Hanson's Disease 101

So! Leprosy. Also called Hansen's Disease, although how Dr. Hansen managed to stick his name on one of the world's most ancient illnesses remains a mystery of hubris. The SRH was actually founded, 30 years or so ago, with the chief goal of taking care of India's leprosy patients. They've expanded to other infectious diseases over the years, mostly HIV and tuberculosis, but you still tell the cab drivers that you're going to the "Kushdaviadee" - leprosy hospital.

I'm not sure if they're setting up a straw man or what, but the SRH doctors often claim that the Indian government has proclaimed leprosy eradicated from India. Couldn't actually find any evidence of this on the interwebs. Either way, patently untrue. Six days a week, the outpatient center here sees leprosy in all its various stages of treatment, mostly repeat patients with complications but at least 10 brand new patients a month, including kids.

The past two days, I've been hanging out in the outpatient ward, trying to look like I understand the conversation and sneaking peeks at the stockpiles of dusty medication boxes (ofloxacin with mango flavour!). The doctors drop knowledge on me in between seeing patients.

Essentially, the leprosy cycle:

1) patient appears with some combination of weird pale skin patches that lack sensation and/or nerve malfunction - can't flex their fingers, pick up their feet, close their eyes entirely, etc.

2) patient has to take at least two antibiotics, every day, for A YEAR

3) patient spends the rest of his/her life dealing with either "reactions", where the body's immune system causes these painful flares in the skin and has to be tamped down with steroids, or secondary infections that happen when patients can't feel their injured limbs.

The infections are what we really spend most of our time doing. In terms of lost productivity/mortality/morbidity/stigma/any other index you care to measure, foot ulcers are the worst by far. It's actually a bit like diabetes in the States, weirdly. When you lose sensation to your feet, you just don't notice when you develop a blister, or step on a nail, or burn your toe - you don't protect your foot, you don't stay off it, and a nasty infection takes hold. And honestly, how often do you look at the bottom of your feet if they're not bothering you? By the time patients notice the smell (the number one complaint), things are often to the point of requiring hospitalization. Chronic infections lead to osteomyelitis (bone infections) leads to gangrene leads to amputation, and then you have a population of people with very little education who can't do physical labor. Bad cycle. The hospital campus is home to many employees-slash-former patients who simply could never find a job anywhere outside.

The new multi-drug regimen, which the WHO recommended in the 1980s, has definitely cut rates of new cases down considerably, but if eradication requires everyone to adhere to a year's worth of vaguely toxic antibiotics, it's going to be tough. In any case, I'm really glad to see these patients - something I'd never get to see in the US, but also very interesting from a public health perspective in terms of managing the long-term consequences of infectious disease.

As a side note, there was a patient today who came in looking just...terrible. Dirty bandages on his broken arm and ulcerated toe, one eye nonfunctional due to nerve damage, hobbling along with a cane...classic image of the leprosy patient. We're waiting in the physical therapy room with him, when a strange little music starts to play - and he hobbles off to talk on his cell phone.

India! Lepers with cell phones.

Take Two

I forget, every time that I travel alone, that the first 24 hours are a bit miserable. The time zone change, the lack of showering, the quiet but constant terror that all your plans are going to fall through and that you'll be left alone at a dark bus station at 3 AM... each time it occurs it feels like the worst thing EVER, all over again. And then, of course, it's fine.

I have to admit, though, that my first 24 hours at SRH might take the prize for the worst way I've ever introduced myself to a new country. The flights here were smooth as could be (hat tip to you, Lufthansa), and the Hyderbadi airport at midnight was remarkably cheerful and peaceful - the pick-up area was outdoors and the smell of some fancy flower was wooshing around the escalators. Folks in saris were lolling around under trees just outside. It looked like a happening spot. But we whisked away through the night, heading west (I think - good maps are thin on the ground here), zipping around little mopeds, until we arrived at the compound gates. Got in my apartment, met Theresa, the X-Ray tech who seems to be my self-appointed guardian, and crashed out quickly. So far, so good.

The trouble began the next morning. Slept right through my alarm and woke up already late, with Theresa chiding me through the door as I hopped into what I hoped was an appropriately conservative outfit. But these are not a group who skip breakfast, late or no - I was hustled over to the dining room and promptly issued a plate of rice-with-mixed-vegetables patties, coupled with a spicy sort of chutney sauce. Watched eagerly by no less than five women from the kitchen, I tried to 1) eat only with my right hand 2) really look like I was enjoying the food, and 3) ignoring the increasingly itchy feeling in my mouth.

Damn you, societal norms. By the time I was walking to meet the chief medical officer five minutes later, I knew I'd eaten something delightfully anaphylactic. My throat was already swelling up, not the point of breathing problems (it's OK, Mom!), but definitely to the point where my voice sounded pretty goofy as I was trying to introduce myself to board members. I spent the next 3 hours touring the campus, sneaking off at one point to load up on benadryl and urging my immune system to quit freaking out.

Well. Suffice it to say that the morning ended with me vomiting uncontrollably three to four times off the side of the path, skirt neatly tucked up under me, as a local physiotherapist watched on in mild horror. (White people are so. weird.) Slept a sweaty, itchy sleep for the next few hours, emerged for watermelon and crackers, then decided to call the day a wash and slept until this morning. Day 1!

Day 2 has been much, much better. First, in terms of food: I was initially afraid this morning that my quest to avoid nuts would leave me eating nothing but rice and chai tea for three weeks ("Local Medical Student Develops Scurvy on Infectious Disease Rotation"), but lunch and dinner both went down fine today. Theresa has taught me the words for "cashew" and "peanut" - seemingly useful, but the main cook looked at me like I was crazy when I tried to ask tonight. We'll see.

Second, in terms of work: spent the day seeing leprosy patients with a trio of docs here. Leprosy is alive and well in India, no doubt about it. Lots of new patients, some of them children, and many with long-term complications. The learning curve is steep but very interesting. Tomorrow's guide might be a bit of a Leprosy 101.

Third, in terms of getting on the grid: like a chump, I forgot my computer microphone, thus making computer-to-computer Skyping a bit of a non-starter. However! With the help of the very competent Krishna who works here, I now have a viable cell phone. Email me if you'd like the number. I wouldn't suggest doing a phone-to-phone call, but the Skype-to-phone rates to India are very reasonable. [Me waggling my head at you in the Indian way that means "yes"]

Namaskarum

Innervated II: Son of Innervated.

That's right folks, in a sequel to the summer 2009 smash hit "Mzungu Takes Dar es Salaam", I'll be trying to update here about my current adventure in Hyderabad, India, at the Sivananda Rehabilitation Home. Touched down late late on Monday night and am still getting over the jet lag/early morning cashew poisoning yesterday (more on that tonight). But currently feeling refreshed. Also hoping to wedge my way into a couple of orthopedic surgeries on leprosy patients with the mysterious Dr. Baine, a German doc-slash-priest who showed up at SRH 26 years ago and simply never left. Germans, man.

More later. Missing the west but sort of simultaneously pleased to kick my western emailing/caffeining/text messaging habits.