On a narrow dirt trail that edged its way through neon green rice paddies, Jinu told us about a young women who lives in the house from which we'd just left, outside the village of Kamasamudram, pop. 1700. She had recently delivered a child at 33 weeks gestational age (of the expected 40) in the back seat of an auto-rickshaw en route to CHAD, the Community Health And Development hospital I've written about previously. The baby survived without complication, but his mother was still in the hospital, having suffered from post-partum hemorrhage and, later, disseminated intravascular coagulation (DIC), a very serious hematological response that can occur as a result of severe illness and that predisposes one to dying. Over the course of three weeks in the intensive care unit, she had stabilized. Jinu's purpose in visiting the house was to better assess their economic status, so the hospital would know how much, if any, they could pay of the enormous medical bill that they had recently issued.
I realized that these CHAD nursing visits to the villages that lie in the 88 village catchment area (I'd previously been told, and written, 69 villages) were about more than the ante- and post-natal visits that had occupied much of the morning, and would occupy much of the afternoon. The community nurses spend 5 days a week touring the villages, working with the assistance of "pitchus" (the part time community health workers) and hospital-trained health aids that oversee them, and to follow-up and prepare for the doctors visits that take place in each village once a month. Today, my last at CMC, we would visit eight villages, ranging in population from 1700 to 114.
Jinu, in her sky blue cotton sari, shielded herself from the bright sun with a black umbrella as she led our group of four to the next home, a mud-brick and thatch dwelling that we could see in the distance beyond a large banyan tree and a herd of contented cows. Behind her was the regional health aid, who assisted the pitchus of the 8 villages, and who wore her faded pink sari with a dignity that matched the severity of the tightly drawn skin of her aging face. Kevin, a very nice medical student from St. Louis, and I followed. The banyan tree was decorated with large cotton satchels hung from its branches and aerial roots. Inside them, we learned, were the placentas of a generation of cows, saved and displayed to increase the yield of the cow's milk that would feed not just the calves but the villagers.
We arrived at the mud home and stepped past the delicately drawn kollam, intricate chalk floor-drawings that sit at the entrance to, and serve to welcome the gods into, the home. A young women with a swollen belly sat on the front step in front of a darkened entrance, her face yellowed from the turmeric powder that I would see on women throughout the day, particularly the pregnant ones. Kevin told me the story of the Tamil prince who'd gone to China, fallen in love with a Chinese woman, and returned home with a new taste in skin color, to which generations of women that followed would aspire. The woman was 26 years old. Married at 16, she'd suffered through 10 years of infertility. Traditionally, women are expected to conceive within the first year of marriage, and I hoped quietly that she'd not been punished by her husband's family for a transgression that was not her fault. We were invited in to do the prenatal visit with Jinu, taking her blood pressure, measuring the height of her uterine fundus, listening for the fetal heart beat. As with several of the 20 or so that we would see throughout the day, we referred her to the hospital for further evaluation of edematous feet and a slightly elevated blood pressure, possible evidence of impending pre-eclampsia. Concerned for this precious child, I'm sure she won't hesitate to seek care.
In Mothakkal, a village of 200 people about 1km from the small country lane where we parked, we met a 25 year old torn between excitement at the birth of his son, a beautiful and healthy child, and worry for his 49 year old mother. Within the past few months she'd been diagnosed with chronic kidney failure as a result of long-standing high blood pressure. The hospital had recommended twice-weekly dialysis, which, at the cost of 5000 Rs per month, was beyond their ability to pay. Even if they could pay, the 2km walk to public transport was prohibitive in her frail state. She looked ill, fed up, exhausted. She will likely die soon. Outside of her clean, brightly painted mud hut a group of grandmothers sorted peanuts and shared gossip, both freshly harvested from the surrounding fields.
As the day wore on, we visited Mothupullam (pop. 900), Chinumothupullam (pop. 114), Kallamburam Kottai (pop. 370) and others. The sun started to fall in the west and we started our journey home, stopping at a busy rural junction for chai. A young boy delivered it from the chai-stand across the road from where we parked. We watched a family of monkeys play on its tin roof, some peering over the edge to stare at the men taking tea.
It was a wonderful final day at CMC, going out to see the village of the families and children that would hopefully stay out of the inpatient wards where I started my month. It was great for the same reason that all home visits are: you understand people's health in the greater context of their lives. You see the fields in which people work, the houses where they make and raise their children, and where they will likely spend their final days. Sometimes all of these things are taking place under the same roof at the same time.
Having been in Vellore for four weeks, some final thoughts are in order. Being in one place has made me think about the difference between living in a place and just visiting. One could easily say that I've just been a visitor here; that is of course true. However, I would suggest that visiting a place requires only a certain level of engagement, one that demands very little of the visitor. Just the other day i sat on a plastic bag on the side of a road as a man replaced the soles of a month-old pair of sandals (or chappals) that i'd already worn through. I made a phone call one day and felt cheated when the man told me to hang up and then demanded that i pay. I refused. He yelled. I yelled back. He slammed his fist on the desk. I stormed out. India taught me several years ago what it is to be angry, what it is to release that anger, and what it is to feel better having done so. Among the places i've traveled, India is unique in that it forces on to respond to the environment in a deeper way. It overloads the senses and waits for one's reply. It pushes one to extremes of rage so that one may know true peace. It forces one to step through filth in order to find its incredible beauty. It makes me feel as if i've lived here, if not now then sometime before, because there are few places in which i felt so alive.
All that said, i'm looking forward to coming home (and to coming back). Thanks for putting up with my daily emails. Knowing that some of you (mom) are reading these has made me look at every experience and every day a bit more closely. Experiences, like food, are better when shared; mine has been made more rich because of you.
Sunday, March 25, 2007
CMC - Day Nineteen
It would appear that my encounter with the horse - which i've been advised, in one of several supportive emails, that i should have bitten back - was merely coincidental in its timing in relation to the flu-like illness that felt so disabling yesterday. Today i feel better - less feverish, less weak - and i've ventured into the hospital to prepare for a talk i'm giving this afternoon on pediatric asthma treatment guidelines. I won't bore you with the details. There is a quotation often (and apparently mistakenly) attributed to Ralph Waldo Emerson and the last line of wich goes something like this: ..."to know that even one life has breathed easier because you have [lectured]. This is to have succeeded." Surely, to lecture on treating asthma is a way to find success.
Today is Hospital Day at CMC and the campus is abuzz with this annual showcase of the hospital and its departments. Set up under three massive and brightly coloured tents in a large parking lot across from the hospital are no fewer than 60 booths displaying the departmental displays, in addition to carnival type games, food stalls, and hospital-associated vendors. The women from CODES, the COmmunity DEvelopment and Society group, a project jointly coordinated by CHAD and the communities to create disposable income for families, are there selling their handicrafts. Reprentatives from the leprosi hospital, Karigiri, are selling their printed fabrics. A large section is cordoned off where medical students are giving free health check-ups for the public. The festive atmosphere and this great display of informational public health lifted me right out of my lethargy.
The department of Pharmacology had a busy and crowded display of posterboards, dioramas, and models depicting pharmacuetical classes, tips for travel and appropriate storage, adverse effects, and routes of administration. A large foam-board image of the front of a man had an inhaler stuck in his mouth, several needles stuck into the foam body, indicating subcutaneous, intraveinous, and intraosseus (into the bone) routes of administration. The adjacent poster depicted a less fortunate man from behind with a large needle jutting out of his painted pink buttock (intra-muscular) and a suppository pushed into his foam bum (rectal). A large foam house diorama sat beneath a foam archway that read, "Keep drugs away from children." Inside the house various acts of accidental ingestion were taking place by little child dolls. Plastic bags of toxic substances surrounded the house, labeled for recognition.
A display at the Obstetrics and Gynecology department depicted the Desert of Gestational Diabetes Mellitus (GDM). Small yellow foam footprints headed in the direction of the road to management, each representing a symptom of GDM: weight gain, hyperglycemia, excessive thirst, and excessive urination. They were placed to aoid the small green foam cacti that represented GDM risk factors: maternal age greater than 30 years, family history of diabetes, recurrent abortions and obesity. A sign in the middle said "Decide Your Path? Which Way?", and signs pointed in the direction of "management" or "complications." On the road to the oasis of management were signs outlining the appropriate steps to monitor GDM - "visit 15 days once till 28 wks, then weekly to term;" "maintain good personal hygiene;" "adequate fluids." Inside a cool blue pool at the end of the management road, surrounded by foam palm trees, one could find "scans" and "drugs" and "investigations." Taking the other route, one found the pyramid of complications, a large Egyptian tomb labeled "macrosomia" (big baby), "congenital malformation," "still birth," "infection/UTI."
One large poster in the background showed the male reproductive system pre- and post-vasectomy. I learned at CHAD the other morning that vasectomy is basically a non-option for Indian males. Not even the women want their husbands to have vasectomies, so powerful is the perception of that certain display of male virility. The hospital is trying to promote it more and more as women are rushing after one or two childbirths to have "tubectomies." This wouldn't be seen as problematic except that so many of the women requesting them are in their early early 20s.
The Department of Cardiology's Planet Heart had row upon row of coloured diagrams depicting the flow of blood through the four chambers of the heart. The Nephrology Department displayed glamorous glomeruli lit up with chains of flashing lights indicating the flow of blood and then urine. The pathologists had their rows of microscopes out for the public scrutiny of various tissue samples. The anatomists had a remarkable display of fetal crania. The dentists had dentures and a smile contest for kids. The operating theatre had a foam diorama that looked like a scene out of "Team America:" a team of puppet size dolls were in the middle of a C-section on a doll that was about a third of their size. "The patient seems awfully small," a young girl pointed out in a beautiful Tamil lilt, before giggling.
A voice interrupted the music: "The 9th grade students of the Ida Scudder school would like to dedicate a song from the film 'Arrop' for their beloved teacher Padmini."
I turned around to see a poster of a women being set on fire, perhaps by her angry inlaws. Such incidents are surprisingly and unfortunately common, even today. The Department of Plastic Surgery depicted how people became burned, the complications of such burns, and photos of their successful repair of the damage. A sign warned in four languages: "No loose and flowing clothes while cooking;" and "never keep the oil lamps and candles near the cot (or) curtains at home when all are sleeping." Next door the department of radiology had a large poster that said, "RADIATION: Friend or Foe?" Flanking this question was one photo of a man being hugged by a large white tiger and, on the other side, a man pointing a gun towards the reader. Not sure what they were trying to get across.
A rather progressive display came from the women of Waste Management, the girls in green saris that can be found on every campus collecting refuse. They had a bucket full of warms displaying thier composting techniques, plastic bags displaying each type of trash collected, and a poster asking us to do our part by not using that plastic bags that are ubiquitous in every aspect of shopping. They are, i'm afraid to say, ahead of their time in India.
Perhaps the most impressive display was a large papier-mache mountain decorated with temples and cities, farms and villages, each depicting a component of the endocrine system. The hypothalamus, a large electricity tower at the top of the mountain, connected to the pancreas, a city full of pizza huts, soda fountains, and ice cream shops. The parathyroid gland - "This is the area of moans, bones, and groans," i was informed by the eager attendant - was a cemetary. Two villages, side by side, represented the hyperfunctioning and hypofunctioning thyroid gland. In the former, skinny farmers rushed about through lush rice paddies. In the latter, lazy farmers and fat cows wallowed around unkept fields.
I've been struck, in the past few weeks, at how alienating it must sometimes feel to be a patient at CMC, the doctors interviewing in the native language but always discussing the cases in english in front of the patient. In medicine we do so much to distance ourselves from patients, from wearing white coats to speaking a language no one understands. To see such a massive outreach to the public in the form of such earnest and elaborate educational tools - in English, Tamil, and other languages - was quite heartwarming. People were learning about what they could do to improve and maintain their health, what the hospital could do in the event that they didn't succeed, and they were having a ball. This was something everyone seemed to be proud to be a part of.
Maybe we need a hospital day back home?
Today is Hospital Day at CMC and the campus is abuzz with this annual showcase of the hospital and its departments. Set up under three massive and brightly coloured tents in a large parking lot across from the hospital are no fewer than 60 booths displaying the departmental displays, in addition to carnival type games, food stalls, and hospital-associated vendors. The women from CODES, the COmmunity DEvelopment and Society group, a project jointly coordinated by CHAD and the communities to create disposable income for families, are there selling their handicrafts. Reprentatives from the leprosi hospital, Karigiri, are selling their printed fabrics. A large section is cordoned off where medical students are giving free health check-ups for the public. The festive atmosphere and this great display of informational public health lifted me right out of my lethargy.
The department of Pharmacology had a busy and crowded display of posterboards, dioramas, and models depicting pharmacuetical classes, tips for travel and appropriate storage, adverse effects, and routes of administration. A large foam-board image of the front of a man had an inhaler stuck in his mouth, several needles stuck into the foam body, indicating subcutaneous, intraveinous, and intraosseus (into the bone) routes of administration. The adjacent poster depicted a less fortunate man from behind with a large needle jutting out of his painted pink buttock (intra-muscular) and a suppository pushed into his foam bum (rectal). A large foam house diorama sat beneath a foam archway that read, "Keep drugs away from children." Inside the house various acts of accidental ingestion were taking place by little child dolls. Plastic bags of toxic substances surrounded the house, labeled for recognition.
A display at the Obstetrics and Gynecology department depicted the Desert of Gestational Diabetes Mellitus (GDM). Small yellow foam footprints headed in the direction of the road to management, each representing a symptom of GDM: weight gain, hyperglycemia, excessive thirst, and excessive urination. They were placed to aoid the small green foam cacti that represented GDM risk factors: maternal age greater than 30 years, family history of diabetes, recurrent abortions and obesity. A sign in the middle said "Decide Your Path? Which Way?", and signs pointed in the direction of "management" or "complications." On the road to the oasis of management were signs outlining the appropriate steps to monitor GDM - "visit 15 days once till 28 wks, then weekly to term;" "maintain good personal hygiene;" "adequate fluids." Inside a cool blue pool at the end of the management road, surrounded by foam palm trees, one could find "scans" and "drugs" and "investigations." Taking the other route, one found the pyramid of complications, a large Egyptian tomb labeled "macrosomia" (big baby), "congenital malformation," "still birth," "infection/UTI."
One large poster in the background showed the male reproductive system pre- and post-vasectomy. I learned at CHAD the other morning that vasectomy is basically a non-option for Indian males. Not even the women want their husbands to have vasectomies, so powerful is the perception of that certain display of male virility. The hospital is trying to promote it more and more as women are rushing after one or two childbirths to have "tubectomies." This wouldn't be seen as problematic except that so many of the women requesting them are in their early early 20s.
The Department of Cardiology's Planet Heart had row upon row of coloured diagrams depicting the flow of blood through the four chambers of the heart. The Nephrology Department displayed glamorous glomeruli lit up with chains of flashing lights indicating the flow of blood and then urine. The pathologists had their rows of microscopes out for the public scrutiny of various tissue samples. The anatomists had a remarkable display of fetal crania. The dentists had dentures and a smile contest for kids. The operating theatre had a foam diorama that looked like a scene out of "Team America:" a team of puppet size dolls were in the middle of a C-section on a doll that was about a third of their size. "The patient seems awfully small," a young girl pointed out in a beautiful Tamil lilt, before giggling.
A voice interrupted the music: "The 9th grade students of the Ida Scudder school would like to dedicate a song from the film 'Arrop' for their beloved teacher Padmini."
I turned around to see a poster of a women being set on fire, perhaps by her angry inlaws. Such incidents are surprisingly and unfortunately common, even today. The Department of Plastic Surgery depicted how people became burned, the complications of such burns, and photos of their successful repair of the damage. A sign warned in four languages: "No loose and flowing clothes while cooking;" and "never keep the oil lamps and candles near the cot (or) curtains at home when all are sleeping." Next door the department of radiology had a large poster that said, "RADIATION: Friend or Foe?" Flanking this question was one photo of a man being hugged by a large white tiger and, on the other side, a man pointing a gun towards the reader. Not sure what they were trying to get across.
A rather progressive display came from the women of Waste Management, the girls in green saris that can be found on every campus collecting refuse. They had a bucket full of warms displaying thier composting techniques, plastic bags displaying each type of trash collected, and a poster asking us to do our part by not using that plastic bags that are ubiquitous in every aspect of shopping. They are, i'm afraid to say, ahead of their time in India.
Perhaps the most impressive display was a large papier-mache mountain decorated with temples and cities, farms and villages, each depicting a component of the endocrine system. The hypothalamus, a large electricity tower at the top of the mountain, connected to the pancreas, a city full of pizza huts, soda fountains, and ice cream shops. The parathyroid gland - "This is the area of moans, bones, and groans," i was informed by the eager attendant - was a cemetary. Two villages, side by side, represented the hyperfunctioning and hypofunctioning thyroid gland. In the former, skinny farmers rushed about through lush rice paddies. In the latter, lazy farmers and fat cows wallowed around unkept fields.
I've been struck, in the past few weeks, at how alienating it must sometimes feel to be a patient at CMC, the doctors interviewing in the native language but always discussing the cases in english in front of the patient. In medicine we do so much to distance ourselves from patients, from wearing white coats to speaking a language no one understands. To see such a massive outreach to the public in the form of such earnest and elaborate educational tools - in English, Tamil, and other languages - was quite heartwarming. People were learning about what they could do to improve and maintain their health, what the hospital could do in the event that they didn't succeed, and they were having a ball. This was something everyone seemed to be proud to be a part of.
Maybe we need a hospital day back home?
CMC - Day Eighteen
I'm afraid to say that the most interesting patient i've seen today is...ME! I haven' t the energy to string this into a story about an Indian romance gone wrong, but I had a rather unfriendly encounter with a beautiful young painted horse. I came away with a bruised ego and something like a love bite on the shoulder. The police officer standing by warned that i should get "a shot" or face a fever. Having not broken the skin, and having been up to date on my tetanus, and unawares about any Indian equine fevers, i ignored his advice. I woke up this morning without a fever but not feeling well otherwise. The doctor in the emergency room, to which i was sent by are slightly overprotective hostel manager, said he thinks i probably have a viral illness - feels like flu - that was already on its way. He gave me some antibiotics to prevent a skin-infection where the horse bit me. He also told me to call him at home if it got worse. I'm going to try to be a good patient.
In case anybody (read Mom) is concerned, i'm in the best place possible to be sick in India. I'm surrounded by talented physicians trained all around the world and the best facilities this side of the Kaveri river.
I was supposed to spend the day with CHAD nurses visiting villages. Perhaps i'll have something to write about that on Friday.
I won't write much more than this: health is something we too often take for granted.
I'm going to lie down.
justin
ps. The temple in Vellore's impressive fort, outside of which i was bitten, houses some of the most impressive and intact temple carvings i've ever seen. Highly recommended to those who might otherwise skip over Vellore.
In case anybody (read Mom) is concerned, i'm in the best place possible to be sick in India. I'm surrounded by talented physicians trained all around the world and the best facilities this side of the Kaveri river.
I was supposed to spend the day with CHAD nurses visiting villages. Perhaps i'll have something to write about that on Friday.
I won't write much more than this: health is something we too often take for granted.
I'm going to lie down.
justin
ps. The temple in Vellore's impressive fort, outside of which i was bitten, houses some of the most impressive and intact temple carvings i've ever seen. Highly recommended to those who might otherwise skip over Vellore.
CMC - Day Seventeen
Chettinai is 65 years old with long grey hair in the early matted stages of imminent dreadlocks. I first noticed her huddled in a dark corner, squatting on her calloused and cracked heals in a filthy green silk sari. The carried the strong smell of an infected wound. Without a blouse her sagging wasted breast could be seen hanging near her waist. A woman, a relative perhaps, yelled at her, beckoning for her to move to a proper seat amongst those others waiting for their appointments. Others, employees, tried to do the same. The women shook her head. She had the crazed look of an animal trapped in a corner, one who only wants to find a place to hide.
During my first week of rotations, in an outpatient session for Child Health I, i noticed a sign in the general OPD (outpatient department) building that said Palliative Care Service. I found this surprising, knowing how underdeveloped such services are meant to be in the developing world. From a resources point of view, palliative care is a more efficient way of taking care of people with terminal illnesses but this is a realization that is coming slowly even at home - refer to the unchanging Medicare Hospice benefit. From a care point of view, palliative services are the most efficient at attending to quality of life when life is limited. I should have expected that CMC would have figured that out.
As this is my last week, i have the chance to float around a bit, and i spent the morning with the palliative care service, headquartered in a 10'x10' room in a corner of the OPD. As many of you know, this is a particular interest of mine, and I immediately felt at home amongst this Hamilton, one of two chaplains on the service (the other being his wife) sat me town and introduced me to the service. The three doctors, two nurses, two chaplains, one social worker and one secretary offer outpatient and home based services to (mostly) cancer patients. This is because, Dr. Rina, head of the department is a radiation oncologist and because HIV patients are taken care of by the HIV team at the end of life. Also, those with degenerative neuromuscular disorders ( e.g. ALS, or Lou Gehrig's disease) are taken care of by neurologists. The team sees approximately 30-40 patients per week in the OPD and 30-45 per week on their home rounds. Their catchment area is an approximately 50 kilometer radius from the hospital. On the mondays and wednesdays that they do home visits the might spend the whole day travelling. They only rarely have inpatients, most of whom come for one procedure or another, because most people want to die at home. A Catholic charity nearby is scheduled to open a 50 bed hospice soon, however, and the CMC palliative care service will provide medical care. Hamilton thinks they will have difficulty filling it. Based on what i've seen at home, how desperately the services are needed, i think they'll be full. Istn' it true that "if you build it, they will come."
The soft-spoken and eloquent young chaplain explained that the service has two primary goals, one to provide patient care, the other to educate about palliative care. Since the department opened four years ago they have made great strides in meeting both. Within the hospital they are now a well and increasingly known referral service and their patient rosters continue to grow as a result. As a result of several donations, they are basically able to provide this care for free. It is not preferentially distributed to those who can afford it. On the education front they have institutionalized their efforts in many ways, providing one week of mandatory training to the undergraduate medical students. Proactively, they are currently encouraging the government to make it a mandatory part of medical education in every Indian medical school. Oncology registrars spend one month per year for two years in the service, and they have initiated a one year post-graduate fellowship in palliative care, the first of its kind in India. The team also invites teams of social workers, chaplains, nurses and physicians from smaller hospitals to complete short training courses so that they may start their own services. All of these educational programs will be run from the first floor of the new hospice building, which will also have housing for residents, fellows and visitors from abroad. It sounds an exciting project. Harrison will be renouncing his role as a chaplain and taking over as director of programming, which will add a new dimension to the teaching he does currently on the spiritual aspects of dying and palliative care.
It all sounds great, and yet their optimism about and pride in their service is coupled with a humility that comes from doing a very difficult job. Chettinai is a case in point. The women who yelled at her to be seated in the waiting room is her daughter-in-law, with whom she lives, along with her two granddaughters. Her son, the father of the grandchildren, died some time ago and the daughter-in-law has been left alone to care for her. This is a difficult task. Chettinai has a type of cancer called spindle cell carcinoma, a malignant epithelial cancer that has eroded through the skin under her right axilla (armpit) and grown like a mushroom into a large fungating mass about the size of a small melon. The infected white flesh had a sheen of oozing fluid. The skin that used to cover the mass hangs on if dried pieces. If you think it's unpleasant to read about i can assure you the sight was far far worse. As was the smell. The young, sweet and very competent physicians with whom i worked explained Chettinai's story.
Even when her husband was alive, she was used to being the boss in the family. When he died, not much changed, except there was less money to go around. She, her son's wife, and two daughters were dependent on her son for their welfare. But she was still the boss and, as in many families, expected to be catered to in her old age. When her son died, i'm not sure how, she might have known about this strange growth under her arm, but i'm not sure anyone else did.
Her daughter-in-law looked strung out, her last nerves worn ragged by taking care of a seemingly unappreciative woman as well as her two daughters. Tears fell intermittently from her tired face. Chettinai, ruling the roost, doesn't seem to let her do anything, including change the dressings that she needs to have changed twice daily or work, which she must do to earn money to feed everyone. Her daughter-in-law defies her, working two days a week, leaving her two frightened daughters at home with a women who smells tremendously and acts strangely. She's come home to find Chettinai in the care of her neighbors after this frustrated, pained (because she refuses her pain meds), and increasingly lonely old women laid herself out on the train tracks to end her life. She worries constantly about her daughters and this morning left to chase her mother-in-law - who left for her appointment alone and without warning - leaving them without food for breakfast.
Chettinai mumbles in pain to the nurse who changes her dressing, lifting matted spiderwebs of dirty hair from the unclean and ragged surface: 'No one wants to come near me. They're afraid it's contagious. My granddaughters won't even come close. Why can't you just give me medication to kill me.' And yet she refuses to take the medications and allow the care that might improve these problems. What is worse, the cancer is malignant but hers will likely be a slow death.
They cannot afford their medications, and they are already given concessions. Their is another son, but he remains aloof. He seems to have abandoned them all to their fate. Their is the new hospice, but the mother refuses to move from her children's home. She seems not quite right, like she could use psychiatric care, yet she remains alert, oriented, without delusions. All of this troubles the team and they spend thirty minutes discussing what exactly to do. In the end, there is no conclusion. They will write for new medications, encourage the mother to accept her daughter-in-laws care, and encourage the latter to be patient with her. Caregiver burnout is a common problem in end-of-life care provided by families. Usually there are resources to support these caregivers. In this case their seem to be none. What can be done?
These are the cases that most challenge palliative care services. Fortunately, they seem to be outweighed by those cases in which individuals and families find meaning, find reward, find each other in the process of dying. It is the challenge of assisting families in this way, of finding solutions when none seem to exist, and of caring for people when there is little time but endless space to do so that holds my interest in palliative care.
During my first week of rotations, in an outpatient session for Child Health I, i noticed a sign in the general OPD (outpatient department) building that said Palliative Care Service. I found this surprising, knowing how underdeveloped such services are meant to be in the developing world. From a resources point of view, palliative care is a more efficient way of taking care of people with terminal illnesses but this is a realization that is coming slowly even at home - refer to the unchanging Medicare Hospice benefit. From a care point of view, palliative services are the most efficient at attending to quality of life when life is limited. I should have expected that CMC would have figured that out.
As this is my last week, i have the chance to float around a bit, and i spent the morning with the palliative care service, headquartered in a 10'x10' room in a corner of the OPD. As many of you know, this is a particular interest of mine, and I immediately felt at home amongst this Hamilton, one of two chaplains on the service (the other being his wife) sat me town and introduced me to the service. The three doctors, two nurses, two chaplains, one social worker and one secretary offer outpatient and home based services to (mostly) cancer patients. This is because, Dr. Rina, head of the department is a radiation oncologist and because HIV patients are taken care of by the HIV team at the end of life. Also, those with degenerative neuromuscular disorders ( e.g. ALS, or Lou Gehrig's disease) are taken care of by neurologists. The team sees approximately 30-40 patients per week in the OPD and 30-45 per week on their home rounds. Their catchment area is an approximately 50 kilometer radius from the hospital. On the mondays and wednesdays that they do home visits the might spend the whole day travelling. They only rarely have inpatients, most of whom come for one procedure or another, because most people want to die at home. A Catholic charity nearby is scheduled to open a 50 bed hospice soon, however, and the CMC palliative care service will provide medical care. Hamilton thinks they will have difficulty filling it. Based on what i've seen at home, how desperately the services are needed, i think they'll be full. Istn' it true that "if you build it, they will come."
The soft-spoken and eloquent young chaplain explained that the service has two primary goals, one to provide patient care, the other to educate about palliative care. Since the department opened four years ago they have made great strides in meeting both. Within the hospital they are now a well and increasingly known referral service and their patient rosters continue to grow as a result. As a result of several donations, they are basically able to provide this care for free. It is not preferentially distributed to those who can afford it. On the education front they have institutionalized their efforts in many ways, providing one week of mandatory training to the undergraduate medical students. Proactively, they are currently encouraging the government to make it a mandatory part of medical education in every Indian medical school. Oncology registrars spend one month per year for two years in the service, and they have initiated a one year post-graduate fellowship in palliative care, the first of its kind in India. The team also invites teams of social workers, chaplains, nurses and physicians from smaller hospitals to complete short training courses so that they may start their own services. All of these educational programs will be run from the first floor of the new hospice building, which will also have housing for residents, fellows and visitors from abroad. It sounds an exciting project. Harrison will be renouncing his role as a chaplain and taking over as director of programming, which will add a new dimension to the teaching he does currently on the spiritual aspects of dying and palliative care.
It all sounds great, and yet their optimism about and pride in their service is coupled with a humility that comes from doing a very difficult job. Chettinai is a case in point. The women who yelled at her to be seated in the waiting room is her daughter-in-law, with whom she lives, along with her two granddaughters. Her son, the father of the grandchildren, died some time ago and the daughter-in-law has been left alone to care for her. This is a difficult task. Chettinai has a type of cancer called spindle cell carcinoma, a malignant epithelial cancer that has eroded through the skin under her right axilla (armpit) and grown like a mushroom into a large fungating mass about the size of a small melon. The infected white flesh had a sheen of oozing fluid. The skin that used to cover the mass hangs on if dried pieces. If you think it's unpleasant to read about i can assure you the sight was far far worse. As was the smell. The young, sweet and very competent physicians with whom i worked explained Chettinai's story.
Even when her husband was alive, she was used to being the boss in the family. When he died, not much changed, except there was less money to go around. She, her son's wife, and two daughters were dependent on her son for their welfare. But she was still the boss and, as in many families, expected to be catered to in her old age. When her son died, i'm not sure how, she might have known about this strange growth under her arm, but i'm not sure anyone else did.
Her daughter-in-law looked strung out, her last nerves worn ragged by taking care of a seemingly unappreciative woman as well as her two daughters. Tears fell intermittently from her tired face. Chettinai, ruling the roost, doesn't seem to let her do anything, including change the dressings that she needs to have changed twice daily or work, which she must do to earn money to feed everyone. Her daughter-in-law defies her, working two days a week, leaving her two frightened daughters at home with a women who smells tremendously and acts strangely. She's come home to find Chettinai in the care of her neighbors after this frustrated, pained (because she refuses her pain meds), and increasingly lonely old women laid herself out on the train tracks to end her life. She worries constantly about her daughters and this morning left to chase her mother-in-law - who left for her appointment alone and without warning - leaving them without food for breakfast.
Chettinai mumbles in pain to the nurse who changes her dressing, lifting matted spiderwebs of dirty hair from the unclean and ragged surface: 'No one wants to come near me. They're afraid it's contagious. My granddaughters won't even come close. Why can't you just give me medication to kill me.' And yet she refuses to take the medications and allow the care that might improve these problems. What is worse, the cancer is malignant but hers will likely be a slow death.
They cannot afford their medications, and they are already given concessions. Their is another son, but he remains aloof. He seems to have abandoned them all to their fate. Their is the new hospice, but the mother refuses to move from her children's home. She seems not quite right, like she could use psychiatric care, yet she remains alert, oriented, without delusions. All of this troubles the team and they spend thirty minutes discussing what exactly to do. In the end, there is no conclusion. They will write for new medications, encourage the mother to accept her daughter-in-laws care, and encourage the latter to be patient with her. Caregiver burnout is a common problem in end-of-life care provided by families. Usually there are resources to support these caregivers. In this case their seem to be none. What can be done?
These are the cases that most challenge palliative care services. Fortunately, they seem to be outweighed by those cases in which individuals and families find meaning, find reward, find each other in the process of dying. It is the challenge of assisting families in this way, of finding solutions when none seem to exist, and of caring for people when there is little time but endless space to do so that holds my interest in palliative care.
CMC - Day Sixteen
Amartya Sen is one of India's most famous academics, having one the Nobel Prize for Economics in 1998. His current professorship at Harvard University followed many years as a Master at Trinity College, Cambridge. In his most recent book, The Argumentative India, he expounds on many things, including the profundity of Indian loquaciousness. He points out, as a representative example, that the longest speech ever delivered at the United Nations, at 9 hours, came from the mouth of Krishna Menon, leader of the Indian delegation in the 1950s.
I was treated to a similar display this morning by a Mr. Ranjit, an administrator at the Community Health and Development (CHAD) hospital that sits at the southern end of the undergraduate CMC campus, to which I moved from the city this weekend. He spoke for three hours without break on all things CMC and the three of us who sat before him were absolutely rapt. I've spent the rest of the day pondering how I might share as much of what he told us without requiring that you spend all day at your computer. (I think I might have failed in that mission.) CMC's hospital would stand alongside some of the most advanced hospitals in the world, such is their capability to provide the latest care in all subspecialties. However, I am more impressed about what CMC has accomplished in the communities that surround Vellore. I'll share with you why.
First, some background. Ida Scudder was the daughter of an American missionary and physician in Vellore in the late 19th century. She was driven to leave her home and to study medicine in America after events which signaled to her – signs from god, she believed – the desperate need for women's healthcare in India.
Ranjit shared with us the story of the night she was approached by three different fathers requesting her help in their wives' deliveries. Ida, 17 at the time, said that she would alert her father, who would attend to the labouring women. The men refused in turn, prevented by culture from allowing a man to help in labour, and left. Without qualification, Ida would not go on her own.
In India, the beating of drums in the mornings means one of three things: a festival is taking place; a couple is to be married; or a death has occurred. Ida awoke the next morning to, what was to her, the ominous sound of drum beats. She asked her butler to find out what was happening and he returned with the news that three women had died in labour in the night. From this she found the motivation that would carry her through medical training at Cornell University, which would help her to start the first all-female medical and nursing college in India and, subsequently, one of Asia's most impressive medical institutions.
Dr. Ida Scudder had two convictions. First, she would train female doctors and nurses to care for all but to guarantee care to women. Second, this care would take place in the community and therefore she would not build a hospital. Her logic was simple: if good care is provided in the community there should be no need for a hospital. Obviously, this latter goal was successful in its failure to be realized (or was it? – more on that later), and I won't go into detail about how a one-room two-bed ward that was deemed a necessity became a 2,300 bed inpatient facility with over 5000 outpatients seen daily, and all supported by a renowned coeducational undergraduate medical college.
CMCs CHAD program began in the 1950s, in order to better serve the community. They realized at some point that, at the same time the hospital and its sub specialist care was growing, the villages that surrounded the hospital were growing successfully and illness rates were relatively low. Physicians and nurses from CMC, mindful of Dr. Scudder's wishes, went out into the community to learn what was going on. Villages in this part of India, if not others, have by tradition one women who serves as a birthing attendant. She is always the wife of the senior member of the caste of barbers – it may or may not be coincidental that the first surgeons were barbers. The daughter in law – who becomes a part of the family in marriage – was trained in succession. The health care workers who witnessed her work relayed to their CMC colleagues that these women were capable midwives, providing excellent obstetric care. They immediately allied themselves with these women, and started to support their work through CMC. The other providers of care were, they found, men of less rigorous training and more lofty perceptions of their own ability, snake charmers. They distanced themselves (and the patients) from these by (falsely) expressing their admiration for them, acknowledging how busy they must be, and informing them that, as a result, they'd consult them only when absolutely necessary. Probable relief on both ends. They only changed one practice of the barber's wives, who traditionally cut the umbilical cord with any old kitchen knife and then packed the wounds with cow dung. Despite the surprising lack of infection that resulted, CMC provided each women with a sterilized birth kit with gloves, half a razor blade and sterile clamps. That was a great success. The "pitchu" (from Part Time Community Health Worker) can be found in every village pointing out the hundreds (or thousands) of children that she helped deliver. And despite the fact that the government mandates that all births take place in hospitals - because of the continued risk of female infanticide and high-risk births - these women still serve a valuable role.
Being community minded, the physicians and nurses at CMC wanted to keep track of the results of all this and asked the traditional birth attendants to keep records. Being illiterate, most of them, this was an impossible task. So CMC hired and trained health aids, who can be recognized by their pink saris and who track health data for a cluster of 3 villages. There is one nurse to three health aids, one doctor to three nurses and three doctors to cover the entire 69 villages that comprise the CHAD catchment area. Here it is by the numbers: The average village has 1500 people, so each "pichu" covers that many; health aids cover 4-5000 people; nurses ~15,000; physicians 45000. Between three physicians they cover approximately 150,000 people. Remarkable! As is how they keep track. Each individual in this catchment area is given a number, based on their age, and on their village, street and home number. The GPS coordinates for each household are kept by CHAD and, in this way, they can track, using digital technology, the spread of disease in the case of an outbreak. Ranjit told us of a recent case in which a "pitchu" and health aid identified a new diarrheal case in one village. Other reports soon came in and they used the GPS technology to plot a map, starting with the first (index) case, of the spread of diarrhea. They were able to recognize that the illness followed the course of a drain. In the village they found that the water pipe ran through the drain and had developed a leak. They contracted to have the water pipe elevated above the drain and repaired. The diarrhea stopped. This is basic new technology used on a large scale with wonderful results. I wonder if the American public would allow their homes to be plotted on GPS and their health monitored so closely. It feels a bit like Big Brother. But in a country where privacy is a non-issue, such things can contribute greatly to the general welfare, and without a fuss.
Ranjit asked us, when discussing the size of the hospital today, its large patient population, and dedicated physicians of every specialty and "superspecialty" (as they say here), if CMC was a success. It was an open question and he wouldn't say what he believed. The most obvious answer would be yes. However, as Ranjit pointed out, CMC would, perhaps, be a much greater success if it was able to provide the type of care - preventative care - in the community that could keep so many of these people out of the hospital in the first place. "If we were really succeeding in our mission," he asked, "might we not need any hospital at all?" I admire the sort of idealism that his question presupposes.
What he is asking is if it is possible to do the job of preventing illness so well that we are hardly needed at all. Do we have the will, the courage, the selflessness to attempt such a thing?
justin
I was treated to a similar display this morning by a Mr. Ranjit, an administrator at the Community Health and Development (CHAD) hospital that sits at the southern end of the undergraduate CMC campus, to which I moved from the city this weekend. He spoke for three hours without break on all things CMC and the three of us who sat before him were absolutely rapt. I've spent the rest of the day pondering how I might share as much of what he told us without requiring that you spend all day at your computer. (I think I might have failed in that mission.) CMC's hospital would stand alongside some of the most advanced hospitals in the world, such is their capability to provide the latest care in all subspecialties. However, I am more impressed about what CMC has accomplished in the communities that surround Vellore. I'll share with you why.
First, some background. Ida Scudder was the daughter of an American missionary and physician in Vellore in the late 19th century. She was driven to leave her home and to study medicine in America after events which signaled to her – signs from god, she believed – the desperate need for women's healthcare in India.
Ranjit shared with us the story of the night she was approached by three different fathers requesting her help in their wives' deliveries. Ida, 17 at the time, said that she would alert her father, who would attend to the labouring women. The men refused in turn, prevented by culture from allowing a man to help in labour, and left. Without qualification, Ida would not go on her own.
In India, the beating of drums in the mornings means one of three things: a festival is taking place; a couple is to be married; or a death has occurred. Ida awoke the next morning to, what was to her, the ominous sound of drum beats. She asked her butler to find out what was happening and he returned with the news that three women had died in labour in the night. From this she found the motivation that would carry her through medical training at Cornell University, which would help her to start the first all-female medical and nursing college in India and, subsequently, one of Asia's most impressive medical institutions.
Dr. Ida Scudder had two convictions. First, she would train female doctors and nurses to care for all but to guarantee care to women. Second, this care would take place in the community and therefore she would not build a hospital. Her logic was simple: if good care is provided in the community there should be no need for a hospital. Obviously, this latter goal was successful in its failure to be realized (or was it? – more on that later), and I won't go into detail about how a one-room two-bed ward that was deemed a necessity became a 2,300 bed inpatient facility with over 5000 outpatients seen daily, and all supported by a renowned coeducational undergraduate medical college.
CMCs CHAD program began in the 1950s, in order to better serve the community. They realized at some point that, at the same time the hospital and its sub specialist care was growing, the villages that surrounded the hospital were growing successfully and illness rates were relatively low. Physicians and nurses from CMC, mindful of Dr. Scudder's wishes, went out into the community to learn what was going on. Villages in this part of India, if not others, have by tradition one women who serves as a birthing attendant. She is always the wife of the senior member of the caste of barbers – it may or may not be coincidental that the first surgeons were barbers. The daughter in law – who becomes a part of the family in marriage – was trained in succession. The health care workers who witnessed her work relayed to their CMC colleagues that these women were capable midwives, providing excellent obstetric care. They immediately allied themselves with these women, and started to support their work through CMC. The other providers of care were, they found, men of less rigorous training and more lofty perceptions of their own ability, snake charmers. They distanced themselves (and the patients) from these by (falsely) expressing their admiration for them, acknowledging how busy they must be, and informing them that, as a result, they'd consult them only when absolutely necessary. Probable relief on both ends. They only changed one practice of the barber's wives, who traditionally cut the umbilical cord with any old kitchen knife and then packed the wounds with cow dung. Despite the surprising lack of infection that resulted, CMC provided each women with a sterilized birth kit with gloves, half a razor blade and sterile clamps. That was a great success. The "pitchu" (from Part Time Community Health Worker) can be found in every village pointing out the hundreds (or thousands) of children that she helped deliver. And despite the fact that the government mandates that all births take place in hospitals - because of the continued risk of female infanticide and high-risk births - these women still serve a valuable role.
Being community minded, the physicians and nurses at CMC wanted to keep track of the results of all this and asked the traditional birth attendants to keep records. Being illiterate, most of them, this was an impossible task. So CMC hired and trained health aids, who can be recognized by their pink saris and who track health data for a cluster of 3 villages. There is one nurse to three health aids, one doctor to three nurses and three doctors to cover the entire 69 villages that comprise the CHAD catchment area. Here it is by the numbers: The average village has 1500 people, so each "pichu" covers that many; health aids cover 4-5000 people; nurses ~15,000; physicians 45000. Between three physicians they cover approximately 150,000 people. Remarkable! As is how they keep track. Each individual in this catchment area is given a number, based on their age, and on their village, street and home number. The GPS coordinates for each household are kept by CHAD and, in this way, they can track, using digital technology, the spread of disease in the case of an outbreak. Ranjit told us of a recent case in which a "pitchu" and health aid identified a new diarrheal case in one village. Other reports soon came in and they used the GPS technology to plot a map, starting with the first (index) case, of the spread of diarrhea. They were able to recognize that the illness followed the course of a drain. In the village they found that the water pipe ran through the drain and had developed a leak. They contracted to have the water pipe elevated above the drain and repaired. The diarrhea stopped. This is basic new technology used on a large scale with wonderful results. I wonder if the American public would allow their homes to be plotted on GPS and their health monitored so closely. It feels a bit like Big Brother. But in a country where privacy is a non-issue, such things can contribute greatly to the general welfare, and without a fuss.
Ranjit asked us, when discussing the size of the hospital today, its large patient population, and dedicated physicians of every specialty and "superspecialty" (as they say here), if CMC was a success. It was an open question and he wouldn't say what he believed. The most obvious answer would be yes. However, as Ranjit pointed out, CMC would, perhaps, be a much greater success if it was able to provide the type of care - preventative care - in the community that could keep so many of these people out of the hospital in the first place. "If we were really succeeding in our mission," he asked, "might we not need any hospital at all?" I admire the sort of idealism that his question presupposes.
What he is asking is if it is possible to do the job of preventing illness so well that we are hardly needed at all. Do we have the will, the courage, the selflessness to attempt such a thing?
justin
CMC - Day Fifteen
It was a busy day in the Child Health Out Patient Department (OPD). Their were at least a hundred children to see and only a few doctors to see them, the registrars off to study for upcoming exams. I spent most of the day with Dr. Winsley Rose. The son of two teachers and a Tamil native he's as gentle an individual as his name would suggest. It is a name you're no longer likely to find, even in England, and it's illustrative of that persistent and paradoxical Indian fondness for the days of the Raj (when the British ruled). He's also one of the newest consultants at CMC. In fact, i've been here longer than he has. He moved here with his wife, a community medicine physician, and their three year old daughter, not two weeks ago. Over the course of the last week i've had a chance to get to know Dr. Winsley and to learn from him about India and the medicine practiced here.
A relatively tall and thin man with square wire rim spectacles, a neatly trimmed goatee and a charming smile, Dr. Winsley has a demeanor that the children seem to love. He told me over lunch that, while it was difficult to say what it was that made him go into medicine, he knew the first day of his pediatrics roatation in his intern year that he wanted to work with children. For one, most children overcome their illness; furthermore much of their illness is through no fault of their own. It provides a health working balance between preventative, acute and chronic care. And he seems very good at it. He finds a way of performing the most thorough exam on the most uncooperative child and half the time, in the end, they seem happier than when he began. This is a rare talent. When it comes to teaching, he is able to stretch the residents' and my own knowledge to its limits without making one feel stupid. Furthermore, he seems like a nice guy to be around. He's invited me around to his house next week and I'm already looking forward to it.
At lunch today he told me about his sister's brother, who lives in Allentown, PA. I asked if he'd every been to the states to visit. "It's too expensive for us," he said. "Aren't you able to save money working at CMC, as housing, food and other expenses are covered." "The only way people find to save money is to go work abroad. And at CMC, we don't make that much money." He explained that at the hospital he just left, the boss who held a job that could soon have been his makes 1.5lakh rupees per month (1 lakh is 100,000). Even senior consultants at CMC only earn about 15,000 Rs per month. That's just under $400. He made much more than that before. "So why," i asked, "did you want to come to CMC?" "I don't think," he began, "that you could find greater job satisfaction than by working in a place like this. Not only because of the variety of cases but also because of your ability to do something about them, even in the most severe cases. In community practice you won't find in a lifetime the types of cases you find here in a week. In a government hospital, you will find them, but you won't be able to do much about it." I am impressed with his pure dedication to good medical care in a profession in which the pursuit of money often seems more common.
I understand his satisfaction, especially in terms of the variety. In today's clinic i saw more children with congenital heart disease - 2 with Tetralogy of Fallot, 3 with ASDs (Atrial Septal Defects), 1 with a large VSD (Ventricular Septal Defect) and 1 16 month old with a PDA (a Patent Ductus Arteriosis, not a Palm Pilot) - than i saw in a week of sub-specialized pediatric cardiology at home. One child had a liver so large it could be felt starting somewhere just above his hips - most of ours are hidden by our rib cages. I wonder if, reading my daily emails, many of you have picked up on this fascination we seem to have in medicine with the bizarre, the extreme, the rare. When an unusual case is presented to a team of physicians, here or at home, you'll often hear people say "good case," or something like that.
I think that it says something about our medical education. In addition to all the things that happen commonly we're also charged with knowing the the most bizarre, rare and unusual causes of any given set of symptoms. We call them zebras. Common things happen commonly, they say. And "when you hear hoofbeats, think horses not zebras." Here in Vellore i feel like i'm on safari. And there is some satisfaction in that, maybe only because it allows one to use the small pieces of information that normally seem so impracticle. Today the consultants were collecting cases for next weeks undergraduate pediatric examinations. Dr. Mammen peaked into the room where Dr. Winsley and I were seated: "Winsley! I've got a child here with celiac sprue," a gluten sensitivity that is not uncommon in white populations of northern European descent. He was genuinly excited. What for them is a zebra is for us a horse. And vice versa. The guy who developed the protocol for treating Small Single Contrast Enhancing Lesions (SSCELs), which he proved in an enormous case series to be (almost always) Neurocystercercosis, is here at CMC. Until coming here, i'd only ever seen cases in books. Here i see children with this, and the seizures that often result, on a daily basis. The problem with our education is that this fascination with the 'fascinomas', as their called, is more likely to make us see the illness before the adult or child that suffers from it: "check out the 'liver' in room three." It objectifies, turning people in patients. And yet it is part of what makes our job potentially more interesting. I'm certainly not the first to write about this conflict, and i will not be the last. But it's something about which we must be acutely aware.
Speaking of arcane knowledge...the exams for medical students and residents here are brutal. For the medical students, a child like one identfied today is brought before them and a panel of four physicians, one from CMC and the rest from outside. The student is told to examine the patient and is then subjected to a barage of questions about the physical exam findings, the differential diagnosis, the probably lab findings, the medications for treatment, etc. The residents' exams are similar, if more difficult. On our morning rounds the other day I saw what exactly these exams can be like. As the rather shy resident stood their shaking...."What is your diagnosis? Why? How can you differentiate between an empyema and a bronchopnemonial effusion? What bacteria is most likely to cause this illness? How do you identify this bacteria? What shape is the staphyloccus? What does the "aureus" in "Staph. aureus" mean? Who described it? What test distinguishes catylase positive and catylase negative bacteria? How do you perform a gram stain? Do you stain with an acid or a base? Or neither?" It was a battery of questions that spanned an entire medical education, including a history of medicine to which i was barely exposed. I can't imagine having an exam like that. It is no wonder so many of the physicians here seem to have encyclopedic knowledge. They have to. If the students or residents fail the test, they cannot start work again and must spend the next 6 months studying until the next exam period comes around. Theirs is an impressive and daunting task. I'm quite grateful for our relatively humanistic (and humane) education, even if i can't wax poetic about gram staining.
I had dinner this evening with some new arrivals, two medical students from the U.S. and another from Australia. As so often happens among people away from home, the discussion made its way in the direction of the restroom. The discussion began with the pros and cons of eating with ones (right) hands, as they do in India, versus eating with a cutlery. James, the australian, noted that a rickshaw driver refused to take money from his left hand, that being the one that is generally used to clean oneself post toileting. It's problematic for him because he's left handed. He went on to declare his disgust at the idea of cleaning oneself with one's hands, and not toilet paper. Kevin, from St. Louis, admitted his ignorance about how the Indians do it, with just a bucket of water and their (left) hands. Thad, from Kansas, couldn't understand it either. In a pinch, Kevin had found himself in a hospital bathroom with only a squat toilet and a bucket. In the end, he sacrificed his sock to the toilet. Laughs all around at that one. An Indian would find that ridiculous. James wondered, if he were in a similar situation, if he would be tempted to use the Indian currency, given its relative lack of value. The others chortled in understanding at his quandry. I may look back someday and think i'm being oversensitive, but i find that kind of talk intolerable, even angering. Ten rupees to us may be a quarter, but for many here it's a days wages. When my proposal that "when in Rome..." was rejected by the three, i informed them that the Indians find our use of toilet paper disgusting. "So what do you think about that?" They didn't think much at all. I have to say that i carry my own toilet paper around in my pocket, or in my bag, because i know it's not likely that i'll find it when i need it. But that doesn't mean i should !&%# on someone else's notion of personal hygeine.
Another weekend arrives. My first and last one in Vellore. I'll be out shopping for the things to bring home. Any requests?
justin
A relatively tall and thin man with square wire rim spectacles, a neatly trimmed goatee and a charming smile, Dr. Winsley has a demeanor that the children seem to love. He told me over lunch that, while it was difficult to say what it was that made him go into medicine, he knew the first day of his pediatrics roatation in his intern year that he wanted to work with children. For one, most children overcome their illness; furthermore much of their illness is through no fault of their own. It provides a health working balance between preventative, acute and chronic care. And he seems very good at it. He finds a way of performing the most thorough exam on the most uncooperative child and half the time, in the end, they seem happier than when he began. This is a rare talent. When it comes to teaching, he is able to stretch the residents' and my own knowledge to its limits without making one feel stupid. Furthermore, he seems like a nice guy to be around. He's invited me around to his house next week and I'm already looking forward to it.
At lunch today he told me about his sister's brother, who lives in Allentown, PA. I asked if he'd every been to the states to visit. "It's too expensive for us," he said. "Aren't you able to save money working at CMC, as housing, food and other expenses are covered." "The only way people find to save money is to go work abroad. And at CMC, we don't make that much money." He explained that at the hospital he just left, the boss who held a job that could soon have been his makes 1.5lakh rupees per month (1 lakh is 100,000). Even senior consultants at CMC only earn about 15,000 Rs per month. That's just under $400. He made much more than that before. "So why," i asked, "did you want to come to CMC?" "I don't think," he began, "that you could find greater job satisfaction than by working in a place like this. Not only because of the variety of cases but also because of your ability to do something about them, even in the most severe cases. In community practice you won't find in a lifetime the types of cases you find here in a week. In a government hospital, you will find them, but you won't be able to do much about it." I am impressed with his pure dedication to good medical care in a profession in which the pursuit of money often seems more common.
I understand his satisfaction, especially in terms of the variety. In today's clinic i saw more children with congenital heart disease - 2 with Tetralogy of Fallot, 3 with ASDs (Atrial Septal Defects), 1 with a large VSD (Ventricular Septal Defect) and 1 16 month old with a PDA (a Patent Ductus Arteriosis, not a Palm Pilot) - than i saw in a week of sub-specialized pediatric cardiology at home. One child had a liver so large it could be felt starting somewhere just above his hips - most of ours are hidden by our rib cages. I wonder if, reading my daily emails, many of you have picked up on this fascination we seem to have in medicine with the bizarre, the extreme, the rare. When an unusual case is presented to a team of physicians, here or at home, you'll often hear people say "good case," or something like that.
I think that it says something about our medical education. In addition to all the things that happen commonly we're also charged with knowing the the most bizarre, rare and unusual causes of any given set of symptoms. We call them zebras. Common things happen commonly, they say. And "when you hear hoofbeats, think horses not zebras." Here in Vellore i feel like i'm on safari. And there is some satisfaction in that, maybe only because it allows one to use the small pieces of information that normally seem so impracticle. Today the consultants were collecting cases for next weeks undergraduate pediatric examinations. Dr. Mammen peaked into the room where Dr. Winsley and I were seated: "Winsley! I've got a child here with celiac sprue," a gluten sensitivity that is not uncommon in white populations of northern European descent. He was genuinly excited. What for them is a zebra is for us a horse. And vice versa. The guy who developed the protocol for treating Small Single Contrast Enhancing Lesions (SSCELs), which he proved in an enormous case series to be (almost always) Neurocystercercosis, is here at CMC. Until coming here, i'd only ever seen cases in books. Here i see children with this, and the seizures that often result, on a daily basis. The problem with our education is that this fascination with the 'fascinomas', as their called, is more likely to make us see the illness before the adult or child that suffers from it: "check out the 'liver' in room three." It objectifies, turning people in patients. And yet it is part of what makes our job potentially more interesting. I'm certainly not the first to write about this conflict, and i will not be the last. But it's something about which we must be acutely aware.
Speaking of arcane knowledge...the exams for medical students and residents here are brutal. For the medical students, a child like one identfied today is brought before them and a panel of four physicians, one from CMC and the rest from outside. The student is told to examine the patient and is then subjected to a barage of questions about the physical exam findings, the differential diagnosis, the probably lab findings, the medications for treatment, etc. The residents' exams are similar, if more difficult. On our morning rounds the other day I saw what exactly these exams can be like. As the rather shy resident stood their shaking...."What is your diagnosis? Why? How can you differentiate between an empyema and a bronchopnemonial effusion? What bacteria is most likely to cause this illness? How do you identify this bacteria? What shape is the staphyloccus? What does the "aureus" in "Staph. aureus" mean? Who described it? What test distinguishes catylase positive and catylase negative bacteria? How do you perform a gram stain? Do you stain with an acid or a base? Or neither?" It was a battery of questions that spanned an entire medical education, including a history of medicine to which i was barely exposed. I can't imagine having an exam like that. It is no wonder so many of the physicians here seem to have encyclopedic knowledge. They have to. If the students or residents fail the test, they cannot start work again and must spend the next 6 months studying until the next exam period comes around. Theirs is an impressive and daunting task. I'm quite grateful for our relatively humanistic (and humane) education, even if i can't wax poetic about gram staining.
I had dinner this evening with some new arrivals, two medical students from the U.S. and another from Australia. As so often happens among people away from home, the discussion made its way in the direction of the restroom. The discussion began with the pros and cons of eating with ones (right) hands, as they do in India, versus eating with a cutlery. James, the australian, noted that a rickshaw driver refused to take money from his left hand, that being the one that is generally used to clean oneself post toileting. It's problematic for him because he's left handed. He went on to declare his disgust at the idea of cleaning oneself with one's hands, and not toilet paper. Kevin, from St. Louis, admitted his ignorance about how the Indians do it, with just a bucket of water and their (left) hands. Thad, from Kansas, couldn't understand it either. In a pinch, Kevin had found himself in a hospital bathroom with only a squat toilet and a bucket. In the end, he sacrificed his sock to the toilet. Laughs all around at that one. An Indian would find that ridiculous. James wondered, if he were in a similar situation, if he would be tempted to use the Indian currency, given its relative lack of value. The others chortled in understanding at his quandry. I may look back someday and think i'm being oversensitive, but i find that kind of talk intolerable, even angering. Ten rupees to us may be a quarter, but for many here it's a days wages. When my proposal that "when in Rome..." was rejected by the three, i informed them that the Indians find our use of toilet paper disgusting. "So what do you think about that?" They didn't think much at all. I have to say that i carry my own toilet paper around in my pocket, or in my bag, because i know it's not likely that i'll find it when i need it. But that doesn't mean i should !&%# on someone else's notion of personal hygeine.
Another weekend arrives. My first and last one in Vellore. I'll be out shopping for the things to bring home. Any requests?
justin
CMC - Day Fourteen
It is getting hotter by the day here in Vellore. I find myself wandering around outside in a bit of a daze, wondering what it could be that's making me feel so lethargic. It's the heat. Hot drinks are as good as cold for keeping one cool ('cause it makes you sweat) and i had a chai just now before seeking refuge in the library, with its cool pale aquamarine walls, its rows of flourescent bulbs and whirring fans. Ice cream is good in this heat. But when i bit into a frozen cone filled with chocolate icecream yesterday afternoon, i felt an ache, a sensitive pang, and it snapped me out of a growing denial. I've been having a tooth problem. Part of this denial is circumstantial. First time I came to India five years ago I saw something on the street that i'd never expected. On the occasional street corner, laid out on a dusty mat, one would find a "dentist," with his tooth extractors, some extracted teeth, some gold replacements, and no anesthetics. Yikes! Perhaps it's the first impression of dental care in India that has caused me to avoid seeking care for a "sensitivity" that i first noticed a few weeks ago. Ok, so i have saught dental care in India already. On the advice of an atypically enthusiastic English woman i met in Kerala, I sought out her dentist for a cleaning. She'd had gum transplants there on two occasions and was very pleased with the results. For 500 rupees (again, at 45Rs to the dollar), a teeth cleaning was a steal. I found myself in a somewhat dimly lit room with water- and mould-stained walls and took my place in a dental chair that was only slightly more antiquated than one i would find at home. I saw the autoclave and prayed that they used it. She, the dentist, pulled out a vibrating metal scraper, not the cleaner i was used to, and "cleaned" my teeth. It was at this time i noticed the sensitivity. I tried to hide my flinching smile whenever she passed over a certain bottom left tooth. When she asked, at the end, if i'd felt any sensitivity, I smiled and shook my head in a vigorous lie. I wasn't going to push it.
So over the past few weeks, with brushing, with cold water, i've pushed my dental dilemma out of my mind and imagined that I could take care of it when i get home. The problem is that it's just so expensive in America. You'd expect that medical students would be offered dental coverage, teeth being an important part of one's health, but no such thing exists. Not institutionally, at least. We do get (barely adequate) medical insurance. I wonder if it's the opposite for dental students. In any event, i've had to rely on my parents to cover my dental care - thanks mom and dad! As I get older, though, i feel more and more guilty about it. Last Christmas they bought me a fancy electric toothbrush, hoping, i imagine, that it might in some ways curb their dental expenditures. It was my favorite present, one i thought, given the current state of affairs, might have failed me. Seeing as how i'm in a relatively sophisticated Indian medical center i decided yesterday, after that provoking popsicle, to ask around for a recommended dentist. Dr. Mona immediately suggested Dr. Santosh Koshi. Having failed yesterday to arrange an appointment, i called this morning at 9:20 and was given an appointment at 9:30. I found my way to the dental outpatient clinic and encountered in the waiting room a rather compact, thin, and carefully dressed Dr. Santosh. I thanked him profusely for seeing me so quickly and, assuring me it was nothing, he quietly ushered me back to the a small cubicle and seated me in the dentists chair, this one no different from what i'd find at home. What we passed through on the way there seemed less a dental office than a dental factory. From three rows of cubicles i could hear the sounds of chisels, drills, and painful moans as the consequences of all that sugar consumption - Indians being the largest consumers of sugar in the world - were realized. Okay, so nobody was moaning. Young female dental hygeinists in clear plastic aprons shuffled about, room to room, delivering to hunched-over dentists sterilized instruments plucked with metal tongs from metal trays.
He sat me down, asked what my problem was, checked my teeth and noted that two of my fillings had fallen out. "Shall i schedule an appointment to have them fixed...i know you're very busy." "No, no no....we'll do it now." And so it was that not five minutes later i was staring, unanesthetized, at the sharp end of a dental drill bit. My fingers gripped the chair until they were drained of blood. Every muscle in my body was tensed. "Relax," he said. And he started to drill: whiirrrrrrrrrrrrrrrrrrrrrrrrrr.
And it didn't hurt. Not one bit. Dr. Santosh knew exactly what he was doing and as he drilled away at the bits he wanted to get out of the way, i wondered if, after all these years, my trips home from the dentist with a numb, asymmetrical feeling lip was really necessary. Mind you, i'm not going to ask them to withhold the anesthesia next time, but i wonder. He repaired my fillings within 10 minutes. "That's it," he said. "You're free to go." I asked him where i could pay. He said i needn't worry about it. I said i felt bad, so many people couldn't afford to pay but did. He said not to worry about it. I think that fixing the fillings was easier for him than explaining to me how to become an official patient at CMC. Most people have to figure it out on their own. So, in the end, i had excellent and free dental care in India. And i can highly recommend it to each of you.
I had a meeting yesterday with a Family Medicine doctor from Tufts, in Boston, Wayne Altman. He's here for a three day conference on starting Family Medicine as a specialty in India. I made a gaff at one point and said Family Practice. He corrected me: "It's family medicine. We're no longer practicing; we're good at what we do." It's a marketing decision made by the American Association of Family Practitioners (AAFP) last year. As an aside, how twisted that, in our health care system, different specialities have to make marketing decisions. Currently there are Family Medicine doctors in India. A handful of them. They get their qualification not through a residency, but through something like a fellowship. Dr. Altman (or Dr. Wayne, here) has been working with CMC to start a residency in Family Medicine, as well as a department in the undergraduate school. It would be the first of its kind in India. "For CMC to start a program like this," he said, "would be like Harvard Medical School starting a new department. Others could be expected to follow." Primary care is so desperately needed here and such a development would be, the conference concluded, a wonderful way to improve the overall health of Indians. With a residency program and a regular turnout of well trained family physicians, one could imagine the development of more community health centers, efficiently run by those who can care for adults, children and labouring mothers.
It also might help to deliver vital preventative medicine. I heard on CNN-IBN (India Broadcast News) this morning a report on Indians and heart disease. Indians have four times the risk of developing heart disease than any other race. Thirty percent of the cardiac patients in India are under 35 years of age. This is pretty shocking. Many speculate that this is due to a phenomenon called famine theory, or thrifty gene theory. Basically, a race adapted to famine develops a certain amount of insulin resistance. Fats and cholesterols were more easily stored in case food was not forthcoming. With a change in lifestyle, a secure food supply, and much of it rich in fats, this is a setup for heart disease. This is a growing health problem for India to contend with and better public health delivered by family physicians might be one part of the solution.
I don't want to think about fat foods anymore. I just had some delicious pistachio ice cream...and my teeth felt great!
justin
Saturday, March 24, 2007
CMC - Day Thirteen
Today was full of physical exam findings. I was surprised, in examining a young child with bronchial pneumonia, as he squirmed and screamed in his bed, six finger on each hand, six toes on each foot - polydactyly we call it - and a rather less exciting pneumonia. I peered into the eyes of a young boy who'd gone suddenly blind, his edematous optic discs in focus through my fundoscope. I heard shifting dullness to percussion on a child with an pulmonary empyema. Cafe-au-lait spots, sacral dimples and super-sized tonsils. And then a rather symbolic case: isolated dextrocardia. Literally, a child with nothing more than his heart in the right place.
It's Valentine's Day, India's new favorite holiday and one that i cherish. The papers are full of advertisements for romantic candle-lit dinners in Chennai's most expensive restaurants. It's "Hickey Night" at the Taj hotel's Veranda restaurant: "It's that time when love fills the air. When candle lights and roses are standard decor. When diamond rings and men on knees are common. When cosy couples exchange sweet nothings, glances and kisses. And when Hickeys become sweet memories." Again, the changing face (or neck) of Indian love stories. One article acknowledges the love that "blossoms" at college canteens. "College canteens have always been a place where teens find time to catch a glimpse of their crush. According to college student Samyukta Ramani, the atmosphere in canteens is very casual and the area outside is even better. 'By sharing food it symbolizes that you can actually trust someone [I couldn't agree more]. So especially if the member of the opposite sex wants to share food with you, we feel that it shows that they feel that little extra for us.'" The Chennai Chronicle covers the growing, though historic, trend of using charms, gemstones and feng shui to improve their love lives. Ashmita Shah, a young Indian executive, has taken to wearing a silver pendant: "I'm quite fed up with my friends trying to fix me up with some guy or the other so I thought that it would be a good idea to wear a love charm around my neck. Somebody told me that this would accelerate my love life so I decided to give it a shot." A young Indian banker overcame his disbelief when "a friend of mine wore this (Voodoo love amulet) and within a couple of weeks he met the girl of his dreams." Superstition is alive and well, and the article points to hollywood for the renewal of this ancient trend, specifically Jessica Simpson, "who began wearing a rooster around her neck as a symbolic gesture for her current lack of love life." Despite the ringing endorsement by feng shui experts and gemologists, how frightening is it that the youth of India (or of anywhere for that matter) might look to a group of people, celebrities, who couldn't make a relationship last if their careers depended on it?
I prefer the old Indian love stories, filled as they are with the kind of love that could move mountains. Flora Annie Steel has retold the Kashmiri story of Gwashbrari and Westarwan.*
"Ages ago, when the world was young and the mountains had just reared their head to the heavens, Westarwan was the highest peak in all of Kashmir. Far away in the west Nanga Parbat stood where it stands now, but its snowy cap only reached to Westarwan's shoulder, while Haramukh looked but a dwarf beside the giant king. But if Westarwan was the tallest, Gwashbrari was the most beautiful of mountains. Away in the northeast, she glinted and glittered with her sea-green emeral glaciers, and Westarwan gazed and gazed at her loveliness till he fell in love with the beautiful Gwashbrari; but her heart was full of envy, and she thought of nothing but how she might humble the pride of the mighty king that reared hsi head so high above the rest of the world. At last the fire of love grew so hot in Westarwan's heart that he put aside his pride and called aloud to Gwashbrari, 'O beautiful far-away mountain, kiss me, or I die.'
"But Gwashbrari answered craftily, 'How can i kiss you, O Proud King, when you hold your head so high? Even if I could stand beside you my lips would not reach your lips, and behold how many miles of hill and dale lie between us.'
"But still Westarwan pleaded for a kiss, till Gwashbrari smiled, and said, 'Those above must stoop, Sir King. If you would have a kiss forget your pride, reach that long length of yours towards me, and I will bend to kiss you.'
"Then Westarwan, stretching one great limb over the vale of Kashmir, reached over hill and dale to Gwashbrari's feet, but the glacier-hearted queen held her flashing head higher than ever, and laughed, saying: 'Love humbles all.'
"And this is why Westarwan lies for ever stretched out over hill and dale, till he rests his head on Gwashbrari's feet."
There is nothing more romantic, more saturated in superfluousness, than an Indian love story. Their ancestral connection to the great Hindu mythologies provides no greater wellspring of torrential and tragic romances. One of the great Indian epics, the Ramayana**, tells us of a divine love between Rama, the great bowman, and Sita, who's beauty knew no equal. As Rama entered the great city where Sita's father, King Janaka, reigned, he spotted one, "fair as Lakshmi, the very picture of love ineffable..." She saw him as well. They pined for each other that night, unaware as they were that the next day they would be married:
'O cruel night,' Sita said, 'who will kill a weakling treacherously? Let the sun but rise and my lord will be gone!
'O mind of mind, eagerly would you go with that dark sun, and with him return. You, who have been so long with me, can you stay just one day more?
'O moon, why do you wish to torture me, an innocent waning day by day, with your beams, a sharp lance burning like the hot sun?
'O south wind, cool and fragrant, though not to me! Why are you, with your hot breath and moon-beam fangs, prowling for my life like a tiger in a cave?
'Why does a warrior of rain-cloud hue roam the street night and day, trailing an unwed girl? Does this become a prince well-bred?
'If that cruel man, dark and wicked, won't come to me, would it be proper for me to seek him? Is this night a black sea, shoreless and lasting aeons?
'The songs don't stop, the day doesn't dawn; thoughts don't flee, night doesn't end; heartache lasts, life doesn't leave; and eyes don't close - O what a fate?
'Tell me, Sea, are you too a maiden cowed down by Madan's killing shafts? Your bangles loose, body weary, now up, now down, are you too a stranger to sleep?'
While thus she spoke distracted, tired and distressed but in virtue firm, let us tell what went through the mind of the spotless one that night in his palace.
'I saw her but once and my boundless love drew with my eyes her picture in my heart. I saw her again, but have yet to see the fullness of her beaty. Who can grasp the lightning?
'O moon, love's embryo, manure, seed and fruit, all in one, what have you done? Are you incapable of helping one who is helpless and alone?
'The night has spread like the dark eyes of the one who has taken possession of me, squeezing my very life out of me. It won't grow less, like the shame of aman who deserts his lord in the field of battle to save his life.
'My mind! You who have gone with that gazelle, have you lost all memory of me? Is it that you don't think of me, or is the distance too great for you? Or is it that you will not bid goodbye to one who care not to ask who you are?
'That poison is only to be found in the fangs of snakes whose eyes spit fire is an ancient story. In my case, it is in the soft glance of one forever embedded in my eyes and heart.
'When there are so many mountains, flowery lakes and groves around, why should a honey-tongued, bright-tressed woman choose my heart for her playground?'
Kiran Desai's The Inheritance of Loss is a newer, more complex Indian tale that won the 2006 Man Booker Prize. A young girl, Sai, who lost her parents to the Russian space program and who falls in love with her Nepali tutor, thinks about that sentiment's origin: "Romantically she decided that love must surely reside in the gap between desire and fulfillment, in the lack, not the contentment. Love was the ache, the anticipation, the retreat, everything around it but the emotion itself."
I find this statement about love so meaningful in its abstraction.
Thank you for indulging me today (and every other day). I get a bit carried away on Valentine's Day and wrote too much, perhaps. Ah well, today is a day to go above and beyond for those that you love. Do something romantic today.
justin
*From 'Folklore from Kashmir' by F.A. Steel with notes by Lt. R.C. Temple. The Indian Antiquary Vol. XI, 1882 and copied from Classical Indian Love Stories and Lyrics, Ruskin Bond (Ed.)
**The Kamba Ramayana. Penguin Books India. 2002
It's Valentine's Day, India's new favorite holiday and one that i cherish. The papers are full of advertisements for romantic candle-lit dinners in Chennai's most expensive restaurants. It's "Hickey Night" at the Taj hotel's Veranda restaurant: "It's that time when love fills the air. When candle lights and roses are standard decor. When diamond rings and men on knees are common. When cosy couples exchange sweet nothings, glances and kisses. And when Hickeys become sweet memories." Again, the changing face (or neck) of Indian love stories. One article acknowledges the love that "blossoms" at college canteens. "College canteens have always been a place where teens find time to catch a glimpse of their crush. According to college student Samyukta Ramani, the atmosphere in canteens is very casual and the area outside is even better. 'By sharing food it symbolizes that you can actually trust someone [I couldn't agree more]. So especially if the member of the opposite sex wants to share food with you, we feel that it shows that they feel that little extra for us.'" The Chennai Chronicle covers the growing, though historic, trend of using charms, gemstones and feng shui to improve their love lives. Ashmita Shah, a young Indian executive, has taken to wearing a silver pendant: "I'm quite fed up with my friends trying to fix me up with some guy or the other so I thought that it would be a good idea to wear a love charm around my neck. Somebody told me that this would accelerate my love life so I decided to give it a shot." A young Indian banker overcame his disbelief when "a friend of mine wore this (Voodoo love amulet) and within a couple of weeks he met the girl of his dreams." Superstition is alive and well, and the article points to hollywood for the renewal of this ancient trend, specifically Jessica Simpson, "who began wearing a rooster around her neck as a symbolic gesture for her current lack of love life." Despite the ringing endorsement by feng shui experts and gemologists, how frightening is it that the youth of India (or of anywhere for that matter) might look to a group of people, celebrities, who couldn't make a relationship last if their careers depended on it?
I prefer the old Indian love stories, filled as they are with the kind of love that could move mountains. Flora Annie Steel has retold the Kashmiri story of Gwashbrari and Westarwan.*
"Ages ago, when the world was young and the mountains had just reared their head to the heavens, Westarwan was the highest peak in all of Kashmir. Far away in the west Nanga Parbat stood where it stands now, but its snowy cap only reached to Westarwan's shoulder, while Haramukh looked but a dwarf beside the giant king. But if Westarwan was the tallest, Gwashbrari was the most beautiful of mountains. Away in the northeast, she glinted and glittered with her sea-green emeral glaciers, and Westarwan gazed and gazed at her loveliness till he fell in love with the beautiful Gwashbrari; but her heart was full of envy, and she thought of nothing but how she might humble the pride of the mighty king that reared hsi head so high above the rest of the world. At last the fire of love grew so hot in Westarwan's heart that he put aside his pride and called aloud to Gwashbrari, 'O beautiful far-away mountain, kiss me, or I die.'
"But Gwashbrari answered craftily, 'How can i kiss you, O Proud King, when you hold your head so high? Even if I could stand beside you my lips would not reach your lips, and behold how many miles of hill and dale lie between us.'
"But still Westarwan pleaded for a kiss, till Gwashbrari smiled, and said, 'Those above must stoop, Sir King. If you would have a kiss forget your pride, reach that long length of yours towards me, and I will bend to kiss you.'
"Then Westarwan, stretching one great limb over the vale of Kashmir, reached over hill and dale to Gwashbrari's feet, but the glacier-hearted queen held her flashing head higher than ever, and laughed, saying: 'Love humbles all.'
"And this is why Westarwan lies for ever stretched out over hill and dale, till he rests his head on Gwashbrari's feet."
There is nothing more romantic, more saturated in superfluousness, than an Indian love story. Their ancestral connection to the great Hindu mythologies provides no greater wellspring of torrential and tragic romances. One of the great Indian epics, the Ramayana**, tells us of a divine love between Rama, the great bowman, and Sita, who's beauty knew no equal. As Rama entered the great city where Sita's father, King Janaka, reigned, he spotted one, "fair as Lakshmi, the very picture of love ineffable..." She saw him as well. They pined for each other that night, unaware as they were that the next day they would be married:
'O cruel night,' Sita said, 'who will kill a weakling treacherously? Let the sun but rise and my lord will be gone!
'O mind of mind, eagerly would you go with that dark sun, and with him return. You, who have been so long with me, can you stay just one day more?
'O moon, why do you wish to torture me, an innocent waning day by day, with your beams, a sharp lance burning like the hot sun?
'O south wind, cool and fragrant, though not to me! Why are you, with your hot breath and moon-beam fangs, prowling for my life like a tiger in a cave?
'Why does a warrior of rain-cloud hue roam the street night and day, trailing an unwed girl? Does this become a prince well-bred?
'If that cruel man, dark and wicked, won't come to me, would it be proper for me to seek him? Is this night a black sea, shoreless and lasting aeons?
'The songs don't stop, the day doesn't dawn; thoughts don't flee, night doesn't end; heartache lasts, life doesn't leave; and eyes don't close - O what a fate?
'Tell me, Sea, are you too a maiden cowed down by Madan's killing shafts? Your bangles loose, body weary, now up, now down, are you too a stranger to sleep?'
While thus she spoke distracted, tired and distressed but in virtue firm, let us tell what went through the mind of the spotless one that night in his palace.
'I saw her but once and my boundless love drew with my eyes her picture in my heart. I saw her again, but have yet to see the fullness of her beaty. Who can grasp the lightning?
'O moon, love's embryo, manure, seed and fruit, all in one, what have you done? Are you incapable of helping one who is helpless and alone?
'The night has spread like the dark eyes of the one who has taken possession of me, squeezing my very life out of me. It won't grow less, like the shame of aman who deserts his lord in the field of battle to save his life.
'My mind! You who have gone with that gazelle, have you lost all memory of me? Is it that you don't think of me, or is the distance too great for you? Or is it that you will not bid goodbye to one who care not to ask who you are?
'That poison is only to be found in the fangs of snakes whose eyes spit fire is an ancient story. In my case, it is in the soft glance of one forever embedded in my eyes and heart.
'When there are so many mountains, flowery lakes and groves around, why should a honey-tongued, bright-tressed woman choose my heart for her playground?'
Kiran Desai's The Inheritance of Loss is a newer, more complex Indian tale that won the 2006 Man Booker Prize. A young girl, Sai, who lost her parents to the Russian space program and who falls in love with her Nepali tutor, thinks about that sentiment's origin: "Romantically she decided that love must surely reside in the gap between desire and fulfillment, in the lack, not the contentment. Love was the ache, the anticipation, the retreat, everything around it but the emotion itself."
I find this statement about love so meaningful in its abstraction.
Thank you for indulging me today (and every other day). I get a bit carried away on Valentine's Day and wrote too much, perhaps. Ah well, today is a day to go above and beyond for those that you love. Do something romantic today.
justin
*From 'Folklore from Kashmir' by F.A. Steel with notes by Lt. R.C. Temple. The Indian Antiquary Vol. XI, 1882 and copied from Classical Indian Love Stories and Lyrics, Ruskin Bond (Ed.)
**The Kamba Ramayana. Penguin Books India. 2002
CMC - Day Twelve
Ascending the numerical ladder of departmental divisions I started this morning my one week with Child Health III. This team, headed by the departmental chair, Dr. Prabakhar Moses, focuses on general pediatrics and asthma. Today is their clinic day and so i spent most of the day sitting on a stool next to Dr. Prabakhar as children were paraded before us with this and that typical complaint: fevers, wheezes, and rashes, oh my! For the most part, Dr. Prabakhar, as the senior physician on the team, sees the private patients, i.e., those willing to pay more for the privelage of being seen by the most experienced eyes. I saw for the first time Indian children in western diapers. Most children of diaper-wearing age come to us with a string around the waste, to ward off evil spirits, and a bottom and front liberated from the constraints of western waste management. If they pee or poop, what cannot be contained goes everywhere. So be it. Mother's change clothes, or, perhaps, invert their saris and life goes on. No cloth diapers to wash. No plastic diapers to buy. I'm told that as a consequence of this arrangment, parents become more in tune with when a child is likely to go and children are more quickly potty trained. This makes sense. In fact, before i left i saw a report on TV talking about parents starting to potty train their babies as early as 6 months, or before, simply by learning to understand better the baby's tells, if you will. They learn to know when the baby is bluffing and when he's gonna lay down a straight flush.
I witnessed today that overprotective parents are everywhere, particularly if they have only one child to protect. Little Suraj, 6 years old, came in with a distant history of febrile seizures. In the past week he'd had temperatures faithfully recorded as follows: 98.2, 98.5, 97.9, 98.6, 98.8 and all the way up to 99.5. Of course they gave two teaspoons of triaminic with every recording. I nearly laughed out loud. He read them off as if the child was on a pyrectic path to an early grave. All the while, happy little Suraj sat in his hot pink shirt quietly listening to the proceeding. "Do you have any other concerns?" Dr. Prabakhar asked. "Yes, sir." His teacher says he had difficulty concentrating in school. He's always up out of his desk, being loud, playing with others. He's not studying well at home." I looked at his chart to confirm that the child was still 6 years old. Yep. Other concerns? "Yes, sir. Do you think it's possible he could have TB?" Huh?! Suraj's father was the owner of a guest house for CMC patients and had occasional guests being treated for TB. Suraj liked to play with the guests. "Well, i suppose it's possible..." Anything's possible. "We can do a Mantoux," the very sensitive skin test used to identify TB antibodies. So this child left with the prescription for another bottle of Triaminic, a slip for a trip to room 8 (the procedure room) for placement of the Mantoux, a referal to a child psychiatrist, and my sympathies for being so precious.
As the morning progressed, and the caffiene from my break-time coffee wore off, i started to daydream of the various characters, most of them beggars, that I see on my way to and from the hospital. There's the child who always seems to find me just after lunch and follows me to the hospital gate, tugging at my trousers, his other hand held out in a cup, which he would bring towards his face in a gesture of feeding. He is chatty and smily as he tugs away, sent by his mother who watches from across the street. And yet, as i reach the gate of the hospital, with its baton weilding guard dressed in blues, the boy his gone. There is the man who sits on the Gandhi road near the paper (bike) stand and holds out his half fingers, the tips taken by leprosy. He has a salt and pepper beard, grown wild and long, and a kind face. Occasionally i drop a rupee in the remains of his hand. There seem to be a gang of wrinkled and short old women who hold out their hands and make the same gesture as the child, moaning and gesturing louder and faster when a white face goes by. "Baba, baba," and as i pass, "BABA!!" Baba means father and is a term of respect and endearment. I wonder every day why the color of my skin makes them blind to my youth. That one becomes "father", respected, because of circumstances out of one's control is unsettling. I pass them by. There's a boy i see occasionally who has, in place of legs, a small wooden board with wheels, that he pushes along. His outstretched hand is accompanied by the biggest grin. In contrast to the old women, he doesn't ask for pity, only money. He says with his eyes: "Check this out. Bad luck, eh? Can you help a brother out?" And i do. There are those that do not beg. One women i see every day, her hair matted into brown, dusty discs that hang suspended unevenly aside her ageless face. She dresses in once bright rags now the colour of dust. Her lips are the brightest red, not from lipstick, but from skin condition that i cannot identify. She looks, with her blank look, alternatively, lost and knowing. She take five steps one directions. Stops. Turns around and walks ten in the other direction. Stops. What can she be thinking? A man who could be her brother wanders the streets in a similar manner, asking nothing of anyone, just observing, actively. I wonder how they survive. There are times when there trajectory seems sure to collide with mine, when i expect an outstretched hand, and when i get not even a look, as these ghosts of the street blow by, inches away.
It's difficult to know how to respond to the beggars that are such a feature of daily Indian life. Do you refuse money to all, on the principle that reinforcing their begging only makes them more dependent? Some do. I have my own policy: I'll put aside a few rupees a day to give to those who seem truly in need and ask not just of me, but of everyone, including Indians. Those that single out westerners on account of the color of their skin will remain off my payroll. Each of us has to make our own rules, to find our own balance in a world where abject poverty abuts obvious, if only relative, wealth.
There is an old man who sits at the tea shop of my favorite chai wallah, and the young boy that accompanies him. He sports a trim goatee, a faded green and blue plaid dhoti, a white cast on his leg, and a look of sorrow. The first time i met him i offered to buy him a tea. At first he refused; then he accepted. He didn't thank me at the time and that really didn't matter. I saw him a few days later, sitting on a stone step, and he reached out his hand to me, asking for a cigarette. I indicated that i had none. Then he made a cup of his hand and waved it up and down towards his face. He was asking me for money. I indicated that i had none and continued on. I couldn't help but feel a little disappointed. It seemed so, i don't know...ungrateful...cheeky. A few steps on I chuckled to myself. Their are things about the economics of an Indian street that i will never understand and that this community of urchins and beggars probably wish they didn't have to.
Funny the contrast between the wealthy getting all the care they don't need and the poor getting none of the care that they do. Medicine - its infrastructure and practitioners - needs to reach out into the community, to help people like these. From inside the high walls of CMC, and many other hospitals around the world, you can't even see them.
justin
I witnessed today that overprotective parents are everywhere, particularly if they have only one child to protect. Little Suraj, 6 years old, came in with a distant history of febrile seizures. In the past week he'd had temperatures faithfully recorded as follows: 98.2, 98.5, 97.9, 98.6, 98.8 and all the way up to 99.5. Of course they gave two teaspoons of triaminic with every recording. I nearly laughed out loud. He read them off as if the child was on a pyrectic path to an early grave. All the while, happy little Suraj sat in his hot pink shirt quietly listening to the proceeding. "Do you have any other concerns?" Dr. Prabakhar asked. "Yes, sir." His teacher says he had difficulty concentrating in school. He's always up out of his desk, being loud, playing with others. He's not studying well at home." I looked at his chart to confirm that the child was still 6 years old. Yep. Other concerns? "Yes, sir. Do you think it's possible he could have TB?" Huh?! Suraj's father was the owner of a guest house for CMC patients and had occasional guests being treated for TB. Suraj liked to play with the guests. "Well, i suppose it's possible..." Anything's possible. "We can do a Mantoux," the very sensitive skin test used to identify TB antibodies. So this child left with the prescription for another bottle of Triaminic, a slip for a trip to room 8 (the procedure room) for placement of the Mantoux, a referal to a child psychiatrist, and my sympathies for being so precious.
As the morning progressed, and the caffiene from my break-time coffee wore off, i started to daydream of the various characters, most of them beggars, that I see on my way to and from the hospital. There's the child who always seems to find me just after lunch and follows me to the hospital gate, tugging at my trousers, his other hand held out in a cup, which he would bring towards his face in a gesture of feeding. He is chatty and smily as he tugs away, sent by his mother who watches from across the street. And yet, as i reach the gate of the hospital, with its baton weilding guard dressed in blues, the boy his gone. There is the man who sits on the Gandhi road near the paper (bike) stand and holds out his half fingers, the tips taken by leprosy. He has a salt and pepper beard, grown wild and long, and a kind face. Occasionally i drop a rupee in the remains of his hand. There seem to be a gang of wrinkled and short old women who hold out their hands and make the same gesture as the child, moaning and gesturing louder and faster when a white face goes by. "Baba, baba," and as i pass, "BABA!!" Baba means father and is a term of respect and endearment. I wonder every day why the color of my skin makes them blind to my youth. That one becomes "father", respected, because of circumstances out of one's control is unsettling. I pass them by. There's a boy i see occasionally who has, in place of legs, a small wooden board with wheels, that he pushes along. His outstretched hand is accompanied by the biggest grin. In contrast to the old women, he doesn't ask for pity, only money. He says with his eyes: "Check this out. Bad luck, eh? Can you help a brother out?" And i do. There are those that do not beg. One women i see every day, her hair matted into brown, dusty discs that hang suspended unevenly aside her ageless face. She dresses in once bright rags now the colour of dust. Her lips are the brightest red, not from lipstick, but from skin condition that i cannot identify. She looks, with her blank look, alternatively, lost and knowing. She take five steps one directions. Stops. Turns around and walks ten in the other direction. Stops. What can she be thinking? A man who could be her brother wanders the streets in a similar manner, asking nothing of anyone, just observing, actively. I wonder how they survive. There are times when there trajectory seems sure to collide with mine, when i expect an outstretched hand, and when i get not even a look, as these ghosts of the street blow by, inches away.
It's difficult to know how to respond to the beggars that are such a feature of daily Indian life. Do you refuse money to all, on the principle that reinforcing their begging only makes them more dependent? Some do. I have my own policy: I'll put aside a few rupees a day to give to those who seem truly in need and ask not just of me, but of everyone, including Indians. Those that single out westerners on account of the color of their skin will remain off my payroll. Each of us has to make our own rules, to find our own balance in a world where abject poverty abuts obvious, if only relative, wealth.
There is an old man who sits at the tea shop of my favorite chai wallah, and the young boy that accompanies him. He sports a trim goatee, a faded green and blue plaid dhoti, a white cast on his leg, and a look of sorrow. The first time i met him i offered to buy him a tea. At first he refused; then he accepted. He didn't thank me at the time and that really didn't matter. I saw him a few days later, sitting on a stone step, and he reached out his hand to me, asking for a cigarette. I indicated that i had none. Then he made a cup of his hand and waved it up and down towards his face. He was asking me for money. I indicated that i had none and continued on. I couldn't help but feel a little disappointed. It seemed so, i don't know...ungrateful...cheeky. A few steps on I chuckled to myself. Their are things about the economics of an Indian street that i will never understand and that this community of urchins and beggars probably wish they didn't have to.
Funny the contrast between the wealthy getting all the care they don't need and the poor getting none of the care that they do. Medicine - its infrastructure and practitioners - needs to reach out into the community, to help people like these. From inside the high walls of CMC, and many other hospitals around the world, you can't even see them.
justin
CMC - Day Eleven
The closest i got to a warm flaky croissant this weekend was a warm flaky baguette and i savoured every bite of it. Along side was a cappucino with a happy face of white frothy cream on a background of chocolate powder. I wish i could say that the happy face was due to the French influence but i don't think the French would go for such outward displays of frivolity. A pout maybe (eh Vincent?). Pondicherry itself is a relatively clean, relatively green Indian city with broad, tree-lined streets layed out in a grid. The signs read in French and Tamil and the names of the streets are often a mixture of the two: Rue Nandhiyavattan, for example. The Indian gendarmes guide traffic and guard the governer's mansion in white pressed uniforms and funny multicoloured hats. Children and adults play in large green park. Pondy, as it's known, is a pleasant city to which i could imagine returning.
My guesthouse for the weekend was in the beachside community of Auro Beach, 6km north of Pondicherry, and part of the large international planned community of Auroville. This community of some 1700 people from over 35 countries is the vision of "The Mother," a now-deceased French female guru and disciple of Sri Aurobindo, a French educated Indian who returned to his native Pondicherry in the early 20th century with a vision of transforming first India, and later, all of humanity. The Charter of Auroville, signed on the 28th of February, 1968, read as follows:
1. Auroville belongs to nobody in particular. Auroville belongs to humanity as a whole. But to live in Auroville one must be the willing servitor of the Divine Consciousness.
2. Auroville will be the place of an unending education, of constant progress, and a youth that never ages.
3. Auroville wants to be the bridge between the past and the future. Taking advantage of all discoveries from without and from within, Auroville will boldly spring towards futue realisations.
4. Auroville will be a site of material and spiritual researches for a living embodiment of an actual Human Unity.
The Mother dreamed of "somewhere on earth a place which no nation could claim as its own, where all human beings of goodwill who have a sincere aspiration could live freely as citizens of the world and obey one single authority, that of the supreme truth; a place of peace, concord and harmony wher all the fighting instinces of man would be used exclusively to conquer the causes of his sufferings and miseries, to surmount his weaknesses and ignorance, to triumph over his limitations and incapacities; a place where the needs of the spirit and the concern for progress would take precedence over the satisfaction of desires and passions, the search for pleasure and material enjoyment." She wrote much more about this dream and from it sprang a community which occupies a few thousand acres of land that radiates outward in the shape of a spiralling galaxy from a large golden meditation dome, the matrimandir, into four zones: International, Cultural, Residential and Industrial. The once red-earthed and barren platuea is now covered with dry tropical forests, agricultural projects, futuristic concrete buildings and good intentions. Its residents are engaged in "a wide variety of activities, including research into a cashless economy, environmental regeneration, organic farming, renewable energy, appropriate building technology, village development, handicrafts and small-scale industries, health care, education, cross-cultural communication and many other fields."
Reading the postings board at the information center one finds any number of classes pertaining to health and well-being, including all varieties of alternative healing modalities, many of which i'd never heard of. As an example, one gentleman teaches Watsu, shiatsu massage in the water. Some aurovillians, as they are called, are engaged in the cultivation of traditional Indian medicinal plants in order to reeducate the surrounding villagers about traditional remedies that have for the most part been lost to them. It was the occasion of several local healers coming together to explain their work that prompted me to extend my visit to Auroville by one day. Informed of this gathering by a young American now working at Martavum, or "healing forest", i found myself sitting around a large, rectangular slate table with six Canadian nurses, two german Aurovillians, three traditional healers (two women and one man) and Shivaraj, the enthusiastic coordinator of this enterprise. The Canadian nurses were traveling together through India for four weeks, two of which were spent in Auroville running workshops on "healing touch" and women empowerment. They seemed to view their trip as a great success and they seemed flush with excitement about the possibility of learning something from the locals in return. We sipped sweet, milky coffee and asked questions of the healers.
A word, first, about this "forest." Hans, the American, explained that this garden was in its infancy. Unlike the rather well developed Pichandikulum, on the other side of Auroville, the medicinal plants here were still awaiting the growth of the large trees that would provide necessary shade for their optimal growth. The signs to explain their utility were also in a stage of early development and did not yet say anything about the utility of the shrubs and trees they identified. The names, themselves, flowered with possibility: Calotropis Proceria, Pongumia Pinnata, Plumeria Rubra, Gauzuma Ulmifolia, Ervatemia Divancata, Helicteres Isora, Cassia Alata, Ficus Religiosa, Vetiveria Zizanoides, Catharanthus Roseus, Dodnea Viscosa, Acorus Calamus, Gymanaea Sylvestre, Garcinia Spicata. How different these lovely names to those of the pharmacueticals we must learn in the course of medical education?
Sagundala was a women in her 50s who at the age of 27 had a feeling that she could heal people. She makes special use of the Neem (Azadirachta indica, cousin of Mahogany) leaf and, while channeling Mahakali, the great and powerful Indian goddess (wife of Shiva), prays and fans the burning neem leaves. What occurs is a form of "aura cleansing" and she uses it to cure fever, body aches and general malaise. What other purposes it serves were lost in translation from this stout, confident Indian villager. She brought along the white and red powder seen on so many Indian foreheads and blessed us each with a dot between our eyes. I saw her take the hands of one of the German women and reduce the latter to tears as she closed her eyes and prayed, swaying back and forth. I asked about the purpose of Neem oil, which I knew had been blown up the nose of a child, causing a chemical pneumonitis (inflammation of the lungs) that led him to the CMC pediatrics ward. I was told that it is most often diluted in water and used to heal skin lesions and their associated pain. The male of the group suggested that sleeping under the Neem tree in the daytime led a general improvement in health. We learned that 2 teaspoons of ground papaya seeds daily prevents/cures parasites, that sesame oil in the naval also cures parasites, and that conch shells are added to ghee (clarified butter), fired, dried, powdered and dissolved in hot water to stop post-partum bleeding. The flower of Cassia Auriculata is boiled into a tea to cure Diabetes. Melivacaea is smashes, filtered and given in two teaspoons to relieve period pains. While i suspect that these traditional healers would have a cure for most ailments, we learned that the most common complaints among Indian villagers are "stomach problems, headache and colds." With the exception of parasites, theirs sounds a lot like those common problems found in any American clinic.
Today i visited Pichandikulum, another forest of traditional medical plants in a far more developed state, to see what else i could learn, and to see how Martavum might someday look. Here, red dirt pathways wound through a maze of trees, shrubs, little ponds; signs clearly displayed the names and uses for well over a hundred of the 400 or so medicinal plants used at one time or another by traditional Indian healers. I found Curculigo Orchioides, which "cures diabetes, heat diseases, leucoderma, eye pain and strenghtens the body and cures poliomyelitis if administered together with appropriate formulations." The roots of Baliospermum Montanum cure "scanty urination"; the leaves cure asthma; the oil relieves joint pain. Spathoda Companulata bark is used in a concoction to treat dysentary, renal and gastrointestinal problems while the leave is infused to treat urethral inflammations. My curiosity about how they discovered these uses led me to consider how the many drugs we use in allopathic medicine were "discovered". Many of them, no doubt, were derived from plants such as these, used as they are/were by traditional healers.
It is tempting to be skeptical of these various shrubs with their various healing properties. After all, few if any have been subjected to the rigorous system of trials that we use to create the evidence base upon which we practice medicine. And yet, i like to keep an open mind. After all, these remedies have been used for hundreds if not thousands of years. As has Ayurvedic medicine, traditional Chinese medicine, Accupuncture, massage. Allopathic medicine and its pharmacopia are relatively new. The aurovillians, in particular, made sure that i understood that and they seemed to size me up with a certain suspicion. What could i, a western medical student, want to know about this stuff? Surely i wouldn't understand that herbal remedies, barks and flowers, energy and prayer could heal. Ironically, their skepticism of my open mind revealed something more about how closed their own minds seemed to be.
I was forced to defend allopathic medicine many times over the weekend to those that had great confidence in any number of alternative therapies but none in those that i will someday soon have to offer. It was as if, ironically, the type of science upon which my education is based was not welcome there, too much a part of the status quo to have any status in an alternative world. I think all this fighting about who is right and who is wrong when it comes to healing is silly and potentially harmful. It is a clash of egos that benefits least he or she who needs healing. Shouldn't we learn to cater a treatment to the individual rather than an individual to the treatment? Can't we all just get along?
I left Auroville this afternoon and returned to Vellore. I'm happy to be back. While some of the work that is taking place there is encouraging, I was overall discomfited by this aspiring utopia, its aura of neocolonialism and strange inhospitability. I am disappointed because i felt like my open mind has been stepped on - how many times have i been told not to open one's mind so much that it falls out. As I rode my bike through the dusty lanes of Auroville the afternoon, a thought recurred in my mind, a salve to my wounded idealism: It's okay to have one's head in the clouds, as long as one's feet are firmly planted on the ground and one's hands are meaningfully occupied somewhere in between. I'm looking forward to going back to work tomorrow.
Hope you all had a nice monday.
justin
ps. i have so many thoughts about this weekend and my short time in Auroville, i've found it difficult to focus this evening. I'll attribute it in part to long and jarring bus ride. Hell hath no fury like an Indian country road.
pps. The literal definition of "utopia" is "no place."
My guesthouse for the weekend was in the beachside community of Auro Beach, 6km north of Pondicherry, and part of the large international planned community of Auroville. This community of some 1700 people from over 35 countries is the vision of "The Mother," a now-deceased French female guru and disciple of Sri Aurobindo, a French educated Indian who returned to his native Pondicherry in the early 20th century with a vision of transforming first India, and later, all of humanity. The Charter of Auroville, signed on the 28th of February, 1968, read as follows:
1. Auroville belongs to nobody in particular. Auroville belongs to humanity as a whole. But to live in Auroville one must be the willing servitor of the Divine Consciousness.
2. Auroville will be the place of an unending education, of constant progress, and a youth that never ages.
3. Auroville wants to be the bridge between the past and the future. Taking advantage of all discoveries from without and from within, Auroville will boldly spring towards futue realisations.
4. Auroville will be a site of material and spiritual researches for a living embodiment of an actual Human Unity.
The Mother dreamed of "somewhere on earth a place which no nation could claim as its own, where all human beings of goodwill who have a sincere aspiration could live freely as citizens of the world and obey one single authority, that of the supreme truth; a place of peace, concord and harmony wher all the fighting instinces of man would be used exclusively to conquer the causes of his sufferings and miseries, to surmount his weaknesses and ignorance, to triumph over his limitations and incapacities; a place where the needs of the spirit and the concern for progress would take precedence over the satisfaction of desires and passions, the search for pleasure and material enjoyment." She wrote much more about this dream and from it sprang a community which occupies a few thousand acres of land that radiates outward in the shape of a spiralling galaxy from a large golden meditation dome, the matrimandir, into four zones: International, Cultural, Residential and Industrial. The once red-earthed and barren platuea is now covered with dry tropical forests, agricultural projects, futuristic concrete buildings and good intentions. Its residents are engaged in "a wide variety of activities, including research into a cashless economy, environmental regeneration, organic farming, renewable energy, appropriate building technology, village development, handicrafts and small-scale industries, health care, education, cross-cultural communication and many other fields."
Reading the postings board at the information center one finds any number of classes pertaining to health and well-being, including all varieties of alternative healing modalities, many of which i'd never heard of. As an example, one gentleman teaches Watsu, shiatsu massage in the water. Some aurovillians, as they are called, are engaged in the cultivation of traditional Indian medicinal plants in order to reeducate the surrounding villagers about traditional remedies that have for the most part been lost to them. It was the occasion of several local healers coming together to explain their work that prompted me to extend my visit to Auroville by one day. Informed of this gathering by a young American now working at Martavum, or "healing forest", i found myself sitting around a large, rectangular slate table with six Canadian nurses, two german Aurovillians, three traditional healers (two women and one man) and Shivaraj, the enthusiastic coordinator of this enterprise. The Canadian nurses were traveling together through India for four weeks, two of which were spent in Auroville running workshops on "healing touch" and women empowerment. They seemed to view their trip as a great success and they seemed flush with excitement about the possibility of learning something from the locals in return. We sipped sweet, milky coffee and asked questions of the healers.
A word, first, about this "forest." Hans, the American, explained that this garden was in its infancy. Unlike the rather well developed Pichandikulum, on the other side of Auroville, the medicinal plants here were still awaiting the growth of the large trees that would provide necessary shade for their optimal growth. The signs to explain their utility were also in a stage of early development and did not yet say anything about the utility of the shrubs and trees they identified. The names, themselves, flowered with possibility: Calotropis Proceria, Pongumia Pinnata, Plumeria Rubra, Gauzuma Ulmifolia, Ervatemia Divancata, Helicteres Isora, Cassia Alata, Ficus Religiosa, Vetiveria Zizanoides, Catharanthus Roseus, Dodnea Viscosa, Acorus Calamus, Gymanaea Sylvestre, Garcinia Spicata. How different these lovely names to those of the pharmacueticals we must learn in the course of medical education?
Sagundala was a women in her 50s who at the age of 27 had a feeling that she could heal people. She makes special use of the Neem (Azadirachta indica, cousin of Mahogany) leaf and, while channeling Mahakali, the great and powerful Indian goddess (wife of Shiva), prays and fans the burning neem leaves. What occurs is a form of "aura cleansing" and she uses it to cure fever, body aches and general malaise. What other purposes it serves were lost in translation from this stout, confident Indian villager. She brought along the white and red powder seen on so many Indian foreheads and blessed us each with a dot between our eyes. I saw her take the hands of one of the German women and reduce the latter to tears as she closed her eyes and prayed, swaying back and forth. I asked about the purpose of Neem oil, which I knew had been blown up the nose of a child, causing a chemical pneumonitis (inflammation of the lungs) that led him to the CMC pediatrics ward. I was told that it is most often diluted in water and used to heal skin lesions and their associated pain. The male of the group suggested that sleeping under the Neem tree in the daytime led a general improvement in health. We learned that 2 teaspoons of ground papaya seeds daily prevents/cures parasites, that sesame oil in the naval also cures parasites, and that conch shells are added to ghee (clarified butter), fired, dried, powdered and dissolved in hot water to stop post-partum bleeding. The flower of Cassia Auriculata is boiled into a tea to cure Diabetes. Melivacaea is smashes, filtered and given in two teaspoons to relieve period pains. While i suspect that these traditional healers would have a cure for most ailments, we learned that the most common complaints among Indian villagers are "stomach problems, headache and colds." With the exception of parasites, theirs sounds a lot like those common problems found in any American clinic.
Today i visited Pichandikulum, another forest of traditional medical plants in a far more developed state, to see what else i could learn, and to see how Martavum might someday look. Here, red dirt pathways wound through a maze of trees, shrubs, little ponds; signs clearly displayed the names and uses for well over a hundred of the 400 or so medicinal plants used at one time or another by traditional Indian healers. I found Curculigo Orchioides, which "cures diabetes, heat diseases, leucoderma, eye pain and strenghtens the body and cures poliomyelitis if administered together with appropriate formulations." The roots of Baliospermum Montanum cure "scanty urination"; the leaves cure asthma; the oil relieves joint pain. Spathoda Companulata bark is used in a concoction to treat dysentary, renal and gastrointestinal problems while the leave is infused to treat urethral inflammations. My curiosity about how they discovered these uses led me to consider how the many drugs we use in allopathic medicine were "discovered". Many of them, no doubt, were derived from plants such as these, used as they are/were by traditional healers.
It is tempting to be skeptical of these various shrubs with their various healing properties. After all, few if any have been subjected to the rigorous system of trials that we use to create the evidence base upon which we practice medicine. And yet, i like to keep an open mind. After all, these remedies have been used for hundreds if not thousands of years. As has Ayurvedic medicine, traditional Chinese medicine, Accupuncture, massage. Allopathic medicine and its pharmacopia are relatively new. The aurovillians, in particular, made sure that i understood that and they seemed to size me up with a certain suspicion. What could i, a western medical student, want to know about this stuff? Surely i wouldn't understand that herbal remedies, barks and flowers, energy and prayer could heal. Ironically, their skepticism of my open mind revealed something more about how closed their own minds seemed to be.
I was forced to defend allopathic medicine many times over the weekend to those that had great confidence in any number of alternative therapies but none in those that i will someday soon have to offer. It was as if, ironically, the type of science upon which my education is based was not welcome there, too much a part of the status quo to have any status in an alternative world. I think all this fighting about who is right and who is wrong when it comes to healing is silly and potentially harmful. It is a clash of egos that benefits least he or she who needs healing. Shouldn't we learn to cater a treatment to the individual rather than an individual to the treatment? Can't we all just get along?
I left Auroville this afternoon and returned to Vellore. I'm happy to be back. While some of the work that is taking place there is encouraging, I was overall discomfited by this aspiring utopia, its aura of neocolonialism and strange inhospitability. I am disappointed because i felt like my open mind has been stepped on - how many times have i been told not to open one's mind so much that it falls out. As I rode my bike through the dusty lanes of Auroville the afternoon, a thought recurred in my mind, a salve to my wounded idealism: It's okay to have one's head in the clouds, as long as one's feet are firmly planted on the ground and one's hands are meaningfully occupied somewhere in between. I'm looking forward to going back to work tomorrow.
Hope you all had a nice monday.
justin
ps. i have so many thoughts about this weekend and my short time in Auroville, i've found it difficult to focus this evening. I'll attribute it in part to long and jarring bus ride. Hell hath no fury like an Indian country road.
pps. The literal definition of "utopia" is "no place."
CMC - Day Ten
The first order of business on Thursday mornings, bible study, is a reflection of (and on) the Christian roots from which this institution draws its purpose. There is a weekly bible study guide published solely for CMC and the weeks bible passages and lessons are read and discussed throughout the week in numerous small conference rooms across this large campus. Today's discussion centered around the notion of the "mission." If you'll allow me a rare opportunity to quote from the bible: "The harvest is plentiful but the workers are few. Ask the Lord of the harvest, therefore, to send out workers into his harvest field." So said Jesus as quoted in Matthew 9:37,38, and so have missionaries risen up in response.
The small accompanying reading told of small missionary hospital in north India that was started by a missionary from Scotland who felt god's calling on a trip to India (please understand that i spell "god" with a lower case "g" because my belief is that "god" is in the small things, and in everything; that uppercase "G" enforces, in my mind, an unacceptable distance to they who would draw strength from that energy). "What happened to those who come to CMC from these mission hospitals for training?" the reader is asked, rhetorically. "Are they nurtured? Cared for? Mentored? For most of them the intense training is an exhaustive experience. These are people who go back to the mission hospitals to take up leadership positions. What a great opportunity to invest the lives of these young doctors who will be the leaders of tomorrow?"
Of the 60 undergraduate medical students - i.e. those at my level - that are invited to attend CMC annually, 45 are sponsored by mission hospitals across India. It is not a financial committment, but rather a spiritual one and a bond to a hospital and to patients in communities in India that would otherwise have difficulty attracting physicians. So a discussion of the "mission" has both religious and practical merits. Questions for reflection and discussion were numbered as follows:
1. How can we be involved in a "mission?" Is it going to a rural place in north India, or is it where you are convinced that god has called you to be? Is it the place that matters or the purpose?
2. Is our mission just providing medical care? Where is the place for the Great Commission in this "mission?" In what way are Christian mission hospitals different from other charitable hospitals?
The discussion that ensued revealed something about India. Beryl, the intern i've mentioned before, was asked about her two years mission experience prior to coming back to CMC - she had trained her as an undergraduate. Her time in a small hospital in rural Tamil Nadu was not without its hardships, chief among them was the constant discussions about and demands for money that infected the staff at the hospital, physicians included. Others chimed in with similar experiences. What evolved was not a discussion centered on the purpose of mission hospitals and the doctors that minister there but the corruption of missions, that is apparently endemic. Dr. Peter, the consulting physician, spoke about his experience: the hospital where he spent two years yielded immense profits from the care they provided and from the money they took in from Christian charities abroad. The doctors were poorly paid and the money was channeled into the bishop's pockets and those of their family, which formed a "small mafia" of sorts. This is not, apparently, an uncommon problem. But it is demoralizing. The hospitals end up being cash rich and care poor.
Being a physician is unique because our professional obligations are in and of themselves missionary based. The first line of the Geneva Convention, which we recite as early as our first year of medical school, says: "I solemnly pledge to consecrate my life to the service of humanity." Christian doctors in a Christian hospital have, in some sense, a double mission, a professional and a religious obligation. I explained to the doctors around our little conference table that physicians and medicine are not free of corruption in the U.S. We nurse a relationship with the pharmacuetical industry that benefits the least our patients; we have a system of healthcare that benefits the most those with the greatest conflicts of interest and bankrupts those who choose to utilize it. What should be seen as the biggest scandal, that we pay double per capita what other industrialized nations pay and have neither a completely insured public nor the health indicators to show for it, is not known, ignored, or, worse, accepted. And so we have the challenge, in a relatively secular medical world, of engendering in students and physicians a sense of purpose, or "mission," that will lead them to refuse the inequities of the status quo, that will lead them to change the system for the sake of our patients. How, i asked, can medical education in India train its graduates not to accept the corruption that exists in the missionary hospitals (or any hospital for that matter)? From what can a Christian medical education, or medical model, draw to teach the rest of medicine about what a "mission" really is? No one around the table could say. What it is certainly not a mission is worrying about inadequate salaries while a hospital and its administrators get rich and the patients suffer? (Put that way, our healthcare system doesn't seem so different from theirs.)
I read an editorial in the Journal of the Mahatma Gandhi Institute of Medical Sciences about medical education in India and how it must shed the standards of training it inherited from the English. The author, an Indian physician now based in the U.S., laments the current and rigorous system of rote memorization of all facts medical. He argues in favor of medical education that emphasizes more the humanities, one that reinforces our central humanness, and might allow Indian medical graduates to more readily empathize with their patients by understanding better who they are and where they come from. The system, he continues, must reinforce patient care rather than patient illness. His suggestions mirror changes in medical education that we've seen in the U.S. in recent years, something for which we should be grateful. Maybe, too, this focus on humanities offers a solution to this question about how to instill in students awareness of their professional mission. After all, in the face of corruption and inequality, it's much easier to advocate for a human than a disease.
On the clinical front, we stared incredulously this morning at a CT scan of the brain of a beautiful young girl admitted for recurrent episodes of staphylococcal meningitis. It showed that the "polyp" we'd seen peaking out of her right nose was actually part of her brain. This young girl has a very rare intranasal encephalocele. We returned to bedside with our flashlight and sure enough we could see a flattened gyrus and minute blood vessels of that essential organ which should be inside the head, not out. This girl will have to have surgery to put it back and to close up the hole that let it out.
I'm off to the beach again, this time in Pondicherry, a former French colony about an hour south of Mahabalipuram. My mission, this weekend, is to find a flaky and warm croissant. I'll let you know how it goes.
bon weekend.
justin
One more thing...
Though not a Christian, i think these weekly bible discussions to discuss faith are probably invaluable to the physicians here. We could do with such a thing, just like we could use a set morning coffee break. Whether a Christian, a Hindu, a Muslim or an existentialist, discussions about how our individual faiths contribute to the practice of medicine could only make us better physicians. After all, if we cannot discuss these things amongst ourselves, how can we be expected to do so with patients. When it comes to improving their quality of lives, understanding what spiritual reserves they bring to achieving that lifestyle is critical.
The small accompanying reading told of small missionary hospital in north India that was started by a missionary from Scotland who felt god's calling on a trip to India (please understand that i spell "god" with a lower case "g" because my belief is that "god" is in the small things, and in everything; that uppercase "G" enforces, in my mind, an unacceptable distance to they who would draw strength from that energy). "What happened to those who come to CMC from these mission hospitals for training?" the reader is asked, rhetorically. "Are they nurtured? Cared for? Mentored? For most of them the intense training is an exhaustive experience. These are people who go back to the mission hospitals to take up leadership positions. What a great opportunity to invest the lives of these young doctors who will be the leaders of tomorrow?"
Of the 60 undergraduate medical students - i.e. those at my level - that are invited to attend CMC annually, 45 are sponsored by mission hospitals across India. It is not a financial committment, but rather a spiritual one and a bond to a hospital and to patients in communities in India that would otherwise have difficulty attracting physicians. So a discussion of the "mission" has both religious and practical merits. Questions for reflection and discussion were numbered as follows:
1. How can we be involved in a "mission?" Is it going to a rural place in north India, or is it where you are convinced that god has called you to be? Is it the place that matters or the purpose?
2. Is our mission just providing medical care? Where is the place for the Great Commission in this "mission?" In what way are Christian mission hospitals different from other charitable hospitals?
The discussion that ensued revealed something about India. Beryl, the intern i've mentioned before, was asked about her two years mission experience prior to coming back to CMC - she had trained her as an undergraduate. Her time in a small hospital in rural Tamil Nadu was not without its hardships, chief among them was the constant discussions about and demands for money that infected the staff at the hospital, physicians included. Others chimed in with similar experiences. What evolved was not a discussion centered on the purpose of mission hospitals and the doctors that minister there but the corruption of missions, that is apparently endemic. Dr. Peter, the consulting physician, spoke about his experience: the hospital where he spent two years yielded immense profits from the care they provided and from the money they took in from Christian charities abroad. The doctors were poorly paid and the money was channeled into the bishop's pockets and those of their family, which formed a "small mafia" of sorts. This is not, apparently, an uncommon problem. But it is demoralizing. The hospitals end up being cash rich and care poor.
Being a physician is unique because our professional obligations are in and of themselves missionary based. The first line of the Geneva Convention, which we recite as early as our first year of medical school, says: "I solemnly pledge to consecrate my life to the service of humanity." Christian doctors in a Christian hospital have, in some sense, a double mission, a professional and a religious obligation. I explained to the doctors around our little conference table that physicians and medicine are not free of corruption in the U.S. We nurse a relationship with the pharmacuetical industry that benefits the least our patients; we have a system of healthcare that benefits the most those with the greatest conflicts of interest and bankrupts those who choose to utilize it. What should be seen as the biggest scandal, that we pay double per capita what other industrialized nations pay and have neither a completely insured public nor the health indicators to show for it, is not known, ignored, or, worse, accepted. And so we have the challenge, in a relatively secular medical world, of engendering in students and physicians a sense of purpose, or "mission," that will lead them to refuse the inequities of the status quo, that will lead them to change the system for the sake of our patients. How, i asked, can medical education in India train its graduates not to accept the corruption that exists in the missionary hospitals (or any hospital for that matter)? From what can a Christian medical education, or medical model, draw to teach the rest of medicine about what a "mission" really is? No one around the table could say. What it is certainly not a mission is worrying about inadequate salaries while a hospital and its administrators get rich and the patients suffer? (Put that way, our healthcare system doesn't seem so different from theirs.)
I read an editorial in the Journal of the Mahatma Gandhi Institute of Medical Sciences about medical education in India and how it must shed the standards of training it inherited from the English. The author, an Indian physician now based in the U.S., laments the current and rigorous system of rote memorization of all facts medical. He argues in favor of medical education that emphasizes more the humanities, one that reinforces our central humanness, and might allow Indian medical graduates to more readily empathize with their patients by understanding better who they are and where they come from. The system, he continues, must reinforce patient care rather than patient illness. His suggestions mirror changes in medical education that we've seen in the U.S. in recent years, something for which we should be grateful. Maybe, too, this focus on humanities offers a solution to this question about how to instill in students awareness of their professional mission. After all, in the face of corruption and inequality, it's much easier to advocate for a human than a disease.
On the clinical front, we stared incredulously this morning at a CT scan of the brain of a beautiful young girl admitted for recurrent episodes of staphylococcal meningitis. It showed that the "polyp" we'd seen peaking out of her right nose was actually part of her brain. This young girl has a very rare intranasal encephalocele. We returned to bedside with our flashlight and sure enough we could see a flattened gyrus and minute blood vessels of that essential organ which should be inside the head, not out. This girl will have to have surgery to put it back and to close up the hole that let it out.
I'm off to the beach again, this time in Pondicherry, a former French colony about an hour south of Mahabalipuram. My mission, this weekend, is to find a flaky and warm croissant. I'll let you know how it goes.
bon weekend.
justin
One more thing...
Though not a Christian, i think these weekly bible discussions to discuss faith are probably invaluable to the physicians here. We could do with such a thing, just like we could use a set morning coffee break. Whether a Christian, a Hindu, a Muslim or an existentialist, discussions about how our individual faiths contribute to the practice of medicine could only make us better physicians. After all, if we cannot discuss these things amongst ourselves, how can we be expected to do so with patients. When it comes to improving their quality of lives, understanding what spiritual reserves they bring to achieving that lifestyle is critical.
CMC - Day Nine
At the end of each day I ask one of the residents or the consulting physician what time I should arrive the next morning. They always say 8 o'clock. So every morning at 8 am I ascend the 10 flights of stairs to the 5th floor, pass the row of bored fathers sitting on the ground outside the ward (only one parent at a time is allowed in) and make my way to the Child Health library, with its old wooden and rusty metal cabinets full of a poorly arranged but impressive collection of pediatrics textbooks. And every morning i'm the only one there. Usually we get started around 9. This 8 am business must be wishful thinking.
This morning i sat down to find a discarded section of yesterday's Indian Express newspaper, this one for school children. On the front page was a discussion of a survey recently published by the British Medical Journal on the 15 most important advances in medicine since 1840, when the journal was first published. Over 11,000 BMJ readers replied and they selected "sanitation" as the most important advance in 166 years. A BMJ article on sanitation that preceeded the survey noted that sewage disposal and water supply systems in 1800s radically improved public health in Europe. In his Sanitary Conditions of the Labouring Population, published in 1842, Edwin Chadwick argued that a desperate need for public health reform must include home sewage piping with water. A few years later, in 1854, Dr. John Snow discovered that cholera was a waterborn disease, not airborne as had been previously believed. That few of us have ever seen cholera in a developed country is a testament to their good work.
Interestingly, and briefly, the first toilet was constructed in England by a godson to Queen Elizabeth 1, Sir John Harrington. He sought to make a "necessary" for himself and his godmother as early as 1596, a feat that brought him little reward and much ridicule. Thus began toilet humour.
According to the World Health Organization, diarrheal disease alone amounts to an estimated 4.1% of the global burden of disease (as measured by disability-adjusted life years, a topic i won't go into) and is responsible for 1.8 million deaths every year. It is estimated that 88% of that burden is attributable to unsafe water supply, sanitation and hygeine, and is concentrated in children in developing countries.
Here in Vellore, one need look no further than my front doorstep to see that this problem still exists here. Let me tell you about my morning walk to work. I step off the first red marble step of Sri Nathan Palace onto a narrow paved dirt and brick alley that is my "street." The first person I see is my barber, sitting in the rusty blue tin stilted shack in which i get my thrice-weekly straight-razor shave. He's managed to perfect the art of delivering the perfect shave while tilted at a 15 degree angle. Waving as i pass, i quickly come to my chai wallah. Wallah, in common parlance, means "one who is engaged in," and he engages very well in my morning, afternoon, and sometimes evening chai. He has a lovely, tall and frighteningly thin young boy with a beautiful smile that works with him, a non-filial relationship i've not quite figured out, but who seems to like me very much and we're always waving at each other. I grab a seat on a plastic blue stool and contemplate the morning while the chai-man works his milk, sugar, and tea powder magic. I wave to the ironing man who's roadside office consists of a board set against the wall, its street end balanced on two thin wooden sticks. He pulls coal from a sac and places inside his giant iron before lighting it up for a morning's work. There's a man selling shirts, one selling brooms, and another selling the stainless steel and nested "tiffen" sets in which so many Indians carry their food to work or school with them. A rickshaw will make it's way precariously down the street. Bicycle bells ring out periodically. A man sells south indian food on a small table: iddlies, dosas, sambar. Fresh fried vadas are cooked in large vats of oil. People mill about. It's a wonderful little street. Oh, but i didn't tell you about the hazards. Each side of this little street is lined with large rectangular concrete slabs, layed perpindicularly to the street. Gaps in these slabs are not uncommon and what does one find beneath but the open sewer? One's nose confirms what one's eyes won't forget: the contents of so many toilets floating in a river of muck. So in avoiding the occasional cow paddy, or cow, or rickshaw, or bicycle, one must be careful to not step too far to the side, or else end up in the sewer. Yikes! The reality is that it is not so different from early 19th century England.
I spent the morning at a small rural satelite community hospital in a vellage outside Vellore. The clinic is called RUHSA, the Rural Unit for Health and Social Affairs. On Thursdays one of the more senior residents (today it was Praburam) hosts an outpatient clinic for those more complicated cases identified throughout the rest of the week. In a room no larger than 10x40ft, four physicians held court as a parade of patients, adults and children, lined up to see them. No fewer than 6 children at a time waited in front of Dr. Praburam's desk, each listening patiently to the stories of those in front of them. There is no such thing as privacy here and one hopes that, if anything, this communal suffering leads to a more communal empathy. We saw about 40 children in 4 hours. Nearly half of them had symptoms, lab tests and chest x-rays concerning for tuberculosis. Western pediatricians are grateful that we no longer (or very rarely) have to contend with this consuming illness. Fortunately, thanks to clinics like this one, children are being identified early and are subsequently getting the treatment that will likely save their lives.
I spent the afternoon at The Swimming Pool, a tranquil and sunny private oasis that abuts the undergraduate medical campus. It's an escape from open sewers and acid-fast bacilli (the type of bacteria that cause tuberculosis) and the endless and nearly unavoidable honking of horns. Some sentence fragments: an olympic sized pool surrounded by palm trees and lush and shortly-shorn grass; a cold coca cola in one hand; a good book in the other. What better way to contemplate the mornings events and what a guilty pleasure?
Life's not all bad.
justin
This morning i sat down to find a discarded section of yesterday's Indian Express newspaper, this one for school children. On the front page was a discussion of a survey recently published by the British Medical Journal on the 15 most important advances in medicine since 1840, when the journal was first published. Over 11,000 BMJ readers replied and they selected "sanitation" as the most important advance in 166 years. A BMJ article on sanitation that preceeded the survey noted that sewage disposal and water supply systems in 1800s radically improved public health in Europe. In his Sanitary Conditions of the Labouring Population, published in 1842, Edwin Chadwick argued that a desperate need for public health reform must include home sewage piping with water. A few years later, in 1854, Dr. John Snow discovered that cholera was a waterborn disease, not airborne as had been previously believed. That few of us have ever seen cholera in a developed country is a testament to their good work.
Interestingly, and briefly, the first toilet was constructed in England by a godson to Queen Elizabeth 1, Sir John Harrington. He sought to make a "necessary" for himself and his godmother as early as 1596, a feat that brought him little reward and much ridicule. Thus began toilet humour.
According to the World Health Organization, diarrheal disease alone amounts to an estimated 4.1% of the global burden of disease (as measured by disability-adjusted life years, a topic i won't go into) and is responsible for 1.8 million deaths every year. It is estimated that 88% of that burden is attributable to unsafe water supply, sanitation and hygeine, and is concentrated in children in developing countries.
Here in Vellore, one need look no further than my front doorstep to see that this problem still exists here. Let me tell you about my morning walk to work. I step off the first red marble step of Sri Nathan Palace onto a narrow paved dirt and brick alley that is my "street." The first person I see is my barber, sitting in the rusty blue tin stilted shack in which i get my thrice-weekly straight-razor shave. He's managed to perfect the art of delivering the perfect shave while tilted at a 15 degree angle. Waving as i pass, i quickly come to my chai wallah. Wallah, in common parlance, means "one who is engaged in," and he engages very well in my morning, afternoon, and sometimes evening chai. He has a lovely, tall and frighteningly thin young boy with a beautiful smile that works with him, a non-filial relationship i've not quite figured out, but who seems to like me very much and we're always waving at each other. I grab a seat on a plastic blue stool and contemplate the morning while the chai-man works his milk, sugar, and tea powder magic. I wave to the ironing man who's roadside office consists of a board set against the wall, its street end balanced on two thin wooden sticks. He pulls coal from a sac and places inside his giant iron before lighting it up for a morning's work. There's a man selling shirts, one selling brooms, and another selling the stainless steel and nested "tiffen" sets in which so many Indians carry their food to work or school with them. A rickshaw will make it's way precariously down the street. Bicycle bells ring out periodically. A man sells south indian food on a small table: iddlies, dosas, sambar. Fresh fried vadas are cooked in large vats of oil. People mill about. It's a wonderful little street. Oh, but i didn't tell you about the hazards. Each side of this little street is lined with large rectangular concrete slabs, layed perpindicularly to the street. Gaps in these slabs are not uncommon and what does one find beneath but the open sewer? One's nose confirms what one's eyes won't forget: the contents of so many toilets floating in a river of muck. So in avoiding the occasional cow paddy, or cow, or rickshaw, or bicycle, one must be careful to not step too far to the side, or else end up in the sewer. Yikes! The reality is that it is not so different from early 19th century England.
I spent the morning at a small rural satelite community hospital in a vellage outside Vellore. The clinic is called RUHSA, the Rural Unit for Health and Social Affairs. On Thursdays one of the more senior residents (today it was Praburam) hosts an outpatient clinic for those more complicated cases identified throughout the rest of the week. In a room no larger than 10x40ft, four physicians held court as a parade of patients, adults and children, lined up to see them. No fewer than 6 children at a time waited in front of Dr. Praburam's desk, each listening patiently to the stories of those in front of them. There is no such thing as privacy here and one hopes that, if anything, this communal suffering leads to a more communal empathy. We saw about 40 children in 4 hours. Nearly half of them had symptoms, lab tests and chest x-rays concerning for tuberculosis. Western pediatricians are grateful that we no longer (or very rarely) have to contend with this consuming illness. Fortunately, thanks to clinics like this one, children are being identified early and are subsequently getting the treatment that will likely save their lives.
I spent the afternoon at The Swimming Pool, a tranquil and sunny private oasis that abuts the undergraduate medical campus. It's an escape from open sewers and acid-fast bacilli (the type of bacteria that cause tuberculosis) and the endless and nearly unavoidable honking of horns. Some sentence fragments: an olympic sized pool surrounded by palm trees and lush and shortly-shorn grass; a cold coca cola in one hand; a good book in the other. What better way to contemplate the mornings events and what a guilty pleasure?
Life's not all bad.
justin
CMC - Day Eight
As she began a patient visit this morning with a young Bengali family, Beryl, one of my favorite interns on the team, advised that when interviewing families, one ask what is the primary purpose for their visit to CMC. It is likely to tell one about the urgency of a child's presentation. In the case of this family, the grandfather was here receiving treatment for some ailment or another. They had brought their daughter in out of convenience. Cute as a button - cute being the 5th vital sign in kids, along with temperature, blood pressure, pulse and respiratory rate - with short black hair, wide brown eyes, and lips pursed in shyness, this young lady looked very healthy. Her chief complaint was actually not hers at all; her parents were concerned about her hyperpigmented tongue. I ask you to understand the word hyperpigmentation in the lightest sense possible. Her tongue appeared only slightly darker than the child that had come before her and she exhibited none of the greyish to black (or even hairy) hyperpigmentation that can be seen in Addison's disease (or, for medical folks: Peutz-Jeghers syndrome, melanoma, amalgam tattoo, toxic reactions to various metals, hemochromatosis, pernicious anemia, scleroderma, Laugier-Hunziker syndrome), or that present as a rare side effect of using certain medications, among them antimilarials, minocycline (for acne), and doxorubicin (for anticancer activity.) In truth, her parents complaint was more cosmetic than medical. Beryl seemed to think that it had something to do with the girls marital eligibility some day. One might be tempted to think that in a country where a family is so much more likely to struggle for the basic things in life that such superficial concerns would be a trifle.
Not so. In India, as in most countries of the world where skin is naturally darker, one finds an assortment of skin-bleaching products on the shelves of even the smallest corner stores. They are advertised extensively, in newspapers, tabloids, billboards. In matters of the skin, is the grass always greener? A few weeks ago i wrote to a new friend, Elizabeth of Uganda, a woman with the most stunning ebony skin, and told her of plans to head to the beach - must tread carefully here as my dermatologist is recieving these dispatches. "Wish you luck with your tanning," she wrote back. "Isn't it amazing? The whites want to be dark so they tan themselves and the blacks want to be light so they bleach themselves! Why we werent given the choice i don't understand. It would make for an easier life. One day white and one day black." I love this idea; it had never before occurred to me. I'm not so sure it would solve any problems, though. Surely skin color would be subject to the same fads that present themselves in all the other areas of our lives in which we have choices. Such a thing might have the positive effect of teaching us all how unimportant skin color really is when it comes down to it. As an aside, in the west the most successful medical students often go on to choose careers like dermatology, which offers good medicine, great hours and a grand income. I mentioned this to the residents over coffee the other day, and to their surprise. In India, despite all this concern about the skin, i'm happy to report that the most competitive fields are in primary care.
We heard an interesting lecture today from the developmental pediatrics team on a condition called Hemiconvulsion, Hemiplegia, and Epilepsy (HHE). This rare phenomena has two types, distinguished by their mechanism of onset. Type I comes about in most cases following an infection in the central nervous system - meningitis or encephalitis - and Type II is called idiopathic because it seems to originate without a cause (but is often referred to as an atypical febrile seizure). The course of illness goes something like this: children usually under the age of four develop a prolonged seizure either as a result of illness or not. This seizure causes damage to the brain tissue which leads in some time to either a flaccid, spastic, or flaccid then spastic paralysis on one side of the body (hemiplegia). Most often it resolves, at least in part; sometimes it does not. In a period that varies in time (in the largest observational studies) from 1.5 to 12 years, children experience the onset of epilepsy. The lecturer raised an interesting point, one that exceeds most peoples understanding of epilepsy: seizures are only one symptom of epilepsy. Many of the children identified with HHE have epileptic seizures only rarely. Depending on where the initial damage took place in the brain, children's motor skills, spatial awareness, verbal fluency, and behavior could, and are, affected. The children identified in the department at CMC presented with rather severe behavioral problems. Now for the treatment: hemispherectomy. That is, they take out the part of the brain that is affected. What has been shown is that not only has seizure activity been eliminated or improved in most cases, behavioral problems have also improved. (for those interested in the article, the reference is: Devlin et al. Clinical outcomes of hemispherectomy for epilepsy in childhood and adolescence. Brain, Vol. 126, No. 3, 556-566, March 2003. you can google it.) Now, what some were wondering, myself among them, was if the children's behavior improved for some other reason than the removal of bad brain tissue. Perhaps the recognized punishment of having part of one's brain removed was enough to get kids to shape up. Take note: the threat of such an operation might be an effective parenting tool in times of bad behavior. In all seriousness, it's a remarkable procedure, one performed with great awareness about what parts of the brain are affected adversely and which are not. With imaging techniques becoming more and more sophisticated by the day -
Medicine is exciting because it concerns itself with the skin, the mind, and everything in between. As the young child with the slighly more purple tongue was being examined, on the chair next to her (remember that there are often two exams going on in the same room at the same time by two different doctors) was a young girl with a cleft lip and palate. She was cute too, a happy and playful child. She had come to CMC for surgery to correct the split in the roof of her mouth and lip, surgery which had been delayed because she had developed a cold. As we examined the child with the cleft lip i noticed that the mother of the other girl kept looking over to watch the former. She could hardly take her eyes of the little one. I wonder if seeing this child with this obvious deformity, correctable though it is, made her think about the complaint she had for her own daughter. I wonder if it made her grateful for what she had.
I'm grateful to be in India and grateful to have friends like you.
justin
ps. As i write, a young physician in the computer room in front of me is surreptitiously surfing the web for photos of his favorite female Tamil film stars, most of whom have fairer skin. It's a funny site and one i see almost everyday. Young male students and doctors gaze at their computer screens, ready, when someone walks by, to pull up another page that would make it appear that they are actually working.
Not so. In India, as in most countries of the world where skin is naturally darker, one finds an assortment of skin-bleaching products on the shelves of even the smallest corner stores. They are advertised extensively, in newspapers, tabloids, billboards. In matters of the skin, is the grass always greener? A few weeks ago i wrote to a new friend, Elizabeth of Uganda, a woman with the most stunning ebony skin, and told her of plans to head to the beach - must tread carefully here as my dermatologist is recieving these dispatches. "Wish you luck with your tanning," she wrote back. "Isn't it amazing? The whites want to be dark so they tan themselves and the blacks want to be light so they bleach themselves! Why we werent given the choice i don't understand. It would make for an easier life. One day white and one day black." I love this idea; it had never before occurred to me. I'm not so sure it would solve any problems, though. Surely skin color would be subject to the same fads that present themselves in all the other areas of our lives in which we have choices. Such a thing might have the positive effect of teaching us all how unimportant skin color really is when it comes down to it. As an aside, in the west the most successful medical students often go on to choose careers like dermatology, which offers good medicine, great hours and a grand income. I mentioned this to the residents over coffee the other day, and to their surprise. In India, despite all this concern about the skin, i'm happy to report that the most competitive fields are in primary care.
We heard an interesting lecture today from the developmental pediatrics team on a condition called Hemiconvulsion, Hemiplegia, and Epilepsy (HHE). This rare phenomena has two types, distinguished by their mechanism of onset. Type I comes about in most cases following an infection in the central nervous system - meningitis or encephalitis - and Type II is called idiopathic because it seems to originate without a cause (but is often referred to as an atypical febrile seizure). The course of illness goes something like this: children usually under the age of four develop a prolonged seizure either as a result of illness or not. This seizure causes damage to the brain tissue which leads in some time to either a flaccid, spastic, or flaccid then spastic paralysis on one side of the body (hemiplegia). Most often it resolves, at least in part; sometimes it does not. In a period that varies in time (in the largest observational studies) from 1.5 to 12 years, children experience the onset of epilepsy. The lecturer raised an interesting point, one that exceeds most peoples understanding of epilepsy: seizures are only one symptom of epilepsy. Many of the children identified with HHE have epileptic seizures only rarely. Depending on where the initial damage took place in the brain, children's motor skills, spatial awareness, verbal fluency, and behavior could, and are, affected. The children identified in the department at CMC presented with rather severe behavioral problems. Now for the treatment: hemispherectomy. That is, they take out the part of the brain that is affected. What has been shown is that not only has seizure activity been eliminated or improved in most cases, behavioral problems have also improved. (for those interested in the article, the reference is: Devlin et al. Clinical outcomes of hemispherectomy for epilepsy in childhood and adolescence. Brain, Vol. 126, No. 3, 556-566, March 2003. you can google it.) Now, what some were wondering, myself among them, was if the children's behavior improved for some other reason than the removal of bad brain tissue. Perhaps the recognized punishment of having part of one's brain removed was enough to get kids to shape up. Take note: the threat of such an operation might be an effective parenting tool in times of bad behavior. In all seriousness, it's a remarkable procedure, one performed with great awareness about what parts of the brain are affected adversely and which are not. With imaging techniques becoming more and more sophisticated by the day -
Medicine is exciting because it concerns itself with the skin, the mind, and everything in between. As the young child with the slighly more purple tongue was being examined, on the chair next to her (remember that there are often two exams going on in the same room at the same time by two different doctors) was a young girl with a cleft lip and palate. She was cute too, a happy and playful child. She had come to CMC for surgery to correct the split in the roof of her mouth and lip, surgery which had been delayed because she had developed a cold. As we examined the child with the cleft lip i noticed that the mother of the other girl kept looking over to watch the former. She could hardly take her eyes of the little one. I wonder if seeing this child with this obvious deformity, correctable though it is, made her think about the complaint she had for her own daughter. I wonder if it made her grateful for what she had.
I'm grateful to be in India and grateful to have friends like you.
justin
ps. As i write, a young physician in the computer room in front of me is surreptitiously surfing the web for photos of his favorite female Tamil film stars, most of whom have fairer skin. It's a funny site and one i see almost everyday. Young male students and doctors gaze at their computer screens, ready, when someone walks by, to pull up another page that would make it appear that they are actually working.
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