A brown sahib in a bus

Date: 07/19/2011

The bus starts out empty.

“Pranay, like it or not, you will be a gringo in India.” Dr. Guerrant warned me as I got ready to fly to India, my own country. Gringo is the picturesque Latin American term for foreigners. Personally, I had felt slightly outraged. I am, after all, a passport carrying citizen of India! Born in humid Kolkata and raised in the dry heat of New Delhi, I did not consider myself a brown sahib, a term reserved for the educated Indians who served the British raj in India. Brown sahibs were often more English than the English.

I was still bristling at Dr. Guerrant’s warning when I boarded the bus this morning. After tossing three well-worn one rupee coins to the conductor, I curled myself into a window seat. I say curled because it is impossible for anyone taller than 5 feet to sit in those seats without an impromptou display of contortionism. Reading on the bus is physically impossible-- the customary jerks are colossal enough to rearrange your visceral organs. If this were not enough, the imaginative interpretation of traffic laws by most bus drivers is sufficient to reacquaint any traveling atheists with the deities they staunchly deny.  I have learned my lesson and now just sit and commune with my fellow Indians quietly.

And ends up looking like this.

Five minutes into my jangly bus ride, I saw a lady, in a gorgeous saffron sari who was squatting behind a small bush. She was defecating. Seeing the bus approach, she made a few perfunctory moves to conceal herself, but she knew as well as I that it was futile. I averted my gaze to give her some privacy. Though I had seen similar sights hundreds of times before, it shook me up in a way that the bus could not. I was struck by the thought that my India was so different than hers.

“India’s economy will soon overtake China’s,” is the proud boast of a vocal minority in India, a minority I regrettably belong to. Indians like me suddenly have the capacity to patronize brands such as Bvlgari and BMW. You know you’ve been left out of the prosperity party when you cower behind bushes as you carry out you basic bodily functions, clutching at the last vestiges of your dignity. This is the case for 638 million people in India. That’s twice the population of the United States.

Two schoolgirls were sitting in the sear in front of me. They were attired in white shirts and navy blue skirts. I got occasional whiffs of coconut oil from their well-oiled braids secured with ribbons that matched their skirts. The braids oscillated in phase with the stochastic shudders of the bus. A wave of nostalgia gripped me as I heard them chanting the preamble to the Indian constitution, a feat every good middle-schooler in India is expected to master:

What do I have in common with these men?

We, the people of India, having solemnly resolved… to secure to all its citizens:

Justice, social, economic and political;

Liberty, of thought, expression, belief, faith and worship;

Equality of status and of opportunity;

and to promote among them all

Fraternity assuring the dignity of the individual and the unity and integrity of the Nation

I couldn’t help but wonder: if Justice, Liberty, Equality, and Fraternity are the lifeblood of modern democracies, is India, with its extreme inequalities, truly a democracy? If we, wealthy and educated Indians spout clichés, act fashionably desensitized to the poverty in our faces, and allow the creation of a permanent economic underclass, won’t our democratic claims ring unforgivably hollow? Won’t history judge us harshly for this denigration of our fellow humans?

 “Doctor sahib, can you help me?”

My reverie was suddenly broken by my young co-passenger who had had spotted my stethoscope. I clarified that I was a lowly med student, but agreed to look at a leg wound that he wanted to show me. The wound looked dirty and was crusted with some dried exudate. A fly promptly buzzed in and began probing the injured area. I swatted the fly away with my hand and suggested some simple wound care and tetanus prophylaxis to the lad.

Often Indians communicate more by jiggling their heads than they do through their words. There is the ready sideways head-jiggle of the Indian who is on the same page as you and then there is the slow, tenuous cranial swaying of the Indian who is mystified, but too proud to admit it. From the amplitude and frequency of the boy’s head, I could tell that my vocabulary and accent were impenetrable for him. My English is inspired by Oscar Wilde. His was inspired by necessity. I broke into Tamlish (a hybrid of Tamil and English) and descriptive gestures to communicate with him.

We need the optimism and perseverance of this man. He knows the street will be dirty within hours and yet he sweeps undaunted.

As I clumsily counseled the boy with broken words and jerky gestures, I felt a sickening twinge: I truly was a wretched brown sahib, a gringo. Dr. Guerrant was right. I spoke, essentially, a different language. As is the case with visiting Americans, the rupee had a completely different meaning for me-- the 3 rupees I had paid thoughtlessly to the conductor are almost 10% of the daily earnings of millions of Indians who subsist on 99 cents a day. My parents, both Doctors, kept saved me from debilitating malnutrition and paid for expensive athletic abilities. No wonder I look physically distinct from the emaciated poor who comprise the bulk of India’s population. In that moment, I resented and despised everything from my expensive education to my posh-sounding accent. They were exposed as the products of inequalities deeply ingrained in Indian society, the same inequalities I vehemently decry. I felt like I had somehow swindled the man next to me.

If you want to meet an optimist in India, shake hands with a traffic policeman. They deal with chaos beyond imagination.

There is, however, a glimmer of hope. My brain is unimpaired by malnutrition. My education hasn’t been discontinued at an early age due to lack of funds. My body is not crippled by preventable diseases. I have the capacity to advocate for my voiceless Indian brothers and sisters. I owe my country and my fellow citizens at least this much. This will be my atonement.

The progress made so far has been at the pace of a bullock-cart. This is simply unsustainable. We, the privileged children of India, can hasten the process of change.

A muted sort of triumph

Date: 07/18/2011

I wish I could have done more

We were only two thirds through the camp and I had already seen over a hundred patients. Kartik and Gemlyn, my fellow medical officers, had seen even more and they had been keeping an eye on me the whole time. It isn’t as herculean as it sounds, really. In most cases, we just do some TLC for people with a motley collection of aches and complaints. We put them on calcium, iron, and multivitamins. Treat their heartburn with H2 blockers, deworm children, treat symptoms of cough and cold, provide antibiotics, antipyretics, and painkillers to the needy, check their hearts and lungs, counsel them on health-related matter, make referrals for ophthalmic, dermatological, and neurological conditions when we're out of our depth, etc. Some people just need to be able to chat for a few minutes with a guy armed with a stethoscope. People really just use us as a one-stop shop. I had a boy come to me with complaints of shortness of breath. Taking a history revealed that he sighed deeply from time to time and his mother freaked out about it. I probably shouldn't have burst out laughing- bad manners. Still, I don’t resent it. India has 70,000 doctors to care for her 1.2 billion citizens. With this insufficient ratio, It’s little wonder why people hoard up their problems-- big and small-- and bring them to community screenings like ours. We see a very wide range of medical problems in our camps in terms of severity.

Yesterday I saw a woman who had lost the use of her left hand after she got a serious electric shock. The hand was a claw. I suspected an issue with the ulnar and the median nerves, but couldn’t do anything. I also met a man whose body was paralysed on the right side. His steppage gait and asymmetric smile gave it away immediately, but there was nothing I could do about it. A wrinkled old lady with only one eye hobbled up to me with a cane next and complained of joint pain. I provided her calcium supplements for her bones, iron, B12, and folate tablets to correct her deficiency, and turpentine ointment for her joints, but-- basically-- I couldn’t do anything substantial for her. Kartik, Gemlyn, and I know that this is not simply not enough. Perhaps this is why we call ourselves “Quacks R Us” or “Two and half quacks”.

We can't blind ourselves to the horror of the health situation.

Soon after the lady limped away with her creaky cane and even creakier joints, a mother approached me with her son and daughter. Over the past three weeks, I’ve learned to quickly scan my patients for a few obvious pathologies. Here’s what I remember thinking in the 5-10 seconds they took to walk over:

Young woman. Looks a bit weary, though. Has the expressions of an older woman. Two children: boy and girl. Girl looks healthier than boy. Mother doesn’t have a patient form. The children do, though. The worry might be because of the health of children. The boy’s shirt is bulging just a tad. Protein Energy Malnutrition (PEM)? Make sure to check. What about the daughter? Anemia? Vitamin deficiency? General Malaise? Naah. Looks good. Let’s look at the boy. Looks a bit tenuous. How old is he? 9? 10? He’s walking a little bit awkwardly and unsurely. Is that just me? Am I scaring him?

I put on my warmest smile for the mother and the children to allay their fears. The boy was indeed tiny. I’m known to have a short torso and I still towered over him even when I was sitting down. The kid was actually 13 yeas old! Clearly, he was the victim of grave malnutrition. The mother complained that he had a weak heart. Having heard the same complaint from a couple of different mothers earlier that morning, I have to admit, I sighed silently and took off my stethoscope somewhat perfunctorily. I had to check for the kid’s PEM anyway so I unbuttoned his shirt. As expected, the PEM was there. Shobana, my translator and a dietician, began counseling the mother on the kid’s nutrition as I visually approximated the location of the the apex of his heart. I found it, placed my steth’s diaphragm on it, and closed my eyes to block out the other stimuli.

Does he look 13 to you? Note the distended belly characteristic of PEM.

Lub..swoosh...dup
Lub..swoosh...dup
Lub..swoosh...dup

My eyes opened wide with shock. It couldn’t be! I moved my steth systematically from the apex to the left of the manubrium sterni then up to the region under the clavicle and then back near the sternum at the second intercostal. To confirm the diagnosis, I checked for the sound in his left axilla. It was there. I had only heard this sound once before. I spun in my seat and decided to consult Kartik, a fount of all medical knowledge: “Kartik...pansystolic murmur...present in axilla...could be MR...please confirm.”

Kartik auscultated the boy and confirmed my suspicions in a minute: “It’s either Mitral Regurgitation (MR) or Ventricular Septum Defect. Tricky. You can feel good about it. Nice catch.” Considering, I had basically picked up rudimentary auscultation by reading in my spare time and with the help of some impromptu tutorials from my father over the phone and a Tanzanian doctor in my bungalow, I glowed with pride. Then, putting aside the glow for later enjoyment, I asked the pragmatic question: “So, what do we do?”

Kartik: What can we do?
Me: Refer to cards?
Kartik: I’m not sure if he’ll meet the requirements for free surgery.

And there we were. The familiar feeling of utter and complete helplessness darkened any remaining glow from a few minutes ago. Judging from his ripped shirt and malnourished frame, it was pretty clear that there was no way this kid’s parents could afford a valve repair or replacement. I hate not being able to do anything for the people who come and see me with hope in their eyes! For instance, I see 60 year olds with classic signs of radiculopathy and have to tell them that there’s nothing I can do for their pain. If they're 30-40, I can refer them to the orthopedics department, but 60 is considered so old that the number of DALYs saved do not justify the cost of the surgery. If these poor people persist, I have to send them off with calcium tablets. I sometimes worry that doing so might shake their faith in doctors and drive them to quacks and witch-doctors that lurk the countryside, preying on those neglected or disillusioned by India’s healthcare system.

 It's not like I think we do more bad than good. We've been able to help an enormous number of patients and catch some tricky diagnoses early. For instance, I caught a breast lump and a nasal cancer in two women yesterday and urged them to get them checked out before they grew any more. I suppose my frustration is just that I am not convinced that the work I am doing in my current capacity is bringing us very close to the utopic future people in global health envision and long for.

They're waiting to get the healthcare they deserve. We can't fool them. We can't cheat them. Not anymore.

Ultimately, we directed the child’s mother to the paediatrics department at CMC where we figured at least his PEM would be treated. We think there may be a chance that his heart problem will be attended to given his young age and CMC’s charitable mission. Thank god, for Christian charity! However, I have never ever been good with uncertainty and the very real possibility that that poor child will be left untreated for petty financial reasons bothers me and makes me smile wryly when anyone tells me I’m doing good work in India. I love diagnosing patients. I love being right. But what’s the point of it if treatment and resolution don't follow?

My serendipitous brush with big pharma

Date: 07/16/2011


Disclaimer: This essay documents some extremely disparaging comments made about Indian doctors by a member of the Indian pharmaceutical industry. I do not believe these are entirely objective observations and I definitely don’t believe that they apply to every or even most Indian doctors. I have only positive superlatives to use for the doctors, young and old, that I’ve met at CMC and AIIMS like Drs. Rama, Pandav, Kartik, and Gemlyn. I respect them immensely and hope to be like them one day. Remember, my parents are also doctors who practiced in India. I don’t mean to offend them or cast aspersions on their ethical impeccability. My sole intention is to bring the corruption that afflicts a certain proportion of Indian physicians and surgeons to attention and reveal the modus operandi of the pharmaceutical industry. 

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With a running jump, I hurled myself into the bus headed to Chennai. Phew! Just made it. After chucking my bag under a seat, I flung myself into a seat, my chest heaving and the S1 and S2 sounds of my heart (LUB-DUP) audible at a range of five feet. I was taking one day off work and nothing could stop me. Being totally antisocial, I wrote a blog post for four-fifths of the journey, but ultimately turned off my mac and gazed at the sights outside. Having no idea where we were, I turned to my fellow passenger, an immaculately dressed bloke with a self assured smile with sharp features. He looked like he was perpetually amused by an inside joke. Let’s call him Lex for the purposes of this post. Lex thought we were on the outskirts (hmm...never quite understood the etymology of that word) of Chennai. We fell into a spontaneous conversation about our lives and he revealed that he was the brand manager for a pharmaceutical company.

My formerly audible heartbeat almost stopped. We med students speak of “big pharma” in hushed whispers and the discussions usually centre on how appallingly greedy they are or how little they care about human life and suffering. Consequently, I felt like I had engaged a minor minion of the devil in a congenial chinwag. I consider myself a pretty ethical individual and hesitated to converse further. My conscience desperately wondered whether there was some way of changing my seat without being too rude. Alas, there was nothing to do, but talk to him while keeping a sharp eye on my soul.

Lex: What’re you doing in Vellore?

Pranay: (very uptight) errr...research

Lex: On what?

Pranay: umm...medicine. So, what do YOU do exactly?

Lex’s smile broadened as he began explaining: “ Look, I travel all over the country with my scientific presentations, but if that’s all I have for a doctor, he’ll instantly toss me out of his office. The gifts and dinners make sure they listen. We help them out with stuff ranging from their daughter’s dowries to recharging the talktime on their prepaid cellphones. Check any doctor’s passport. You won’t find a single page empty. Who do you think funds that travel? The idea is simple. If we put in 100,000 worth of gifts, we expect them to prescribe that amount of our medicines every month. If they don’t, we stop sponsoring them and showering them with gifts. This is why they tack on multivitamins and other supplements to your prescriptions. It’s the poor man on the street, who doesn’t know what the drug is for, who suffers financially.”

“Ha! So, we agree on a few pharmacies in town. We ship our drugs to these pharmacies and the doctors ensure that their patients buy their prescriptions at these specific pharmacies. This is how we monitor whether the doctor is doing our bidding. Frequently, the doctor asks patients to check back with them ostensibly to check whether they got the correct medication. In fact, they do so to ensure that they purchased the correct brand, our brand.”

I was horrified at Lex’s smooth explanation of his modus operandi, but I couldn’t stop now: “Surely, it’s the older doctors who do this. The younger blokes must be idealistic, right?” Lex threw his well groomed head back, clapped his hands very hard, and laughed. 

“Who do you think we do phone recharges for? We get the young doctors doing their post-graduate medical studies early. They need money to buy bikes, afford cable TV, take out their girlfriends for valentine’s day...just name it! Pranay, I used to think of doctors as gods when I was a bachelor’s student in pharmacology, but when I see them asking us for these petty things and queueing up for extra pens and bags at our conventions, I can’t help but think of them as puppets and-- I hate to use the word-- beggars. We have them in our pockets.”

Hearing his awful tales, I felt a need to justify myself: “Listen, I am the University of Virginia which has banned medical reps from the premises and we’re not even allowed to have pens from pharma industries.”

At this point, Lex revealed something interesting: “You know, Dr. Ketan Desai, head of the Medical Council of India (MCI) was instituting strict rules preventing doctors from accepting our gifts. We were actually happy! The pharma industry had numerous conferences discussing the return to scientific marketing instead of gift based marketing. We even drew up standard operating procedures on how to sell drugs to doctors using scientific pitches. However, just three months after the MCI edict, the Dr. Desai was arrested in a bribery scandal and the anti-gift rule fell by the wayside. Consequently, it was business as usual. I was annoyed, but it wasn’t like we hadn’t corrupted the doctors in the first place.”

Lex was trying to portray science based marketing as ethically impeccable so I decided to call him out on it: “Lex, it’s not like you guys don’t muck around with your scientific studies. I have heard so much about your manipulation of the controls and enrollments in your clinical trials to make your drugs look better than they are.”

Lex was clearly taken aback for a second: “Oh, very good. Not many of you take the time to really look at the papers, but we actually go beyond that even. I have frequently visited big research hospitals and given the doctors there a set of results I want for a particular drug. I follow up with a cheque for a large sum that we’re willing to donate to their department in return for a favorable publication.”

“Aren’t they offended when you do this?”

“Hah! They’re usually ecstatic at the opportunity to supplement their income.”

My horror had long turned to indignation. I had had enough: “Lex, you admitted that you guys corrupted the doctors in the first place and that it’s the poor man who suffers. Don’t you ever feel bad about this?”

His ever-present smile faltered and he lowered his eyes and gazed silently at the black folder with his company’s name emblazoned on the cover. He slowly fingered his expensive looking purple tie with his right hand as he contemplated my uncharacteristically direct question. When he spoke again, the self-assurance was missing and it seemed like he was, for once, not entirely convinced of his utterance: “In business...you have to...you can’t...be...you can’t be emotional in business. It won’t...work.”

I left a significant chunk of my alacrity on that bus. The elephant in the room (in the bus,  rather) had been whether I, Pranay Sinha, would ever succumb to the temptations of the pharma industry as a full fledged doctor. I pray that I remain strong and never falter in this regard. And my plea to my colleagues in the medical industry is to stay strong and resist this temptation as well. We CANNOT make a laughingstock out of our noble profession. Saving lives and assuaging wounds is a calling and a privilege, not a business. We CANNOT discard our emotions and ethics like Lex!

Cast of characters part 1

Date: 5/27/2011

Dr. Guerrant and I

I thought it important to introduce the cast of characters on this side of the Atlantic. First comes the man who sparked my interest in the connection between malnutrition and cognitive development: Dr. Richard Guerrant. It was his pioneering work in Brazil that first aroused my interest in studying this topic in Indian populations. Dr. Guerrant has been a frequent victim of my angsty ravings about how little some people are affected by the horrors of childhood malnutrition and health disparities in impoverished regions of our world. He has attempted (and mostly succeeded) to calm me down about this .

Another person who has greatly guided me and shown a lot of patience with me is Dr. Rebecca Dilllingham (pictured below). If I can ever develop a bedside manner half as warm as hers, I'll consider myself a very lucky man.

Dr. Dillingham in her office at UVA

The grant that made this possible was given to me by the Center for Global Health at the University of Virginia where I am enrolled in the school of medicine.

This is the brand new medical education building at the University of Virginia.

Last, but not least is April Ballard who guided me through the tortuous rigmarole of the grant application process and helped me get the grant despite my discreditable adoption of Douglas Adams's attitude towards deadlines: "I love deadlines. I like the whooshing sound they make as they fly by." She refused to let me photograph her, but I'm going to do my best to convince her in the coming weeks.