Wrap it up, wrap it in

Following Supertramp's advice, I took the long way home from Lilongwe:

Took off from the Lilongwe Kamuzu Airport, named after the first president/dictator of the country, Dr. Hastings Kamuzu Banda. Apparently Kamuzu means "roots". The cult of personality is strong. Watched the land fall away beneath us, an orange-brown expanse speckled with dark, stubborn trees.

Flew for a brief one-hour stop over in the Democratic Republic of the Congo, where we hung out inside the plane on the tarmac for an hour, watching UN planes load cargo before taking off again.

Long layover in Addis Ababa, where three friendly teenage Ethiopian girls shared their dinner with me and a pair of Indian men insisted I pose for pictures with them. The whole airport smells like burning frankincense and seeping black coffee. Have decided Ethiopia might have to be my next big adventure. Already composing future Innervated posts in my head.

Then 24 hours in London, putzing around Covent Garden and marveling at the wonders that are salad and Mexican food. Naively rented a bike, neglecting to realize that I 1) have no knowledge of the city layout or 2) ability to drive/bike on the left side of the road. Sweating bullets but lots of fun. Great theater at the Old Vic with my uncle's brother, a fine American ex-pat.

And then home on Sunday morning to Chicago, seriously confused about what time it was and what this water coming out the sky could be. I left in the summer and came back in the fall. But at least there are Honeycrisps.

Annnnnnd photo highlights, for anyone interested.

Donors

This morning, before my fellow med students had even cracked an eyelid, I was off on my own personal clinical adventure: the maternity ward at Kamuzu Central Hospital! I’d been on a tour through the labor and obstetrics floors with the rest of the group a week or so ago, but this time, I was going to be more than a tourist – I was going to go behind the scenes. Dr. Sethi happens to know an American physician, Dr. Chambers, who’s working as an Ob-Gyn at KCH for a year. Since Dr. Sethi knows my heart of hearts isn’t really into this whole skin thing, she arranged for me to spend my last full day in Malawi tagging along with Dr. Chambers and seeing what the day-today life is actually like for an American physician integrated into the Malawian system.

As it turns out, the day-to-day life of Dr. Chambers…appears to be a bit like living in a Kafka novel. I caught her on her post-call day; she’d spent the past 24 hours living at KCH, taking care of all the overnight emergencies on the antenatal/labor/postnatal wards. So the hard part should’ve been over, theoretically – the rest of the staff was back to help out and take over from her.

Things proceeded efficiently at first. The turnover meeting, where everyone talks about the patients together and gets on the same page, actually even started on time. I recognized the whole procedure all from the US system, with the exception that there’d been a maternal death the night before (almost unheard of back home).

But from there on, the system started to show its flaws a bit. The first patient for us to see that morning was essentially the victim of a botched C-section at another hospital; she obviously had some big collection of fluid in her left belly that was causing her a lot of pain. From the limited view available via ultrasound, the docs suspected it could basically be either blood (from an injury from the surgery) or pus (from an infection) – either way, she’d need a second operation. And this when she’s still knocked out quite a bit from the first surgery and is trying to take care of an infant (who had his own tiny pile of blankets next to her in the patient bed. Aw).

But still, that was the fault of doctors elsewhere, not the big fancy central hospital. I could compartmentalize that….until the next task of the morning, in which we tried to find someone to sign off on the plan of care for a woman with widespread tuberculosis (TB) and a planned C-section. There is a dedicated TB ward at KCH, so this seemed straightforward to me. We walked across campus, right up to the TB office: empty. We asked across the hall – donde estan los TB officers? Not in yet, came the response. They usually come late. But we could leave a message. Did we have the Official Consult Form and the patient’s file?

We did not. We walked all the way back, found the required form, and realized that if we took the patient’s physical file with us, the anaesthesiologists wouldn’t be able to have it in THEIR official pile and would cancel her C-section. (The “patient file”, mind you, was just a loose pile of papers. No one had bothered to even put it in a folder yet, let alone organize it.) So we returned with just the consult form….only to find that both the TB officers AND the folks across the hall were now missing. Patients lined the corridors, waiting, but no doctors to be found. A nurse told us we’d have to go see the general medicine physicians upstairs; another 5 minute walk led us to discover that they, too, were not in their clinic. Back downstairs. Someone finally picks up a phone and calls in the TB officer. Great! We establish a plan in two minutes for the baby’s medicines – but he won’t give us the medicines now, or write down instructions for what the dosage should be. No, he’d rather the extremely sick patient and her newborn just come across campus to this office after the C-section and he’d see to it then. No doubt he’d be in his office – eventually.

The next adventure was more of the same. Two patients in the postnatal ward were in extreme need of blood transfusions, but two major things seemed to stand in their way. First, they needed blood samples drawn so that we could make sure they got the right type of blood; theoretically this had happened the night before. Second, there had to actually BE blood to transfuse. (Not a barrier I often consider in writing my US patients for transfusions, really.)

Trying to work out this bloody (heh) situation got increasingly ridiculous. First, turns out there were exactly zero pints of blood for adult patients in the whole of KCH. Not a single one. The national blood transfusion service had taken the day off yesterday, and were taking their time getting running again this morning.

So we decided to try to work out the blood sample in the meantime. We walked to the lab; the lab claimed to somehow have only received one of the patient’s blood samples and required a second. We walked back to the ward; the nurse on duty claimed it had been sent. Back to the lab; some half-hearted searching for the blood tube and coming up empty-handed. Back to the ward, awkwardly lugging a freezer box full of three units of commandeered pediatric blood for the most needful patient, who had the lowest blood count I’d ever heard for a living human being (hemoglobin of 2, med school friends. 2!). Back to the lab to return the freezer box and bring the new sample for the other patient. This all took about 90 minutes altogether, and still no sign of any adult blood units from the transfusion storage folks. As Dr. Chambers stated matter-of-factly on our 11th or 12th walk, “I’m pretty sure most of what I do here does not require a medical degree."

Because what she does, essentially, is follow through. The American medical system ingrains it into all its physicians: your patients are YOURS. You must do what you need to do to make sure they get care. In truth, the American system probably takes it too far – this is how medical residents end up working 100+ hours a week and making sleep deprived mistakes. But on the other hand, no US surgeon would ever refer a pregnant patient to another hospital for a C-section because he was “tired” and “didn’t want to do any more C-sections today”, a note Dr. Chambers recalled from a recent referral. She says she struggles daily to find a balance between making sure her patients get what they need and not doing the hospital staff’s jobs for them; there’s no incentive to find your blood samples, follow up labs, or actually take your patients’ temperatures, if someone else will always do it for you.

For someone trained in the American hospital system, I think this could quickly make you insane – so much inefficiency, and so much feeling that you can’t rely on other hospital staff to consistently do their jobs. Dr. Chambers apologized throughout the morning for being “cynical”, but said that she tries to keep in mind just what it’s like to be trained in Malawian hospitals: for the most part, extremely sick patients don’t do well. Working harder for your patients might not really make much of a difference. It’s hard to stay motivated and driven when the guy next to you, who just sits around and plays tetris on his phone all day, has patients that do just as well as your own.

So, despite not seeing a single birth or C-section today, I actually felt like I learned a lot more today about what it means to be an Ob-Gyn working in a resource-poor hospital. You make some clinical decisions, yes, but a significant part of your day is spent simply trying to keep the momentum moving forward, personally seeing that each small step in the process happens and generally fighting inertia. Very eye-opening. Part of me feels like I would be quickly beaten down by that daily existence, and that I should focus my future global health efforts on the policy or research level rather than the clinical. But I admit – part of me also sort of likes the idea of being the one who sees things get done, crossing all your own Ts and dotting your own Is. Saving lives, for sure.

In the meantime, I figured I could at least try to help kickstart the blood service again – my fellow med student Laura and I stopped on the way home to donate a pint each to the Malawian Blood Transfusion Services. (Just like the experience at the Red Cross, but with squash juice!) Dr. Chambers says she’ll be on the lookout for them in the maternity ward.

Whole lotta nothin'

For all the build-up, the feared Day of Protests turned out to be nothing. I did a little walkaround in the evening time - everything was quiet, even quieter than usual, and the streets were the emptiest I've ever seen since coming here. Guess everyone decided to stay inside, either to avoid the riots or to avoid a day with no customers. It was a little sad to see the guy at the busstop trying to drum up customers for his vehicle - not a soul in sight that wanted to go to Area 17. Not a good day for public transportation business.

Off to the maternity ward this morning! My little Ob-Gyn-loving heart flutters.

Protesting on the inside, maybe.

Not a peep all day. Once, we heard a siren. That's about it. We've had a few visitors to the house (Dr. Sethi's flying out tomorrow, so folks are coming by to wish her bon voyage), and all of them say the same thing: the stores are closed and the streets are quiet. Lots of apprehension for nothing, it seems.

Well, if nothing else, I made good progress on my pile of crosswords.

Protests?

The morning dawns! Nothing so far except the usual street sounds outside and bright sunshine filtering through our windows. I admit to wearing my navy blue sweatshirt right now, which I think makes me a patsy of the established party, but I'll change it out for a nice neutral green later.

Just had a quick flashback to the very first protest/rally/march I remember attending: we were all under the age of 10 and Mom took us to downtown Annapolis to support more restrictive gun laws. We loved the chanting. Imagine tiny voices: "What do we want?" "GUN CONTROL!" "When do we want it?" "NOW!" Still do, I guess.

Limits

Between the speeches, the dancing, the ululating, and the sunblock distribution, I completely forgot to mention the “testimonial” portion of Albinism Awareness Day. There was only one offered, but it was a doozy: a young man named Coco who’d made it all the way through graduate school in the Congo (DRC), only to be hunted down one night by armed, anti-albino vigilantes in his own neighborhood. He fled out of his parents’ back window and basically didn’t stop running for the next several years. He went out of the DRC, through Burundi, into Tanzania, futilely seeking protection from the police against those seeking to make some money off an albino corpse. Finally, a sympathetic Tanzanian cop directed him to the Dzaleka Refugee Camp in Malawi, just 45 minutes outside of Lilongwe.

And that is how, as guests of Coco, we got invited out to visit Dzaleka this morning. Boniface, who came with us, told us that “Dzaleka” means something equivalent to “limit”, or “barrier”; prior to its incarnation as a camp, the area was actually a political prison, reserved for those so-called troublemakers whose political activism the state judged to be beyond the limit. Now, of course, the name has a different implication, but still sort of fits: The refugees inside are both far beyond their native barriers while simultaneously limited in terms of movement within Malawi.

I’ve never been to a refugee camp of any kind before. As we rode out, I was steeling myself for a terribly depressing tent city, full of squalor and sickness and people who’d born the full cost of Africa’s many disastrous governments.

That last one, of course, is true. The camp has about 15,000 inhabitants now, with about 400 new refugees arriving each year. They come from the DRC, Somalia, Rwanda, Zimbabwe, Burundi, and occasionally places as far Sudan. Our little bits of Chichewa were rather useless in a sea of non-Malawians; the lingua franca is a mix of English, Swahili, and French, with an occasional smattering of Amharic thrown in.

But my other fears turned out to be pretty damn far from the truth. The Dzaleka Refugee Camp is rather amazing. The UN and the Jesuit Refugee Services do a remarkable job of accruing resources, making the most of them, and then putting smart, dedicated people in charge. Simple tactics, but easier said than done.

And they do this at many levels; people come to the camp with a wide variety of backgrounds, physical capabilities, and education, and the Dzaleka coordinators seem to do an admirable job of catering to as many groups as they can. We saw, for example, a beautiful computer lab designed for those refugees seeking higher education credits, with at least 20 shiny PCs and a central projector that would’ve been at home in any US college campus building. And the computers actually worked! They hadn’t broken and then been abandoned for lack of technical know-how! There was an IT guy on hand to fix any issues and about a dozen young men and women working at the consoles, waiting for their Skyped-in lecture to start. And the whole building is powered with solar panels on the roof. Amazing.

And then, for those refugees less likely to pursue college coursework, the wider camp is a remarkable testament to some UN flunky’s love of organization. All the typical community institutions – churches, medical clinics, even rec halls – are located prominently in the camp and have the staff and at least the minimum amount of supplies necessary to do their jobs well. (Dr. Sethi’s already trying to figure out how to bring a derm clinic to the camp next year.)

And the community itself is much, much more than a thrown-together tent city. Upon arrival, every refugee is issued a designated plot, within walking distance of a standardized water pump and with a built-in connection to electricity. They’re free to build whatever kind of home suits the needs of their family, and are likewise free to grow whatever kind of crop they want on their allocated piece of farm land. The streets are wide enough to stay clear and the buildings, made of some sort of mud-concrete mixture, feel permanent. Chickens and lambs and goats putter around through back yards. The people look busy – no one is simply waiting for handouts. In truth, Dzaleka seemed like a much more pleasant place to live than many of the rural Malawian villages we’ve seen so far this month. It’s also the only place I’ve ever seen in East Africa where the homes actually have addresses – every door is marked with a letter and number combination which helps the camp coordinators find particular refugees in case of emergencies.

It also struck me, as I was walking around, how a camp like Dzaleka is a bit of an economist researcher’s dream. It’s a large, essentially captive population, with a steady stream of known inputs (rations of oil, rice, beans, etc.). What happens to this community? Classic Econ 101 stuff, it turns out. You get an amazing second-hand market – we walked by folks selling everything from Disney blankets to traditional Ghanian fabrics to shovel heads. A few businesses can exist targeting only a specific subpopulation in the camp – we saw an Ethiopian restaurant, for example – but most business survive by catering to the needs of all refugees, willing to sell to anyone with something worth trading for. You also get the development of an entertainment business: we poked out heads into a Dzaleka “movie theater”, a dark home with benches where patrons can pay 20 kwacha (about 8 cents) for the privilege of watching 4 hours of whatever DVD happens to be playing in the ancient TV at that time.

You also get the formation of new alliances. Our tour guide, a young man named Thierry from the DRC, actually met his wife in the refugee camp. He fled the Congo at age 25 for reasons he preferred not to say (though he does bear scars from bullet wounds on his right leg), traveling with his mother across the border in the back of a pick-up truck. A few months after arriving, he met a lovely woman also from the DRC – and the rest is history. They’re both learning English now, wondering whether the powers that be might see fit to relocate them to Australia, or the US, or Norway – countries that tend to accept the most camp refugees, apparently.

Because no matter what their training or education, or how useful they’d be in the “Warm Heart of Africa”, Dzaleka refugees are in no way eligible to become Malawi citizens. Likewise for babies born to refugee parents. They are resigned to wait – wait in the camp, wait to be returned home, wait to be sent on to a brand new life. Our guide Thierry told me he simply doesn’t think about it. As far as he can tell, he has no say in the matter. So in the meantime he’s simply living his life at camp, with his young wife, relaxing in the evenings by watching DRC music videos on the TV in their 2.5 room home. Not the terrible life I worried I would see, but a strange one nonetheless.

Hmm. That was a long post. Apparently my brain had a lot to get out. Apologies.

We’re on a bit of a lockdown for tomorrow’s protests – no going to the hospital, no venturing outside the house walls, and no wearing of red or blue (political party colors here). If my internet card holds out a little longer and there’s anything of interest to write, maybe I’ll do a little live blogging. So far, all is calm and all is bright.

Clinical Judgment

Well, that went quick. All of a sudden, we’ve just finished our last day of clinic. It’s a bit of an abrupt ending, too; usually we go every weekday, but a combination of special opportunities and somewhat perilous political situations will be keeping us out this week. Tuesday and Thursday we’re off to a nearby refugee camp and a leprosy clinic, respectively. And Wednesday…well, Wednesday is a bit of a toss-up. After canceling them earlier in the month, the Malawian opposition has decided that their protests are now back on, and scheduled for the 21st. Most of the ex-pats and Malawians I’ve talked to don’t seem too impressed; we might end up staying home in our compound for the equivalent of a loud town meeting. But then, given that the last protests ended in 20 civilian deaths, seems like it might be better to err on the side of caution. We’ll see.

In any case, today’s clinic was a nice snapshot in terms of the most important things I’ll take away with me from this odd little rotation. For one, regardless of whether I’ll ever use it again in my future career, I’ve become pretty confident in my tropical derm skills. Chicken pox? Pellagra? Nima-soap-induced skin reaction? (Nima is a brutal soap used here.) I’m on it. Rashes are my cup of tea. I got to see only the most rare and exciting patients for three weeks, with virtually none of the boring! It’s like eating only the top of the dermatology muffin! Working in the clinic here reminded me of all the fun parts of derm that appeal to me – while simultaneously reminding me how infrequently these types of derm patients show up in the US dermatologists’ offices. Just what I wanted.

For two, this has been one of the first rotations where I’ve actually been a teacher as well as a student. The medicine hierarchy puts third-year medical students at the very last rung on the ladder; they are there only to receive wisdom, not to pass it on. (I actually got reprimanded last year for trying to remind a patient what had just happened in her recent surgery. “You are here to watch and to learn, and nothing else,” my resident yelled.) But this month, amazingly, there were people around who know less than I do. I shared a clinic room with one of the second-year students for two weeks, and I tried my best to be like the senior students I loved during my early years – full of information, not overbearing, willing to let the younger student try her hand at some smaller tasks and take credit for any successes we had as a clinical team. The last one is particularly hard, I found – it’s hard to not want all the glory for the application of your hard-earned knowledge – but I think I got better. We also had Malawian nursing students with us, rotating through for a week in their training. Teaching through a language barrier is extra tricky, but I was really happy with the way our morning with today’s student turned out: after I took the time to explain all about herpes zoster (aka shingles) for an early morning patient, our student triumphantly identified a second zoster patient who walked in a few hours later. There were high fives. Instantly gratifying.

And then, as with every international health experience, there are the moments of doubt. On Saturday, our visiting surgeon had operated on an albino woman with several horrific skin cancers on her face. Two cancers came off rather simply, with an elegant skin flap to cover the open space on her cheek, but the third…the third was a monster. Almost 7 inches wide, it clearly had been growing for years and looked like it actually reached down to her skull in the center. (The patient had taken to simply covering it with a head scarf at all times – we didn’t even realize it was there until someone finally thought to have her take it off.) Our surgeon decided to operate on her, even if there was only a partial chance of a cure – with her skull exposed like that, it seemed like only a matter of time before the cancer crossed through the bone and gave the patient meningitis. But during the operation, after cutting carefully for a few hours, our surgeon realized that the cancer was already in the bone. Simply removing the skin around the cancer would do no good. So we sewed the patient’s forehead right back up, and sent her to the general hospital for wound care.

Today, 48 hours later, we saw her back – and her face is clearly infected. Part of the skin flap has died and turned black; there’s nothing to do for that except wait for it to slowly scar over. Wound care at the hospital has been less than ideal – she didn’t have a fever yet, but there was pus and a distinct odor around the stitches.

We’ll start her on antibiotics, and hope that her sisters at home can do the diligent wound care that she’ll need for the next few weeks. But I really found myself wondering – what have we done? This woman was in no pain before we took her to the operating table. True, the smaller cancers are gone. But the one that’s going to kill her is still there, and untreatable in Malawi. And maybe we’ve even shortened her lifespan by exposing her to these infections. And next week, the two main doctors involved in her care will be half a world away, back in the US, inaccessible.

Part of me feels that to do nothing, to not have tried to remove the biggest cancer, would be just as morally blameworthy, if not more so. But it’s hard to reconcile the fact that, all things considered, her outcomes are no better, and probably worse, than if we had never treated her at all. There are many other patients that I think were genuinely helped by our presence here, but it’s hard to remember that when you’re looking this poor woman’s face.

Learning, teaching, then reevaluating your work in an ethical light – a worthwhile clinical experience, overall. Looking forward to the refugee camp tomorrow.

Running for Office

I’m not a great runner – I have an inefficient stride, little floppy ankles, and a tendency to wince involuntarily at the mention of marathons. But here in Malawi, where so much of my time is spent behind the walls of some “mzungu-safe” institution (even our house in Lilongwe has barbed wire atop the outside walls), the idea of ranging freely is very appealing. So my little sunburnt ears perked up when one of the housestaff here mentioned a previous runner’s solution – the Lilongwe golf course.

Running, or any non-work-oriented exercise, for that matter, isn’t really done in Malawi. (To be honest, I’ve never really seen “joggers” of the American type outside of the US in any of my trips; even England and Western Europe don’t really seem to do gyms or laps or any of those purposeful-wasting-of-calories activities.) So trying to go on a simple run can be a bit overwhelming. In addition to the usual special attention one gets for being a tall white woman in the streets, you get twice as many stares for being a damp one wearing shorts. I’ve never been so conscious of my knees in my life. It’s enough to keep a little globe trotter inside.

But the golf course! Brilliant! If I can handle the stares for a short half-mile trot to the opening gates, I get all the wide open space I can handle – as long as I get out before 7 AM. I’m not a morning excerciser at all in the States, and I’m only a sporadic one here. But if I can drag my lazy bum out of bed early enough, trotting around the course in the breaking dawn is actually a lot of fun. As you might imagine, the “greens” in a golf course where it hasn’t rained in four months are…not so green. Lots of dried grasses and red-brown dirt underfoot. It’s also much less manicured than the golf courses of home – lots of leaping over holes and dodging fallen “sausages” from the sausage trees. Between that and the fact that there are almost no signs to orient me, it’s a bit more like trail running than jogging. I even used the position of the sun to navigate when I got turned around last week. A run where you can get covered in dirt and really quite lost is pretty exciting.

And today’s was even extra exciting! Celebrity sighting! On most runs I only see one or two workers clearing brush, if anyone at all, but this morning I was running amid a flurry of activity: police officers, people wearing important-looking Safety Orange vests, and drummers audible in the distance. I eventually gathered that some sort of tournament was underway, and headed for the exit at my usual time – only to be stopped for the presidential motorcade! Bingu wa Mutharika himself! I saw him in the back of the presidential limo, looking a bit grumpy but clad in a fine-looking polo shirt and headed for the clubhouse. Guess Malawi’s current political imbroglio (ahem) is no reason not to get a few holes in.

White to Bare Arms

Albinism Awareness Day! Man, am I aware right now. The fabric sign tied to the front of the tent actually said "Albino Awareness Day", but apparently this is something of a politically incorrect term - these are "patients with albinism" rather than "albinos". It's all about not letting your skin condition define you. I can get behind that. (I will now insist on being called a patient with mzunguism.) But typing out "patients with albinism" each time on this blog post will get a little boring, so I'm going to use the shorthand; no offense meant.

Today's event was definitely in keeping with my experience with previous conference-type events in Tanzania. As a general rule, the speeches are more boring than in the US - but the dancing, ululating, and music are much better. The crowd trickled slowly in from about 8:30 AM on, both on foot and in big group buses. We probably ended up with about 150 folks in total. I'd say about 65% of the crowd was composed of albinos, with the other 35% being their darker skinned family members. Albinism is a recessive trait, which means you often see non-albino parents with albino children, or groups of siblings with two dark faces and two white. If you have one albino parent and one non-albino parent (rather unusual, given the stigma against albinos), you can also end up with an albino mom carrying a little non-albino baby on her back.

The skin damage in the crowd also varies enormously. There are a few people like the event coordinator, Boniface Masa, our Albino Awareness Coordinator Extraordinaire. He’s an extremely well-educated albino man with similarly educated parents, who took extra care to protect him from the sun from a young age. He’s always snappily dressed for maximum sun protection, with long sleeves, long pants, topped with a wide-brimmed blue hat. And his skin is flawless. (Lives up to his name.)

But there were so many faces in the crowd who clearly had been exposed to far too much equatorial sun. Melanin, the skin pigment that’s missing in albinism, not only makes us browner but also serves as a sort of shield against UV light. Without it, albinos burn even easier than those red-haired Irish folks you see – and suffer the long-term consequences at much, much younger ages. There were lots of kids with horrible-looking infected chronic sunburns, and lots of teenagers and young adults with permanent dark blotches on their faces and arms (the places that catch the sun). A number of the older folks also had obvious skin cancers in the same spots; I could see our visiting skin surgeon, Dr. Schmultz, checking them out with a practiced eye, no doubt plotting her afternoon clinic schedule.

Between the sun damage, the vision problems (melanin plays a big role in our retinas, so albinos have poor eyesight), and the many stigmas and pejorative beliefs attached to albinism in East Africa, albinos are certainly an outcast group in Malawi. But yesterday’s event, the 5th annual AAD, seemed like an important day in terms of turning that around. For one, it was fun – lots of little albino kids dancing together in their new wide-brimmed hats. (I put on my old mzungu hat and headed out there to join in, trying to do that isolated butt moving thing that every little kid in Malawi can do but just makes me look like I’m losing my balance.) For two, it’s a good opportunity to make sure albinos can stock up on and learn how to use their anti-sun weapons; we gave out boxes full of donated sunblock, sunglasses, and of course the ubiquitous sensible hats.

But for three, it’s a chance for these patients with albinism to see not only are they not alone, but that they’re not inherently limited by their skin. Seeing other albinos has the potential to changes albinos’ perspectives about themselves, especially seeing albinos as well-to-do and well-spoken as Boniface and some of the other event organizers. Dr. Sethi says that she always sees the dark-skinned mothers with albino infants watching Boniface very intently during AAD; they’re starting to think big, she suspects.

So an impressive event, with an appropriately impressive flood of albino patients into our clinic yesterday and continuing today. It was a bit odd to suddenly see so much pale skin in clinic after two weeks of only dark. Lots of opportunities to do some sunblock-related education, commend appropriate hat usage, and zap some pre-cancers using liquid nitrogen, my favorite dermatology tool of all time. It looks like the dry ice they use in witches’ cauldrons at Halloween, if only the witches wore latex gloves. Love that stuff.

Elephant stalking tomorrow. Tell no one.

Stigma

Prior to coming to Malawi, all we rotators got a little booklet of information, which we all dutifully printed out and arrived off the plane clutchingly tightly to our chests. Most of it is dermatology information, but there's also a bit in the way of useful Chichewa phrases ("Kuyabwa?" = "Itchy?") and some general cultural info about Malawian society. One of the paragraphs that caught my eye was dedicated to manners and social graces. Malawians are very polite, it said. They prefer to ask questions in euphimistic terms and may sometimes answer questions with what they percieve to be the answer that the questioner wants, rather than the truth.

I'm always skeptical of texts that label a whole people as polite, or brusque, or any personality trait for that matter. But I have noticed that particularly in relation to more delicate medical questions, some of our medical conversations in clinic don't go very easily. With sick babies or children, for example, we're taught in the United States to inquire whether the kid is still urinating normally, or producing the same number of wet diapers - it's a good way to tell whether the child is dehydrated. (Less in, less out.) But the Malawian nurse who helps translate our questions is always reluctant to ask this question of patients; I get the impression he considers it rude. I've been trying to work around it by asking more questions about eating, and whether the child is lethargic or sleepy, which seem to be acceptably polite, but it's not quite the same information.

And then there's the HIV question. Even in the US, of course, this is a tricky question to ask. But there are quite a few skin conditions that really only exist in HIV+ patients; it's important to know their status, whether postive, negative, or unknown, so that you can begin to narrow down what exactly those itchy bumps are.

We had two or three female patients yesterday with rather severe itchy bumps (later diagnosed as a "papular pruritic eruption" - not fun), each of whom looked so classic for a HIV-related rash that we immediately asked for her HIV status. Each woman quickly replied that she was negative for HIV, and that she'd been tested within the past month or so. Huh, we said. What else could it be? We hemmed and hawed for a bit, then wondered if it might be a reaction to another drug she'd recently taken. Each Malawian carries a little notebook with a handwritten record of all her medical visits, so we quickly paged through past encounter notes, looking for clues. And for each of the three women, we saw CD4 cell counts and a "reactive" HIV test - pretty much knockdown evidence that they were HIV+.

And so we awkwardly asked again - was she SURE she wasn't HIV+? Two women quietly replied that, indeed they were. And that was the end of it - no explanation for the initial denial. We took it in stride and set about getting her medicines set up. But the third woman continued to reply that she was negative, despite a positive test two years prior and multiple appointments afterwards at an HIV center. By the cell counts written in her book, she was actually even a candidate to begin anti-retroviral therapy, or ART. (Malawian hospitals don't begin treatment for HIV until patients reach a certain nadir in their immune systems.) But there had either been a complete breakdown in communication in her encounters with the HIV center, or she was purposefully choosing to provide us with false information.

Having three of these encounters in a single morning, it was hard for me to pick apart how much of this was personal denial versus social avoidance of impolite subjects versus the overwhelming stigma still attached to HIV in East Africa (and everywhere else in the world, honestly). About 11-12% of Malawi's population is thought to be HIV+. The government finally started providing ART about 5 years ago, and health outcomes have certainly improved, but it seems like medical treatment can only take a country so far if there's still such a social and personal reluctance to acknowledge one's condition publicly and seek treatment.

And speaking of stigma - it's Albinism Awareness Day today at Kamuzu Central Hospital! No doubt you have heard about it on the TV and radio. We have been advertising heavily. Word is that whole bus-fulls of folks are coming north from Dedza just for the event. Very exciting. Looking forward to giving out lots and lots of sunblock and sensible wide-brimmed hats.

Great Expectations

I’ve just come back from the internet café, where I ran into Laura, one my fellow med students, as we headed out the door at the same time. She, like me, was in a bit of a self-acknowledged snit. As far as we could gather, internet service was apparently slow all over Malawi – not even the official café had anything resembling functional service, although they’ll certainly charge you for the five minutes it takes you to figure this out. A bit frustrating when you’re trying to do things such as pay your gas bills (me) or finish your looming applications for medical residency (her).

And I know, I know, this is Africa – heaven help the mzungu sucker who assumes (or worse, plans ) that any transaction will go smoothly or efficiently. Power outages happen during peak dinner cooking hours about every other day, ATMs regularly run out of money, scheduled car rides don’t happen. And in the clinic, of course, everyday drugs simply run out and don’t get refilled.

I’d say we only end up using about 10 drugs on a regular basis in the skin clinic: a few antibiotics for infections, some steroid creams and anti-histamines for itchiness, an antiviral for chicken pox, and exactly one antifungal, Griseofulvin, that we give out like candy to the many little guys that come in with tinea capitis – basically ringworm of the scalp. (This, for some reason, is way more common in scalps of African descent than European descent, both here and in the US. As my pediatrics attending once remarked, there’s a bit of a tradeoff – white kids don’t really get tinea capitis, but then, black kids don’t get head lice. Odd.)

So griseofulvin was available and plentiful last week, freely available to any patient we sent up to hospital pharmacy with a handwritten prescription. Easy peasy. And then, suddenly, patients started coming back down to us. The pharmacy was out. And that was the end of it. No one knew when more was coming, and the pharmacy itself was unreachable. From our point of view, there was no way of knowing if the hospital itself was even aware of the problem, let alone working on it. And there’s no real alternative to griseofulvin – for those kids who aren’t rich enough to buy the medicine at a private pharmacy, they’ll simply be stuck with itchy, rather unsightly scalps until the hospital procures more. It’s not life threatening, but it’s stigmatizing and irritating – and contagious. More infections for siblings on the way.

I had trouble figuring out exactly why I can’t just go zen about these sort of situations. I’ve been shot down enough times by now that I’d expect a total shift in expectations, but no – I still find myself naively planning for quick ‘n’ easy in a place that’s more slow ‘n’ convoluted. It was actually kind of a relief to find that Laura was feeling a bit of Malawian fatigue as well – she was a Peace Corps volunteer in Guyana back before med school, so the fact that she was still struggling with her own expectations made me feel a bit better.

The more I think about it, the more it actually seems like classic Pavlovian stuff. Our brains here are victims of inconsistent reward. If we were out in the rural areas, this wouldn’t be an issue at all – no technology or institutions to fail, so no letdowns. But in a place like Lilongwe, which has many of the trappings of developed countries but not much in the way of foundation underneath, the rug just keeps getting pulled out from under you. You see that internet and electricity and banking and gas stations CAN exist here, so you get repeatedly tricked into assuming that they WILL exist when you want them. This is the mistake. My western brain assumes all or nothing, when in fact the reality is somewhere in between.

And now, as I finish this, there is a line of waiting cars wrapping around the block from the gas station down the street, each waiting 2 to 3 hours to fill their tanks. Word on the street is that the country will be out of gas by the weekend, and everyone’s trying to store up. Guess we’ll be walking to the hospital tomorrow?

Weekend the first!

After a long week of exhausting, 7-hour days with 2-hour lunch breaks, the other students and I decided that we'd earned a little vacation. Time to blow this Lilongwe popsicle stand and launch out for Malawi's most dramatic feature: Lake Nyasa (as the locals say), aka Lake Malawi.

They nickname it the "Calendar Lake" - 365 miles long and 52 miles wide, a long and skinny freshwater border between Malawi, Tanzania, and a little bit of Mozambique. We flew over it in the plane coming into Lilongwe, a huge blue expanse that stretches out over the curvature of the earth. It begs to have toes dipped in it. We'd decided to do a overnight visit to Cape McClear, a little nubbin of land that sticks out from the southernmost tip of the lake and has national park status. But how to get there? As with all African transport, we're always striking a balance between adventure, comfort, and safety - a private plane is lovely but doesn't give you much of a feel for the country, and public buses, while clearly the people's transportation, might just give you scabies. Ee.

So we opted for a middleground - a boat ride! We launched from Senga Bay, on the west coast of the lake, and zoomed out into some pretty coccyx-smashing waves (the Zimbabwean lady who set up the our ride kept calling the breaking waves "white horses", which I liked). I was having the time of my life in the front, despite some serious wind-knocked-out-of-me moments, but I suspect that some of my fellow riders were very grateful for the fact that we'd chosen to do the return trip by car. If only they'd grown up boatriding with my Uncle Joe, who makes it a point to drive right up and over as many waves as he can, they would've been ready.

No docking necessary - we zoomed right up onto the sand directly in front of our little lodge, where we found our "chalets": basically sturdy little huts with private porches, perched about 20 feet from the lake edge. Couldn't ask for a better view. We took bets on the exact time of sunset as the giant orange ball dipped below the surface.

The lake itself is fully integrated into the community, in ways I wasn't expecting at all. There's a tourist economy, of course - plenty of young guys walking the beach and trying to convince you that you want to go on a boat ride or have a beach fish fry or head out to the nearby island for snorkeling. (For that last one, they were right. We were secretly dying to go snorkeling. I think they saw through our pretended nonchalance during the haggling session, but it was definitely worth it. We plunged off the boat into the cool clear water and were immediately surrounded by cichlids of every color, backlit by afternoon sunlight filtering down from the surface. Awesome awesome awesome.)

But it turns out the lake is more than just looks. It's a huge source of food, of course - we saw dozens of fisherman paddling around off the Cape in handcarved canoes. But it's also a giant kitchen sink. From the time we woke up in the morning until the sunset, there were lines of men, women, and children lined up along the shoreline, washing their clothes and their dishes and their babies. It caught me completely by surprise, mostly because I was expecting Cape McClear to be a tourist spot - a freshwater Aruba, maybe. But even though my brain went "Oo! Ocean!" everytime I looked out into the water, I should've suspected that folks in a country as dry as Malawi would take full advantage of endless, free freshwater.

A hike through a baboon-infested park on Sunday, a cramped-but-amazingly-scenic carride back through the orange Rift Valley mountains, and we were home...if home is a net-covered bunk bed, I guess. A worthy adventure. And no one got sunburned! We're a good little bunch of dermatologists in training.

Hospital-ity

One week over at the skin clinic, and it's already very familiar - I chat up the nurses, I have the one clinic room that I like best, I know where the secret bathroom (with the unbroken toilet seat!) is. But our little clinic is a little ways away from the true Kamuzu Hospital complex, so my perspective until recently was limited to our building and the canteen.

Yesterday, however, we got a personal tour of the hospital grounds from the Head Matron herself, a friendly woman dressed in a sharp blue suit with green/white epaulets and a matching tiny hat. Very stylish. She led us all over the grounds through the different wards, stopping to introduce us to various nurses, therapists, and doctors, most of whom offered just a "You are very welcome!", but some of whom offered mini tours of their own departments.

I've seen a number of hospitals in Tanzania during my time there, and I have to say that I was pretty impressed with Kamuzu Central Hospital, overall. In what seems to be a common architectural style for hospitals in hot, lower resource areas, most of the walkways between wards are open to the air - probably not the utmost in terms of sanitation, but definitely pleasant when you're walking through. Kamuzu has these covered walkways too, but the hospital was remarkably clean - we saw many folks engaged in active mopping as we walked by, and many the indoor areas were totally spotless, at least to my casual eye.

The actual quality of the care being offered seems to vary quite a bit depending on which ward you happened to be walking through. The general medicine ward, usually the most miserable and crazy place in any hospital, was somewhat disheartening: multiple patients to a dim room, a noteable absence of bednets, and frequent nursing shortages. (Just like University of Chicago, now that I think about it, though with rather dingier beds.) Then there were wards that had great potential but weren't quite living up to it just yet. We saw a fine dialysis unit, for example with at least eight modern machines - but all were broken, waiting to be fixed. Didn't look like any patients had been there in a while.

And then, the brand spankin' new maternity ward, named ostentatiously for the president's wife - very impressive indeed. Wide white spaces, a dedicated OR for C-sections, and individual patient rooms, each armed with its own armada of emergency drugs. A giant reminder to encouarge breast feeding was painted in foot-high letters, high on the wall, and a clear list of prices for patients was tacked to the waiting room wall for all to read. (You can save 700 kwacha (about $5) by not coming in until the third stage of labor!) It was great to see it all. I could work there. I could do this.

So an interesting tour of a hospital working its way towards western standards, albeit a bit unevenly. But there are still a few features to remind visitors that no matter how high-tech the hospital gets, it's still smack in the middle of Malawi.

Today, for example, as the morning in clinic ended, we heard the definite sounds of drumming and harmonious wailing coming from the nearby hospital parking lot. Our chief Malawian dermatology officer, Mr. Jimmy, informed us that a member of the Chewa tribe had recently died in the hospital, and his fellow tribe members had come to collect him from the morgue. Since a hospital death can't be marked by the traditional dancing, singing, and music as it would in the countryside, the Chewa tribe has decided to bring the funeral to the hospital.

We watched, amid the crowd of non-Chewa hospital workers, as a chorus of blue-dressed women and accompanying drummers serenaded a trio of extraordinarily dressed dancers, each stomping and swirling and leaping to the music. Dancer outfits consisted of rather terrifying masks (a skull, an eye-less mass of feathers*) and then hundreds colorful strands of fabric tied to the body, which twisted behind them as they danced. Very, very cool. Not your usual hospital lunchtime.

*More sinister than you might think.

Adventures in Hummus

One 0f my medical school professors, who taught a global health course and had been all over the world, always joked that no matter how exotic a location he visited, there was only ever one question people asked when he came back: How was the food?

It's true. We're hungry hungry humans, and by golly we judge our own experiences and those of our friends by how tasty the lunches were. (The main thing patients at the University of Chicago talk about in their comment cards is how much they liked or hated their hospital food - not the nursing, or the surgeon's technique, but how over/under done their eggs were.)

So I always keep track of my culinary adventures when I'm abroad, in anticipation of conversations back home. But the truth is, I've been here nearly a week and I have no idea what Malawian food is like. The city streets are full of little rundown restaurants selling more greasy, less flavorful versions of Indian, Italian, and American food, and at home we're left to our own devices. Word on the street is that the native meal involves a lot of cassava, but I've only seen that once since arriving - on the plate of a fellow med student at the hospital canteen.

I can, however, tell you of my new found appreciation for all the cooks out there who work from primary ingredients. Take my dinner today, for example: hummus and carrots.

In Chicago, carrots and hummus for dinner involves walking to the grocery store 50 yards from my apartment, buying a bag of baby carrots and a tub of hummus (Garlic Lover's), then returning to my home to eat them in peace. My only difficulty, if any, is getting off that little plastic cover over the hummus. Sometimes it rips and comes off in two pieces. Tragedy.

In Lilongwe, hummus and carrots for dinner is actually a two-day undertaking. Getting the hummus itself ready involves:
1) walking over potholes to the local market, dodging the young men at the corner who want to chat you up;
2) discovering no one sells canned chickpeas, and opting for a huge bag of dried chickpeas instead, then waiting patiently to buy them when the power goes out in the whole indoor market and everyone waits around in pitch black for a bit;
3) taking those chickpeas home and dumping them in water to soak overnight, then draining those chickpeas the next evening to discover many tiny dead and dried bugs floating among your peas;
4) plucking the bugs out one by one, boiling the peas for an hour while mashing the tiniest garlic cloves you've ever seen and deciding that plain yogurt could pass for tahini;
5) deciding that you yourself are the "food processor" mentioned in the recipe and mashing peas with the bottom of a cup until your arm hurts; and
6) resolving that "chunky" is a perfectly good adjective for hummus and sitting down at last for dinner.

Only six short steps! Carrot procurement is not quite as involved, but involves more dodging of young men trying to sell you things and more haggling in an arena where you have no idea what things should actually cost.

So hat tip to all those ladies of old (and of current) who make much more complicated things every day for a much more demanding audience. I'll probably try a few more cooking adventures before I return home, but more likely my future meals will involve quite a bit of peel-able fruit and prepackaged crackers. Solid options.

Explanations

It occurs to me, for any readers I have that aren't Mom (do they exist?), that I should explain what exactly I'm doing here in the "Warm Heart of Africa". (Great country motto.) Several months ago, when I was still mincing around on the fence between Ob-Gyn and dermatology as a future career, I set up a three-week away rotation in "Infectious Dermatology" here in Malawi. It's run by a young dermatologist from U of C who specializes in dermatology in developing regions, particularly East Africa and her native Pakistan. She is, as you might suspect, sort of a badass.

I realized after my dermatology rotation at U of C that derm wasn't the right route for me; women's health stuff just calls my name/pulls my heartstrings/pushes my buttons in a way that no other field really does. But hey - I'd already applied for and been accepted to the program, Pritzker had graciously agreed to pay my way, and I still think derm is pretty neat-o. And it even fit my schedule perfectly.

So off I went and here I am. The other med students here all want to be dermatologists when they grow up (with the possible exception of one second-year student, who I may be slowly winning over to Ob-Gyn), but luckily the learning curve in our clinic is so steep that the slight experience advantage they'd have at home is totally wiped out here. There was never any chance that any American medical student, even a gung-ho derm one, would ever recognize zinc deficiency on the first go 'round.

One thing I have come to appreciate, however, is how uniquely suited dermatologists are to short global health missions in developing regions. Unlike other specialties, where you really need to 1) know the patient's history (Does it hurt? When? How long has it been going on? etc.) and 2) be able to follow up with the patient (prenatal visits, blood pressure checks, etc.), dermatology needs none of that. It's all in the visuals. Dr. Sethi doesn't speak much Chichewa - and she doesn't need to. She simply takes a look at a patient's rash, asks whether it hurts and/or itches, and can make a diagnosis in 90% of the cases. It's great to watch. And I imagine most American dermatologists could do the same, with a little practice - it's a speciality that is uniquely visually oriented. I remember a colleague of my Dad's, a dermatologist who often bemoaned the fact that his patients wanted him to talk to them. Why bother? He knew within the first seven seconds what the problem was and how to treat it.

So lots of potential for global health involvement for any young dermatologists out there. It's not enough to turn my head - just love those ovaries! - but I can definitely appreciate the appeal.

The Skin-ny

So back in East Africa, and realizing, sort of surprisingly, that I am not quite the same person I was two years ago. And realizing, also, that I recognize many things here, things that I didn't even remember making a mental note of. These didn't make the "final cut" of my memories of Tanzania, so I hadn't really thought about the orange-red color of the dust, or the way every little corner store sells chips and chicken as a combo meal, or the way you have to haggle for some things (tomatoes) but not for others (cell phone minutes).

But now it all comes rushing back. It's couched in a quite different context - I'm among other Americans, in a much cushier living situation, and I seem to know a bit more medicine - but I do like feeling, for once, that not everything is completely new. Yesterday, when I broke my sandal on the first walk through town? Didn't even blink an eye. Walked right over to the corner market and found the shoefixing guy that I KNEW would be there, because he'd always been there in Tanzania, who promptly repaired the sandal for the equivalent of $3. Done. Felt savvy.

But the big story today was our first trip to the Kamuzu Hospital Skin Clinic, where we six students, under the supervision of Dr. Sethi (from the University of Chicago) and the Malawian dermatology officers, see any and all patients that care to show up on a given day. Queueing outside the clinic appears to begin well before we arrive at 9, and continues until we either run out of patients or run out of natural light. (No electricity in the clinic.) A bit of somewhat organized chaos seems to be the order of things.

But exciting! I emerged today having seen several patients with skin conditions I'd only ever read about in textbooks before - most notably pellagra, which truly hasn't existed in the US since the 1930s. It's like seeing someone riding a pennyfarthing bicycle - except, you know, a rather miserable condition that'd could only happen to someone suffering from some serious malnutrition. Amazing and a bit disheartening at the same time.

Looking forward to going back tomorrow. I VOW to recognize measles this time.

Moni Moni

Chicago to Ottawa to London to Addis Ababa and finally here, touched down safe in Lilongwe. Beautiful scenery out the window on the final leg over East Africa - our pilot kindly pointed out Mount Kilimanjaro as we flew over, a dark spike from the the earth topped in a dollop of fancy clouds.

More impressions later, but so far, expecting the living to be both 1) easy, and 2) a little less exciting than previous trips of this nature. Already chafing a bit at the restriction to not leave the guesthouse without accompaniment...what's a mzungu to do without the chance to do some solo random wandering and get pointed at by small children?

Pixelation

And photos, somewhat organized.

'Til next time, blog of mine.

Home

I finished my Thursday morning HIV presentation, had one last delicious lunch with the ladies of the canteen, put on my sneakers (so strange after 3 weeks of toe-exposing sandals), and set off, heading west (young woman).

Car to the plane to the bus to the plane to the plane to the El and I was home Friday morning, seriously confused about what time it was. 15 hours on a single plane just throws off all your bodily senses: whether you should be tired, or hungry, or how long that baby's actually been crying. Additionally, the Mumbai airport, for any of you who've ever been there, is a total trip. Very Kafka-esque. The international terminal is only accessible from the domestic terminal via a 30-minute tour bus-style ride, where all passengers dump their own luggage into the underside of the bus and a 20-year old Indian security guard with an extremely large gun might decide that he wants your seat and you should sit in the back. All security lines are split male/female, and the female line moves ridiculously slowly thanks to individual, curtained-off patdowns. Big flights technically board an hour prior to departure, but they start taking passengers into a weird little holding area a full two hours before, without explaining the reason. I'm a bit shocked I made it out without major snafus (with luggage, no less).

So back in Chicago, for 48 hours now...and India already feels very far away. While I'm glad to be back among friends, drinking tap water and eating unpeeled fruit with impunity, I'm a little disturbed to transition back so easily. It feels like I should be shocked at the luxury of western living, put off by the coldness of American strangers, and confused by the sound of the TV, like I did when I got back from Tanzania. Maybe three weeks isn't enough to really change my default expectations - or maybe I'm getting used to moving between worlds more quickly. Even if I'm not waking up expecting to hear the sounds of the Mumbai highway, I'm still hoping that SRH left an imprint on my subconscious, from anything as small as the ability to recognize a tuberculosis x-ray to issues as big as how to efficiently allocate scarce medical supplies.

Last Day

Spent the last 24 hours here in what felt like a flurry of activity - but looking back, it turns out that I really only did one extra thing. Still. That's a lot in a place with an easy-going tempo like here.

Yesterday morning was my first official visit to the HIV Orphanage that's part of the SRH campus. I'd been there a few sporadic times before - once on my first day, stumbling through a haze of Benadryl, and again when some French folks wanted to donate a TV to the boys' ward and Dr. Hrishikesh thought another white person in attendance would make them feel at home. And then of course, kids rarely stay where you put them - there are often small posses of kids in identical uniforms and hairstyles running around the hospital grounds, waving to me and shouting "GOOD MORNING MADAM!" at any time of day.

But yesterday was my first official visit. It's a small, clean, and efficient place, run - as such places always are - by incredibly dedicated women who came for a 1-year, part-time position and ended up staying for 16 years. The home started with three orphans and has since expanded to 36, more than half of whom are on daily antiretroviral drugs for their HIV. (All the inhabitants are kids who are HIV+ and whose parents have already died from the infection.) They work amazing transformations. Kids come in with no education, with weights and heights in the <1 percentile, and - through drugs, schooling, nutritious food, and adults who aren't afraid to touch them - become normal children.

They've done such a great job, in fact, that they now have to figure out what to do with these kids when they become adults. The oldest girl has just graduated secondary school. How can she get a job, when employers ask about HIV status and refuse to hire any positive candidates? Where will she live, when unmarried women virtually always live with their parents? Can she get married? Who will arrange it? Good problems to have, given her prognosis when she first arrived at SRH, but tricky issues nonetheless.

Today: presentations, exchanging of small presents (nail polish remover and a Cadbury egg, so far today - already traded in my flashlight for my final 5th and 6th giant watermelons last night), packing, and then 24+ hours of traveling. Oof. God grant me an empty neighboring seat on the plane.

XX-Rated

Wrapping up my last days here - presentations to finish, flashlights to trade in for watermelons, vada (sort of an Indian falafel) to cook. The end of the trip, with all the mini celebrations - always the best time.

For the first two days this week, I've been heading over to SRH's sister hospital, the Ramdev Rao Memorial Hospital. It's a general hospital, not free but very reasonably priced - there doesn't seem to be anything like health insurance in India, so when you're paying for every single lab test, you really want them to be cheap. (And necessary!) The eponymous Ramdev was the husband of the woman who founded SRH, so they're sort of buddy institutions, happy to trade around a goofy foreign medical student for a day or two.

And it was great to get back into a general hospital setting, if a bit different than the US equivalent. Lots of the staff there are retired government doctors, who did their time in the Indian equivalent of Cook County Hospital for decades before scoring a spot at RR Hospital, with its grilling 9:30 AM to 1 PM schedule (including a tea break). That usually means they're teachers, which is a great benefit for me. I spent my mornings with a posse of older pediatricians and gynecologists, tagging along as they showed me where to identify tuberculosis in a child's chest x-ray, or how the Indian vaccine schedule works, or why they suspected Dengue fever in a very sore little patient. Lots more of the Indian doctor brusqueness, even with kids - but I guess when parents assume that coffee is enough breakfast for a kid hospitalized with malaria (families bring in their own food), a little scolding might be warranted.

Since it seems that my doctor life is probably heading in an Ob-Gyn direction, I had a special interest in seeing how that particular morning clinic went down. Dr. Chaya had me plopped down on the other side of her desk as she zoomed, zoomed through the two dozen or so patients queuing outside her door (no appointments here). Between reading her notes over her shoulder, picking up decidedly non-Telugu words like "meningomyelocele", and getting the occasional explanatory tidbit throw my way, I feel like I learned quite a bit.

The majority of the visits were antenatal or infertility visits; as Dr. Chaya explained, life is all about getting married and immediately having babies for most young Indian women. Family planning is a big issue in India, which Indira Ghandhi herself endorsed many years ago, but most planning happens post-kids. If they're interested in a small family, women quickly have their two children by their early 20s, then go in for a permanent contraception method afterwards - sort of the reverse of the US. Likewise, infertility workups happen way earlier; as opposed to US fertility clinics, where half the patients are women over 40, we were working up childless 21 year olds yesterday.

Most of the patient problems and medical services offered were remarkably the same as the US, though perhaps not as numerous - urine pregnancy tests, blood counts for anemia, ultrasounds. But every so often there'd be a quick blip that I was far from home. In the ultrasound room, for example, Dr. Chaya was pointing out heart/head/femurs of a fetus, then quickly mentioned, "and you see, this is an XX fetus". I looked a little confused, and she noted in a quiet voice that it is illegal in India to tell mothers the sex of their fetuses on ultrasound, for fear they'll abort the girls. Thus, the "XX" or "XY" medical code. I also noted that all women's medical charts have their marital status in prominent lettering on the front page; doing a vaginal exam on an unmarried woman might be a life-ruining event for her, if it throws her virginity into question later on. Yikes.

So two very interesting mornings, although probably too short. I was just getting used to the flow of things (and the delightful tea). One more day with the HIV kids' ward at SRH, then repacking my life in my trusty suitcase.

Aesthetics

Biriyani turned out quite well, at least by my tasting. (Theresa kept sniffing that "there is not very much spice", while I was visibly panting secondary to chili overload.) Biriyani is both tasty AND delightful to look at; photos will follow, but it's a beautiful mix of colorful veggies and leaves, all swimming in saffron-dyed yellow rice.

And aesthetics are key around these parts. I realize, before I leave off blogging, that I have to write a bit about the sheer visual impact of walking around in Hyderabad. Clothes, faces, temples, hubcaps, babies, dinner, doorways - the Indian motto seems to basically boil down to "No Valuable Thing Left Unadorned". (Occasionally, "No Lily Left Ungilded".) Either way, it has my vote.

My current location - a free-of-charge, safety net hospital overlooking the highway - certainly isn't the wealthiest place around. But it turns out that doesn't really matter. Even the little girls living in plastic tarp tents on the side of the road are wearing dainty metal anklets on each foot. And for the middle class, the accessorizing is downright impressive. I took a close look at Dr. Sugunamma the other day and took careful inventory: for a basic weekday clinic, her professional dress includes a gorgeous silk sari, at least 8 bangle bracelets, one gold ring, two necklaces, gold dangly earrings, a diamond nose stud, gold anklets, two silver toe rings, a gold watch, a colorful hair barrette, the traditional red Indian forehead dot (a "botu" in Telugu) and red dye streaked through the midline part of her hair. There's no way I could afford to keep up here.

Shopping downtown near the Charminar last weekend showed me where it all comes from: the streets are crammed with jewelry shops of every quality, from plastic rhinestone-encrusted bangles to multi-string necklaces of real black pearls. And it's not as if it's all a matter of upstaging one's neighbors: I saw bustling groups of Muslim women in full black burkhas buying armfuls of bangles, in every shiny design and color - that no one outside of their houses will ever even see.

No matter the price of the materials, the design approach is always the same: ornate to the point of overwhelming, at least for my bland American sensibilities. Necklaces have multiple layers of strands, hair brooches are a sparkly swirl of colorful cubic zirconias (called "American diamonds" here, which cracks me up), rhinestones are decorated with...more rhinestones. And while I find that any one item looks like costume jewelry on me, the overall effect on Indian women wearing 20+ items of this style is spectacular. Sparkly sparkly sparkly.

However, going shopping with other Indians here can be a bit tricky. They find my tastes baffling. Supraja, one of the social workers at the HIV center, kindly offered to take me out shopping last night around her 'hood. It was fun to feel like part of the shopping crowd, rather than (just) an easy mark, but I found myself in the slightly uncomfortable position of having to politely decline all of her suggestions. Having seen my empty pierced ears and rubberbanded hair, for example, she kept filling my hands with of earrings ("hangings") and hair clips made of gold-painted plastic that looked like they'd been Bedazzled. It's quite hard to explain that you don't want something because it looks like it'd be part of some little girl's Belle costume in the US, even though you honestly think it looks great on the suggester herself.

The funny thing is that I somehow expected this sensibility only to apply to the analog world. But working with Dr. Sugunamma and Supraja on this series of Excel graphs and Powerpoint presentations, I've realized just how all-encompassing the Indian aesthetic is. I look at a chart and I think, "This is terrible! It's all too busy, and the pie chart colors are way too 80s" - whereas the Indian ladies look at the same chart and think, "This is terrible! All those colors match! Nothing is in bold! This needs more orange and neon pink, immediately! And can we change everything to Comic Sans?" It's been an adventure in learning to ignore my belief that "professional" = "understated"; after all, they know their audience's tastes far better than a boring, unadorned American like me.

Micro/Macroscope

While my mother, a product of the Catholic school system, vehemently affirms that Nunophobia is more powerful than any of us ever imagined, I was a little disappointed to discover yesterday that not every tuberculosis treatment center has its own resident Sister. There are many "direct observation treatment" centers for tuberculosis patients scattered throughout the country here: a somewhat self-designated "responsible person in the community" holds on to the boxes of drugs for all his TB-positive neighbors and doles them out accordingly. It's a good system, with much higher rates of compliance than when people are just given their doses for 6 months and sent along.

But before they can be treated, they must be diagnosed. Our small posse, consisting of me, Dr. Reddy, and Senior Lab Technician Miss Claramma, ventured out to two of the nearby microscopic centers, where suspicious patients are encouraged to hack up a big ball of phlegm for closer examination. It turns out that the Andhra Pradesh microscopic centers use EXACTLY the same type of microscope that the University of Chicago uses in its microbiology labs! Small world. I felt very smooth indeed checking out slides with Miss Claramma. Lots of fun little bright red bacteria to be seen, swimming in a pool of blue-stained phlegm. (Ewwwww.)

Dr. Reddy was meanwhile making his way through the line of waiting patients, dealing with them with typical Indian doctor brusqueness. I've noticed that the patient-doctor interaction style is particularly given to lecturing and exasperated sighs on the part of the physician; there's not much sympathy for patients who forget to take their drugs, can't afford new bandages, or don't understand that TB still requires treatment even if they feel better. Empathy is not high on the agenda here. It's not necessarily bad - patients expect it, really - but not exactly what they're teaching us back home in terms of Touchy-Feely Skills 101.

The other interesting part of the morning was the chance to see life at the city-countryside edge, making our way through pockets of suburban poverty. I think that my mental image of "Third World Poverty" is always something I gleaned from National Geographic long ago: women with clay pots on their heads, weaving cloth under thatch roofs. Although I was disabused of this image often enough in Tanzania, I still forget that that's not what you see out there at all.

You see plastic. Dirty plastic everywhere, in every possible use, scattered with the world's most recognizable brand names. It makes complete sense - plastic is more durable than clay or thatch, and significantly cheaper. Why lug earthen pots around when you could just carry an Aquafina water bottle for years? Steal cast off cinderblocks from construction sites, gather some pieces of torn plastic-weave tarp from truck stops, dress your kids in polyester Chinese-made tshirts, and you're good to go. When traveling through the tent cities at the edge of Hyderabad, it's much less a village built from nature than a village built from garbage. Urban poverty is much less quaint than it is in my mind's eye.

Making biriyani with Theresa tomorrow morning. Pre-purchased ingredients include ginger, chilis, some sort of dark green squishy cucumber-looking thing, and a wide assortment of leaves and teeny flowers (!). Wish us luck.

Out here in the field

Unexpectedly very exciting day yesterday! I've been hopping from department to department this rotation - leprosy last week, then HIV, and then yesterday beginning with the tuberculosis (TB to friends) department. TB's obviously an important disease in terms of public health, but the treatment is more a matter of dogged persistence than instant gratification - patients take 6 months of 4 separate antibiotics, three times a week, with regular checks of their phlegm to see if the infection's out of their lungs yet. If they're clear at 6 months, they're pronounced cured and sent on their merry way. It's the same treatment, roughly, as in the US. No whiz bang surgeries, no fast cures.

However. Since the great Dr. Beine has just returned to Germany for two months (he refuses to operate in the hot months, believing patients don't do as well), the task of emergency leprosy surgeries falls to Dr. Reddy, the tuberculosis doc. Apparently there's not the surgeon/non-surgeon divide here that we cling to in the US.

In any case, that's where I spent the morning - watching septic surgeries for leprosy patients' ulcers and doing my best not to pass out. Those of you who are a little squeamish might want to skip down - I LIKE surgery, and I was feeling a little queasy watching this. (Matt, looking at you here.) As I mentioned before, the main complication of leprosy isn't the leprosy infection itself, but the fact that patients who can't feel their feet tend to get nasty infections on their soles. When this gets down to the bone ("osteomyelitis" - infection of the bone), it requires quick intervention. No waiting for Dr. Beine allowed.

So patients hobble down from the inpatient wards, the women dressed in their everyday saris and the men in business casual shirts and linen pants - the operating theater waiting area looks more like a bus station than anything else. One by one, they expose their uclers, gingerly walk themselves into the OR, hop up on the operating table, prop up their injured foot and wait patiently. Dr. Reddy (clad in typical street clothes, a cotton mask, and wearing the clean blue plastic flip-flops that wait in neat rows outside the OR door) dons his resterilized latex gloves (waste not, want not, folks), swabs on some iodine, and basically goes to town.

Now, these patients don't feel much in their feet - obviously, or they wouldn't have the ulcer to begin with. But watching a surgeon start cutting away at skin on an awake, unanesthesized patient is tough to watch. The only purpose of the surgery, really, is to get that infected bone out of there. So the doc goes digging and cutting, down through the ulcer, until hitting bone - where he proceeds to scrape and dig, a lot more vigorously than I was comfortable watching. This is made harder by the fact that many patients still retain some sensation in the middle of the foot, near the infected bone, so they start to wince and writhe a bit as the doc goes on scraping. Eeeeeaaaaah, said my brain. Luckily I was wearing a mask to cover what were no doubt uncool facial expressions.

[Squeamish readers, come on back.] In any case, I made it through without embarrassing myself in a fainting spell. (Did that on my first day of surgery rotation. Ah, memories.) We zoomed through four or five surgeries within 90 minutes or so - turns out that OR turnover time is incredibly quick when the patients walk themselves in and out, there's no anesthesiologist, and no one cleans the room between patients! Who knew? By mid-morning, we'd already seen some new TB patients in the outpatient clinic and were taking a social chai break with Dr. Sugunamma. Dr. Reddy was done for the day at 2 PM. Whole different kind of schedule here, readers.

Off this morning to one of Dr. Reddy's rural field clinics, where TB patients get their meds only under observation - turns out we humans are much more likely to follow up with 6 months of antibiotic therapy if a stern nun is watching us take them. Nun-o-phobia should be an acknowledged psychological entity.

Alphabet soup: SRH, HIV, ART

One of the great, and occasionally terrible, things about being a medical student is how quickly people offer your their confidences. I'm continuously surprised by how quickly people I've just met are willing to tell me their health problems once they've figured out I have a (wee) bit of medical training. Old high school friends, cab drivers, sales ladies, airplane seatmates - all have on occasion offered me personal tidbits that I wouldn't share with family members, let alone some weird girl who claims that she'll be a doctor someday.

But I do enjoy, as I get further through this school thing, that I'm able to offer a bit more actual information to these confidants. One such occasion happened on my tour bus adventure Sunday. My seatmate, after a few hours of friendly chatting, began to ask me a series of hushed questions about HIV - what was it, exactly? How could you get it? How can you test for it? Was it true that you should never shake hands with an HIV+ person? Could you not just take all of a person's blood out of their body at once and cure them that way?

Mind you, this is an extremely well-educated, wealthy Indian businessman. Despite being slightly concerned about the adequacy of Indian HIV education outreach programs, I did my best to offer accurate information, assuage fears, quell rumors. He seemed reassured. It was good. I actually felt useful for once.

So all this is a lead up to my past two days, spent at the HIV Community Outreach Center here at the SRH. They act as a sort of primary care center for a few thousand HIV+ patients in the area near the hospital, taking care of minor infections, offering support, and forwarding serious cases on to the local hospital.

Back in my old job at the NIH, I spent a lot of time thinking about HIV in this very sort of setting - desperate, stigmatized patients with very few resources in a terribly resource-poor system. I developed a bit of HIV fatigue, I think. It's such a huge problem, with no good solution and an ever-increasing patient population, that I sort of wanted to stop thinking seriously about it for a while after leaving that job.

But I enjoyed the chance to meet patients and chat over chai with Dr. Sugunama and Vikram (one of the SRH board members) about their take on the big questions in public health. For example: should patients pay some nominal fee for their antiviral drugs, to make them "value" the drugs more, or should such life-saving drugs should be free? It's a huge question, smack at the intersection of public health, business strategies, and individual psychology, but it's always enjoyable to hear the perspectives of folks coming at it from a totally different background.

The only trouble is that you quickly realize the limitations of the discussion when some participants are chatting in their third/fourth/N-th language. At one point, for example, Dr. Sugunamma pointed out that where antiretroviral (ART) drugs are free, such as in Hyderabad's state, there's about a 30% noncompliance rate of patients choosing not to take their meds. In a bordering state, where the same drugs cost about 3000 rupees a month, compliance rates are much better.

All well and good. But the appropriate comparison group, by my take on it, isn't how many people who get the ART drugs take them, but how many people who SHOULD get the drugs actually take them; that is, in the pay-for-drugs states, you have to factor in all the folks who should be getting ART but don't because they can't afford it.

But that is some slightly tricky language right there. It took me a few minutes just now to type it clearly, so you know it came out decidedly more garbled when I tried to first say it aloud - and then there's the aforementioned language barrier. So instead of continuing our debate, we got stuck trying to figure out what the other person was even saying and had to give up after a few minutes. I could see how global public health discussions could get frustrating.

But I got to hang out with Dr. Sugunamma and her team of nurses and social workers, watching patients drift in with various complaints and poking through their impressive data collections. (While I'm here I figured I could help out with some of their data analyses; my mad Excel skillz have earned me a modicum of respect today. I am a Chart Master.)

I also got a couple of interesting snapshots of how Indian culture is adapting to a growing population of HIV+ citizens in its midst. For example, the Center often gets emails recruiting patients for HIV+ arranged marriage matchmakers. Part of me feels like this is a bit too much like the caste system rearing up again, but another part of me acknowledges that if you're going to arrange marriages anyway, who's to say whether you can't add another factor into the matchmaking equation. Thoughts welcome.

Salwar + Sensible Hat = Good Times

The last 48 hours in Full Tourist Mode has made me remember many of the things I like about traveling - the walking! The looking! The taking of stealth photographs! The moment when you take off your shoes at the end of the day and realize you have thick dirt covering every bit of skin except where your sandal straps lay! These are the things that warm my heart. That and the sunstroke.

Yesterday was my first opportunity to really venture out into the downtown Hyderabad area - where the history is, as Eddie Izzard would say. At the urging of the medical chief officer here, I'd signed up for an Andhra Pradesh Tourism Company "City Tour" - probably not what I'd have chosen for myself, but when Dr. Hrishikesh insists and it costs all of 270 rupees (roughly 5 bucks), I'm game.

It actually turned out to be quite enjoyable. The itinerary was a bit rushed - we hit up maybe 7 or 8 famous sites in the course of a single day - but in all honesty, it let me see a handful of smaller sites that I probably never would've taken the time to visit otherwise: The H.E.H. the Nizam Museum, for example, where the 7th Nizam's 80m-long, 2-story-high personal wardrobe is on display. (Rumor is that he never wore the same outfit twice. The Nizams were a series of fabulously wealthy rulers of Hyderabad in the 1700s-1900s, and the possibly aprochryphal tales about their lavish lifestyle are pretty awesome: one refused to ever wear a piece of jewelry once it had touched the ground, another used a Rolls Royce as a garbage can, etc.) Other highlights included the Salar Jung Museum, filled entirely with third Nizam's positively enormous collection of random stuff, and the Birla Temple, a beautiful white marble Hindu temple overlooking the city, filled with painted monks chanting and holy flames and chains of flowers.

The other unexpectedly great part of tour bussing was my fellow travelers. I'd been expecting a group full of painfully white folks like myself, equipped with fanny packs and sensible hats, but all the other tourists were actually Indians from other parts of the country. (There were still a few sensible hats aboard.) So that was a fun group to be a part of, especially in my snazzy red salwar outfit. We took pictures together, sweated up the Golconda Fort steps together, snuck away from the harried tour guide to buy ice cream together. My seatmate, a jeweler in town from Delhi, was especially happy to make my acquaintance, doing his best to explain Hindu gods to me and making sure the bus didn't leave me behind. Nice to feel like part of a tourist team, rather than going it alone.

Unexpectedly, today turned out to be an extra day off: April 4th is the Telugu New Year, Ugadi. From what I can gather, it's a government holiday on the order of, say, President's Day in the US - every person I asked acknowledged that yes, there are festivals somewhere, but they themselves were planning to spend the day sleeping, eating, and catching up on laundry. So this afternoon, after a power outage wiped out all the Excel graphs I'd been working on for the HIV center here (love those random brown outs), I headed back downtown to try my hand at some solo touristing.

And that's how I got to spend the rest of the afternoon, bustling around bustling places. There's an incredible energy in the old city of Hyderabad, radiating from a central building known as the Charminar, a fancy four-pointed structure built in celebration of the city's founding in the 1600s. It's got a sort of Arc de Triomphe feeling, complete with a surrounding chaotic traffic circle - except where Paris has little tasteful cafes nearby, Hyderabad crams the curbs with bangle carts and pearl merchants and dudes carrying around 40 lbs-worth of samosas on beaten silver trays. Good scene. I perused the merchandise for a bit, practiced my haggling, posed for cell phone photos whenever someone was brave enough to ask, wandered north, got lost, hopped in an autorickshaw, ate mango ice cream, found a lakefront park crammed with families enjoying the holiday, and headed back home. An excellent evening.

I've recreated my Excel graphs in preparation for my days at the HIV hospital this week; hope Dr. Sugunamma approves.

Fashion

Two things:

First: India victorious! I still don't know what the score was and when the game ended, but judging by the cheering, fireworks, and outright explosions happening outside my window until 2 AM last night, it was an awesome cricket game. Wickets were blasted, bats were thrown, maidens were rescued, no doubt.

Second: Spent a long day of hardcore sightseeing and will provide some details and hopefully photos tomorrow, when I'm less tired and overheated. I'll just say that my decision to wear my salwar (a gift long ago from my college roommate Priya) was a BIG hit. On one hand, I think for some reason I blended in a lot better - still much too tall, but at least looking fairly normal from neckline down. On the other hand, I became a bit of a tourist attraction myself. The other folks visiting the historic sites, mostly people from other areas of India, were generally delighted to come across me. Everyone wanted to be in pictures with me: posses of teenage boys, young married couples on honeymoon, groups of small, terrified children whose Mom wanted a photo-op for them. Now wishing I'd had the foresight to get copies on my own camera...new policy from now on.

Casts, Crowds, Cricket

I was going to write that my first weekend has been going pretty well so far, but I'm not actually sure that anyone in Hyderabad counts Saturday as a weekend. Most folks in the hospital, at least, kept the same schedule as a weekday, at least in the morning. Is Saturday then a half day, you're wondering? Hard to say - no one really does too much work on the weekday afternoons, either. Too hot. Plus, sometimes the cricket world cup is on and the patients refuse to be treated during the games.

So I'll just say my first Saturday went well. I spent the morning in the physiotherapy suite for the leprosy patients, watching the esteemed Mr. Ganapathy oiling/casting hands and educating/leturing patients. He has the kind of teaching style that I sort of love, where he'll say an important sentence ("This is an example of a patient with a trophic ulcer"), and then immediately repeat himself, with an obvious verbal blank space ("This is an example of a patient with Aaaaa?.....[wait for it]....trophic ulcer"). I like to feed him answers.

Most of the patients came to the suite today at various stages in the series of operations that fix lepromatous claw hands, which are caused by contractions due to malfunctioning motor nerves. First, if the patient's been clawed for a while, skin tends to grow across the joint angle, making it impossible to actually extend the fingers at all; these folks require liberating skin grafts from their own abdomens. Ow. Once that's healed, they can then approach the SRH resident orthopedic surgeon, Dr. Beine, who does a nifty sort of tendon switcheroo, essentially reattaching the fingers to different, functioning nerves and giving patients back their pincher grasps. (Other med students, I'll give you the technical lowdown later.) Suffice to say it is pretty sweet. After a long few weeks of daily casting of the individual fingers at physiotherapy, they're free to go - not perfect-looking or good as new, but well enough to drive mopeds, count out rupee bills, pick up grains of rice - all key to the Hyderabadi lifestyle.

Later in the afternoon, at the urging of the one female board member at SRH, I was sent out shopping at what was simply described as "Central City Mall". As more of a wander-around-the-bazaar kind of foreign shopper than a mallgoer, I admit to being a little wary. A similar thing had happened back in Dar es Salaam, where the western-style mall is a point of pride for many locals; but overly bright indoor lighting, shiny floors, and shops selling tshirts and jeans really weren't what I came to Tanzania to experience.

But I have to admit - the Indian mall was kind of fun. There are the fancy jeans and tshirt stores, of course, but there are equally fancy stores selling very hip, Indian-style clothing. Western dress and saris/salvars/kurtis exist side-by-side, both in the storefronts and among the chatty teenagers bouncing around the place. Likewise with the food - a prominent McDonalds out front sat right up against a Super Chaat store selling savory little snacks. Even the entertainment works out nicely - the Muzak seemed to be stuck on "Time After Time", but downstairs a large posse of people with ice cream were watching a single TV turned to the aforementioned cricket world cup. India vs. Sri Lanka! I'd like to tell you the outcome, but I watched for a good 45 minutes and just looked up the google results - and I honestly have no idea who won or if the game is even over. "SL 274/6(50) Ind 35/2(9)" is the first hit. What does this mean? And is cricket truly Calvinball in disguise?

"Anam ti na rah?"

"Did you eat?"

I get asked this by multiple people, at every possible time of day. Everyone is extremely concerned about my getting enough food, and whether said food is nearly good enough. Please note that this has absolutely nothing to do with the nut allergy disaster of my first day; most folks here don't know about that, and if they do, they're not quite sure what to make of it. Also, it's not at all as if I'm left to my own devices, or that I'm eating street food: a posse of extremely friendly women manning the hospital canteen serve me hot, freshly made food for every single meal I'd care to come by. (This includes tea, which happens every day at 4 sharp.)

Rather, there is just a general, overriding concern for guests' stomachs. The first few phrases I was taught in Telugu included "My name is", "Fine, thank you", and "I ate." The last is incredibly important, but often ignored. I tried it last night, having planned to just have some fruit and biscuits later in my apartment, but Lakshmi of the kitchen staff was not dissuaded - she continued knocking on my window, saying "Dinner!" loudly, making eating motions and waggling her head disapprovingly until I agreed to come have my chapatis. (I know, rough life.)

Meal-ing itself is also a bit of an event. The kitchen ladies watch like cheerful, extremely obliging hawks. I'm still trying to find an adequate balance between seeming appreciative of the food without making it seem like a request for more. There was a bit of a snowball effect yesterday when the ladies got into an argument about whether the rice-curd combo was better with sugar or with salt; samples were heaped upon my plate as I tried to avoid picking sides, until I finally went with the age-old stomach-holding symbol for "Please no more rice or I will explode". (Also, for the record, sugar is WAY better.)

So, obviously, I'm jumping on board. Theresa, my apartment mate, has agreed to teach me to cook some Indian dishes. She was reluctant at first, arguing that she didn't know anything fancy, until I convinced her that, to me, spicy sauteed vegetables count as fancy. Plus, if there's one thing Theresa likes, it's haggling for produce. She is a force to be reckoned with. The woman somehow worked out a deal that we get a free watermelon every night from this truck by the side of the road in exchange for my American flashlight when I leave. Such a deal.

So she's warming up to the idea. Tonight we did the zesty vegetable dish, and we're planning a future filled with biriyanis (spicy Hyderabadi rice dish), vadas (some sort of ginger lentil spice balls!), a coconut upo (don't even know what this is) and other curries. Probably will be trying to smuggle mad spices back through customs.