Seeing as my group had some difficulties here and there and here again many of us thought it kind to write our own little support guide to augment the helpful informtation supplied by UTHSCSA. As I was reluctant to donate limited photo space to the cause we created the blog on a different site under a different email address. Thankfully we got links:
http://cmctrip.blogspot.com/
Hopefully that'll cure what ails ya.
Wednesday, March 5, 2008
Tuesday, February 26, 2008
Ending Photos and Closing Jibberish
And now the end.
Thank you everyone who helped set up and support this elective. Good times.
But first some photos!
Here's Dubai...
And Vellore/CMC...
And finally our after trip to Delhi, Jaipur, and Agra.
But back to the ending.
So, what is the sum total of my four weeks, extended traveling, and numerous contributor dollars? Well, a little and a lot. Physically I am much the same. I miraculously lost little weight surviving on a diet of mostly refined starches, and to my knowledge I have brought no guests back with me in my gastrointestinal tract. Financially I am much the same, thanks to the generous scholarships so graciously provided. Emotionally and spiritually? Still the same unmoved faithless guy as before. Mostly, I have changed mentally. Not that my thoughts themselves have changed, as for the most part they have not, but they have certainly become more clear and refined. Medicine and infectious disease have even greater appeal and resonance to me than they did before -- and they appealed to me a lot before. International work has been the direction I have felt pulled in for years and the pull is even stronger now. Humanism -- that conglomeration of reason, ethics, and justice -- has always made sense to me, but its essential value was made apparent to me during my stay.
During the trip and in the ensuing weeks in Washington DC thereafter, these and other thoughts culminated in the coalescing of my beliefs. Up until now my patriotism, love of science, and enjoyment of politics had always been separate and independent issues. Now, however, I feel and see that they are all very connected. The stark contrasts of Delhi, India, and Washington DC, USA, forced many questions, the greatest of which concerning the nature of each nation's differences, pasts, and futures. Although in many ways very modern and daily modernizing even more, my eyes were constantly drawn to the numerous vestiges that keep India in the past. Internecine religious conflict, cultural chauvinism, oppressive gender roles, and a historical legacy of corruption, despotism, and inequality have and still hold India back from the power that is rightfully its own. In Washington, however, the multitude of monuments and museums espousing and celebrating the country's birth as the political incarnation of the Enlightenment highlight most everything that has helped make the United States and the West great. The scientific method, rationalism, liberty, equality, civil society, and democracy are certainly not the only things that have given America its power, but they were and are important foundations for the dramatic rise to prominence that it has experienced. It is also all these which will continue to empower a safer, fairer, and richer not only West but entire world. My trip therefore served as a display of contrasts of what the world frequently is and what the world should be.
These contrasting observations, though obviously exaggerations, can arguably be said to be held by people the world over. No matter what many think of the United States as it now is, the United States as a concept is for many synonymous with Westernism and with all the ideas and values previously listed associated with that. The uniting realization that I have come to is that it is essential that this remain the case. Without imperialism and the technological superiority it once had, the West faces an inevitable decline not necessarily in absolute terms, but certainly relative to the population giants China and India. As America becomes then more and more simply one out of many global powers the unquestioned legitimacy of all that it stood for will be increasingly examined for merit. If the US abandons its foundational principles to further cling to what remaining power it has or if it more quickly crashes into irrelevance through selfishness and conceit the ideas of the Enlightenment will be likely found wanting, and the world will suffer. And so it all comes together. The Scientific Revolution brought about the Enlightenment which birthed the United States, and it is now the United States which represents these in the world today. It is only through their continued union, at least in the short term, that both will be guaranteed survival. Western power will fade, but without Western thought there can never be a lasting peace or prosperity.
So that’s my revelation. Until the rising powers are successfully anchored in the humanistic ideals it is critical that the US be there to preach them. My patriotism which, like most loves was always a bit irrational, now has a clearer base to stand on. In a small way I feel that in as much as I practice a religion this is it. Salvation, at least here on Earth, will only come through a humble, honest philosophy championed by a righteous nation. It is essential then that we return to righteousness. All of this said it should be noted that I do not nor ever would claim that the United States is perfect or without error. Likewise I do not wish to create the impression that my impression of India is only negative; hopefully my previous posts would at least suggest otherwise. All of the troubles I have listed as observing in India can be readily seen in the States just as in any developed or developing nation. Truly no country or peoples is completely free from the ideological chains that have for forever bound them all. Similarly, I believe India to in many ways be a great country with many positive attributes of its own. It is simply that though during these past two months my eyes have been drawn to a great number of things, for the purposes of this discussion my mind has had to focus on but a few. I don’t know if I will be going back to India anytime soon, but I will always be happy I went.
So that’s what I’ve gotten out of India. That and a pleasurable set of memories that I will hopefully not soon forget. And just to prove my philosophical credentials I offer up a photo of me in India, with a very scholarly beard.
Thank you everyone who helped set up and support this elective. Good times.
Wednesday, February 13, 2008
Water no Gas. Sugar no Ants.
It has been about two weeks since I have returned to the States, and yet I still have not posted any photos or shared any concluding thoughts. Well, it ain't gonna happen anytime soon. It seems I am a bit busier than expected -- and a bit lazier -- and with all the other pressing matters -- and sites to see in DC -- it may be another week or two before I get 'em posted. So instead I'll just post this post further delaying things.
Good day!
Good day!
Saturday, February 2, 2008
Liberation
"Hello."
"Howdy."
"How may I help you?"
"Uhh. Yes. I was told to tell you that I have a security item."
"A what?"
This time I made sure to use finger quotes to convey that my word choice was not my own, "Uhh yeah. I just went through security -- the x-ray and metal detectors over there -- and they told me to come over and tell you guys that I have a 'security item.'"
"I'm afraid I don't know what that is."
"Okay. Yeah me neither. Thanks."
And so began hurdle number fourty-three on my quest to get back home. The Dubai security personnel had just politely informed me that the wire netting that I had been carrying around with me for the past month to secure my luggage when out and about was in fact not allowed on the plane. Thus it was a "security item." I still don't know what that means, and it seems others didn't much either, but, practically speaking, it did mean they had to stick it in a manilla envelope to be packed away in the cargo hold with the rest of my luggage. (Come to think of it, I never picked it up from baggage claim. Oh wells.) Needless to say I still fail to see how a small mesh net could really pose any threat. Did they think I was going to throw it over the pilots gladiator style? If so they forgot to inquire about the trident which I had cleverly stowed away in my other carry on. Truthfully, I was planning on hijacking an international flight at some point during my trip, but procrastination led to me putting it off till the very last one. Curses! When will I learn? Next time I think I'll just stick with an ingenious mixture of various gels and creams.
After that the rest of my security screen was relatively uneventful. The final twenty hours of my layover in Dubai were uneventful as well. I am not entirely sure what I did for all those twenty hours, but at least eight of them were spent sleeping behind a set of chairs in a relatively unusued portion of the terminal that I had scoped out earlier in the day. For better or worse the Emiratis are a climate control loving people, and so the generous use of air conditioning made it quite chilly during the evening. I eventually had to resort to pulling my hoody over my head turtle style to get any sense of warmth and any extended sleep. Rest aside, the layover was long and boring and marked only by two mediocre cheeseburgers from the airport McDonalds. An inpatient and unexceptional return to American cuisine. The twenty hours would be extended by another two complements of a flight delaying sandstorm.
Speaking of poor sleep and delays, though, my last evening in Delhi was also marked by both. It have never really been able to imagine how train delays can occur barring a series of individual delays at all the various stops, but it turns out, in India at least, that trains can also be delayed by simply shutting down and stopping. Not necessarily at a train station or even any developed area, but really anywhere is sufficient. My evening train from Agra to Delhi, expected to arrive at ~ 10:30, did had multiple such unscheduled breaks during the trip and so my arrival into New Delhi Station was instead a much later 12:30 in the morning. I was a little worried about bandits, but more annoyed by the seemingly pointless sometimes extensive train rests. By the time I had checked in to my hotel and showered off it was 1:20 in the morning and I had another cold night of turtle sleep to look forward to.
Before Delhi, though, there was Jaipur and Agra -- my last two stops with Kristen and Kathryn. Jaipur, the "Pink City" as it likes to be called was not terribly pink, but it was pleasant enough to visit. The city is known for its forts and city palace which are all built out of a pink stone -- or more recently just painted pink but let's not hate -- and so we spent our day roaming the old city and its landmarks admiring the architecture and history. They were lovely and many of the buildings were unique, but I cannot say there was much to write about. What was an unexpected surprise was a 15th or 16th century astronomical center complete with a number of sizeable stone devices used to measure a whole host of astronomical and astrological measurements I had little to no understanding of. It was unexaplainably impressive. We did at one point also have the chance to make off with a momentarily abandoned auto-rickshaw while I was in my bearded disguise, but we settled for some pictures instead. So that was Jaipur.
The next day we moved on to Agra home of the Taj Mahal. It's here that I feel we should stop to talk briefly about expectations. Things get praised and sensationalized, and so are made dissapointing. Things are dismissed and disregarded, and so are made amazing. Ask anyone and the Taj is incredible. Even people who have never seen it and know little about it are eager to one day lay eyes on it. For Americans it is literally half a world away in a particularly foreign foreign country. Sum this all together, and you get expectations that no structure no matter how impressive can live up to. And so I saw the Taj, and it was big and it was fancy, but, honestly, I did not have any sense of awe or wonder. I was and am happy to have seen it, but it will not go on my list of amazing sites that I have seen in my life. The lack of rooms and public spaces made it seem monolithic, and the Islamic proscriptions against the engraving of people and images made it seem characterless. I was expecting the Taj Mahal!, but got just the Taj Mahal. I am sure it was truly a site to behold; I was just expecting something else.
The Agra Fort, on the other hand, was a pleasant surprise. Extensive, well maintained, and with multiple detailed displays I was happy. Everyone talks about the Taj, but thankfully no one talks about the fort. Kristen and Kathryn were eager to attend to our "Elephant Safari," though, so we were rather pressed for time and had to leave early. Hopefully some of my photos will do it some justice.
Speaking of the Elephant Safari, if you have to ask why we would want to spend our time riding elephants you will never understand. Which is likely why I asked myself this question many times before and after our pachyderm rodeo. For reasons unkown Kathryn and Kristen both eagerly wanted to climb onto the backs of both elephants and camels, but as only elephants were in season in Agra they had to settle and settle on only one elephant at that. The safari consisted of us driving to a big dirt lot cleared of anything but an improvised cricket game, about two dozen kids, a man, and an elephant. We paid him 100 rupees a piece, climbed onto the back of the elephant, and proceeded to amble about in no apparent pattern for 5 to 10 minutes until we had our pictures and had lost interest. Thus concluded our safari. Not terribly awesome, but, hey, I probably am not the one to be asked about that. At least we stimulated their economy?
The next day Kristen and Kathryn woke up early to return to Delhi to go their respective ways, and I was sad to see them go. The sadness was tempered by a certain amount of liberation that came with their departure, however, and so I was in relatively good spirits again after breakfast. And what did I do with my last full day in Agra and India? Avoid the bloody touts is what. That meant spending a few hours atop the hotel's roof lounging and sketching the distant Taj amongst all the neighboring buildings and trees, idling away some more time at a local Internet cafe, and, later, going to watch a Bollywood film! Hurray?! Yeah, sort of.
Having become rather tired of seeing the sites and dealing with the hordes of people selling me things I had absolutely no interest in buying I decided to try and find something else to occupy myself with. And Hindi movies was the most immediate answer that came to mind. The movie I chose based soley on posters and showtimes was "Taare Zameen Par." Roughly translated it means I have no idea what. I also did not understand a single word that was spoken that wasn't in English and there only about a dozen of those. Nevertheless with the music and acting and emotion I was still able to follow the movie remarkably well, and I must say it was a very good movie. Plus the volume was of the theatre was set at such a level that I did not much notice the baby screaming next to me or the group of friends talking a few seats down. Some other curiosities about Indian cinema? Every movie begins with the Indian national anthem and each movie has a 10 or 15 minute intermission where waiters come to sell you snacks. Wacky.
After the movie I had to evade the touts a little longer, but in no time I was on the ill fated, long delayed train to Delhi mentioned earlier. My escape would take me over fourty-eight hours and would also include an unexpected medical emergency stop in Stockholm, Sweden followed by an equally unexpected night in Houston at the local Marriot Hotel on Friday. Flying into San Antonio finally on Saturday morning, though, I could not help but smile. Perhaps "liberation" and "escape" are too strong of words to use in describing my return home, but it is very much how I felt. My trip to India was a good trip not because it was always an entirely fun one. I can easily see how someone could travel only to the sites of the Golden Triangle and return strongly disliking the place. The tourist industry is like a swarm of mosquitos that envelops you whenever you leave your room. Individually each merchant is not particularly troublesome, but taken as a whole they are a continuous nuisance that slowly suck dry your desire to be there. Plus I am pretty sure they spread disese with their proboscises. The last few days have consisted of even more traveling, and I have still not had much time to fully consider my experiences, but for now I am just happy to be home.
"Howdy."
"How may I help you?"
"Uhh. Yes. I was told to tell you that I have a security item."
"A what?"
This time I made sure to use finger quotes to convey that my word choice was not my own, "Uhh yeah. I just went through security -- the x-ray and metal detectors over there -- and they told me to come over and tell you guys that I have a 'security item.'"
"I'm afraid I don't know what that is."
"Okay. Yeah me neither. Thanks."
And so began hurdle number fourty-three on my quest to get back home. The Dubai security personnel had just politely informed me that the wire netting that I had been carrying around with me for the past month to secure my luggage when out and about was in fact not allowed on the plane. Thus it was a "security item." I still don't know what that means, and it seems others didn't much either, but, practically speaking, it did mean they had to stick it in a manilla envelope to be packed away in the cargo hold with the rest of my luggage. (Come to think of it, I never picked it up from baggage claim. Oh wells.) Needless to say I still fail to see how a small mesh net could really pose any threat. Did they think I was going to throw it over the pilots gladiator style? If so they forgot to inquire about the trident which I had cleverly stowed away in my other carry on. Truthfully, I was planning on hijacking an international flight at some point during my trip, but procrastination led to me putting it off till the very last one. Curses! When will I learn? Next time I think I'll just stick with an ingenious mixture of various gels and creams.
After that the rest of my security screen was relatively uneventful. The final twenty hours of my layover in Dubai were uneventful as well. I am not entirely sure what I did for all those twenty hours, but at least eight of them were spent sleeping behind a set of chairs in a relatively unusued portion of the terminal that I had scoped out earlier in the day. For better or worse the Emiratis are a climate control loving people, and so the generous use of air conditioning made it quite chilly during the evening. I eventually had to resort to pulling my hoody over my head turtle style to get any sense of warmth and any extended sleep. Rest aside, the layover was long and boring and marked only by two mediocre cheeseburgers from the airport McDonalds. An inpatient and unexceptional return to American cuisine. The twenty hours would be extended by another two complements of a flight delaying sandstorm.
Speaking of poor sleep and delays, though, my last evening in Delhi was also marked by both. It have never really been able to imagine how train delays can occur barring a series of individual delays at all the various stops, but it turns out, in India at least, that trains can also be delayed by simply shutting down and stopping. Not necessarily at a train station or even any developed area, but really anywhere is sufficient. My evening train from Agra to Delhi, expected to arrive at ~ 10:30, did had multiple such unscheduled breaks during the trip and so my arrival into New Delhi Station was instead a much later 12:30 in the morning. I was a little worried about bandits, but more annoyed by the seemingly pointless sometimes extensive train rests. By the time I had checked in to my hotel and showered off it was 1:20 in the morning and I had another cold night of turtle sleep to look forward to.
Before Delhi, though, there was Jaipur and Agra -- my last two stops with Kristen and Kathryn. Jaipur, the "Pink City" as it likes to be called was not terribly pink, but it was pleasant enough to visit. The city is known for its forts and city palace which are all built out of a pink stone -- or more recently just painted pink but let's not hate -- and so we spent our day roaming the old city and its landmarks admiring the architecture and history. They were lovely and many of the buildings were unique, but I cannot say there was much to write about. What was an unexpected surprise was a 15th or 16th century astronomical center complete with a number of sizeable stone devices used to measure a whole host of astronomical and astrological measurements I had little to no understanding of. It was unexaplainably impressive. We did at one point also have the chance to make off with a momentarily abandoned auto-rickshaw while I was in my bearded disguise, but we settled for some pictures instead. So that was Jaipur.
The next day we moved on to Agra home of the Taj Mahal. It's here that I feel we should stop to talk briefly about expectations. Things get praised and sensationalized, and so are made dissapointing. Things are dismissed and disregarded, and so are made amazing. Ask anyone and the Taj is incredible. Even people who have never seen it and know little about it are eager to one day lay eyes on it. For Americans it is literally half a world away in a particularly foreign foreign country. Sum this all together, and you get expectations that no structure no matter how impressive can live up to. And so I saw the Taj, and it was big and it was fancy, but, honestly, I did not have any sense of awe or wonder. I was and am happy to have seen it, but it will not go on my list of amazing sites that I have seen in my life. The lack of rooms and public spaces made it seem monolithic, and the Islamic proscriptions against the engraving of people and images made it seem characterless. I was expecting the Taj Mahal!, but got just the Taj Mahal. I am sure it was truly a site to behold; I was just expecting something else.
The Agra Fort, on the other hand, was a pleasant surprise. Extensive, well maintained, and with multiple detailed displays I was happy. Everyone talks about the Taj, but thankfully no one talks about the fort. Kristen and Kathryn were eager to attend to our "Elephant Safari," though, so we were rather pressed for time and had to leave early. Hopefully some of my photos will do it some justice.
Speaking of the Elephant Safari, if you have to ask why we would want to spend our time riding elephants you will never understand. Which is likely why I asked myself this question many times before and after our pachyderm rodeo. For reasons unkown Kathryn and Kristen both eagerly wanted to climb onto the backs of both elephants and camels, but as only elephants were in season in Agra they had to settle and settle on only one elephant at that. The safari consisted of us driving to a big dirt lot cleared of anything but an improvised cricket game, about two dozen kids, a man, and an elephant. We paid him 100 rupees a piece, climbed onto the back of the elephant, and proceeded to amble about in no apparent pattern for 5 to 10 minutes until we had our pictures and had lost interest. Thus concluded our safari. Not terribly awesome, but, hey, I probably am not the one to be asked about that. At least we stimulated their economy?
The next day Kristen and Kathryn woke up early to return to Delhi to go their respective ways, and I was sad to see them go. The sadness was tempered by a certain amount of liberation that came with their departure, however, and so I was in relatively good spirits again after breakfast. And what did I do with my last full day in Agra and India? Avoid the bloody touts is what. That meant spending a few hours atop the hotel's roof lounging and sketching the distant Taj amongst all the neighboring buildings and trees, idling away some more time at a local Internet cafe, and, later, going to watch a Bollywood film! Hurray?! Yeah, sort of.
Having become rather tired of seeing the sites and dealing with the hordes of people selling me things I had absolutely no interest in buying I decided to try and find something else to occupy myself with. And Hindi movies was the most immediate answer that came to mind. The movie I chose based soley on posters and showtimes was "Taare Zameen Par." Roughly translated it means I have no idea what. I also did not understand a single word that was spoken that wasn't in English and there only about a dozen of those. Nevertheless with the music and acting and emotion I was still able to follow the movie remarkably well, and I must say it was a very good movie. Plus the volume was of the theatre was set at such a level that I did not much notice the baby screaming next to me or the group of friends talking a few seats down. Some other curiosities about Indian cinema? Every movie begins with the Indian national anthem and each movie has a 10 or 15 minute intermission where waiters come to sell you snacks. Wacky.
After the movie I had to evade the touts a little longer, but in no time I was on the ill fated, long delayed train to Delhi mentioned earlier. My escape would take me over fourty-eight hours and would also include an unexpected medical emergency stop in Stockholm, Sweden followed by an equally unexpected night in Houston at the local Marriot Hotel on Friday. Flying into San Antonio finally on Saturday morning, though, I could not help but smile. Perhaps "liberation" and "escape" are too strong of words to use in describing my return home, but it is very much how I felt. My trip to India was a good trip not because it was always an entirely fun one. I can easily see how someone could travel only to the sites of the Golden Triangle and return strongly disliking the place. The tourist industry is like a swarm of mosquitos that envelops you whenever you leave your room. Individually each merchant is not particularly troublesome, but taken as a whole they are a continuous nuisance that slowly suck dry your desire to be there. Plus I am pretty sure they spread disese with their proboscises. The last few days have consisted of even more traveling, and I have still not had much time to fully consider my experiences, but for now I am just happy to be home.
Monday, January 28, 2008
Excuse Me While I Pee on this Wall
Well this is certainly different.
I have been, more or less, consistently cold for the past two or three days straight. Not an experience I am entirely familiar with. At least when I am not camping. Delhi it turns out is quite a bit colder than Vellore with the nightly temperatures falling down into the low 40s and upper 30s. And no heating system of any sort. Add to that the recent development of a upper respiratory tract infection and an increase in the general number and aggressiveness of touts in the North and I have not felt too great. Nevertheless, the experience remains enjoyable. I know some of the minor difficulties and discomforts are only passing, and so they just give the trip character. It is also a bit amusing seeing auto-rickshaw drivers zipping around in blankets and caps and gloves. Unfortunately I have none of those and the only pair of shoes I brought with me were my sandals. I technically could purchase many if not all of these, but my dang frugality prevents me from doing so. I already got more gloves and hats and shoes than I need in a town that almost never freezes. And so I am cold and in Jaipur and enjoying it all. Well, most of it all.
My entrance into Delhi was relatively uneventful. Air Deccan, the airlines I flew north with, is much like Southwest airlines, but with far less leg room. Sitting fully upright and with my butt to the back of the seat my knees were still snug up against the back of the chair in front of me. Upon arrival the pre-paid taxi I took, which are generally supposed to be the most legitimate, tried their best to take me anywhere and everywhere they could. After unexpectedly stopping at Humayan's tomb, which I had no desire to go to but which they took me to anyways amongst the confusion of poor English being spoken by both parties, they finally dropped me off near my hotel and asked for money for lunch in addition to the extra gas money for taking me to the tomb. What?! This has been the second time I have wanted to curse out in anger, but this time I held my tongue. I gave them the 20 rupees I had in my pockets (about 50 cents worth), they scowled, and we went our separate ways. I hope they lead unhappy lives.
Our hotel (Kathryn and Kristen would arrive later) was in the "tourist ghetto" of Paharganj. "Tourist ghetto" is quite accurate as our hotel (Smyle Inn Hotel) was back in some alleys behind some urinals, shops, and other budget hotels. The space in the area is so crowded and narrow that taxis generally never go out there, but instead drop you off at the entrance to manage your way on your own. Thankfully I found the place without too much difficulty (with some help), and the girls got an airport pickup from the hotel which guided them directly to it. Despite the rooms being about the size of prison cells and the bathrooms so small that upon sitting on the toilet my knees hit the piping underneath the sink, I didn't mind the place. The breakfast they served was great and the shower was one of the hottest and strongest I've had in my entire stay in India. Those two things almost always win me over. So that was our housing arrangements.
Our itinerary was fairly haphazard. After intermittent discussion and the undertaking of a few errands we were ready to head out shortly before lunch time. We started first with the Jama Masjid in Old Delhi. It is India's largest mosque and, I must say, quite impressive. One of the minarets was also accessible for a small fee allowing an amazing and informative view of the city. Everywhere you look for miles and miles is civilization. Buildings and buildings and buildings. Visibility was admittedly limited by the perpetual hazy skyline as Delhi is one the world's most polluted cities, but it was a view I cannot say I have ever seen before. I was unable to take panoramic pictures of it all due to the construction of the minaret and the number of people up there with me, but hopefully the few pictures I could take will do it justice. Anyways, we also went to the Old Fort, but there were huge lines, and, as time was limited, we headed off to the National Museum instead. After I picked myself up a beard that is.
I had tried to go to the National Museum the day before as I had arrived earlier than the ladies and had had some time to kill, but, unfortunately, Republic Day celebrations completely killed that idea as everything was closed. Doubly unfortunately, all the Republic Day festivities took place in the morning and as my plane did not arrive till about 130 in the afternoon so I was not even able to partake in them. Curiously much a similar thing happened to me and a friend of mine a few years back in Paris on Bastille Day. Oh wells, I can imagine the parade in my head and it is beautiful. Getting back to the story at hand, though, we went to the National Museum and here, after an hour or so, parted ways. Kristen and Kathryn went off to catch an earlier train, and continued to tour the museum. Although not quite as impressive as many of the museums in Europe, and generally lacking in any singularly impressive exhibits like the Ishtar Gate or Rosetta Stone, it was nevertheless a remarkable place and well presented. I would certainly recommend it.
So now alone again I, and with most the major sites already closed for the day, I headed back to Paharganj to have some dinner, use the Internet, and make some calls. At approximately 8:45 I headed off to the Old Delhi train station for my night train to Jaipur. My train wasn't due to depart till 10:40, but as I was unaware of how Indian trains worked and I was foolishly hoping for some respite from the masses inside the station I decided to head over early. The end result of my decision was me sitting on a cold bench with a bunch of blanket clad Indians and a few rats for two hours. There was some brief confusion with finding and boarding my train, as there seems to be with just about everything I do here, but by 10:40 I was in my almost completely empty sleeper car and the train was headed out of the station. I don't know how you, random reader, feel about trains, but, personally, I love 'em. Not so much trains themselves, but riding in them. Night trains are particularly great. After setting up my bed platform for the evening I locked up my bags and promptly fell to sleep.
And then -- lest it get too peaceful -- things got tricky again. I arrived at the Jaipur train station at 4:30 in the morning as scheduled, and, after securing an auto-rickshaw, proceeded to make my way to where the girls had set up residence for the night. It is an almost universal trait amongst auto-rickshaw drivers here, and I imagine everywhere they exist, that they will always claim they know where the place is you want to go even if they have only a vague hint of an idea. There are a few exceptions who will tell you they do not know the place, but this auto-rickshaw driver was no exception. We drove about somewhat haphazardly it seemed on the mostly deserted streets and finally came up to a street closed off by a locked gate. The driver and I exchanged a few words -- both not understanding anything each other said -- and the driver and I proceeded to shake and bang on the gate for a while. Within a few seconds a barking dog and an older man came out of a nearby guard shack and opened it up for us. We then proceeded to the next gate outside Shahar Palace itself which was thankfully not locked, and then began to wander about the poorly lit premises. Finding no one awake and few lights on we resorted to the tried and true method of shaking and banging on random doors. This time we had no success, however, so we headed back to the gate so that I could send the driver on his way. It was then that we finally disturbed the owner of the place enough to get him to come figure out what exactly it was we were doing on his property. Within a few minutes and the unexpected awakening of two English girls in the room next door by mistake I was finally able to join up with Kristen and Kathryn. There was some rejoicing, but mostly just the sleepy, disoriented exchanging of hellos. And so commenced the Jaipur portion of my venture north.
Will our hero see the Pink City successfully? Will he escape the clutches of the touts and scammers?! Will he Will he make it out alive?! Find out next time! On this blog. Right here. Woohoo. Seriously.
Now a Public Safety Announcement. If you ever come to India, and especially the Golden Triangle, do not ever, ever sit against a wall along the streets of whatever city it is you happen to be in. Why? Because they've probably, at at least one point in that week, been urinated upon. Possibly twice. This has been a Public Service Announcement. Have a good one.
I have been, more or less, consistently cold for the past two or three days straight. Not an experience I am entirely familiar with. At least when I am not camping. Delhi it turns out is quite a bit colder than Vellore with the nightly temperatures falling down into the low 40s and upper 30s. And no heating system of any sort. Add to that the recent development of a upper respiratory tract infection and an increase in the general number and aggressiveness of touts in the North and I have not felt too great. Nevertheless, the experience remains enjoyable. I know some of the minor difficulties and discomforts are only passing, and so they just give the trip character. It is also a bit amusing seeing auto-rickshaw drivers zipping around in blankets and caps and gloves. Unfortunately I have none of those and the only pair of shoes I brought with me were my sandals. I technically could purchase many if not all of these, but my dang frugality prevents me from doing so. I already got more gloves and hats and shoes than I need in a town that almost never freezes. And so I am cold and in Jaipur and enjoying it all. Well, most of it all.
My entrance into Delhi was relatively uneventful. Air Deccan, the airlines I flew north with, is much like Southwest airlines, but with far less leg room. Sitting fully upright and with my butt to the back of the seat my knees were still snug up against the back of the chair in front of me. Upon arrival the pre-paid taxi I took, which are generally supposed to be the most legitimate, tried their best to take me anywhere and everywhere they could. After unexpectedly stopping at Humayan's tomb, which I had no desire to go to but which they took me to anyways amongst the confusion of poor English being spoken by both parties, they finally dropped me off near my hotel and asked for money for lunch in addition to the extra gas money for taking me to the tomb. What?! This has been the second time I have wanted to curse out in anger, but this time I held my tongue. I gave them the 20 rupees I had in my pockets (about 50 cents worth), they scowled, and we went our separate ways. I hope they lead unhappy lives.
Our hotel (Kathryn and Kristen would arrive later) was in the "tourist ghetto" of Paharganj. "Tourist ghetto" is quite accurate as our hotel (Smyle Inn Hotel) was back in some alleys behind some urinals, shops, and other budget hotels. The space in the area is so crowded and narrow that taxis generally never go out there, but instead drop you off at the entrance to manage your way on your own. Thankfully I found the place without too much difficulty (with some help), and the girls got an airport pickup from the hotel which guided them directly to it. Despite the rooms being about the size of prison cells and the bathrooms so small that upon sitting on the toilet my knees hit the piping underneath the sink, I didn't mind the place. The breakfast they served was great and the shower was one of the hottest and strongest I've had in my entire stay in India. Those two things almost always win me over. So that was our housing arrangements.
Our itinerary was fairly haphazard. After intermittent discussion and the undertaking of a few errands we were ready to head out shortly before lunch time. We started first with the Jama Masjid in Old Delhi. It is India's largest mosque and, I must say, quite impressive. One of the minarets was also accessible for a small fee allowing an amazing and informative view of the city. Everywhere you look for miles and miles is civilization. Buildings and buildings and buildings. Visibility was admittedly limited by the perpetual hazy skyline as Delhi is one the world's most polluted cities, but it was a view I cannot say I have ever seen before. I was unable to take panoramic pictures of it all due to the construction of the minaret and the number of people up there with me, but hopefully the few pictures I could take will do it justice. Anyways, we also went to the Old Fort, but there were huge lines, and, as time was limited, we headed off to the National Museum instead. After I picked myself up a beard that is.
I had tried to go to the National Museum the day before as I had arrived earlier than the ladies and had had some time to kill, but, unfortunately, Republic Day celebrations completely killed that idea as everything was closed. Doubly unfortunately, all the Republic Day festivities took place in the morning and as my plane did not arrive till about 130 in the afternoon so I was not even able to partake in them. Curiously much a similar thing happened to me and a friend of mine a few years back in Paris on Bastille Day. Oh wells, I can imagine the parade in my head and it is beautiful. Getting back to the story at hand, though, we went to the National Museum and here, after an hour or so, parted ways. Kristen and Kathryn went off to catch an earlier train, and continued to tour the museum. Although not quite as impressive as many of the museums in Europe, and generally lacking in any singularly impressive exhibits like the Ishtar Gate or Rosetta Stone, it was nevertheless a remarkable place and well presented. I would certainly recommend it.
So now alone again I, and with most the major sites already closed for the day, I headed back to Paharganj to have some dinner, use the Internet, and make some calls. At approximately 8:45 I headed off to the Old Delhi train station for my night train to Jaipur. My train wasn't due to depart till 10:40, but as I was unaware of how Indian trains worked and I was foolishly hoping for some respite from the masses inside the station I decided to head over early. The end result of my decision was me sitting on a cold bench with a bunch of blanket clad Indians and a few rats for two hours. There was some brief confusion with finding and boarding my train, as there seems to be with just about everything I do here, but by 10:40 I was in my almost completely empty sleeper car and the train was headed out of the station. I don't know how you, random reader, feel about trains, but, personally, I love 'em. Not so much trains themselves, but riding in them. Night trains are particularly great. After setting up my bed platform for the evening I locked up my bags and promptly fell to sleep.
And then -- lest it get too peaceful -- things got tricky again. I arrived at the Jaipur train station at 4:30 in the morning as scheduled, and, after securing an auto-rickshaw, proceeded to make my way to where the girls had set up residence for the night. It is an almost universal trait amongst auto-rickshaw drivers here, and I imagine everywhere they exist, that they will always claim they know where the place is you want to go even if they have only a vague hint of an idea. There are a few exceptions who will tell you they do not know the place, but this auto-rickshaw driver was no exception. We drove about somewhat haphazardly it seemed on the mostly deserted streets and finally came up to a street closed off by a locked gate. The driver and I exchanged a few words -- both not understanding anything each other said -- and the driver and I proceeded to shake and bang on the gate for a while. Within a few seconds a barking dog and an older man came out of a nearby guard shack and opened it up for us. We then proceeded to the next gate outside Shahar Palace itself which was thankfully not locked, and then began to wander about the poorly lit premises. Finding no one awake and few lights on we resorted to the tried and true method of shaking and banging on random doors. This time we had no success, however, so we headed back to the gate so that I could send the driver on his way. It was then that we finally disturbed the owner of the place enough to get him to come figure out what exactly it was we were doing on his property. Within a few minutes and the unexpected awakening of two English girls in the room next door by mistake I was finally able to join up with Kristen and Kathryn. There was some rejoicing, but mostly just the sleepy, disoriented exchanging of hellos. And so commenced the Jaipur portion of my venture north.
Will our hero see the Pink City successfully? Will he escape the clutches of the touts and scammers?! Will he Will he make it out alive?! Find out next time! On this blog. Right here. Woohoo. Seriously.
Now a Public Safety Announcement. If you ever come to India, and especially the Golden Triangle, do not ever, ever sit against a wall along the streets of whatever city it is you happen to be in. Why? Because they've probably, at at least one point in that week, been urinated upon. Possibly twice. This has been a Public Service Announcement. Have a good one.
Thursday, January 24, 2008
Leaving Empire
And before you know it, it's over. Or so the CMC - Vellore portion of my trip is at least. I am actually currently in Delhi, but just this post we'll pretend I'm still back in Chennai awaiting my flight out of the south and into the north.
So three weeks is done and it feels to have been all of three days. I imagine that's the expected response isn't it? Well it's a good response because as it is true for many parts of life it is certainly true for our trip to South India. I'm not leaving India entirely, of course -- I will spend about a week traveling about with Kristen and Kathryn to Delhi, Jaipur, and Agra next -- but this will certainly be the end of my time in Tamil Nadu (the state Vellore and Chennai are cities in.)
Reflecting on the experience to date here and there I have felt that, in as much as the two time periods can be similar and relatable, we have lived as good Western imperialists. Truly in a country such as India it is almost impossible not to live a significantly wealthier life apart coming from places like the United States or Europe, but I feel our stay went beyond even this. I am not saying "imperialist" in the sense that we adopted official honorifics, practiced mercantilism, and attempted to restructure Indian society, but rather in a simpler, more modern touristy way our stay was leisurely, luxuriant, and apart. Our extended contacts were primarily with the highly educated while our interactions with the "common" Indian were almost always either through acquiring services and products, necessitating their friendly disposition, or as speechless observers tailing various nurses and doctors, necessitating no interaction of any sort. Our living quarters, described in earlier posts, further emphasize the point. We were housed in old stone buildings far larger and magnificently built than the most of the housing of the rest of the populace. We lived in a sprawling, landscaped compound in a country where most people do not own their land and live in a density not seen much elsewhere. We had a host of Indian guards constantly on watch and always ready to greet us with a smiling "good morning." And we were so isolated that the world around us could be erupting in civil war, and we would be unaware of it save some curious sounds in the distance. I do not know how the experience could have had any more the feeling of empire without a group of natives waiting to carry us about in litters. Maybe a parasol for the ladies?
Anyways, to the point of all this. Well, honestly, I do not currently have a point. It is just a feeling I have that I currently do not know what to make of or do with if anything. Maybe it's just a superficial similarity. I have always been aware, I feel, of the disparities of the Western world and the rest of the world, but that has always been in a mostly intellectual sense. And this is certainly not the only time I have witnessed first hand the differences as I have seen and felt them many times before. This is the first time, however, that I have felt myself to be a major character in that story. I am not saying that the West currently practices a modern form of imperialism or that anything in the West is necessarily good or bad or right or wrong -- that is an overwhelming conversation for another time -- just that I am much more of a participant in it all than I ever would have cared to imagine.
Sooo....
This last week in Vellore has been uneventful. I joined up with the Internal Medicine I team this week which specializes in infectious disease. Or so they say. Truly, aside from the HIV clinic on Wednesday afternoon, there was less infectious disease on this service than on the Internal Medicine II service specializing in rheumatic diseases. Oh wells, thankfully the HIV clinic was pretty great. In addition to seeing a variety of unusual cases like isosporiosis, meningeal syphilis, and tuberculosis lymphadenitis, I was also given a brief but succinct explanation of how AIDS is dealt with in India.
The physician I worked with, Dr. Abraham -- whose name I remember only because it is not Indian and could actually understand it when it was spoken to me -- explained that while the US generally practices a patient specific form of HIV treatment tailoring medications to the patients other conditions, tolerance levels, and the virus's genetic resistance, in India such care is simply not feasible. Instead the government simply provides a basic triple medicine cocktail that is potent and cheap. The side effects are often significant, including hepatotoxicity, lipodystrophy, peripheral neuropathy, and lactic acidosis, but they are powerful and efficient uses of the government's limited resources allowing the government to pay for AIDS medications for anyone requesting it. If the virus is or becomes resistant to any of these medications or the patient cannot tolerate them, well, that's life. Currently the government provides this one line of treatment and that is it. As such they do not check viral load or CD4 counts or anything because it would not alter care. In the future they are planning on developing a second line of medications to augment the first line, but that is still in the works. At CMC they provide a level of care intermediate to the US and Indian government. It, unfortunately, is not free, but still considerably cheaper than the average cost of care in the states. I very much wish I had a better understanding of health care systems in differing parts of the world. If anyone has any reading suggestions let me know!
Ok. Enough for now. I had a lot of time to write today because the National Museum here in Delhi was unexpectedly closed for Republic Day. But that's a post for later....
So three weeks is done and it feels to have been all of three days. I imagine that's the expected response isn't it? Well it's a good response because as it is true for many parts of life it is certainly true for our trip to South India. I'm not leaving India entirely, of course -- I will spend about a week traveling about with Kristen and Kathryn to Delhi, Jaipur, and Agra next -- but this will certainly be the end of my time in Tamil Nadu (the state Vellore and Chennai are cities in.)
Reflecting on the experience to date here and there I have felt that, in as much as the two time periods can be similar and relatable, we have lived as good Western imperialists. Truly in a country such as India it is almost impossible not to live a significantly wealthier life apart coming from places like the United States or Europe, but I feel our stay went beyond even this. I am not saying "imperialist" in the sense that we adopted official honorifics, practiced mercantilism, and attempted to restructure Indian society, but rather in a simpler, more modern touristy way our stay was leisurely, luxuriant, and apart. Our extended contacts were primarily with the highly educated while our interactions with the "common" Indian were almost always either through acquiring services and products, necessitating their friendly disposition, or as speechless observers tailing various nurses and doctors, necessitating no interaction of any sort. Our living quarters, described in earlier posts, further emphasize the point. We were housed in old stone buildings far larger and magnificently built than the most of the housing of the rest of the populace. We lived in a sprawling, landscaped compound in a country where most people do not own their land and live in a density not seen much elsewhere. We had a host of Indian guards constantly on watch and always ready to greet us with a smiling "good morning." And we were so isolated that the world around us could be erupting in civil war, and we would be unaware of it save some curious sounds in the distance. I do not know how the experience could have had any more the feeling of empire without a group of natives waiting to carry us about in litters. Maybe a parasol for the ladies?
Anyways, to the point of all this. Well, honestly, I do not currently have a point. It is just a feeling I have that I currently do not know what to make of or do with if anything. Maybe it's just a superficial similarity. I have always been aware, I feel, of the disparities of the Western world and the rest of the world, but that has always been in a mostly intellectual sense. And this is certainly not the only time I have witnessed first hand the differences as I have seen and felt them many times before. This is the first time, however, that I have felt myself to be a major character in that story. I am not saying that the West currently practices a modern form of imperialism or that anything in the West is necessarily good or bad or right or wrong -- that is an overwhelming conversation for another time -- just that I am much more of a participant in it all than I ever would have cared to imagine.
Sooo....
This last week in Vellore has been uneventful. I joined up with the Internal Medicine I team this week which specializes in infectious disease. Or so they say. Truly, aside from the HIV clinic on Wednesday afternoon, there was less infectious disease on this service than on the Internal Medicine II service specializing in rheumatic diseases. Oh wells, thankfully the HIV clinic was pretty great. In addition to seeing a variety of unusual cases like isosporiosis, meningeal syphilis, and tuberculosis lymphadenitis, I was also given a brief but succinct explanation of how AIDS is dealt with in India.
The physician I worked with, Dr. Abraham -- whose name I remember only because it is not Indian and could actually understand it when it was spoken to me -- explained that while the US generally practices a patient specific form of HIV treatment tailoring medications to the patients other conditions, tolerance levels, and the virus's genetic resistance, in India such care is simply not feasible. Instead the government simply provides a basic triple medicine cocktail that is potent and cheap. The side effects are often significant, including hepatotoxicity, lipodystrophy, peripheral neuropathy, and lactic acidosis, but they are powerful and efficient uses of the government's limited resources allowing the government to pay for AIDS medications for anyone requesting it. If the virus is or becomes resistant to any of these medications or the patient cannot tolerate them, well, that's life. Currently the government provides this one line of treatment and that is it. As such they do not check viral load or CD4 counts or anything because it would not alter care. In the future they are planning on developing a second line of medications to augment the first line, but that is still in the works. At CMC they provide a level of care intermediate to the US and Indian government. It, unfortunately, is not free, but still considerably cheaper than the average cost of care in the states. I very much wish I had a better understanding of health care systems in differing parts of the world. If anyone has any reading suggestions let me know!
Ok. Enough for now. I had a lot of time to write today because the National Museum here in Delhi was unexpectedly closed for Republic Day. But that's a post for later....
Tuesday, January 22, 2008
A Tropical Medicine Break
Finally! The long awaited, highly acclaimed "demonstration of an in-depth understanding of one tropical disease." And the topic? Japanese Encephalitis. Spectacular.
I chose to write about Japanese Encephalitis primarily for three reasons. One, I just found it to be interesting. Two, it is a tropical disease with just enough incidence to have both an adequately accessible volume of written material on it and also to be potentially clinically significant if I were to ever pursue Infectious Disease -- which I currently certainly plan to do. And three, its pathology is not so diverse and broad that the amount of information out there would result in my demonstration of knowledge being long, tiring, and tedious or so superficial as to be readily found on any "health" website on the Internet. Alright, Japanese Encephalitis time.
Culex tritaeniorhynchus. I have no idea how to pronounce it and will likely never in my life be able to spell it, but this mosquito is the source of the thousands of cases of Japanese Encephalitis virus (JEV) which occur every year throughout South and East Asia. Numbers on the actual rate of infection vary and are believed to be underestimated, but the average guess is that 35 - 50,000 people experience symptomatic JEV infections a year with another 250x as many suspected asymptomatic infections. Mortality rates vary as well based on accessibility and quality of medical care, but they range from 5-10% in areas with access to intensive care units all the way up to 35% in poorer, undeveloped areas.
The virus itself is an arbovirus (meaning arthropod (i.e. insect) born virus) of the family flaviviridae (a collection of single stranded RNA viruses) thus relating it to the Dengue Fever and West Nile viruses. It exists where ever the Culex mosquito exists, its only carrier, which allows it to spread west to Pakistan, east to Japan, and down south, rarely, to Australia in a triangle of territory that covers almost half the world's population. It is not endemic in all these regions (meaning it is native and naturally prevalent to the area), but rather in some areas occurs in sporadic epidemics that come and go (meaning it occurs in bouts where it otherwise does not normally exist.) It has a seasonal occurrence typically arising from June to September in most states with the bugs most active at dusk and evening hours.
Assuming you are unfortunate enough to have both been infected with the virus and then become symptomatic, here is kind of what you can expect. The flu at first. Initially, like many viruses, you will just feel like crap. Most people experience fevers, headaches, nausea, vomiting, diarrhea, and muscle pains (myalgias) though most commonly not all these symptoms are experienced by each and every patient. These symptoms can last a few days or more and will eventually lead into altered mental status and altered neurology as the virus moves from the blood to the brain (thus making it an encephalitis [en- meaning "within", kephalos- meaning "head", and -itis meaning "inflammation.") The mental status changes can range from mild confusion and agitation all the way to delirium and coma. Beyond this 85% of children and 10% of adults will experience seizures which are associated with a particularly poor outcome. A few other things to look for include nuchal rigidity (stiff neck) in 33 - 66% of cases, cranial nerve palsies in 33% of cases, and Parkinson like symptoms (tremor, masked facies, rigidity, etc.) in a good majority. A few unusual and rare presentations include mutism and acute flaccid paralysis.
If you look towards the labs, upon spinal tap you will often find the typical viral meningitis picture in the cerebral spinal fluid (CSF). Opening pressure will be normal to mildly elevated, CSF protein will frequently be mildly elevated as well, and white blood cells (WBCs) will vary from 10 to several thousand with a lymphocyte predominance. With regards to blood related studies, a complete blood count (CBC) could possibly show a mild leukocytosis (increased WBCs; mostly neutrophils) or thrombocytopenia (decreased platelets) while an examination of electrolytes could show hyponatremia (decreased blood sodium.) Curiously, a recent study of a 2005 Indian outbreak also showed an increase in liver function tests (LFTs) in children with AST elevated in 100% of cases and ALT in 47.2% of cases. All these nonsensitive and nonspecific tests aside, the key to a diagnosis of JEV is an ELISA of both the blood and CSF. Assuming both are done, almost 100% of cases can be picked up. Unfortunately ELISAs are not typically easily or cheaply done especially in the field. Fortunately a newer test, IgM enzyme dot immunoassay, of the CSF is much easier and portable with almost the same accuracy its sensitivity and specificity being 98.3% and 99.2% respectively.
EEGs, CT scans, and MRIs can also show fairly characteristic patterns as well, but, like the other tests mentioned earlier, they are generally not sensitive or specific and so are only supportive.
It is worth noting, half way through this, that there are three aspects of JEV infection that make it a particularly treacherous disease. One, already touched upon, is the fact that most of those who become symptomatic become severely so. The second is that there is no cure. This is not uncommon for viral infections as most do not, but even recent trials with interferon-alpha and steroids, which have shown positive results with other viral related illnesses, have shown no significant benefit for JEV. Essentially all one can do is attempt to control the symptoms administering antiepileptics for seizures, mannitol for increased intracranial pressure, and ventilation for respiratory failure. The third aspect of JEV infection which makes it not a disease to be taken lightly is its long term sequelae. Personality and cognitive changes are frequent and it is estimated that up to 50% of symptomatic patients will have lasting neurological damage including seizures, paralysis, movement disorders, and blindness.
Thankfully, for all its dreariness, there is some hope. If you happen to have been previously infected with Dengue Fever or West Nile virus cross-reactivity will significantly decrease your morbidity and mortality. Since I would gather most of you have been infected with neither of the two, there's always technology to assist. Through a variety of vaccines, currently a killed version and shortly a live version in the US, we can, through a few shots, provide nearly 100% protection against the disease. Moreover, the side effects of the vaccine are relatively minor and uncommon making mass vaccination possible even with the relatively low incidence of the disease. While country to country vaccination policies differ significantly, in the US the CDC currently only recommends getting the JEV vaccine if (1) you are planning to travel to an afflicted nation for greater than one month OR (2) you are planning on spending a major part of your time outside in endemic areas OR (3) you are entering a specific area with an active epidemic. Needless to say you probably don't know anyone that has ever gotten one, and if they claim they did they are probably mistaken. Someday with better public health measures and vector control maybe most of Asia can say that too.
And that's all I got to say about that.
Sources not cited include:
Mandell, Bennett, & Dolin. Principles and Practice of Infectious Disease. 6th ed. Philadelphia Churchill Livingstone, 2005.
Kallen, Alexander. "Japanese Encephalitis." http://www.emedicine.com/med/topic3158.htm WebMD, 2008.
Online Etymology Dictionary. "Encephalitis." http://dictionary.reference.com/browse/encephalitis Douglas Harper, 2001.
I chose to write about Japanese Encephalitis primarily for three reasons. One, I just found it to be interesting. Two, it is a tropical disease with just enough incidence to have both an adequately accessible volume of written material on it and also to be potentially clinically significant if I were to ever pursue Infectious Disease -- which I currently certainly plan to do. And three, its pathology is not so diverse and broad that the amount of information out there would result in my demonstration of knowledge being long, tiring, and tedious or so superficial as to be readily found on any "health" website on the Internet. Alright, Japanese Encephalitis time.
Culex tritaeniorhynchus. I have no idea how to pronounce it and will likely never in my life be able to spell it, but this mosquito is the source of the thousands of cases of Japanese Encephalitis virus (JEV) which occur every year throughout South and East Asia. Numbers on the actual rate of infection vary and are believed to be underestimated, but the average guess is that 35 - 50,000 people experience symptomatic JEV infections a year with another 250x as many suspected asymptomatic infections. Mortality rates vary as well based on accessibility and quality of medical care, but they range from 5-10% in areas with access to intensive care units all the way up to 35% in poorer, undeveloped areas.
The virus itself is an arbovirus (meaning arthropod (i.e. insect) born virus) of the family flaviviridae (a collection of single stranded RNA viruses) thus relating it to the Dengue Fever and West Nile viruses. It exists where ever the Culex mosquito exists, its only carrier, which allows it to spread west to Pakistan, east to Japan, and down south, rarely, to Australia in a triangle of territory that covers almost half the world's population. It is not endemic in all these regions (meaning it is native and naturally prevalent to the area), but rather in some areas occurs in sporadic epidemics that come and go (meaning it occurs in bouts where it otherwise does not normally exist.) It has a seasonal occurrence typically arising from June to September in most states with the bugs most active at dusk and evening hours.
Assuming you are unfortunate enough to have both been infected with the virus and then become symptomatic, here is kind of what you can expect. The flu at first. Initially, like many viruses, you will just feel like crap. Most people experience fevers, headaches, nausea, vomiting, diarrhea, and muscle pains (myalgias) though most commonly not all these symptoms are experienced by each and every patient. These symptoms can last a few days or more and will eventually lead into altered mental status and altered neurology as the virus moves from the blood to the brain (thus making it an encephalitis [en- meaning "within", kephalos- meaning "head", and -itis meaning "inflammation.") The mental status changes can range from mild confusion and agitation all the way to delirium and coma. Beyond this 85% of children and 10% of adults will experience seizures which are associated with a particularly poor outcome. A few other things to look for include nuchal rigidity (stiff neck) in 33 - 66% of cases, cranial nerve palsies in 33% of cases, and Parkinson like symptoms (tremor, masked facies, rigidity, etc.) in a good majority. A few unusual and rare presentations include mutism and acute flaccid paralysis.
If you look towards the labs, upon spinal tap you will often find the typical viral meningitis picture in the cerebral spinal fluid (CSF). Opening pressure will be normal to mildly elevated, CSF protein will frequently be mildly elevated as well, and white blood cells (WBCs) will vary from 10 to several thousand with a lymphocyte predominance. With regards to blood related studies, a complete blood count (CBC) could possibly show a mild leukocytosis (increased WBCs; mostly neutrophils) or thrombocytopenia (decreased platelets) while an examination of electrolytes could show hyponatremia (decreased blood sodium.) Curiously, a recent study of a 2005 Indian outbreak also showed an increase in liver function tests (LFTs) in children with AST elevated in 100% of cases and ALT in 47.2% of cases. All these nonsensitive and nonspecific tests aside, the key to a diagnosis of JEV is an ELISA of both the blood and CSF. Assuming both are done, almost 100% of cases can be picked up. Unfortunately ELISAs are not typically easily or cheaply done especially in the field. Fortunately a newer test, IgM enzyme dot immunoassay, of the CSF is much easier and portable with almost the same accuracy its sensitivity and specificity being 98.3% and 99.2% respectively.
EEGs, CT scans, and MRIs can also show fairly characteristic patterns as well, but, like the other tests mentioned earlier, they are generally not sensitive or specific and so are only supportive.
It is worth noting, half way through this, that there are three aspects of JEV infection that make it a particularly treacherous disease. One, already touched upon, is the fact that most of those who become symptomatic become severely so. The second is that there is no cure. This is not uncommon for viral infections as most do not, but even recent trials with interferon-alpha and steroids, which have shown positive results with other viral related illnesses, have shown no significant benefit for JEV. Essentially all one can do is attempt to control the symptoms administering antiepileptics for seizures, mannitol for increased intracranial pressure, and ventilation for respiratory failure. The third aspect of JEV infection which makes it not a disease to be taken lightly is its long term sequelae. Personality and cognitive changes are frequent and it is estimated that up to 50% of symptomatic patients will have lasting neurological damage including seizures, paralysis, movement disorders, and blindness.
Thankfully, for all its dreariness, there is some hope. If you happen to have been previously infected with Dengue Fever or West Nile virus cross-reactivity will significantly decrease your morbidity and mortality. Since I would gather most of you have been infected with neither of the two, there's always technology to assist. Through a variety of vaccines, currently a killed version and shortly a live version in the US, we can, through a few shots, provide nearly 100% protection against the disease. Moreover, the side effects of the vaccine are relatively minor and uncommon making mass vaccination possible even with the relatively low incidence of the disease. While country to country vaccination policies differ significantly, in the US the CDC currently only recommends getting the JEV vaccine if (1) you are planning to travel to an afflicted nation for greater than one month OR (2) you are planning on spending a major part of your time outside in endemic areas OR (3) you are entering a specific area with an active epidemic. Needless to say you probably don't know anyone that has ever gotten one, and if they claim they did they are probably mistaken. Someday with better public health measures and vector control maybe most of Asia can say that too.
And that's all I got to say about that.
Sources not cited include:
Mandell, Bennett, & Dolin. Principles and Practice of Infectious Disease. 6th ed. Philadelphia Churchill Livingstone, 2005.
Kallen, Alexander. "Japanese Encephalitis." http://www.emedicine.com/med/topic3158.htm WebMD, 2008.
Online Etymology Dictionary. "Encephalitis." http://dictionary.reference.com/browse/encephalitis Douglas Harper, 2001.
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