i got skinny. now i’m getting fat.
skinny from a bout of delhi belly. culprit? i think it’s the undercooked chicken that i ate on the rooftop of raj palace hotel.
they say the reason meats are cooked in curry is to hide those unsavory pieces better left untouched.
skinny from the pollution populating my sinuses, turning into a wonderful green sputum producing collection, robbing me of my desire of food. riding twice daily with a suicidal auto-rickshaw, putting my once pristine clean lungs to battle, over and over. now i’ve graduated to the helmet-less scooter ride. i convince myself that if i crash at forty kilometers an hour, things won’t be *that* bad.
as i equilibrate, i find myself fat.
fat from oil rich curries, from meat-serving seerock or ‘partly a/c vegetarian hotel’ vasant vihaar. now sangeetha (‘full a/c’ at that) is moving in – some competition to the local stalwarts.
fat from the continuous flow of madrasi coffee – drenched with cream, sweetened with sugar – puts dunkin donuts to shame.
fat from pizza hut, dominoes. hey. viva la’merica.
this is how it is:
kanthima serves coffee.
she does other things. like washing our dishes after lunch.
she's five foot zero. maybe you can add a half inch to that.
she was scared of me, would only show half of her toothy gap smile to me.
the second day,
armed with my seven year, $240,000 and rising education,
i locked myself into the bathroom.
kanthima and her half toothy smile and disheveled hair,
washing our dirty dishes
was just outside.
i proceed to bang on the door
she continues washing
so i begin to say some random words in telugu
hoping to get her attention.
she finally hears
runs
and tells everyone there's a ghost in the bathroom.
so everyone comes running
kick in the door
to reveal me, in my glorious quarter million dollar stupidity.
kanthima, shaken, nervously laughs, full gapped.
but she still can't make sense of my height, my accent,
and why i always insist on waiting
before scalding my hand on the tin cup she serves
her near boiling sweet madras coffee
'but you must drink it hot...' she scolds me in tamil
i think.
she can't make sense of me,
and she can't say my name.
a south indian who can't say sreekanth.
strange. but then again, kanthima is strange.
so they tell her that i'm rajnikanth's brother
rajnikanth, the movie actor with 153 films under his belt,
with mystic powers of box office draw
where villagers build temples
and bath idols of him in milk
and now kanthima
ever more baffled,
she thinks
i'm tamil nadu's most famous movie actor's
brother.
she can't understand why his brother
would be stupid enough
to lock himself into a bathroom.
neither can i.
yeah,yeah. you're getting tired of reading about hiv, and i'm getting tired of writing about hiv. i'll going to start writing less about it. but bear with me, this is an article in the hindu, one of the largest circulating papers in india, about the epidemic.
August 17, 2002
The spectre of AIDS
By N. Gopal Raj
AIDS, THE Acquired Immune Deficiency Syndrome, and the Human Immunodeficiency Virus (HIV) which causes it, is rarely perceived as a major public health problem in India. After all, the prevalence rate of the disease among adults is still under one per cent when some countries in Sub-Saharan Africa have prevalence rates of over 20 per cent.
But, with India's huge population, the low prevalence rate hides the fact that nearly four million Indians are estimated to be currently
living with the disease and the number is growing. The only country in the world with more HIV/AIDS sufferers is South Africa with five million. An increase of a mere 0.1 per cent in the prevalence rate in India means half a million more people have fallen prey to the disease. No wonder, then, that the World Bank warns of a "narrowing window of opportunity" to confront the epidemic before it becomes overwhelming.
Since the first HIV-positive case was detected in India in 1986, the virus has moved beyond the confines of high-risk groups, such as sex workers, and entered the general population. The most worrying sign of this is the growing numbers of pregnant women who turn out to be HIV-positive.
In India, heterosexual contact remains the most common mode by which HIV transmission occurs. Since women in India tend not to have sex outside marriage, their risk of contacting HIV ought to be minimal. But, the husbands can get infected by visiting sex workers or indulging in relationships outside marriage, and then pass on the virus to their wives. A recent nationwide behavioural surveillance study carried out by the Central Government's National AIDS Control Organisation (NACO) showed that nearly half the clients of sex workers were married and most of them were currently living with their wives.
In India, married women are at the end of the line of HIV transmission, points out Jacob John, a leading expert in infectious diseases,
formerly with the Christian Medical College, Vellore. Commercial sex workers have the highest risk of getting HIV/AIDS, their clients less and married women have the least risk. So, the proportion of pregnant women with HIV/AIDS indicates how much the disease has spread among society at large.
More than one per cent of the pregnant women being HIV-positive puts a State in the high-prevalence category. In 1994, only Maharashtra was in this category. It has since been joined by five more: the three southern States of Andhra Pradesh, Karnataka and Tamil Nadu, and Manipur and Nagaland in the northeast. HIV/AIDS is slowly spreading its tentacles in India, and cases are being reported from every State.
It is not just those visiting sex workers who risk picking up HIV, observes V. Ravi, Head of Neurovirology at the National Institute of Mental
Health and Neuro Surgery (NIMHANS) in Bangalore. Now any multi-partner sex is high-risk behaviour, he says. The myth that HIV/AIDS would be principally an urban phenomenon too has exploded. Hospitals were now regularly seeing people from really rural areas, he points out.
The stigma associated with HIV/AIDS, which still tends to be seen as the wages of sin, is only one of the problems faced by those unfortunate enough to get infected. Still without a cure or an effective vaccine, HIV/AIDS condemns its victims to a lifetime of medical expenses. Indian drug companies offer some of the lowest prices anywhere in the world for anti-retroviral drugs which can check the virus' growth in the body. Even so, such therapy still costs about Rs. 1,600 a month. Since the drugs do not rid the body of the virus, it is medication which the person has to take for the rest of his or her life.
So, conscientious hospitals and clinics consider starting anti-retroviral drugs only when the patient's immune system is judged by suitable
blood tests to have weakened to the point where opportunistic infections could easily set in. That could happen five to eight years after a
person is first diagnosed with HIV, says N. Kumarasamy, Chief Medical Officer of Y.R.G. Care, a leading Chennai-based charitable organisation providing HIV/AIDS care.
Even when this point is reached, these hospitals insist on extensive counselling before prescribing anti-retroviral therapy. Apart from the
question of being able to afford the lifelong treatment, the drugs can have side-effects and the patients should be capable of adhering to the prescribed drug regime. About half of the 4,000-odd patients coming regularly to Y.R.G. Care probably need anti-retroviral drugs, but they can be prescribed for only 30 per cent of them, according to Dr. Kumarasamy.
Anti-retroviral therapy can increase a HIV-infected person's lifespan and improve his/her quality of life. Those without anti-retroviral drugs
are likely to develop opportunistic infections more quickly. Some of the treatments for these infections are themselves very expensive, says Dr. Ravi.
Now, the representatives of Indian drug companies are said to have started aggressively marketing the anti-retroviral drugs within the
country. There are also reports of doctors prescribing these drugs for short periods, such as for just two weeks, and following non-standard regimes. The experts this correspondent spoke to confirmed that they had seen such prescriptions or heard of such practices.
If so, it is a dangerous trend and one which requires that doctors throughout the country be educated as a matter of urgency. HIV is notorious for the speed at which it mutates and thereby changes its genetic make-up. So drug resistance can develop quite rapidly. Already, 10 per cent of new infections with HIV-1 strains in the United States and Europe are resistant to at least one class of anti-retroviral drugs. Prescribing non-standard treatment regimes will hasten drug resistance. The spread of multi-drug resistant tuberculosis in India is a cautionary lesson. Monitoring drug resistance in Indian HIV infections has also become vitally necessary, and several groups are just establishing facilities for this purpose.
The Central Government has recently decided that by the end of this year all major hospitals, public and private sector, would be able to
offer anti-retroviral drugs to pregnant mothers who are HIV-positive, says Dr. Ravi, a member of the National AIDS Committee. It was a very welcome measure which would reduce transmission of the HIV infection from the mother to her unborn child. There were different short-course treatments possible for the purpose, and studies abroad indicated that they did not lead to drug resistance developing, adds Dr. Kumarasamy.
But this is still a far cry from Brazil which in 1996 gave its citizens the right to free medication for HIV/AIDS. On the other hand, the
problem in India is already of a larger magnitude. There were over one lakh people receiving anti-retroviral drugs in Brazil at the end of 2001. In India, there might be a million people who currently need such medication, believes Dr. Kumarasamy. In that case, the annual bill in India for providing anti-retroviral drugs would be over Rs. 1,900 crores, ten times the present Central budget allocation for the entire National AIDS Control Programme.
"We have the will, we want the money," India's new Health Minister, Shatrughan Sinha, reportedly said at the recently concluded International AIDS Conference in Barcelona. It is understandable that India should seek international help. What is less easy to understand is why India does not do more for itself. A country that is willing to spend over Rs. 76,000 crores for its defence, allocates just one per cent of that amount for its Centrally funded public health programmes.
i went to chirala this week.
chirala is a town 9 hours northwest of chennai, part of yrg’s scale up project, providing capacity building services to organizations in earlier stages of operational development. yrg is a fairly sophisticated operation, with four offices throughout chennai, each concentrating on some specific facet of the hiv epidemic, and with significant cross-collaboration between the offices (and an upcoming consolidation to one main office). few organizations in india have scaled up to yrg’s level, but yrg also knows that it needs regional partners throughout the country if any sort of effective change in the epidemic is to take place. so, the administrative wing of yrg have undertaken this scale up project.
the story of how chirala was chosen as a site, as dr. suniti solomon, the head of yrg quipped, is disturbingly similar to a bad hindi bollywood fil-um. one day she received a call from a one dr. solomon from chirala. he had received a package of hers from the national aids control organization (india’s horribly ineffective governmental solution to hiv), and realized it wasn’t for him, but for his unrelated and unknown to him, future colleague, dr. solomon of chennai. so he gives her a call, he tells her what happened, they trade hackneyed jokes about the confusion, determine the next best steps for the appropriate delivery, and hang up the phone.
fast forward; one year later. dr. solomon of chennai is in nellore, three hours north of chennai (and the hometown of a significant portion of my family) visiting the family of her son’s friend. and of course, as all bad bollywood films go, coincidence would have it dr. solomon of chirala is sitting there too, also friends with the same family. so off they go, conversing about hiv, the growing epidemic in chirala, the massive resource constraints he’s facing, etc. etc. and dr. solomon of chennai is drawn to this man who exudes a humility and compassion that you just don’t see in many doctors. that is how dr. solomon of chirala and dr. solomon of chennai began their professional partnership.
so for the past two years, yrg has been helping shadows, the clinic that dr. solomon runs in chirala, to implement the basic tools needed for any health care delivery system to deal with hiv. chirala is a small town, on a trucking route between vijawada, ongle, nellore and chennai. the hiv epidemic in india early on, and in many parts of the world, has been clearly documented to travel along highways. truckers, away from their families, enjoy the comforts of the world’s oldest profession, becoming unknowing vectors spreading the virus from city to city. and of course, bringing it back to commit the ultimate domestic violence, infecting the monogamous wife. that’s why many of the women we see at yrg, their only risk factor for hiv transmission is marriage. since chirala is part of this trucking route, it has a thriving sex industry that goes back at least a hundred years. chennai, one of the world’s ten largest cities, has a 1% seroprevalence rate among antenatal women. the small town of chirala has over 4%, a staggering amount that shows no sign of slowing down… the amazing thing about the solomon family is that his father and grandfather were involved in empowerment of commercial sex workers over a hundred years ago, realizing that poverty (now finally being realized as the biggest risk factor for hiv) was what was driving these women into the trade. so dr. solomon is already blessed with amazing activist genes…
i accompanied dr. solomon of chennai, swarna, the co-ordinator of the scale up project (with perhaps india’s most suicidal driver that yrg so conveniently hired for my first trip on india’s highways) to chirala for the final site visit of the chirala capacity building initiative. i won’t even talk about my experience on the road, because i died a thousand deaths on that trip. i’m lucky to be alive. i guess that’s the good thing about being a hindu – this reincarnation schtick is not that bad... anyways, seeing the chirala site made yrg’s hospital look like a state-of-the-art medical wonder. there literally is nothing there. he’s lucky to have sustainable electricity. he has no diagnostic equipment besides his hands, his stethoscope, and a flashlight with a dying battery. but there’s a sense of hopeful desperation among the patients there – a hopeful desperation, because they know that he’s all they have before dying. though dr. solomon is a general practitioner, he’s been branded as the only doctor willing to compassionately treat patients with hiv in over 200 kilometers, transforming his general medicine clinic into an hiv ward.
because giving life saving antiretrovirals is a foregone conclusion –one month of drugs costs most people a year’s worth of salary, despite cheaper production from indigenous generic manufacturers such as Cipla and Aurobindo – dr. solomon has concentrated on reducing vertical transmission, the passing of virus from pregnant mother to newborn child. with the proper scheduling and administration of nevirapine, one of the cheaper antiretrovirals in india, and refraining from breast-feeding, doctors can now protect newborns from receiving the virus from their mothers. dr. solomon has chosen this target population (though, of course he treats all) because there’s some sort of positive outcome. however the sickening thought is that this mother will die, the father will die, the child will be an orphan by the age of one. maybe two. how do you stop the death of a family with a dying flashlight?
but the respect that both dr. solomons hold in that community is amazing. when we arrived at the clinic, there were almost a hundred patients waiting in the balmy palm and tropical fruit tree courtyard. and the longer we stayed, the more word spread throughout the town that the famous dr. solomon of chennai was in chirala, and by the time we left the clinic was teeming with patients hoping to catch a glimpse, or grab a diagnostic moment with either solomon. the sad thing is that it’s quite easy to diagnose the patients. the overwhelming repetition even in the three weeks on the wards at yrg has allowed me to recognize the physical patterns of pathologic presentation. but what can you do when you have no drugs, you have no money, you have no resources …
but as trite as it sounds, i guess you have to have hope that there is the possibility of changing something in your world somehow. dr. solomon of chirala is now committed to making his clinic a strong secondary, and potentially tertiary, hiv center. maybe he can help that pregnant mother to live. or keep the father from ever giving it to the mother. or empower the commercial sex workers to practice safe sex.
he’ll be coming to brown university within the year to receive training in the management of hiv. i hope that those of you who are in providence, and especially those of you who are on the wards in Miriam take a trip across the street to the fain building, clinic c, and take some time to meet this man. take him out to dinner, and let me know how it goes. till next week…
i've written more to post to the site, which i'll put up tomorrow. however, till then take a look at this:
yrg care's website:
an article in the new yorker about aids in india, with the later half focused on yrg care. probably one of the better, more nuanced articles about the epidemic in india that i've read in awhile:
http://www.michaelspecter.com/pdf/aidsindia.pdf
and, of course, email me anytime. sreekanth.@alumni.brown.edu.
sreekanth.
so what exactly is sreekanth doing in chennai, you might be asking… or maybe not. but i'll tell you anyways. here it is: the main reason i'm at YRG is to run a protocol researching the efficacy and safety of structured treatment interruptions for antiretroviral therapy. translation: patients when diagnosed with HIV have to take drugs for every day for the rest of their life. the problem with that is many-fold: 1) the sheer burden of taking drugs all the time – stigma / inconvenience 2) cost 3) side effects… for a class of antiretrovirals, the protease inhibitors, some of the side effects include fat redistribution on your body – so a the person will lose the fat in the legs and arms, and underneath their cheek bones, and get it behind their neck (so-called buffalo hump) and in the stomach. it's horribly disfiguring. so what is STI – or structured treatment interruptions? simply put – the thought is that if we give patients some time off from taking drugs all the time, then 1) less side effects 2) less inconvenience 3) less expensive. in resource limited settings such as India, the third reason is probably the most pressing reason to research STI. theoretically we know that STI can and should work. however, we don't really know what the structure should be in a structured treatment interruption. pretty important, one would think. so i'm going to take a group of patients and try a therapy and see if it works. it's a two year study and i'm only here for ten months, so they protocol will be taken over by the research staff here.
when i'm not doing administrative work preparing for the STI study, i've got a bunch of other projects that i work on? problems of rural surveillance, acceptability of microbicides, efficacy of generic antiretrovirals, describing cases of lipodystrophy, and a series of immune reconstitution, and possibly helping start a microcredit loan scheme for widowed seropositive women. just tryin to keepbusy.
so how is my day structured? i get up around seven in the morning, watch the news for a bit, get ready, then go read the paper over breakfast. i then ride an auto-rickshaw to the southern end of the city, Adyar, where VHS hospital – and in the back, YRG CARE – is located. i spend about an hour reading or working on a research project – and then i go on rounds with the attendings. that usually takes about an hour to two hours, depending on the load. i then go back to my research – but i work in the outpatient department, so i'll see outpatients with the attendings if the case is interesting. since much of the work on that project i described above is operational, much of my time is spent working on other papers that haven't been finished at yrg because of one reason or another. so i'm getting a good mix of clinical and research work. i'm hoping that his will help me to decide if i really want a career in academic medicine or not. not some sort of epiphany or anything like that – but all part of some process…
yrg is an exciting place to be – and hopefully i can convince some of you medical types to come work here.
it’s been one week since i’ve arrived in chennai, india. i’ve been sweating furiously, working even more furiously. it’s overwhelming, and i don’t think i knew what i was getting myself involved in by committing myself here for a year.
first things first. chennai: stalin vs. karate. stalin, the dictatorial mayor of chennai, lover of singapore, recently deposed by the political machinations of karate, attempted to make chennai the cleanest city in India. i don’t know if he succeeded, but it takes some time to get used to the smell of jasmine, cow poo, incense and diesel exhaust. don’t know if i ever will. the city is definitely still stuck in the eighties. annie lenox was blasting in some coffee shop yesterday.
next: hiv in chennai. morbidly appropriate, the clinic is set halfway between the main campus and the morgue.. there are two floors – the bottom, inpatient, upstairs, outpatient. twenty four beds. sample inpatient census: pcp pneumonia, cmv retinitis, intractable crytposporidial diarrhea, toxo encephalitis, partial small bowel obstruction secondary to tb abdominal adenitis, tb chorioretinitis, and a patient literally bursting out of his skin from a gastric lymphoma. it’s a foregone conclusion that these patients all have a cd4 count under 200. antiretrovirals are inaccessible, unless you’re enrolled in some research protocol – the plight of the poor – or you’re, well, rich.
chennai houses the world’s largest tuberculosis sanitorium, which i visited yesterday. there are almost one thousand inpatients. but only seven hundred beds, so you either double up, or sleep on the ground. oh yeah, there’s only one attending physician. the outpatient department has 2 doctors who will see 400 patients each in the morning. 15 seconds per patient. every morning a sea of humanity, is what they call it.
today i met with the president of the Indian network of positive people. after a polite discussion of hiv pleasantries, he began to talk with the sort of ferocity that i guess knowing that you’ll die will only bring about. all money is in prevention, no money for treatment. then there are the siddha, homeopathy and ayurvedic doctors all claiming to cure, the allopathic doctors for the most part ignorant of any treatment regime.
on rounds this morning, a patient died just minutes before we reached him. he didn’t say a word. we just closed his eyes and let his wife cry.
i don’t think i really understood what i was getting into.
sreekanth.
correspondence one:
i’m one degree and change from the equator, writing from the world’s strangest experiment gone horribly right. welcome to singapore, asia lite. headlines on arrival:: cpf non-taxable contributions reduced, citizens in uproar. somehow i can’t imagine an equivalent story (roth ira contribution reduced to $1.5K – citizens demand pres bush to be ousted) to make similar waves. page A2: pickpocket caught. sentenced to seven years, plus max caning of 24 times to the backside. i think in america, the most you get for first time possession of cocaine is five years, sans backside. page c13, lifestyles: romanians like women with mustaches. they think they are more fertile. what? welcome to singapore.
rolling the r’s: welcome to sing-ah-poorra, mistah. the taxicabi proceeded to give me a detailed outlining of all the sights on my trip to the hotel room i had booked just a few minutes back. cheerily: there’s sun-tec city, mistah. the biggest mall, mistah. my ears perked up. he had just hit on my newjersyite materialistic sensibilities – big mall? i’m there. looking around, the whole damned city is mall. chanel to the right. yves saint laurent to the left. louis vitton. armani exchange. lest i forget, mcdonalds. starbucks.
singapore is a small city state, south of malaysia, multicultural, multilingual, capitalistic, and proud. i’m sure some of you already know this: it’s comprised of primarily four major groups. the chinese. the malays. the indians (primarily tamilians). and the consumers. the chinese run the show here, for the most part. walk around the financial district, and you’ll find chinese women, decked out in their finest black gucci skirts, a fashionably appropriate top, coach suitcase in hand. the chinese men – well, they look like chinese men. you’ll be hard pressed to find malays or indians in these quarters – though they are number in the government.
the malays – i’m not sure where they are – but you see them around now and then. and the indians, walking in their lungis smelling of curry and cheap camera shops, are primarily service economy. they had a good time with me, making sure to point out my gringo indian accent. but they cut me discounts (at least they made me think that), cause i’m one of them (which i’m not).
i took the obligatory bus tour of singapore – the tour guide pointing out vestiges of britain’s old colonial rule, singapore’s pride and joys (the biggest man-made waterfall, man-made beach, man-made fountain…) and of course, the shopping malls. i met a pudgy kashmiri fob travelling from kuala lumpur on the tour, and for the next two days, he discoursed on indian, malaysian and general world politics, while i listened obligingly on boat rides, tram cars, and taxicabs. nice guy. due to my brilliance in planning my visa to india, my six month visitor visa will force me to leave the country for about a week. what better time to visit the kashmiri in malaysia.
as some of you know, a day prior to leaving for singapore, i spent a week in belgium, netherlands and luxembourg. 36 hours respite in new jersey. then onto philadelphia, denver, san francisco, tokyo. four days in singapore. and now, i proceed northward and westward, after half year’s anticipation to chennai. i start work tomorrow. wish me luck.
sreekanth
it's amazing how prevalent the web is in india - but how hard it is for me to post anything to this website! well, it's prevalent in the sense that there are internet connections everywhere - but they aren't always working. servers are always down... and if you go to an internet cafe - they don't let you use a disk - so i can't post prewritten stuff. which is frustrating, to say the least. but today, the stars are aligned, and i can finally post two updates which i have written some time back - one from singapore airport, about two weeks ago, and one from last week. i'll try to update this page at least once a week, if not more.