The fearsome face of leprosy in India

Date: 07/21/2011


Being fond of superlatives, I use horrifying and terrifying quite flippantly and usually in a comic context. After meeting a patient with leprosy in one of the community health screenings, I decided to google the following term: “Leprosy pictures”. When I describe those pictures as horrifying and terrifying, I don’t believe that is an overstatement at all and humour is very far from my mind. As I browsed through the pictures of the faces and bodies marred by leprosy, they seemed a hybrid between a monstrous phantasm and a human. Indeed, the disfigurment of the face due to leprosy is described as leonine facies (lion face). Seeing this made the aetiology of the stigma and the mistreatment associated with leprosy perfectly clear to me. It was fear.  

A quick internet search about leprosy produced this article: http://southasia.oneworld.net/Article/laws-in-india-criminalise-leprosy

It contained a list of the anachronistic laws in the Indian constitution related to leprosy. Most of them date from the British Raj when leprosy was considered highly communicable and incurable. In fact, leprosy is immensely treatable and is not easy to contract since about 95% of us are naturally immune to Mycobacterium leprae, the bacterium that causes leprosy. In fact, 90% of the cases of leprosy in India are tuberculoid which is not as infectious as the infamous lepromatous leprosy. I’m still in the process of checking whether these laws are  in effect or not.The key points are as follows. Leprosy patients in India cannot:

1. Get a driver’s licence.
2. Ride in a train.
3. Compete in local elections.

Moreover, numerous marriage laws pertaining to hindus and muslims consider the contraction of leprosy as just grounds for the dissolution of marriage. Considering the fact that leprosy tends to be a disease of the poor and the abandoned, these laws are by the wealthy against the marginalised poor, by the majority against a defenceless and very ill minority. Of course, these legal wrongs are not the worst problems for patients of this ancient disease. 

The social stigma is immense and even some very highly educated Indians I’ve talked to seem to be fairly ignorant about leprosy and its mode of spread. Indeed, even people who had leprosy as children and were cured without any deformity accruing are seen with suspicion and their job prospects suffer.

 (picture courtesy Wikipedia)

This is a picture of Mahatma Gandhi massaging the legs of a brahmin who had contracted Leprosy and was considered an outcast/untouchable as a consequence. The Mahatma took him in and changed his bandages personally in an attempt to de-stigmatize the disease. Why is it, then, that the people who call him Bapu (father) still force leprosy patients to live in isolated colonies reminiscent of the dark ages?


From the little bit of reading I’ve done so far, it seems, experts are quite unsure about India ever being able to eradicate leprosy. There are some scientific hypotheses behind this. My personal hypothesis for the continued survival of the disease in India is simple: fear. The fear of disfigurement leads people to banish leprosy patients from society and make them live in isolated communities instead of initiating prompt treatment. These poor people do not get treated and their leprosy progresses to the lepromatous stage at which they start losing limbs and getting disfigured. It is this scary face of leprosy that society sees and sustains the fear of the disease. Do you see the vicious cycle? I’ll write more once I’ve ascertained the status of the laws and visited the Schieffelin Leprosy Research and Training Centre at karigiri which is quite close to CMC. 

When asked what separates us from “lower” animals, the most frequent answer is reason. It is the absence of good reasoning that creates a milieu conducive to fear. Good reasoning requires true premises. As doctors, medical students, economists, and educated persons, we have the potential to be public intellectuals! It is our role, as those in the know, to provide our fellow citizens with good, accurate, and up-to-date information so that their premises can be better educated, their actions and laws less inspired by fear-- more human and more humane. 

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?

Scabies scare

Date: 07/12/2011

I was pretty foxed by the skin lesions the boy's mother thrust into my face. Finally, I consulted Gemlyn and Kartik. In a few minutes,we had diagnosed a boy and his family with scabies, an appalling and rather infectious mite (Sarcoptes scabei) borne disease. Kartik prescribed some permethrin ointment to them and we sent them on their way before they infected anyone. It was probably a really lucky thing for the young man that we caught it before his mother took him to a local quack.

We found similar lesions in his mother and treated his sister prophylactically as well.
I like the fly.

Many quacks that lurk in rural India give gratuitous injections to their patients. The patients naively believe that this is the best standard of care. Usually, these injections are simply B12 or saline injections. However, some actually give intravenous steroids. Steroids tend to put you in a really good mood when you take them so the poor patients leave on cloud nine singing the quack’s praises. Injudiciously administered steroids have the potential to make some diseases (like tuberculosis) worse. Topical steroid application can actually throw scabies infections into overdrive. I’m not 100% confident if steroid injections would do the same, but we do know that steroids suppress our immune systems. Immunosuppressed patients (such as HIV/AIDS patients) can develop a particularly severe form of scabies called Norwegian scabies (don't google it). In any case, I am glad we caught him before he infected all his classmates.

Two nights later, I woke up at 3 am:

3.00.00: Huh, my fingers are itching.
3.00.05 : Which ones?
3.00.10: Right hand. Above the distal and proximal phalanges. Differential diagnosis time!
3.00.25: You ass! You worked with the family with scabies without gloves.
3.00.30: Ah, but I used turpentine and spirit to clean my skin afterwards.
3.00.35: Oh yeah because turpentine and spirit kill everything! Let’s embalm everyone in the malaria zone with turpentine and spirit. That’s a nobel prize worth idea right there. Wake up and check the bite pattern, moron!
3.00.40: Fine, fine, no need to get sassy. I’ll get permethrin in the morning in any case. Just let me sleep now.
3.00.45: Not so fast, what else could it be?
3.00.50: Ants raiding my overripe mango? Allergy to that odd soap I used? Polycythemia Vera? Cutaneous T-cell Lymphoma? Doxycycline dermatitis? Mosquitoes? I don’t know and I don’t care. I wanna sleep!
3.01.00: Man, you’re gonna suck as a doctor.

A few minutes later, I heard an annoying buzz in my ear. I quickly swatted it and I don’t think I’ve ever felt more pleased to feel a mosquito’s crushed corpse between my fingers. How’s that for a diagnosis?

Stomach issues

Date: 07/08/2011

“It made me sick to the stomach!”

No, you don't understand. It really did. By "it" I mean some medicines I am on and possibly some food I consumed last night that was probably laced with only the choicest mix of gourmet bacterial enterotoxins. The repeated trips to the bathroom make me feel like a pregnant father. I console myself by remembering that this too will pass (at a rapid rate from both ends of the gastrointestinal system).

This dish should have been labelled as follows: "You'll be sorryyy."

Conquering the urge to bivouac myself into the bathroom, I gingerly dressed and poured myself into a nearby auto. I usually ease my way into ambulances that run between the college campus and the hospital by casually tossing a stethoscope around my neck-- in this tiny college town, doctors (even pretend ones like me) are seldom stopped from doing anything. They, the public reckons, probably know what they’re doing. I love it! Given, my ginger GI system, the auto was an awful choice. My liver rattled against my ribcage as usual and my spleen seemed to be accompanying it today. Fortunately, I followed my golden rule of not watching where the auto was going. It’s not something the faint of heart or gut should do. My eyes were firmly fixed on my Haematology book’s riveting discussion on anaemia.

After extricating myself from the auto, completely oblivious to how many times I had come close to shuffling off my mortal coil, I looked to the left and then to the right.

Left hemisphere:(clipped, sergeant major tone) “No, idiot, you’re in India!”
Right hemisphere: (slow, dull voice) “Oh, OK.”

I looked right and then left.

Left hemisphere: Hmm...not much point to it, is there?

Unlike countries that have established walk and stop signs, crossing streets in India is an adventurous activity. It is widely known that your safety on the road is your own responsibility, not that of the vehicle hurtling towards you at imprudent speeds. My morning ritual involves hopping cautiously across the street dodging cycle rickshaws loaded with school-going children and milkmen on motorbikes. All this while, I find myself chanting “Dekho Dekho!” (look out). I heard a non-Indian pooh pooh the notion that you have to be careful in India a few days ago. “India Schmindia” were his exact words. Poor bloke, he’s going to meet a sticky end faster than the driver of a speeding bus/auto-rickshaw/elephant can shout “DEKHO DEKHO”.

An oddly uncrowded street in Vellore. Notice how fearlessly the man in the pink shirt is crossing the road after a gang of yellow autos rampaged past him.

Having safely, crossed the street without being gored/stomped/trampled, I strode into the hospital. A familiar sight awaited me:

Perhaps this is a testament to the secularism of India. Hindu women praying in front of a cross.

This small lady seems like she has immense faith in divine intervention.

Can you see the number of candles?

This is a cross between a church and a little hindu temple. Christian Medical College (CMC) is a 2500 bed hospital that has been around for the past 111 years and I often think of how many millions of candles people of all faiths have lit here and how fervently they must have prayed. I usually stop for a second and pray with them. Frequently, I watch them from a distance (somewhat creepy, I accept) and can almost see their unshakeable belief in the mercy of christ/vishnu/allah/karma exuding from their bodies like a fragrant vapour. Today, I surreptitiously photographed them with my iphone.

Snake bite? Abcess? Occupational injury? Dog bite? Buruli's ulcer? Leprosy?

Having been reliably informed that I look like a pervert when I smile, I didn’t stare too long and walked into the main corridor of the hospital. Here, I usually encounter what medical students call “Zebras”, rare diseases that you’ll probably never see in your life. CMC is a referral hospital and it sees patients from all corners of Asia. The old saying goes: “When you hear hoof-beats, think horses, not zebras.” At CMC, you think zebras. My two minute walk to the GI department is spent staring rudely at the people I pass in the corridors and trying (usually failing) to guess their ailments. Many patients are impoverished and they receive free care here. For instance, there’s no chance that a child with a treatable entity like Acute Lymphoblastic Leukemia would get turned away from the Haem/Onc unit at CMC regardless of his ability to pay. I thank Christ/Vishnu/Allah that institutions like this exist in India where people can access world class care.

I work in Williams building and I pass poor patients like these on a daily basis.

However, just as I reached the GI unit, I felt a familiar rumble in my tummy. No, this was not the product of nasty medications or exotic enterotoxins. It was the gut wrenching realization that millions of my countrymen don’t have the economic wherewithal to travel to CMC. It was time to get to work.

------

Sorry, this blog post didn't turn out quite as well as I had hoped. I was attempting a Gogol-esque funny beginning with a ridiculously sad ending (like in "The Raincoat"). I was trying to show how my day begins with personal issues, moves on to medicine, and-- ultimately-- to public health. It gets progressively less funny because there's nothing funny about India's public health situation. Unfortunately, I couldn't quite pull it off. 

Helplessly yours

Date: 07/03/2011

“Kavalai padadhinga, sari agidum.”

I stumbled over these newly-learned words with obvious difficulty. I doubt I inspired an iota of confidence in the patients I said this to despite the flashy stethoscope slung over my shoulders to assure them that I am a denizen of the medical world. Shobana, a lovely nutritionist at CMC, had taught me a few useful Tamil phrases despite the hectic pace of the community health screening we was working in. I could now say “Sapttangala” (Have you had breakfast?) and “Unga pirachanai yenna” (What is your problem?). “Kavalai padadhinga, sari agidum” roughly translates as follows: I’m sorry to hear that. Everything will get better.

The problem was that I didn’t believe things would get better at all.

"Nalla irukkingala" (How are you?). I was trying to figure out how this gentleman hurt his feet. Shobana (pink sari) is translating for him. She's "nalla" (very good).

We had advertised the camp (the common Indian term for a community health screening) on Saturday and were expecting about 600 people to show up. The turn out was still unbelievable-- 155! Kartik, Shobana, and I were talking to the patients and listening to their complaints. We checked their blood pressure, looked for anemia induced pallor of their eyes, and dispensed acetaminophen, anti-histamines, mutlivitamins, and calcium as we saw appropriate. I even prescribed antibiotic creams to a couple of people, notably to someone who probably had a mild case of Hansen’s disease (leprosy) and had some infected wounds on his feet.

Kartik talked to the eutherian sabre tooth tiger's share of the patient load (sorry, inside joke).

Kartik, Dr. Rama’s son and the chief medical officer of the event, handled the majority of these patients on his own. I think I may have seen about 20-30 with Shobana helping me out with the translations. Dr. Bala also made me practice doing blood draws so I did about 25 of those, oftentimes with people crowding around me to witness the grotesque spectacle of blood spurting into my vacutainers. Some of the children stood so close to me that their little heads got in the way of my hands as I tied the tourniquet and changed containers.
Drawing blood from a particularly hard case. Third time was the charm.

We only had a few minutes with each patient and it was very frustrating for me not to be able to properly investigate the aches and pains that the patients brought to me. Moreover, as Kartik pointed out to me, it wouldn’t do them much good. He insisted that many of them, like a gentleman, who sported a white beard that matched his white kurta and seemed to be showing signs of Parkinson’s disease, wouldn’t be able to afford the treatment. For similar reasons, we found ourselves unable to do very much for a gentleman who came to us with blurry vision and jaundice. When we listened to his heart, through his disheveled red checked shirt which was only buttoned in two spots, we heard a pretty clear mitral valve regurgitation. The edema (swelling) in his feet, probably due to his heart condition, was so gigantic that Kartik initially thought he had Elephantiasis (a condition aptly named because your legs and arms can swell to a freakish degree and resemble the limbs of Elephants). We just had to let them go, knowing what fate held in store for them.

One of my motivations for getting into medicine was that I didn’t want to stand around helplessly when someone was sick. And yet, I was forced to watch indignantly as the gentlemen with Parkinson’s shuffled away from me: “Damn it! I knew how to treat him! Why the hell can’t I or someone else treat him?” This happened again and again and if there was a lab test for cynicism, a blood sample from me at the end of the camp would show trace bits of it today. Change is needed...and fast. It’s up to our generation of physicians and economists to facilitate it. I’d rail more, but I’m exhausted and I don’t want to devolve into melodrama.

Hopefully, one day, I’ll be able to say “Kavalai padadhinga, sari agidum” and believe it.

Suresh, phlebotomist par excellence, did at least 100 blood draws today and came to my rescue at least twice.

-----------
In less depressing news, it rained in Vellore today which gave us all a respite from the heat. I was walking to the canteen for some Uttapam when I kicked a frog accidentally. As I watched it complete its parabolic trajectory, a thought made me feel sick. Rains meant frogs and frogs meant snakes. Oh dear!

By “Oh dear”, I really mean “OMG, I don’t want to be eaten by a gigantic Krait that chooses to creep into my room or snare me while I am galloping back for a second slice of truffle cake at the college store! I much preferred the hot vellore sun which nearly solved Indian agriculture’s irrigation issues by inducing torrents of sweat from my body to this stupid monsoon that brings me monstrous serpents.”

As Tintin would say: “Great snakes!!!”

Confused in Chennai, Vacuous in Vellore

Date: 07/01/2011

A street view of Vellore

The cool interiors of the aircraft gave way to a tarmac that was bindingly bright and blistering at a 100 degrees Fahrenheit. With a groan, I shrugged off my black sports coat and boarded the bus that ferried me to the terminal. As I was exiting the bus, I heard an unintelligible (to me, at least) yell.

Lady: (insert white hot fury expressed in Tamil that made the tarmac look cool)

Me: (dumb look)

Lady: (angry gestures that I should let her spawn exit the bus first)

Me: Sorry!

As I let the kid and the lady exit the bus, I experience deja vu. I was in the South.

Vellore is marked with the red oval.

India is a massive country with 1.2 billion people. The country is divided into 28 states and 7 union territories. The states were created along linguistic lines. Each state is roughly the size of a European country so traveling between states is almost like traveling between different countries in that the language and the culture changes distinctly. The steepest divide lies between the northern states and the southern states due to reasons beyond the scope of this blog post.  I'm now in the southernmost Indian state of Tamil Nadu. The main language here is Tamil. It is one of the most educated and progressive states of India. There’s a widespread delusion among second generation Indians in the US and even some non-resident Indians that you can communicate with basically everyone in India if you speak Hindi and English. In my case, three days in Tamil Nadu have rendered any vestige of that belief dead in the water. More on this soon. 

My bus ticket to Vellore from Chnnai. Journey time: 2.5hrs

I took a bus from Chennai to Vellore and then was mobbed by auto drivers. Autos (as in Auto Rickshaws) are surely a conspiracy of some religious secret society to ensure piety among Indians. When you’re within an Rickshaw as it careens through Indian streets at imprudent speeds and brushes aside pedestrians who’re forced to run for their lives, you quickly abandon atheism/agnosticism and beg God to forgive your waywardness and get you home safely. A young lad in the mob of auto drivers finally out-shouted everyone and gave me an organ-rattling ride to my accommodations. He must have heard my liver rattling against my ribs so he decided to regale me with his life story and simultaneously practice his accented Urdu on me. He was the sole offspring of his parents and was married very early so he had no option but to forego education and take care of them by driving his auto. When we got to Bergen house (my guest house) I poured myself out of the rickshaw, gave him a generous tip (for not killing me and to take care of his pregnant wife), and began dragging my suitcases up the stairs. He rushed up and asked to make a request of me.

Me: What do you want?

Lad: Sir, when you’re a doctor, please charge the impoverished half the rate you charge the wealthy.

Me: Will do

The significance of the request was not lost on me. The impoverished fall ill more often and suffer great economic setbacks due to medical expenses, which-- in turn-- leads to more sickness. A real poverty trap. Esther Duflo and Abhijit Banerjee do a beautiful job of describing it in their book, Poor Economics. An interesting discussion of it can also be found in a report by Harold Alderman for the disease control priorities project.

Bergen House: my wonderful, though slightly pricey, abode in Vellore. It's on the CMC college campus pictured below.

The next day, I got a call on my room’s phone. A deep voice identified itself as Dr. Ramakrishna, my mentor at CMC. He’s the head of the Dept. of Gastroenterology and is involved in all sorts of brilliant project. He drove down a few minutes later to pick me up from Bergen House. Dr. Rama is a tall man who talks deliberately and takes a second to think before answering your questions in a lucid and well-considered way. Even his laugh is deliberate, deep, and rich. We began talking about the logistics of my project and talk turned to the state of healthcare in India. By the end of the ride ee were discussing the disorganization and the inadequacy of funds that plagued the public health system. India spends about 3% of its GDP on health. America spends about 17%. neither extreme is good. One of the interesting things Dr. Rama said during the ride was with respect to cancer. He said that India has a poor tumour directory because documenting tumours is very very far from his priority. When faced with the illness of a family member, Indians, particularly poor ones, are known to sell their lands and take outrageous debts. Therefore, his main priority is actually to prevent cut-throat money lenders, witch-doctors, and quacks from bleeding patients dry.

Christian Medical College (CMC): One of the finest medical colleges in India.

Having ascertained that I hadn’t had sufficient breakfast, Dr. Rama took me for a vada ( a delicious lentil based southern recipe) and delicious filter coffee. Drs. Pugazhendhi and Shrikanth accompanied us. Once we got our coffees and vadas, we sat at the table looking at each other with awkward smiles. Dr. Rama introduced an icebreaker

Dr. Rama: Do you pronounce your name the Bengali way (PranOY) or the other way (PranAY)

Pranay: PranAY.

This gave me the opportunity to rant about my appalling name. The ice was broken. Phew! We were all chuckling now. Next we talked about my complete incomprehension of Tamil.

Last year, I had brought my then girlfriend to India. It is only now that I understand her plight. She had been mostly dependent on me for translating the goings on even though she spoke a little Hindi that she’d learned from Bollywood movies and Rosetta stone. 


I, on the other hand, was utterly dependent on Dr. Rama and the other doctors for communicating with people. I felt like a complete moron standing around, not understanding a SINGLE word. I felt even worse when people broke off their high-speed conversations to explain the gist of the dialogue to me. They did this very slowly in case I didn’t understand even their English. Vettri, the driver who has been taking me around, probably thinks that I am mentally challenged because our conversations go as follows:

Vettri: (in Tamil) You need to go to that shop to get a passport picture.

Pranay: (thinking he’s asking me how I like Vellore) errr...very nice

Vettri: (now confused, still in Tamil) Umm...go to that shop over there, I’ll wait here.

Pranay: (thinking he’s talking about films) I’d love to watch a Tamil movie. English subtitles?

Vettri: (in heavily accented and broken english) Go to the damn shop now.

Pranay: (with my patented look of dumb incomprehension) Eh?

Vettri: (gesticulating furiously now) GO!

Pranay: (understanding finally dawns) Ok, ok, keep your shirt on.

I’m obviously kidding. Vettri has shown me the greatest politeness and tolerance. However, I do need to learn some Tamil to make things easier for the people I’m working with and the individuals I’ll be interviewing.

I’ll write more about the projects I am involved in in future posts. Watch this space. I’m also putting up pictures from the trip on my flickr photostream.

In India, the versatility of your vehicle is only limited by your imagination. Kudos to this gentleman in Chennai who had precariously balanced this old television on his motorcycle.

The story begins

Date: 5/20/2011

This photo of an Indian sage with a duffel bag waiting for a bus was taken in Jangpura, New Delhi in Summer 2010. I was taking a relaxing break before beginning med school.

I'll keep things brief here. I am an Indian medical student at UVA and just won a research grant to go and study malnutrition's impact on cognition at Christian Medical College, Vellore, India. This means much more than a free trip home for me. It's my first real step in the world of global health policy after an academic career devoted to basic science research. Considering, I hope to have an impact on the health care policy of underdeveloped regions of India and other developing countries, this is a very big step for me.

I'm really excited and hope to document the experience comprehensively out here. Sometimes, I might post things before I have fully processed stuff in my head. Please excuse me.


Om Ganeshaye Namah.

Vande Matram!