Black and White

I have made two trips to Pune now. Neither has lasted more than 24 hours. As momentous as this trip was today, it certainly doesn’t hold a candle to my first trip, in 1996. It was the day I met my wife.

I arrived in Pune 15 minutes ahead of schedule last night, and within 25 minutes of landing was standing in my well-appointed hotel room. My host at the National AIDS Research Institute, Dr. Srikanth Tripathi, met me in the hotel lobby an hour later and we headed out for a light dinner of pav bhaji. On the way, he took me to the Maharashtra answer to Tower Books/Records.

This morning, Dr. Tripathi took me to a couple of HIV clinics run by NARI, one at the National Institute of Virology, where he launched his research career, back in the day, and one at Sassoon Hospital. A distinctive feature of both of these clinics, one that I have observed nowhere else save YRG CARE, is the seamless integration of clinical care and research. Unlike most government clinics, these are by no means overburdened with patients. They see 20-30 a day. A pittance compared to the 100-150 they see at Osmania or Gandhi in Hyderabad. Every physician here, however, seems at the top of their game and they all seem to be involved in clinical trials.

After seeing these satellite clinics, we headed to the mother ship. NARI itself. This is where Dr. Tripathi sees patients these days, as well as where he heads up the TB and retroviral resistance labs. He gave me a whirlwind tour of most of the labs as well as the clinic. One of the medical officers, Dr. Sampada, presented a fascinating case of unexplained 6th nerve palsy that progressed, then improved on ART, without any other directed therapy. Then it was time for my lecture and we were off to lunch. Perhaps the most memorable interaction for me, besides the great discussions I had with Dr. Tripathi, was with Dr. Mawar, an anthropologist that is tackling the critical problems of bioethics training and stigma research in healthcare providers. After lunch, I was taken to the airport without complications. Everything proceeded like clockwork. Obviously.

Ganesh Chathurthi kicked off yesterday. In Andhra Pradesh, this festival is also known as Vinayaka Chavithi, and is a pretty big deal. For the past week or so, as we have traveled through the city, we have seen Ganesha statues of varying hugeness making their way around Hyderabad on the beds of autos, trucks, and other conveyances. These machinations, however, are nothing compared to Ganesh Chathurthi in Pune. So I have been informed by everyone from my uncles to Raju, our taxi driver. Apparently, this holiday is the big one in all of Maharashtra, and worshippers go all out. Dr. Tripathi was kind enough to bring me in some sweets that he and his mother rolled last night. They were delicious. Too bad we will not be in India for the dunking of the statues at the end of the 9 day celebration.

Mint Mischief

Being back in Hyderabad is fantastic. I understand what is being said around me and the plans are mine and not someone else’s. We all got to meet Shobha face-to-face, finally, and anticipate that it’s going to be a great 2 weeks here. The folks at SRH, as usual, delivered the goods today; I will leave it to the team to expound on that. They also were pleased with the rest of the medical equipment we brought over from Medwish.

As Brooke mentioned, we made a trip to the local supermarket. I tried to get things with exotic names/flavors. Mango tic tacs. Clove gum (which I don’t really like in the US but am hoping will be different here). Two bags of chips, the first of which is called Mint Mischief and the second, which Tim will probably mention. Mint Mischief is the early winner, thus far, in my opinion. I will leave it to my companions to reveal what the competition was.

Tomorrow, I hope to check in on my research collaboration at Nizam’s Institute of Medical Sciences. Also, we will be having Indo-Chinese.

Goodbye Pondy, Hello Hyderabad

So we have made it to Hyderabad. Our last meal in Pondy was with our friends at Coffee.com/Touskilfo.  We had a special meal prepared in the Mughlai style, which was absolutely fantastic.  It consisted of dal and marinated roasted chicken.  Our resident vegetarian had paneer in spinach.

The dal was so incredibly rich and creamy, and the roti melted in our mouths.  Afterwards our chef came out and explained how he cooked it.  He told us to properly cook the dal, it takes at least 24 hours.  He also told us that nobody cooks dal in this way anymore.

We all got ice cream afterwards, and it was Gopal’s first try of the saffron ice cream.  Apparently, when Gopal makes it at home, it comes out very grainy, so he wanted to get some pointers.  Sugar, it turns out, is like poison to ice cream, and makes it turn out more grainy.  our man uses honey to sweeten the saffron ice cream.  In addition, he uses whole cream milk straight from the cow.  He does boil it to make his custard, which is better than pasteurization.  He also doesn’t use any machines to churn his ice cream, it’s all done by handheld electric mixer.

We will definitely have to have a CIT2 reunion–with ice cream.

After a surprisingly uneventful journey into Chennai, we made it to the central station with 40 minutes to spare, and were not kicked off the train, as Gopal had feared.  We are now in Hyderabad, and have had our first taste of Suresh’s food.

Slumming in Chennai with YRG CARE

It is just past midnight on my most exhausting day yet, but I want to get some thoughts down. Today I left the crew in Pondicherry and headed north. My driver was an hour and fifteen minutes late and brought a vehicle with an empty tank. Gas (“petrol”) can be purchased at petrol bunks along the side of the road as well as at apparently any other stall. We made for such a stall after leaving the MGMCRI campus, then took the coastal highway to Chennai. This is much more picturesque than the faster route we took on our way in, and goes through Kovalam, an area that was heavily affected by the tsunami.

I arrived at the Y.R. Gaitonde Center for Aids Research and Education precisely at noon. It is located on the campus of a hospital called Voluntary Health Services and was started by Dr. Suniti Solomon, the person who, in 1986, reported the first cases of HIV in India. It is a non-governmental organization and boasts one of the most prolific HIV research publication records of any center or institute in India. Aadia has blogged about her time at YRG CARE here. My contact at YRG is Dr. Sunil Solomon, one of the physician/investigators here and the son of the Dr. Solomon. One of my Case students will be spending a few months here later this year for his thesis, and Sunil was kind enough to arrange a tour for me of YRG CARE’s facilities and programs.

I will leave the description of YRG CARE’s research activities to their website. Suffice it to say that they are a model organization, whether it comes to clinical care, research, or humanism. I would prefer to describe my activities after the tour of the premises, lunch with Sunil and his mother, and my lecture to the staff there. I got into to one of the official YRG CARE autorickshaws (Alicia, hope you are paying attention) with Suresh, who heads up many of their outreach activities.

Suresh took me to two slums, then their clinic for injection drug users, then to their community research building. The slum visits were an unforgettable experience. The first one, Jothiammal Nagar was on the banks of a “canal”, which is a euphemism for “large open sewer the size of a small river”. We were to meet in the community hall but it wasn’t ready, so we actually met in one of the houses of one of the CPOLs (Community Pxxxx Opinion Leaders). The CPOLs are nominated by each community, and consisted in this case of 4 men and 4 women. To enter the house, one walks across a wooden plank to cross the two-foot wide open sewer drain running in front of each house. This CPOL’s house was a room about 10 feet by 20 feet, with a curtain dividing the room into sleeping and non-sleeping areas. The kitchen was in one corner near the front of the house, and there were two chairs in the middle of the room, on the dirt floor, for Suresh and myself. The 7 available CPOLs and the YRG outreach worker sat on the ground.

For about 20 minutes, I had the chance to ask them questions about their experiences in their new roles. The center had only been open for about 3 weeks. The focus at this center, as in many others, was domestic violence. The CPOLs seemed confident in their abilities, their training, and their responses thus far to the incidents that had taken place. They themselves identified alcohol as a major contributing factor in domestic violence, and expressed their desire to tackle that problem in addition to what they were already doing. There had not yet been much in the way of referral HIV testing at the center, but this will start picking up soon, I imagine. After the meeting, I said my thanks and namaskaarams to everyone, and was led to the main thoroughfare of the slum by two of the men, along with Suresh and the other YRG CARE worker. Near this tiny intersection was a modest brick-and-mortar structure that would not have made me look twice ordinarily. Its presence in the slum was incongruous. When I asked Suresh about what it, with one or two other similar ones adjacent, was doing there, one of the CPOLs declared proudly that it was his own house. This is an iron man’s house, he said in his English as he thumped on his chest. I am iron man, he continued, pushing an imaginary iron over a matching ironing board. Then he pointed to his biceps and said in Tamil, hard work. I learned that he had put his son through college recently. He and the other CPOLs certainly seem well chosen.

We left Jothiammal Nagar and headed next to Kothavalchavadi. This was different in a couple of ways. It was government constructed tenements, rather than makeshift, inhabitant constructed domiciles. Additioanlly the program there had been in place for a few years, and the CPOLs had had much more experience. Most of the men CPOLs were out working, so I only spoke briefly with the women, but was just as impressed as in my first experience. They were only too happy to allow me to take pictures and told me to spread the word about the squalor in which they lived.

After the slums, we headed off to northern Chennai, to a clinic for injection drug users that Sunil runs. There, Pradeep, who had previously shown me the inpatients at the main YRG hospital earlier, appeared again for his evening shift. He gave me the 5 rupee tour, I took some more pics, and then it was off to another YRG research area. I checked my email, freshened up, and was then dropped off at the Solomon residence, where I was accosted by three large golden retrievers that required constant petting and scratching. Sunil and Dr. Solomon took me out to a typical Tamil meal with some of their close family friends, then sent me to the very comfortable guest house where I spent the night.

YRG CARE is a fantastic organization. I am impressed with their interest in all ID things as well as social issues, and I am sure that my slum experience will stay with me for a very long time.

Another one bites the dust

Brooke is feeling better.

Paras is not.  Overnight, Montezuma’s revenge caught up with him.  Or should I say Shiva’s revenge.

We’re all experiencing varying levels of GI distress, from heartburn to traveller’s diarrhea.

Yesterday Tim was pimped by the Dr. Walsh of MGMCRI.  Pimped mercilessly as the rest of us watched.  I think he almost broke down in tears.  I’m kidding about the tears.

This occurred during one of the upper level medical school lectures, where it’s kind of like CPC format-stump the attending.  Although it was more of a teaching session where the attending (in this case the department head) went through the process of clinical analysis of a patient.  In this case it was a case of edema and ascites.  Clinically, I think he concluded that it was caused by one of the hepatitis viruses.  I don’t think there was even a discussion of laboratory investigations.

The poor man probably didn’t even speak English, and was sitting in this room for an hour and half, wondering why we were talking about him.

In the afternoon, we spent a few hours looking at microscope slides with Dr. Singh.  He pulled out various tropical parasites–malaria, leishmaniasis, filariasis and other worms–and even a slide showing Negri bodies of rabies.  It’s kind of cool because I remember pathology in medical school being quite boring–this is the liver…this is an abnormal liver….this is a kidney….this is MPGN….   It was fun to be able to see things under a microscope that we wouldn’t otherwise see in the US…and textbook plates just don’t do it justice.

They have malingerers in India as well.  However at 5000 rupees for an ICU admission day, and 1500 rupees each day afterwards, it’s kind of expensive to be a malingerer.  In the drama that is becoming our usual morning routine, a nursing student apparently went into convulsions.  She’s had evaluations done, including an EEG, at another private hospital which were all normal.  Our leading diagnosis now is pseudoseizures.

As for yesterday’s snake bite patient, they think that it was all hysteria induced.  They gave her a dose of antivenin, but decided to withold medications to see what would happen…and nothing did.  Whatever bit her was not likely poisonous.

Our excursion du jour for yesterday was to the Kailash Beach Resort, about 3 km down a side road from the Eye hospital up the main hospital.  Even though we weren’t supposed to, we snuck onto their beach and went for a nice long walk (please, no jokes about long walks on the beach).  It was very pretty, and it was sandy unlike the beach in the city.  If you walk far enough, you get to the public area where the fishing boats were pulled up onto land, and the fishermen were untangling their nets from the day’s work.

It was all very pretty, until I turned around and saw someone squatting bare-bottomed on the beach and realized these were not stray dog droppings that we saw along the way.

The resort itself has a beautiful pool, decent restaurant, and while very expensive by local standards, was quite reasonably priced.  We sat and drank a couple of beers while waiting for the restaurant to open, and in the meantime filled up on cashews, peanuts, and other Indian equivalents of beer nuts.  By the time the restaurant opened, we decided to just get “snack” sandwiches, which turned out to be triple decker sandqiches with cheese and fresh vegetables.   I picked the vegetables off, and hope that was good enough.  They even called an auto-rickshaw for us to take us home!

It was nice to finally have a nice walk where you didn’t feel the stifling heat.  The breeze off the ocean kept things nice and cool.

This morning on rounds, our last discussion was about methods of suicide attempts in India compared to the U.S.  What rolls into our medical wards and ICUs are things like Tylenol, anti-depressants, and prescription medication.  Here it tends to be more things in the community–pesticides, posionous berries that are used as decorations, etc.  Just imagining how many people attempt, but don’t make it to the hospital for care, or cannot afford care is just mind-boggling.  The population of Pondicherry is about 1 million–more than the City of Cleveland, but about half the population of the metro area.  And this little private hospital-one of dozens of private and government hospitals– that’s less than half full has at least 1 or 2 OP poisonings at a time.