Instead of talking about different diseases and infections that I’ve seen the last couple of days, I’d like to address some of the dissimilarities I’ve seen from a cultural standpoint. Since the majority of my day is spent with patients, I see people here under unique situations. There are obvious similarities that all sick people share, most notably the desire to feel better and to do so quickly. No one likes being sick or hurt. I have attempted previously to describe what doctor’s offices and hospital clinics are like. The small space where people dance around each other to get in and out, the speed with which the examination and diagnosis are made, the volume of patients seen in a day, are all staggering. But within this description I haven’t mentioned one of the peculiarities of the doctor’s appointment. In the western culture this appointment is a private matter but in India almost no one sees the doctor alone. Everyone brings along a friend or family member—not only to the waiting room but to the examination as well. Even in the slum clinic where the exam room barely holds the doctor, a medical assistant, two student observers, and an in-house pharmacist, the patient will come in with at least one companion. When privacy is warranted a curtain is pulled across a shower pole only to have everyone peer through the sides. The curtain seems more for reassurance than anything except when the door to the examination room is opened. In a country of one-billion people privacy doesn’t seem to exist, personal space shrinks and people are comfortable with one another’s presence. Men hold hands or put their arms over one another’s shoulder as a sign of friendship. Their proximity becomes a physical sign of their closeness. So, a cousin witnessing a tetanus shot in the butt isn’t weird. To them. Out of thirty patients maybe five will come alone due to infections in the crotchal region, although even this doesn’t prohibit a tag-a-long.

Another difference to life back home is the vendor-customer relationship. Street vendors expect you to bargain over a price but an established store will have established prices. Salesmen here are aggressive and so any slight show of interest triggers their full attention. If you seem to like a particular shirt they will bring out at least three more that are similar, if you don’t like the price they will bring at least two of lower cost. When you attempt to leave the store they will do everything in their power to keep you there, even to the point of complaining that you wasted their time for not buying anything. My roommate went to get a suit tailor-made and while sorting through the hundreds of cloth patterns we were served our drinks of choice. Shopping here is an all-day affair here. Not for the squeamish, it requires the buyer to be assertive and firm in response to the vendor’s torrential pushiness. After my minimal experience in India’s consumer culture, I’m afraid to see what their car salesmen are like, they must be dangerous.

This morning’s rotation at K.B. Bhabha Hospital was the greatest trial by fire so far. After meeting with the directors of the hospital, we were escorted to the outpatient department where doctors were attending to the general public with their complaints. Clinics in India are an amazing thing. The average time that the doctors spend with any one patient is around five minutes. A line forms from the doctor’s desk of huddled bodies and extends out of the room. In other institutions the patients enter the room at the sound of a buzzer used by the doctor to signify that the previous patient is done. More often than not the doctor buzzes in the next patient before the first is finished asking questions, resulting in a traffic jam as patients enter and exit with their families all clamoring for the doctor’s attention. Throughout the shuffling noise, with a stethoscope to his ears, the doctor listens for tiny variations in heartbeat or respiration.
I have become accustomed to this scene since all clinics here are some variation of this ordered chaos, but until now I’ve been playing the part of silent observer. This time the doctor asks me to take patient’s signs and histories so that he can attend one group while I do the prep work for the next group. It sounds easy enough until you start doing it. I would pass along the histories to the doctor where he would then ask me for information that I didn’t think to ask the patient. Taking blood pressure is simple and writing down complaints is too, the difficulty lies in what line of questioning to take and becoming comfortable in what you’re doing. To make matters worse, the patients that go to this hospital are predominantly from the lower socioeconomic class and speak Marathi. The last couple of weeks I’ve only been practicing Hindi. At closing time the doctor told me I did okay, which calmed me down but those few hours were tense.

January 20, 2006

The miracle of anesthesia is a beautiful thing. An advantage to rotating through BSES hospital is the opportunity to observe surgeries. They have a few surgery rooms and offered to let me watch a cesarean section. Never had I witnessed a surgery or a birth before, so overall it was a good first experience. While the doctors cut through skin, tissue and muscle, the mother lay calm and cool. She was a bit more attentive when the doctors showed her the beautiful baby girl, and quickly fell asleep while they began to patch up her uterus. Respect for women isn’t something I lack, but witnessing the birthing process brought about newfound awe for this aspect of womanhood.
As the doctors began to finish their last pass of the suture, a technician rushed me off to the next surgery where a man was having his prostate laproscopically removed. Although the removal would not improve his cancer, it would bring new comfort to his daily needs. Unlike the cesarean, this operation was a more time intensive. It took two hours for the surgeon to feel confident that everything was removed. As I watched intermittently between the screen and the man’s legs I was once again amazed by modern anesthesia. Having a laparoscope followed by a catheter shoved through your urethra isn’t a pretty picture. Nor is having your abdomen cut and stretched to let a baby out.
Before the surgeries I spent the morning in clinic just as I had the rest of the week. A little boy came in with the complaint of a bump on his wrist. His father said it would come and go with fevers and that his schoolwork was suffering, that his handwriting was getting worse. The doctor also said he had a murmur. It was an amazing feeling to recognize this child had rheumatic fever. After studying this disease for two years it was inspiring to know that my work will help someone. Someone other than myself. It’s a strange feeling. My work exists because there is a disease that endangers children, and India has a high incidence of this disease. How do I reconcile my excitement with my sympathy?

A night on the town. One of the doctors that we work with and his wife invited the group to party last night at one of their favorite pubs. The food was good, the drinks were ordered and everyone was dancing. It was interesting to see the night life of Bombay, being one of the more cosmopolitan cities here in a very conservative country. The men were definitely more abundant than the women—no different than any other club I’ve been to—and it seemed the bulk of them hovered around our group with the hopes of dancing with the Americans. It seems universal as well that it’s the women that dance while the men drink. I always love to watch people in these types of social situations since I don’t drink but don’t feel uncomfortable around those that do. After a fun night of drinks and music and dance a few of my companions were a bit more tossed than planned. For the most part it didn’t stop anyone from rotating through the hospital this morning but a few were drowsier than others.

Today’s rotation was one of the more informative sessions so far, not so much from the perspective of medical knowledge, but more from the observational view. A few of the patients that came in had manifestations that didn’t have any specific diagnosis like one man with ulcers all over his tongue that had no distinguishing morphology. What took the cake was an internist working in the medical out-patient clinic. An advantage to being a pre-medical student is the justification for not knowing answers to the questions that the doctors ask about clinical situations. My roommate is just finishing his final year of medical school at Boston University and doesn’t have that same escape from the clinician’s purposeful harassment. Part of learning medicine is extensive testing by doctors that have passed through the training ground of experience. It was eye-opening to see the trial by fire that I hope to pass through soon and amazing to see the immense knowledge that this veteran doctor had. My roommate did well and handled the inquisition with composure.

After leaving the hospital we accompanied an o.b.-gyn to the slums with some residents for a free community outreach clinic. A local government leader from the area had set up the program with the doctor and today was the first day. Although most of the woman came with no gynecological complaints it was interesting to see this massive group of woman gather to receive healthcare and shoo out all the men with the exception of us and the driver. The clinic was held in a large hall with a stretched canvas tarp serving as partition. The pretense of a line passed by the residents who took medical histories, to shuffle past the canvas to receive physicals, at which point we didn’t see the women until they left. To entertain ourselves, we practiced Hindi with the kids.

Today was our second day at BSES M G Hospital. The facility is run by an NGO (non-governmental organization) called Brahma Kumaris’ Global Hospital and Research Centre that emphasizes the role of spiritual well being during the convalescent process. They do this by implementing rajyoga, a non-physical form of yoga meditation, and through the help of devoted spiritual guidance counselors called Brahma Kumaris Sisters. From the western point of view this kind of facility would look as if it were run by a bunch of new age quacks, but the medical care given at this hospital is good. They have the best facilities I have seen so far with an excellent staff. Some of the rooms look as if they came out of hotels with a single bed, TV and lounge all in one room. They are a semi-private hospital and as such are more expensive than what the majority of the population can afford, but they do maintain 33 % of their beds for low-income individuals and provide free services to them. Companies can buy different medical plans through the hospital and people can use their health insurance as well. After rotating through the wards I could easily imagine the women clad in white saris floating from patient to patient as nuns in habits and the meditation room as the hospital chapel. The philosophy is different, and I don’t know enough about either situation to make further comparisons, but after seeing a patient have an abscess incised and drained the size of a tea cup, the faint and soothing music in the background helped me out. The patient on the other hand could have used a bit of morphine to take the edge off the excruciating pain.

At this point I want to simply take note of some of the more interesting things I’ve seen so far. Vancomycin resistant Staph aureas (according to the chart at least), a submandibular lymphatic infection of tuberculosis, a clinic and hospital requiring people to take off their shoes before entering treatment areas including the ICU and maternity ward, multi-drug resistant TB, a man with smallpox scars, and a host of other medical conditions that would surprise me if I knew what they were.

Friday we spent the day going to two STD clinics, one in the red light district and the other which is situated across the main street and has been renovated to include a museum used for sex education. While we visited the museum a batch of 13-15 year old boys were going through with their teacher. You would think that in the country where Kama Sutra was written that sex would not be as taboo as it is. Even one of the doctors in the HIV ward at Survoday hospital said that he had no problems talking about sex—so long as it wasn’t with his own children. In school it is sex education is called family health education in order to not raise any red flags. So, a museum with life size models of sexual organs and pictures of various STDs is quite progressive. So much so that it is singular in the whole country. Visitors receive a walk through explaining everything from basic anatomy to HIV awareness to dispelling myths about sex in the culture. The museum is on the second floor of what used to be the big STD clinic in that area, but since they had so many problems getting commercial sex workers going, they set up shop across the street in one of the alleys. An outpatient clinic is still there and used for HIV testing and a multitude of general medicine cases.

Since the clinic set up shop closer to the red light district the prevalence of HIV in commercial sex workers has gone down fifteen percent. About five years ago it was at a staggering 65 % but now has lowered to one in two. For ten rupees an HIV test is conducted and patients can receive care for 10 days along with food and medication. The public health workers try to get the HIV negative workers in there every three to six months for testing. Out of curiosity I asked the head of the clinic on average how many customers a worker will have in a day. For someone that works closely with prostitutes I was a bit surprised to see how uncomfortable she was with my line of questioning. It turns out that a typical worker will get two to four customers per day, but can be up to six or so. So an HIV negative worker will see about 150 customers between testing by conservative calculations. Needless to say, being a prostitute in Bombay isn’t good for your health although the pay is better than a construction worker.


On a lighter side of things, I got to go the Elephanta Island. Situated of the coast of Bombay, it has caves dating back centuries that contain statues of the god Shiva in his different aspects. It took about an hour for us to get to South Bombay where we embarked at the Gate of India. This giant gateway was to commemorate the visit of King George and Queen Elizabeth but is remembered better as where the last British soldiers left India after independence.




The island was peaceful and it was nice to get away from city life for a bit. The pollution from the city was still noticeable in the air despite the hour ferry ride to get there. But, there was a distinct calmness to the island. Plenty of people were visiting that day and on the way home I made a friend. As I was talking with one of the girls in our group I noticed this Punjabi guy staring at me. I decided not to do anything simply because it was a bit uncomfortable. Punjabi men are very identifiable. Typically they wear colorful turbans with a white or off-white suit consisting of a long shirt and baggy pants. They also keep long beards and about 60 % are Sikh. After an hour return, as we are all getting ready to disembark, Surfjen approaches me and says, "I want to make friendship with you." This had me a bit scared and confused but he quickly made explained himself by repeating the words "pen-pal". I was pretty excited about having a pen-pal from Punjab and we exchanged addresses. Mom, Dad, let me know if you get a letter from India.

Yesterday we went through Survoday Hospital. Meaning "Good For All" or "Prosperity For All", Survoday is a free hospital to the community and offers special services to people with HIV and tuberculosis. In addition to providing the community with healthcare, a hindu temple, buddhist shrines, a mosque and a christian chapel are all on hospital grounds. We started the day by visiting these various religious sections and were oriented a bit on Hinduism. The statues were impressive and it was interesting to see this aspect of Indian life at a closer level. More than anything what impressed me about this facet of the hospital were their efforts to accomadate everyones religious practices. In a country where tension runs high between two of the world’s major religions, it was refreshing to see that strides are being made to ensure harmony, especially in a location were faith is so necessary.
Although tuberculosis is present in the United States, it represents a minor public concern. The american cities where it can be found are the poorest sections of the country where population densities are high and the quality of life is low. Just as in the U.S., tuberculosis afflicts the poor sections of Mumbai—which are a large portion of the city. I don’t want to depict Bombay as being a city filled with the diseased spreading TB everywhere; the city is spectacular, but it does have public health challenges particular to its situation. HIV is also a concern and with around 11% of tuberculosis patients being HIV positive, and with HIV patients having a 60% chance of contracting TB at some time in their lives, the two diseases combine to form a deadly alliance. To further complicate matters rifampicin, an antibiotic of choice here against TB, inhibits certain antiretrovirals.
The government has implemented measures which have helped to decrease the numbers of people that are infected with either disease, especially in indigent areas. However, the program isn’t perfect and there are some challenges associated with its application. People infected with HIV who are in need can receive healthcare and medication at no cost upon proving their economic position and permanent residence in the area corresponding to the hospital. The reason for the proof of residence is because the program is similar to the TB DOTS program, directly observed short-course chemotherapy, where the patient is dispensed the medication at the proper time by the healthcare provider. This is to ensure medication is taken properly. One of the problems is that one of the high-risk groups in Mumbai is the migratory workers. They move from place to place as day laborers scraping together an income. Truck-drivers fall into this category as well as their work carries them to all ends of the country. Directly observed therapy becomes out of reach and along with it the healthcare needed by these people.
Other problems exist as well. Antiretroviral drugs carry side-effects and patients sometimes become noncomplient. Rather than notify the doctor, they simply accept their medications but stop taking them. They do this out of fear of being denied healthcare if they report their complications. Perhaps they have the hopes of restarting medication later, or maybe they feel the healthcare they receive is enough without the medication. They come to the doctors then wanting treatment for their symptons without dealing with the cause.
Another group particularly in danger of becoming infected with HIV is housewives. It seems too many husbands fail to disclose to their spouses that they are positive. Many marriages are arranged and sometimes this occurs with the person’s family keeping the secret from the other.
When I asked the doctor in charge of the AIDS ward what the largest problem was in India regarding the treatment of these patients as well as people living with HIV he said something quite interesting. "The biggest problem is the same as in other countries—apathy of the educated class. The upper and middle class don’t want to bother with the disease until it reaches their own neck."

Today was the last day at the leprosy hospital. We were able to see where and how they made specialized therapy equipment and shoes for people affected by this debilitating disease. We also were able to visit one of the patient wards. In the United States we really don't deal with leprosy, it isn't very contagious and very easily treatable, but the stigma associated with it still causes people to cringe. Even in India were the majority of the world's cases live, the disease will soon be eradicated. The causitive bacteria has no other host than humans and does not survive on growth media. So, if all the people with leprosy are cured then no one can be infected. Unfortunately this doesn't erase the gruesome and pitiful disfigurement resulting from lack of proper care. It is the stigma that causes these poor people to be ostracized by society.







I thought about posting a picture I took inside the patient ward but decided against it. It felt as if I was making a spectacle of their condition. Dehumanizing them in a way. Besides, the kindness of this place, and the sheer beauty of the facilities is a better reflection of what I learned than a photograph of mutilated limbs. Acworth used to house up to 500 patients at a time. Now the few who remain do so temporarily for treatment or because their deformities impede autonomy and their families have disowned them. They recieve shelter, treatment, food and community support through the hospital, and are given a much better life than what they would recieve outside.








If you are lucky in Mumbai, you live like this.





















If you're unlucky, you live on the side of the road.



















Too many live in slums, plagued by overpopulation and decent shelter.

I've arrived. Writing in this hot and sticky room, crowded with other people typing away in this internet cafe is a sharp contrast to the posh Starbucks in downtown Barcelona I last wrote from. Downloading pictures may be tough to do. The digs are nice. Everyone from the program lives together in a guest house at the university. Our meals are cooked and it's pretty nice. The shower is a lot larger than what I had in Barcelona. We had a short orientation today and one tomorrow as well. People are friendly but it takes a bit sometimes to understand what they're saying. Some of the other kids don't have a hold on it yet though and it's much harder on them. I just remind myself that my accent must be just as hard for them to understand.

We start our rotations next week and I'm way excited. The first hospital on the list is the Leprosy hospital followed by an STD clinic. Not too bad a start don't you think.

Upon arriving, I had the initial jerk reaction to the living conditions as we drove by the slums on the way from the airport. Seeing people living in such decrepit communities is like a punch to the gut. I've been mulling over it all in my head, trying to get a grasp on everything, and will post later what I wrote the first night. I just wanted to let everyone know I'm here and alive, and enjoying myself.

So as I leave Barcelona I do so with a couple of cool stories for the day and a couple of random thoughts. First, the mullet is alive and strong in Europe. Our European brothers have embraced it, flaunt it with pride, and have made it fashionable--at least in this part of the world. Men, women, young and old, babies and even pets sport the mullet with dignity. For some it may just be another reason to hate the crazy Euros, for others it may signify paradise. As much as the mullet is in fashion, the scarf beats it. I don't think Americans know how to truly appreciate the style and utility bundled together in this simplistic accessory. It's magical.

When I awoke this morning at 5:30 am, I found the day was glorious. I packed my bags and ate breakfast, and prepared to leave this town. Only I still had some chores to complete. First, I went to Parc Guell. InSpanishh it's pronounced Parque Guey. I couldn't help but laugh at the name, but as I strolled through the different sections of thisgemm, I found myself saying over and over "NO WAY". Designed by Antoni Goudi, this park is amazing. And huge. I got lost and had to ask directions. Two of the nicest gentlemen kindly put me back on track and we enjoyed pleasant conversation about life and the park.

After the park, I went to "la Pedrera", a house designed by the same genius. His designs are truly magnificent I can't write anything that can convey how awe-inspiring the house is. The few pictures I posted are only a portion of my snapshots and I hope you enjoy them.

What an opportunity it has been to stay in this magnificent city.

This is just part of what's on the roof. From the front it resembles a dragon, or so they say, with a sword thrust through it (sword not shown). 

This was just a hallway. 

This place was more beautiful than the pictures can show. 

How would you like the inside of your house to look like this? 

 

This is at the entrance to the park. 

 

These guys are serious athletes. Don't let the looks fool you. They put me back on track in life.

This is part of the forest section of the park 

When I got to the top of the hill at the park, this guy was already sleeping there.
Don't worry I didn't wake him.

Just a suggestion. When there's an escalator in the middle of the street, take it. 

Here in Spain, a tortilla is their version of an omellete made with eggs and potato and other stuff. It makes a wonderful breakfast with toast. 

All the cool people shop at Sephora. 

I almost bought an umbrella. A purple one.
It’s been drizzling outside and today seems like it might end up a bust.
For right now, I’m content to just sit in Starbucks and wait it out.
Hopefully it won’t rain too long.

This little place is inside the mercado. Just outside of the picture is a lady who looked like a skiny Zsa Zsa Gibor on a bad day. She even seemed a little uppity to boot.  

Instead of the guy painted up in silver and pretending to be a robot, Barcelona has a ton of different street performers. Some do nothing but hold the same position for hours on end like human statues. Others will move as soon as you give them money. One even sits on a toilet in a derby hat and suit, pretending to have a particularly bad bowel movement. 

I have recieved quite a few questions regarding posting comments to my blog. Feel free to do so through the blog or through my e-mail. To tell you the truth I'm still a rookie to this whole thing and am not quite sure how it works. Whichever way works best for you is fantistic for me. The more feedback I get, the better the postings will become, I hope.

Just big enough for a bed, a desk and a TV, my room is quite cozy for 35 euros a night. I also get my own bathroom which isn't even big enough to take a picture of.