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....