My final words...

As I look back at my pictures and think about my time in India, I realize that going to experience this country was one of the best decisions I have made in my life thus far. I remember arriving to Chennai, three plane rides and more than 20 hours later and thinking, "What did I get myself into?" Everything around me was new, yet now I realize that after a couple days all the honking, water-bottle carrying, hand sanitizer using and cattle watching, these were everyday things in India and I soon adapted to my surroundings.

I made a list of the top ten things I learned while in India.....Here it goes.....

10. Always be aware of your surroundings...I made the mistake of not watching before opening the car door in Jaipur and knocked two guys right off their bike. Lucky for me they didn't yell or scream. They just put their sandals back on, brushed off their shirts and continued their ride. :)

9. Beware of Indian monkeys....they may take your food when you're not looking. Luckily this didn't happen to me, but hey you never know.

8. Try to drive a rickshaw if you get the chance....this was definitely a once in a lifetime experience. Sorry to my fellow MSIVs who feared for their lives as I drove! :)

7. Bargain, bargain, bargain....I got some cool things for cheaper than cents all because of a lil' bargaining.

6. Nightclubs across the world are way cooler than those down the street.

5. Pap smear samples can be taken even with a tongue blade, you don't need those fancy brushes!

4. Don't use your left hand to pass something...that hand has a sole purpose (ask me why personally and I'll tell you)

3. There's always time to get away from work for a coffee/tea/lime juice break! :)

2. If you are lucky enough to go to India, you can't leave without riding an elephant....Bimpe and I rode an elephant to the top of Amber Fort in Jaipur. It was something I will never forget!

1. A head moving from side to side, does mean "Yes!" Ok, so you ask what does that mean? Well I never mentioned it before, but on our first day in India at the check-in desk of Avanna Hotel, we asked the hostess to tell use exactly what we were paying for in our deposit. In doing so, she began to bobble her head from side to side as a way of agreeing with us, yet since I had never seen that before in my life, I automatically thought she was becoming angry and giving us a head shake with attitude! It was the funniest thing ever. After that day we noticed that everyone, even little kids, do the famous head bob; and after a couple days finally interpreted it as a form of agreement with whatever you are saying. Even the waiters bobble their head as you say your whole order at a restaurant. Sometimes it can get confusing because you might confuse the bob for a maybe, but no...it does mean yes! I also noticed that only people in South India do this, since I never saw anyone in the north bobble their head. It was an interesting custom and I guess I became so accustomed to seeing it everyday that I still do it now! :)

Thank you India for everything you have taught me about culture, life, medicine, but especially about myself. My month there was an experience I wouldn't trade for the world. I am forever grateful to the contributors of the Paul Brand, M.D. scholarship for making all this possible. Thank you!

Elephantiasis

As you walk on the streets in Vellore, you will most likely see a person such as the man above, with an enlarged, edematous lower extremity, which is a common manifestation of a condition called elephantiasis or lymphatic filariasis. According to the World Health Organization, over 120 million have been infected and a third of those infected live in India.
The cause of this infection is due to the thread-like, parasitic filarial worms (Wuchereria bancrofti, Brugia malayi and Brugia timori) that multiply and circulate in the lymphatic system causing obstruction of the fluid secondary to the inflammation produced as a defense mechanism against the worms. These worms are transmitted by mosquitoes which ingest the microfilariae circulating in the blood of an infected human. The microfilariae develop into larvae and are then passed to other humans when the infected mosquitoes bite them. This type of infection is common in underdeveloped countries such as India, due to the rapid and unplanned growth of cities, thus creating breeding grounds for the type of mosquitoes that transmit these worms (3). The mosquitoes that act as vectors are usually from the following scientific genera: Anopheles, Aedes, Culex and Mansonia. It is known that W. bancrofti is mainly transmitted by the Anopheles genus and B. malayi transmitted by the Mansonia genus. Infection usually occurs due to a large number of microfilariae, and thus many infective bites are required to reach that number. Therefore, those people living in areas endemic to this infection are more likely to become infected versus people traveling to the endemic countries for a short period of time (1).
People usually become infected as children; yet don't start manifesting symptoms until adulthood. Signs and symptoms vary from person to person and are different in the acute and chronic settings. Acutely, a patient may have three main symptoms of fever, lymphangitis and lymphadenitis. The fever is usually called "filarial" or "elephantoid" fever and is known to be immune-mediated in nature. Lymphangitis, or inflammation of channels within the lymphatic system, is typically seen in the extremities or genital regions, accompanied by erythema and edema along the channels. Lymphadenitis, or the development of nodules in the lymph node areas, is due to collection of the worms within the lymph nodes and lymph vessels. Though some patients present with acute symptoms, others infected with the microfilariae have no obvious symptoms and are known to be infected only because of the levels of the microfilariae in their blood. This will then put them at a higher risk of developing the chronic symptoms (1).
Chronic symptoms of filariasis are more of what I saw while in India. As mentioned before, it most likely appears in adulthood and more often in men than women. A hydrocele is a common example of a chronic manifestation and is due to the high numbers of worms found in lymph vessels around the scrotal area. Lymphedema is also a sign of chronic infection and includes the development of edematous extremities secondary to the collection of lymph fluid due to the destruction of the lymphatic vessels by the worms. The most debilitating and shocking of the chronic manifestations is elephantiasis, which is thickening of the skin and underlying tissue most commonly in the extremities, genitals and breasts due to the prolonged obstruction of the lymphatic vessels (1). Living with this manifestation can also be a social stigma in these underdeveloped countries secondary to the disfigurement and shame it can cause the infected individual (3).
Until recently has the diagnosis of this infection been available. In the past it could only be detected microscopically with the visualization of the worms. Yet this was a difficult task in itself because these parasites were found to have what scientists call a "nocturnal periodicity", therefore limiting their appearance in the blood to hours around midnight. Now a very specific and sensitive test to detect the filarial antigen is available and can detect whether a person is infected with only a few drops of their blood (3).

In order to completely treat the infection, the worms must be killed in their adult-stage. Albendazole and diethylcarbamazine citrate (DEC) have both been shown to be effective as single therapies or the combination of both albendazole and DEC or albendazole and ivermectin have been shown to be 99% effective (1). Currently it is though that in order to completely stop transmission of the parasite, the combination of drugs must be taken every year for 5 years (2). The treatment can improve the symptoms of lymphatic filariasis, yet progression of the serious symptoms is augmented with secondary infections from bacteria or fungi to the infected extremities (3). Prevention of these secondary infections is an important factor, and education of proper hygiene and care for infected extremities is also necessary for the population with literature that is easy to comprehend such as the above pictorials.
Individual treatment is important to help a particular patient with their symptoms, yet treatment with a community-wide focus is more important in an endemic country such as India. Since the parasite is transmitted by the mosquito vector, using insecticides can help tackle root of the problem. It is also important to halt transmission of the microfilariae from the blood of one infected individual to many other individuals, so treating the masses with the proper regimens, even if the vectors are not controlled, can also play an important factor in elimination. As an example for mass control in other countries where filarial infections are endemic, DEC has been added in small amounts to help control the spread of infection and has shown to be successful (1). In India, the 2006 mass drug administration campaign was delayed a year and began in 2007 with 74,840,000 people being given the combination of albendazole and DEC. Details about the campaign's success are not currently available (4).
In researching this topic, I came across a website called, The Global Alliance to Eliminate Lymphatic Filariasis. This alliance was formed in 2000 with the purpose to eliminate lymphatic filariasis as a public health problem by 202o and to alleviate the hardships of individuals suffering from disability secondary to lymphatic filariasis (2). The alliance has made some dramatic leaps in eliminating filariasis with its implementation of mass drug administration, yet there is still much to be accomplished in order to reach their goal. I feel grateful to have seen this problem in person and now know more about its etiology, symptoms and treatment. I hope to one day hear that this parasite has been eradicated from the world, maybe even during my medical career.

References

1) Hills-Evans, Kelsey. "Lymphatic Filariasis." [Online website.] March 2008. http://www.stanford.edu/class/humbio103/ParaSites2006/Lymphatic_filariasis/index.htm

2) A Future free of LF, Global Alliance. "The Global Alliance to Eliminate Lymphatic Filariasis." [Online website.] March 2008. http://www.filariasis.org/index.htm

3) World Health Organization. Health Topics. "Filariasis." [Online website.] March 2008. http://www.who.int/topics/filariasis/en/

4) World Health Organization, Geneva. Weekly epidemiological record. "Global programme to eliminate lymphatic filariasis." No. 42 (2007): 361-380. http://www.who.int/wer/2007/wer8242.pdf

Images (in the order in which they appear)

"Elephantiasis.gif." Yahoo search of elephantiasis pictures. Retrieved March 10, 2008.

"Life Cycle of Wuchereria bancrofti." Parasites and Health. Filariasis. May 2004. Retrieved March 10, 2008 from http://www.dpd.cdc.gov/dpdx/HTML/Filariasis.htm.

"How can we manage LF?" The Global Alliance to Eliminate Lymphatic Filariasis. 2000. Retrieved March 9, 2008 from http://www.filariasis.org/resources/managelf.htm.

"Microfilaria of Wuchereria bancrofti, from a patient seen in Haiti." Image Library. Filariasis. August 2002. Retrieved March 11, 2008 from http://www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/Filariasis_il.htm.

The Golden Triangle

My last week in India, Bimpe and I planned a trip to the Golden Triangle which includes the three cities of North India- Jaipur, Agra and Delhi. Before heading up North, we visited Bombay (Mumbai) and meet up with Neha and Ruchi, two other students from our class who were doing rotations in Delhi.
Bombay was interesting. It is known as the wealthest city in India, yet has about 90% poverty on its streets. We visited the Gate to India, where the British first arrived when they reached the country, and toured the best hotel in India called the Taj Mahal Palace. It was amazing and had all the best shops located inside. We also visited one of the shores and saw some of the homes of the famous Bollywood actors. We even visited a nightclub not really expecting much, but to our surprise it was so much fun and the music was even better than in the states!
After our fun weekend in Bombay, we flew to the North and started our week of travel in Jaipur. I had heard that Jaipur was amazing, yet I really didn't realize it until we got there. It is known as the "Pink City" since many of the buildings have a pink color because of the type of clay used to build them. It was so cute and the shopping was unbelievable! We visited the Jantar Mantar, which is a famous observatory build by an astronomer about 200 years ago. It was really cool to see how the instruments could give you the local time based on the sun within minutes of the time on one's watch. We also toured one of the famous palaces, now called City Palace Museum. The architecture and views were great and the museum of art and artifacts was interesting. Outside of the museum were two large silver urns that were used by a king to carry his water on all his trips away from India. They were huge!

Our second day in Jaipur, we went to the beautiful Amber fort and were lucky enough to get the famous elephant ride to the top of the fort. It was so much fun and an experience I will never forget! Seriously, how can you go to India and not ride an elephant?! (Bimpe informed me that Indian elephants have smaller ears than African elephants, which I thought was a cool fact.)

Our last day in Jaipur, we went to Chokhi Dhani, which is a renactment of an typical village from Jaipur in the past. It was fun and we got to see cool dancing and eat traditional North Indian food.
Next we travelled to Agra. There we visited the Agra Fort and the next day we saw one of the seven wonders of the world...the Taj Mahal!!! It was indescribable to actually see this beautiful monument and everything about it was perfect. It is known as a symbol of love and was built by a king for one of his wives after she died. It is so perfectly made that it took 22 years to build.
Our final stop was in Delhi where we saw the home of India's president and some of the different parliament houses. We also saw a tomb of one of the king's and visited the famous lotus-shaped temple. In one of the markets we got some henna artwork on our hands, which is traditionally done for a Indian wedding or party. It was really cool seeing the man draw the designs freehand and the ink dried in about 30 minutes. This week of travel was amazing and I feel fortunate to have been able to visit these places and experience many new unforgettable things!

Karigiri

Yesterday we took a trip about 20km from CMC hospital to Karigiri, where the leprosy hospital is located. It was established in 1955 to care for the leprosy patients in and around Vellore and as a center for leprosy research. Due to advances in the treatment of leprosy, it has evolved into a hospital with multiple departments for that particular area near Vellore. It is now called the Schieffelin Institute of Health Research & Training Centre, named in honor of Mr. William J Schieffelin, the then president of American Leprosy Missions.
We took a tour of the hospital grounds and learned about the lastest research in leprosy that is currently being performed at the institute. We also toured the building where they make prosthetics for the diabetic and leprosy patients.
Afterwards, we stopped by the outpatient center for another tour of the facilities. One of the physical therapists showed us how he performs a diabetic foot exam and explained the different instruments he uses to assess neuropathy in a diabetic foot. It was an interesting trip and I felt honored to visit the place where Dr. Paul Brand performed many miracles for the leprosy patients during his time at the institute.
Tonight we had a going away dinner at Darling Hotel to talk about our experiences over the last three weeks and to wish everyone good luck in their future medical careers. I feel lucky to have met so many wonderful medical students from different parts of the world and learn from their perspectives on medicine. It was a fun night yet a little sad because we were all going our separate ways. I hope to keep in touch with some of the cool people I met during my time at CMC.

CHAD is awesome!

So my last two days have made this whole trip worthwhile. Going to the villages and meeting the people is reason enough. They are so friendly and so grateful, it's just amazing.

Yesterday I went on what the Community and Health Development Department calls "Nursing Rounds." Basically, one nurse and a community health aide who usually lives in the village, design a plan to make home visits to particular patients within that same village. The village we visited is called Palavansathukuppam! There are about 5,000 people who live in that village, and the health aide who lives and works there for CHAD named Janasee, coordinates the visits for all these people.

During the day, the main objectives are to do well baby checks, antenatal checks and chronic illness checks for things like blood pressure and blood glucose. This particular village was located fairly close to CHAD hospital, which is a different hospital located near campus. According to the nurse I worked with, even though the hospital is close, home visits are still necessary because the village patients would not go to the hospital otherwise.

We saw a variety of patients from pregnant moms to preterm babies to geriatric patients. At one home we checked a pregnant mother for fundal height and blood pressure and her friend whose house we were in showed us her tongue. Because it was so pale, it was obvious that she was anemic, so because of the home visit we were able to refer her to CHAD and get her some help as well.

In another home we visited a baby who was born at 34 weeks gestation. The baby was still underweight, yet he was growing appropriately. One interesting thing was while we were there the baby got hiccups, so the mom put a leaf on top of his head as a remedy to make the hiccups stop. I don't know if it worked because we left soon after that, but it cool to learn a remedy that the villagers believe in.

Today was a great experience. I went on "Doctor's Rounds," which is similar to nursing rounds except the patients in the village come to a certain location at a designated time and in the van physical exams are performed and outside patients are seen for acute and chronic conditions and get prescriptions which are filled instantly since the medications are taken to the villages.
The day started out with health education by one of the residents. Today's talk was about hypertension and its effects on the body. It was great to see the people so interested in their health. One interesting case in this village was about a family of 5 siblings whose father had a history of progressive spinal cerebellar degeneration. Currently three of the siblings, two females and one male, have different severities of the same disease and a group of researchers from Chennai are studying their family's pedigree and looking to see if there is a relationship between the severity of the degeneration and number of tandem repeats in the gene known to cause this debilitating disease.
We then travelled to a different village and used the same system of seeing patients. In the third village we visited, named Arcottankudisai, we started with a visit to a 17yo female's home with a history of a cobra snake bite about 2 years ago and subsequently her muscles became paralyzed and she became blind. Over the last two years though, with physical therapy and treatment of anti-venom, she can now stand and walk a few steps on her own and she has progressively regained her vision. It was sad knowing that if she had transportation to the hospital that day two years ago, she may have never suffered these losses because the anti-venom could have prevented it if given soon after the bite.

Here the women were very kind and grateful. As I was helping the intern tally the patient population, I felt someone putting something in my hair and realized it was flowers. Whenever I see the older women from the village, I think about how much they possibly endured living in this village their whole lives and what interesting stories they might have for younger women such as myself.

I also saw a 6yo girl with tetralogy of fallot who never had surgery to correct the problem and now lives with heart failure at such a young age. We wrote her prescriptions for Lasix, Digoxin and potassium. I also noticed the clubbing of her thumbs and great toes, which is a sign of chronic heart failure. One other woman was seen for her elephantiasis, which is when there is swelling and thickening of the skin usually in the legs and genitals due to a parasitic nematode worm.

At the end of the day, all the children from the village were returning from school. The tallest girl in the middle of the picture started talking to me and asked me my name and if I was from CMC. Once the other children saw her, they all wanted to gather around. They were all so cute and when I wanted to take pictures of them, literally 40 children surrounded me! It was cool interacting with them and seeing their smiling faces.

At the end of the day as we drove away from the villages back to CHAD, I realized all the positive aspects of this community health program and how many lives were impacted in just one day.

Off to Bangalore

The reminder of my medicine week was interesting. We did some more ward rounding and outpatient clinic work. I did see a 34yo female patient with somatization, which to a doctor means she may be using her physical complaints to mask emotional problems because her chart was filled with notes from many different departments, yet all her tests were negative. It was difficult to explain to her that we couldn't find anything wrong, so Dr. George gave her a psychiatry referral.
I also saw a 46yo male with 9% eosinophils on his CBC differential (which by the way is a sign that the patient may have a parasitic infection because the normal count is around 1%). Come to find out he has strongyloides, which is a roundworm that lives in the mucosa of the intestine. Don't worry though, we gave him a prescription for albendazole which should cure it. Speaking of prescriptions, I like how I can walk down almost any street and find a pharmacy with a sign that reads, "Dr. So and so, Druggist and Chemist." (Whatever that means.) Because of all the pollution and dust, I've had to buy the Indian version of Zytrec and Flonase. The good thing is that they work pretty well and they are definitely cheaper than in the states!
This weekend Bimpe and I went to Bangalore, which is described as the "IT" (information and technology) city of India. Surprisingly at one point I felt like we weren't in India anymore because the city has some developed areas and there are huge malls and great restaurants. We decided to go by train, which wasn't as bad as I thought. We even ate the Indian version of McDonald's!
Touring the city was nice. We went to the Iskcon Temple, which is similar to the golden temple in Vellore, but definitely not as captivating. In the temple people were chanting, "Hare Krishna, Hare Krishna, Krishna Krishna, Hare Hare, Hare Rama, Hare Rama, Rama Rama, Hare Hare." I read that you are asked to chant these words a minimum of 108 times daily! We also went to a palace where Tipu Sultan (I think he was a king) lived in 1790 AD. It was interesting and if you are not from India you have to pay 100Rs to see it!
The best part of the tour was visiting the botanical gardens. There are beautiful flowers everywhere, ancient trees and monkeys playing on the sidewalks. It was refreshing to get away from the busy city streets and enjoy the nature around me.

I can't believe my trip is already half-way done. The time has flown by and there is still so much for me to see and learn. It is fun to meet people from different places as I travel and ask me if I'm from any country you can think of. Everyday I'm from a different part of the world! So far I've been asked if I'm from North India, Nepal, Australia (I don't know where that one came from), South Africa, Malaysia and Indonesia!!! I guess these people haven't see to many people from Mexico. :) Tomorrow I start my Community and Health Development Week which should be exciting. I am looking forward to meeting the people who live in the villages and I hope to see and learn some new things!

Harrison's Textbook in Person!

Yesterday we went to the Golden Temple called Mahalakshmi. It is located on 100 acres of land at Sripuram, near Vellore, and is headed by the spiritual leader Sri Sakthi Amma. He is said to be the reincarination of three sisters, so his physical appearance is male yet his soul is female. The temple, covering 55,000 sq ft, has intricate carvings and sculptures in gold. Except for the star-shaped pathway, the entire structure is composed of gold and copper and has quotes from the Bible and the Quran displayed on either side. I read that it is worth 160 million USD, which is ridiculous considering all the poverty that surrounds it.
We went around sunset and it was an amazing sight. You walk up to the temple on the pathway for what seems like forever and finally when you get there it's a huge temple made out of pure gold and the crowds are endless. At the end we all got a red dot on our forehead which represents a third, inner eye that everyone receives after leaving the temple. It is a Hindu tradition to have three eyes, two for seeing the outside world and the third to focus inward towards God. Here's a picture of us with our third eye!
Yesterday I started medicine with Team II in the outpatient clinic. It was cool seeing some of the same diseases that people in the states have, like the average hypertension and diabetes. There wasn't anything too different or exciting and Dr. George was a good teacher.
Today though was a completely different story. Team II had what they call, "Grand Rounds," in which we round on all the Team II patients in the MICU and Ward C. It's about 50 patients total so it took a good 41/2 hours, but it was really cool and Dr. T. David is an awesome teacher.
Here is a list of some of the patients I saw....
1. 35yo F with pneumococcal meninigitis
2. 32yo F with Rickettsial infection, scrub typhus type with eschars on her abdomen
3. 27yo F with middle cerebral artery stroke with history of pre-eclampsia during here first pregnancy
4. 60yo M with organophosphate poisoning on a ventilator
5. 28yo F with another Rickettsial infection, Rocky Mountain Spotted Fever (one of the classic diseases we learn about to cause a rash on the palms and soles)


6. 23yo F with oleander flower poisoning causing complete heart block because of the cardiotoxicity of the substance in the seeds (supposedly there's a lot on campus so I'll be staying away from those!)
I can't even imagine a ward like the one I was on today. It was like each patient was from a different chapter in Harrison's textbook, except rather than reading it, I was learning about it in person! There were many more patients with classic medical problems, but the above were a few of the ones that I might not ever see again in my medical career. I am so excited that I was able to see only a sample of what the medical students from CMC see on a daily basis.