Public Health Through the windows of rickshaws, busses, and cars

June 28, 2007

There's nothing like riding in an auto rickshaw in India, especially when there are 5 or more of you in a vehicle designed for three small people, but if you're lucky enough to have a window seat instead of sitting on someone's lap or in case of Paul, our only male CFHI student among 7 women (this is a different story all together) you seat on the side bar and bump into motorcycles in traffic and nearly topple one of them over, who then pursued us and hurled accusations at our rickshaw driver for about 10 minutes our first week in Delhi.

Nonetheless, if you are lucky to have a window seat, you can see a great deal of life and subsequently public health happening right in front of you, including slums, extreme poverty, landfills in the middle of neighborhoods, and random people either urinating or defecating on the side of the highway.

Another great way to see public health and rural life in general was traveling long distances to Jaipur and Agra in an air conditioned bus or private vehicle. Leaving behind the noise and chaos of Delhi and traveling across deserts, agricultural lands and villages really afforded us an opportunity to observe what most tourists don't see, rural India.
Most of the landscape is dotted with little huts and small villages, lots of colorfully decorated trucks that have way too much cargo packed on and look like they're going to tip over any minute; water pumps with women gathered around it trying to get water, which they will carry for miles on their heads, as well as little children washing themselves by the water pumps. And of course cows and camels in Jaipur. Trying to get a photo of all this public health and life as it happens from the window of a moving bus is another matter altogether, even if you have movement stabilizer on your camera. I found myself uttering expletives after each photo as the results would come out blurry or with a truck in the way.
Nonetheless, here are some attempts:


Huts in villages



She's either carrying water or rocks for construction

While in Delhi there is a lot of construction going on and development is the buzz word, the countryside is far from such lofty goals. Reliance, the telecommunications giant of India has plans to invest $5 billion in rural India to modernize it and with private and public partnerships this is more likely to happen than some reports of government desires to create more jobs in the countryside to encourage millions of people from migrating to the cities to seek better employment opportunities. The private industry moves much more quickly than the corrupt government in India.

We all know India is embracing the IT sector and as Farah mentioned in her blog a couple of days ago I believe, higher education is highly emphasized while primary education is highly neglected, this is especially true in rural India of course.

We're all aware of the importance of educating women to help bring real change and improvement of quality of life. Well in rural India women's literacy rate is 30.4% compared to 63.9% of urban women (fao.org). The village we visited in Sawai Madhopur in Rajasthan had an informal school for children with the most educated woman in the village held classes for the village children. Brilliant idea. So is the public school created by the Prakratik Society named Faheh Public School, which offers free education to the girls from the village if the parents decide to participate in family planning (no more than 2 children) or offer education in their state of the art school at a very reduced rate.
In its attempts to become a global power and on its path to development, India with its highly male dominated culture and society must and will eventually come around to the fact that the value and education of its women is a fundamental prerequisite to development. To that end the country has a lot of work to do in terms of ending traditional practices that are harmful to women, including dowry deaths and preference of male child and the subsequent social harm women suffer when they birth to girls.


Fateh Public School in Sawai Madhopur



This image was posted on the window of our Medical Director Dr. Raina's office.

I'm home! Stay tuned for reflections on India...

Monday June 25, 2007
I arrived home about 48 hours ago and very happy to be back, I've missed Todd, Mina and the rest of my family terribly. I've rested well although I am still jet-lagged and loopy and don't feel very creative or productive at the moment. I haven't really had an opportunity to analyze or fully digest everything I've seen in India and how I feel about the whole thing, which I imagine will occur naturally as I conduct my analysis for my final reports and paper. All in all the trip to India was a life changing experience, it has raised my consciousness and challenged me physically, mentally, emotionally, and intellectually. I've learned to be more patient, although I still have a lot more work to do in that regard to work in a developing country. I've learned to be more professional, more mature and accepting of situations and what "is."
I'm looking forward to my reflections on the entire experience in the next few weeks and I invite you to keep reading this blog as I intend to continue to update it. While in India when writing this blog most of the time I was really tired and fog headed after a 12-15 hour day, hopefully there will be more of my voice and opinions on here, and less of what we did today and what we plan to do tomorrow and certainly less spelling errors :)

In the meantime, some more pictures from India.

The gang at Taj Mahal in Agra



Monkey's point of view from Agra Fort where Shah Jahan, the builder of the Taj was imprisoned by his son and could see the Taj from a small cell. Tragically romantic!




Slums on the side of the highway in Delhi

Naturopathy and Yoga

We've been back in Delhi for a couple of days now, it took us about 10
hours to get to our new apartments from Jaipur, there was a screw up in
both picking us up at the bus station as well as our accommodations.
Now all eight of us are cramped into a three bedroom apartment with two
semi-functioning bathrooms, but I'm not complaining because it's not
the hostel atBapu and there are no furry creatures running around in our room.
Monday we started our rotations at Bapu Nature Cure Hospital and Yogashram's
Outpatient department (www.bnchy.org/). They split us up into groups of
two and we first visited the physiotherapist who was mostly treatingperiarthritis
clients with manual modalities and most of her patients were elderly.
It got me thinking about the differences and similarities between the
degenerative diseases in the West and the developing world. Most of our
degenerative disease andCVD comes from our inactivity and indulgence in
unhealthy foods, whereas here it seems most of the arthritis etc.
results in hard manual labor and just a hard life all around. Women
work so hard here, always bent down sweeping for carrying jugs of water
on their heads. Of course we also have preventive care in the West,
here people can only address their problems when it's too late, if they
can afford to do that at all.
Our next rotation was with the acupressurist and while I've been practicing what's called tennis ball accupressure (I'll wait for the laughter to die down now, but it is a legitimate way to break up the knots, tightness and chronic trigger points that form in the muscle, a skill I learned in physical therapy and one which has
helped me heal myneuromuscular condition (are you laughing still?). Nonetheless, I've never really been to an actual accupressurist or what they would call a reflexologist. She explained to us that all the nerve endings in the foot and the
palm correspond to different body parts (Farah & I are still
baffled by the science behind it) but Ioff erred her my foot and when
she pressed the inside curve, which corresponds with the lumbar spine
(the bane of my existence), I wanted to scream bloody murder it hurt so
bad. I've experienced this in massage therapy before and I am now a
believer and want to look into seeing one for treatment when I get back
home.
We also met with the Naturopathy doctor, whose name shamefully escapes me, but he does have a B.N.Y.S. - Bachelor of Naturopathy and Yoga Sciences which requires 5.5 years of training. The whole philosophy behind naturopathy is assisting the body in healing itself from within naturally, with diet, exercise and yoga.
After lunch we had a lecture on naturopathy
from Dr. Nair, wife of the founder and director of the clinic and it
was rather interesting and reminded me of the Ancient Greek beliefs
about medicine and the human body
(with the elements of air, fire, earth and inbalanace of elements = disease) before Aristotle introduced empirical scientific data.
While our rotations this week have nothing to do with HIV/AIDS, it is
intended to introduce us to traditional medicine in India as it is an
accepted form of medicine by the Indian government and really quite
fascinating.
After lecture we had a guided meditation during which I
think I fell asleep for about 15 minutes but it refuelled me for the
rest of the day, which was just amazing.
In the evening, we decided we wanted to expand our cultural immersion and went to see a Bollywood
movie at a mall. It was ridiculous, horribly done, but very funny
because of all those reasons. There goes 2.5 hours of my life I will
never get back but when in Rome....

This morning started out very early with yoga at 6:30, rotations in the morning, lecture and meditation in the afternoon and tonight, Paul and I are venturing out
to seeAkshardam Temple in
Delhi,(http://www.indiatravelportal.com/delhi-placestovisit/akshardham-temple.html)
while the rest of the gang may be going to a nightclub/restaurant.Akshardam is the most elaborately built temple in India and it looks just amazing. I will post some pictures tomorrow.
Thursday we're supposed to go to Taj Mahal, so I'm keeping my fingers crossed for that.
Now I have to get back to rotations. Namaste!

Oh Bapu

Our last morning in Jaipur and we're all a little meloncholy. After breakfast we head out for a five hour ride back to Delhi where it's purportedly raining, which means that the wildlife that puts the "nature" into Bapu Nature is going to be sharing our rooms even more now. As much as I'm looking forward to practicing yoga at a yogashram, I think the mouse in our room, the flying cockroaches in our bathroom and the ever present lizards, mosquitos and all other manner of wildlife really craps our style.

They did feed us good nutritious foods though, because they emphasize a good diet for a healthy body, as you can see from the sign on my profile, there are signs everywhere in Bapu emphasizing the importance of naturapathy, but I know we will miss our protein, Farah for sure. But it's only one week, and one of those days is going to be spent going to the village of Mewat, which had to be postponed because of the riots of the Gujjari people a couple of weeks back, and another day is supposed to be a planned trip to Agra to see the Taj Mahal for several but not all of us. I'm scheduled to leave India early Saturday morning next week and it's bittersweet, I would like to have stayed a little longer albeit at better accommodations, preferrably without sharing a room with a lizzard, whose dropppings I have to pick up (ew). So I want to come back to India one day soon with my husband and see the history of it, which I haven't had much opportunity to do on this trip. However, I have learned so much about public health and how it's actually practiced and what it really is and I had to travel across the world to find out, but it has been an educational experience, I think I've grown personally and certainly professionally. More on this when the trip is actually over.
Namaste Jaipur, I'm off to breakfast!

Goodbye Jaipur

Today was our last full day in Jaipur and we spent the morning preparating for the presentation we gave to Dr. Goyal this afternoon. We presented on all our activities during our week in Jaipur and we each picked a country to present on to give a more global picture of HIV/AIDS, to compare and contrast these countries' efforts at combating the virus and give recommendations based on what we've learned and observed in India thus far. I chose Russia and I think it can learn a lot from India's efforts to combat HIV/AIDS, including strengthening its public health infrastructure, creating harm reduction programs such as needle exchange programs, and create targeted interventions for high risk groups including Commercial sex workers, IV drug users and men having sex with men (MSM). There are also issues of policy that Russia must deal with including providing free universal access to ART to all those who need it and social marketing campaigns to reduce the atrocious stigma attached to PLWHA and IV drug users.

Since we had the afternoon off we decided to go to a Bollywood movie, but the movie we wanted to see was sold out and the other available movies were deemed too sillly. So we ended up at a mall, or a bizarre and 7 girls ganged up on a poor sales guy to bargain for gifts to bring back home.

Yesterday afternoon was spent at Bapu Market, a major bazar in Jaipur and Linda helped me sharpen my bargaining skills, I had tons of fun and bought a bunch of gifts for people at home, although I really should stop otherwise I won't have any roomin my suitcase.

This week at Jaipur has been really good, the accommodations have been top notch, the institute welcoming and modern, and the food just wonderful. The only dissapointment I have is I didn't have an opportunity to explore the historical sites and the monuments. The only opportunity for this happened the first day when the rest of the gang went to explore the city and Farah, Sejal and I stayed behind to work and the rest of the time we've devoted to shopping. I would have taken a car alone, but the old part of the city is all the way across town (25km)and really I haven't had the time or the opportunity. So I suppose this gives me an excuse to come back to Jaipur, not that I need one.
Tomorrow we ride the bus back to Delhi and back to Bapu Nature to have our last week of rotations at the ayurvedic clinic and yogashram. Yoga is on the schedule, but I'm learning in India, schedules don't mean very much. We shall see.

Political Activism for HIV+ People

June 15, 2007

We visited an organization called RNP+, a network that links HIV+ people together throughout Jaipur and other regions, provides them a transitional home when they come in to visit the only two ART treatment centers in the whole state of Rajastan, some of them travelling great distances and having no other accommodations and helps train positive people to be peer educators for HIV patients in hospitals, as well as helps nourish skills that positive people may have, placing them in jobs such as front desk receptionist etc. The network also participates in political activism to further the rights of People living with HIV/AIDS (PLWHA). As a matter of fact, we were unable to meet the president and founder of the network because he was participating in a hunger strike infront of the Rajastan AIDS Control Society, making a number of demands (see Farah's blog because her description of this visit is much more eloquent and comprehensive and she also has a copy of the demands on there), including the abolishment of a new practice of issuing identification cards to HIV+ people with their photo on it, which would tremendously increase stigma and further marginilize positive people.
Political activism from the gay community in the US in the 1980's and the present has given them a political voice, reduced stigma for PLWHA and helped bring abaout policy change. Similar efforts are being undertaken here in India with such organizations to bring PLWHA out of the shadows and into mainstream society.

Tigers & Peacocks: Safari in Ranthambhore Park

On Thursday June 14 we woke up at 5 am to go on a Tiger Safari in two jeeps into Ranthambhore National Park to fully understand the importance of the work that Prakratik Society is doing to save the tiger, the forest, and provide the surrounding villages an alternatives means of livelihood (read previous blog entry for more info on this).
We separated into two groups, group A with Sophia, Linda, Jazmin and Satoko were taken to zone 3 and our group with Farah, Sejal, Paul and I travelled to zone 5. The jungle was beautiful. peaceful and full of wildlife, including deer, rabits, antellopes, monkeys and peacocks. Unfortunately, our group wasn't lucky enough to spot any tigers despite waiting for over an hour by a watering hole that the tigers have previously been spoted by forest guards. Group A was lucky enough to spot a tiger with her three adolescent cubs, but according to the locals, you can go to the jungle a dozen times and may not see a tiger once. This is how reduced their numbers have become, which is really really sad, because they are magnificant animals.
But our dissapointment was abated somewhat by an incredible display of other wildlife including witnessing the courtship dance of a peacock
There were no takers for him despite the fact that there were 4-8 peahens right infront of him, but according to our safari guide, the peahens play hard to get and it takes a really really long time for the peacock to prove his ummm virility? beauty? ability to shake his booty? I don't know. But I think human males can learn a lesson from the peacock especially its persistence in trying to woe a mate. (This doesn't include my own husband of course, he was as persistent as a peacock although he doesn't strut like one, at least not in public) We also have some peacocks and peahens on the campus roaming around, or in the case of the peacock strutting his stuff, it's hillarious to watch him walk because he is aware of his own beauty.

During the safari I had a whole new appreciation for the work that the Prakratik Society and Environmental and Wildlife societies do in general and I fell like this is a big part of public health, especially when the programs implemented are multi-sectoral and multi-pronged social ecological projects that aim to change social norms to better the planet and the preserve the future of humanity.

Social Ecological Projects for Environmental Preservation

June 13-14,2007
On Wednesday we travelled three hours to a village called Swai Madhopur to visit the Prakratik Society and Ranthambor Sevika. Ranthambhore National Park, once the hunting reserve of the Jaipur Royalty became a Wildlife Sanctuary in 1955. There are 96 villages surrounding the national park and because of the dire poverty the villagers use the forest to graze their cows, harvest the grass, and hack the trees for firewood. Poachers have also been illegally hunting the tigers to sell in Asian markets for their various parts, including China and Lasa, Tibet. Each tiger with its separate parts can fetch up to $50K on the black market and as a result the tiger population has decreased down to two dozen tigers.
While poachers have confessed and officers have been occused of being complacent with poachers, there have been no prosecutions by the government. The Prakratik Society started by Dr. G.S. Rathore, the son of the world famous tiger man Fateh Singh Rathore WITH DR. FATEH SINGH RATHORE
was started as a social ecological project with the aim of protecting the forest and the tiger by providing alternatives means of livelihood to reduce the villagers' dependence on the forest and its resources. To reduce the villagers' dependence on firewood, Prakratik created alternative energy sources such as the Biogas Project, in which the villager is encouraged to stall feed one or two cows, instead of several, and deposit their manure into biogas units which then generates methane gas that can be used for cooking. There are now 482 biogas stations in the villages and growing BIOGAS UNIT
Another project is Artificial insemination of cows to create a better stock of cows to produce more milk, the surplus of which can be sold.
Yet another project is family planning, in which women who have 2 children are encouraged to get sterilized and if they do so their children will be able to attend the Fateh Public School, another project started by the society. FATEH PUBLIC SCHOOL
Education to village girls is absolutely free and for boys it's at a reduced price compared to urban children. Fateh Public School is a modern state of the art school in a rural setting that provides the future generation of village children education and an opporutnity for upward mobility.
Tiger Watch, an associated NGO helps provide the poachers rehabilitation, medical help and trains them to understand the significance of the forest and the tiger and trains them to become guards against other poachers.

To gain the trust of the surrounding communities, Dr. G.S. Rathore opened a state of the art rural hospital before establishing all the other projects to provide much needed medical services to the 96 villages, including Family Planning, general outpatient services, Ophthalmic clinic, OBGYN services, Antenatal and postnatal care, and general surgery.

After meeting with Fateh Sign Rathore, we travelled to one of the villages to interact with the villages. They were welcoming and curious about us as usual and we took some great pictures with them. Sophia brought animal cookies for them which thrilled them to no end.

My Purple Belt Husband

June 12, 2007

Those of you who know Todd know what an amazing person he is and how trully lucky I am to have found him and got him legally bound to me. He has always supported me in anything I want to do and has been incredibly supportive throughout this process of planning and actually going to India to work. He was also my rock when I was having anxiety and insomnia when I actually did get to India.
Most husbands would not be half as supportive. So I wanted to thank him and congratulate him on the accomplishment of earning his purple belt (skipping several belts to boot to get to purple) in Arjukempo Karate. Nobody deserves it more anoushik jana.





This is something that he enjoys tremendously and I support him wholeheartedly, just sorry I couldn't be there to see him get his belt, but there will be other belts to come, which I won't miss for the world.
CONGRATULATIONS BABY, ILWAMHAMSAETIA, Siroum em kez hokis.

Elephants and Camels

June 12, 2007

Jaipur is located in the desert of Rajastan state, so everywhere you look you see camels on the street, so we have been yelling "Camel" every other minute so the others can grab their cameras. We've been so busy we haven't really had a chance to explore the city very much at all. We've either been in lectures, at NGO visits, or at the computer lab working on our blogs, practicum stuff, and the presentation we're supposed to make at the end of the week. But hopefully Saturday after the presentation we will have an opportunity to go see some sights and do some shopping.

Last night Dr. Goyal and our coordinators took us to a resort which resembles an authentic Rajastani Village, which took us back hundreds of years in time, with traditional dancers who can bounce vases 5 feet tall on their heads while dancing (I'm sure either Sej or Farah must have pics so check out their blogs as well).





We had a traditional Rajastani dinner in a beautiful restaurant and we got to ride an elephant and a camel and it was a blast, a bit scary especially when the camel goes to kneel down, you feel like you're going to fall off, but it was so much fun.

So here's my own camel. I don't think we got a picture of me on the camel itself but I have ask the other girls.

And here's my elephant, he was so cute he would pose for pictures!


Tomorrow we're going to a village in Swai Mathupur to visit a rural hospital and Thursday we're supposed to go on a safari to a tiger sanctuary. Can't wait.
Love and miss you all
E

Jaipur, IIHMR and FXB

June 11, 2007
We've settled into our new institute and had our first lecture by Dr. Goyal on HIV/AIDS in Southeast Asia. While we're hearing different figures from different people in the field, since there is no official national HIV/AIDS registry, all statistics are based on estimates. The complete picture that emerges is that HIV in India is transmitted through high risk behavior in the general heterosexual population.
In the afternoon we went to visit an NGO called FXB fxb.org, the NGO was started by Countess Albina du Boisrouvray of France after her son passed away in Mali and currently operates in 17 countries to provide a voice for AIDS orphans and other volnerable children, advocating for their rights and support.


With Dr. Gupta at FXB

Dr. Gupta, the director of the FXB center in Jaipur was an extremely passionate and energenic person and we enjoyed meeting him and his staff. They are currently running four projects, including an HIV awareness program at barber shops, which educates barbers in disseminating HIV and safe sex messages to their clients as well as providing free condoms. They are currently working with 254 barber shops and have distributed 40,000 condoms in the last 2.5 years.
The second project is installing condom vending machines that Dr. Gupta and his team have designed themselves at petrol (gas)stations. This project is still in its infancy because it's difficult to get permission from the petrol company owners, but it is an innovative idea as are most of the projects run by FXB Jaipur.
The third project is a school sex education program, however, they are not free to speak about condoms and safe sex due to conservative political pressure similiar to the U.S. The last and possibly the most touching project he told us about has to do with Street Children which would fall under the vulnerable children category. They do outreach to these kids, who are mostly runaways or AIDS orphans who often live in train stations or on the street and collect empty water bottles off the trains as the trains pull into the station. They are referred to as rag children. Dr. Gupta's team provides them with soap and towels, which they get from unused hotel soaps that you and I leave behind. They also have a health camp for the kids, where they feed them and try to educate them. Currently they have 500 registered children.

Communication in Public Health

June 11, 2007
Watching people work in public health in India has reinforced the notion that effective communication and professionalism are major prequisites for any public health professional. The ability to work with people of diverse backgrounds, interests and opinions is an asset one must possess in order to be able to work in a team, which is what public health is really all about. I believe it takes emphathy, maturity, an ability to assess your own shortcomings and a willingness to work on them in order to become a more professional practioner as well as a better person.

The Pink City

We arrived in Jaipur, Rajastan about 3 hours ago on an air conditioned bus, thankfully. It took us five hours to get here from Delhi and we passed through some beautiful countryside as well as some really poor villages. Life must be so very difficult for these farmers who try to compete in this global economy and often fail.
We arrived at the Indian Institute of Health Management Research (IIHMR) http://www.iihmr.org where we will spend the next week attending lectures and doing field work, all of which will culminate in a powerpoint presentation we are going to make based on our observations and work in the field.

Although we haven't seen too much of Jaipur just yet, it seems less chaotic than Delhi. Tomorrow we're going to venture off to explore the city and I will take pictures to post, as this institution has a sophisticated computer lab at our disposal.

IIHMR's hostel is also very nice, our rooms are modern, clean, and air conditioned, we are thanking our lucky stars. We do have lizards everywhere though and getting used to them running up and down our walls in our rooms is going be a challenge, but I have no doubt we'll get used it. We just had dinner, which was prepared just for us and it was quite delicious with a soup course, a chicken dish, baby eggplant dish and all the trimmings.

India and her woes

A small slum on the side of the highway in Delhi

Friday June 8, 2007

We visited Sahara's Women and Children's Center which takes in abused and trafficked women as well as drug addicts to give them a safe place for themselves and their children. The center also counsels them on drug addiction and teaches them practical skills to help them find employment. Unfortunately, a lot of the women leave the center without completing the program, some leave because their abusive or addict husbands come to take them back and they willingly go, but return some time later for the same reasons, so it's a vicious cycle.

In the afternoon we visited Sahara's Men's Drug Rehabilitation Center and sat in at a group session in which the men were talking about the challenges of the past week and the small goals they set for themselves for the coming week.

Having been here for two weeks now, I'm starting to form a more complete picture of India, her people, and its challenges. There are so many public health issues in India:
1. Sanitation: the sewage channels are above ground and often filled with stagnant water which leads to an atrocious stink and undoubtedly contributes to the overabundance of mosquitoes and results in endemic malaria. I'm not sure if the government is doing something about this but there is lots of roadside work going on, so hopefully there will be some improvements. The city is trying to beautify itself for the 2010 Commonwealth Games so perhaps some of these issues will be addressed.
2. Poverty and slums. There is a huge migrant and mostly illiterate population that comes from the villages looking for work and there's not enough affordable housing for them and India has squatter's rights laws so they build makeshift tent-like dwellings on the sides of the roads and live in absolute squalor. According to some public health people we've talked to the government and the private sector are trying to create more employment opportunities for them back in their villages so they will stay there, but there's a real estate boom going on in Delhi right now, probably due to the 2010 Commonwealth Games, so the migrants come for the construction jobs.
3. Infectious Disease: The above described living conditions and poverty are the poverty are the perfect breeding ground for TB, HIV, and Malaria. The public health system seems to be doing a good job but there's only so much they can do for a billion people.

There are so many more issues but we are on our way to Jaipur so I must say Namaste for now and will return to PH issues later, including begging children, women's rights or lack thereof etc.

To bargain or not to bargain, this is the question

McDelivery, yes McDonald's delivers here. Lovely


June 7, 2007

Today was our last day at Sahara Michael’s Home Care, we had our usual rotations with Dr. Gupte and he gave us a presentation on Mother to Child HIV transmission and Tuberculosis. I mentioned in my blog yesterday that TB is an opportunistic infection in HIV patients but today Dr. Gupte clarified that it’s actually a co-infection, but commonly referred to as an opportunistic infection.
Since we don’t have TB in the US all of us are pretty ignorant of it, so it was interesting to hear about a disease that just about every Indian is affected with at one time or another. Obviously TB is endemic in India and according to Dr. Gupte 40% of the population has the bacteria, 10% of whom have the disease at any time, and that number climbs to 60% for HIV patients.

In India they conduct a sputum test not the skin test for TB and apparently one sputum positive patient can infect 10-15 other people in one year. Pretty scary. The treatment consists of antibiotics for a 6 month course with strict adherence for a first infection and goes up to 8-9 months for subsequent infections. There’s also the concern for multi-drug resistant TB (MTB) and the treatment consists of 4 drugs, most of them highly toxic on the liver. India participates in the WHO’s DOTS program, Direct Observation of Treatment Site to make sure patients adhere to the drugs because once they feel better after a month or two of taking the drugs they stop taking them thinking they’re better, but they’re not. Let’s just say I’m crossing my fingers that I don’t test positive when I get home, the treatment sounds worse than the disease.

With program coordinator Philip and program manager Doi

In the afternoon, we accompanied a couple of the staff to a nearby village to purchase rations for the center, including lentils, oil, rice etc. Since today was our last day at Sahara, Aunt Jennie organized a devotional where we all sat in a circle, one of the patients played a guitar and we all sang Amazing Grace. They thanked us for our contribution to their organization, but really it is we who are grateful to have been allowed to see their work and dedication to the community.
In the ambulance on our way to purchase rations.


After work we went to a Lajpat Nagar, an open market but it was extremely busy, hot and once they see a foreigner the price goes up triple fold and my bargaining skills were wasted on a fellow who wasn’t willing to budge for a pair of cute shoes. A part of me wants to pay full price because it’s so little to us in American dollars and it means so much to them, but Sej and others tell me they are ripping me off because I’m a foreigner so I suppress my overgenerous side and bargain. Anyway, I walked away from the pretty shoes, but it was painful. Maybe in Jaipur.

Namaste from Delhi.

Public Health by day Discotech by night

Hanuman
Hindu Temple to Shiv


June 6, 2007

Today was our third day at Sahara Michael’s Care Home and we started the morning by doing ward rotations with Dr. Gupta. After lunch Dr. Gupta continued his lecture regarding HIV, the World Health Organization’s (WHO) Clinical Stages of HIV/AIDS: Stage 1. Window Period –the virus has entered the body and the body is making antibodies but not enough to show up on a test, this period is usually 3 months. Stage 2 is when CD4 (white cells) count is 500 and the patient is asymptomatic (normal person’s CD4 count in between 1000-1500); Stage 3 involves CD4 count of 300; and Stage 4 the CD4 count is less than 200, this is when opportunistic infections (OI) attack the body and this stage is defined as AIDS. In the US Antiretroviral (ART) medication is usually started at CD4 levels of 400, however in developing countries like India they start it at 200, mostly due to cost and the toxicity of the medication. Most of the patients that present at the clinics have CD4 counts of less than 50, usually around 10, as they often wait to be tested for various reasons, including socio-economic and socio-cultural stigma.

Tuberculosis is almost synonymous with HIV here from what we’ve seen and what we’ve been told by the doctors that work with HIV patients, as it is a highly opportunistic infection and in such cases, the OI must be treated first before the patient is put on ART.

The WHO criteria for suspecting HIV include 1. Clinical, 2. Weight loss, 3. CD4 count; 4. Performance scale-if the patient is bedridden for 50% of the month, which usually occurs in stage 4 aka AIDS.

Farah and Paul are pre-med and have a scientific background, Sej is a nurse, but this is all new to me, well with my BA in History and while I don’t understand most of the uber biological stuff, I am able to comprehend and appreciate most of the clinical stuff. And while I’ve read and learned about HIV in fragments, this lecture gave me a more rounded view of the virus.

After our rotations we went sightseeing and saw some beautiful temples devoted to Shiva and took some wonderful pictures. We decided to go to an upscale Indian restaurant called Indian Colours and Spices however it was not yet open so we ended up at an another upscale restaurant right next to it called Tonic. Tonic was more like a ultra-lounge/restaurant in the Euro-American style and while we were finishing up dinner a dj set up and started playing techno music for the beautiful Indian people. We had a great time laughing about our public health clothing in such an upscale establishment, but a three-course meal including ice cream cost us $15 each, so we’ll file this one under indulgence.


Tomorrow again is Sahara Michael’s Home, Friday we’re going to Sahara’s Women and Children Center, whose director is a strong advocator of women’s rights, so I’m looking forward to that. Saturday is supposed to be Jaipur and we have our fingers and toes crossed that it will happen because we want to ride elephants. Yes me on an elephant. Farah wants to ride a camel, but those things are temperamental and I would rather stay away from them than be spat at by a camel.

Sahara Michae's Care Home II: HIV Patients and IV Drug Users

Tuesday 6/5/07



Today we had our second day of rotations at Sahara Michael’s Care Home for PLWHA. Dr. Gupte with whom we are supposed to have ward rotations was out of town today so we interacted with a patient there named Urmila who’s been receiving care at the center for HIV. Her daughter Anjali is also staying with her, she’s 5 years old and very cute. We played with Anjali while Urmila told us of how she contracted HIV. Her husband is a trucker and when she first found out her positive status, she blamed him for it, accusing him of being unfaithful, however, he tested negative.


She mentioned that for a couple of years she complained of aches and pains and would go to her local doctor, who would give her injections for just about any ailment she presented with, which we’re learning is a pretty common practice. She mentioned the injections would often be more painful than the original condition and would not help her symptoms at all. As a result, she has surmised that she was infected by dirty needle use by her local practitioner, which is a fairly common problem in rural areas as mentioned earlier in my blog. Apparently they just wash the reusable syringe under tap water and use it on the next patient. This in my humble opinion is a crime against humanity to be transmitting HIV to a unsuspecting and often illiterate population. Her husband continues to be supportive of her and Urmila is receiving good care at Sahara.

We also talked with Ompraksh, a man in his mid forties, who became addicted to drugs at the age of 10 and used just about any drug he could get his hands on for most of his adult life. He said one day he was sitting and smoking (don’t know what exactly ganga perhaps?) and a foreign stranger who spoke Hindi approached him and asked him why he doesn’t quit. Ompraksh replied he had nothing and nobody to live for so he’d quit when he dies. The stranger told him he could help him quit and took him to Sahara Care home and as a result Ompraksh has been sober for the last 8 years. He’s tried to look for the stranger but now believes that this stranger was a godsend. He now works for SMCH. Most of Sahara’s staff is actually ex addicts and as such they understand the daily struggles of their patients.

Anjali

After lunch we talked to Auntie Jennie, an older lady who’s the counselor at Sahara. According to her, patients or clients as they call them come in when they’ve hit rock bottom or have been exhibiting high fever, diarrhea and canditis or have been referred to Sahara after testing positive in other hospitals. They are they sent to be detoxed at an offsite center for 15 days and then receive mental rehabilitation for six months. Rehab teaches them to accept responsibility, be honest and accept their addiction. Sahara also treats addicts for abscesses they’ve developed as a result of injection drug use. The center also educates the patient and family on taking precaution when the patient returns home. According to Auntie Jennie SMCH requires two things when patients or clients as they refer to them come in: 1. Hygiene: they wash and groom their clients and 2. Discipline: because discipline is required for ART adherence, which must be taken on a daily basis at the same time.

At Sahara Michael's Care Home

After work we took our taxi to Delhi Haat a swat meet like shopping center and purchased some gifts and I did my first bargaining, it came naturally to me, perhaps because I’m Armenian and it’s in the blood. Sejal says I still paid too much, but all in all it comes to be very cheap in American dollars and I don’t mind contributing to the local economy. This is a skill that I’m going to work on honing however, because it was too much fun!
Tomorrow we’re again at Sahara and Saturday we’re supposed to finally head off to Jaipur, but this is India and anything can change.

I miss you all, but I’m having a great time. I’m beginning to see the spirituality that I’ve been seeking, especially now that I’m getting sleep. So please keep your fingers and toes crossed that I will continue to sleep so that I can continue on my journey. I hope you’re all well and I love you.

Sahara Michael's Care Home Day 1

The SWOT girls at the India Gate

June 4, 2007

Last night we moved into our new apartment in Vasant Kunj and it seems to be in a much better part of town, however, we are imprisoned in our own apartment because the Gujjra conflict has now moved to Delhi and two buses were burned and two bombs went off. We are not at all affected by this so please don't worry about us, our coordinators' first priority is our safety and they would not willingly put us in harm's way, besides Delhi is so huge.

Since we weren’t able to travel to Jaipur this week because of the political conflict of the same community, today we started our rotations at the Sahara Michael’s Care Home for people living with HIV/AIDS (PLWHA). Sahara is a unique Non-Government Organization (NGO), which has for the last 28 years pioneered new and innovative approaches in responding to the needs of people living with HIV/AIDS (PLWHA)and PWUDI (People who use drugs illicitly). Sahara's programs are located in various parts of Delhi so that they are most accessible for the communities most in need of their services.

The Mission of SAHARA is to empower people facing difficult situations due to substance use and HIV/AIDS. Sahara has implemented a range of strategies to empower people, strengthen communities, to encourage safer behaviours and to aid in the reintegration of people into society. Today Sahara runs 39 projects most of which address substance use and HIV/AIDS across 5 states in India reaching between 350,000 to 400,000 people per year. Sahara is run almost entirely by former substance users and PLHA. Sahara runs services for men, women, children and the transgender community.

Some of Sahara’s projects include HIV/AIDS Care and Support Homes, which provides medical care, nutrition, counseling and Antiretroviral Treatment (ART) free of charge; HIV/AIDS Transgender Community project, which we visited on Monday 5/28/07; a Drop in Center/Night Shelter for Street Children, which supports street children through the provision of education, food, detoxification and referrals to other organizations that provide vocational training. Sahara also runs a DOTS project, which is a treatment program that provided tuberculosis medications to patients on a weekly basis to reinforce compliance and adherence. Sahara also runs a Women and Children Shelter, which we will be visiting this Friday. The Shelter provides a haven for women who have had traumatic experiences, providing them with HIV care, rehabilitation, job training, midway homes, and adult education and job placement. The Women and Children Center also has an Income Generation.

Last but not least Sahara has a Working Women’s Hostel, which is specifically for women who have been trafficked, and their children who are usually homeless with no job skills. The program teaches them vocational skills and helps them finds jobs. Sahara also provides advocacy and sensitizes medical and paramedical professionals to HIV positive people to reduce the stigma they face when seeking health care. While the stigma situation is getting better there’s still a lot of work to be done in this regard. Follow up and evaluation are a big component of Sahara as their funding agencies, the Catholic Relief Society and Family Health International demand results.

Sahara established Delhi's first hospice for PLWH/A (Michael's Care Home-the site of our visit today)that could provide medical and palliative care in a manner that treats HIV+ people with the dignity and respect as any human being deserves. Michael’s care home has 35 beds and at any given time has 85% - 90% occupancy. The home receives support from NACO (National AIDS Control Organization) and from international NGOs such as Catholic Relief Services (CRS) and Family Health International (FHI). A physician comes in to make rounds each day, and they also have staff nurses around the clock and full time counselors provides counseling, medical care, clean needles, spirituality services to both HIV/AIDS patients as well as IV drug users. The program also gives hands on care training for HIV+ patients and their families so that they can become reintegrated into the family and community, because a lot of times when a family finds out a member is HIV+ they kick them out of the house because of fears of getting the virus themselves.
Sahara also runs an income generation program for the patients where they make clothes, tapestries and other handicrafts.

It seems so far from all of our visits and conversations with experts, that people in India know the term HIV/AIDS but they don’t know any details as such they have many misconceptions about what it is, how it is transmitted resulting in stigmatization. One of these falsehoods is that everyone who gets HIV must have had sexual relations with a commercial sex workers or participated in MSM activities. In reality, modes of transmission vary here from blood transfusions, as was the case of a young man we met during our rotations at St. Stephens who got HIV at 14 years old from a blood transfusion, or dirty needle use from quack practitioners as I’ve previously mentioned.

An Adventorous Week

It's been more than a week since we've been here and in that time we've experienced enuogh to last a lifetime. Tonight we moved out from Bapu Nature into the CFHI apartments at Vasant Kunj in a much more afluent part of Delhi. We have our own coordinator who cooks for us and the apartment is generally much more comfortable than Bapu. The group of medical students that are part of the program as group A moved into Bapu and will most likely experience the same initial shock, then acceptance of the wildlife at Bapu as well as the busy and loud neighborhood that it is in. I wish them luck, as we're going back to join them in Bapu during week 4.
More reflections later, for now I'm really tired.

My first hand experience with the Indian Health System

Slum in Delhi

As you all know by now Farah had her first experience with the Indian Health System when she fainted at St. Stephen's Hospital on Wednesday. Well I guess it was my turn to try it out. I've had insomnia since we got here and while the first several days I was highly functional during the day despite sleep, the last two nights have taken me beyond the edge as I've had panic attacks during the night, mostly because of frustration over the lack of sleep and my inability to function normally anymore during the day as a result. The past couple of visits to community sites have been unbearable for me, because I've barely been able to keep my eyes open and my brain is so fried I cannot ask any informative questions.

So today our coordinator from CFHI Hema Pandey came to take me to Apollo Hospital to see a doctor and since our medical director Dr. Raina is out of town, I waited about 2 hours to see a colleague of his, Dr. Nag.
From my previous blogs you may have gathered that Apollo serves the wealthy Indians and in the waiting room I was the only foreigner. The out of pocket fee to see Dr. Nag was 700 rupees, a little over $17, which is nothing for us Americans since we pay so much more than that, but this is perhaps a month's salary for a hard working impoverished Indian.
He was really very nice and diagnosed me with anxiety, which is still odd to me because I don't feel anxious, I'm actually enjoying being in India, the people are warm and friendly but I suppose my anxiety is on a more subconcious level. In any case he prescribed some anti-anxiety medication which takes 2-3 weeks to work (which I don't understand), and Clonazepam to help me sleep. He suggested I take a .5mg when I got home to help me take a nap, but alas, nothing. At this point I feel like a horse tranquilizer would not phaze me. I've decided that if I cannot sleep tonight and tomorrow night, I'm taking a flight to LA on Monday or Tuesday.
As dedicated as I am to advancing the health of the public, I cannot do any such thing if my own is suffering. Normally I would see this as a failure on my part, but at this point, I see it as being wise about my health. On top of anxiety, I'm also suffering from a cold and a cough thanks to the pollution that hangs over Delhi and penetrates all your pores. Those of you who know me, know that I've suffered a great trauma to my spine followed by spinal surgery several years back from which I am still recovering on a daily basis. I did not let my back discourage me from traveling halfway across the world to educate myself, however, if I cannot sleep and if I have anxiety, I cannot function and am therefore no use to anyone.
So at this point, I'm really hoping the meds work so I can get some sleep and return to my work.

India: A land of contrasts

June 1, 2007
Today we went to visit a drug rehabilitation camp in South Delhi, where we met and interacted with both health workers and current and former drug addicts. Most of these men became addicted to "smack and ganga" as teens and have been addicted most of their adult lives while neglecting their families and spending all the money they earn on drugs.
The camp's goal is not get the men to stop, which is what happens in drug rehab in the US but to get them to reduce their injections and practice safe injection methods. For instance, I talked to a man who'd been using drugs since he was 14, up to 10 times a day and with the program's help has now reduced injections to once per day. Considering the huge challenge both these men and the center face, this is a real victory. The program also teaches them to read, as most of them are illiterate and as such empowers them and gives them something other than drugs to think about. According to Yunus, the health worker I met with they want very much to have normal lives and discontinue drug use.
After playing Bollywood Trivia designed by Sej to get the men to open up to us, they sang and recited poetry for us. Farah also sang a beautiful verse, she's got a beautiful voice.

I feel like I could have enjoyed the meeting much more if it wasn't so stiflingly hot, but this is India in the summer for you. For lunch we went to Pizza Hut because we've been craving it since we got here, which is funny because I never touch the stuff at home. Sedarshun, one of our coordinators drove us to a Pizza Hut in South Delhi. It's a sit down restaurant here with waiters, plates and all. It was quite the contrast to see the patrons of Pizza Hut compared to the poverty stricken masses that I've seen so far. This is the high middle class that can afford such frivolities as American fast food. Oh and McDonald's delivers, it's call McDelivery.
After lunch, Sidarshun dropped us off at a mall in South Delhi and the first store we walked into, called Shopper's Stop, could have been any posh department store in the US. With Mercedes S500s in the parking and a Apple store it was a bit of shock to walk into such prosperity when we see so much poverty everywhere else.
We finally made it home, four of us in one rickshaw and needless to say we are exhausted and possibly have heat stroke. Tomorrow is Saturday and we're planning to visit the National Museum. The situation in Jaipus has not yet improved, so we're spending the next week at Bapu Nature doing Traditional medicine rotations, as well as yoga and meditation. This should be an interesting experience.

Truckers and Commercial Sex Workers

Education Message at Truck Stop of SPYM
May 31, 2007

Today we had our weekly meeting with our medical director, Dr. Raina at Apollo Hospital in Delhi where he is also director of blood services. He gave us a tour of the facilities including the blood donation center and the blood supply testing facilities. In India blood donations are not done on a voluntary basis the way it is done in the U.S, there are donors who donate repeatly and while the government used to pay for donations that practice has been suspended and now the patients'friends and donate blood as the patient needs it.
Apollo tests their blood supply for HIV, Hepatitis A & B, Syphilis and Malaria. For HIV they conduct both an antibody test as well as a nucleic acid test to look for the virus. Unlike most facilities that test only for HIV antibodies, Apollo is able to conduct both tests because of its vast resources. It serves the top 1-2% of the population that can afford to pay for high end medical care, as well as medical tourism. Despite the stringent tests, 1 out of every 40,000 blood samples still contains HIV.

We had an enlightening lunch in the Executive Dining Area with Dr. Raina as we discussed the human condition, especially in India, religion and global health. He is incredibly nice and hospitable. When he found out I was having a hard time adjusting, he invited me to stay at his house! No doctor in the US would do that!

In the afternoon we visited SPYM's local HIV/STD testing and counseling center at a truck stop in Delhi. SPYM (Society for the Promotion of Youth and the Masses, spym.org) is an NGO that serves the community in developing and prevention of HIV/AIDS, STDs and drug abuse. We were able to interact and pick the brains of health management workers, peer educators and HIV counselors. The truck drivers, who spend months away from their families come in to the truck stop and have sexual relations with the local commercial sex workers(CSW). The center works to educate both the truck drivers and the CSWs in safe sex practices, HIV and STDs and gives out free condoms and free HIV tests. The CSWs are mostly impoverished women from the local community who are forced to sell their bodies to support their families, often because their husbands are unemployed or/and are abusing substances and chose to look the other as their wife goes to her daily duties. Through the sheer will power of their elderly peer educator, the center has been successful in empowering the local CSWs to demand condom use from their clients. She said she will often accompany the women to the designed room or a spot in the forest as they conduct their transaction with the truckers to make sure that they use a condom and use it correctly. Most of CSWs and truckers know her, respect her because of her age and therefore listen to her advice.
This particular visit was extremely enlightening because Sej has given a presentation in class about this very topic in class and to be here to see it first hand and talk to them personally is a quite extraordinary.

Tomorrow we were supposed to visit a remote village called Mewat (and Jaipur on Saturday), where an indigenous population has hung on to its ancient roots, however, there is currently a political uprising by this population and all roads leading out of Delhi are blocked. So we're staying put in Delhi for the time being.