Coming to an end

Well, apparently, I have spent the last several days in a sort of black hole of modern technology in Munnar. Munnar is up in the mountains on the western border of Kerala in a range called the Western Ghats. It's essentially a region that is blanketed in tea plantations. It's really quite beautiful. We visited the tea plantations and sa how the families that work the plots live, etc. The plantations used to be owned by the Tata Corporation but now are owned by some other conglomerate. The main reason we visited was to see how the Tata folks were promoting education and health. They have a corporate hospital set up that offers a wide array of medical and surgical services that are free to the workers and their families. Others may use the hospital for a nominal fee. The hospital manages to deliver high quality care to about 50,000 people for about $1 million/year. they get a pretty good value for a relatively small amont of money. We saw the hospital as well as the satellite clinics in each various tea estate. They are not funded through the same soures but manage to coordinate care fairly well. I cannot post pictures at the moment but will soon. Very cool.

However, when we were in Munnar, apparently the internet just "doesn't work sometimes" (like for the 3 days we were there). Also, I exerienced a ell phone failing to get a signal in India for the first time in all my trips here. Bizzare. I did eat some really strange fruits in a market and manage to escape uncontrolled dumping of my guts. So, you win some, you lose some.

Right now, I'm in a seedy internet cafe by a train station in Ernakulum. They have me sequestered in a little booth with a closed door. I can't decide if I should confess my sins or masturbate. More later when I have real internet and computer access.

Trivandrum

The town we have been in thus far is in southern Kerala along the coast. It is called Trivandrum. From what I can tell, it has essentially two main industries, government and medicine. The seat of the Keralan government is here so that's where the governmental aspect comes in. It is a democratically elected communist government, so you see the hammer and sickle all over the city on political signs. Apparently, when the communists were originally elected, they did a lot towards attempting to alleviate the tremendous economic disparities that existed here. They were involved in land redistribution, public education, public health, and job creation among other populist projects. However, the people that I've spoken with here say that the party has softened its stance on populism in recent years and now in many ways is indistinguishable from competing political parties. I suppose that as money becomes more plentiful and available, any sort of popularly derived governmental mandate for egalitarianism diminishes.

As I mentioned above, medicine is another large industry here with multiple medical (private and government), nursing, science and technology schools. There seems to be a fairly large hospital on every corner. Also, there are little pharmacies everywhere (literally one about every 25 feet) as well as imaging centers that offer ultrasound, CT, X-ray and MRIs. It's kind of strange. I mean, there's really not that many people here (<1 million) so it's a small city by Indian standards. I

It is described as quiet and laid back. I suppose it is compared to places like Mumbai and Calcutta. However, it still seems crowded and loud to me. It is relatively easy to find some streets and neighborhoods that have little traffic except some pedestrians, so that has been nice.

Attached are some pictures.

A looper...

So I jump ship in Hong Kong and make my way over to Tibet, and I get on as a looper at a course over in the Himalayas. A looper, you know, a caddy, a looper, a jock. So, I tell them I'm a pro jock, and who do you think they give me? The Dalai Lama, himself. Twelfth son of the Lama. The flowing robes, the grace, bald... striking. So, I'm on the first tee with him. I give him the driver. He hauls off and whacks one - big hitter, the Lama - long, into a ten-thousand foot crevasse, right at the base of this glacier. Do you know what the Lama says? Gunga galunga... gunga, gunga-galunga. So we finish the eighteenth and he's gonna stiff me. And I say, "Hey, Lama, hey, how about a little something, you know, for the effort, you know." And he says, "Oh, uh, there won't be any money, but when you die, on your deathbed, you will receive total consciousness." So I got that goin' for me, which is nice.

Pallium India

On Thursday and Friday, I spent time with an NGO here in Trivandrum called Pallium India. It is an initiative started by an anesthesiologist here to attempt to adequately address the (essentially) complete lack of palliative care services in Southern India. Of course, a few of the larger hospitals offer palliative care services but these are limited to wealthy people. Additionally, they tend to be in-patient services that simply manage pain at the very end of life. Since most people prefer to die at home with their families, these services really don't offer much.

So, several years ago, Dr. Rajagopal, became interested in this gap in care. He was working in Cochin at the time and starte his group up there, first as an NGO that was later morphed into a government run service. When he retired (forced age of retirement for government employees is 55) he moved back here to his home in Trivandrum. Once again, he noted the lack of adequate palliative care services and basically redid what he had started in Cochin. (Side note -- there is a tremendous amount of reinventing the wheel in medicine here)

He started the program in Trivandrum about 2 years ago, I believe. What they do is provide a variety of outpatient palliative care services to poor people. They have some donated space in a central hospital that they run a clinic 6 days a week. Also, because obviously not everyone from the local area can make it in to Trivandrum to be seen, Pallium India has a number of satellite clinics in the surrounding areas they staff as well. They travel to a given clinic (different village each day) and see patients each day of the week except Sundays. Finally, for those patients that cannot get to any clinic, they will do regular home visits with the frequency depending on the acuity of the patient. For example, we went to the house of a man with fairly advanced metastatic oral cancer who is in pretty bad shape. They said they have been seeing him 1-2 times/week recently.

The group provides medical care, pain management, nursing care (often doing dressing changes), social work services and spiritual counseling. In addition to the cancer patients (about 50% of the patients), the group also acts as primary care providers for poor patients with advanced chronic disease such as arthritis and diabetes. Many of the patients we saw without cancer were elderly women whose husbands had died and had no children living with them. Therefore, they were alone and some seemed to come just to have something to do. There also seemed to be a fair amount of depression being treated. In total, they told me they have about 600 patients on their census.

I think this is the coolest thing I have done here. Definitely not as funny as the condom factory. However, this was somewhat more satisfying and I was able to get some pictures. I found Dr. Rajagopal to be a fascinating man who is incredibly dedicated to his patients. The nurses, volunteers, students and doctors working with him were incredibly gracious and patient. I am deeply thakful to them for allowing me to participate. I learned a tremendous amount about the variety of cultural interactions here that influence the delivery f health care. For anyone who wants to know more about this group, there is a website, www.palliumindia.com.

This week

So this week, I've been spending some time at the Sree Chitra Tirunal Institute for Medical Sciences and Technology. It is a hospital that deals solely with cardiac and neurosurgical patients here in Trivandrum. I have been following one of the senior anesthetists around and observing some pediatric cardiac surgery. It is interesting to see that, in many ways the technology and training of the practitioners is essentially the same as the US. For example, the monitors and anesthesia machine used here are the same as in Boston or other major US medical centers. I think the major difference, is that there is no systematic approach to quality improvement or safety. There seem to be very few if any systems in place to prevent injury to the staff or the patient. There was discussion about a few strokes that have occurred over the past several months. When I asked what the etiology of the strokes was, I was told they just sometimes happen. There was no review of those cases to find any common threads that could be identified to prevent further events. That sort of approach wasn't even on the radar. So, I think that improvements here ultimately will have little to do with training or technology. Rather, there needs to be a sea change in the approach to evaluating care. There needs to be less of a blame culture and more open, self reflection. I think that this can only come about through the development of systematic approaches to evaluation, such as morbidity and mortality registers, complication databases, and the like.

Tomorrow, I'll be spending time with a remarkable organization. There is an anesthesiologist here who has pioneered a community based palliative care program that operates along community health models to reach poor people who would otherwise be unable to receive such care for end of life issues. More on that to follow. BTW -- I've almost reached my limit on dosa for a while.

And then there was Sunday...

It's been said that a picture is worth a thousand words. Good times in India....

Catching up from the weekend

We took a little tour of the Kerala backwaters on Saturday. We were on a little houseboat and just putzed around for a few hours. It was very nice and very relaxing. I kept having to remind myself that, not only was I still in India, I was only a couple of kilometers from the omnipresent buzz of human life that pervades this place. The backwaters were laid back, uncrowded, QUIET and tranquil. Lots of beautiful vegetation, churches, temples, mosques, and villages. One of the main forms of income is fishing in this area. Many of the little houses on the shore have large Chinese fishing nets they use to catch fish. Overall, quite a nice way to spend an afternoon.

Back to the task at hand...

Alright, I've gloated enough for the morning. It is bound to continue for at least several months. There's certainly a sweet, familiar taste of contentment and fulfillment when your hated rival falters. In this case it is an annual occurrence that you can plan for. Ha ha ha, you consanguineous degenerates.

In any case, we went to hear a lecture on Friday about Women's issues in Health in India. One of the things that was discussed is the proliferation of prenatal diagnostic clinics (ultrasound) that will determine the sex of the baby. This is important because of the 2 child limit here. Because in many families, boys are desirable, elective termination may be the result of finding out the baby is a girl. There apparently is a big problem with that here. In Kerala, it seems as if steps have been taken by the government and other advocacy groups to attempt to limit this behavior. By limit, I mean to not base elective pregnancy termination on sex, but rather on other things. I was wondering while this professor was talking about the moral justification of electively terminating a baby with a survivable condition such as Down's versus terminating a baby because of sex. It is entirely possible that I misinterpreted her statements and arguments, but I was left wondering why it is OK to abort a Down's baby but not a female. She did mention that disability advocacy groups are increasingly involved in the dialog, which I think is a good thing.

I don't mean to equate Down's syndrome with being a girl/woman. Rather, if people have the freedom to proceed with elective termination, why is one reason acceptable and another is not? I certainly don't think people should be selectively terminating girls, but on the other hand, freedoms come with consequences. It would seem to me that the root of the problem is the inherent value placed on boy children over female children. If I have mischaracterized her arguments and misstated her position, I am deeply apologetic.

The next stop was a center that promotes HIV/AIDS awareness and education for male sex workers. It was really quite something to see. It coordinates its efforts with other advocacy and education centers that focus on other high risk groups like female sex workers, etc. The group can be viewed as a model for how community based healthcare programs should be developed. It began as an NGO and through grassroots efforts in the local community developed community buy in and acceptance. It developed a database of its efforts and had clear health goals and a well defined target population. It was able to assess clear outcomes. Because of the well layed plans and early success of this center, the NGO was able to transfer control and responsibility to local governmental authority to continue its efforts. I was particularly impressed with the center's ability to alter public perception of these sex workers in only 5 years. I believe that part of that is a sort of shared denial between the sex worker and the family of the worker. When we asked if the families knew the father/brother was gay and a sex worker, the immediate and definitive response was no. Given the size of the community and the prominence of the center, I find it difficult to believe that people don't know. Rather, I think they choose to pretend to be unaware so the issue simply doesn't come up. It was interesting to see on one hand, a government funded agency specifically targeted at the health and education of male sex workers (which would obviously never happen in the current USA). On the other hand, no one will publicly live as a gay man because that is unacceptable. So, once again, I'm left thinking about how the US can, at times, seem so conservative compared to other parts of the world, and simultaneously so far ahead of those same parts of the world. Food for thought. For anyone interested, I will give details of the educational component of that lecture in person.

Finally, we went to a surgical hospital (finally, something that I can directly relate to) that offers a variety of subspecialty surgical services at a tremendously reduced cost. I spoke with the chief of surgery there, a neurosurgeon, about trying to follow outcomes. He said that was a good idea and now wants my help. So, I think I have found a little project in Kerala. Awesome.

The only picture from this is a demonstration of what a circumcision is. It's worth seeing.

Getting Caught Up

First of all, I haven't addressed some of the significant events in the world over the last few days. I would like to take a moment to remedy this slight. Let me paint a contrast for you. The unending struggle between good and evil. I think the pictures do more justice than my limited English skills can. For your viewing pleasure.

The Condom Factory

So there's good news and bad news. First the bad news, apparently, the condom manufacturing method employed here in Kerala is tantamount to stealth technology and we were banned from taking pictures. That absolutely killed me. The good news is that I now have an intimate knowledge of the process of making condoms. I do have one picture of a sample product they let us have.

Anyway, the factory and company are in reality quite interesting. It is a latex company that is run by the Keralan government. They make something like over 500 million condoms every year. Most of the product is marketed in India. The company also provides childcare, education stipends, and stipends for healthcare to its employees. The company, called Hidustan Latex Limited, is very involved in the community and has funded small public works projects including building municipal parks and other charity initiatives such as AIDS education. Finally, the company has "adopted" to children whose parents died from AIDS when they were young. Overall, the company is a fantastic corporate citizen. Keep in mind, this is a state run company.

Now back to the stuff I thought was funny. In each condom package, there is an insert that gives position suggestions. There is a series of 9 different inserts. I asked the PR guy at the factory if you won a prize if you collected all 9. The question was lost in translation and my only answer was a smile and a bobbing of the head. "Masti time"

The Big Tease

Let me create an image for you. It's about 0630, the air is thick with the smell of cooking fires, horns are already blaring on the street, I'm watching Loony Tunes cartoons in Hindi and we're getting ready to visit a condom factory. Should I ask if it is true that one gets no love without a glove? Pictures to follow this evening. Not to be missed.

Ayurveda

Today we visited an Ayurvedic school here in Trivandrum. Pretty interesting approach to medicine, but difficult for me to swallow. I guess it's just my years of training in a scientific approach to medical care. Anyway, they do some pretty cool stuff at the center. They essentially operate a small charity hospital and feed 1000 people free lunch every day. Good stuff for the community. I'm still trying to figure out the picture thing. The first picture is from the factory that makes the commercially available Ayurvedic compounds. It reminds me of Laverne and Shirley. The second picture is the place where the poor people can come get a free lunch. The third picture is from the herbal garden at the center. It's a good thing I came here because I have really been looking for a good uterine tonic. The last picture is the front of the complex.

Night before leaving

So I'm trying to get to sleep but I'm convinced that I've forgotten some significant item that will make or break my trip. The reality is that I've probably brought a bunch of crap I just don't need. Oh well, guess I'll find out tomorrow. Hopefully the hotel in Trivandrum will be OK. I'm pretty sure it cannot be more interesting than the first hotel I stayed in India in 2003. It would be described as quaint and rustic. Ah, the Giridih Hotel Swagat.... Complete with "electricity", bees, livestock and the obligatory Ambassador sedan.

Figuring it out

Still trying to figure this out. Gonna try to post a picture.

First post!

This is my first post. I will be trying to keep this blog while in India so people who may be interested can look at this and have some vague idea of what I'm doing.

http://www.youtube.com/watch?v=W45DRy7M1no