Leaving Chennai

OK, finally going.....I'm definitely ready for some relaxation, and some time with my favorite person and his family in the Philippines.

I have been back at the Dr. MGR University Dept the past few days and a nice send off lunch today with some biryani, I'm heading to Kuala Lumpur for a 36hr whirlwind Malaysian experience.

In the mean time, check out some of my pics on smugmug. They are all out of order right now cause I had some crazy issues with how my disk formatted and not enough time online to sort it all out....they're not labeled either really....just a few labels for orientation- I'll fix them later and put up the other 200 pics I have!!!

Wedding fun...and not so much fun

I feel very privelaged to have had the experience I had last week at the wedding. So far, I had been to a few wedding receptions. One shows up at a big wedding hall, waits in line to go on stage and take a picture next to the bride and groom who are done up to the nines, and then walks down and gets fed in a very mechanical, rotating feast, where one sits down in front of a clean banana leaf and servers place piles of rice, iddly, chutneys, sweets, etc in front of you, and when you're done, you just go...and someone else sits down infront of a new leaf and eats...

This wedding was different. As I mentioned before, Anandani's Auntie is close friends with the groom, so we spent a lot of time during the week with the family. We met the bride on Monday and went saree shopping with her and her mother and the groom's mother...so we know the bride almost as well as the groom- he's only met her 2 more times than we had prior to the wedding! We also stayed at the groom's parent's house and watched all of the wedding preparations and got to hear about how to plan a wedding with 15,000 invites sent!
When we returned from Ooty, we got a hotel (even though the groom's family said we could stay with them! This is really hospitality...but we didn't want to make them crazier than they were). We got up early to attend a 6:30am ceremony at the groom's house. He was dressed in a dothi (like a wrap skirt that is traditionally worn by men) and barechested so that he could receive a ritual bath from his brother in law and grandmother in the front yard. They poured hot water over him and then circled his head with pongal (a rice mixture) and then blessed him with ash and placed a putu (like bindi- vermillion and ash on the forehead). Then he had "wedlock" toe rings placed on both 2nd toes. These are worn after marriage (instead of finger rings) by all married Hindu women. Somehow now, traditionally men wear them from this ceremony only for 3 days and take them off...after that they have no sign of marriage (hmmm why do women get burned for presumed extramarital affairs and it's pretty much ok when men do it....) Anyway, after the ring was placed, all the older family members followed the mostly now-extinct tradition of giving him money in auspicious denominations (11 rs, 101 rs, 1079 rs etc). For every relation who gave money, no matter how little, the groom's parents gave that person an article of clothing. Then breakfast was served to everyone (there were only 50 people at the house for this, not all that were invited to the wedding).
Then, before the reception that evening, I suddenly came down with a bad case of gastroenteritis, so I spent the rest of the day in the hotel room/bathroom, while everyone else got dressed in new outfits and glamorous fake gold costume jewelry, new bangles, etc for the reception...but then Anandani got sick half way through and came home early to share my misery.

At 4:45am when we had to get up for the actual wedding ceremony on Monday morning (the aupicious time ends at 7:30 so everything had to be done before then), I somehow felt good enough to shower and go the wedding hall....Anandani didn't. She stayed back and watched the porecelin horse go by.
I dressed in a really "grand" platinum and burnt orange colored silk saree with gold embroidery and beading lent to me by Anandhi, put on her costume jewels, a really sparkly bindi, bangles, embroidered slippers, and went to the ceremony. We got there early and went to the groom's quarters, where about 25 people had slept on the floor that night and were busy trying to take bucket baths and tie beautiful silk sarees, and coconut oil their hair.
The ceremony was long and complicated. First the 2 hindu priests sat on the stage- all adorned with flowers and garlands- and prepared the ritual fire and did some blessings with the groom and his brother and law only (bride still away). They put a traditional turban on him and vermillion and ash on the forehead again. After about 40mins the bride came out in about >$1,000 saree that had so much gold work, you could hardly tell that the silk background was orange and copper underneath. She also had fake hair extension braid down past her rear, small gold charms hanging off her hair, a real!! gold belt and gold necklaces, earrings, chains, and arm bands probably totalling over a 1lb. (PS: gold here is sold by weight so about $25/gram and the price of each piece changes with the market. So a nice necklace is all gold so they just put it on the scale and tell you how much it costs...same no matter the design... and this is how she has a dowry....they buy thousands of $$ of gold to put all over her and later if the couple needs money they sell pieces. )
So...the bride came out and with her attendants, circled the fire and the groom 3 times and then sat. The priest did a few blessings with the couple and then the groom tied the thali around her neck. This is a necklace, usually on a cord rope, but with 2 solid gold figurines on the bottom that she NEVER takes off in her life...she showers and sleeps always with it and it is long, but tucked under her saree blouse so the actual religious part (that varies based on caste etc) is not usually shown in public. After the groom tied the thali around her neck and the parents of each helped him, the crowd threw rice.
And, for a strange turn, they all went back to their rooms behind the stage to await the arrival of the big movie stars/politicians who were the guests of honor and partial wedding sponsors. But, as movie stars are, they were late...so after a 15 minute break, the wedding procession came on stage again and walked to the back of the auditorium to greet them. AND THEN ALL HELL BROKE LOOSE. 5,000 people rushed the stage....screaming and crying and trying to see them. These are (old) movie stars but some of the biggest names in Tamil movies- Sarathkumar and Radhikha. Sarathkumar is now the party head for a Tamil political party and the groom is the Coimbatore district secretary for the party, hence their closeness and appearance at the wedding. After about 20 mins of chaos, people kind of settled down and only 1/3 of people were on the stage. Sarathkumar addressed the audience. A family friend dragged myself and Auntie Victoria onto the stage and formally introduced us to Sarathkumar and Radhikha and we got to take a picture with them and the bride and groom.

After this, I still felt like a dead dog, so I left before the gigantic mechanical meal event occurred because I hadn't yet eaten in 2 days....and I unfortunately didn't take any pictures, but I will be getting a CD from the wedding photographer with the famous people! Anyway, I left, slept for a few hours, and by that time Anandani was feeling better, so we managed to travel back home to Namakkal 5 hrs in a car, and here we are, back at work!

Flashback: A Newer, cleaner Special Ward

Saturday. It was the day when we shook stuff up at the hospital before leaving that night- I just didn't get to talk about it yet...so here goes.

Earlier in the week our shipment of new mattresses, rubber sheets, etc arrived from the medical supply company in Salem.

Anandani was more than half the financial partner on this enterprise, but unfortunately had to leave already for Salem (to meet with before mentioned Auntie), so I enlisted people to help with the ward swap. The medical superintendent of the hospital nicely let us "borrow" some "low level workers" to help clean and move....but funny how they showed up and then just left again after taking out the garbage can. So, Antony, Vijima'am, Anandhi, and a few positive people from other organizations as well as sons, husbands, etc of family members helped us with the tremendous task...so we had no janitors/housekeepers as we were promised, but instead people with lots of masters degrees, medical students, other willing hands, etc got down and dirty! And since it was a pretty rought job, I made sure people wore respirators/masks and gloves (stop worrying, Mom).

First we took all of the ambulatory patients from 1 ward half (8) and others who couldn't walk, and layed them on sheets out on the terrace. Then we carried the old mattresses outside to await incineration. Most of these mattresses were soooo broken down that they couldn't even be carried without sagging or pieces coming off. One was soo soaked with water, black mold, and (i don't want to know what kind of bodily fluids) it was 2x as heavy as the others!!! Then, we took bleachwater and soap and scrubbed down the metal frames, scrubbed the fans and the wall tiles, the shelves, the floors....everything. Nothing had been cleaned for months or years- there was food and who knows what else on the walls. Old X rays hidden under the beds....stashed meds.

After everything was clean and dry, we brought in the new mattresses, covered with clean rubber sheets, and brought the patients back in. For patients that were very sick, we cleaned 1 bed, then transferred them, then cleaned their original bed. Then, we did the other ward room- 7 beds on the 2nd side...

After working straight 11am-4:30pm, about 10 people, we finished. We brought in spray bottles and instructed the nurses how to mix bleach and water and spray down beds between patients and requested we do this EVERYTIME after patients got discharged. Patients were soo excited about the new look of the ward- one girl set for discharge even asked to stay another night to sleep on the new bed.
The reason we had to do rubber sheets is because the hospital doesn't provide laundry service for the about 10 cloth sheets the ward actually has (somehow all the other wards have sheets and they get cleaned....subliminal message about the status and stigma of HIV infected people) so they are never used since they can't be cleaned....this was our way to have sustainable cleanliness.

Hopefully I"ll be able to post pics of the ward before and after soon!

Coimbatore and Ooty

After a very tumultuous couple of weeks including politics at the hospital, difficult situations in our staff house, and some sad news from home, I decided to join Anandani and her Auntie from Malaysia on a trip to Coimbatore, Ooty, and returning to Coimbatore for a wedding next weekend. The Auntie went for a week of Ayurvedic treatment there, so she sent us off exploring with her sort-of-nephew as a chaparone ( he's 19, but he is just supposed to make sure no scary men bother us...Indian women aren't really allowed to travel alone, we felt comfortable doing it since personal safety is really not a problem, but anyway...we have a non-English speaking chaparone).

We left from Namakkal to Salem to meet Auntie Victoria last weekend by bus, stayed overnight, then took a rented car at 5am the next morning about 4hrs to Coimbatore. The driver was supposed to take us everywhere this week, but we hated the way he drove and swore at other drivers, so we let him go and decided to just wing it. In Coimbatore we stayed with a family friend of Aunty's where we've been experiencing some famous Indian hospitality. Just to be clear- Auntie Victoria is in no way related to Anandani- their families have been friends for about the last 20 years. And the people we stayed with in Coimbatore met Auntie's family on a train many years ago and have kept in touch and she stays with them whenever she comes to Tamilnadu. AND this family is the family whose son is getting married Sunday. And they insisted we stay with them and have been amazing to us...and oh, only 5,000 people are expected at the wedding. I think they're insane for having total strangers in the house the week before, but I guess they also wanted to show us all around....and also give us very expensive sarees to wear for another wedding and want me to keep mine as a wedding present....yeah....and the mother rubbed oil on my tummy when I got a stomach ache...this is hospitality!

So, now we've escaped to Ooty (which is short for Udhagandamanadamandnan or something like that). This is the most famous British hill station in south India and is a favorite honeymoon spot. We hired a car to take us up the mountain- which is about a 3hr ride up a nearly single lane, switch back, through beautiful eucalyptus trees and finally reaching the tea estates with miles of terraced fields full of tea. We stopped along the way at a tea estate/factory and watched people picking tea, toured though the roasting process and got to sample masal tea, chocolate tea, green tea, etc...and bought some for home. Then we detoured for several hours through small roads impossibly switchbacking between the terraces and went to really picturesque viewpoints, saw some monkeys, visited the hillstation of Coonoor, and finally ended in Ooty late in the afternoon. We're staying at the YWCA bungalows here- after a great experience in Chennai- and they are very nice with beautiful flower garden. However, it is really cold here- which is refreshing, but still a little chilly without heat- maybe close to 30 last night (which is a big change from highs of 110, lows 80)...

Today, we toured around Ooty- took a peddleboat out in the lake, visited the botanical gardens, and went up to the highest peak in the Nilgiri hills (part of the western Ghats that run from Maharastra down through here and Kerala...we're just a few miles from Kerala and Karnataka states here). Sadly, there was not so much view at 8,800 feet because of dense fog, but it was still nice...bought some fresh mango, carrots, custard apples.... actually the climate and flora is kind of like coastal Oregon or Northern Cali except the Eucalpytus trees and tea. They are growing a lot more root veggies and cabbage, sqashes and things because it is cold here, though warmer in the summer. They also have lots of conifers and deer, which is amusing because pinecones are really exotic things to bring home here.... and it is so beautiful. The tea trees are kept pruned to about 2 feet high and are in neat clumps that form rows that are on terraces down impossibly steep terrain. And each section is a different shade depending on how long it's been since it's been plucked. The newest leaves are very light, bright green, and after plucking, those rows become darker and less yellow, so they look sort of like a baseball field that is mowed in different directions. And there are beautiful tall trees planted in perfect intervals between them to provide shade and also regulate the water in the ground, so this provides another level of gracefulness of the fields. And the land just falls away for thousands of feet below with fields stretching as far as one can see.

We wanted to go to Mudamalai Nat'l park tomorrow, except during dry season, I guess only deer are out. Usually there are elephants, tigers, wild boars, and buffalo etc. We've been wondering where they go. Maybe on vacation to Bombay during the off season? We're sad we can't see them.

Maybe the best part of the day today was having a pizza for lunch. I haven't seen any kind of food besides very good, but monotonous south Indian food, with occasional breaks of Tandoori and Indian "chinese fried rice", so the pizza today was amazing. I haven't seen cheese in 7 weeks!

Looking forward to a few days of lots of tea, gardens, yoga, and reading before heading back to what I assume will be an insane wedding, followed by a return to hospital work next week.

I'm a real Indian woman now!

I survived all of yesterday in a saree. I was kind of excited to try one one, but also fearful since I have been hearing that it takes a lot of composure to keep your saree arranged properly all day and white girls don't do so well in sarees. In fact, young girls here traditionally wear a pavida (a saree blouse appearing shirt over a long gathered skirt because they would never be able to manage saree. When they are older, like 9-12, they transition to pavida-davini, or half saree. This is a saree blouse and the same long broomstick skirt but with a long swath of cloth looped around the waist and over the shoulder- like just the top half of the saree over a skirt. They often wear matching skirt and half-saree with contrasting shirt, as if the skirt and cloth were one piece. Nowadays, a lot of girls in Namakkal and a lot of young women in Chennai wear salwar kameeze instead (this is the long shirt with loose pants and a scarf worn across the chest- think Pakistani dress).
So, since I've been here, I've been wearing a few salwar kameeze I had made by a tailor and also some pants and shirts or long skirts....but never saree. Many friends and coworkers had offered to lend me beautiful sarees, but you have to have the very fitted half-shirt to go underneath. This is a huge problem because everyone here it very small boned and the biggest girls are 5'2" and I can't even get their sleeves past my elbow because the bone is just bigger (not even talking muscle or fat parts...my elbow is bigger than the bicept part of their sleeve!!). So, in anticipation of a wedding we're attending, I had a saree blouse made to wear a really phenomenal silk saree of a friend's. And another friend let out a few inches from her blouse so it would fit and I wore her casual saree (synthetic, light summer material, not gold embroidered silk like a fancy one) to work yesterday.
The saree was actually pretty easy to wear...because Anandhi spent 20 minutes tying me into it! And then it was pinned in 3 places (this is a newbie thing to do) so it wouldn't fall off. And the middriff ventilation was nice...except I'm not used to having my upper back and part of my side showing at work...but here this is much more acceptable then having your ankles or cleavage showing...and I got so many compliments that I looked like I'd been wearing one for years.

And yesterday- Venus and Serena Williams played at a tourney in Bangalore and they posed wearing saree also...except they looked not nice at all...they had their stomachs all showing and they weren't tied right...but it was amusing. OH well, I"m glad I look better in saree then the Williams sisters cause I sure as heck won't ever play tennis like them!

The Magic of ART

Amidst all of the sadness of caring for very sick patients that often have problems that beat our capability of diagnosis and often our ability to treat, it is rewarding to see the magic that is Antiretroviral treatment.
The voluntary testing center here has tested about 20,000 people for HIV since they started 2001. Since they are the referral center for several hundred km around, they have registered around 7,000 HIV+ people that they follow with CD4 tests every 6 months. Over 3,000 people are on Antiretroviral treatment. They get seen every month and given a months worth of medications.
I love seeing patients come in that were very sick when they were diagnosed- very wasted, maybe weighing 70 lbs, tuberculosis, bedridden, etc...and then they come back, maybe only a year later. They've gained 10,20, 30 lbs. Their hair is shiny again, they have meat on their cheeks, they look well, and maybe they've even gone back to work. It's really amazing what these drugs can do when people take them every day. People are so thankful once they get on them. But sometimes it's a stuggle convincing them it's worth it to start. People often live very far away and coming here every month is a financial and time burden. But people go to incredible lengths to come here...and slowly, more centers are opening so that people can transfer care to closer to home. It's really amazing that this small town (400,000 people is small here) is considered the best place for HIV treatment anywhere in India, except maybe for 2 big gov't hospitals in Chennai and Delhi!

New Mattresses

Anandani and I have been brainstorming on how to best serve the hospital with the sum of extra money in our grant that is set aside for this type of thing (Thank you kindly to the University of Washington, the Puget Sound Partners for Global Health, and the University of Arizona!). The situation in the Special Ward is a bit dicey, as I mentioned before, in that there are multiple funding parties and responsible parties for that ward, but difficulties in allocating funds for things other than direct patient care for AIDS-related infections due to how the money is provided. We have opted to donate new mattresses since the ones in this ward have the stuffing coming out of them and also at times have small creatures coming out of them. Also, this ward has no sheets, so the patients are lying directly on these mattresses, which is not at all sanitary, since the mattress covers are so destroyed that there is no intact layer to wipe clean between patients or to clean body fluids up when they inevitably land on the bed. Also, there are 16 beds and usually about 16-19 patients, so many patients are sleeping in the hall on the floor. I won't say any more about why this is, but it involves politics.

Today when I went to speak with the hospital's superintendent about this donation, there was for some reason a news crew in the office, and so when I made the announcement (Anandani was at another hospital) they asked me to pose for pictures with the hospital superintendent and pose for pictures in the ward (which was difficult because we had to make sure they didn't take pictures of patients). So apparently, I'm going to be on the local news and in the newspapers tomorrow! I hope that they use the publicity correctly to show the needs of the hospital and specifically HIV/AIDS patients....we'll see about this. I have a little bit of apprehension about how everything will turn out. But the mattresses arrive tomorrow, so this will be great news for the patients.

I'll get you my pretties....

Yesterday, some of the group made a site visit to the Government hospital at Tirchengodu, so we took the chance to visit the temple there, which like the temple at Trichy, is high up on a rock mountain. I don't know if i mentioned this before, but the geography here is insane. It is pan flat, except for these gigantic red-gold sandstone outcroppings just plopped, it seems, at random. If you were ever unsure that India used to be attached to Madagascar (and Mozambique) then you just need to see the landscape. For those of you who have seen pictures of either of these places, you will see the similarities. The rock outcroppings are impossibly steep, sometimes cut at angles that seem very unlikely to have been created by movements of water, techtonic shift, or really anything else geological at all- maybe more lunar. I guess for this reason, the towns are centered around these mini-mountains with either a fort or temple (or both) near the summit. Since very ancient times here, it seems these areas have been both sacred and very practical for defense purposes to the people living here. The temple at Tirchingodu is no exception. Since it was quite hot out (when is it not, really) Antony and Anandhi decided we should take the bus to the top. I really wanted to walk up the several hundred (or maybe 1000 steps to the top). They protested, so I said I'd meet them up there, but then Antony came with so that i wouldn't be alone. They were very worried that I, the white American, would not be able to manage this climb in the 100 degree heat. I, the American who works out daily, was worried that these flat-landers, whose exercise is walking to work, would not be able to make the climb, or would take an hour to do it. So, Antony and I set out by foot, leaving Anandani and Anandhi at the bus stop with plans to meet at the top. Antony set out quickly, becoming out of breath at the first turn of the stairs, and I asked him to slow down because I could tell this might end badly otherwise. We stopped for rest at a small shrine 1/2 way, where a woman in a very beautiful, gold threaded saree was lying down, nearly fainting- and so we gave her husband water for her. They told us that they were newly married and so they were making the pilgramage to the top, as is traditional for newlyweds, except that she was also pregnant (pregnancy, heat, and 9meters of gold fabric wrapped around you= bad idea). As we started again, Antony kept telling me he would have to take the bus down because his legs were hurting and he was very tired...mmmm..somehow I was doing fine.
I made him promise that in the future they wouldn't be so protective of me- whenever we walk anywhere, our friends are constantly worrying that my lazy, pampered American body won't take a 15 min walk, can't carry my own bag, or deal with the heat- their conception is that I drive everywhere and so I must not be used to this. (That, and they somehow think that just cause I have light skin I've never seen sun...I don't think they realize that no matter how much sun I get I don't turn dark... I think to them it's not so much that we were born looking different but that they're dark because they've lived 25 years in sun and my light skin is just an absence of tanning an not a hereditary difference).
Anyway...as we got near the top, there were monkeys and monkeys- sitting on the steps, hanging from the trees...they came towards us and Antony took my bag and held it tight so that they wouldn't get at it. I knew they were pests, but I didn't realize that we should be scared...but they didn't really approach us. I yelled at one and it hissed back...which frightened me, but they left us alone.
At the top, we got cold drinks and waited for the bus to bring the other girls up (yes, we got up in 35 mins and they took 1hr by bus). People leaving the temple gave us packets of rice wrapped in banana leaf that they had brought to be blessed and then distributed to the devotees coming in (this confused me- I am only used people giving food to the poor, but somehow we ended up w/ 5 packets of dinners). The 4 of use then entered the temple, went to the various shrines, and observed the ceremony of the newlywed couple- they placed flower garlands over eachothers heads and then received a prayer from the priest. Then we headed down by the stairs after stopping to wash our feet at the tap.
There was a monkey sitting about 4 feet above me at the tap, looking the other way. I splashed him with some water to see if I could get him to go away...but this unfortunately caused him to turn quickly and jump- AT ME. or well, at the water faucet where I had been until I ran. Believe me- these are not cute monkeys that you feed- these are scarey thieves that will bite you if you don't give them your bags (even if you don't have food in them...and oh yeah, we had 5 bags of rice). But, this monkey just turned the tap back on and proceded to drink the water from his place above on the wall...I was safe...from this one. We dediced to quickly descend. We were a little sad actually that the monkeys had all disappeared from where we had seen them on the ascent. But then they appeared a bit lower down... they started all coming towards us- maybe 15 of them...coming from all sides. So Antony took off his show and started growling at them. This made them very mad and the nearest one growled back. I started praying..."Oh please...don't let me get a monkey bite and have to fly to Dehli to get the rabies immunoglobulin and then 5 rabies vaccines....oh please". The couple ahead of us told us just to hold our bags close and pick up sticks and walk quietly....that they would only be threatened if we yelled at them. So we picked up sticks and quietly went down.... the monkeys just sat and looked at us. We threw some rice into the bushes. I threw In old shoe I found into the bushes...they just sat and looked at us. But none of them came closer....Some of the moms were tumbling with the babies and they looked so cute, but we just kept going down quickly....we didn't want to get fooled by monkey cuteness. Thankfully, we descended to the level below which the monkeys don't go without any problems....I think that it would have been ok had I not splashed the monkey and had Antony not yelled at them....maybe they wouldn't have been so defensive. The whole time I was thinking about The Wizard of OZ and the scene where they are in the Wicked Witch's castle with the monkeys all around them. "I'll get you my pretties....."
The rest of the trip home was fine. The priest at the bottom shrine offered a puja for my family since I'm a traveller....and then he charged us 20 rupess for his efforts....very nice of him. I wonder if some of the priests here take off their little loincloths and put on a nice silk suit and drive away at the end of the day...

Kungum Tamil Teriuum

So, things in hospital land are getting a little better as far as seeing patients is concerned. I'm starting to understand the way the system works and also what are the typical conditions seen here and how they usually treat them. I think it's much easier than coming from here and landing in the US because there is a much smaller range of diagnoses and treatments that can be given. However, I'm trying to understand better whether certain things I know from home are not seen here, or whether they just can't diagnose or treat them because they don't have the facilities for tests etc, so they "don't have them" because they cannot prove them in any given patient. That said, the Tamilnadu AIDS control group, TANSACS, has provided free medications both for antiretrovirals and for any opportunistic infection people might have. So while we have a limited variety of drugs to proscribe, we have plenty of free medication for people. As long as it's related to infections. For example, if a patient showed up with blood pressure or diabetes, we'd have nothing to give them (but the rest of the GH provides free/cheap care so they'd go to the general medicine clinic for that i guess).
I'm starting to see patients either by myself or with the help of a translator first, before comparing notes with the medical officer to make sure i'm not missing anything and am thinking of the right treatments. Kungum Tamil Teriuum= "I know a little Tamil". I can ask a patient their name, age, if they have any problems. I can ask about fever, cough, sputum, blood, all the fun things your guts can produce, etc....and I can ask for how long they've had the symptoms, if they're eating, drinking, sleeping well. Sometimes this works alright. Sometimes I ask a patient "how many days have you had a fever?" and they talk very rapidly for 4 minutes and point to every spot on their body. At which point I say "Mother, I know a little, little Tamil" and ask the question again. Some patients understand that I don't speak much Tamil and speak slowly. Sometimes I ask them a question in Tamil and the patient leans over the table towards the doctor and tells them "Sir, I don't understand English. " The Dr. then tells them I am speaking Tamil to them and that I asked the question correctly and they should refer their answer to me.

Slowly, it's coming together...between the language part and the clinical part. Feeling more confident, but also still feeling like I couldn't fix a lot of the problems that patients have even if I had all the Tamil and time in the world....

Trichy and Tanjuvor

We decided to see the famous South Indian temples in these sites yesterday, so we headed out early (with Indian Promptness, finally leaving the house around 9am). We boarded a rickety buss for the 2.5hr trip to Trichy (short for Tiruchipalli). After arriving, we had a quick veg lunch of dosai and parotta, we circled the base of the rock fort (there's one in our city) to the temple entrance. Were greeted here by the temple elephant, to whom I gave 5 rupees and received a blessing by way of a tap on the top of head with his trunk. He was painted with pink and white chalk all over his face, ears and trunk, and while beautiful, looked a little sad chained inside his grand, pillared post at the temple. From there we ascended about 500 stairs to the temple at the top of the rock formation, and since it was noon, the sun was very hot. But, we did puja (blessings/prayers) at the temple at the top, where the priest hands out roses and marks your forehead with ash. We walked around the temple and took some phenomenal pics looking down over the city amd the nearby river. We had some icecream and jumped back on the bus for 1.5 more hours to Tanjuvor, arriving there by 4pm.
The bus was very crowded and it there was no sitting room (we got seats) so a young couple just handed their 5mo old, 2 and 4 year olds over to us to let sleep in our laps so they didn't have to carry them. I've seen this a lot here- people are very trusting- it's easier to just hold someone's baby than give up your hard-won seat! and everyone is so trusting.

In Tanjuvor, we visited the royal palace of Raja Serjofi, which must have been quite grand when it was built in the 1700s, but is a huge dump now. Literally, the courtyard is full of trash! Which is weird because they charge something like 100 rpes for foreigners to enter, so one would think they wouldn't burn trash inside. Also, you pay extra to enter the museum, in which there are many old plates, photos, furniture, etc, but no one dusts them, so you can hardly see some of it- nothing is preserved- the old fabrics are just rotting in the heat! It was really disappointing because it was beautiful and supposed to be a big tourist attraction, but it was hard to even find the signs for the entrance from the main road.
The Big Temple at Tanjuvor was not disappointing however. It is one of a few temples in India on the Wold Heritage registry- and it is phenomenal. It is famous for its size and also that it doesn't cast a shadow. No one knows exactly how this was done, but it is built with each layer in the pyramid slightly off-set so that nothing lines up...but it is barely visible that it is crooked. It also contains the world's largest lingham in the shrine. For those not acquainted, this is a phalace- about 4meters tall and 7m around...representing the male force of Shiva. It was made of stone and all covered in gold (i won't make any jokes here, but it's hard not to). We stayed there until sunset and watched the towers of sandstone turn colors.
After a dinner of chicken biryani, we started our journy home, arriving back in Namakkal at 2am...so it was hard to get up for work today!

Dinner Time!

If anyone is familiar with South Indian food, it is very different from North Indian food. And for the most part, American Indian restaurants are all north indian. I haven't seen many of these dishes on the menu ever! First off- restaurants and dining preferences are listed as "Veg" or "non-Veg". This is very refreshing compared to the US where the weird thing is to not eat meat. In fact, most restaurants are Veg because many castes of Hindus only eat veg and no Hindus eat beef and the 12% of the country that is muslim eats no pork...so Veg is the norm.
We eat veg at the staff house here, except for rare chicken and fish.
Dinner is served in metal serving dishes and passed around. We sit crosslegged on the floor, take food from the pots, and eat with our right hands.

Dinner always consists of a starch- iddly (a rice flour based steamed mashed potatoes consistency type thing) , Dosa (a rice and lentil flour thin fried pancake) , Chapati (a wheat flour tortilla type thing), or else rice- this is the most frequent.
On this, we eat usually a vegetable curry, some sambar (lentil and tomato based sauce), and a variety of pickles (relishes of beets, lemons, ginger etc- usually very sour or spicy).
Daily protein is usually egg for breakfast or boiled egg with dinner and often curd (like yoghurt homemade- with little chunks like cottage cheese) and then lentils.

what I"m not used to from home is taking rice with very wet sauce, and just sticking my hand right in it, mushing it all for a few minutes to mix well, and then shoveling bits into my mouth...it feels an aweful lot like playing with your food. It would be weird here though to pick up a clump of rice and dip in sauce- more appropriate and tastier (and easier to keep the rice together) to mush the sauce all in it first with the fingers!

the GH

I haven't yet really mentioned anything about the work that I am doing at the Government Hospital in Namakkal. I think this is because #1 I needed to first figure out what I was doing #2 I needed to just digest everything because I didn't have the system quite sorted to explain anything appropriately #3 I wanted to make sure that I was assessing the situation in a proper manner and not making judgments about the hospital or the system that weren't true.

Since my main goal here was to see HIV and infectious diseases in general, I have been spending time with the 3 medical officers for the ART center (Anti-Retroviral Treatment). It is sort of like a normal day at home, but really not at all in some ways. We meet in the morning to round on inpatients before seeing outpatients for most of the rest of the day, minus a big break for lunch. There are 2 HIV inpatient wards here.
The ART ward is simply an observation area where people are admitted for a 5 day period (monday-friday) when they are clinically ready or have low enough CD4 counts to start ART treatment. They are all sick in some way but stable in that they don't have any severe illnesses
going on. They just stay and learn from nurses and counselors how to take the medication, talk to other patients about their situation, and are monitored daily for drug reactions and also given support if the meds give them nausea, vomiting, crazy dreams etc which is very common with them when they are started. All patients here follow WHO guidelines of starting 3 drugs. They have a total of 5 drugs here, so they can do some switching if someone has a reaction, is pregnant, etc, but they don't have much options to treat resistance, since the drugs are similar classes.
The other ward is the "Special Ward," where very sick HIV patients come whether or not they have been previously treated. This is where they often stay for diagnosis of illnesses, and most patients have either tuberculosis (lungs or in any part of the body) or else meningitis, fevers, or are too sick to be able to eat for any reason.
It seems that the mortality of this ward is nearly 50% by their estimates- though the official count is much lower because many patients go home to die when they can't do anything else to help them here. Many patients here also get better- here they are often diagnosed with rip-roaring TB and are started on treatment, discharged when they can eat and drink, and then are readmitted to the ART ward to start antiretroviral therapy once they have been on TB treatment for a few weeks. Many of the patients in the Special Ward are there for Immune Reconsitution Syndrome, which is what happens when a very sick person with little immune system suddenly gets treatment for HIV and TB (or any other severe illness) at the same time and suddenly their body produces a tremendous attack against the bug since they were actually too sick to fight it before they got HIV treatment.

I'll write more about the ward another day- it's pretty spooky- it looks like a concentration camp since many patients weight 60-80lbs because they have been sick and undiagnosed for so long.

The rest of the day- outpatient ART. This means 3 doctors sitting in a small office with a huge line of patients pressed outside, waiting to see the doctor. They come with new HIV diagnoses (tested across the hall or at smaller centers around the district) and with CD4 results (the test showing the # of cells that are both part of the immune system to fight these other diseases and are ironically also attacked by the HIV itself, hence why HIV is such an aweful and sneaky disease-lower counts = more progressed HIV/AIDS and also more susceptability to things like TB and diarrhea). Doctors give quick 1st evaluations and decide whether patients should start the antiretroviral treatment.
Patients on ART also come every month for followup checks. Patients HIV+ but still well come every 6 mos to have their cell counts tested and for an exam. Patients also come whenever they have any new symptoms.

Ok. that's the short (long) version. I'll keep evolving details as they happen. Hoping to go to the sex-worker treatment clinic this week and maybe go to some field visits....

And yes, mom, I am wearing my respirator the entire time i'm in the Special Ward since it's all in one room, and whenever I see any patient with fevers, and/or a cough....

Sunday Temple Visits

After a frustrating early afternoon of trying to load pictures onto smugmug, I resigned myself to waiting until we get home to load pics- after an hour at the internet cafe, they still hadn't loaded!

During the early evening Antoni, Anandi, Sarasvati, Danalakshmi, Anandani, and I went to visit the 3 main Hindu temples in Namakkal. The first is up about 100 steps at the foot of the rock formation that the fort sits on (we still haven't climbed up to visit). It is a cave temple burrowed into rock and is from about 500 year ago at least. The god Parimon and his wife are there- he is lying down on a bed with a 5 headed snake. We gave offerings and accepted some holy basil and perfumed water. Water flows from underground beneath the giant rock formation into a few pools there. We brought puffed rice to feed the fish in the pond, who jumped into the air to retrieve it from the surface.

We walked around the base of the rock mountain to the 2nd temple, dating about 1500 years back. There was a ceremony there for a couple- it is done here when the man turns 60, if he is stilled married to his wife, the couple comes to the temple to get blessed and the priests sing, drum etc. Very festive, with bright floral garlands.

The temples are simple semi-open stone structures, but with very ornate carvings. The inner shrine stays locked unless the priest is there, and one enters for a quick prayer to whichever god is inside and gives offerings. The inside is usually filled with many candles and the statue is dressed in expensive fabrics and sometimes gold headpieces.

The last temple was a modern temple with the monkey god who assisted Brahman in creating the world. It has an open roof so that the god (statue) can keep growing taller all the time. We bought camphor here and lit it as an offering in front of the small shrine of Ganesh at the front.

One of the girls bought a bag of sweets and fruits, which the priest blessed and handed back. We snacked on these in the front of the temple, because it is a tradition to spend time there before and after doing puja (praying) so that you don't seem like you're in a rush.

After prayers we went to a small hotel (what they call restaurants) for a meal of dosai.

Slumber party

It has been really nice to move into the deptartment staff house. I had really wanted to live there, but the professors in Chennai were really hesitant because it's not like a hotel where there are lots of amenities- they were concerned about us sleeping on the floor, not having clean water etc, but these worries haven't proved to be real problems. Anandani (U of Arizona MPH student) and I have been there since tuesday night. Besides us, there is Viji Ma'am, a middle aged woman who is a counselor for the HIV program here and in Rasipurum (35km away)- she is not married so she stays in this house since people don't live alone here ever really. Anandi is our age, the lab technician who runs the CD4 counts here and is also in a MS in bioinformatics currently- we share a room with her. Tiliga is 28, a nutritionist with the program. Sarasvati is a counselor in Rasipurum and her husband lives in Chennai, so she lives with us when she works in this district. Janila, also counselor and lab technician, is 24. There is also Antoni- a fabulous counselor here. Since he's male, he can't live in the house, but he lives close by and eats all of his meals at the house (he is dating one of the girls/engaged to her pending her parents' approval). 3 of us sleep in each room, so we bought our own cushion-mat things and sheets that we just put on the floor and I bought a mosquito net since it's not quite mosquito free. The house all cooks together, so that's really nice too- i feel like we're always having tea or coffee whenever we're there- pretty much 2-4 times a day- filled with lots of sugar and milk, but we only drink about 4oz at a time. Anandani and are are taking their drinking water supply (delivered by truck from the mountains, but not filtered) and just filtering it into a big storage jug for ourselves so we don't get sick.....this is easy- in fact easier than the hotel cause we'd have to buy water there for 75 cents (22rupees) a liter and waste so much plastic.

Hopefully we'll go on a bit of an adventure tomorrow (we work 1/2 days on saturdays here).....

Namakkal

Overnight train to Namakkal on Monday night. 2 Tier AC sleeper (myself, Dr. Parem from Chennai and Anandani, the other US med/MPH student)...arrived in Salem at 5am and were picked up by private car form the hotel for a 1hr ride through the most horrific road. 2 lane highway with so many trucks that I think we spent more time in oncoming traffic passing them then in our (left) lane. But this is really normal here, so I'm not supposed to have a heart attack right? One just makes profuse honking and light flashing so that the oncoming cars know that you are coming....somehow everyone cooperates.

We stayed at hotel Nala that night. Met the staff of the Government Hospital for the District of Namakkal. Dr. Parem introduced us around before leaving the next morning. Anandani and I were very welcomed by the staff of the perinatal HIV project (run by the MGR university in Chennai and the U of Washington). There are 6 women who work there who all live in a house together and they invited us for dinner and to try out staying there to see if it would be acceptable before leaving the hotel. It is a really nice house, very safe neighoborhood, and we're excited to cook and spend time with them. I guess the previous students all spent time there but slept at the hotel (and guys had to stay at hotels since it's a women's only house). It is not as fun to have to take autorickshaw back to the hotel every night from that place...and very expensive.
We decided this morning to move in and will hopefully learn how to make good dosai, iddly, and chapati....and the company is nice, though privacy will be at a premium with 7 people in 2 bedrooms!

For the next few weeks I'll be spending time seeing outpatient HIV patients as well as taking care of sick patients or newly diagnosed patients in the "Special Care" ward for AIDS pts.

Mahaballapurum

Saturday was a great little trip. Whitney (an undergrad studying at U of Madras from the University of Rochester, staying at my hostel) and I took a bus 2 hrs south on the coast to the town of Mahaballapurum, where there are some phenomenal Pallavan temples from the 7th century. We saw the 5 rathas- 5 monuments carved out of natural rock formations dedicated to 5 hindu gods. Next, we went to see several temples also from the 7th-10th century carved into the rocks of the hillside. Krishna's butterball is a gigantic stone, nearly round, and 100 tons, balancing on an incline...very strange (and thought to be natural). The Shore Temple is the crown- a very unique temple right on the beach, that was miraculously protected by a dike even before the tsunami. It is very cool, because unlike most other Dravidian temples, there are no pictues of kings and gods, instead it's all pictures of normal life- milkmaids, old men, cows, elephants, etc. The 2004 Tsunami hit this area very hard and there are habitat for humanity settlements and many other temporary villages set up to house the people that got their homes destroyed. The beach was beautiful, Indian Ocean (Bay of Bengal) very warm, but no swimming for us, as there is a rip tide, and also, beaches in this part of the country are attended in full clothing. If one went in a swim suit, I'm not sure what the locals would do!

When I have more time, I will upload some of the pics I took onto smugmug. Not much time to write now.

Catching an overnight (3tier AC!) train to Namakkal tonight to start work there tomorrow. Thankfully, there is another student from the US who will be staying with me- she is from the University of Arizona and contacted my professor about working here- but somehow she knew I would be coming, but no one told me she would come. She is very nice and I think we'll get along great, so it will be good to have a co-conspirator. Especially because she speaks some Tamil since her family is Malaysian-Tamil, originally from this area. More from Namakkal....

Might as well be a Mason-Dixon Line

I think that when we (or at least me and most Americans I know) think of a few things when we think of "the divide" in India. We think of Jammu and Kashmir and the border with Pakistan, or we think of the Hindu/Muslim discussion, or maybe the language divide. What I never realized was the depth of the divide between North and South India. It's not a violent type of stuggle like some of the others are, just a huge culture difference. Most of the differences stem from the fact that the people in the south are Dravidian descent, so their ancestors have been on the sub-continent much longer than the ancestors of the northern Indians. Their languages also are Dravidian and are apparently not much changed from 3000 years ago, as opposed to languages like Hindi and Urdu that come from Sanskrit. To start with the language problem- since colonial times, the working language of the country has been English. However, since independence, and since the backlash against a lot of British customs, there has been a move to develop an Indian national language. The obvious choice (to most people) is Hindi. And this is ok with most people- in the North, many people speak their regional language or dialect and then also Hindi for business etc (and English if they're educated). But, in the south, where the Dravidian languages are much older, and not at all related, they really don't like the idea of speaking Hindi. Obviously, in Tamil Nadu, the language is Tamil- all signs are in Tamil and English. and in Kerala it's Malialam (also related). So, the business language is English, and Tamils and southern Indians would prefer that English be the national language to avoid Hindi.



Then there's Bollywood vs Kollywood vs Tollywood. We all know Bollywood and how fair skinned, tall, and beautiful the actors are. Well Kollywood is the Chennai based Tamil language film industry that is quite booming as well over here, but not as big overseas. and Tollywood is in Telegu. Apparently, the southern Indian quotient doesn't like to watch movies about beautiful people. They like movies about chubby men with mustaches and well proportioned or even a little rounded women. There is always a good guy and a villan trying to get in his way. Apparently there is a big controversy about winning Kollywood movies getting remade in Bollywood or Bollywood actors coming down to make movies down here and then getting dubbed over in Tamil.

It seems like people in the south just are a little more laid back and they like to talk about how the people in the north wear so much western (read: skimpy) clothing and do things faster. Although this probably refers only to the bigger cities. So far here in this city listed at 8 million with really more like 12 million, I have not yet seen an Indian woman wearing anything above mid-shin or anything less traditional than a corti (longish traditional shirt) over a pair of jeans, though there are plenty of ads for things that are looking like swim suits. And these ads all feature north Indians.

One of my Australian friends here apparently was in Kolkatta and told one of her local friends there that she was going to do research down south. To this, the friend responded "You mean, with those Dravidians?"

Maybe there would be more tension, except that apparently, the official sentiment of Tamil is ambivilence- as in ambivilence to the issue of Tamil independence in Sri Lanka or to some of the other border/culture/ethnic skirmishes. Overall, however, one of the national mottos is Unity and Diversity, so people seem to just go about their business, as much as they make fun of people from other parts of the country.

So, you ask, what am I actually doing?

Since monday, I have been going to the Dr. MGR Medical University here in Chennai Each day. This is a big Health Sciences research university, but with no affiliated hospital. I am sponsored by my University and our professional connections here with the Experimental Medicine Dept. I am spending the week here, getting to know what is going on prior to leaving for Namakkal (a small district hospital in the center of Tamil-Nadu) on Monday night. MGR is the reference laboratory for many of the PCR and serologic tests in the state as well as the neighboring state of Andhra Pradesh and part of Karnataka (this is an area of about 100+million people). So I am just spending this week in the lab, watching the dark field analysis and serologic testing for leptospirosis ( a nasty bug that causes a fever disease from animal urine-contaminated water) as well as watching the advance testing for HIV done here. They do all of the early confirmatory and reference tests for babies born to HIV+ mothers, for example since this requires in depth and expensive procedures and not just a rapid test to be done on-site. These are all techniques I did a long time ago in college, but now I'm revisiting them and remembering the indications for each one, so that is good.

The people in the lab are technicians, PhD students, post-docs, and a few MDs and they are all very nice and very helpful (and are all still trying to feed me).

I take the train here from my lodging at the YWCA. It is a regular train, but operates like a subway. I walk 10 min to the station, buy a return ticket for 10 rp (about 30cents) and then wait for the train. I try to line up with the women and go in the women's only compartment. At first it upset me that it was segregated, but when I realized that it is wall to wall people and the elderly people just shove the younger people to make way, I found it reassuring that the only people patting my butt were other women. And I think it's probably safer as well. I ride the train past Chetpet, Nungenbakkem, Kondabakken, Mambalam, and Saidapet (I love these names) and get off at Guindy, walk another 5 minutes and I'm there....relatively stress-free and cheap compared to the autorickshaws who like to get you there faster by veering around the slow busses into oncoming traffic!

Lunch: Have you tried Indian food?

Somehow most people are amazed and flabbergasted that I've had Indian food before, let alone cooked it in my home. They ask "have you tried this?" "Is rice ok" "You might not like, it's spicey." My conclusion is that the entire department staff at Dr. MGR University is like a Jewish mother. They worry that the food won't agree with me, that the spices will upset my stomach. Each person asks me every day what I had for breakfast and if the food at the YWCA (where I am staying) is alright. ( I get free breakfast, which is Indian + eggs and toast usually).

When it comes time for lunch, I order either rice with sambar (spicey sauce based on lentils) or chapati with another sauce from the canteen for 20rupees (50 cents). I pay a woman who brings it up from the canteen and we all sit and eat together: professors, students, lab techs, and myself. Everyone brings a little metal canister full of rice from home with a little metal dish or bottle full of some sort of vegetable curry or sambal, or other sauce. Then everyone passes the sauces around, takes some from everyone elses and puts it on their rice. The custom is to eat with your right hand (left hand is for dirty stuff). You put your hand right in the saucy rice and scoop a bit and put it in your mouth. This is hard, since it's not like sticky rice....and since I'm left handed, using my right to do this is tougher, but I'm getting the hang of it. And, since I am new here, everyone asks "Rachel, have you tried this bitter melon? Have you tried this vegetable? This sauce? Yogurt curd?" Please take some! And someone even broght me idly, which is a rice batter that is steamed into a spoon shaped cake, used for dipping in sauce. So I bought a little rice and then people gave me part of 6 other meals! And I feel all eyes are on me to see if I like it. Which is ok, except me eating rice with my right hand isn't quite smooth yet, so I get nervous that they're watching me smear sauce and drop rice everywhere....
I brought a chocolate bar for everyone to share....that was a hit!

I'll write more about food at some point I'm sure, since people (mostly my parents) have lots of questions...

Bob your Head

When I first arrived, I thought people were giving me unenthusiastic answers to everything I asked- like if it was safe to take the train or walk in a certain area or if the temple in the south was nice to visit. Every time I asked a question, people gave me this very subtle head tilt back and forth from side to side. Sort of the bobble head thing, not really a forceful shake. It made me wonder if I was being too forceful in my questioning or asking to be to brave in my exploring of the city.

This side to side head bob replaces nodding yes here. If someone agrees or answers yes, they simple bobble. And it also is a sign of approval, thanks, sort of a polite parting gesture as well. Sort of like how when we walk out the door we say something like "Ok then" "Sounds good" or "take care". As a matter of fact, people seem to bobble pretty much any time, while talking about things that are good or exciting. Or the people who are listening to someone else will bobble showing that they are hearing, understanding, agreeing.

I'm trying to learn to do subtle bobbing as well, since I tried nodding and it just seems to confuse people. It is very common to bow one's head when taking leave of someone, but this does not replace the nod. Nod is replaced by bobble. Subtle bobbling is hard. I tried and it first came out as a shake, it makes you a little dizzy. It's getting better- and hopefully I'm making myself understood. So if I come home bobbling, you'll know why!

First Looks around Chennai

It was a long trek to finally get here. 14hrs to taiwan, 7.5hrs to dehli, then wait 4 hrs in dehli, then 3.5hrs to chennai.

Indira Ghandi Int'l Airport was incredibly unorganized. I waited for a shuttle from the international airport to the domestic airport with a swedish couple who had been waiting for 6hrs for the shuttle to the other airport. the ride took 20mins and then the other airport was chaos- I was surprised that they can move that number of people around with the confusion I can't even describe.

My first impression of Chennai was that it smelled exactly like Mozambique, which surprised me. It must be humid people and maybe decaying plants....but once I was out of the street, the buildings smelled much sweeter- everyone here burns incense, even in the shopping center. The main difference from other crowded cities in developing countries I have been in is that the streets and structures look the same except the billboards are for platinum, life insurance, and blackberries- it is obvious that the poor here are just as poor in Mozambique but there is a wealthy part of the society that was missing from there. Also- driving around is much more chaotic and frightening!
As i got in late, I just went to bed at the YWCA guesthouse- very nice and clean, friendly people that work there.

Today I had a nice breakfast at the guesthouse, got up, and went shopping- mostly to get my bearings and buy a cell phone. I think I will wander around today, try to adjust to the new time zone, and then prepare for a short field trip tomorrow to the stone temples at Mamallapuram.

Getting on the plane

Hi All-

Tonight I leave for India. I'm flying through Taipei and Delhi before arriving in Chennai (the new/old name for Madras as you might know it) on Friday night. I'm planning on spending about 5 days in Chennai, meeting physicians and staff from MGR Medical University before moving on to Namakkal, a small town in the NE corner of the state of Tamil-Nadu, where I'll spend 8 weeks.

I'll try to report to this blog on a relatively frequent basis, so keep checking for updates and pictures! I appreciate everyone's support and interest in my trip!