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