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.

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....

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.

Beaches, Indifference, and the European Union

This last weekend, after much debate, we went to Mamallapuram on the coast of Western India. Some had suggested Puducherry, a former French colony, as a more beautiful beachy alternative, but then again everyone seemed to have a different opinion and just about every opinion was expressed. With so much contradictory information to deal with, a norm now for us it seems, we decided to just go to Mamallapuram as it was closer and had some rock carvings. I believe we made the right decision. Mamallapuram had a beautiful beach of its own, and was a lovely, relaxing way to spend the weekend as Western tourists.

Being a "resort town" in a third world country the geography was typical. Nice, luxury hotels were immediately adjacent to a hundred poorer homes and a thousand little shops. Intermixed in all this were a smattering of cheaper, shadier hotels catering to less affluent tourists who either by choice or by accident ended up in them. As we were playing tourists, and many of the carvings for sale were I felt quite impressive, I myself decided to partake in the shopping ending up with a few gifts and items for myself and family. Since my parents seem to have most the things they want and usually buy the things that they don't when they do want them, I was having a difficult time finding something to get for them. Thankfully my mother is an avid necklace designer, and is always looking for more beads to work with. After an extensive search I found a place selling some and went in to inquire further. Like most bead vendors the world over they had their standard fare of cheap crap beads made of materials you can find at any Michael's or Hobby Lobby in the US, but they also had some very pretty carnelian beads which to me seemed to be fairly unique looking. Unfortunately unique beads apparently come at a unique price as they were 45 rupees a gram (~ 40 rs per $1) and quite dense. The small pouch of beads I had collected weighed about 160 grams and so cost about $180. After about 30 minutes of unwanted haggling over the price I eventually realized I would not be able to convince him I was unwilling to pay very much for them or any beads and so haggling would be fruitless and simply told him thank you and goodbye. I am not sure why it went on so long or why I even wanted so much to explain to him that a transaction would never be possible, but well, that's shopping in India for you. It was strange. And sweaty.

Of course the reason we went to the coast was not to shop, but to swim. For some reason the Indian Ocean has had a strong appeal to me ever since I knew I would be going to India, and so I was looking forward to the chance to see it. Aside from some boats and a little more trash it looked just like the Atlantic. Relatively soft sand and fairly small waves. It was fairly warm and tasted salty. Not much in the way of fish or sea life that I could make out. After about 15 minutes I had had my fill, and I returned to the pool along with everyone else. Though I always thought it a relatively ethnocentric and egotistical thing to think, I can honestly say that, in my experience at least, Indians do enjoy a good stare at white folk. For reasons known only to themselves -- though perhaps they don't even know why they do it -- just about wherever you go and at all times of day people will stare at you. It seems to be less so, or at least less noticeable, when walking, but whenever you sit and whenever you swim you're a source of at least momentary interest. Perhaps I should start selling shirt space to major corporations. I could be like one of those NASCARs: Viva Viagra! and Wonder Bread!

So that was our weekend. It is notable that during all our trekking about we did essentially no site seeing. As we were driving back the driver offered to stop at a local temple of some significance so we could have a look, but we all politefully declined. I imagine there are actually a great many other things I would politefully decline in India elsewhere as well. While part of it may be very well that, like the many cathedrals of Europe, we simply had no desire to see more of the same, I think a greater part of it was that to me much of India has felt inaccessible. The significant language barriers are given, but beyond that the history, society, and culture are all so incredibly foreign, even if only superficially so, that they do not resonate with me. The most boring and unadorned of cathedrals of Europe could usually still move me with their grandeur if I would simply stop to take it in, but though I have tried to learn a good deal about Hinduism, Buddhism, and Jainism since given the opportunity to come here the temples of these religions still feel only like large, cold constructions of stone and wood. Beautifully carved and impressively constructed though they may be I cannot help be indifferent. Likewise in the castles, towns, and palaces of Europe I felt that I could get a sense of the history and an understanding of the times, but even knowing the conquests and accomplishments of the kings and emperors throughout India's existence their forts and cities and tombs, equally magnificent if not more so, are simply forts and cities and tombs. I feel no connection. Perhaps it is because I do not feel these people to be my people and their history to be my history, or perhaps because I am still too ignorant of it all to get even an outsider's appreciation, or perhaps it's simply because I have some ethnocentrism inside myself myself, but, the CMC aside, I imagine when I leave India it will simply be just a nice place I visited one day. Oh well, I feel that way with Denmark too.

Changing the subject completely, I do not feel many Westerners have a good concept of India as a country even in a general sense (myself included), and although my readings before our trip did not necessarily give me a taste of or for India I do feel they have at least helped me to better understand it. As such I feel inclined to share with you all my own thoughts of what India, as a country, is like. So here, my friends, is a random aside.

India is, basically, the European Union. Not in the details of course, but in its character. Just like "Christendom" for centuries could be a descriptor of Europe but mean next to nothing politically, "India" could always refer to a region populated by a people of fairly similar ethnicity and religion but it would have never made much sense politically. French Christians spoke differently than German Christians, had different customs than Spanish Christians, and looked different than British Christians. Likewise the people of West Bengal, Tamil Nadu, and Rajasthan, though all members of the Indian subcontinent and in many ways similarly sharing an interrelated history, are remarkably different and distinct. It is only recently, initially under British control and now independently, that the term "India" has meant anything in a political sense. Only recently has the concept of being an "Indian" carried any significance. In such a light I feel the success of India in its development and unity, Pakistan and Bangladesh aside, is quite remarkable. India is not some homogeneous behemoth that exists only because it has always been that way or is too unenlightened to have ever felt the divisive pulls of nationalism and self determination. It is actually a quite remarkable political success story that is worthy of much the same praise that the European Union has received, and, if essential reforms continue and its violent past with its neighbors settled, perhaps in the future even more so. It has a lot of problems, but it also does not have much to work with. I will probably never love India, but I certainly do like it.

CHAD (Community Health and Development)

As I have said before, CHAD is awesome. In other words, CHAD inspires awe. And this is why...

Modern medicine has produced a lot of pretty fantastic things. Unfortunately almost all of them require all the trappings and resources of a modern medical system and infrastructure. For rural or developing countries it is often only the urbanized or well to do who benefit much from all that current medical technology can provide. In order to combat this a great many programs, plans, and, as they say in India, "schemes" have been developed, and CHAD is one of them. Through a whole host of lesser programs and schemes CHAD has succeeded in providing medical care and social and economic development in many of the surrounding villages of Vellore that would otherwise miss out on the resources CMC has to offer. But all my pretty praises of CHAD are trifle if I do not tell you what it does so let's get to that. CHAD offers:

Daily doctor visits to surrounding villages. A well equipped and well staffed medical bus goes to four villages daily providing prenatal care, managing chronic disease, monitoring child development, providing medications and injections, and generally curing what ails ya.

Additionally, a daily nurse visits take place to other surrounding villages. Though smaller and without much of the equipment and medicines of the doctor mobile, the nurses spread out through the villages checking on patients in their homes and maintaining continuity of care.

A micro loan program, successful and popularized throughout the world, has been developed to help poor entrepreneurs start small business.

An array of STD ISD phone booths have been set up giving handicap people access to jobs

A whole series if lesser, lesser programs and schemes provide job training

Truly it should be called CDAH, as there seems to be more development than health, but I do not imagine "kuh-dah" has the same appeal. If you want a more extensive and descriptive list of what they offer, though, check it out here.

I spent my last week there and, though I was unable to attend the nursing rounds as scheduled due to over scheduling (which itself was likely due to the fact that Indians do not seem to like writing things down), I was able to venture out on doctors' rounds on Thursday. The fact that we have only the limited status of "observer" for our trip combined with no interpreters meant there was painfully little we ourselves could do, but simply seeing how it all worked and flowed was an enjoyable experience. In each of the four villages we pulled up, set up, and in short time usually had 30 - 40 patients coming to receive care. Most of it all done outside in some shady area of town where the people mingled and talked and waited to be seen. The physician in charge attempted to enforce the concept of lines as patients had previously complained about sitting for long periods of time only to have others be seen before them, but as elsewhere the lines generally degraded into people shoving their health records into the intern's face who was either too indifferent or intimidated to protest otherwise. Nevertheless most people seemed patient and content. Perhaps it was simply the fact that we were practicing medicine outside -- something I have always fantasized would somehow be possible in the US -- but even though I did not do much anything but observe and help set up I felt a tinge of excitement that I have only infrequently felt otherwise in my medical education to date. Though I do not necessarily have the data or statistics to back it up, I felt CHAD was making a difference in these peoples lives and in a significant manner. I have often felt that the world maybe needs a little more health and development and a little less free markets, democracy, or many of the other trappings of Westernization, and I feel even more so now.

Clinically speaking the pathology was not terribly diverse. Generally speaking most patients either had rheumatic fever (a consequence of strep infections gone bad) or seizure disorder (which was almost always treated with phenobarbital for better or worse). There was also of course some diabetes and hypertension and the like, and some COPD in old men, but by and large: rheumatic fever and seizure disorder. Why? Who the heck knows. I'll spare you all my boring likely inaccurate hypotheses. Completely changing the subject we did also have one elderly gentleman with Parkinson's. It was actually kind of weird seeing such a familiar almost Western seeming disease in a small, random village in India. All the disease aside, we concluded our day playing catch with some boys and a cricket ball.

Anyways, I am in an extremely hot Internet cafe taking a break from the outdoor clamor of Mammalapuram so I'll leave things at that. In closing, let me just say that CHAD is awesome.

The Smells, Sounds, and Tastes of India

My parents keep asking me what the food is like here. In fact I believe its been in every email my loving mother has sent. In order to finally appease them and stop deferring my answer till later I will share with you all now our menu.

But first let's talk about the stink. Actually, so far India has smelled much less than I anticipated it would. I had heard from many people and sources that due to trash and hygiene and pollution and sewage issues (in some areas sewage disposal is a cement ditch immediately outside your residence) India would be quite smelly. At times it is and a few times it definitely is -- outside the fair grounds on the way to the hospital there is about a 100 yard stretch where I think vomiting would be inevitable if you stayed too long -- but for the most part, however, India has not smelled too bad. By and large most of the time it smells like any other dusty city aside from an occasional whiff of stink here and there. The only smell that does seem to be just about everywhere is the smell of burning diesel fuel. I would gamble there is not much regulation of automobiles and motorcycles as the streets can be a choky haze at times. So while the aroma of India, or Vellore at least, may not by and large be too great, it is certainly tolerable.

The sounds, on the other hand, are a little bit crazier. There is of course the usual sound of incessant honking to accompany the smell of smog, but the sounds of the city are not too out of the ordinary. It is the sounds of nature that are nutty. The birds, primarily, are the ones out of control. There are growling crows, sonar beeping birds, and what I imagine to be little finches chirping as loud and as fast as they possibly can. Add to that an occasional monkey fight (or sexual encounter possibly) at 11 pm and you have an almost nonstop background chorus in the trees. They do all eventually calm down around 2 or 3 in the morning, but at 4 on comes the Hindu music blared for all to hear over the seemingly invisible but ubiquitous loud speakers. The songs change almost daily, as do their volume, duration, and location, but they are just about always daily. Ear plugs are a must for light sleepers here.

And now, finally, the tastes of India. At first I loved Indian food, it was great, but after almost two weeks of nothing but spicy Indian food I am confident I am ready to move on. It all tastes the same. There is some Chinese food in town which is different, kind of, and the "samozas" do taste a lot like chimichangas, but our options are otherwise pretty much only Indian or Indian. Oh wells, you guys do not care to read my complaints and whines I imagine so instead I'll get on to our eats : (I cannot guarantee by the way that I've spelled anything correctly.)

At the cantina on the CMC campus where we're staying the menu is pretty limited, but it's cheap and tasty. You have your bread type foods like "dosa," a thin, almost crepe like fried bread that I do not particularly care for; "champatthi," a good tortilla like bread; "parotta" a thicker, chunkier bread without easy comparison and my easy favorite; and stuffed "gnon," which is like dosa kind of but usually stuffed with something to make it taste a little better. There's also the "vegetable biriyani" which is basically rice with vegetables and curry, "onion uthapam" which is essentially a pancake with onions in it, and the "egg and cheese sandwich" which is essentially a sandwich with egg and cheese in it. Many of these dishes do not taste too great by themselves, but with the accompanying sauces, or "gravies" as they like to call them, they're usually quite nice. For whatever reason the cantina only serves certain items at certain times so while you can get a vegetable biriyani and ice cream at lunch you cannot at dinner.

If you want meat -- and especially if you want it without a hundred little bones -- you must go off campus, though, in which case you have three main options. Right across from the hospital is China Town, a place that despite its name is pretty good; Hotel Darleeng, which is good but generally slow service; and Hotel Shitabi, which is great and generally has fairly quick service. Here you can get all sorts of chicken, fish, and mutton dishes in a wide variety of sauces. "Chicken Tika Masala" seems very popular amongst our group. I personally think the "Dragon Chicken" is best And the "Devil's Chicken," despite all its bluster, is not too spicy or flavorful. Make sure you order rice or a bread along with the meat dishes, though, or you'll just be eating a small tin of meat with a whole lot of gravy.

As a side note there is also a YWCA cantina on the hospital grounds that is Western friendly, but it's essentially a less nice version of campus cantina previously mentioned.

The drink options are, everywhere, essentially Coke, Sprite, or Fanta with a few places offering Pepsi. There are juices in many places too but they tend to be rather pulpy and so are not really juicy in the typical American sense. The tea is all chai, for the most part pretty good, and I hear the coffee is great too though I do not care for coffee myself. Milk is usually warm.

And deserts? Well, there's ice cream. I like that. Some places offer "lassis" which I have never tried but have been told are sour and absolutely terrible. And there is a guy who bikes around the fair grounds which a huge stack of cotton candy affixed to his ride, but we've never purchased any ourselves. To my knowledge that is about the extent of the desert selection though I kind of have to imagine we're missing something. The campus store is about 40% packaged cookies, though, so there's always the cookie option.

So that is what we have been eating for the last 14 days. I've liked it all, but I cannot wait for a pizza, box of donuts, and cold glass of milk. So, in summary, India is a sometimes smelly, often noisy, and generally tasty place.

And now off to Mamallapuram for the weekend!

A Meeting With the Devotees

Initially I had planned to write every two or three days. Long enough to not be spending all my time on the computer but not so long that each entry became excessive and tedious. This week I will make an exception because this week, Monday, I met with God.

I do not mean I met with God in a personalized, spiritual sense. And I do not mean that I met with God in a mysterious or metaphysical sense. Rather, I actually walked up to God after a brief wait in line, and She handed me a scoop of holy water. Realizing that it is not every day one meets in person the divine I figured it would be good to squeeze in a few extra blog entries for the week. So now, too, through my hopefully supernaturally inspired fingers you also can have an idea of what it is like to know God. Or as She likes to be called: Amma.

- disclaimer -
It is likely that bringing up the topic of religion will result in my stepping on some people's toes. It is also likely that in this particular case I may dance on a great many toes. I am admittedly ignorant about a great deal of the intricacies of Eastern religion, and I am also admittedly inclined to be skeptical of the supernatural both in its ancient and newer manifestations, but I am going to go ahead and, from what I do know, say that Amma and her devotees are, straight up, a cult. I understand that for some if not a significant portion of Hindus such gurus are a significant and real part of their faith, but seriously people, Amma and her devotees are as cultish as you get without a sizable arms cache. I am sorry if this offends anyone, but even more sorry that anyone would find this offensive.
- disclaimer -

So back to the story. Looking for things to do in Vellore is not an easy task as it is a relatively small, relatively rural town. The fort was nice, and I enjoyed visiting the temple, but that, it seemed, was about all there was to do tourist wise aside from shopping. Until someone told us about the Golden Temple that is. Just 5 km outside of Vellore was India's largest golden temple, and, yes, by golden temple I do mean the temple is covered in actual gold. In this case about 1.2 or 1.5 tons of it. Not sure of the actual number, but when you start talking about gold in tonnage I don't imagine the decimal points really matter. The temple is composed mostly of other material and copper of course, but all of it, just about every square inch, is covered with at least 6 layers of gold foil that have been intricately plated on. We're getting ahead of ourselves, though, so I'll return to the beginning.

Upon hearing of this golden temple, actually more formally known as Sri Puram Golden Temple, we decided we had to go. Conveniently that Monday Rachel, Paul, Rebecca, and I had the afternoon off from CHAD. As we had been told it was a couple hour ordeal we decided that now was the time, and so, after obtaining for ourselves a few autorichshaws, off we went. About a 15 minute bumpy ride through the outskirts of town later we were there though from the outer perimeter walls we could not really see anything yet. It was only after we dispensed with our shoes (as you are to do in all Hindu temples I believe) and Rebecca's camera (cameras and phones are banned as they detract from the spirituality of the experience) that we were able to get in the first cordon of walls and begin the actual experience of Amma and Her Golden Temple.

Before we could get our first glimpses of it all, however, we had to walk through an extensive series of lines. Thankfully today was a relatively light day and the lines were not nearly as long as they could sometimes be so within a few minute we were to the cages where visitors must amass before their final entrance to the temple complex itself. Here, in one of three or four holding cells, we waited with about 200+ Indians for our turn to make the trek. I am under the understanding that we are sequestered there momentarily to prevent an overwhelming deluge of people onto the temple grounds at any one time, but I am not sure. Whatever the reason we sat in metal chairs surrounded by huge metal fences for about 10 minutes before being allowed in. In order to begin to awaken our souls to the cosmic forces further within -- and likely to make it feel less like a prison holding cell -- the area was surrounded with pictures of Amma and Her cohorts and various quotes and sayings primarily from Amma herself.

Once we got through the metal detectors and x-rays we got into the temple grounds itself and it was, quite literally, a bit hard to describe. It all seemed very, very similar, and yet very, very different. It looked like a theme park, and yet felt nothing like one. The entrance was a long, stone, immaculately clean path split in two by an elaborate series of water fountains and falls. Everything was landscaped and tidy. At the end of about 70 or 80 yards of the entrance walkway the path veered abruptly left in the beginning turns of what would eventually be a Star of David design (a very spiritually charged shape we were later told.) The path itself was covered by a colorfully painted awning and on either side of the path the vedic and Amma quotes continued. We later found out that you are supposed to walk this path in silence and contemplation, but we did it as noisy, American tourists chattering amongst ourselves. I was not particularly attentive of the other visitors, but I am pretty sure we were actually not the only ones talking, though. Anyway, after about 15 minutes of walking with 85% of the star complete we made it to a separate path, again with water fountains and falls, which finally took us into the center of the star and to the golden temple itself.

The golden temple was, in and of itself, nothing entirely remarkable. It was a ring around a water filled area with another more central area inside the moat where the various Hindu rituals actually took place. The outer ring was like the path before, stone and painted wood, while the inner area was, as mentioned before, almost completely fashioned out of gold leaf. The pillars, the statues, the ceilings, and roof were all gold. It is hard to describe the dimensions, but it would have been a relatively large house in India if that is at all a helpful comparison. (And likely not.) There were also some, in my opinion, rather gaudy glass chandeliers hanging intermittently from the gold ceiling, but most everything was glinting, shining gold. There were a few people who for whatever reason had been given access to this inner area and at the most extreme end of the temple where the open air, pillar supported area gave way to a small also golden room there was some sort of swami character performing the daily pujas to better the world. He was not golden as far as I could tell.

The temple, for all its glory, was not where the real fun began, however. That came with our visit to the information center/gift shop. As we were not allowed to take photos we needed to find something with a picture that we could share with others so the gift shop seemed a good place to start. As we approached we noticed through the windows there was a white woman inside, and usually where there're white women there is easily understood English so we were excited. We began talking to her, and she did indeed speak excellent English, but within a few minutes if not seconds her excitement level kicked up a notch. "Would you like a chance to receive a blessing from Amma?!" "Amma what?" "Come there's little time. I was just about to head over there myself to receive the blessing he is such a nice man you are so lucky to have come at this time so feel people receive such an opportunity..." and so on and so forth. As she spoke quickly, friendly, and was already headed out the door we, somewhat confused, headed out after her. We crossed the street, bypassed a few lines and pushed through a few others, and finally arrived at a separate, smaller, less golden temple a little ways away.

In this comparatively boring temple we were introduced to her husband. He was a family practice physician in Canada, and she, it turned out, had a variety of PhDs in a variety of things including world religion. These Canadians were the first of a few "devotees" we were to meet and who, after experiencing a variety of miracles/magic tricks, began to believe in this Goddess called Amma. In preparation for meeting with this deity we were instructed to cup our left hand under our right, receive the blessing -- which in this case took the form of spiced water --, take a sip, and pour the rest over our heads. If Amma chose to speak to us we could certainly talk back if not initiate the conversation ourselves, but with little time to think of what to say to God in man's form we were before Her receiving our blessings. The Canadian women gave us a brief introduction which seemed to have slightly startled the otherwise tranquil Amma and, though I cannot remember who he asked this to as its blurry and he spoke softly, I believe he asked us how we were liking India. (Yes I went from "she" to "he" here, but, well, the goddesses -- there's three in all that compose the goddess that incarnated herself as Amma -- decided to take the form of a 31 year old man.) I myself said nothing to him as he was saying to us all that he hoped we enjoyed our stay when I was before him, but I simply took my blessing, sipped the surprisingly tasty water, and then poured the remaining amount over my head but mostly over my forehead. And that concluded our meeting with Amma the man goddess.

After all was through and the curtains had been drawn, we reunited with the Canadians. They told us Amma had apparently liked us as he had ordered them to give us these thin yellow booklets which were allegedly only very rarely given out. The books contained a reiteration of the quotes which surrounded the complex along with a little more information and some pictures. Thanks, I guess. The Canadians then proceeded to share with us the history and wisdom of Amma while we waited for our books, but we were all interrupted by Rebecca's startled cry of, "Oh my god is than an elephant?!" It was indeed an elephant, the temple elephant apparently, and within a few minutes were we feeding it and receiving its blessing as well -- which consists of it rubbing its trunk all over your head and face. We were honored, and then promptly all offered tea and the Western guest complex.

The complex, or compound perhaps, was a walled, guarded, and very clean dorm area full of various Westerners dressed up in traditional Indian clothes. Although we'd seen many white women in Indian garb as it seems to be a popular thing to do, this was the first time I saw white men in Indian dress as even many Indian men have traded theirs for European clothes and fashion. Perhaps my hardened heart colored my gaze, but I think we all definitely got a weird vibe from the place. Here we met one or two more devotees, who too seemed a little off and not terribly friendly, but spent most of our time with the Canadian physician and a pot of chai tea. The tea was great, but the conversation I felt got a little old after a while. I care only to spend so much of my day discussing the intricacies of what seemed to be a relatively simple theology dependent on the complete suspension of disbelief with regards to the life, times, and teachings of one otherwise ordinary seeming man. The others in our group, probably less scornful and more inquisitive than myself, pressed the conversation further, however, but within another hour or two our tea was gone, dinner was advancing, and we had to return to town. The Canadian gentleman gave us a quick tour of the complex's roof and surrounding area, and we concluded our time with Amma and his devotees.

So what is it that Amma teaches exactly? Well I believe it can be broken down into two basic precepts. (1) God is love, and (2) for a good time do good unto others. Nothing terribly new or unique there. It should be noted that Amma does not demand obedience, allegiance, or really anything from Her followers, but he does charge for services rendered. (A trend I noticed also in the Jalagandeeswarar Temple at the fort in town. It seems indulgence-esque to me, but perhaps I am just ignorant and/or biased.) Apparently a blessing of the sort we received typically runs a couple hundred rupees, and though a trip around the temple is free the exit is heralded by a large donation area fully capable of accepting Visa, Master Card, and American Express. A good deal of this money does go to charity work, or so the devotees would at least claim, and a good many projects in health care, education, occupational training, and environmental repair have been at least partially funded by Amma (from what I can tell his followers often take all of the credit even if they do not provide all of the funds.) So despite his multimillion dollar temple he himself has done good in the world, and this gets me to wondering....

How much is truth worth? I have always believed that "truth," in as much as it can be obtained, is, to be a bit mundane, priceless. Real progress in the world, in affairs with each other, and in life is, I feel, only possible with the constant upholding of truth. Both knowledge and intimacy are dependent on it being sacrosanct. With such in mind inaccuracies, falsehoods, and lies such as Amma's, no matter how well intended or charitable they may be, should always be resisted and exposed for what they are. We do not necessarily have to be aggressive or belligerent about it -- and it is certainly advisable to cognizant of the appropriate time and place for such matters -- but while momentary toleration may at times be prudent ideas that are inherently false should never be accepted as equal with the truth. But then again I am not starving. I am not sick. I am not without shelter, water, or clothes. I do not stand to greatly benefit from the charities of these organizations. Championing truth is easy when it comes cheap, and so I wonder if in other shoes I would care if my caretakers are crazy out of their mind. When people are the world over suffering perhaps it is more important to be kind than correct. For the long term advancement of the world and mankind I am still inclined to disagree, but maybe I am wrong. Maybe India will teach me otherwise.

If, despite all I have said, you too wish to become a devotee of Amma you can find more information here. If you'd like spiritual emancipation with less effort, though, just send me 500 rupees and I'll spend it on something nice. For the world I mean. Something real nice.

Some Cases and a Fort

As stated previously this last Friday completed my time with the Internal Medicine II team. Although there was a lot of time spent standing or sitting around waiting for things that never seemed to take place, a common event it seems here in India, there were a few brief moments of extreme education here and there. I got to see things I'd never seen -- and I'd gamble many physicians in the US have never seen -- in quick one hour spurts during rounds with the individual medicine subteams. I cannot go into great detail unfortunately as much of the time I was not privy to such detail not being fluent in Hindi or Tamil, but I can give you all a taste of what I saw.

For starters, I saw lots of diabetes. This obviously is not terribly different from San Antonio, but I mention it because of how unexpected it was. Much like diabetes type 2 was relatively uncommon a few decades ago in the US, the progressive Westernization and, more importantly, increased processing and access of foods in India has lead to a significant increase in their own incidence of the disease. Many have speculated that, like many subgroups in the Hispanic population, having adapted to a relatively meager diet for centuries the Indian people are particularly prone to developing insulin resistance in response to a surge of refined sugars in their diets. Thus India has been introduced to the world of diabetes. It almost made me feel at home again.

With diabetes of course comes heart attacks and strokes. Not surprisingly Indian heart attacks and strokes are much like American strokes.

Now we get to the good stuff.

DRESS. Never heard of it -- initially doubtful it really existed -- but DRESS (or Drug Rash with Eosinophilia and Systemic Symptoms) is, as its name would suggest, a violent reaction in response to the administration of certain drugs. In our patient's case it was some antibiotic he got from who knows where, and he responded with airway narrowing, significant angioedema, hepatic enzyme elevation, and, of course, a rash. I am still not terribly sure how it differs greatly from a generic anaphylactic reaction, but DRESS does sound much more dreadful. Acronyms are scary.

Scrub Typhus. Ooh, exotic. A rickettsial illness that, like apparently all rickettsial illnesses, cleans up quite nice with doxycycline, and is associated with relapsing fevers and chigger bites. According to the doctors at CMC it is also associated with an eschar (funky looking scab) that 95 - 99% of the time tells you it is scrub typhus. Now that I look at how to spell Rickettsia I have learned that the bug has been renamed Orientia tsutsugamushi. You know, just so there's no confusion.

Typhoid. Typhus would not be complete without its close sounding but completely unrelated friend typhoid and so my patients obliged. We had to go to the isolation ward to see this guy. He was infected with Salmonella typhi, and, well, there really isn't much else to say about it. The problem with not getting much in the way of a patient history on rapid rounds with the doctors is that all the patients have nice name tags attached to their illnesses, but when you look at them they just look like sick people. Being transmitted through the fecal-oral route there were no cool eschars to see so, aside from looking unhappy, this guy did not appear too out of the ordinary. Nevertheless I was thankful for my oral typhoid vaccine.

Last interesting case that I can remember and care to share: organophosphate poisoning. For those not in the know -- and a pity you are not -- organophosphates are major components of many industrial pesticides. Combine this and ready access in developing nations with the compounds' cholinergic affects and you have a great way to attempt suicide. Or so many people seem to feel. Such was the case with this young man. As usual I was not able to get much in the way of a history from this guy as I saw him only briefly during Grand Rounds, but he had apparently ingested a large amount of it and properly gone comatose. We gave him a healthy dose of atropine (an anti-cholinergic) and by the end of the day he was awake and fairly normal again. It is an interesting side note that suicide in India, like many other developing nations, has only increased significantly with its recent industrialization. Make of that what you will.

I also saw some malaria, some tuberculosis, some connective tissue disease and rheumatoid arthritis, but, honestly, I do not care to comment about them. I either did not get enough information to say much or I do not think they make for the best stories.

But this week comes CHAD (Community Health And Development!) I'll go more into this amazing project later -- and like much of the rest of CMC I do believe it is worthy of the adjective "amazing" -- but for now I'll simply wrap up with a short summary of our weekend.

Saturday we went to see the 16th Century fort, if I remember correctly, that came to be occupied over time by a wide variety of Indian kingdoms, empires, and, finally, the British. Eventually like most forts it became obsolete and so has become instead a store house for a wide variety of government programs and buildings including a number of museums -- if I may be so generous with the term -- a university, and a police academy of sorts. The highlight of the museums? The giant, green T-Rex statue out front. They were otherwise like the Dubai Museum but without the mannequins. A few artifacts here and there, but little in the way of descriptions, history, or impressive appearance. There was also a Hindu temple on the grounds, the Jalagandeeswarar Temple, which we were unfortunately unable to take pictures of, but I will hopefully be able to describe in detail in my next post. For now let me just say it was... uhh... interesting? Back to the fort, though. It was big and impressive, but being stripped of most its features there is not much to write about.

Sunday we took a quick hike up a nearby granite cliff. Being around 12 noon it was a bit hot and a bit hazy, but it was about a 25 minute hike at leisurely speeds, and so was not very taxing. It was fun to be outside, though, and the view of the city and surrounding tropical green areas was nevertheless very nice. It looked a great deal like Enchanted Rock outside Fredericksburg in Texas I felt, and I longed for my climbing shoes. Amazing how geography and geology can be so similar thousands of miles away.

The last of the weekend was spent doing the American thing. After the girls moved into the Johnson House (completing their move out of the roach friendly new building) we discovered a television and proceeded to make use of it. There were a surprisingly large amount of English channels, and, as it was late at night and we had nothing else to do, we watched When A Stranger Calls on Indian HBO. For those of you not familiar with the movie it's about an hour and a half of phone calls followed by a 5 minute chase to close the movie out. Even for those removed of a TV for a week it made for a pretty crummy movie night, but it was relaxing, though, and nice to be free temporarily from the constant churning of Indian life.

What in the Heck?

As expected India has much of the unexpected. The most surprising of which occurred this last night during a concert at the Winter Symposium (a series of cardiology lectures given by various distinguished physicians and PhDs). The singer whose name I can no longer remember was billed as having "the voice of an angel," and he chose to share this heavenly gift by covering a variety of American songs including Green Day, The Police, Bob Marley, and, best of all, Billy Ray Cyrus. All this was done while he hopped and kicked his away across the stage. The audience reviews were mixed and even now I myself am not quite sure what to make of it all, but I will surely not get "Achy Breaky Heart" out of my head anytime soon.

American songs sung with Hindi accents aside, what has also been interesting is the curious head shake many Indians use to communicate. It is basically an abbreviated "no" with less rotation at the neck and more side to side lateral movement of the head. It seems to communicate everything from, "I hear you" to "yes, ok" to "I'm shaking my head though I've clearly not understood a word you just spoke to me." I did not actually notice it myself at first, but after it was pointed out by other students on the trip it became readily obvious as just about everyone seems to do it.

An unfortunate thing that I was not expecting has been the general distaste for making change and the even greater distaste for giving coins in change which is particularly problematic as many of the ATMs give only large impractical to use bills. My ticket may be 41 rupees but they will only grudgingly accept a 50. "Nope. 41 rupees," they'll say. "Give me 1 more rupee." "But I can't, you guys never give me change." "Ok, then give me 45 rupees." "I don't have any 5's either!" Today I believe I said my first words in anger for the trip as, running down to only 500 and 1000 rupee bills, the local minimart clerk refused to cash a 500. I do not understand what the source of this financial problem is, but it does agitate me sometimes. And sometimes a lot.

An at times annoying thing that I was unaware of until arriving has been the fact that the concept of a line does not exist here. Only pushing mobs. It does not matter if you are standing immediately behind someone placing an order for food and the two of you are the only ones in the area. As soon as that person is done ordering another person will come around the corner, immediately thrust themselves forward, stick out some cash, and proceed to place their own order. Unlike the change issue this does not bother me as much as it does others on our trip, but I often wonder what the source of the problem is. Do they not realize we were waiting to order? Do they not care? Is it such a nonissue here that they do not even think to care?

So some other things...

It seems the vast majority of the population does in fact use their left hand to wipe themselves after the restroom. I guess it saves trees. And spreads enteric fever....

It also seems the vast majority of the population uses their hands to eat (though predominately the right for the above reason.) Seeing as much of their diet consists of rice it is a curious sight seeing a man and woman sitting with grains of rice sticking up their forearms. As silverware is often difficult to come by at some restaurants I too have taken to eating with my hands -- which I honestly get a secret joy out of -- but as I am left handed I frequently use it primarily without thinking. I can only wonder what the Indians think of that.

And then there's the trash. The world is India's trash can it seems. Even on the relatively clean and Westernized medical school campus where a few trash cans do exist, people will step outside their place and gingerly throw a plastic cup down onto a heap of debris immediately adjacent to their porch steps. I have given it a fair amount of thought and am yet still at a loss as to why they do this. Is it cultural and just what they have always done? Is it personal and they each just individually do not care? Does trash in huge sums not bother them? Is it because the government does not provide waste disposal? Is it because the Indian people as a nation have other things to worry about? Truthfully I cannot conceive what an India without trash would look like. Even more beautiful I imagine.

Trash and change and hygiene aside, beyond some occasional irking the cultural differences have not troubled me too much. Really such things are surprising only in that I am finally seeing them in practice. The trip by and large continues to be an enjoyable and unique experience. Work yesterday was cancelled for the previously mentioned Winter Symposium thus completing my week of Internal Medicine II. I attended a few of the lectures, but they always seem to be too narrow in scope to be of practical use. Or so it seems to my simple medical student mind. They had a traditional Indian dance presentation on Thursday too, and that was nice. Hopefully I can load a video of that when I return.

Monkeys Among Us

Much as many cities of the United States are riddled with chipmunks and squirrels, the cities of India are swarming with monkeys. Although informed of their presence upon our arrival, we did not actually see any until yesterday morning when about a dozen of them commenced to migrate from one group of trees to another to do whatever it is monkeys do. We were also told not to try and befriend them as as charming as monkeys may seem, to some people at least, these are actually thieving monkeys. And they bite too. Or so the rumors go. Who knows what they're actually capable of, but I will keep my distance unless one of the little guys forces my hand. Until then, live and let live.

Speaking of monkeys, though, I myself am about to start throwing poo at some people after two days of my Internal Medicine II service. We created our schedules Monday, but it seems that is about as deep as the organization goes in this elective as I have been only given a sheet of paper with times and locations and nothing else. While that may seem sufficient, and I myself would normally be inclined to think so, I must also add that many of the activities are missing, many of the activities I am in fact not intended to go to, and when I do show up I have no idea what, if anything, I am supposed to do. That last statement goes double for the residents as whenever I ask them where I should go or what I should do I can just about guarantee I will get two different answers from two different people. Confusion was mildly frustrating but acceptable on my own in Dubai when I wasn't supposed to be doing anything in particular. Now that I am it is getting rather annoying. I would not care to only attend rounds a few hours a day, and they are quite nice rounds, but at least say that that is all that is expected. Asking too much? Quite possibly so.

Since I briefly mentioned that I am the Internal Medicine II service I will go ahead and post the rest of my clinical schedule for the next three weeks.

This week (07 Jan - 12 Jan): Internal Medicine II
Plain old internal medicine and rheumatic disease (like arthritis and lupus and stuff.)

Next week (14 Jan - 19 Jan): CHAD [Community Health something or other]
A community outreach program that takes the clinic to the surrounding areas.

Last week (21 Jan - 26 Jan): Internal Medicine I
Plain old internal medicine and infectious disease (hurray!)

Back to rounds, though, they are generally the only real education packed parts of my day, and they are generally over with in an hour. They occur just like rounds in the states but typically with much worse pathology. We go from bed to bed with the residents and the attending (or registrar as they seem to be called here) and briefly discuss each patient and the plan. Although I frequently do not hear much of what is said during Grand Rounds (all the teams together), as they speak rather softly, and I frequently do not understand much of what is said during normal rounds, as I just cannot seem to deal with the India accent sometimes, they are interesting. Where else would I see bacterial endocarditis, malaria, scrub typhus, typhoid, and organophosphate poisoning? And only in two days at that. They almost make up for the fact that I usually then spend the following two or three hours sitting around the hospital reading or staring until the next random activity.

As I am on the topic of medicine I will also just pause to say that the CMC Hospital is amazing. It's like an entire medical compound. Imagine a dusty, 1950s looking version of the Houston medical center. There are a few really nice, modern facilities, but most are fairly old and jam packed with desks, beds, and people. On the ward I am currently on there is about 3 feet between each iron frame bed and easily 12+ patients along each side of the wall separated only by what appears to be a shower curtain. There are a few more private rooms and obviously some isolation rooms, but by and large the amount of space allotted to a patient and his visitors is about the size of many small apartment kitchens. It seems they expect and are used to such conditions, however, as I am not aware of any complaints, but it is definitely medicine as I envisioned it being practiced about 50 years ago at least in regards to the facilities. The quality of the care, on the other hand, is, as far as I can tell, amazingly high in light of the undoubtedly few resources available. India for all its growth is still a poor country and the needs are ever many so the fact that they can provide top of the line medicine, CT scans, chemotherapy, and the like in such a setting is something I feel worthy of envy. CMC is an amazing place and I cannot wait to share some photos when I am able to load them back in the good ol' USofA.

And while I am on the topic of amazing things I will add the CMC campus itself. Amazing may perhaps be too strong a term, but it is quite lovely. Very green and pleasant. I know I discussed it briefly earlier as a camp setting, and it is, but it is kind of a early 1900s British colonial India camp setting. Lots of old stone buildings with thick panes of glass separated by slightly overgrown gardens. In as much as the legacies of empire can be a good thing, this is a nice place.

Meanwhile life goes on. Rachel and Rebecca moved from their roach infested squatter's roost to a much larger and nicer place similar to mine and Paul's. Luggagewise, Paul and Rachel have both finally received theirs and Rebecca is expecting hers tomorrow. There's a 50/50 chance her toiletries will be missing. No signs of traveler's diarrhea or typhoid as of yet. No histrionic longings for home. No trips to Indian jail.

Foreign is Foreign is Foreign

It's been a few days.

Here's what has happened.

I sat at an airport for a while.

I sat some more.

I watched some cricket on TV.

We traveled to Vellore.

That was basically Sunday. Today, Monday, has been devoted not to sitting around idly at airports, but to sitting around idly at the CMC campus. Seeing as none of us are really into planning ahead no real planning ahead took place and, with a few exceptions here and there, we were generally unprepared for our first official day in Vellore. Had to talk to Sally, but in reality we had to talk to Samantha, or maybe Sandra or Susan, and then sign this, sign that, what was that?, repeat that?, and so on and so forth. It took only about 2 hours to, in able to avoid autorickshawing back into town, to make some sketchy photocopies of our drivers licenses so as to provide the school with small, passport size photos for our CMC IDs. Mine definitely looks like it was made in someone's garage. Oh wells, at least I am official now. Huzzah!

Speaking of autorickshawing, though, that's fun. Kind of like being chauffeured around in a go cart. Also crazy cheap. About $1.50 for three of us on a 10 minute ride. For those of you who don't know what an autorickshaw is, fun cultural fact #2, it's essentially a three wheeler with a small bench strapped to the back and a carriage cover placed over it all to make it look a little safer. They seem to essentially have replaced taxis in Vellore, which is fine with me because you cannot reach out and snatch thinks from passing bikers in a taxi. Not that I have done that. Yet.

Our accommodations are rather rustic; I feel like I am at camp. Complete with the separation of sexes lest any unchristian hanky panky take place. Paul and I lucked out I think with the Big Bungalow Annex. Though everything seems to be made out of cement and stone, we have a nice big bedroom, bathroom with separated shower to prevent the entire area from being flooded with water (apparently quite rare here), a kitchen without any appliances, and a screened in patio: my pride and joy. There's no AC but it's not needed now, and the toilet has some flushing issues, but all in all not a bad place to live. Being on the heavily vegetated college campus and with about 2 or 3 guards per a square foot it's actually pretty nice. The girls, however, seem to not have lucked out as much living essentially in a third world apartment block. The especially unlucky ones, Rachel and Rebecca, have/had a roach problem, but some aggressive counterinsurgency tactics by Katheryn and her insecticide fogger may have hopefully remedied that.

Amongst all this, what has really surprised me is not the people, poverty, or place we currently reside at, which I have not discussed in any great detail, but how generic the whole experience has been so far. Although it was a long, long time ago back when I was a sophomore in high school, I feel that my experience then to Honduras was much like this experience now. Though many of the details were different as clearly no one would confuse Honduras for India, the thoughts and feelings that I have so far felt have been essentially the same. Likewise with my experiences in Dubai and some cities in Europe. Looking back I suppose there is not necessarily any good reason why my thoughts and feelings would be any different as, despite the details, I am a first world traveler in a third world country in both instances, but regardless I have so far been unmoved and unstirred. Not that I feel I do not appreciate the reality of life as it is in India, in as much as I can as a first world traveler in a third world country, just that I feel it's the same story with different characters. I am sure I will get a great deal out of this trip, but, as of now, I do not think it will be because this is experience is anything new.

Do You Understand the Words That Are Coming Out of My Mouth?

Being a fairly cosmopolitan town Dubai has two primary languages: Arabic and English. The English, however, is not a form I have ever heard of. Much of the time I have felt wild gesticulations communicated more than any English being spoken to me. Oh wells, I will be in India soon enough. I hear they speak proper Queen's English there. Oh I say!

Anyways, the problem with goal directed wandering is that it is still wandering, and the problem with doing this towards your hotel at night and from a different direction than which you originally started from is that it quickly regresses into just plain old wandering. After walking for more than three hours back from the mosque, interrupted a bit for some dinner at a Lebanese restaurant, I then spent another 30 - 45 minutes circling the neighborhood my hotel was located in but never quite finding it. All I wanted to do was get back to my hotel to have a sip of water and a good sit, but instead I traversed street after street which, though looking familiar enough, were generally not too close to my actual hotel. I finally did find Eureka Hotel and after washing up I promptly fell asleep watching the Orange Bowl. Good times.

The only major highlights for today have been finally finding the Dubai Museum and finally figuring out the water taxi system. The Museum was not much to write about. Just imagine mannequins in Arabic garb with a few captions strewn about. For about a $1 admittance, however, I could not complain. The water taxis on the other hand were even cheaper, and even more enjoyable. If there's anything I enjoy as much as in-flight meals it is boats. Well there are plenty of things I enjoy as much or more than in-flight meals actually, but nevertheless crossing Dubai Creek (about 130 yards across) on what seemed to be almost a glorified motorized canoe with about twenty other people was quite nice. Perhaps it was just because I was off my feet; though, I think I need some arch support.

It probably comes as no surprise that the Westerners are where the money is, but it seems in Dubai that this is also where the Arabs are. Despite being at the Eastern terminus of the Arabian Peninsula the city grew so fast and the indigenous population was initially so small that the Arab population in the city is clearly a minority and is, in general, almost as wealthy as the tourists and businessmen coming to visit. The significant majority of the less affluent population, on the other hand, would appear to be from either SE Asia or the Indian subcontinent. It almost appears to be a colony of the latter at times. Curious.

Well, off to India tonight. Dubai's alright, but I'll be happy to move on and to me up with the other UTHSCSA folk. Just need to get past sitting at the airport for 5 or 6 hours tomorrow morning. Oh bugger!

The Marigolds are Abloom in Dubai

Part of the reason I have essentially never traveled by myself abroad is simply because I have never desired to do so. Truthfully, I do not even desire to do so now. I would prefer the company of friends and loved ones, but, in light of the fact that these same people often do not have the same interests or opportunities that I do, I will have to make do. The reason for this feeling, I believe, is because of how profoundly isolating foreign travel is. A different language, a different culture, a different people, and a different location thousands of miles from home force the idea of separation on you. In small quantities this feeling is not bad, and can even be enjoyable in a way, but I have generally felt it to be a downside when it comes to international travel. Not that it'd prevent me from doing it, but I certainly don't like traveling far far away *because* it makes me feel different than other people.

To drag this thought on a bit longer, I think this sense of "aloneness" is only exacerbated by the fact that foreign travel is usually accompanied by a feeling, at least for myself, of adventurism -- a form of romanticism. It is exciting, new, and adventurous -- even if in a relatively controlled and unadventurous sort of way -- and it generally serves to both increase your basal adrenalin secretions and awaken your senses ever so slightly. How could you not want to share this experience with someone then? Certainly words will never suffice and pictures, though lovely, are only pictures. It is because of this romantic adventuristic spirit that I feel the sense of isolation has been only all the more prominent for me. Not that I feel lonely -- that is certainly not the case -- and not that I am unhappy with my experiences so far -- by and large these first few days are going great -- it is just that I acutely feel the desire to be sharing in my travels with others. I've noticed that marigolds seem to be the flower du jure in Dubai as they are planted in great beautiful numbers all along the city's main thoroughfares, but no matter how much detail I may go into explaining this fact and no matter how great my photos of these long, stretching lanes of flowers may be, the image I create and the image I am experiencing will never match. A shame.

All that ho hum aside, life in Dubai is good. The trip did not start off entirely well as my first flight from San Antonio to Houston was almost subverted by my own silliness as I tried to check in at the Southwestern kiosks for a Continental flight, but after some gentle correction I was on my way. The Emirates flight was packed and the 777 we flew on was huge. I found my way to my economy class seat, dutifuly put up my luggage, and then did not move for 13 hours. For all the restrictions in movement, though, the individual television screens just about made up for it. I watched some Simpsons, some Scrubs, some Transformers and Balls of Fury (both fairly terrible movies), and played a variety of video games so that, despite not really sleeping at all, the flight went by relatively quickly. This was even with the extra hour added on to defrost the pooper which had apparently somehow frozen over (in Houston of all places.) The highlight of the trip, however, was the food. Perhaps because it is generally never served on domestic flights anymore, or perhaps I just get excited about stupid things, but in-flight meals have always made me happy. It is almost kind of like eating around a campfire. The food is not usually anything great, but the experience is.

My night in Dubai was uneventful as it was late, I had already eaten, and so simply checked into my room and went to bed, but the following day, today, has been busy. After giving myself a brief pep talk to get myself out of the hotel room and into the world, I left the hotel and immediately went to the small neighborhood market across the street. Breakfast today would be a box of fig newtons -- or the Arab equivalent at least -- some water and a granola bar. Not terribly satisfying to say the least, but not knowing what was safe to eat of the local fare I was generally terrified of the local restaurants. Not terrified so much as generally completely unwilling to eat there. I will have to ease into that.

My travel strategy, when it comes to places I am unfamiliar with, is generally a goal directed wandering. I pick some places I want to go, figure out a basic route, and head in that direction. As I frequently am unable to figure out road signs very well -- in foreign places or at home -- I am usually content with simply heading in the right direction. As such I wandered completely past my first destination, the Dubai Museum, and instead into one of the local souks which, for today's culture fact #1, are Arabic open air markets specializing in one particular class of goods. Dubai is known primarily for its gold and spice souks, but I stumbled upon its silk and cloth souk. Being as Friday is a weekend day and apparently the weekend day of prominence (kind of like Sunday in the US) most the market was closed. Oh wells, it just so turns out I have all the silk and cloth I needed anyway. Myeh.

After traversing the silk souk for a brief while, I continued along the shoreline of the Dubai Creek passing what was possibly a hundred different empty tourist dhows which I had heard are a fairly popular means of getting across the creek, but as they were all universally empty I decided to defer a leisurely river cruise till a later date. Now particularly hungry and not finding many in the way of appealing looking restaurants I ventured into a nearby Carrefour hoping to find a food court. It turned out not to be an Arabic minimall, though, but an Arabic Walmart complete with a thumping electronics department, cheap hair salons, a handy optometrist, and a one hour photo. After briefly watching some foreign gentleman play some sort of race car game on a Playstation 3 for a minute I got myself a sandwich and moved on.

My last destination, really the only intended one I have actually made it to so far, was the Grand Jumeirah Mosque. I made it there right as the imams were calling for prayer, and not knowing how they would react to a foreign gawker with a camera, I decided to wait across the street till it was all over. I'd like to say it was a remarkable experience watching hundreds of men in unison bow to pray while the speakers blared overhead, but it wasn't. Perhaps because I am familiar enough with what they were doing to be indifferent, or maybe because I had seen it on television so many times before, but for whatever reason I sat down and lost myself in thought while they continued to lose themselves in prayer.

Well in the interests of time, both for the reader and my internet cafe bill, I will bring this to a close. I am not entirely sure how interesting or entertaining this entry is as it has mostly been mildly edited stream of conscious, but hopefully with more time in Vellore I can edit things down a bit. Or at the very least learn to write less.

Now for a two hour walk back to the hotel!

Formal Dress With Sandals

At 2:30 this afternoon I will be in the air on the first stage of a multistaged trip to India. Neat.

Although I am not generally one to show much in the way of emotion aside from an occasional goofy smile, I do feel that I'm getting there. Feeling it. A bit excited. A bit anxious. A lot unsure of what to expect. Even though I will only be by myself for a few days and only in Dubai, I have only been by myself abroad once before for a day in Berlin, and I imagine things are a wee bit different in the UAE. Well, actually, I imagine they're remarkably similar with just a different tongue, dress, and slightly different mannerisms, but the fear of the unknown nevertheless makes me contemplate otherwise. We'll see soon enough I suppose. If this turns out to be my second and only entry feel free to assume I've been abducted and am somewhere in Saudi Arabia or Yemen.

On a more scientific note, we will be conducting a short series of experiments while in India. Specifically, does doxycycline *really* make for good antimalarial chemoprophylaxis? The sample size will only be three, there will be no placebo control, and blinding is impossible, but I think we may be able to get a publication out of this. Our second clinical trial will unfortunately, or perhaps fortunately depending on your view of things, have an n = 1, but I am fairly confident it's a novel research question. We get to see if storing oral vaccines needing to be refrigerated instead briefly at room temperature will affect the quality of host immunity generated. The end point in this study will be whether or not Rachel gets typhoid or not. What fun science is!

And on a final note, amongst all the packing and running about preparing for this trip I was pleased to note that on the CMC site the expected dress is "formal" which consists of, "a short sleeved shirt, a pair of trousers, and sandals/shoes." Truly India is an enlightened nation to have finally cast off the oppressive rule of closed-toe footwear. I think I may like this place.