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.