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Vellore, Tamil Nadu, India
I'm a frood who knows where his towel is.

Wednesday, June 29, 2011

Amputations and Asymmetry

Date: 06/29/2011

I noticed the streams of sweat run down his bare neck and chest as I was squashed between my brother and sister-in-law in the back of a small air-conditioned Hyundai. It was an oddly humid night in New Delhi and he was only wearing a loin cloth. He was younger than me and, for a second, I found myself envying his toned chest and abdominal muscles. But my envy was short-lived because I suddenly realized the most striking thing about this handsome lad: he was missing his left arm and leg.

Asymmetry is one of the first things we’re taught to note as medical students. Perhaps that’s why I was captivated by him when I saw him hobble up to the car next to mine at a red light. I anticipated that he’d come to us next and started scrambling for my wallet and couldn’t find any reasonable change-- the smallest denomination I had was a 500 rupee note (~30 USD PPP). I frantically urged my mother, brother, and father to give him something smaller, but the light turned green and we had to drive off just as he got to our car. His eyes met mine for an instant. I wanted to tell him to wait. I wanted to tell the traffic light to wait. I wanted to tell my father, who was driving, to wait. My voice failed me in my desperation, the car moved on and he was gone. I slumped back in my seat and felt ill.

I’ve seen beggars all my life. I’ve seen mothers with desperate looks in their eyes and emaciated babies cradled in their arms braving the heat and the horrific fumes of vehicles at red lights. I’ve had mud-smeared children, with bellies distended because of protein-energy malnutrition, approach me with their pleas for alms. I’ve been threatened with curses and promised divine blessings by beggars of several different faiths. I’ve seen hundreds of mangled bodies-- amputated limbs, distorted trunks, legs bowed by vitamin and mineral deficiencies, blind eyes, and undernourished bodies that just barely look human, clinging to a wisp of life with progressive tremulousness. Why then did I feel ill? I should have been inured to these sights by now. Was it guilt due to my relative prosperity? Was it my long sojourn in the west? Was it the incongruity of the coexistence of his muscular physique and his chopped-off limbs?

I don’t know.

As I slumped silently in the back of the car, my stomach churning at the lachrymosity of the situation, my thoughts drifted from the asymmetry in the lad’s amputated body to the asymmetry in the landscape of Indian society. New Delhi is filled with posh malls, BMWs, palatial bungalows, luxurious hotels, and world class hospitals. It’s also home to emaciated children, amputated beggars, and poverty that is capable of exhausting the world’s supply of tears. I understand how it is easier to ignore the agony of people who live away from you and whose suffering doesn’t immediately affect you. However, I cannot fathom how the lawmakers of India, who inhabit Delhi, reconcile themselves to the simultaneous existence of BMWs and beggars in the city and the dichotomy of malls and mutilations. I beseech them to do something.

This slum, under a bridge in New Delhi, is only a few kilometres of the government of India (pictured below). Note the infant in its mother's arms.

When I got home, I looked at the Rs. 500 note in my wallet. I hadn’t been able to give it to the anonymous amputee. Any middle class person would have justified my inability: “It’s too much”. In a practical sense, they’re right. You’d have to be very very rich to be able to give Rs. 500 to every beggar you meet in India. However, I feel Rs. 500 is simply not enough! Even Rs. 5000 is decidedly not a long term solution that’ll free them of the poverty trap. Instead of only giving money once in a while to a beggar whose sorrow moves us, it is important for us to agitate, to educate, to advocate, to vote, and to ultimately bring about significant changes.

Perhaps giving alms to beggars is something we do mostly to salve our consciences, to atone for the asymmetry.

P.S: In the upper-middle class Indian society I inhabit, encounters with amputated beggars are usually followed by discussions of horrific gangs that abduct and amputate children to force them into mendicancy. This practice was also depicted in Slumdog Millionaire, where a homeless child who was a decent singer was taught a religious song, blinded in his sleep, and forced into beggary. These discussions frequently (not always) conclude that we should not give money to the mutilated mendicants on the streets. The logic: by not giving alms we express a refusal to be emotionally manipulated that will make this heinous practice unprofitable and force the gangs to find other wicked ways of making money. I follow the logic, but-- at the end of the day-- it doesn’t help me ignore the individual pain of crippled beggars. What if he isn’t the pawn of a diabolical gang? What if he really has been disabled by some tragic accident and can’t find work? And even if he is the victim of a gang that is using him to tug at my heart strings, can’t I at least spare him a beating from his boss today by making sure he doesn’t go back empty handed?

Saturday, June 25, 2011

I for Iodine

Date: 06/25/2011

“Medicine is a social science and politics is nothing more than medicine on a larger scale.”-- Rudolf Virchow
My study of public health in India began in All India Institute of Medical Sciences (AIIMS) in New Delhi (marked on the map). While in America, I had a serendipitous reconnection with Ritwik Pandav who was my best friend in third grade. His father, Dr. CS Pandav, is the head of the Department of Community Medicine at AIIMS and an expert on Iodine deficiency disorders (IDD). Dr. Pandav very graciously invited me to an intra-departmental symposium where I got an excellent primer on the principles and practice of community medicine and public health in India. Today I want to blog a bit about Iodine deficiency which was a big part of our discussions.
This image (courtesy Zimmermann, Jooste, and Pandav, 2008) tells the story of this little girl from western China who suffers from IDD. SHe has severe mental retardation and stunting. Some common facial features you can see here are the widely spaced eyes, saddle nose deformity, immaturely developed jaw bones, and thickened and dried skin and hair. I keep her face in my head when I think of Iodine deficiency disorder.

Iodine deficiency has been a much researched topic at AIIMS since the work of V. Ramalingaswami, a giant in the field, in the 1970s. Iodine deficiency in children can begin while they’re still in the uterus. Iodine is necessary for the production of thyroxine in the thyroid gland. Thyroxine is necessary for both the development of the brain and the body. It is important in the formation of myelin sheaths, which insulate the brain cells, in the brain and the spinal cord as well as the formation of connections between brain cells (synapsis) in foetuses and children. Severe iodine deficiency, unsurprisingly, results in mental deficiencies, physical stunting, and spasticity. Indeed, there is a 13 point difference in the IQ of children in Iodine deficient and Iodine sufficient areas of the country! This, coupled with physical stunting, leads to a very significant difference in income.
Fortunately, these deficiencies are reversible in childhood (to a certain degree) by correcting the iodine deficiency. In fact, the Disease Control Priorities Project (DCPP) suggests that the iodination of salt is an excellent investment. It involves an investment of 5 cents per child per year. When making policies in public health, we consider a concept called Disability-Adjusted-Life-Years (DALY) which is a measure of the the number of years of life lost through the morbidity and mortality of disease. If you value each DALY at $1000, salt iodization gives you a 30:1 benefit: cost ratio-- a smart idea (see the DCPP table below).
Ensuring the adequate iodine intake of the population involves frequent testing. T3, T4, and TSH tests are not sensitive tests. Urinary iodine concentrations are therefore used to assess iodine sufficiency. A concentration above 100 ug/L , which indicates an iodine intake of 150 ug per day, is considered sufficient. Pregnant women should consume about 250 ug of Iodine everyday (150-249 ug/L of Iodine in urine). Excessive consumption of Iodine yields a urinary output of 300 ug/L (500ug/L in pregnant women). Another direct test for severe Iodine deficiency is looking for goitre, an increase in the size of the thyroid gland.
This image (courtesy zimmermann, Jooste, and Pandav, 2008) shows an incredibly large goitre. The requirement for goitre to be diagnosed, ordinarliy, is that each lobe of the thyroid gland in the neck is larger than the size of the distal phalanx of the thumb (the tip-most bone of the thumb).

There was also some discussion of the salt iodination programme in India. Apparently, the government of India had placed a ban on the sale of non-iodized salt in the country in 1997. However, elements in the medical community raised concerns regarding the side effects of Iodine overdose and the government ended the ban in 2000. Consequently, the fraction of households using iodized salt fell by 12% (Zimmermann, Jooste, and Pandav, 2008) Fortunately, researchers-- spearheaded by those at AIIMS-- proved that the horrors of IDD eclipsed the possibility of over-iodination. As a result, the government reinstated the ban in 2005. Considering the devastation Iodine deficiency wreaks on human capital through its effects on physique and cognition, I find it deeply disturbing that more than 17 million south asian children are born in houeholds that are not protected by iodized salt every year.
Amartya Sen describes poverty as an individual’s incapability to realize his or her full potential as a human being (as cited in Banerjee and Duflo, 2011). If we accept this description, correcting iodine deficiency disorders is a key step in reducing the poverty of our world. Zimmermann, Jooste, and Pandav underline the importance of educating political leaders and forming public coalitions to address this issue. This responsibility falls largely on the shoulders of doctors who are, after all, public intellectuals. The more I proceed in my medical education, the more I feel that our battle is not so much against disease as it is against poverty.

"Only in India" moments:
I was walking in the street when I saw a scooter hurtling towards me. I leapt aside with a yell to avoid being mown like a helpless lawn.
Pranay: Dekho Dekho! (Watch out!)
Scoter driver: Arrey, side hato na! (Why the hell don’t you get out of the way instead of yelling?)
Ah, I love my country.

  1. Zimmermann, MB, Jooste, PL, and Pandav, CS. Iodine deficiency disorders. The Lancet: 372 (2008)
  2. Alderman, H. Stimulating economic growth through improved nutrition. Disease Control Priorities Project ( (2008)
  3. Banerjee, AV and Duflo E. Poor Economics. Random House India. 2011

Thursday, June 23, 2011

Back in the land of snake charmers and special economic zones

Date: 06/23/2011

My Jet Airways flight boarding at Brussels.
My flight failed to crash and burn on the way to India. Consequently, I am back in the land of snake charmers and special economic zones, the land of cows and computer programmers. The heat wasn't appalling when I landed. It was only about 98 degrees Fahrenheit. Phew!
A shot from the air.

I've never liked how much larger the symbol for the plane appears when compared to the symbol for the final destination. I always worry that the plane won't fit in the city.

Euclid defined a line as an entity of infinite length and zero width. Clearly, he had never been to India. Lines, though unending, are bizarre entities in India because people behind you in the line stand a little bit to the side in a way that makes it a little bit unclear which of you is actually in front. This yields the line the breadth of two to three people. In such situations, you have to watch them closely. If they sense your distraction for a second, they'll slip ahead of you and pretend that that is where they were to begin with. I experienced this betrayal several times in the immigration line last night.

The new airport terminal in Delhi has these gigantic hands as decorative pieces in the immigration area. The shot does no justice to the chaos of the "line" I was in.

Clearly, I've been abroad far too long and forgotten the tricks of my clever countrymen. However, I did note that people seemed less likely to perpetrate these linear swindles on non-Indians. I asked them some of them about it:

Pranay: "So you clearly pushed ahead of me, but why did you let the Chinese gentleman go?"
Stranger 1: "I don't want them to think ill of our country, you know. They're guests."
Stranger 2: "We can't expect them to know the tricks of the country so we have to be kind and welcoming."

Ah, I love my country and the welcoming spirit of my countrymen.
Ras Malai: The most delicious dessert in the world. A very hearty breakfast, but after six of them today, I feel some tightness in my arteries.

P.S: My reward for dealing with the dust, heat, and line jumping was a delicious breakfast of three ras malais (a delectable dessert made from milk and cream) and I finished another three over the course of the day. I think I need some serious diet counseling.

Friday, June 17, 2011

Vanishing and Reappearing

Date: 06/17/2011

The writing's on the wall: I am going to do horribly on the final exam for the gastrointestinal system because my brain is already yearning for the heat of the Indian summer and Indian chillies. The latter has a remedy (Indian mangoes!!!) and the former is meant to be suffered bravely (which allows you to boast freely when you meet people from more temperate parts of the world).

I was just having an evening coffee with a friend from med school. As we parted, I got into my car, revved up the engine and almost ran the stop sign just as she was crossing the street while also being on the left side of the road. She gave me a very very befuddled look and I had to embarrassedly tell her to move on and not judge me (Sorry, Sandi!). What can I do? My brain thinks it's in India already.

My flight to India is on Tuesday. I get to fly my favourite carrier: Jet Airways. They serve mango lassi and Indian food and, most importantly, give me a chance to catch up on all the escapist Hindi cinema that I've been missing in America. As I get closer to my flight, I cannot get a quote from one of my favourite books, "If on a winter's night, a traveler" by Italo Calvino, out of my head:

"To fly is the opposite of traveling: you cross a gap in space, you vanish into the void, you accept not being in a place for a duration that is itself a kind of void in time; then you reappear, in a place and in a moment with no relation to the where and when in which you vanished."

You can imagine how exciting the prospect of "reappearing" in India is for me.

This picture was taken three years ago in the Montreal airport as I waited to vanish and reappear in New York City.