In summary…

After spending two weeks in Hyderabad, I landed at the JFK airport approximately 12 hrs ago, greeted by severe downpours and traffic delays.  Sight of my apartment, bed, bathroom was comforting and as expected, I am fully awake at 3 AM thinking what would I have been doing in Hyderabad at this time if I were still there.  Finally, being able to access internet (a privilege I have been deprived of) gives me an opportunity to finally share my humbling experiences at the SRH, NIMS and fever hospital.  And as Dr. Anant Reddy from SRH would say, “to speak from your heart and not lips.” 

Days in SRH were spent learning about leprosy, examining patients, physiotherapy provided, attending reconstructive hand surgery.  Absolutely AMAZING work by Dr. Reddy who has put my faith back in surgeons and humanity.  At SRH, they not only take care of medical issues but provide them with housing, food and vocation so they can be independent and live with dignity.  We also learned about the TB and DOT program, visited off site DOT centers around the city, and discussed the obstacles they face, and also talked about PMTCT program briefly with Dr. Venkat Reddy.

Next was the adult 20 patient HIV ward (aka the care and support center) managed by Dr. Rao and Dr. Suguna where patients are never turned away regardless of complexities and complications, regardless of not being able to obtain the diagnostics/procedures, which would eventually be very frustrating for me but to physicians at SRH – they do with what they have. CD4 count is sent out, viral loads are not done anywhere, WBC count is but platelet count is not available, diarrheal cases are seen but cultures are limited; For TB patients, AFB smears are done but cultures and susceptibility testing is done when failure on therapy is suspected with referral to the Chest hospital, isolation but no negative pressure rooms are available. A definitive diagnoses is infrequently made but is presumed as it is solely based on history and exam, and a response to most possible readily available treatments. Yes, we are privileged to have many resources available to us. 

At the Care and support center, besides medical, social support to patients and family is provided, healthier nutritional frequent meals are guaranteed, a referral to government sponsored ART centre to initiate or continue antiretrovirals is given- which if I recall correctly is limited to AZT/3TC/ may be d4T, efavirenz, nevaripine and I don’t think anyone was on a protease inhibitor. But even if the medications are available, travel to an ART centre when patients are ill also affects adherence. It is also a social stigma of seen at these centres that refrains them from being compliant. Resistance, I wonder? Second line regimen, especially if patient has severe complications to the 1st line regimen, is very difficult. What I have learned and practice in US is yet not possible there. Granted the resources are limited, challenges many but still the care provided by clincians is truly inspiring, and brilliant. 

My favorite place to visit at SRH was the children home.  Each child has one poignant story than the other but they seem to be so connected with each other, almost as if there is an unspoken bond amongst all. And a thought keeps recurring  - what would have happened to these innocent children if this home was not there, and what about the children who have not found a home like SRH. I am sure there are many out there, abandoned and left to beg on the streets, suffering the cruelties of our society. One of the mommy’s, as is addressed by children, nineteen-years old, shared that once she was married to a man twice her age, had a baby boy who is healthy and now 3 years of age. Husband was found to be HIV positive and when her test was positive, in-laws and husband disposed of her, took away her child and since her family couldn’t take care, she is now at SRH taking care of children (a teenager herself). Her eyes well up with tears as she showed me the only picture of her son, making sure I was seeing it under light and admired his big beautiful eyes.  Also, the teacher, Mrs. Prasana, likely in her forties has devoted her life to SRH since she was sixteen. She aspires to infuse as much education possible into these children so when they grow up they will be self-sufficient.  She has been teaching the children of the leprosy patient but she feels attached to the HIV orphans.  She is their teacher during daytime, motherly figure around festivals, and at night makes a special trip to discipline them to change to night clothes, take the meds and to be in bed by 8 pm.  I asked her to send me a list of all the birthdays for children, since for a few, birthdays come and go with no celebration or a gift. If anyone interested, please let me know. 

Besides SRH, my experience at NIMS (Nizams Institute of Medical Sciences) was exceptional. I especially enjoyed meeting Dr. Laxmi, an outstanding microbiologist and Dr. Subbalaxmi, professor of internal medicine, involved with HIV care and in my opinion an expert in infectious diseases (although she doesn’t admit it as ID is not recognized as a separate subspecialty).  We rounded on a few patients with residents in the acute care ward.  Piperacillin-tazobactam seems to be the drug of choice currently and she showed her frustration at not de-escalating therapy and increasing resistance especially the feared ESBL’s at NIMS. The cases we discussed and actually saw– meliodosis, falciparum malaria, suspected leptospirosis, possible disseminated TB (only x-rays and MRI’s).  I plan to continue my correspondence with Dr. Subbalaxmi and to return next year more prepared, organized and with a few lectures relative to the pathology seen in India.

Last visit was at the fever hospital, where we did see cases of diphtheria, tetanus, dengue (suspected) pyrexia ward, malaria but I really wanted to see rabies!!! Perhaps next year 

After delicious lunch on our last day, I finally parted with the rest of the CIT2 gang, all of whom are exceptional and no doubt are compassionate, caring physicians themselves. And off course, thank you Gopal for making this happen for all us. I look forward to CIT3 already!!!