Shades of Gray

I am back in Pondy, reflecting upon yesterday’s voyage, as Brian foreshadowed. Also, I uploaded some posts I had been working on when I did not have internet access over the past couple of days here and here.

I spent Friday in aunt’s house in Nellore. Nellore, the last major city in southern AP before one hits Chennai in Tamil Nadu, is the ancestral home of my mother’s family, and is where my mother was born and spent some of her formative years. I had not been there in 16 years. I spent about 18 hours with my aunt, including the night stay. Saturday morning, I awoke and bathed. Upon exiting the bathroom, I immediately perceived that the door to my bedroom was now on the floor. This was not entirely surprising, since my aunt had complained on the previous night of the white ant problem in that door frame, and I had already ascertained that the door was had been staying affixed to its frame primarily by the adhesive properties of the white paint on its exterior. I cleaned up the shards of wood, saw none of the offending termites, who had presumable headed off long ago to greener pastures, and, after a quick breakfast of pongal, proceeded to the Nellore YRG CARE clinic at about 11am. I was then apprised of the first of a series of unfortunate events.

Sunil had not come. Although his presence was not required for the tour, which was to be conducted by Krishnan and Vasu anyway, it was essential for my return to Chennai that afternoon. At least, it was according to the plan we had worked out 48 hours previously. Since I had an appointment with the Chairman of the Balaji Trust (the parent organization that started MGMCRI) in Chennai that evening, I rapidly became apprehensive and voiced my concern to Krishnan in a half-crazed, high-pitched tone. His eyes widened and he spoke to me very slowly and deliberately, acknowledging that I must be frustrated. This is exactly what I have been trained to say when dealing with “problem” patients and generally works extremely well. It infuriates me when I am subjected to it. Once he outlined a very reasonable course of action that would get me to Chennai by mid-afternoon, I calmed down and my pulse came back down to the low 120s, which is the baseline I achieved following my volume-depletion after cleaning up the disintegrated door frame in 90 degree weather with the ceiling fan off. Krishnan then cheerfully remarked that Americans such as myself are all so black-and-white about plans. Here in India, there are only shades of gray, but you are not used to that, he laughed, and Vasu looked up from his laptop to sagely waggle his head and laugh in agreement. Yes, I said weakly, shades of gray. Hehe. We headed off for the tour, which Krishnan conducted with supreme competence and efficiency I have now come to expect of YRG staff. I called Mrs. Asha to confirm my appointment with the Chairman. She seemed rather surprised to hear from me, even though she had asked me to call at exactly that time on that day. She asked me to call her back in the afternoon, when she would divulge the particulars of the meeting venue and time. We dined at Murali Krishna’s, a fantastic restaurant serving typical Andhra fare, and tried to call Sunil to gloat but he was not available. Then they dropped me off at the bus stop. I left my water bottle in the car.

I boarded the bus to Chennai and payed about $2.80. My recliner didn’t work, and I was too exhausted to find a different seat. It was 1PM and the heat was unbearable; I could barely wait until the driver started off so that we could turn on the A/C and the TV. Sure enough, within five minutes, we pushed off, and I realized that there was no A/C on this bus and that the TV did not work.

We made about 15 stops in Nellore and picked up about 4 people. The last was a man on the outskirts of the city. I don’t know where he was going, but the driver charged him 10 rupees compared to my 114 fare, so I decided it couldn’t be that far. The man was barefoot, dressed in a blue short-sleeve shirt and a darker blue lungi folded at the knees. He held a basket against his hip and spoke in a gravelly baritone very deferentially to the bus driver, ending all his sentences with “saar”. After paying, he stepped into the main part of the bus and began to hawk his wares in an unbelievably shrill voice, walking up and down the aisle several times before realizing that none of the eight of us passengers was a future customer. For whatever he had in that basket. So he sat down and demanded that the driver turn on the TV, not taking no for an answer. The driver yelled something back at him and he quieted down. Meanwhile, my shirt was slowly being steeped in sweat as we rarely got enough wind coming through the windows, what with the frequent stops. My mind started swimming, just a bit, and I began experiencing mildly paranoid ideation. Specifically, thinking a bit about lungi-boy’s abrupt change in behavior, I imagined that the driver and he were in cahoots and that they would perpetrate some heinous act upon us once we were in a more rural setting. I felt a sharp tap on my left shoulder and looked back to see lungi-boy gesturing to my watch. I started to take it off and then thought briefly and said 3:15. This seemed to satisfy him and, after a while, I managed to fall asleep.

When I awoke some 20 minutes later, sweat was dripping off of my brow and streaming down my face. I reached for my water bottle which was safely in the back of Vasu’s car. My kidneys began to shut down for the afternoon. I realized that there was an argument going on. The driver and lungi boy were yelling at each other. Initially, only the driver was yelling, and lungi-boy was trying to plead his case. The driver felt that he had taken him 10 rupees worth of road. Lungi-boy wanted to go a bit farther. Then lungi boy started screaming. He was agreeable to getting off, but he wanted 2 rupees back. He felt that he had only gotten 8 rupees worth of transport. Some of my fellows passengers suggested that lungi boy get off, so he asked the driver to step outside. They would handle things behind the bus. The driver eventually assented, and they stepped off the bus. 10 seconds later, lungi boy came back to put his basket on the bus. Confidence. 5 seconds after this, the driver came back and left with the basket. Then we heard the argument continuing outside. I craned my head to see across the bus, but to no avail. The villagers were gathering to witness the proceedings, and I began to ponder the potential outcomes of the altercation. For my money, the driver could have taken lungi boy. But what if he couldn’t? Could I drive the bus? Don’t they have gears you need to shift? Would my head stop swimming? Fortunately, the driver came back and we headed off. I relaxed and reached again for my water bottle, which continued to be in the back of Vasu’s car.

I called Mrs. Asha to get the details of my appointment with the Chairman.

Yes, Mr, Gopal, you have to get to Ashok Nagar as soon as you get off the bus.

OK. Then what?

But how will you find Ashok Nagar?

Excellent question.

You do one thing. You call me back in 10 minutes.

I did not understand why finding Ashok Nagar was not on the problem list 4 days ago when we planned this meeting. I also did not understand why Mrs Asha had a phone that could apparently only receive calls. I called back in 10 minutes.

Mr. Gopal the Chairman has left for the day.

Really? He left? This is what transpired in the last 10 minutes? HE LEFT? Was it because of the Ashok Nagar dilemma? Really?

Yes. Really. Can we schedule for Monday?

No.

I have fixed an appointment with him at 9:30AM on Monday, OK?

No.

I will see you Monday. The Chairman wants to meet you. You bring your students. Bye.

I called Krishnan to let him know that I no longer had an appointment with the Chairman, and I would just go to Sunil’s house, as we had discussed. Umm, Gopal, there has been a bit of a change. Sunil’s dog is sick. He cannot meet with you. You can go to our guest house.

I want to go back to Pondy.

Yes, yes, that makes much more sense. My driver will meet you at the bus stand. He will put you on a wonderful bus to Pondy. More gray, hah? Hehehe.

Hehehe. Cough cough. I reached for my water bottle. My kidneys began putting their affairs in order. Talk to you later.

We pulled into Chennai at 6PM, where I was to meet Krishnan’s driver. Krishnan called. Hey Gopal, can you do one thing? Can you find the bus to Pondy on your own? It is just that the driver is waiting outside the stand, and he would need to park if he would come to help you.

Sure. Sounds great.

You can’t miss the bus, Gopal, it’s very easy. Go to Enquiry and ask. OK?

Sure. I eventually found the platform with the buses going to Pondy. All ten of them. I got on one. The one with four conductors waiting outside. Or it could have been two. Or one. I ran my bone-dry tongue across my cracked lips, brushed some uremic frost off my arms, put my backpack down and reached for my water bottle. Then it hit. An epiphany. An inexplicable moment of clarity. I ran off the bus and bought a bottle of Aquafina. The bus took off, I downed about half the bottle’s contents, and took stock of my new vehicle.

It wasn’t as fancy as the other one, but the TV worked well enough to blare a 45 minute tape of Ilayaraaja‘s selected hits repeatedly over the next four hours. We made about 10 stops in the city of Chennai and the bus was packed by the time we hit the east coast road. There was standing room only, and not much of that. I fell asleep (lost consciousness) for some 10-15 minutes. When I awoke a blurry toddler was staring up at me from the floor. I stared back at him through my dry, opacified contacts. He was wearing a shirt, nothing below, and lying in his mother’s lap. I then realized that she was sitting on the floor of the bus, breastfeeding him. She glanced up at me and glared. I jerked my head up violently to look in another direction. Any direction. My head hit an object behind me and to the left. It was a man’s posterior. He was sitting on my left shoulder. This explained the excruciating pain just left of my spine. I straightened up and heard something crack in my spine. I glared at him much in the same way the lady on the floor continued to glare at me. He smiled broadly and started singing along to some of Ilayaraaja’s greatest.

This continued for 3 hours before I saw the familiar mien of the Pondy Chief Minister on a billboard. I had had intermittent contact with my aunt and with Brian via text message. The team was waiting for me at the Ajantha hotel. I got off the bus at the Pondy Bus Stand at 9PM and hailed an auto. The trip to Ajantha took another 10 minutes. The team waited patiently for me as I consumed my dinner and brought them up to speed on my activities. We walked out of the restaurant, Satsanga, and saw two autos parked outside. We quickly agreed on a price of Rs. 250.00 per auto and set off for MGMCRI. Tim, Alicia and I talked in our auto about some slum related issues. Then it stopped. The auto did. It just stopped. No petrol?, I asked the driver. He gave me a winning smile, produced a Sprite bottle with an amber-colored liquid, and disappeared behind the vehicle. A minute later, we were full speed ahead. Until we go to the edge of town. Then we stopped again. This time, he had no extra bottles. Fortunately, his friend up ahead realized we were not right behind them and came back. As they conferred with each other, 3 dogs approached us. I proposed that we hitch our auto to these sturdy specimens, but the other auto driver then pulled out his own sprite bottle and we were off and running again. until we were well into the dead space between Pondy and the campus. The first auto came back. There was no backup any more. The three of us joined Brooke and Brian in their auto and we sped off again. My muscles had already adapted to unusual postures thanks to the man that sat on me for 2 hours. Brooke, however, lost feeling/circulation in her right leg after a few minutes. This proved to be reversible once we arrived at the hostel, and the only thing left to do was explain to the auto driver why we would not be paying him 500 rupees. This only took about 20 minutes and was assisted by translational help from the security guard, who spoke only Tamil and no English, and two student passers-by, who spoke a lot of English and Malayalam but little Tamil. That went almost as well as one would predict and we settled on a sum of 400 rupees. I left the driver muttering to himself, no doubt planning his revenge. Some 13 hours after I set out from Nellore, I walked into my room. Never did I expect to be so pleased to see that place. I called home, spoke to Toohie, heard Geethanjali’s voice, and the gray lifted. I slept well.

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.

Cozy bus ride.

We are back at the official CIT2 hangout, Coffee.com and enjoying ourselves once again. I’m amazed that Desiree remembered all of our names, except for mine, which is understandable- I am quite forgettable. Paras is happy that she recalled his as he thinks she is kind of cute. She also added a note on the menu that their ice is made with water that is filtered by reverse osmosis to avoid further annoying questions such as Gopal’s yesterday. We took the bus into town again and this trip was not as pleasant as our last. I think the bus route is much more popular on Mondays than over the weekend. It was a bit hot, crowded and without the festive music. Unfortunately, it seems to be very difficult to get the rickshaws to take us into town so I don’t think we have much of a choice but to chance the bus again.

Today was our first day on the wards as the others have mentioned. Brian summed up our experiences on the peds side well. I also was very impressed with the federally-funded immunization program and the technology of the NICU. I am excited to spend more time there tomorrow. As Brooke mentioned, shoes have to be removed before entering all ICU’s and interesting enough, we had to put on a gown before entering the NICU. It is a very strange feeling to walk around the NICU in barefeet. I’m going to spend some time in the theatre with the pediatric surgeon on Wednesday which should be interesting. I’m hoping the scrub techs wear fancy scrub dresses as they do down under.

I think we are going to finish our coffee and find a restaurant on the beach for dinner. Then another ride on the rickshaws back to the hospital.

Great day in Pondicherry

Hello all,

My travel companions that have just recently blogged have summed our recent events up fairly well. I’ll try not to be too repetitious. Today has been our first full free day and it has been fantastic so far. I already find myself saying “fantastic” more often after only a couple of days with Gopal. We had breakfast at the canteen at the hospital which has pretty good food and most meals average around 50 cents. We then were enlightened with Paras’s talk on organophosphate poisoning, which invoked some interesting discussion as Gopal mentioned. We then headed into town on the bus which did have great music along with some interesting light effects. Now we are hanging out at a great coffee shop, which my lonely planet guide book described accurately as a “hip cafe.” They have espresso which makes me very happy and good food. We’ve heard they will play us a movie for Rs 100 (a little over $2) so we definitely will be spending an evening or two here.

Overall, it’s been a great experience thus far. At times I’m overwhelmed with the poverty and state of things, but at others impressed with the fine clothing, jewelry, cars, etc. It’s a very interesting place. It’s been more difficult to communicate then I expected, but we are getting by.

I forgot to mention- We traveled from the bus stop to our current location by rickshaw, which is an interesting motorized 3-wheel auto. I really liked it, I wish I had one of my own. I could probably pick one up for a few thousand Rs but getting it home might be an issue. Hope all is well at home.