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.

I Heart Elephants

The chances of me doing justice to my last ten days in Tanzania grow increasingly slim as the days zoom along. This is especially true given that I'm heading out to Peru tomorrow morning, accompanying a group of fellow medical students as we visit urban hospitals and rural clinics in the Peruvian health system. After Tanzania, I have to admit that Peru seems like a much easier hill to climb: I can speak the language (decently, anyway), I'll be in the same time zone, I'll be traveling with friends the whole time - and I've even been there before. Not nearly as nervewracking as my departure for Dar in mid-June.

But a quick sum up of the Denny Family Adventures, before I fill my brain with aventuras nuevas. Successfully navigating the airline ticket craziness (see two posts down), Dad and Lexi arrived early in the morning on Friday, looking both sharp and exhausted in the way that only well-dressed international travelers can. The three of us spent a few days in Dar, alternating between city strolling and jet lag reeling; we didn't manage to get to the Annual Dar es Salaam Charity Goat Races, but we did manage to hit the city fish market on a pretty good day. (Enormous manta ray, anyone? I always wonder if their "horns" are delicacies.)

Then off on safari! We flew to Kilimanjaro airport and headed to Arusha, where we met our guide Juma. Over the next few days we visited four parks: Tarangire (rolling plains spotted with baobab trees, sprinting warthogs, 30+ flocks of giant ostriches and scores of elephants), Manyara (my personal favorite, a soda lake surrounded by forest, where a sudden turn in the road can put you face-to-face with 80 baboons or a family of elephants. Plus an delightful hippo pool and an excellent array of giraffes), the Serengeti (camping in the confines of the park was exciting to the edge of terrifying - hyenas stole our trash, baboons our breakfast), and Ngorongoro crater (a 20 km wide volcano crater with a condensed population of wildlife: hundreds-strong herds of herbivores with an accompanying smattering of cheetahs and lions). Each park area felt very different. The Serengeti, especially, is a truly amazing-looking place, even aside from the animals; vast, flat, grassy plains run out for miles in all directions, right up to the horizon. The name comes from Serenget, the Maasai word for "endless space". True story, Maasai, true story.

The Maasai, it should be noted, have been kicked out of the confines of the Serengeti National Park (or rather, were strongly pressured to "voluntarily leave" in the 1960s), but they still have free reign in Ngorongoro crater. This leads to amazing scenes where you have hippos, zebras, hyenas, and wildebeest all in your view - and then you notice a Maasai man and his cattle strolling by about a half kilometer behind them all. Neat.

After 5 nights of tent camping (although it's hard to say we were "roughing it" by any standard - I think it's safe to say I ate better food on safari than I did for the rest of my Tazanian stay), we headed to Zanzibar. We arrived, in fact, on the first full day of Ramadan, which I think added some extra interest to our stay on the island. Zanzibaris are about 95% muslim, which means that finding food or water during the daytime became quite a bit of a challenge for us; we were reduced to sneakily taking sips from our bottles in dark alleyways. It's like contraband. But at night fall, the whole island jazzes up noticeably. A huge siren announces the official sunset, and then locals and tourists alike go seeking food. One of my favorite aspects of Stonetown, the capital, was Forodhani Gardens, where a couple dozen local chefs nightly serve up tables heaping with seafood or fresh-pressed sugarcane juice or "Zanzibar pizza" (an egg/veggie combo fried in a very thin crepe). The seafood itself is often labeled in particularly egregious (and delightful) English; I myself opted for a skewer of "tuner fish", but there was also "black sneeper" and "paracuder" for sale. Other highlights included a spice farm tour, where we knowledgably sniffed our way through several dozen different varieties of spicy barks and leaves. The scent of cloves, especially, seems so very exotic.

After a particularly rough ferry ride back to the mainland (ie, sick bags were distributed), we spent a final dinner at the Badminton Institute with the housemates before our very early morning departure. That in itself was a bit of an adventure - the taxi didn't show at 4 am, thanks to the insanity that is Swahili Time, so I spent my last few hours in Dar jogging through the darkness in search of a ride to the airport. Sort of put a nice cap on my whole experience, really. Cairo was the typical craziness, London was pleasant (and cool!), and Chicago has been very welcoming. It's a little sad to me how quickly I fall back into my old lifestyle patterns; I'm trying to be more conscious about the way I live, particularly about how I spend my free time and how I interact with other people.

There will be photos posted soon (some already made it to Facebook, the destroyer of worlds), but in the meantime, an interesting article about women, birth control, and East Africa.

Nyumbani

Four time zones, three flights, two Tube rides and one terrifyingly late taxi later...I am home. Back to my toddlin' town.

I will write a bit more tomorrow, when I can remember what day it is and where I woke up more clearly. The absent weeks were spent adventuring with Dad and Alex in the Serengeti region (heck yes we saw elephants!) and Zanzibar (during Ramadan, no less - daytime water is for the weak). The trips were excellent - really amazing parts of the country, truly. Good photos to share.

But now I have to try to begin adjusting to my new apartment, where my room is full of moving boxes and the sound of TV seems terribly jarring. I'm a bit discombobulated; it took me a good two minutes to figure out where I was and what was going on after my nap this evening. Hopefully all will seem more reasonable in the morning.

Karibu, Baba na Kaka

You know that feeling you get when you think you've reached the botton of the staircase, but there's actually one more step? And you experience a half-second terrifying shot of adrenaline before hitting the ground?

That deeply unnerving feeling of having the ground briefly disappear out from under you - that's sort of like what my Dad and brother went through 48 hours ago. (Although theirs was much more expensive.) Approximately 20 hours before they were planning to depart for Tanzania, my brother Alex realized that instead of buying plane tickets for the first leg of their journey for Wednesday, he'd actually gotten the same flight for Thursday. Which meant they'd be 24 hours late to London. Which meant they'd miss all subsequent legs of the trip to Dar es Salaam, including the flight to begin our safari on Sunday morning.

Instant terror adrenaline surging on all fronts. They tried to just move the flight up a day; Continental said no. (Or rather, no unless you give us $6000.) They tried to buy a one-way flight to London in order to be on time for their second flight; Continental said their policy is to cancel the return tickets for anyone who doesn't check in to their outgoing flight. It is now 8 AM on the day they must depart.

Long story short, they had to buy brand-new, day-of tickets to get to London in time, stopping in Canada on the way. Oy. But they made it! Picked 'em up at the airport this morning and then let them go straight to bed. (Although I did wake them up to have them eat lunch at the office with us. Everyone said we looked alike. "You all have merry faces," announced Christine. "You smile from your hearts.")

Another day of jet lag adjusting tomorrow (and of course the Dar es Salaam annual charity Goat Races in the afternoon), then off on safari on Sunday. Send me an email if you want me to bring you back a baby hippo.

You gotta fight for your right to...go to clinic

Good God. I promise to never complain about my commute again, even when it's -17 degrees and I'm trying to bike over the ice to school.

For I have seen the Posta-Masaki daladala on a weekday morning.

It is completely and totally out of control. I've had fairly good luck getting out to CCBRT before via the Posta-Masaki route, but I think before yesterday I've been riding a little after the peak of rush hour. The number of buses on this route is completely insufficient given rider demand, so big groups of people are already running alongside the bus as it pulls up to the Posta station, masses of hands clutching at door frame. People inside the bus trying to disembark have to literally fight their way out - I saw one woman actually get trapped inside the bus by the entering mob, unable to get out the door. As soon as (most) people inside have exited, the door hangers (mostly young men) go absolutely nuts, shoving each other and throwing themselves up towards the door in an attempt to get on board, giving no quarter to kids or the elderly or small women also trying to get in. Particular tenacious teenage boys jump up through the open back windows. A huge chunk of the waiting crowd is always left behind (usually those unwilling or unable to shove), hoping to wedge onto the next one. It took me three tries to board a daladala yesterday (I think the trick is to come at the door at an oblique angle). It'd be funny if you didn't have somewhere to be, but if I had to do that everyday on the way to work I'd go crazy. Or I guess maybe I'd start shoving.

But I finally made it to CCBRT hospital again in the morning, probably for my last visit. (Though maybe not - I feel rather welcome and wanted at this point, so much that I'm considering visiting on the day before I fly home. The nurse gave me a hardboiled egg yesterday! Nothing says appreciation like a hardboiled egg. We'll see.) I arrived mid-ward rounds again. Dr. Robert greeted me by announcing that several women were leaking urine that morning - he termed it a "disaster" but didn't strike me as that concerned. Later patient file review seems to indicate that leaking is not that uncommon for fistula patients that later experience full recoveries. Ward rounds are kind of funny: Dr. Robert kind of acts like a sardonic uncle figure to all the patients. At each patient's bed he cracks jokes, mostly making fun of her, and she and all the other women giggle. It's like The Today Show for the fistula ward.

After ward rounds, Tuesday clinic commenced. Last Tuesday I was surprised that only one true fistula patient showed up; this time, there weren't any true fistulas at all. Or at least no clearly obvious ones. But I do think that the kind of women who end up at the clinic give a sort of representative snapshot of life as a woman in Tanzania. At one end of the spectrum was an 80-year old woman who arrived with her two daughters, incontinent and a bit senile but clearly well-cared for. The nurse noted quietly to me, "Look how much those two ladies love their mother." Seemed to be true: their mom was confused, stubborn, and clearly feeling the pangs of a hard-lived life (her permanent hunch made her about 3'5" tall), but the good-natured daughters kept her clean and rather sharply dressed. At the other end of the spectrum was a 10 year-old girl with painful urination; it was unclear to all involved why she'd been sent to the fistula surgeon. Off to urine analysis she went.

Then, in between these two extremes, we saw two women of childbearing age whose main problems had actually been inflicted by the Tanzanian medical system. One woman, complaining of incontinence, had obviously had some massive surgery in the past. She wasn't sure what the doctors had done, but the scar on her abdomen was enormous and Dr. Robert pointed out the marks of at least three drains on her belly. "In these cases, we have a song," said Dr. Robert. "You know 'Return to Sender'?" So back she was sent to her original Kilimanjaro hospital. The second woman was suffering uncontrolled urination after her delivery in a Dar es Salaam hospital three weeks ago. The C-section scar was clearly fresh - so fresh, in fact, that the nurse discovered a bit of suture still in the skin that the doctors had simply forgotten to remove. That's hygenic, I'm sure. Oy. Dr. Robert suspected that her problem might actually be due to the C-section itself: every so often doctors will detach the ureters during a C-section surgery and reattach them in the wrong place, leaving them to drip urine into the abdominal cavity and causing incontinence. The problem is technically considered a type of fistula and can be repaired at CCBRT, at least, but she'll need more tests.

And finally, the dye tests. Dye tests are the moment of truth for fistula patients: after two weeks of post-operation rest, their bladders are filled with bright blue dye to see if there's anything leaking out. Two ward patients were up yesterday. One was a success: no blue leaking, even with pressure, so when she fully heals she'll be on her way home. The second, sadly, was a no go - bright blue dye came seeping through her stitches almost immediately. She'll have another two weeks of waiting around with a catheter in hopes that things will spontaneously heal. It seemed very unfair, particularly for this woman: she's 30 years old, but it's clearly been a hard 30 years. She looks to be in her early 50s. And she's all alone - the one child died during childbirth, and her husband left. She deserves some good luck at CCBRT at least. Fingers crossed.