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!