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.