Week 2 (June 25th – June 29th)

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Going to our next destinationThe second week starts full of diverse activities. On Monday morning, we visited the Humsafar Project in Vakola, Santa Cruz (East) (www.humsafar.org). The purpose of our visit is to gain an understanding of level of preparedness and awareness that exists in India about HIV. As I enter the room where the presentation was an about to begin, there were Psychology students that are getting ready to become counselors. There were about 25 of them, men and women, almost in equal numbers. As we come into the room we are offered India tea and biscuits (lovely! What else I can ask for?).

The Humsafar Trust Project was set up in April 1994 by the leading gay activist
Ashok Row Kavi along with two more self-identified homosexual men who desired to reach out to the gay population in the Mumbai Metro and surrounding areas. After much networking and advocacy with the Mumbai Municipal Corporation for over a year and a half it became the first openly Gay Community Based Organization to be allotted space in a Municipal building at Vakola, Santacruz (East) Mumbai in October 1995.

Main Goals

HIV infection prevention in risk groups

Advocacy, sensitize schools, colleges and communities about HIV and AIDS

Capacity building-mobilizing different communities

Research, explore ideas to find out what the community needs and assess their knowledge about AIDS and HIV infection

Assess and understand the extent of different behaviors that exist in India within the population and reach out to offer programs of assistance for these communities.

Reach out to rural areas and isolated communities with the capacity to provide them psychology, testing and counseling services

One of the main goals of the Humsafar project is to report cases of HIV in India. Through its commitment in community involvement and work in an ethnical diverse society as India is, this organization has to overcome many stigmas. Some of the important methods in HIV prevention are:

Distribution of condoms to promote safe, and responsible sex.

Providing resources to the Indian community in the form of HIV testing, targeting interventions, and screening movies that promote activism and prevention.

There is also a center for women called Womeng center located in Santa Cruz West. The numbers of HIV infected women are rapidly increasing. These groups of HIV infected patients are challenging to reach out because of the language barrier. There are 26 different dialects that are currently spoken in Mumbai alone. There is a location barrier because of where these women live, usually impoverished, isolated towns that lack the basics resources as electricity, sewage and running clean water. One of the important issues talked about was the challenge in overcoming a patriarchal society, where women are told what to do, and are expected to perform and fit a specific role: wife, mother, homemaker, and child-bearer.

The population that the Humsafar Project targets is most MHSM, which stands for Men Having Sex with Men. In particular, this group has a higher risk of HIV infection than women to women HIV transmission.

Some of the important components of the center are:

A research unit, which deals with issues that arise with parents and relatives of HIV patients.

A counseling unit that provides assistance to patients with HIV information sessions, personal counseling, weekly events as group workshops and a support system.

There is also a testing center that provides access to HIV accurate testing through ELISA, which is a test that measures the levels of HIV antibodies in the blood.

Confidentiality is kept at all levels, from the time they are interviewed by the physician about their condition and symptoms until they reach to receive mental-and psychological assistance sessions with a counselor.

Some of the main concerns that MHSM have are:

The fear of letting their parents, spouse and relatives know about their homosexuality.

Most of them have difficulties accepting themselves and the reality of homosexuality in their lives.

To deal with pressures that families expect to be fulfilled as of marriage, and having children.

As the session went on, different members of Humsafar Project introduce themselves and spoke about the goals and main objectives. After the presentation was finished, there was time for Q&A. One of the questions that struck me was why homosexuality is not socially accepted in India, after so many years?

The head counselor decided to answer the question. She plainly said that the reason why homosexuality is still not accepted is because is considered immoral by the majority of Indians. She affirmed that the level of education that people have does not have anything to do whether homosexuals are accepted or rejected in Indian society. Although the fight still continues to break the homosexual stereotyping the road to travel is difficult. Indian society has its moral values highly tight with its religious beliefs.

Later on that day, after the session ended, we headed to the Student Health Center at University of Mumbai, Kalina Campus for a presentation on HIV-AIDS and STD Control Program in India by Dr. Vaswani.

Dr. Dilip Vaswani works with the Future Group International India Pvt. Ltd, based on Washington D.C., which purpose is to aid people infected with HIV, and other sexual transmitted disease infections in India. There has been a total investment of $30 million dollars exclusively for nurse training for HIV care in India.

Not only the control of HIV has been an increasing concern but also Dr. Vaswani assured us that the management of STD’s might contribute to HIV control. There is a great level of ignorance about the nature of the disease, stigma and unawareness of being HIV infected.

There are a low percentage of infected women, because it is not being properly reported. India is a man-dominated society where women are not allowed to attend the doctor by themselves. I have witnessed this during my first week in clinical rotations. Women see their physician either with their husband, mother in law, sister, a friend or even a female neighbor. This increases the possibilities of the patient to hold important information to their physician for proper medical diagnosis.

The most accurate method to diagnose HIV is through a clinical diagnosis. This leads to a 50% correct ratio of accurate HIV diagnosed cases and the other 50% due to mixed infections. Due to the similarities in the symptoms, a clinical diagnosis is confirmed with the results from the ELISA test.

Important components of clinical diagnosis are:

To identify STI symptoms, offer confidentiality to the patient, ask to bring their partners, and provide condoms as a prevention method of infection.

The medical provider or physician should learn a different approach when treating HIV infected patients. It is important to use the appropriate language when explaining the patient the different stages of the disease and the social stigma that come with it. Keeping the patient’s privacy is most important; especially because it will dictate whether a relationship of trust can be developed between patient and physician. Being non-judgmental and becoming culturally sensitive to HIV infected patients must be a priority when physicians counsel and treat these patients.

In this presentation, Dr. Vaswani provided a great source of information for me personally. I have learned that you don’t only need to be a competent physician but mainly a compassionate one when treating patients with diseases that have a very strong social stigma and suffer discrimination from their own families, and relatives.

Some of the sexual transmitted diseases that were presented include syphilis, chlamydia, chancroid, granuloma inguinale, herpes genitalis, LGV, Gonorrhea, Vaginal discharge, genital warts. Symptoms, specific characteristics and treatment were also mentioned for each one of them.

The method of treatment for HIV in India is called Syndromic Management. Doctors are trained to monitor HIV through antibody scan in the blood, administer antibiotic treatment, and to constantly provide sex education to the patients.

History of HIV in India

Human Immunodeficiency Virus, better know as HIV, had its first case in India since 1986. In 1990 the National AIDS Control Program was established with the goal to increase testing capacity, awareness and slow down the spread of HIV.

Nowadays, it has already infected 2.5 million people in India. 1/5 of the total cases are in the state of Maharashtra. The group age affected is between 15 to 49 years old. Apart from HIV being a sexual transmitted disease, some of other ways of infection are through blood transfusion, needle sharing in drug use and from mother to child.

Some of the most common symptoms include persistent diarrhea, high fever, and loss of weight. There is high incidence of Tuberculosis co-infection with the management of HIV due to the immunosuppression caused by HIV.

Prevention of HIV is the most effective way to cure and stop the infection worldwide. Other methods include post-exposure prophylaxis and close monitoring of ART (Anti Retroviral Therapy) patients.

As a final review to the presentation, there is a video that Dr. Vaswani shared with us, Here is the link:

http://www.boehringer-ingelheim.com/news/news_topics/HIV-AIDS-news.html

Getting ready for the Rural Rotations in Panvel

 Yeap! Tuesday has arrived. It is 9 am and I am already coming down the stairs of the hostal to meet Claver, the local coordinator, to take us to the Kurla Train station. We are taking the train to Panvel. He is coming with us, but he does not travel in the same train wagon. There is still sex segregation in India. Women and men, or should I say men and women in India ride in separate train wagons, enter temples, airports, and government buildings through separate doors.

Train ride to Panvel

As we boarded the train, I found seats by the window. I would like to see if there is a change in scenery as we leave Mumbai behind. And there is! It turns out that the farther away you are from Mumbai; the number of green land increases and becomes such a beautiful place to see. There are hills at a distance that are entirely covered with dense, thick vegetation. It has that shade of green that peace to your mind and heart. The air feels cleaner and lighter when touches my face. Then, the rain started and stopped just as nature would have realized that is was not time to rain yet. Many other women come and go. As we got closer to our destination, the train stations became modern, and looked cleaner. Newer benches were in the flyer free platforms and trash bins were strategically located along their length. New train stations have been built as the population of Mumbai increased. It has been a challenge for the state and city governments to provide adequate infrastructure due to the constant migration and rapid population growth in the city.

According to the 2011 census, the population of Mumbai was 12,479,608. The population density is estimated to be about 20,482 persons per square kilometer. The living space is 4.5sq meter per person. Mumbai suffers from the same major urbanization problems seen in many fast growing cities in developing countries: widespread poverty and unemployment, poor public health and poor civic and educational standards for a large section of the population. With available land at a premium, Mumbai residents often reside in cramped, relatively expensive housing, usually far from workplaces, and therefore requiring long commutes on crowded mass transit, or clogged roadways. Many of them live in close proximity to bus or train stations although suburban residents spend significant time traveling southward to the main commercial district creating uncontrolled traffic congestion.

It is about 10:30 am and we have officially arrived to our destination: Panvel. Our first stop is the Alok Dermatology Clinic of Dr. Dipak Kulkarni. He has been practicing medicine in India for over 23 years. Before patients come into the consultation room, he gives us a brief introduction of the health care system in India. He starts by explaining that every Indian citizen has access to medical care at municipal hospitals for very low-cost, however there are not specialists at these hospitals, and if there is a need to see one, the patient has an out-of-pocket expense, that many times, they can not afford.  There is high demand for physicians that are specialists, especially dermatology. The types of cases that he treats are infectious diseases (leprosy), non-infectious diseases (scabies, vitiligo, fungal infectious, psoriasis, eczema), cosmetic issues (acne, hair loss, reduction of skin tone, wrinkles, etc). His clinic employs 5 to 8 physicians to keep up the high volume of patients that can sum up from 70 to 80 daily. The clinic is open 12 hours a day, 6 days a week. Some of the physicians do home visits offering a more personalized care. He told us that patients that can afford the expense are willing to travel over 100 km to come to his clinic to see a specialist rather than to go to a municipal hospital where medical care is lower than standard. The waiting time would make them lose a day worth of wages and the hospitals are overcrowded. He mentioned the status of leprosy infection in India and how often he treats leprosy patients, that is, because many of them come to treat scars left from unhealed wounds caused by leprosy. Although leprosy cases have been dramatically reduced in India, nonetheless, the number of reported cases still continues to occur 6 in 10 000 in the population. He affirms he has an average of 200 leprosy patients a month that are following treatment.

During the hours we spent at his office, he was able to see over 10 patients. Due to the constraint of time (which I though it did not exist in India because people just seem to find time to do everything, even to chat with strangers that do not speak Hindi = me) Dr. Kulkarni spent an average of 5 to 10 minutes with each patient. There was no interaction between the physicians and patient as the one I saw at Dr. Mehta’s or Batla’s office. The consultations were straight to the signs and symptoms, and diagnosis was followed. The goal is to see maximum number of patients (and, yes, in some circumstances make medicine profitable). Are physicians loosing their personal and human side required to practice the best medicine? Or is there a way to become a highly efficient physician and at the same time inspire trust and confidence from the patients?

I am in the personal hunt for these answers. Regardless of the pressures of time and money that medical providers face, I believe it comes down to the physician personal choice. Whether they choose to spend an extra 10 minutes in a consultation room with their patients or not, it means that they would have to spend 10 minutes less in anything else they want to do, or become highly efficient in another task that would have taken 10 extra minutes to do. Whatever is that they decide to do, I hope that is in the best benefit of the patient’s health and they place that as their ultimate goal.

 Some of the cases seen at this Dermatology clinic were:

A 16 year-old female with Pityriasis Versicolor. This is a condition characterized by a rash on the trunk and proximal extremities. Caused by the Malassezia globosa fungus, although Malassezia furfur is also responsible for a small number of cases. These yeasts are normally found on the human skin and only become troublesome under certain circumstances. immunosuppression, warm and humid environment are some especially during monsoon season.

A 18 year-old female with premature gray hair. She seem to be very concerned about it because she was not married yet and gray hair is not accepted in Indian culture in young women. Dr. Kulkarni explained to us that beauty is race specific and women have to deal with issues that involve their hair color and skin tone.

A 22 year-old male presenting a cyst on the left side of his face for the last 4 to 5 months. There is no pain on the site. Dr. Kulkarni suggested a surgery to remove it because of the size and where it is located. A possible reason for the cyst is due to sebaceous deposits. They are usually smaller and they can be drained; however due to its size it is better to have it remove surgically.

A 29 year-old male presented with Androgenetic Alopecia. This is the most common cause of hair loss and thinning in humans. This condition is also commonly known as male pattern baldness. In classic pattern baldness, hair is lost in a well-defined pattern, beginning above both temples. Hair also thins at the crown of the head. Often a rim of hair around the sides and rear of the head is left. Hair loss is related to hormones called androgens, particularly dihydiotestosterone (DHT). Male pattern baldness is caused by a genetic sensitivity of hair follicles to DHT. This hormone causes follicles to shrink or “miniaturize”. In turn, this shortens their lifespan and prevents them from producing hair normally.

As our visit winded up at the Dermatology clinic, lunchtime had arrived. Dr. Kulkarni leaves his office at 1pm and comes back at 3pm to continue treating patients. Our local Panvel coordinator came to pick us up to take us to the local restaurant for a bite to eat. The restaurant was crowded, almost no empty tables, full of men ordering lunch. Multiple silver plates were carried in one arm and delivered promptly to the corresponding table. There was steam coming out from the kitchen window that faces the dinner. The smell of hot oil wraps you in and invites you to find a seat closest to the kitchen.  Naan or rotti?  our waiter asked as we finished placing our order. Naan, please. Plain or Buttered? Plain will do. Naan is a leavened, oven-baked flatbread. It is typical of and popular in West, Central and South Asia. Naan is cooked in a tandoor, which is a cylindrical clay oven used in cooking and baking, and where tandoori cooking takes its name. This distinguishes it from roti, which is usually cooked on a flat or slightly concave iron griddle called a tava. Modern recipes sometimes substitute baking powder for the yeast. Milk or yogurt may also be used to give greater volume and thickness to the naan. Typically, it will be served hot and brushed with ghee or butter. It can be used to scoop other foods, or served stuffed with a filling.

 

To my surprise, a salad consists of sliced tomatoes, carrots and cucumbers seasoned with some spices. I have been craving raw vegetables since I arrived in Mumbai, so I was gladly surprised with a generous portion of them and ready to dive in. I decided to stuff the naan I ordered with the vegetables and some of the chutney that were at the table. Chutneys are fresh and pickled preparations made of any combination of vegetables, fruits, herbs and spices. They are usually grouped into either sweet or hot forms; both forms usually contain various spices, including chili, but differ by their main flavors. Simply delicious!!!

We were then taken to Kushtarog Niwaran Samiti. It is located approximately 2 hours from Mumbai, and 20 minutes from Panvel railway station. Spread over a 122-acre plot in Wakdi village, off the Panvel- Matheran road, the Shantivan ashram has been treating and rehabilitating leprosy patients for 50 years. Mahatma Gandhi was one of the first Indian leaders take the initiative to eradicate leprosy. The ashram was founded by two Gandhians, Annasaheb Dastane and Apasaheb Vedak, with the government granting them a 70-acre plot in Panvel taluka where the prevalence of leprosy was as high as 150 persons per 10,000. Thanks to the samiti’s work, the prevalence rate has come down to six per 10,000. With more time at its disposal, Shantivan has expanded its activities to rural development besides adding a residential school for adivasi (indigenous minority in India) children, a home for the aged, and a home for the invalid, a cooperative credit society and a naturopathy clinic. These activities on the campus also help convey the message that leprosy is not hereditary, that it is curable and that patients need not be isolated as this is the least infectious of diseases.

Lizard crawling!

According to Uday Thakar of the samiti’s managing committee, Shantivan has 110 patients at its campus and 350 others in its units spread in 185 neighboring villages. There are around 100 000 thousand leprosy patients today and around 60 per cent of them Indians. In Maharashtra, the number of registered patients is around 41,000.

We were taken to the bungalows located in the back of the plot. They have been used to host CFHI participants for the last couple of years. They are simple, wide rooms with two beds and a bathroom. They are all we need for the next three days of rural rotations. There are families that live here year round. One of the most beautiful and peaceful places I have ever visited. I took one of the chairs out to the porch and I just enjoyed what is before my eyes. There were children playing around, a man walking two cows, puppy dogs running back and forth, a small lizard crawling on the wall of the porch, a group of elder men having a conversation across the road and in the background T.V. noise coming from one of the neighbor’s home.

Recovered Leprosy patient Senior Home in Panvel

The following morning we are taken back to the city of Panvel where the Purohit Clinic is located. But before we arrive there, we make a stop at the local market for some chai tea. Our presence caused a bit of a deal once we starting browsing the shops. It is close to 10 am and most of them are already open for business. Here in India, the days start late and they end late. Normal businesses hours are from 10 am to 8pm or even later than that. As we walked through the market, I took pictures of the locals and what they sell. There was a rancid but familiar smell that makes me look for…. anchovies! They were sun dried and sold by the kg. Flies buzzing around them trying to get their fair share are spooked away by the merchants and passed onto us. Ugggr!!! But chai tea makes everything better.Indian Cup of Tea!           Indian Spices at the market

We arrived to the Purohit Clinic. This hospital specializes in treating accidents (I believe all types of accidents) and maternity care (labor and delivery). We were taken to the 3rd floor where the operating room was. We changed into scrubs and then proceeded to enter the operating room. There was a cardiovascular surgeon that presented us with the case of a 40 year-old male that has been in a car accident. There had been internal bleeding for the last 3 to 4 days in the left leg and the patient risks a possible leg amputation. There is a previous condition of diabetes mellitus II, hypertension and the patient was intoxicated when the car accident occurred, which is reason why the surgery was delayed. After the patient was put under anesthesia, the surgeon proceeded to make a cut along the lower part of the leg to examine the condition of the muscle and blood vessels. Unfortunately, the leg could not be saved, and an orthopedic surgeon came in to do the amputation. Right next to this, there was another operating room where a 26 year-old female was going under a Cesarean section to deliver her third baby. The patient did not have any relatives present during the procedure. Although is quite a custom in the U.S. for the father of the baby to be present at the time of birth, this does not occur in India. I asked one of the doctors why that is. He said that there is still much ignorance in the population about childbirth and someone might overreact to what is happening during child labor, however, the idea of having the father present at birth has been already introduced and it does happen in smaller settings or per request and depending of the circumstances.

           

The third and last day of rural rotation is spent at Gune Hospital in Panvel, Mumbai. In contrast with Purohit Clinic, Gune Hospital is a municipal corporation hospital, that is, the city government runs its administration and the majority of the population are able to see a doctor for a very small charge. The physician in shift gave us a tour of the hospital as he was checking in all his patients. Due to the monsoon season in India, the number of cases of infectious diseases dramatically increases. Most of the patients had malaria and dengue fever. Some of them presented common viral infections. After he checked in every single patient that was hospitalized, he had a line of more patients waiting to be seen. Some of the cases we were able to attend were persistent headache (due to high pollution in the air), sinusitis, abdominal pain, COPD, hypothyroidism, and hypotension.

We spent the majority of our last day at this hospital. We auscultated patients and also checked their blood pressure. There were medical students from India that had recently finished their first 4 years of study. They are starting their residency at this hospital. We were able to discuss the differences that exist between the U.S Medical Schools and the Indian Medical Schools in relation to the length of time and requirements to enroll.

Being part of this program has provided me with a unique opportunity to spend time in the rural area to gain a better perspective on the differences in healthcare services between urban and rural India. And there are major differences. From the infrastructure to the ratio of physicians to patients, rural hospitals are under staffed and overcrowded. They do not offer the same medical services as hospitals in the city, and they lack modern, adequate medical equipment. In rural areas the number of infectious disease cases take a greater toll in the population because scarce supply of clean water, higher illiteracy rate, people live in remote locations difficult to reach, personal and religious beliefs interfere with the type of medical care that they look for, and finally the most low-income earning citizens live in rural areas.

I have learned to appreciate the good side of the health care system we have in the U.S. Although far from being perfect, it is a system where everyone has access to medical care, in the sense that no one is denied medical care services. Not everyone can afford it, but that is a topic for another blog. However, if there is a need to see a physician, hospitals cannot deny service to anyone, which is not the case in India.

You can tell you have arrived to Mumbai when your rickshaw driver honks the horn to a street free of traffic just to announce its presence. Yeap! We are back in Mumbai, but I have brought with me the memories of wonderful people I met, the pictures to remember and live again. Most important the level of experience and education I had acquired in a clinical setting are priceless.

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