Delays at Temples

First Bonalu at Golconda Fort

It is the festival of Bonam (Bonalu). George, in his usual thoughtful manner, has already touched on the first of the celebrations here in Hyderabad, held last week at Golconda Fort. There are now celebrations in the streets in different parts of the twin cities.  I was witness to several small celebrations in Secunderabad on my way back from the airport yesterday. As R wound his way through Paradise and the General Bazaar areas, we were flanked by women and girls dressed to the nines and groups of faithful assembling for mini-processions.  Some women carried decorated pots of ceremonial food on their heads while others danced. I saw at least one Potharaju dancing as well. R tells me that the Potharaju will be invited into people’s homes during the procession so that he can beat them. And he does not mean in a competitive way, say like at Parcheesi. He means with a flail. At least, that’s what it sounded like to me. This is felt to cure disease. After he beats them, they thank him and he moves on. He is not paid for his trouble, according to R. There is also a woman in each part of the city that will make predictions about events that are to take place in the upcoming year. I asked how the women are selected and if they confer in advance in order to make sure everyone is on the same page as far as the predictions go. R laughed heartily at this and said he doesn’t know.

I enjoyed seeing the Bonalu for a number of reasons, not the least of which is that it afforded me the opportunity to see how women of different socioeconomic strata get decked out for a big festival. The men, predictably and with rare exceptions, just wore nicer versions of what they usually wear.  There is also a lot of temple-going even by non-processioners. I cannot believe the delays my fellow VIPs are causing. Not sure how they live with themselves.

Vellore, Part 3

July 29, 2010; 14:30

I am back in Anand’s office, digesting my Tamil Meal. We are waiting for one of his research assistants to take me on a tour of the medical college and other outlying areas. We have already discussed collaborations, his history, my history, and pretty much anything else we can think of. I have already checked my email. Twice. There is still 30 minutes to go.

14:55

Anand’s research assistant arrives a few minutes ahead of schedule and is met with great enthusiasm by both of us. I say my goodbyes to Anand, who bestows upon me a commemorative CMC Vellore coffee mug. I am very pleased. I love receiving coffee mugs, though I don’t share this tidbit with Anand. I do hope to collaborate with him in the near future, after all.

15:20

I am taked to the LCECU. This is a community outreach unit for the city dwellers of Vellore. It is part of CMC and the care here, unlike at the main hospital, is heavily subsidized. We walk through the facilities and end up at a ward. Here, a Dr. Sunil Abraham is making rounds with several medical students. Most seem to be of American origin. He is kind enough to break from rounds and review some of the more interesting cases with me. The place reminds me of a general medical version of the community care center at SRH. Except that is slightly better resourced and there is much more teaching going on. And of course, they are not restricted to seeing persons living with HIV infection. The physicians that work there are all trained in Family Practice, and they all seem like outstanding doctors and human beings. Dr. Sunil tells me that my students are welcome to make rounds with him any time, for as long as they want. I continue to be impressed with the openness and academic approach that permeates every aspect of CMC Vellore.  I thank him and assure him that he will see CWRU students soon enough. We leave the LCECU and go to a similar, larger center that caters to the rural population that surrounds Vellore.

16:15

Our tour ends with a visit to the actual medical college, which is in a wooded area a few miles away from the hospital. This is not my first time here. I came 18 years ago, between my first and second year of medical school, for one night. I distinctly remember having dinner with two students named Priya and Hannu. I vaguely remember a basketball court and some sort of hall where a party was going on. As we pull in, I see the basketball court on the right and the auditorium and entertainment hall on the left. Everything else is new to me. There has been a lot of construction in 18 years. We walk around the campus, which is beautiful. CMC is routinely ranked among the top 3 medical colleges in India. This is based on academics, of course. If it were based on the campus, I cannot imagine it being less than number one. After wandering around for a while, and speaking briefly with the head of Biostatistics* we drive away. I wonder if it will be another 18 years before I return.

*We ran into him while checking out a particularly stunning building. They run a training program for persons interested in learning biostats and epidemiology. This went on for ten years, but now funding has run out, and they have had to get a bit creative. The department also consults on the numerous clinical trials taking place at CMC and houses much of the data on their servers. It is very professional outfit. But this is not unexpected at this point, is it?

16:50

A tour has been arranged for me at the Golden Temple. The other Golden Temple. Not the one in Amritsar. This temple has been open for about 3 years I am told. I want to see this temple because my aunts told me I should. Multiple times.

The Sripuram Golden Temple in Vellore

Arrangements have been made for me to get the VIP tour. We walk around the hexagram path that surrounds the sanctum sanctorum. Everywhere, there are signs that look like quotes from the Mother Goddess. I am not sure to whom she was speaking, but many sayings are attributed to her here. They are written in Tamil, Telugu, Hindi, Kannada, and English. Because we are on the border with Andhra Pradesh, I hear a lot of Telugu around me. The second most striking thing about the Golden Temple is the number of pictures and posters throughout the entire campus that feature the head priest. His visage and likeness is everywhere. One can literally not look in any direction without seeing his face. I would forgive anyone who thought that this was a temple dedicated to him, and not the Mother Goddess. I am not entirely sure myself. There is even a life-size poster of him in the sanctum sanctorum. Just behind and to the right (our right) of the main idol.

The most striking thing about the Golden Temple, of course, is the gold. The entire structure that houses the sanctum sanctorum is encased in gold. I have never seen anything like it in person. I have seen several pictures of The Golden Temple, of course. Not having been to Amritsar myself, I cannot compare them. But in front of me here is a ton of gold. Actually, one and a half tons. Probably closer to one and a half tonnes, Balaji tells me. We enter the VIP line and are escorted past the waiting throngs. It is actually a light day and it is only a mini-throng. I join a small group of fellow VIPs in a clear area between the altar and masses. We sit for a while, gazing alternately upon the idol of the Mother Goddess and the poster of the head priest, who is not on duty. We cannot hear the priest that is on duty, but believe that he is chanting the appropriate mantras. It is time for the haarathi. One of the VIPs stands up but hastily sits back down after someone yells at him from behind us. “Down in front!” in Tamil, I guess. Then another VIP attempts a shashtanga namaskaaram, but is strongly admonished, this time in Telugu. There are no shashtanga namaskaarams allowed at the Golden Temple. The rest of us remain motionless until the chanting is finished and the on duty priest emerges. We are then blessed, given prasadam, and led out of the hall. On the walk back to the entrance, I am accosted by teams of temple employees looking for donations. There is also a laddoo stand, but the line is long. We go back to the car, don our footwear, and head off to the hotel in which I am to spend the night.

Vellore, Part 2

July 29, 2010; 10:00

Dr. Abraham sits with me a while and discusses my background and the plan for the day. He will entrust me to the care of one of his underlings who is currently on rounds. It is agreed that I will round with them for an hour or so and then be taken to the research area. Dr. O.C, as he is known by everyone, takes me to the medical ward and we get to talking. We arrive at the prescribed ward, but instead of dropping me off, he spends a long time with me. I am shown the online system used to track labs, discharge summaries, and other data. A proto-EMR of sorts. I am duly impressed. In fact, I am impressed at every turn. The physical plant is similar to that of government and semi-government hospitals that I have been to before, but it is much cleaner and much more organized than any of those places. Much more. There is an alcohol-based antimicrobial cleanser at the foot of each bed. I find this astounding. Dr. O.C. takes it upon himself to show me some of the more interesting cases himself. Our first stop is at the bed of a woman with scrub typhus. My knowledge of typhus is restricted to a board review course I took in 2002 and my recent reading of the novella “Ship Fever”. Now I get to see a case. The tache noire has long-since fallen off. It looked like a cigarette burn, I am told. Now I can only see what looks like a harmless abrasion, less than half a centimeter. We move on to a more dramatic case. It is of histoplasmosis.

Histoplasmosis?

Yes. We see it here too.

The case is presented to me first at the bedside. A young lady presented with an 8 month history of progressively enlarging cutaneous lesions and cervical lymphadenopathy. Eventually, fungal forms are seen on biopsy and she responds to amphotericin B. Treatment is stopped after a few months but the disease returns with a vengeance. She is on antifungal therapy once more. There is no known immune deficiency. As Dr. O.C. tells me the facts of the case, the patient jumps in from time to time, in English, to clarify some details. I learn that there are now signs of fibrosing mediastinitis, a feared complication. At this point her gown is removed in order to examine the affected area. Knowing what I do about histoplasmosis, I expect small, smooth, raised lesions. Perhaps umbilicated like molluscum, perhaps large enough to be characterized as nodules.  I cannot hide the reaction I have to what I see. There are enormous, verrucated, almost cauliflower like lesions, up to 3 or 4 centimeters in diameter, extending from the supraclavicular area down to the left nipple and going from the L shoulder to the right midclavicular line. They are large and they are striking. There is rock hard lymphadenopathy palpable – and actually visible – up the anterior cervical chains. There appears to be jugular venous distention bilaterally. Some more details of the case are discussed, the patient is covered up again and thanked by the both of us and we proceed from her bed. I feel a mix of thoughts and emotions. I did not know Histoplasma was seen anywhere in India. I did not know histoplasmosis could present in this severe cutaneous form, particularly in an otherwise healthy person. Most of all, I do not understand how a young, attractive, educated woman would not seek medical attention for something like this for eight months. Dr. O.C. seems as perplexed as I about this latter point. He tells me one more story about a 16 year old girl who presented with typhoid the previous week. She seemed to respond to antibiotic therapy initially, but was then found in her bed in a decerebrate posture and expired shortly thereafter. Also otherwise healthy. The ward staff is still reeling from this loss. We leave the medicine ward and head to the intensive care units.

There are two units on the medical side. One for less complicated cases – usually with only one organ system affected, and one for patients with multiorgan dysfunction. Each has 12 beds. We discuss many interesting aspects of the ICU, including the close relationship their critical care department has with an institution in Australia. Particularly interesting to me is the fact that pyelonephritis is a common reason for ICU admission. Antimicrobial resistance is so common in E. coli (not to mention other gram-negative bacilli) that many people with UTI will have no response to their initially prescribed antibiotics and end up presenting to hospital with upper tract disease and sepsis. I wonder what my colleagues back at the Cleveland VA would have to say about this as we leave the ICU and head back to the department.

July 29, 2010; 12:40

They give me coffee. This is literally the first thing to pass my lips since I awoke. I am eternally grateful to the Department of Medicine but refrain from making a spectacle of myself.  Anand reappears and escorts me back to the IDTRC. I am to have lunch with Abhishek, ostensibly since his friend and I share the same last name.

July 29, 2010; 13:10

We eat at a vegetarian restaurant. Abhishek has correctly guessed that I am vegetarian based on his friend’s history. Being a big believer in ordering food typical of an area, I order Tamil Meals. I actually want to go with aappam, a keralite specialty, but Abhishek has counseled against it. He warns me that, as a fellow Telugu person (and, I suppose, as a Yadavalli), I will be disappointed in the level of spiciness of the Tamil Meals. He is right. It turns out Abhishek is interested in Psychiatry. He has been working at CMC for 2 months. He will put in a good year or two of research, I muse, before he applies for a PG  position* in psychiatry. Apparently not. He has been accepted into a position at NIMHANS unexpectedly. He leaves this weekend. I mention to him that I was just at NIMHANS a few days ago and extoll its virtues. Abhishek, however, has already been drinking the NIMHANS kool-aid. He says it was an offer he couldn’t refuse and laughs heartily. I immediately start wondering if I will be able to finish watching Godfather III on the flight back home.

*PG=Post-Graduate; the term for residents in India.

Vellore, Part 1

My quest for new collaborations continues in the state of Tamil Nadu. Faithful readers will recall that this was the setting of the first half of CIT2.

July 28; 20:00

I arrive at MAA, Chennai International Airport. It is not as horrible as I remember. In fact, baggage claim is spectacular. I think to myself that if I was not in such a hurry, I could just hang out here for a while.  My phone does not pick up an Airtel signal until I am past the point of no return beyond baggage claim. I call my local contact Yogesh, a medical student at Madras Medical College, who tells me that he is 20 minutes away. I will wait at the coffee shop along the exit from baggage claim. Some 30 minutes later Yogesh asks me to come all the way out to the car area and meets me there in – of course – an Innova. There has been a change of plan. Rather than staying at Varun’s* apartment, I am conducted to the Residency Hotel. It is just as well, I think to myself. I just need some sleep at this point and this hotel sounds comfortable. Lord knows I don’t need to eat any more than I already have today. Yogesh assures me that he and I will be dining at the all-you-can-eat buffet in one of the hotel restaurants.  He confesses over appetizers (paani puri for those keeping score at home) that I am much younger than he imagined. He did not, apparently, think that the professor he was receiving would be dressed in blue jeans and an untucked white linen shirt. He is pleased that I am young and cool. Later I declare that the kootu was the best dish in the buffet and he immediately rescinds this compliment.

July 29; 05:00

I awake and prepare for the ride to Vellore. Balaji, the driver Vivek has arranged, arrives exactly on time and I check out of the Residency. The drive to Vellore will take about two and a half hours and I am to call Dr. Mathai when I am about half an hour out. He has also texted me his research associate’s mobile number in case he himself is not reachable. I am pleased that we have this plan, since there have been miscommunications between us about today’s visit. I sleep intermittently on the ride over and awaken exactly at 8AM. I look at the number that Dr. Mathai has sent me. It is one digit short. I decide to call Dr. Mathai and risk interrupting his Chennai plans. My phone is not working.

July 29; 09:00

I have contacted Dr. Mathai using Balaji’s phone and have gotten directions. I make my way to the Infectious Diseases Treatment and Research Centre (IDTRC). There I meet Anand Manoharan, PhD, MPH, who heads up much of the research that takes place in the Department of Medicine. I also meet a Dr. Abhishek, who has eagerly been awaiting my arrival. One of his closest friends, a classmate of his at Rangaraya Medical College (Kakinada) is  also named Yadavalli and he wants to know we are related. I don’t know him. Interestingly, his friend’s hometown is near Vijayawada, likely very close to my father’s hometown of Machilipatnam. Perhaps more interesting to me, his friend is currently doing internal medicine residency at Albert Einstein medical center in Philadelphia, which I consider my hometown.  In any event, Anand has had his fill of the non-reunion taking place between me and Abhishek and takes me to the hospital, where he introduces to the Chief of Medicine, Dr. O.C Abraham.

*Varun is one of our PGY-2 residents. He has been instrumental in my attempts to explore collaborations in Tamil Nadu and has made many of the arrangements for my trip along with his brother Vivek.

New city, new friends

I arrived in Bengaluru yesterday and have started to meet the students in the course. George, of course, you all know from his insightful blogs in this space. I also have met interim17. He is taller than I thought. Not sure why the other students aren’t blogging yet, but I expect we will have some entries soon, after today’s experience at the Poornaprajna Vidhyapeetham.

My interaction with priests and the like here in India has been minimal during my adult life. There was the man that officiated at my wedding in Hyderabad (and then, incredibly, did the same at the wedding of one of my closest friends in NJ many years later). That’s about it. My discussions with that priest primarily involved saying things like “huh?”, “what was that again?”, “you mean this loincloth?” and “I really don’t see a star over there”. My married Hindu brothers and sisters will understand that last one.

My discussions with that priest did not involve death, dying, abortion, biomedical research, homosexuality, or AIDS. These were some of the issues I and my new bioethical friends discussed with the priests/monks/ascetics at the peetham today. We were privileged to sit with four or five scholars for two hours of uninterrupted Q&A. While we did have a set of questions prepared for them to address in advance, they were very willing and interested to have an interactive discussion, allowing us to explore some tangents and clarify points as needed. I had the chance to ask some questions that have lingered in my mind for several years, especially as I became an HIV doc with global health interests. Nicole orchestrated the session and formulated many of the questions the pandits answered. Deepak served to some extent as a translator or facilitator of the discussion, and to some extent to keep them honest by asking about scriptural sources for their comments. It was a wonderful opportunity for us, and I look forward to seeing the reflections of my companions here soon.

Everybody’s here

All the team is now in Hyderabad, recovering from their travels. We are currently without internet access in the apartment, so blogging will be a bit spotty for the next day or two.

An enterprising visit

By the time I arrived on Thursday I had an interesting email from a Case med student, Arsalan, who is spending the summer in Hyderabad. He is working at Lifespring as an intern. While his job duties are not typically medical, he has had the opportunity to observe a range of Lifespring’s activities, and asked me to come check it out. So I went the next day.

Lifespring is a group of hospitals here in AP that focus maternal health. In their own words, they strive to “meet low-income women’s demand for safe, dignified, and affordable maternal care”. Each facility has about 20-25 beds that are divided into 3 tiers. Patients in the third tier help to subsidize the care for the patients in the first tier. I believe that one of the eye hospitals in town uses a somewhat similar tiered approach.  There are about 8 or 9 Lifespring facilities across the state, The corporate headquarters, where I met Arsalan and some the of the Lifespring leadership, is located in the hospital in Chilkulguda, not far from where we are staying in Secunderabad. After an enlightening and exciting discussion over tea (of course), I got the 10 cent tour. The facilities are clean and the operation is extremely well organized. A few things really stood out:

First, there is clearly a focus on the delivery of high quality care. Specifically, there is tremendous emphasis on patient safety and quality improvement as outlined by the Institute for Healthcare Improvement and others. I have never seen something like this before here in India. In fact, the title of the obstetrician with whom I met is “Head, Clinical Quality”. And she is very enthusiastic and passionate about her mission.  Patient safety and quality are matters that I hear about quite a bit these days. The Cleveland VA, my employer, happens to have a core group of highly accomplished scholars in this area. Additionally, over the past two years, our residency program has developed a rotation for our senior residents focused on quality improvement, and as of this academic year, we have added a fourth chief resident rotation with a focus on patient safety and quality. So I am used to hearing about this stuff a lot, just not during CaseIndiaTrips. Lifespring has protocols, standards, and continuing education programs for its staff to ensure that the highest quality care is provided to their clients, regardless of their ability to pay.

Second, this organization is a social enterprise. Many of our readers may be very familiar with this concept, but I certainly am not. My feeble understanding is that they are a business, interested in making profits, but in a deeply socially and ethically conscious way. I am used to hanging with people from academic hospitals or NGOs on these trips. Meeting members of a social enterprise is a new thing for me, and I am intrigued. They have kindly agreed to allow the CIT4A crew to spend some time with them in a couple of weeks; it will be interested to see people’s thoughts. It is a new angle on global health that integrates fields other than medicine. We talk a lot on CIT about social inequalities and the huge disparities in income correlating with/determining the disparities in health outcomes in resource-limited settings. I must add here, of course, that even so-called well resourced countries have this problem in their own way; this is one of the take-home messages of CIT (I guess that was a spoiler of sorts).  Social enterprise actually tries to address this in a theoretically cool way. I hope we hear more about this from my companions in the near future.

Finally, there is great scope for learning for a medical student or resident here. I am hopeful that we (Arsalan) can set up a standing collaboration between CWRU and Lifespring so that both institutions benefit.  I also hope that Dr. Masters has a chance to visit here in a couple of months. This seems kind of up her alley.

PPTCT

Next week, the CIT 4A team will start off their experience at the Sivananda Rehabilitation Home. Our regular readers know that this is generally a highlight of CaseIndiaTrips® and I will not describe the scope of SRH’s work. No doubt, you will hear more next week from the CIT4A team. I want to talk here about something that SRH doesn’t do. Or, more precisely, something they no longer do.

The prevention of mother-to-child transmission of HIV, abbreviated PMTCT in most parts of the world, is a critical piece of HIV prevention efforts. It is actually one of the few interventions that truly, unequivocally, reduce new infections. There are a couple of strategies that  are now in use. The original report of successful PMTCT is from the trial ACTG 076, performed 17-18 years ago. Using only oral and intravenous zidovudine (AZT), investigators were able to reduce transmission from the 30% range to less than 5%. In India, as in many resource-limited settings, a single oral dose of the medication nevirapine is used in mom with the onset of labor and then in baby, and this is highly effective in PMTCT as well. The National AIDS Control Organisation oversees PMTCT efforts and calls it PPTCT (mother is changed to parent to make sure it is clear that dad should play a role in taking responsibility). Most PPTCT programs are run out of government clinics, but some NGOs and other organizations have been empowered to do this work also. NACO provides ART and some manpower to run these programs.

At least, they did until recently. SRH was asked by the state NACO branch – the Andhra Pradesh State AIDS Control Society (APSACS) – about 3 years ago to run a PPTCT program near their DOTs catchment area. They agreed, and proceeded to do it very well. This despite funding coming irregularly. I am now informed that all funding for SRH’s program, as well as several like it, has been pulled very recently and that these PPTCT efforts have been shut down. This is very sad news. I am not sure what the long term plan here is, but I am reliably told that there is no short term measure to ensure that pregnant women in the area are being tested and referred. Perhaps this is a reflection of the tough economic times, I don’t know. It is alarming to think, however, that there more children will likely be born to HIV-infected mothers without the benefit of effective, proven prophylaxis. In AP, a state that already has the biggest HIV problem in India, which has the third biggest HIV caseload in the world.

Packing

It is the night before my departure and I am packing. Well, more like looking intently at my suitcase. There isn’t a whole lot to pack, since I try to maintain a wardrobe in Hyderabad, but I will be bringing some updates. The suitcase is really for the loot I will be lugging back in a month. I have called our hosts in Tarnaka to confirm our arrival this week. I have also requested our usual driver, R. I am hopeful that R will pick me up at Shamshabad Thursday morning. And that he will take me directly to my family’s home without unscheduled stops. One of the highlights of CaseIndiaTrips for me each year is my conversations with R every day.

I am also looking forward to my aforementioned Triumphant Return to Bangalore. And to meet the students in the Bioethics course. Especially the one that has chosen the moniker interim17.

Finally, a word about my flight. I am, for the first time, taking a direct flight from the US to the subcontinent. Newark to Mumbai. 15 hours. The longest I have been on a plane before this is 9 hours. Not sure what to expect. Everyone who has told me it will be terrible has reported never doing it. Everyone I have spoken to who has done it has said it is fantastic. Will I, as my friend Federico likes to say, be the exception that proves the rule? I have loaded some books on the iPad and will also have my laptop with me. I am not taking any sedative/hypnotic despite the recommendations of many. Maybe the extended time aloft will spur some inspired blogging.

T-30 Days

There is less than a month to go for CIT4A. I am leaving for India on the 13th of July and will be receiving our four 4A team members on the 17th.  The excitement is building now, but there is still a lot to do. Somehow, though it has been less than a year since CIT3, I miss India and the CaseIndiaTrips experience more than usual and am glad we are going to get started soon.

So every year, I try to do something new. This year, it is the Bioethics course. Concurrent with CIT4A, we are running a 3-week Bioethics course for undergrads and grad students at CWRU. The first week will be in Bangalore and the other two will be in my familiar environs of Hyderabad. The course director is the elusive Professor Nicole Deming, about whom I have written in this space previously. Faithful readers will recall that she accompanied us on last season’s CaseIndiaTrips in a guest starring role. This year, Nicole is part of the regular cast, and I am hopeful that she will join me in the blogosphere very soon.

Although I am not part of the planning of the Bangalore portion of the course, I am planning on tagging along with the group. We will be visiting a Madhva monastery, where our guide will be Professor Deepak Sarma, the other co-director of the course. I am eager to make my triumphant return to Bangalore (still not used to calling it Bengaluru) after 15 years and am intrigued by what we could learn there.