A Trip to Remember

Hi everybody,

We’re all back home safe and sound after our 28 hour journey from Hyderabad’s runway to Cleveland’s runway. Just woke up and realized that I didn’t get any mosquito bites last night or hear any of the traffic horns this morning from India’s streets. There’s no delicious South Indian breakfast awaiting me either. Shouldn’t I have been offered Indian tea or coffee about 3 times by this time of the morning? Definitely glad to be back, but at the same time, I’m really going to miss these past several weeks in India.

The group has been simply fantastic. There’s such a gel between all of the members. We’ve really had some great laughs. I can honestly say that everybody has probably laughed their quota for the year over the past three weeks alone. Lots of character and personality in each person – so many jokes/stories – truly spectacular! I’m very confident that we’ve all developed lifelong friendships as a result of this trip.

Even beyond our group, the physicians, medical staff, family, and friends that we interacted with while in India were always delightful company. It was always enlightening to learn more about each one of them and their life experiences.

Our program exposures included tremendous diversity including government hospitals, private hospitals, rural hospitals, research facilities, community outreach programs, etc. Places we ended up visiting included Sivananda Rehabilitation Home, NIMS, Osmania General Hospital, Sir Ronald Ross Institute of Tropical and Communicable Diseases (aka Fever Hospital), Mediciti Hospital, CCMB (Center for Cellular and Molecular Biology), and Kamineni Hospital.

Diseases were abundant – in addition to what has been mentioned previously throughout this blog, we went to the Fever Hospital on Friday and saw patients with Dengue, Diphtheria/Tetanus, Malaria, Measles/Mumps, TB, and a variety of acute diarrhea syndromes (these patients even had their own “acute diarrhea beds”). Hopefully, none of us breaks out with a fever in the next week – differential would be ridiculous!

On top of our daytime experiences, we explored India despite the blasts that took place while we there. List of visited sights included the Golkonda Fort and Charminar in Hyderabad as well as Gandhi’s house, Hanging Gardens, Elephanta Caves, and various temples in Mumbai. We also spent our evenings and weekends simply enjoying our time together from late night chats to watching sports like Cricket to playing card games like King’s Peasant to watching movies like the Godfather to playing our favorite Indian game Carrom (Wikipedia – Carrom or carroms is a family of tabletop games sharing a similarity in that their mechanics lie somewhere between billiards and table Shuffleboard. The game has various other names around the world, including carrum, carum, karam, karom, karum, and “Indian finger billiards”).

Food was beyond lip smacking – favorites included chilli paneer gravy, vegetable manchurian, hot and sour soup, chicken 65, guava, aavakkai, butterscotch ice cream, idli, sambar, various chutneys, mango, pomegranate, and essentially all of the members of the potato family.

This has truly been a trip to remember – a chapter of my life that will always be a favorite to reflect upon for the rest of my life. It has broadened my horizons and given me refreshing perspective. I’m already looking forward to the potential Case India Trips – Part 2 (aka CIT 2).

Peace and love,

Vijay

What’s Ahead

Hey Everyone.

Wednesday night here. Well, more like Thursday morning as it’s past midnight. Today, our group had the opportunity to visit another hospital. This differed from the others in that it is a private, corporate owned and operated facility. The contrast from the others was quite drastic. First, when we arrived, I felt as if we were coming upon a hotel and immediately wanted to know where the swimming pool and bar were. Everything in this hospital is fee-based payed by the patient. We had an extensive tour of the facility. It was clean, everything was fairly new, and they had a more extensive superspeciality presence. We also comparison shopped as we visited wards from the economically poor, which was one large ward with over 30 beds, open to anyone who cannot pay. We then progressed upward economically to visit rooms with 7-8 persons (500 rupees = a bit over $10/day), 4-persons (800 rupees = $20/day), 1-2 persons with or without air-conditioning (at least 2000 rupees = $40/day). They had several ICU wards, costing each person 1800 rupees daily. Now, this cost is just to reserve the bed. Labs, imaging, and other care are extra.

So, what’s the point of me rambling all of this off? Well, over the past few weeks, we’ve had the opportunity see a government operated hospital where trash and foul odor predominate with limited resources, and saw the hospitals in between until the other spectrum of the corporate hospital that we saw today. One thought that I had to myself was seeing the physicians, imaging they pay, quality of life, interests. Why did some choose to stay at the government hospital while others the private facility, or further why some went overseas? It brought me to wonder about what is ahead for myself in my career. I wondered this to my family and also to my fellow travelers these past few days.

As I told them last evening over dinner, as residents, most of us have had set goals and timetables. Four years of high school with the goal of getting into a good university, four years of undergrad, medical school, then residency and fellowship. But, then what? Yeah, finally, find a job. But, I see “the working world” as being in this static place as I feel that I have no defined objectives, goals or clear path. And, I find this particularly difficult personally as, being the anal-retentive type A personality that most people in the medical profession are, I like to know what’s coming ahead and to plan. Sure, my passion is to help others, but how does that specifically translate into a career with clear objectives? Will I be the physician in the government hospital, corporate hospital, or none of the above?

Luckily, as I posed these thoughts and questions to the others, we all had the same response…”I have no idea.” It was great hearing that I wasn’t the only one. Plus, as Bindu pointed out, family and friends look at us as if we are the balanced, level-headed ones who have things figured out. However, I like to see it was we are the ones who prolonged the inevitable career decisions as long as possible by persuing the longest educational route possible. Or, as my Mom said, “Things will unfold by themselves. Plus, you are thinking too much…you must be homesick and need to come home. And, you need to make sure you are eating and sleeping enough. (insert further concerned, motherly comments here)”.

Well, I am off to bed. Hope to see you all soon.

Jones

Sunday evening

I came back to the apartment from my family’s house mid-afternoon or so. Spent most of the weekend getting some sorely needed sleep. Also, I read Circus by Alistair MacLean. For probably the sixth of seventh time. It is a book that really enjoyed as a kid, but more so, it is a connection I have with my late aunt. One of the greatest highlights of every one of my visits to India, until her premature death in 1995, was spending time with her. We shared a love for certain books, the most important being the Three Musketeers. Circus was up there as well.

My cousin Bobby came over in the early evening to take me shopping for comic books for my daughter before the team came back from Mumbai. After waiting a few minutes for the drizzle to let up, I got on the back of his Honda motorcycle and we sped off on our mission. We made a left onto the Tarnaka main road, went under the flyover, turned right and worked our way through the expansive campus of Osmania University. This is not an area of the twin cities that I have frequented before this trip, and Bobby is my guide to all things Hyderabad whenever I come here. But it sounded very strange when he pointed the campus out to me. It seemed like such an obvious thing. I guess I am getting to know this place for myself.

The streets were full of the usual masses of humanity. I cannot estimate the numbers of persons one passes on the road even on a brief excursion like this one, but it must number in the thousands. I love traveling by two-wheeler in India. It is second (albeit a distant second) only to travel by rail. Car travel is convenient but too protected if you want the full Indian experience. Countless times, my knees missed by inches motorcycles, cars, autorickshaws, buses, bullock carts and people. It was not until we reached a large intersection that Bobby put on his helmet. I tried to be invisible as we passed the traffic cop, remembering an interaction two-and-a-half years ago, when we got busted for no helmets. Better luck this time, it turned out. After the intersection, we ran into a semi-impromptu parade consisting of about 30 participants, 4 or 5 musicians earnestly blowing into woodwinds and beating on drums, and an innominate deity.

We made our way down a road that I recognized from our week going to Osmania General Hospital. We proceeded to hunt for bookstores and were directed to a strip mall of sorts. We entered the first store and asked for Chandamamas in Telugu and Hindi. The guy looked at us like we were insane. “Only English, saar”. I picked out some Amar Chitra Kathas and for some reason got a 10% discount. Which Bobby tried to talk down even more, using such logic as “500 is a round figure, why do you want us to pay 550?”. It made sense to me. Next door, still no luck, and next to that was strike three. We got back on the motorcycle and headed back home. Passed roadside carts full of guavas, oranges, fried stuff, and corn. It was dusk now, and the coals on which the corn was being roasted looked and smelled incredible as we sped by. Saw a total of about 10 men relieving themselves on the side of the road. By the time we reached the poorly lit Osmania campus the sun had set completely. We passed another thousand people or so by the time we reached road 12-5-55 and pulled up in front of Samskruthi Heaven apartments.

My hair was coarse with dust kicked up from the road. My lungs burned from smoking the exhaust of 250 two-stroke engines. My blue pants had a rim of black at the cuffs and my back ached from maintaining my position behind Bobby on his Honda. I headed up the steps with a deep sense of contentment. After sixteen days of being here, I finally felt like I was in India.

Mumbai

Well, we just came back from our Mumbai weekend which was great. While the others saw the sights and did some fine dining, I was subjected to the mercilessness of my family. Never do you feel as inadequate as when you are repeatedly asked why you aren’t married and if you feel that you might be “too old.” Such is the life of an Indian girl! Regardless, being with my extensive Indian family also makes me realize how lucky I am that so many people care so unconditionally and only want the best for me.

On the work perspective, I did have a little chat with some of my family members about their perspective on the HIV epidemic in India. The fact that I could talk about it with them at all was fascinating because in general they tend to be very conservative, the the terms “HIV” and “sex” couldn’t even be uttered the last time I was here three years ago. I did find that their beliefs are that most people in India contract HIV through blood transfusions and unsanitary health care practices, not so much from unprotected sex. While I don’t believe that’s true, I’m glad that they’re at least thinking about it. I was asking my younger cousins whether they had any sex education in schools and the answer was an unsurprising no. But they do believe that the times are changing here and hopefully for the better.

I also a road experience while in Mumbai; a car accident. We’re all okay, however I have no idea who was at fault, and let’s face it, it probably doesn’t matter anyway. I’m not entirely sure there are “right of way” rules here. The way my cousin planned to resolve the situation was finding the other guy’s address and throwing rocks at his car. Hmmm

Only 4 more days left, and I still haven’t eaten any good, off the street, Hep A enriched food yet…..

Adherence

My exposure to clinical cases has been limited over the past two weeks, as I have spent my time more on research efforts. Among the patients that I have seen, though, there are some that will stay with me for a long time.

I saw a lady in her mid-40s who acquired HIV via a contaminated blood transfusion during the delivery of her second child, 15 years ago. Although free treatment is available for HIV through government centers, if at all a person living with HIV/AIDS can scrape together the requisite funds, they will do everything in their power to go to a private setting. There is really no insurance to speak of for the common man (up to the lower and middle middle class) so paying out-of-pocket is the only option. A typical day for a doctor at a busy government ART center involves seeing 100-150 patients between 9am and 4pm or so. The quality of the interaction is therefore suboptimal at best.

So the patient I saw was in a non-ART centre setting. She had survived 15 years by paying her way for meds and care. Now, she was failing her second line regimen and her immunity was again waning. When questioned initially about her adherence, she said (like so many of my own patients) that she was doing well. It took only minimal prodding and a look in her still 3/4 full pill blister pack to realize that her adherence was nowhere near the 95-100% we all preach to avoid the development of drug resistance. She indicated that she was stretching out the pills over several weeks because she couldn’t afford them any more. What followed was a poignant and haunting exchange between doctor and patient. Her physician asked whether there really was no way she could pay for the meds. She pulled out her mangalsutra and said this is all the jewelry she had left in the world. There was no question, from her tone of voice, about whether selling that particular item was an option. So what then, were they to do when the inevitable immunological failure occurred, she was asked. Her daughter was doing well in college, her son was poised to follow, and she had told them both that mom may be here tomorrow or may not. She was ready for the inevitable and had apparently prepared her family accordingly.

This is a situation that happens all over the world hundreds, if not thousands of times a day. It is something that I was well aware of before this trip. Intellectually, at least. I am quickly finding out that hearing about it and seeing it are two different things. What I saw was a lady who was clinically relatively healthy, intelligent, devoted to her family (despite her husband’s frequent suggestions that she kill herself to alleviate the financial burden on the family, including outlining specific methods to do so) and not in a situation that, in the US, would be considered end-stage at all. I have had multiple patients die in the past few years, but none of them fit the profile I saw before me. Depression, other psych problems, ongoing substance abuse, cancer, liver disease and poor social support are what have killed most of my patients. Poverty was the only thing keeping this lady from seeing her grandchildren.

I can hear certain people asking me now, so what? Are you going to save her? How about the next 150 people who come in tomorrow? I guess I won’t be doing things too differently. I am not in the business of eradicating poverty. I am an HIV doc. I conclude that there is a lot of work to be done out there, if I am interested. And a lot of ways to contribute. Whatever I do, I hope that when it’s my time, I can feel as proud of how I have lived my life as this patient has every right to feel, and that I can face my end with half as much dignity.

R&R

The team is off in Mumbai for the weekend. I am told they went to the Elephanta caves today, something I’ve always wanted to see ever since reading the associated Amar Chitra Katha as a kid. I am taking a day off myself tomorrow to spend with my family here in Hyderabad.

On the gastronomic front, now that I am back on a regular diet (more like soft mechanical with aspiration precautions) we had another dose of Indian Chinese Wednesday night. It wasn’t the best, but I am definitely going to miss that stuff when we get back to Cleveland. Have also been having guavas daily. Still in search of the elusive sapota.

I spent some time today with a social scientist who has done some pretty cool work on HIV prevention. This brings my perspectives on HIV care in India to five: a government-sponsored center for antiretroviral therapy, a tertiary care, academic referral hospital where patients pay for everything before its done, a private “corporate” hospital that serves the upper middle to upper class, a non-governmental organization, and today’s social scientist. Each perspective has its unique aspects, but there are some themes that cut across organizations. Everyone thinks that the HIV problem here, despite the recent reduced estimates in prevalence, is spiraling out of control. Everyone also agrees that there is a ton of money floating around, but little accountability for how it is spent. I am surprised to see the universally negative feelings toward most NGOs. The glaring exception, of course, is Sivananda. Opinions on them range from: “they are in it for the money” to “they want to convert people to Christianity” to “they are incompetent”. Nobody is particularly happy with the government response either, calling it a bunch of hand-waving. For my part, I am happy to have met people both in the government service and in the private sector who are really devoted to the cause.

Another common complaint here is about the brain drain. This is an often devastating problem in Africa as well. It is interesting to see that in India, this applies disproportionately to physicians. The boom in the tech industry has led to IT people who stay here leading extremely comfortable lives. This obviously does not carry over into medicine, so a lot of people are always finding ways to go overseas. Despite this though, we have come across some incredibly intelligent clinicians.
I feel like working with these guys for a month, in a resource-limited setting where you can’t just blindly order tests, would be an invaluable, required rotation in an internal medicine residency. For attendings like me too!
Finally, in answer to the query about tea, if you are only getting tea twice a day in India, you are getting shortchanged. We have had tea pretty much 4 times daily here. Plus coffee. Nice.

Lecturing and such

While the team has been seeing cool clinical stuff, I have been spending my time lecturing, networking, and writing concept sheets for grants. Clearly a different experience, but just as educational. It has been an exhausting first 10 days for me, but I am content to know that I have accomplished a great deal in that time. I have given 5 lectures so far, with 3-4 more to go. Being a faculty member, lecturing is certainly not a new concept to me, but maintaining relevancy of my message to persons whose clinical experiences are so far removed from what I see has been a neat challenge.

Now speaking of lectures, today I had to give a talk on HIV drug resistance. Given the state of my exhaustion and some major abdominal pain I have been having, the team decided, on their own, that they would prepare my lecture for me. Over two nights, these guys researched antiretroviral resistance in textbooks and on the Net and put together a pretty impressive talk. I delivered it today with minimal modification and it has easily been the best received of all my lectures so far. So a pat on the back for my peeps here; they are truly the best, and I was very touched at their generosity. More that that, thought, it was fascinating to see the enthusiasm, teamwork, and brain power on display over the past two nights. My fellow travelers have blogged a bit already and have talked quite a bit about the opportunity to just learn, without interruption or any other pressure. Watching them work with such focus, such motivation, and actually seem to have fun doing it was completely unexpected, given that when assigned something like this most of us tend to groan. Now this response from them could clearly be just a reflection of the magnitude of my pathetic appearance, combined with some obviously humanitarian tendencies of this group. Part of me does like to think, though, that they actually learned a lot from going through this self-assigned exercise. I feel like I have witnessed learning in its purest form, driven entirely by the learner. Maybe there is a model there for medical education…

For those concerned (Amma), I have pretty much recovered from my aforementined GI ailment and am back to eating stuff I have no business eating. Today was a banner day, with notable items including avakaya , hot pepper bajjis, and guava. No sequelae to report. Feeling great. Although…I do have two lectures early next week…hmmm…I wouldn’t be surprised if I had some more abdominal pain starting Sunday afternoon or so…

New Perspective

Hi everybody,

Hope you all are doing well back home. We’re all doing well, and I think I speak for everybody when I say “THANK YOU” to all of you for being so concerned about us. Hearing from all of you has really meant a lot to each one of us.

I think I also speak for everybody on this trip when I say that our experiences over approximately 10 days have really given us some new perspective in a lot of different ways. I think you have all read our blogs from last week regarding our excitement for some of the programs here that really amazed us with their efforts, so I don’t need to say more about that aspect of new perspective.

This past weekend, the blasts definitely had their impact. It really is quite a different experience to read or watch the news on CNN each day and hear about the 30 or 40 people across the world who died because of blasts compared to when you’re actually in the city where the blasts took place. You see and feel the effect on yourself, the people around you, the city as a whole. This morning, we were scheduled to go to one of the 2 hospitals where a lot of the victims had been taken from the blasts on Saturday night, but the security levels are so high right now, strikes were taking place today nearby, family members are swarming the hospitals, etc. that we were advised to hold off from going to the hospital at least for today. We may be there tomorrow morning, and I can only imagine what things are like right now, especially for the family members of those victims in critical condition. My prayers are with all of them.

Today, we went to NIMS, which is a different hospital here in Hyderabad, and even there, we had a moment of silence and saw a lot of grief on the faces of the medical faculty as one of their doctors had passed away in the blasts. Anyways, I think you all get the idea. Wish we could do something more about it. For now, glad we’re alive and well. Let’s all pray for the victims and their families.

Continuing along with today, I think we all had quite an educational experience that offered some fresh perspective. We went on rounds today for several hours with one of the medical teams at NIMS hospital. These rounds were GREAT in many ways. Residents (five of them) were not paged or called a single time by a nurse or anybody else for any orders. The attending literally was teaching for 3.5 hours while we were with them, and we left before rounds were over. So how could 3.5 hours of rounds be great for residents with so much work to be done, right? Well, when our group left their group, we also realized that the residents didn’t really have any orders to place afterwards, any discharge planning to solve, no to minimal notes (I’m pretty sure none). Only limited things could be done, so there wasn’t as much work afterwards. They were just learning from their attending and focused on thinking about their patient’s care. After lunch, they had time to come attend lectures (topics included HIV Perspective in India, Candidemia, and Rhinosporidiosis) for a couple of hours (in addition to the one hour conference that we all attended this morning). Imagine if we had 3-4 hours of teaching rounds and 3 hours of lecture/conferences every single day. Obviously, our systems are different – there is only so much that can be done for these inpatients due to the lack of money. Lab tests, imaging, treatment options are all limited due to cost. Before every potential diagnostic test is ordered, the attending discussed the costs involved and whether it would be feasible to pursue further diagnostic testing for these patients. Often times, the efforts were focused on empiric treatment rather than any labs or imaging with the goal being strongly on getting the patient better with what the best clincal diagnosis was rather than using any of the cost on extensive labs or imaging. Not too much focus on evidence based medicine. It really was quite interesting to see. The ward consisted of 20 beds across one huge room (talk about your geographic localization). In this entire room, there were only 2 iv poles hanging – one person getting IV abx and one getting a blood transfusion. Nobody was on nasal cannula. Diagnoses being discussed on these patients included HIV opportunistic infections in the lung (i.e. PCP, pneumonias, TB, fungal infections), malaria, TB, snake bites, leptospirosis, brain mets, lung effusions/lesions, HIV medication complications, DIC, lactic acidosis, etc. Somehow, they all looked fairly healthy. Just an incredibly unique experience.

Not even half way through the trip, eyes are wide open!

Keep in touch,

Vijay

We’re okay!

Hi everyone
Some of you may have heard tonight about the bombings in Hyderabad. About 3 hours ago there were two separate bomb blasts; one in a park crowded with people seeing a laser lights show and the other in a restaurant. The origin of neither has been determined yet. Over 30 people have died and several more injured. The police have recommended avoiding public places for the time being. Our group was on the verge of going out for a night on the town immediately prior to finding out about this, however we’re now all sitting around, contemplating what has happened. For the most part, our immediate thoughts went to our families, and I believe we’ve all now called and let you know we’re okay. We know how worried you all must be, but please know that we’re doing fine. On a personal note, it helps to know that there are 5 other people here who must know exactly how crappy this feels and I think we’re all doing a good job of keeping each other’s spirits up. This isn’t really one of the experiences we were expecting to have in India, but nonetheless, it’s just as significant as all the others. I really don’t think, though, that this can detract from all the other incredible things we’ve seen this week. We’ve seen people at their best and at their worst now, and I can say for certain that I know which sticks out more clearly in my mind……..
Time to lighten things up a little. Tomorrow, we were planning on spending the day sightseeing, however needless to say, that will no longer be happening. Instead, we get the pleasure of each other’s company. I can honestly say though, that I don’t mind!

Rainy Saturday afternoon in Hyderabad

I figured since I hadn’t posted anything for about a week that I should probably do so, even though I don’t think I’m going to reinvent the wheel with my blog after reading everyone else’s from this past week. As everyone else has said, we are having a great time with each other and have quickly set up what can probably best be described as a very dysfunctional family away from home. One of the attendings from NIMS (Nizam Institute for Medical Services, where Dr. Y has been spending most of his time) who had lunch with us, was quoted as saying we were “interesting” and found us amusing, which Dr. Yadavalli says she meant in a good way, but I think the jury may still be out on that one. We’ve had terrific Indian food all week and as Jess said are seldomly left without a cup of tea in our hands or our bellies empty(in response to Dr. Armitage, I think tea at conferences and available somewhere at 4pm would improve resident morale tremendously, if nobody else’s then at leaset mine).
Currently, I’m sitting in the internet cafe downstairs from our apartment, listening to the rain falling and with every good intention to work on presentation I’m giving this upcoming Thursday on C. diff, which surprisingly is said to not be a very big problem in India. Earlier in the afternoon it was a beautiful day, but now its been raining for about the past hour. Since getting back from a morning of lectures and briefly rounding with a hematology team and discussing a few cases, we’ve been playing this as a typical lazy Saturday afternoon with a good deal of napping and lounging. Bindu’s having the most excitement as she is (finally) Sari shopping with one of Sujan’s aunts. This morning, Dr. Yadavalli gave a talk to the internal medicine department at NIMS (Nizam Institute for Medical Services) and then one of the professors in the microbiology department gave us talks on the Chikungunya and Dengue fevers.
As everyone else has said, this week has been a tremendous experience with our exposure to the Sivananda Rehab Home. I was most amazed with their coordination of medical and social services for the leprosy patients, first by treating them (antibiotics and correcting disfigurements secondary to their illness) and then providing vocational training so that they can return to their homes and be able to be provide for their families and be an active member in their community. Ultimately the best part of these services is the restoration of pride in these people who may have been shunned by those around them because of their condition as there is a great deal of social stigma in India regarding the illness.
As everyone else has said, the leprosy care is just one aspect of the work done at Sivananda. They are involved in the national TB program, which Bindu previously described and are expanding their work on HIV, including a new program dealing with reducing mother to child transmission.
The one thing I have to add to everyone else’s comments from this week and I have found interesting is the difference in the differential diagnoses here. From speaking with the residents on rounds this morning and from our experience with the TB program, much of what the internist sees is infectious and their primary causative bacteria are completely different from ours (for example on rounds this morning we saw aplastic anemia secondary to what they thought was an unidentified hepatitis virus, malaria and leptospirosis). Their first thoughts to cases are often such illness as tuberculosis, malaria and chikungunya, illnesses we only have a very limited exposure to or none at all. I asked a resident this morning how often he sees cases of malaria and he said usually one to two every other day and speaking of chikungunya, this area had 8,000 cases (I think, it may have been 80,000, but I thought best to underreport) in a recent epidemic in this city of 4 million estimated. If you think about it, in our most notable insect-borne illnesses we have seen about 2000 cases of West Nile and 20,000 cases of Lyme disease per year in the entire US population, compared to just this one locale (and its outlying areas). Pleural effusions here are looked at as tuberculosis first, anything else second. Well its about 5:30 here now and we’re planning on starting our evening on the town in about half an hour so I’m going to get going. Guess I’ll get to working on the presentation later. Hope everyone is doing well, keep us posted on what’s happening back at home. See everyone back at Case in a couple of weeks.