Demystifying Social Medicine in Loni, India

I have the privilege of working with the Pravara Institute of Medical Sciences in Loni, India, for six weeks.

[rachelinloni-blog]

Week Five

On Monday (11.08) I was involved with Directly Observed Treatment, Short-Course chemotherapy (DOTS) for tuberculosis. I learned that 20% of the world’s TB patients are living in India. This is a consequence of poor hygiene and crowded conditions. This is the “Designated Microscopic Center” where sputum cultures are assessed:

Upon finding a New Sputum Positive (NSP), treatment is given under the observation of volunteers from the community. These services are made available within five kilometers of patients’ residences to minimize the burden of travel and time missed from work.

The department head insisted that none of his patients were contagious, but I insisted on wearing a mask in the ward because tuberculosis. We came upon a woman who was diagnosed post-partum, isolated from her fifteen-day-old son. Her baby does not necessarily have TB, a disease that is spread by respiratory secretions, but chemoprophylaxis (medication for the prevention of infection) is necessary.

On Tuesday (12.08) I had the pleasure of working with Dr. Ravishanker, the only man brave enough to work as a plastic surgeon at Pravara Hospital. In fact, his is the only burns unit within a 100-kilometer radius. I stepped into his office to find a baby post-operatively who was put under the knife for extravasation (vessel leakage into surrounding tissues) from her cephalic vein, a complication from the IV antibiotics that she received for septicemia (infection of the bloodstream).

A mother asked about her child, “Have you inserted plastic into her?” A common misconception about plastic surgery.  Plastic surgeons perform reconstructive procedures to correct congenital abnormalities (e.g. cleft lips and palates) or impairments caused by injury (e.g. burns). Of course, some plastic surgeons also perform cosmetic surgeries to alter the appearance of patients, but Dr. Ravishanker does not involve himself in these cases. 

Cleft lips and palates are best treated at three and nine months, respectively, but many families hold out for the prospect of a free procedure. This boy of twelve years still needs a palate repair for this reason: 

Not only was his speech impaired, but he could not walk in without assistance due to untreated burns on his leg. Skin grafting should have been initiated immediately, but two years without proper care have cost him. Although the function in his leg will be restored, the limb will forever remain shorter. Both procedures will be taken up in April of 2015, Dr. Ravishanker’s next available.

The most common “cause” of burns is kerosene stove combustion, though the burn properties may lead the surgeon to believe otherwise. He reports that around 80% of cases are not accidental. Every patient is a medical legal case and requires psychiatric evaluation. Perhaps domestic disputes or unsettled dowries furnish the female ward.

Neglect is often to blame. We came upon a nine-year-old girl who suffered electrical burns. She was playing on a roof when she fell, clung to a 440V cable, and swung into a window.

An eleven-year-old girl presented with a scalded chest and face with cuts on her wrist, throat, and abdomen. She explained that a pressure cooker burst and the lid was ejected toward her head; the edges of the lid cut her neck; she then slipped on water and fell on an open vegetable cutter (vili), perforating her intestine; meanwhile, her wrist struck the edge of a pot on the table. One of the medical interns, Pallavi, was convinced that this incredible set of circumstances did in fact explain her injuries. Others insist that she is covering up a darker truth. I can’t be convinced either way: I don’t have the facts. I only wish that the resources were there to allow for an in-depth investigation in every case. 

Dr. Ravishanker provides comprehensive therapy that prioritizes the patient’s emotional well-being. One of the women under his care has been isolated from her baby due to the risk of infection in the unit; however, he makes an exception for breastfeeding to keep the woman happy, because he knows that recovery depends on the right state of mind.

Dr. Ravishanker maintains strict standards in his department. He mandates that every patient receive a bath with soap and water daily. His nutrition protocol includes cheap, available ingredients (eggs, butter, sugar, and milk) that provide the nutrients burns patients need at an affordable price. Antibiotics, blood products, and immunoglobulin are only used when absolutely necessary. The amniotic membranes that he harnesses are readily available. Because of his cost-saving measures, a fee of < 100,000 Rs is achieved for these patients. The banking of amnion and skin grafts is an advanced practice, though the rural hospital’s storage conditions may appear primitive:

I visited a woman in acute condition who sustained 60% burns. Her wailing was unnerving, but we didn’t linger. When I inquired about her pain medications, however, we learned that the ER had prescribed none. Tramadol was started immediately thereafter, and the patient’s moaning subsided. Morphine would have been preferred, of course.

Wednesday (13.08) morning was spent in general surgery. In the afternoon, I watched my colleagues present their findings from our visit to Chandrapur for the Health Bank Study. Of the eight groups that presented, theirs was among four selected to present at a symposium. These students’ theatrical presentations strongly appealed to the pathos of the audience. Before describing the poisonous effects of pesticides, the first group asserted that they were about to “blow [our] minds off!” Another group likened diabetes to a tiger: “if you feed it and never turn your back on it, you can live with it; but if you ignore it, it will pounce on you and rip you to shreds!” 

I requested a posting in the psychiatric department for Thursday (14.08). The psychiatric department is entwined with every other department in the hospital, particularly antenatal care, because pregnant women may be depressed by the harassment of in-laws who push their daughters toward over-exertion, and, of course, the burns unit. Here, I joined med interns as they interviewed patients about psychosocial stressors—marital problems, death of family or friends, financial problems, discord with neighbors, legal problems, calamities—in addition to the standard questions involved in taking a medical and social history. 

Because so many people in other departments had indicated that mental illness was heavily stigmatized in rural India, I was curious to know about the psychiatrist’s reality. Dr. Chaudhury explained that the stigma exists in providers only. To demonstrate this, he questioned a presenting couple about their willingness to address mental health: the husband explained that he found his wife talking to herself. She insisted that God was telling her to make a pilgrimage to a distant temple. Having observed similar symptoms in his sister, he didn’t hesitate to seek treatment. She has been stable on anti-psychotic therapy for months now. He has a friend who also receives treatment for mental illness. 

The RGJAY funds do not finance any psych meds, unfortunately. The cost of these medications at Rs 100-200 per month is feasible for most patients. For others, anti-cholinergics may be sacrificed from the regimen. These drugs are normally on board to prevent movement disorders that may result from anti-psychotic medications.

Dr. Chaudhury was involved with the military before he began his career as a psychiatrist. I was curious to know about the extent of PTSD in his comrades and patients. PTSD is not so much of an issue here—which he attributes to a difference in moral justification, among other factors. Soldiers are never deployed outside of India.

I learned of some suicide attempts, many in response to seemingly trivial situations. An 8/9-year-old was not pleased with his art supply. He wanted markers, but his mother made him suffer for another month with crayons only. Ignorance led him to swallow organophosphate (pesticide), but luckily it was too bitter for him to stand in fatal quantities. Another—when a father confronted his son about neglecting the farm, the son proceeded to swallow organophos. A pregnant woman attempted hanging because her alcoholic husband was gambling despite their child on the way. A boy rang his girlfriend, but instead got an answer from her brother. The trouble he got moved him to swallow whatever medications he had, maybe a few Benadryl and Tylenol. His friends were unable to wake him up for class, so they brought him to the ER where he came to. Unfortunately, there is a lack of follow-up in these patients due to fears of legal repercussions.

[rachelinloni-blog]

Week Four

The second half of my program is made up of experiences in various departments here at the hospital, particularly looking at how they do drugs. On Monday and Tuesday (04-05.08) I visited the hospital’s department of oncology in the basement. It is located below ground level to protect small children and pregnant women from exposure to radiation, but there I was, standing outside of the radiation treatment center… Sensing my apprehension, the resident explained that a dosimeter continuously measures radiation levels for safety.

We first visited the Treatment Planning Room where the precise dose and beam angle of radiation therapy (RT) are determined. The main tumor and neighboring organs are outlined on the patient’s CT scan results. A cumulative dose volume histogram illustrates what doses these areas will receive, expressed in grays (Gy). For the main tumor, this should be 90%, while surrounding tissues must not receive more than a specific amount. RT is given externally or, in the case of brachytherapy, internally. We saw the instruments used to insert radiation directly into the organ for internal beam RT, like whoa:

We were shown the two RT machines. Some patients undergo RT with manual planning due to financial need: depending on whom you ask, this may mean radiation without an MRI or CT scan. The RGJAY funds assist needy patients in Maharashtra, but some cannot produce the necessary documents to obtain coverage. I wonder how the beams can be manually arranged without compromising precision. A bladder even can vary by 1-2 cm depending on fullness.

I watched five men argue over a women with breast cancer exposed on the table. The energy was all wrong. They were laughing about I don’t know, dropping things. A phrantic fysicist entered the room to hurriedly calculate the times for each dose. I couldn’t help but think of how anxious and vulnerable I would feel if I were the patient. But how did she feel? Did she know her rights as a patient? Did she fully trust her providers? She was tachypnic—breathing rapidly. I later asked the oncologist what they were arguing about in Marathi. A: the placement of dividers to prevent radiation to her brain.

Opioids are a staple in cancer patients in the US; however, India has restrictions on morphine due to its abuse potential. The Narcotic Drugs and Psychotropic Substances Act of 1985 leaves cancer pain largely undertreated here. Morphine is only used 1-2 times per week in this department, usually in cases of bone metastases. Tramadol, diclofenac, ibuprofen and paracetamol will have to do, otherwise. 

Back in the outpatient department (OPD), patients might stand or sit wherever with no privacy or guidance. Residents discuss biopsy results across the table. Patients peer over their shoulders. The residents might retreat without notice, leaving me with questioning patients who speak only Marathi. It is, in a word, chaos. I asked the residents to interpret the patients' complaints when it looked like they had a moment. In the meantime, I studied a physician’s reference book on chemotherapy. Patients maintain their own medical records. This is hugely convenient when the biopsy or lab results from another facility are readily available; this avoids the trouble HIPAA imposes to obtain another provider’s findings. 

The inpatient wards are very public: female and male patients are divided between two rooms, with the exception of neutropenic patients who require isolation precautions. On Tuesday morning, I accompanied the doctors and residents on rounds. Afterward, I watched and winced as one of the residents (Amrita) inserted a nasogastric tube into a patient whose lung tumor was compressing his esophagus at an astonishing 11 cm. By the nurse’s request, she inserted an IV drip into a patient with squirelly veins. She scampered around asking for “spirit.” This is the term everyone uses for alcohol swabs. The residents do it all! The roles of doctors and nurses are so very different here. 

Chemotherapy is administered in the Day Care Ward. The RGJAY funding is huge for locals to receive such expensive medications at no cost.

Wednesday and Thursday (06-07.08) were spent in the department of orthopaedics with Dr. Pushkar. The department comprises four units, with the head of the department leading Unit 1 and the most junior professor in Unit 4. 

In the inpatient wards, we saw X-rays of the stainless steel nails which serve as internal splints in cases of simple fractures. Many patients were admitted to have these nails removed now that their fractures have healed. For compound fractures in which bone is exposed to the environment, however, an external splint is necessary. The majority of patients in the ward were very young or old. While lumbar spondylosis is age-related, the strain of farm labour most likely contributes. There are also the conventional bike accidents, tree falls, cricket-related injuries.

We observed a case of compartment syndrome in which a man’s leg had swollen so much that the pressure had obstructed vascular and lymphatic drainage from his muscles. To prevent tissue necrosis, a fasciotomy was performed, leaving his leg exposed at the fascia layer. Unfortunately, intellectual disability has kept this patient from following the doctor’s instructions to perform active movements, so the function in his leg probably will not be restored. The resident explained that the personal care he needs cannot be provided in the ward. His child of six years is basically his caretaker. His wife cannot speak.

I was invited to sit in on the practical examination of physiotherapy students. It was unlike any practical I’ve ever experienced. The nervous students were ruthlessly grilled by Dr. Pushkar. They were asked to assess a patient case, identify instruments and bones, and interpret X-ray findings. The first chap nervously held an X-ray blatantly backwards, leading him to diagnose a fracture in the wrong leg. Dr. Pushkar explained that the ‘R’ is not for Raju, but denotes the right leg, and he “must have been absent for the surgery and X-ray notes.” Yikes. Another student, when asked to pick up any instrument, reached for a bone. It was difficult for me to watch, but I can’t imagine Dr. Pushkar was pleased with the last six months that he spent teaching these students. Nonetheless, he intends to pass them all. I guess they will never forget the content on which they were interrogated.

On Thursday I had the amazing opportunity to observe a hemiarthroplasty—the head of the patient’s femur was replaced after its fracture. Here is the original:

I wondered how the surgery compared to my dad’s hip replacement back in the States. I hope that none of the surgical assistants for his procedure slipped on a glove after it had fallen to the floor (I took this to be an individual rather than system error). Orthopaedic surgeons are essentially carpenters for tissue and bone. They hammered into an undernourished leg as I stood in the corner concerned with the clanking sounds. The cauterizer was the hardest for me to tolerate, though. The smell of burning flesh permeated the room. That dizzy feeling of consciousness fading never came up, though. Maybe I’ve become desensitized. It's whatever:

On Friday morning I visited the Health Bank in Pimpri Loki. Here, the ASHA provides first aid, antenatal care, screenings (blood pressure, blood sugars, pregnancy), nutritional supplementation, rehydration, and contraception. If needed, patients are referred to the hospital for skilled care at no cost.

I revisited the blind and deaf students, this time for the SHAPE program. It was a delight to find that one of the deaf girls (Neetan) remembered me from nearly a month back. The posters displayed easy-to-follow visuals while the teacher translated in sign language. 

At the end of the day, five blind students busted out a harmonium, tambourine, and drums to give us a delightful show.

[rachelinloni-blog]

Week Three: Dichotomy

On Wednesday (30.07), we traveled 120 kilometers north to the office involved in work for the prevention of HIV/AIDS in Malegaon. Here we learned that truck drivers and migrant workers comprise a bridge population that carries HIV from a high-risk core group to the general population. The core risk group includes female sex workers (FSW), men who have sex with men (MSM), transgender individuals (TG), and IV drug users (IDU). FSW are grouped by the location of their work—brothels, homes, private establishments, roadside establishments, or highways.

We endeavored to gain a direct understanding of the occupation at a low-end brothel in town, but this was a huge challenge in an environment replete with language barriers and devoid of trust. This is one of three cubicles in a brothel shared by 6-7 women:

After touring the facilities, we gathered around a porch where two women were playing cards on their downtime. They clearly felt exploited by the mob of inquisitive students and loiterers standing around them. Nonetheless, we grappled for answers.

The owner did the talking. I inquired into the challenges these women face: they are disturbed by non-paying solicitors, drunkards, and malicious customers. Ideally, the safety of these women would take precedence in these situations, but police involvement is out of the question due to the illegal nature of their work. The government should really make provisions in the law for their safety.

The owner here, a former sex worker, is their only source of protection, entrusted with their mental and physical well-being. In turn, she receives 50% of their profits. She accused the project worker of providing condoms for other brothels, but not her own. The project worker explained that FSW have been left to pay for their own condoms for the last month due to a lack of government funding. I regret to say that this is most probably because the state budget for this project has been misappropriated. 

We ended our day at the office for migratory workers. In Malegaon, these workers are predominantly involved in the construction, cotton, and hotel industries. The project provides such services as HIV/AIDS testing, syphilis and other STI testing, regular monthly check-ups, and condom distribution.

On Thursday (31/07), we visited the Nashik office to learn about the Mukta project. We were shown a documentary about the project’s involvement with FSW in Nashik, Manmad, and Malegaon: sex work was presented as a profession with occupational hazards like any other. The goal of the project is simply to minimize these risks by reducing the rate of STIs and HIV, creating a favorable work environment, making condoms available, and providing overall health care.

When it was launched in 2005, the women had no will to live, and so the first challenge was convincing them to live for themselves and their children. Such low self-esteem stemmed from a lack of respect from society and family even. Advocacy workshops encouraged community members and police officers to respect these women. Care centers were instituted to establish school and boarding for the children of FSW; before these, children were displaced from their homes when their mothers received customers. Perhaps they would roam the streets or wait outside of their doors.

Once trust was established, FSW began to accept assistance. Many were uninformed, however, and scared to find themselves ill. Merely distributing condoms was ineffective: demonstration of their use was necessary in this illiterate population. Leaders emerged within the community to become peer educators: these women demonstrated proper condom use and served as bridges between their colleagues and the office.

We then visited a more upscale brothel in town. The contrast between our experiences at the Nashik and Malegaon brothels was huge. We were shepherded to an intimate sitting room secluded from unwelcome spectators. Ujjwala, the outreach worker, was embraced like family by the women. Eighteen women aged 20-32 years share the space.

Interestingly, all are married and their husbands support their work. I asked if ruffians are so much of an issue here, but the owner insisted that the peace is kept. I questioned the owner about the brothel’s relationship with the police to learn that she basically pays them off. 

There were glaring flaws in the interview process, especially regarding language barriers. Good translators—like, really good translators—are the salt of the earth. If you don't have a really good translator handy, not to worry! First, be prepared to persistently re-phrase your question until the translator demonstrates at least a hazy understanding of what it is you are wondering. Misunderstandings are to be expected here. Once you have secured a relevant answer, you can bet that it will be punctuated by the translator's premature interpretation. Don't bother puzzling over the signs that point to an incongruous translation.

Of course, the interviewee is more likely to be open with an interviewer whom he/she trusts. A one-on-one dialogue would have illuminated so much more about the lives these women lead. Instead, we received generic, sugarcoated responses from brothel owners.

Our biggest question was how these women found themselves in the business. The generic answer: these women are drawn to sex work because their families and society have deserted them, and it is good money (Rs 60,000/month). It is often felt that a brothel is the only place for an illiterate, abandoned woman. The owner explained how she found herself widowed with a 1½ year-old child after a marriage of five years in her hometown 800 kilometers away. Her mother was too occupied with her six brothers to offer any assistance. When her job as a domestic helper proved insufficient, she pursued sex work. She was a prostitute for twenty-five years.

At one point the women laughed amongst themselves, wondering what we were thinking. I was the first to say that I am glad to find them safe and healthy. I really wonder what emotional tax the work demands, though. I wonder how many are left with dissociation, substance use disorders, depression, suicidal ideation. I wonder how heavy their existence feels. I wonder how many of these women are victims of physical and psychological violence. I can't help but grieve for the women whose empowerment was lost to poverty.

On Friday (01/08), we returned to the Mukta project office where the district manager, Asawari, answered our lingering questions. The legality of sex work is ambiguous. Police only raid brothels in response to complaints or for rescue purposes. Being a prostitute is not an offense per se, but solicitation and trafficking are prohibited. Many police officers are oblivious to the law, guided instead by their moral beliefs. This posed challenges for a project associated with sex work. Initially, complaints were lodged in the community and there were difficulties securing the office premises. It had to be explained that this project was launched in accordance with the Maharashtra government, and that directives are given by the National Aids Control Organization.

Asawari explained how age and consent are confirmed in newly admitted women. In the rare cases of underage or trafficked work, the women are presented to the police department and then transferred to a women’s hostel. Their parents are contacted, and the women are sent home. When families are unsupportive, vocational training is provided.

The first session also involves counseling on legal and societal repercussions in addition to surveying the women’s other vocational aspirations. Survey answers are incorporated in a proposal to Women and Child Welfare. Sex work was presented to us as a product of exclusion and economic issues. If this paradigm of victimization holds true, the influx of women to brothels could be curbed if the government subsidized alternative occupations for these forsaken women.

While I am extremely grateful to the Mukta Project for addressing health concerns with such a risky business, I am also somewhat disappointed that it maintains an attitude which legitimizes the profession rather than addressing the underlying issues.

That day we also learned about the CHILDLINE India Foundation. This incredible project fights to save children from labour, marriage, trafficking, abuse, and neglect in 279 cities. Thousands are trafficked across states to be sold for pitiful amounts in exchange for sexual exploitation, domestic work, etc. Due to poor financial conditions, families compromise the futures of their children by compelling them to work in hazardous environments. These marginalized children may be starved, threatened, tortured, raped, or killed if action is not taken. CHILDLINE responds to complaints issued through its 24/7 national hotline with outreach services—relief, rehabilitation, emotional support, and justice. The project also rallies to raise awareness against social issues among the youth. It is a shame that I will be gone for CHILDLINE Nashik’s Varsha run this month: the 6K event has already recruited over 2,000 participants to raise money and awareness!

We also heard from a partner organization, the Urvi Ashoka Pirmol Foundation, which offers mobile health services in 22 villages or slums in Nashik. While local doctors may collect up to Rs 100 for a routine visit, these mobile units offer check-ups for a more affordable Rs 10.

Next, we visited a workshop through which the Yash Foundation offers vocational rehabilitation for people living with HIV (PLHIV). Recycled denim is used by women with HIV to make gloves for the corporate sector. Companies were initially hesitant to purchase these products due to ignorance about the spread of infection, but the enterprise is now supported by Mahindra & Mahindra, a major car manufacturer with hundreds of vendors. We also learned of the foundation’s programs to raise awareness about HIV/AIDS and those which support over 150 children living with HIV/AIDS.

Our last stop was at the Nashik office of a community-based organization (CBO) that reaches out to the FSW, MSM, and TG community. These CBOs provide a sustainable outlet for these at-risk groups if it should happen that the government-sponsored projects are terminated.

My experience this week was a serious dichotomy between the cruelty of poverty and marginalization / the beauty of humanity.

[rachelinloni-blog]

Goan On a Vacation (Never A-Loni)

I set off for Goa with Leonard early (early-early) on Saturday (26.07). The forecast predictive of rain checked Kiana, Kylie, and Peyton. The irony of it all is that while they had enthusiastically launched the Goa project, I was initially on the fence about it. Anyway, I never ended up using my big blue poncho, but the others got to experience the delights of Mumbai so it worked out.

While our interstate bus ride had been scheduled to depart at 1:30 AM, we ended up waiting outside of Hotel Holiday Park in Shirdi from 12:45 until 2:30 before I had enough. I roused one of the hotel workers from his lobby nap and, through a broken conversation, compelled him to make a couple of fruitless phone calls to the ticket agent. He told us to continue waiting for another hour; we weren’t having it. We asked if he could send a taxi our way; he insisted that none were in service at the time. We resolved to find a rickshaw home, but as soon as we reached the end of the drive our bus pulled up. That’s the way she goas. 

The actual layout of the bus was a distant relative of the online seat selection. It’s a wonder that Leonard and I picked two adjacent sleepers, because beds 27 and 28 presented as one alcove at the very back of the bus. A 5’10” Leonard spanned the entire length of our den. For a five-hour stretch of time between stops, the back of the bus was the last place I wanted to be. I won’t even try to describe the pit stop bathroom either…

Through it all, we arrived in Panjim, Goa, at 7 PM. Due to the usual miscommunication with the CSM about our postings (language barriers: they remind me of this thing called patience), our return trip needed to be rescheduled for an earlier time on Tuesday. The bus office could do nothing without a physical, printed ticket, though, because apparently they don’t have a computer system for reference (patience is a thing).

It was not difficult to find a taxi: as foreigners, everyone assumes at all times that what we need is a taxi. The trouble is agreeing on an equitable price. This is done beforehand. There are no meters. I presented my handy-dandy hotel directions, but our trip was peppered with diverting stops for directions anyway. Loved it (seriously, tho).

We made it to Hotel jüSTa in time for COMPLEMENTARY MANGO JUICE. And it was just-a what I needed. Me juice-ta, amirite? Anywaaaay, next up the bellhop showed us every aspect of our room, even took the time to find a good show on the TV. Thanks, guy. By this time I was so ready for Goan fish curry and paneer tikka. I’ll dedicate a post to Indian cuisine eventually, of course. 

On Sunday (27.07), we took a bus from Panjim to Calangute. I passed Leonard Rs 50 for our tickets, and watched as he received change corresponding to double the fee charged to locals. For a solid minute I was fuming about the discrimination, and then I realized that it’s Rs 40, that the exchange rate is very good to me, and that sometimes I’m a terrible person.

Being disorientated tourists, we took a taxi to the Ocean Palms hotel which was probably a half-mile away. Here we received COMPLEMENTARY salty-red-juice / I don’t know. We didn’t waste much time in the hotel room with the beach belt of Goa to be explored. I screen shot a bunch of Google maps to guide us to Infantaria—an Italian restaurant where I was reunited with the golden carbs (pasta and beer). We then took a taxi to Chapora Fort. The stony ruins gave way to staggering views in every direction.

Our driver led us to Curlie’s beachside shack in Anjuna next because, as he said, “you haven’t seen Goa until you’ve seen Curlie’s!” I soaked up the undertow, the old hippies, and the constant club music.

Leonard ventured to try the drink of Goa, distilled cashew juice—kaju feni. The smell and taste were in synch and… distinctly interesting. Speaking of distinctly interesting, a group of young men randomly requested a picture with us on the beach. Yeesh.

For dinner we enjoyed a seafood platter and paneer tikka set to Beatles karaoke at Britto’s in Baga Beach. I wasn’t *driven crazy* by the honey walnut pie, but I ate it anyway. 

On Monday (28.07), Leonard finally got his hairs cut. Looking fresh, we stumbled upon thee coolest book store, Literati. We followed the stone path from the side street past a mobile library for children to a charming porch. We abandoned our shoes to enter a cozy book sanctum. Here I unearthed a handmade book of art and folklore from the Gond tribe, an extremely useful Merck pocket medical manual, and excerpts from J. Krishnamurti’s diary.

That afternoon we visited the Basilica of Bom Jesus in Old Goa. Wooden pillars, friezes, and arabesques gilt in pure gold make up the whole back wall. To the left, a mausoleum houses the Venerable Relics of St. Francis Xavier. Next-door we found the Sé Cathedral. 

At the jetty in Dona Paula we enjoyed yet another gorgeous stretch of sea. A husband and wife requested a picture with me, and then their daughter. I figured they wouldn’t mind taking a picture of me and Leonard. A flock of people figured it would be casual to whip out their phones and get pictures too!

We drove by Our Lady of the Immaculate Conception Church in Panjim, then experienced actual service at Sher-E-Punjab. I guess I can include a little pharmacy in this post:

More professionalism to come!

[rachelinloni-blog]

Week Two

On Monday (21/07) Leonard and I returned to the Rural Health Center in Rahata. Here we observed an obstetric examination and afterward Sorabh explained the components of the antenatal care interview. Pregnant women are asked about any hereditary diseases: beta thalassemia major is a common recessive hereditary disease in this population that is characterized by a severe form of anemia. Consanguinity is also a part of the interview: ‘caste disorders’ prevail due to incest despite government advocacy of intercaste marriage.

During my time at the clinic I was on call for any and all intramuscular (IM) injections. While administration into the deltoid muscle is standard in the US, malnourished patients lack muscle here, making the more invasive gluteal site the preferred route. Syringes are disposed of at the clinic only after placing the needles in a burner.

On Tuesday (22/07) Sachin, the lab technician, showed us the labs performed for pregnant patients at the Rahata clinic. A dipstick was used to reveal urine glucose and albumin based on color change: abnormal findings are suggestive of gestational diabetes or eclampsia, respectively. Blood samples are divided amongst three plates where anti-A, anti-B, and anti-Rh antibodies are added. A clumping response reveals the patient’s blood type. Blood samples are combined with hydrochloric acid and left to react for a few minutes. Distilled water is then added until the sample matches the reference colour on the Sahli haemometer, and the resultant volume is indicative of the patient’s hemoglobin level.

I thought it would be great fun to put a sample of my own through these tests despite my precarious history with blood. I turned my head from Sachin and his masterful finger-sticking technique. O+ as I already knew, me and the rest of the world. Hemoglobin was twelve, low-normal. As I sat and processed everything that went down, I got that old familiar feeling of dizziness and darkening vision. The plain sight of me in a chair, legs suspended, is pretty ridiculous I guess, so I moved rooms to be ridiculous in private.

On Wednesday and Thursday we were involved in the Targeted Intervention to Migratory Workers for the Prevention of HIV/AIDS. On a rainy Wednesday (23/07) the mobile clinic made its way to Shrimpur to be visited by factory workers. Once I came across the mobile clinic’s drug supply I busied myself with inventory management while we waited for patients...

I sorted out cups that held a smorgasbord of different drugs and arranged the drugs by category (allergy/cold, pain/inflammation, stomach, infection). I had to pretend I didn’t see the syrup-coated measuring cup.

Once patients’ blood samples were collected for HIV/AIDS testing, Dr. Jitendra K. Patil addressed any complaints that they might have had. Notably, allergic bronchitis was seen as a result of working in a dusty factory.

The mobile clinic’s next stop was a five-star hotel in Shirdi on Thursday (24/07). Complaints of lipomas were the trend in these hotel workers. The physician prescribed ciprofloxacin for a patient’s acne, though my first recommendation would have been doxycycline. Welcome to the complex concept of ‘clinical judgment:’ medical professionals base their recommendations largely on personal experience in addition to their assessment of the patient’s unique problem at hand. It is an artful science.

Giby, the medical intern, explained that if Leonard and I were not present, there was no way the hotel owner would have given us all a tour of the place. We saw the hotel’s reproduction of the Shirdi Sai Baba temple, the spa on the fifth floor, the rec room, the kitchen—even the employee break room. Honestly I was pretty indifferent to it all, but the owner’s pride was totally endearing.

On Friday (23/07) all of us international students joined a group of BDS (Bachelor of Dental Surgery) and physiotherapy interns and nurses for the school, health, hygiene, and environment program (SHAPE) in Bhandardara: the dental interns—Aanchal and Aarathi—reviewed brushing technique and cavity prevention with the schoolchildren, while Kalyani of physiotherapy covered wrist and neck exercises and the nurses covered personal and environmental hygiene.

We visited the region’s two Rural Health Centers, which were very similar to the clinic in Rahata. Bhandardara was different from any other village we had seen, however. It is stunningly gorgeous, in the middle of mountains and meadows.

[rachelinloni-blog]

Multi-Diagnostic Camp

Leonard and I were given the amazing opportunity to take part in a multi-diagnostic camp on the Sunday before last (20/07). The Institute’s dermatology, ENT (ears, nose, throat), general medicine, dentistry, ophthalmology, internal medicine, gynecologic, orthopedic, and physiotherapy departments set up makeshift OPDs at these camps in prearranged villages every month or so.

We were on board… on one of two packed buses at 7:30 AM, taking care to sit at the very front to avoid a rollercoaster ride at the back. The most obnoxious horn you could imagine blasted an unsuspecting me while Leonard drifted to sleep. I was pleasantly surprised when we arrived at the village of Nepani Vadgaon after only fifteen cacophonous kilometers, having been briefed about a 100-kilometer trip.  Our nutella and kayli (banana)-filled selves were also not expecting a breakfast of carb-heavy pohe to be provided. The only thing I've come to expect is discrepancy here. I'm improving my flexibility sans yoga.

Twenty minutes later, flocks of nurses, residents, and department heads were buzzing on breakfast while I stood with Leonard and Mangesh (of the CSM) to the side—but not for long. I approached the nursing students who were obviously laughing at us, and spoke infantile Marathi at them. They ushered me to a masala tea party where I tried to add to my growing Marathi dictionary, but their foreign phrases were left untranslated. I’ve found that, as a rule, the nursing students of Pravara are not fluent in English.

In the ladies’ restroom of Nepani Vadgaon I finally experienced a squat toilet. Look at the not-so-private stalls that changed my life:

Before long, the camp was inaugurated. Villagers sat Indian style (naturally) and watched as the hospital’s department heads were presented with coconuts and bouquets. Mangesh pointed out the sarpanch (head of the village)—a woman dressed in a yellow sari. Many of the towns in the district of Ahmednagar are headed by women.

Once the clinics were opened up in the surrounding schoolhouses, the villagers lined up outside to be seen. I dropped by the skin clinic first, where I saw cases of tinea corporis (ringworm), lipomas (fat tumors), allergic reactions to kumkum (a powder used to mark the forehead), hyperpigmentation, eczema, vitiligo, and neurofibromatosis. I asked the residents what treatments these patients had tried for their skin conditions, and learned of the population’s lack of health literacy. Medical records are not maintained. Prescribed treatments are blindly taken, if at all. Non-adherence commonly leads to fulminant and recurrent disease patterns.

In the ENT department, we observed a patient whose right tympanic membrane was perforated from a recurrent upper respiratory tract infection that had migrated via Eustachian tube. Surgical reconstruction was in order, but first the infection would need to be controlled with antibiotics.

In the mobile dental clinic, basic minor procedures were under way, including scaling (deep cleaning) and uncomplicated tooth extractions. ‘Mishri’ is a form of tobacco that is rubbed on the teeth and gums, while ‘bidi’ is smoked. These habits lead to teeth staining and palate issues in this population.

To manage illiteracy, the ophthalmology department assesses patients’ abilities to count circles from a distance in contrast to the traditional Snellen letter recognition.

In the pediatric department we heard about children who suffered pesticide or kerosene poisoning. During monsoon season, poisonous snake bites surge as burrows become uninhabitable. Snakes are regarded as the “farmer’s friend,” but venom can be neurotoxic or hematotoxic from a provoked krait or viper.

At lunch, the locals ran around offering jalebi—sweet rings of deep-fried flour. I asked one of the internal med residents how I might say ‘no, thank you,’ and he was dumbfounded. He explained that there is no need, that there is a mutual understanding. These patients do not thank him for the services he provides.

In the orthopedics department, the residents were worn down by the many knee osteoarthritis cases, and so I enthusiastically counted exercises out for patients (ek, don, tin, char, panch...).

At the end of the day I left with a better understanding of the population and new connections in every department.

[rachelinloni-blog]

Life In An Indian Village

By Tuesday night I had accumulated enough dirty threads such that the manual laundering process could no longer be post-poned. Here I will share my strategy. You will first need one metric heap of time. Start by rubbing a bar of Tide soap directly onto your clothes in stripes. Add a splash of water and friction. Or, wait, dip the soap into a bucket of water and form a lather in your hands. Apply the suds to a 3” x 3” area, fold this over, and vigorously rub the cloth together. Maybe now you could dunk the article repeatedly into your bucket. Okay, no, I think the favored technique is the Arm Overhang Lather-Line. Your new kurtas will convert the water to their respective hues, no worries. Good luck (appreciate your washing machine).

On Wednesday morning Leonard and I joined the other international students (Kylie, Kiana, and Peyton) and a group of nursing students in the nearby gaon (village) of Pimpri Loki in a study to assess the needs and aspirations of the women aged 13-25 years. We visited the huts of families with 2+ girls (‘mulgees’—single, divorced, or widowed) to inquire about each family member’s marital status, education level, employment, earnings, and expenses. This data will be used to select 100 families for the provision of educational, employment, and/or financial services. The Accredited Social Health Activist (ASHA) appointed to Pimpri Loki accompanied us from house to house: she is responsible for the provision of primary health services (e.g., antenatal care, immunizations) at her subcenter (a rural clinic that targets a population < 3000). It was clear that every family we surveyed could benefit from some assistance. The first family brought in a mere 3000 Rs (approximately 55 USD) monthly. It is a wonder that they can afford the annual fee of 1000 Rs for their 13 year-old daughter’s education in Rahata. They lack basic amenities. They have no furniture. I asked sister Aarthi what they had said about ‘pani’ (water): they were discussing the lack of rain which has been devastating for farmers this season.

In the afternoon, we were tightly acquainted with a group of medical students in a jam-packed bus headed to the Chandrapur gaon. We traveled from door-to-door to obtain the blood pressure, blood sugar, height, and weight measurements in addition to the demographics (age, sex, religion, caste, education level) of all villagers aged 25+ for a Health Bank Study.

Working with the medical students as a team was wonderful. Nihar took blood pressure and height while Anannya interviewed the subjects and I operated the glucometer (device used to measure blood sugars). Our streamlined process was met with some difficulties, however: at the first house, an older man, the village drunk if you will, fled the scene when he saw the needles we would be using for finger pricks. He was not the only villager with a fear of needles either, though most people were very cooperative. Many of our subjects were emaciated and hypoglycemic (having low blood sugars).

At one point we established a sort of clinic with two plastic chairs in the middle of the road where surrounding residents flocked. I applied cotton swabs to their pricked fingers and instructed them to ‘dabun dhara’ (press and hold). It was extraordinarily amusing for bystanders. All of us were also thoroughly entertained by one elderly woman who, when asked her age, insisted that she must be at least 200 years old by now.

I amassed an entourage of children who followed me around wishing for a proper goodbye (see below). As soon as we relocated our clinic to someone’s front yard, I caught the lingering villagers laughing, assumedly at the white girl who just left them (hint: that’s me).

As we made our way through the village we watched a wild canine attempt to weave through a group of seated women only to be brutally caned. It was painful for me and Anannya to watch, but couldn’t be undone. Half-naked children could be found playing in the dirt or standing around real casual-like. How do you afford your rock and roll lifestyle, children? Once we had surveyed twenty-five subjects we re-traced our steps to the original hut from which the drunkard’s broken melodies emanated. The goats and cow did not appear impressed.

Back at the CSM, a fasting medical student, Murtaza, doled out holy Prasad from Tirupati Balaji, a temple in the south. Prasad refers to a religious offering of food in Hinduism, but this holy cereal did not satisfy. What we needed were oreo shakes from the local café, as Namita strongly advised. While Namita may feign mischief, she has not yet steered me wrong. I mean, one of our first interactions involved her steering me toward a deep gutter for startling sake, but always with a methodical control of my well-being because she is actually a saint. The patron saint of nourishment. The medical interns truly gave us the ultimate work and play experience. Here I am with Anannya, Namita, Murtaza, Isha, Kylie, and Kiana:

On Thursday something (Murtaza) possessed us to wake up at 5:30 in the morning to watch the sunrise from the Lontek temple. It was actually worth it.

Later that morning I got to experience the patient perspective at the Pravara Family Medicine Clinic where I sought an alternative anti-malarial medication. It should be noted that this perspective was biased because, as a visitor, I was given VIP treatment. Based on years and years of experience, Dr. Linge prescribed chloroquine for me.

That afternoon we returned to Chandrapur for the Health Bank Study, this time surveying a more wealthy part of town. These families have many farm animals, nicer pieces of furniture, and many rooms or two stories to their homes. They were also much more nourished, with higher BMI and blood sugar measurements. Of the seventeen residents available for surveying, only three were male. I assume the men were out farming at this time. We encountered an elderly woman who decided to forgo our survey to continue relaxing and chewing tobacco. Meanwhile, the woman next-door summoned her husband, whom she called ‘maalik’ (master).

On Friday we rejoined brother Somnath and sister Kaveri for the survey of the needs and aspirations of girl children in Kelwad gaon. One family was headed by a man who had completed 3rd grade partnered with his ‘ashikshit’ (illiterate) wife. This is not uncommon for farmers, though their children aspire to receive higher education.

[rachelinloni-blog]

Rural Health Center

On Tuesday Leonard and I visited the Rural Health Center in Rahata. The clinic is operated by two nurses (designated brothers or sisters), a doctor (called a medical officer), a medical intern, and a lab technician. Dr. Arsude, the medical officer, provides both Ayurvedic and allopathic medicine to patients depending on their preferences. Observation soon reveals the immense amount of trust and admiration that patients bestow upon her. The patient-provider interaction is completely and wonderfully forthright.

The medical intern, Sorabh, described the drugs commonly used at the clinic. Anti-helminthic (anti-parasitic) drugs are frequently prescribed in this rural population: tinidazole is available in a fixed-dosed combination with the antibiotic norfloxacin to treat dysentery. Labendazole is used to treat neurocysticercosis, a parasitic infection caused by the ingestion of infected pork.

We were introduced to Rajesh, the project manager for the Targeted Intervention to Migratory Workers for the Prevention of HIV/AIDS. These migrants from other states or districts are glad to occupy jobs which locals are too proud to accept as custodians, hotel workers, or construction workers. The Targeted Intervention is aimed at five surrounding towns, each estimated to take in 10,000 migratory workers. Only those at high risk were tested, including men who have sex with men (MSM), sex workers, and battered women. IV drug use is not very common due to poverty. Patients at risk are interestingly identified via body mapping—behavioral changes, itching, and anorexia are all red flags. Of the 50,000 migratory workers, 30,000 were registered, 6,000 were tested, and 8 cases of HIV/AIDS were detected. While this number may seem small, these patients can have exponential effects on the region. These patients are provided with anti-retroviral therapy at no cost with a government-authorized report from a testing center. Here you'll find me cheesing with the nurse, Sorabh, Rajesh, the lab technician, Leonard, and a social worker:

We traveled by tum-tum (rickshaw) to the local Anganwadi where 3-to-6 year-olds receive health care in addition to standard pre-schooling at absolutely no cost. The height, weight, arm span, chest circumference, and head circumference are continuously assessed. Most importantly, weight-for-height is compared to a growth chart, and nutrition supplementation is given if necessary. The Indian government started these pre-school-cum-clinics to combat child malnutrition. Because farmers in these rural areas do not prioritize health care, the government provides services such as these. The children were all so well-behaved, and a couple boys recited numbers and poems for the class.

Back at the rural clinic, I developed an understanding of some common disease states in the rural population. Malnutrition and poor hygiene are the most common sources of concern. A pregnant woman presented with anemia as evidenced by lower palpebral (eyelid) conjunctival (white part of the eye) pallor. A reference sheet will allow her to be seen at the hospital at no cost. Pica is a common illness as a result of iron deficiency, usually involving an appetite for sand, chalk, soil, or lead. A 3 year-old child was brought to the clinic due to soil-eating. His iron deficiency may or may not be related to minute, continuous blood loss from an intestinal hookworm (Ancylostoma duodenale), and so anti-helminthic drugs were prescribed in addition to iron supplementation. Other common pediatric diagnoses include nocturnal enuresis (bed-wetting) and breath-holding spells (the cessation of breathing to seek attention from caregivers, often associated with cyanosis).

Because of poor hygiene, rheumatic heart disease is a frequent complication of streptococcal throat infections for which benzathine penicillin is prescribed. A 12 year-old boy presented with complaints of headache and fever. Despite the absence of a sore throat, his lymph nodes were examined because of the prevalence of tonsillitis in this age group.

[rachelinloni-blog]

Orientation

On Monday morning Leonard and I were de-sandaled, presented with bouquets, and ushered to the golden statue of Dr. Vitthalrao Vikhe Pathil. We offered dried flowers with a sign of prayer at the base of the statue with incense smoldering in the background. From there, we visited the illustrious sugar (sakhar) factory which this revered man worked so hard to establish.

This factory tour is not for the unwary: every step requires care, beginning with the sparks that rain down spectacular on the pathway. Though sugarcane is harvested from November until March, the place was teeming with workers involved in maintenance. Come November, sugarcane will be transported to the factory by the truckload. The shoots will be compressed to produce a juice and a powder. The powder will be sent to a furnace to be used for energy, while the juice will be sent upward to be refined. The molasses will be mixed with sulfur and limestone, and then heated to produce red crystals. From there, these granules will be categorized from smallest and least sweet (1) to largest and sweetest (3). Mr. Jana reflected that perhaps grade one is for the diabetic. These raw granules will be further refined to give white sugar!

Outside of the factory a couple of men requested a picture with me and Leonard. “Five rupees,” I muttered to them before we assumed our poses. Turns out we’re not worth that much.

We then visited the distillery where the byproduct of molasses is processed for sale as ‘country wine’ (deshi daru). The bottling process is both a manual and a mechanical process that enthralls. The resulting product is largely banned. I was told that it is 60% methyl alcohol and 40% ethyl alcohol.

We took things down a notch at the Pravara Public School. The goddess of knowledge, Saraswati, may be found outside every school in India. We were given the opportunity to question a classroom full of students. We learned that their favorite subject is computer science and they are all feeling happy.

We then visited a special needs school, first stopping at a classroom occupied by ten blind students, all boys. One English-speaking student printed our names in Braille, and yet another student recited a beautiful song for us.

In the next room, deaf girls adorned with pink sashes were holding class. The crafts that they had woven were astoundingly lovely, and so I linked my thumb and forefinger to demonstrate my compliments. One student wondered what my name was, chalking on her personal board “what name why.” I chalked, "What is your name? Rachel." Her name? Neetan (far left).

That afternoon we visited Pravara’s satellite colleges. The Krishi Vegan Kendra (KVK, Farm Science Center) caters to farmers in every possible way. The center treats plants as patients. The lab where farmers’ diseased plants receive treatment is actually referred to as an OPD (outpatient department). The KVK finds solutions for plants in addition to finding plants for solutions: the drumstick tree (Moringa oleifera, pictured below) is rich in iron, thus valuable for anemics, pregnant women, and children. The protein-rich azola is used to supplement animal feed. We found spirolina, the only algae with single-cell protein, at a pH of 11 in pools requiring constant agitation for oxygenation. This algae is dried for supplementation, potentially in cancer patients and astronauts.

From there we re-entered the center to check out the various strains of fungi which the KVK cultivates due to their high specificity for pests. Packets of sex pheromones are valued for their ability to trap insects of the opposite sex. The KVK also serves farmers through a radio program that broadcasts answers from experts twice daily, reaching farmers up to 30 kilometers away.

Eventually we entered my domain at the Pravara Rural College of Pharmacy. The pharmaceutics professor kindly showed me the various instruments used in their heavily practical curriculum. The students here actually prepare pharmaceutical products. I was first shown the compression device used to fashion tablets (pictured below). The final products are tested for friability, dissolution, pH, viscosity, and other properties in the adjacent room. The autoclave on site is used to sterilize parenteral products. Compatibility of drugs and excipients is assessed at varying temperatures over time using a stability chamber.

In the pharmacology lab, animal subjects are assessed using photoactometer (measures movement), analgesiometer (measures pain in response to increasing temperatures), spirometer (measures respiratory function), rotarod (measures muscle strength), metabolic cage (measures urine output), and kymograph (measures blood pressure) among other devices. 

I learned of the College’s work with pharmacognosy—the extraction, evaluation, and preparation of plants. At the conclusion of my tour, my guide plucked a flower for me: the Madagascar periwinkle is the main source of anti-cancer vinca alkaloid drugs. It is beautiful, but smells cancerous.

At the neighboring College of Business Management and Administration we were introduced to the newly furnished lecture halls used to hold up to 400 students.

[rachelinloni-blog]

Introduction to India

Believe it or not they do things a little bit differently 8,445 miles from Chicago. I am exceedingly grateful to the driver accompanied by a Mr. Jori (of Pravara) who delivered me and Leonard (Drake health sciences student) from Mumbai to Loni unscathed, because the roadways here lack both rhyme and reason. Lane markings? Mere guidelines. Honking? Yes, please ("Please OK horn" is actually posted on the back of "goods carriers"). Not only is honking a frequent and seemingly random occurrence, but the spectrum of tones blared from these technicolor vehicles is astonishing. Buzzing rickshaws may gravitate within inches of pedestrians. All very exciting.

On Friday, Mr. Jana introduced me and Leonard to the campus, starting with the mess hall. The food is less spicy than I imagined. Conversely, finding out the names of the items has proven to be more difficult than I would have expected. My attempts at this have only gotten me additional portions from staff: I guess you could say these were both successes and failures.

The Pravara Institute of Medical Sciences (Deemed University) is comprised of a Medical College, a Dental College, a College of Physiotherapy, a College of Nursing, a Center for Social Medicine, and a Center for Biotechnology. The beautiful campus is bordered by plant life at every turn. And I can't omit the fauna: cats, dogs, and peacocks pay us no mind.

We were introduced to Mr. Sanjeev Kulkarni, Pravara's International Coordinator and Associate Professor in Microbiology. He shared Pravara's history with us: at a time when Loni boasted a flourishing sugarcane industry, much of farmers' profits were being lost to outside distributors... until a visionary, Mr. Vitthalrao Vikhe Patil, proposed a radical scheme within which farmers would operate a sugar factory of their own. The Indian government agreed to satisfy 85% of factory costs, and Mr. Patil petitioned the people of Loni to raise the remaining funds through money, gold jewelry, or any other valuables that they could spare. Once erected, this factory gave Loni the means to establish Pravara Hospital in 1972 with 100 beds to provide health care to a community in need. The Medical College was introduced thereafter to train the locals, ultimately supplying the area with health care providers.

From there, we were introduced to Mr. Soma, the Director of the Centre for Social Medicine (CSM). He oversees a Center that upholds a mission “to support and encourage interdisciplinary research, training, and services in the field of social medicine and community development for the benefit of students, faculty and the needy community at large.” The CSM provides community-oriented primary health care for underserved, remote villages through mobile and remote clinics; advocates for at-risk groups; and empowers community members for their health and development. I believe that everyone is entitled to good health and am eager to explore my interest in social medicine with the CSM! The Center’s work provides a forum to advocate social justice. I look forward to cooperating with other professionals to solve health problems in vulnerable populations!

Three fellow International students (one nursing, two public health) are here from Oregon, and they introduced us to the local shops which I basically ravaged in search of traditional Indian garb. It was an awkward process: shopkeepers pried the packaging of garments open to unfold and lay out an array of blouses, and then looked to me for answers that I was reluctant to voice. After leaving a wake of kurta destruction, I maybe had a taste for one or two selections. The assimilation process can be difficult, and you can bet I still draw attention from locals even with my new kurtas.

I had exchanged 149 USD for 7717 RPS at the airport. This is a small fortune. To give you an idea of the local economy, a pack of twelve 1L water bottles, five kurtas, two electronic adapters, a small tupperware set, Tide soap, mosquito repellant cream, a strawberry swiss roll, an apple, two oranges, three bananas, an ice cream cone, a scarf, and two pastries later I have $31 (1630 RPS) less to my name and, now that I mention it, significantly higher blood sugars. Worth it.

While breakfast and lunch went over swimmingly, I couldn’t stomach dinner. I had been feeling dazed and confused, dizzy, tired, not myself. And so I laid down for a minute. Burned through Wi-Fi hours. At a reasonable bedtime I found myself surprisingly stimulated. Nonetheless, I laid down for bed and within an hour woke up reeling from an emotionally disturbing experience of a dream with mild visual hallucinations and a heart rate up to 100 BPM. The dream weighed so heavy on me that I found myself in tears. I didn’t mind using some of my precious international cell phone minutes just to hear a familiar voice.

At this time my weekly anti-malarial medication, mefloquine was at its peak concentration in my blood. Yes, as any self-respecting pharmacy student would have, I had perused the drug information before taking it. There is an FDA Black Box Warning that mefloquine may cause neuropsychiatric adverse reactions that can persist after the drug has been discontinued: for this reason, it is not to be prescribed in patients with major psychiatric disorders, and should be substituted if symptoms develop. Because I usually consider myself to be free of major psychiatric disorders (though I can’t be too sure about minor disorders ha) I assumed the drug to be safe. Never assume though, you know. So now I have a drug in my system from which people have reported such casual side effects as aggression, agitation, restlessness, anxiety, confusion, convulsions, depression, encephalopathy, hallucinations, memory impairment, mood swings, panic attacks, psychotic or paranoid reactions, sensory and motor neuropathies, suicidal ideation, and suicide. I plan on submitting an adverse event report to FDA MedWatch and finding an alternative, and I guess you could say that I strongly discourage use of the drug in situations when other options are acceptable.

On Saturday, we had the honor of meeting Pravara’s Vice Chancellor and the CEO of the Institute. Our plans for the next six weeks and future practice were laid out for them, and the welcome was definitely warm.