called people cured from leprosy) were brought to church for the last time, made to "die" to their human life, and sent outside with ten foot pole attached to a bucket which they could use to beg for food or money. Thus, "I wouldn't touch that with a ten foot pole".

The disease itself is quite interesting. It starts with an infection with mycobacterium leprae. Only about one in 200 people are even susceptible to this infection, and of those infected even fewer become symptomatic. It can be spread by droplet, but again you have to be in the group susceptible to be infected. I haven't found a great explanation as to its origins and predilection for tropical areas, but some sources think it is in the soil and armadillos (don't eat roadkill). This mycobacterium replicates in the nerve cells in the body, preferring the colder areas of the body such as the nose, earlobes, and nerves closer to the skin surface. This replication causes inflammation, edema and ischemia killing the nerve slowly over time. Eventually, the patient loses sensation in the areas serviced by the dying nerves. Symptoms include hypopigmented lesions (tuberculoid leprosy) or rhinorrhea with nodules (lepromatous leprosy). An inbetween varient called borderline leprosy also exists.

This loss of sensation proves to be horrendously problematic. When you and I step on a sharp object, we recoil in pain and nurse our wounds until they heal, treating them with tender care. If a person who is without sensation steps off a curb the wrong way, he may break his ankle yet continue walking because the brain never receives the red flags of pain. Eventually this process will lead to open and infected wounds, leading to chronic inflammation and bone resorption. In this way the disease becomes disfiguring. Before the etiology of the disease was appreciated, thanks much to Dr. Paul Brand, it was commonly assumed that these sores and disfigurements were the disease itself attacking the skin. But, as proven by Dr. Paul Brand, paying careful attention to the skin can actually halt the destruction and there are surgeries available to reverse some of the debilitating changes. It appears as if fingers and toes are falling off the patient, but the bone is just being resorbed by the body due to the chronic, local inflammatory response. In the Vellore hospital, Dr. Brand discovered that in some cases the appendages were gnawed off by mice or other rodents - the patient slept soundly because they could not feel a thing but would wake to find their fingers had "fallen off".

An effective treatment for leprosy, the sulfone drugs, has been around for decades. But, as you might guess, once the nerve damage is done clearing the infection will not reverse the consequences. There are people "cured" from leprosy, but still dealing with the insensate portions of their body that are blinded to the very important signals of pain. There are still about 100 new cases of leprosy per year in the USA and many more around the world. With prompt treatment, the patients tend to do very well, but this is not widely available in the developing world.

So why would American medicine still care about leprosy? Isn't it treatable and a historical novelty? Well, many of the research done in leprosy also applies to diabetics and all of us know the prevalence of that disease is dramatically rising. Though diabetics lose their sensation through high sugars and ischemic nerve damage, the end result is the same. They cannot feel their feet. One relative of mine feel asleep with his feet near a space heater and his wife woke him when she realized they had sustained significant burns. He just could not feel it, just like a leprosy patient.

About 4,000 patients in the United States are infected, estimates as high as one million worldwide. According to a physician I met at Karigiri, research has dramatically dropped off since the AIDS epidemic as philanthropists shifted their gifts for research to the effort against HIV.

I will share more soon, but time is up for me. Thanks for reading.

Nurse Rounds

Men readying their boat to fish in the morning.








hello all -
I am going to postpone my leprosy blog once more because I need to do some more research since it will be part of my grade. So, instead I will share about our nursing rounds on Friday and our great trip to Mumallapurum.

The Jist:
I have started my last week at CMC, now rotating through the PM&R department. I will blog on that after I have been there for a few days. I leave on Saturday for Dubai, where I will stay until returning back to the states on Tuesday.

The Medical:
CMC has an outreach program called Community Health and Development (CHAD). Part of this program includes nursing rounds. A group of villages have a health aid, a group of groups of villages has a nurse, and then there is a head nurse who covers around 20,000 people and visits the villages as needed, hitting each village about once every two weeks. The purpose is to field any minor problems to prevent patients from having to go the the ER. They also keep records of deaths and births along with pregnancies. Many of the visits are for prenatal care. That is just a quick summary, but pretty much they check on people in their homes. Doctors rounds, as blogged about earlier, is really a mobile clinic and there are no home visits.

It was an eye-opening day and the nurse who was with us was very open to questions and ready to teach. Our first visit was to a home (see picture above) to investigate a recent death of a 65 yo man. The family and other members of the community gathered to recount what had happened and this quickly became an argument, forcing the daughter to leave the house as she disagreed with the details given by others. It was a tense encounter, though in another language I could sense that this was a difficult situation. This picture is one of my favorites because it tells a story. On the right sits the nurse, recording the details of the death and turning her eyes towards someone speaking about the circumstances. The middle lady is the wife of the man who died. For seven days after the death of the husband she is allowed to wear bridal clothes, expensive jewelry and other decorations - including the traditional necklace she is wearing which she acquired at her wedding. On the seventh day her family will remove these objects and she will no longer be allowed to dress in anything other than a plain sari. She will never again wear jewelry or a red mark on her forehead (called a bindi, signifying a married woman - but more recently young unmarried girls wear bindis as a fashion mark). Widows are considered bad luck. In the past, widows were known to throw themselves on the funeral pyre of their husband because life as an unmarried woman is harsh. That is less common, but the stigma still persists.

We also visited the home of the young boy who is pictured. He suffers from juvenile rheumatoid arthritis, quite a disabling and progressive condition. His father carries him everywhere. All who know him comment that he is one of the smartest children in the village. His older brother suffers from seizures and is mildly mentally retarded. This is quite a burden for a farming family and I wonder how they make it but they do. The love for their children is palpable. Just as we were about to drive away the mother approached the car in tears, asking for medication of some sort for a pain, but I had this feeling maybe she felt she could express to us safely that she was a bit overwhelmed herself. The nurses talked with her for a while and handed her some pills, likely vitamins or something.

We visited more villages and the nurses performed several prenatal exams. We examined one child for malnutrition. The nurse saw a patient who just two weeks prior was laying in the street unresponsive. She had a stroke and was left for dead by her family, but they took her to the hospital with the nurses encouragement and on this day at least she was walking and smiling as we encouraged her to take her medication.

I really enjoyed the change in scenery, being out in the rural areas reminded me of the place where I grew up. I had quite a chuckle when the other students were snapping multiple photos of the cows and goats. Smells were very familiar to me and I felt proud to have grown up around nature. I noticed a bag hanging from a tree (pictured above) and soon found out it is tradition to hang the cow's placenta in the tree to encourage cow fertility. Now, I don't remember seeing that as a child but whatever.

I like the system because it has layers of intimacy between the medical community and patients. Each village has an aid that seems to know the business of everyone in the area since that is her job. She was able to predict who would be home when based on their habits and whether or not they were seeing family for Pongal season. She is even able to coax out of them the truth of their medication compliance, since it is fairly common for them to not disclose noncompliance to their doctors.

CHAD was something I heard about during the presentation by the students from last year that made me want to come to CMC. My feelings were justified, it is a unique and privileged experience. People will invite you into their home and make a place for you to sit. It is like seeing patients up close and personal, on a real life level. I can't recall doing anything similar in the states which is a shame.

The Beach:
We had a great, restful weekend in Mumallapurum - a beach town south of Chennai. I was able to get a one hour massage for $12. A four course feast runs about $5. I am thankful to be in an area with such cheap prices, I have decided Europe is way too expensive and money can go a lot farther in places like India. For one meal I was teased by another student for ordering something "safe" - a vegetable coconut curry. I asked the waiter to bring me the hottest thing on the menu, and he brought me something called Devil's Chicken. I ate the whole thing and am still alive with no intestinal difficulty.

Take a break

My hands with mahindi, temporary tatoos, designed by the villagers from Pongal Day.

Cute kid on a motor bike, dad nearby getting coffee.

The ever present, instant coffee machine.

Hello All blog faithful -

I had a full day in Karigiri, the hospital originally founded for the treatment of leprosy. It was quite a priveledge to walk the grounds of Dr. Paul Brand and other leaders in the fight against this disease. I am too tired to give it justice at this point so I will defer until next week to give you the full scoop. My friends and I will be traveling to the beach town of Mamallapurum for a quick getaway before our final week. I will start my Rehabilitation Medicine rotation Monday so will talk about that as well. Thank you, have a nice weekend.

Happy Pongal!

A woman preparing food for Pongal celebrations. The chalk drawings are common during the festival.

My favorite village, on Pongal Day

The Jist:

There is a festival going on to honor the Harvest and Sun gods. I have been out in the community this week, will attend the leporsy hospital rounds tomorrow and next will enter my final week at CMC on a Rehabiliation Medicine rotation.

The Medical:

I was lucky to be assigned to a great teacher today, Dr. Santosh, and we had very good conversation about many of the practices he sees in this community.

I spent a good part of my day in prenatal clinic and learned about some interesting cultural challenges unique to this area. The Indian govt has "encouraged" couples to limit themselves to two children, therefore after the second child a tubal ligation is routine. However, in many parts having a child of your own, particularly a son, is regarded as your social security as they have the tradition of caring for their elder parents. So, the poorer parts of the population tend to have four or five children on the hopes that one or two may survive to care for them. Also, having two girls is disastrous and infanticide is common. In fact, the hospital will not reveal the sex of the baby before birth as a policy due to the problem of "accidental" abortions if pregnant with a female.

So what is wrong with being a girl? Well, the parents will feed, clothe and educate them only to lose them to her husband and have to pay a handsome dowry to their new son-in-law. The daughter takes care of her in-laws, not her own family. Plus, if the dowry is not paid on time in full the in-laws often physically and mentally abuse the bride until her debts are settled. The situation can worsen beyond that if the couple is infertile, which is even more reason to heap abuses on the woman - to include accidental burnings - despite the fact that about 30-40% of infertility is due to the husband. The dowry system, though outlawed, is still practiced even in the highest castes and most affluent communities. The general feeling is that as long as this example is set by the wealthiest, it will continue to prevail in the smallest of communities.

Another medical concern is a wives tale that if baby weight is not lost right away it will stay on forever. It is common for women to be starved right after childbirth, given only a handful of rice per day. You can imagine after the blood loss of birth and the fluid demands of lactation this leads to severe dehydration. This is consistent with a patient we saw on neurology last week, who was starved after giving birth and had a stroke in the postpartum period. Not a good way to start caring for a new baby, now she has her own problems to deal with as well.

One more issue is that preganancies are tightly spaced. It takes about two years for the body to recover from childbirth, and getting pregnant so quickly after having a child means that you can start the pregnancy already immunocompromised and anemic. This leads to fetal growth restriction, pre-term births, and other complications.

Last but not least, there is a cultural belief that fruits and vegetables cause respiratory infections and should be avoided while pregnant and right after childbirth. In a place where vegetarianism is the norm, you can imagine this limits the nutrition available to those adhering to this rule.

Please don't think that Western culture is immune to very similar harmful practices in the perinatal population. Though our average level of education is higher, you would be surprised the number of misconceptions surrounding this process. I do find it strange that some Indian women, with no money or resources, give birth at home and wish they had the means to provide full prental care and a safer delivery to their child in a community hospital and all the while there is a trend back in the states for women, with full access to healthcare, electing to have a child at home and taking advantage of minimal prenatal care. Go figure.

Happy Pongal:

We visited four communities yesterday on Doctor Rounds. We took a large mobile clinic bus and parked at the city center where patients and families gathered for routine check ups and medication refills. We were allowed to walk around in the communities and see the festivities for Pongal Day. In one community we were quite the show! We were given front row seats to the games being played in celebration. In fact, we became the entertainment. Two Australian students and I were asked to play musical chairs by running in a circle as music played over the town loudspeaker and villagers cheered on. It was down to me and one other student, who pulled the chair out from underneath me! So, the villagers promptly crowned me the winner and booed at him. I had to make a speech to accept my victory and new sari. I told the village I had been training for this for years and was happy to participate in their Pongal Day. This generous community also gave us cold mango juice and quickly responded when I said I was interested in henna tatoos for my hands (pictures coming later). It was quite an experience and I will never forget their generosity.

Quiet possibly my strangest day yet

A dinosaur outside the Vellore museum. I told David there is never a shortage of large, green fiberglass dinos in the world.

As an aside, I have learned the cow is holy because she is selfless. After feeding her calf, she continues to give milk for the whole community to enjoy. She is a symbol of one who gives unconditionally and without protest. Some say why do these starving people not slaughter the cow to feed their bellies, but then you would be out of milk and have nothing to help plow the fields. Just in case you were wondering, cows have the right of way at all times.

The Medical:

So... We have a lot to talk about and unfortunately it isn't really CMC related. We went to CHAD, the community health hospital, in anticipation of travelling into the communities with nurses to see the villages and tribes. Well, this is a festival week so our opportunities were limited. We spent the morning in clinic where I saw a case of mumps and mitral regurgitation, a common ailment after rheumatic fever. Otherwise uneventful, but interesting to learn about their community initiatives. What started as an outpost for primary medical care has morphed into a social and community center that helps with job placement, social conflict resolution, and even sex education for the youngsters. Arranged marraige is still the norm here, so you can imagine the social strife that arises from that and the false promises between families of a dowry, which is still quite prevalent. They employ "the differently" abled from the community to run phone boothes so foreigners like me and locals can make phone calls. It was quite impressive the scope of services offered, Dr. Scudder's vision has really grown. Long story short, I will be going on nurse rounds tomorrow but today was kind of slow since afternoon clinics were cancelled.

The Strange:

So we had the afternoon off and this is where it all started. Another student was told about a golden temple nearby, the largest of its kind in India and just opened last August. How did we miss this? I don't know, but we figured with a few hours to kill it wouldn't hurt to check it out. We hailed a rickshaw and took the bumpy backroads to Sri Lakshmi Narayani Temple, outside of Vellore. You know if you are going to the outskirts of Vellore you are really off the beaten path. Once there, we checked in our shoes and cameras to be permitted inside. We walked several hundred yards, like cattle, up to the temple grounds. Thousands of people were coming to the temple, and we were placed in cages, each holding several hundred people, where we gathered and waited to be released onto the grounds. It isn't as bad as it sounds, just crowd control. There are seats inside the cages and people are nice. Once let out from the cage we walked up to a metal detector and placed all belongings into an xray machine.

Finally we had arrived and it was a pretty incredible sight. There was a large golden buildling surrounded by a path in the shape of a star. You had to walk along the path, mostly granite and marble, which took about 20 minutes. Along the sides of the path were posters with vedic quotes such as "God is Love, Unconditional Love" and "Your reincarnation depends on your karma" and all sorts of things. The temple was blinding! Pure gold, nine to twelve sheets deep, around the entire building. A total of over 1500 kilos of gold or 1.5 tons. Once we reached the ornate temple we were pushed to the front to see the inside of it. I guess we looked so foreign they figured this was our only chance. I will not lie, it did cross my mind that maybe I was to be sacrificed or something but I quickly remembered that Hindus are not violent, in fact they won't even curtail the mangey dog population. All in all the trip seemed to be entertaining, especially for an anthropologist wannabe like myself.

After further lollygagging around the temple we went in search of a brochure, as we weren't allowed to take pictures and we wanted some memoir. A side office which sold relevant books was nearby and we flooded into it. There we found a Canadian woman behind the counter who took interest in our story as to how we might find ourselves at this temple on this day. It was very refreshing to find a local who spoke perfect english, so we began talking. She looked at her watch and said "Oh, we must go now, and get the blessing from omma, the time to get a blessing is nearly over, would you like to come?" Well, I am not in the business of refusing blessings, and I was intrigued by her enthusiasm so we all fast walked, shoeless across the street to a nearby less golden temple. The time was short so there was little explanation, I figured this was some customary Hindu ceremony that we could take in. She told me to cup my right hand and walk up to omma, then drink the water and pour the rest on my head. I assured her that I was Christian and not Hindu and wanted no part of disrespecting their faith, but she said it was not a problem. Apparently these blessings are few and far between, usually people line up by the thousands to meet omma, including the President of India who has met omma several times. We were the last ones allowed in for the day.

So I walked up to omma, a 31yo man, who poured a ladle of water mixed with spices into my open right hand. I drank just a sip then poured the rest on my head and then watched my friends do the same. We met up with Canadian lady's husband, a family practice doctor from Canada, and walked outside to talk further since we had so many questions. She said omma liked us, and wanted us to have a book usually reserved for heads of state and people of the hightest status. So, she began to explain that omma is not a man, but the incarnation of three female Hindu gods who has come to earth to do good. WHAT?/!!?!? This Canadian had several phds, one in world religion, so it was interesting to talk to her. She said we were given special clearance and he must have thought we were all benevolent spirits. She continued to talk about the vedics/hindus/ etc until I nearly shouted "Oh my God is that an elephant?" Literally as she was talking an elephant walked by randomly, apparently she lives there and just walks around. She gathered some food for us to give to the highly decorated elephant. I stuffed my hand deep into the elephants mouth with a cookie for her and the elephant blessed me by putting her slobbery trunk all over my head and face, it was pretty awesome. Elephants are very holy in these parts.

We were invited to their dwelling near the temple for tea, which I was happy to attend with my friends because this was pretty much the strangest sequence of events and needed further explanation. He explained that they are devotees of omma, a human incarnation of god, and are in line with ommas vision for mankind to surrender themselves and devote their lives to the betterment of all. They have built orphanages, hospitals, water facitilities and more. Omma procures funding only from people who gained wealth by honest means, nobody involved in gambling is allowed to donate to the causes. This doctor become a devotee when omma made rice fall from his hands and his wife became a devotee when omma manifested a crucifix out of thin air. We met other devotees, mostly educated Westerners, many of them doctors, all living in a complex near the temple. Maybe more like a compound as I look back on it. Mostly from California.

So I always thought Canadians were a little strange, but this was way out there. I hope my story does not make you worry for me, I am still as Christian as the day I was baptized. I will always though be fascinated by people, their decisions, their lives, their pathways and this was quite possibly the strangest yet. If you can get past the "miracles", women gods in male bodies, and rice/crucifixes falling out of nowhere their way of life is quite beneficial to the local community and fits in well with the surrounding Hindus. Also, we had great conversation about Indian healthcare which answered quite a few of our questions. He talked about how CMC faces the decision, when given a large sum of money, to purchase a CT scanner to attract the richest of the rich (Arabian princes frequent the hospital) to fund their charity, or should they spend any and all funds on just providing as much charity as possible. Difficult situation I can imagine.

We talked about why build a golden temple when money could be used for schools and healthcare. Omma says that the temple is meant to inspire other people to go out and build schools and hospitals, etc. Tea time was over and it was getting dark, so we headed out and thanked our host for his time and patience while fielding our probing questions. For whatever it was worth, it was the strangest four hours of my life by far and pretty exciting. I have spices and elephant saliva in my hair. God does work in strange ways. I am very content with my Christian spirituality, which I think makes it easier for me to learn about others without feeling like my own salvation may be threatened. I am glad Christ did not encourage us to build golden temples because it seems like a poor use of limited resources and I am proud of our own heritage of selflessness. I hope that all people some day run into some vedics or omma devotees and you may find that they are a little strange but soon you realize they are people too, who were searching and searching, then found something, and moved half way across the world because they believed in it - which makes for great conversation.

I found this website, the temple is now finished but here are some pictures:

http://www.myistop.com/blogs/fordac/golden-temple-tamil-nadu