India Trip - December 2010 - Days 1-3 - Mysore

This blog is by Deborah Shefler, PINCC Board Member, who is extremely grateful to be included as the volunteer on this trip.

Day 1 - Mysore

The day started with a visit to the government hospital where we will be working to make sure all was in order for the clinical training starting the next day. We will have a spacious room with 3 examination areas, which is ideal. This hospital treats the poor for free. Relatively few can afford the private hospitals. Patients do not make appointments, but come and wait on the grounds for someone to see them. Most are illiterate. They sit on the ground in clusters talking with each other and many are with their children. There are only wards in this hospital, with white metal beds and thin mattresses. Patients are expected to have a relative or friend stay with them to procure food, give comfort, and provide miscellaneous services that paid professionals would normally provide in the States. Most of the health care personnel are women, but men seem to occupy many of the leadership positions.

We spent the rest of the day preparing and being present for Rhoda's presentation at the medical college. The format was a continuing education program. It was very well attended, perhaps 150 people. There were post-doc students who all sat in the back, professors who sat in the middle, and honored guests (like me) who sat in front. Virtually all the women professionals wore beautiful, and I mean beautiful, saris, with diamond and gold jewelry. I have to say that one of my strongest impressions of the day was the exquisiteness of the women, the gorgeousness of their clothing, and the realness of their jewelry. I was wearing one of my borrowed cotton outfits with repatriated silver earrings, and I was way under dressed. The most poorly dressed attendees were two Berkeley grads who are working as interns for the summer at PHRII (Public Health Research Institute of India) with which we are associated in Mysore, getting ready to apply to medical school in California.

Half a dozen people helped set up for the presentation. A technician tested the sound system for 2 hours. The presentation itself was preceded by a catered lunch of Indian food for all the attendees. The program started at about 2:15. The first half hour was all about thanking certain attendees, i.e., health care leaders, and giving them flowers and gifts. Rhoda was of course included in that, and even I got flowers. There was an invocation, including two women chanting a lovely song from the dais, and a butter lamp ceremony involving lighting wicks in a brass stand that had been festooned with little flowers. This all took place in a small amphitheater in the medical college facility, which had apparently been funded over the years by Indian doctors in the US. They all had their photo portraits in the entry hall.

Dr. Rhoda was a terrific speaker, in part because she so obviously spoke from the heart. She explained PINCC and what we do, the high prevalence of cervical cancer in certain countries including India, the cytology/pathology of the dysplasia and cancer (think graphic slides in the Power Point presentation) and the importance of preventive screening. John followed with a short presentation about the commitment needed to establish cervical cancer screening as a government priority. Preventive medicine is not widely practiced here. The doctors in government service tend to be overwhelmed with acute care. One high level doctor explained that the reason PAP smears are not regularly done here is because there is no one whose job description includes transporting the slides to the pathology lab.

The program ended at 4:30, at which time a drug company representative gave a pitch for a particular brand of calcium with vitamin D that included lots of data about vitamin D deficiency and its bad effects during pregnancy. I have read that most Americans suffer from vitamin D deficiency, including yours truly in the past. Indians and other dark skinned people are particularly susceptible. There didn't seem to be anything special about this particular product, and many people quite reasonably walked out, having already completed the professional education requirement.

The weather is perfect, slightly humid tee shirt weather. The evenings are a little cooler, so you don't need AC or even a fan.

We are staying in a very "real" neighborhood in Mysore. We are in a basic but clean and comfortable small hotel. My room has 2 single beds, a desk, free wireless that works instantly, a TV with all possible channels, several chairs, AC plus ceiling fan, private bath, and a little kitchen with a breakfast table and chairs. It is quite spacious. There is some street noise, but nothing disturbing.

The neighborhood has a mellow and benign feeling. It is the type of place few tourists come to, but they should if they want to learn what it's really like to live in an Indian city. Mysore has a population of about one million. It is a relatively small city for India. The streets were once paved, but you have to watch carefully where you walk. The traffic is chaotic, the trucks have signs saying "honk please," cows walk in the street (but they look well fed, milked and cared for). People gather outdoors at night, in their front yards, at cafes and "tea shops" (seem to be places to smoke), enjoying the mild weather and each other. There are lots of motorcycles and motor bikes but so far the fumes don't bother me. We went to a little neighborhood restaurant for dinner and for $3 I had delicious, moist barbecued chicken with onions, spicy fried cauliflower (one of the best preparations I've ever had), and hot and sour soup. The restaurant only had 2 knives, so one of us had to do without. Everyone here eats with their fingers.

Day 2 - Mysore

Today was the first day of the PINCC clinic. We had a large room so there was space for reception and registration, gathering patients on floor mats for informed consent and education by the social worker, taking histories, recording everything in a computer data base, three exam tables, paper file maintenance, slide arrangement for smears, little cups of formalin for biopsies, and a separate room for sterilizing the speculum, retractors, biopsy tools, and other equipment. The latter turned out to be my special task. The used equipment is picked up from each examination area and washed grossly by a maintenance person, who puts the stuff in a tray of cleaning solution. I then inspect her washing and return pieces to her for re-washing as necessary. After soaking for awhile, they go into boiling water for 20 minutes.

Again, the clinic or "camp" was preceded by a butter lamp ceremony to bring auspicious spirits to the endeavor. We saw 44 women. We had six trainees. We expect additional trainees will participate tomorrow.

Rhoda is an awesome teacher. She is patient, clear, pleasant, and conveys gratitude to those who want to learn. What is special about our protocol is that we can do everything in one visit, including telling the women the results of the screening most of the time. This is hugely important for countries like India, where the women are bussed in to our clinic from distant villages and can't afford to return again and again. An important distinction is that we do a low tech, low cost screen with diluted acetic acid before PAP smears, so most of the women don't even have to have a PAP for pathology. We can do biopsies, cryogun treatment (destroys pre-cancerous cells by freezing them until they explode), and even LEEP (a surgical procedure more invasive than cryogun and involving excision of tissue with an electrical current). PINCC donates the cryogun and LEEP machine when we feel the clinic personnel are adequately trained. The Indians would like to have colposcopy machines, which are expensive, widely used in the US, but really only magnify what you see with the naked eye.

The camp is running exceedingly smoothly because of the excellent facilitation, collaboration and services of PHRII, a foundation that has accomplished amazing things in its five years of existence. They arranged for space in the hospital, organized the transportation of the village women into Mysore, provided highly qualified social workers and nurses to support the education, registration and screening, and generally made us feel at home. We hope PINCC's relationship with PHRII will continue and become stronger.

I glimpsed the famous Mysore palace from the car. It's indeed quite something. They specially light it up Saturday and Sunday nights, and we plan to see it before we leave on Sunday morning. There are lots of tiny shops, few big buildings, and few modern buildings. There are a lot of slender logs used to hold up buildings under construction. One hopes Mysore is not in an earthquake zone.

We had dinner with a lovely Indian family who are good friends of John and Rhoda. The wife is from Karnataka (the state where Mysore is located) and the husband is from Tamil Nadu. This means they grew up in different cultures, speaking different languages. They had an adorable seven year old daughter who speaks precise English in an adorable way, and a handsome 10 year old son. We ate at a nice hotel. The total cost came to about $56 for all 7 of us. The conversation ranged far and wide.

For those of you who have wondered about all the Indian languages, here's the situation: States were established at the time of independence (1947) based on language groups. There are about 28 states, and at least that many languages, most with numerous dialects. Many of the languages are based on Sanskrit, but no one speaks that any more. It's a little like Latin and romance languages. However, the Indian languages are not necessarily much alike. So someone from Tamil would not necessarily be able to speak to and understand someone from Karnataka or Kerala or Andhra Pradesh (where we are going on Sunday). Think about someone from Oklahoma not being able to understand someone from Texas. Even the written languages are different province to province. The national language is Hindi, and now everyone has to take it by 5th grade. But most people do not speak Hindi. The only common language is English, but it is spoken fluently by only 5% of the population. Many "English speakers" speak it hardly at all. The only things the provinces seem to have in common are religions and castes. They all have castes, but there can be differences in the strata from area to area. Generally people marry within only a few levels of their own caste, which tends to perpetuate the system regardless of what the government does, e.g., teaching non-discrimination in schools, caste quotas in government jobs and in the legislature.

Day 3 - Mysore

Today was the second day in the clinic. Again we saw 44 patients, and did our first LEEP Procedure.

I installed myself in the instrument cleaning room where I spent most of my day timing the instrument sterilization process. This meant I had a lot of down time, so I brought my iPod, which created a bit of a stir among the maintenance woman and the nurses, called sisters. I had them listen to Willie Nelson on my iPod and it was clear this was a new experience for them. The maintenance woman spoke no English. She nevertheless kept trying to communicate with me. Somehow we discovered that we both like chocolate, so she kept smiling and saying "chocolate" to me.

I also became friendly with one of the nurses, who is a Christian. She advised me that in Exodus it says women should wear no adornment, so she, unlike virtually all the other women, wore no jewelry, not even a wedding ring. (Hindu women do not wear wedding rings, but rather gold and black mundulas or necklaces, many of which have gold pendants and are quite beautiful.) She questioned me about my knowledge of the bible and was soon able to conclude I was unenlightened. She is bringing her bible in tomorrow to show me where it forbids adornment. I promised her I'd read it (and I certainly hope she's wrong). She invited me to her home, but then remembered it was being repaired. She gave me her phone number for next time I'm in Mysore. This woman also informed me that the white race had been given all the beauty. I quickly demurred, and pointed out to her all the exquisite women in the clinic, and that she herself had a radiant smile. I may have convinced her. She further believes that Jews are the chosen people. I suggested everyone was equal under god. At any rate, you can see I'm having some interesting conversations.

We had another simple dinner at a dosa restaurant near our hotel. I had a "paper" dosa that was about 3.5 feet long and came rolled and held up by 2 plates. It was crispy, somewhat greasy, and positively delicious. I was able to eat less than half of it. It came with 4 condiments. It cost about 80 cents. John and Rhoda had different types of dosas, also delicious and unbelievably cheap. Our waiter entertained us by reciting his work history, which included several years when he worked as a hospital orderly full time plus as a waiter part time. It rained while we were in the restaurant, and, guess what, the power went out. All the shops and restaurants have generators, so the lights came back on quickly.

After dinner we met with one of the Mysore Rotary Clubs to request that it support PINCC. Both PHRII and John and Rhoda's friend from last night facilitated this important meeting. The Rotarians were already amazingly knowledgeable about the cervical cancer problem, described the things they could do for us, and invited us to submit a proposal. The meeting was all we had hoped for and more. I talked afterwards with two of the members. One was a young man who I thought might be the Indian Tom Cruise. He wore a suit, about the first I've seen here. He's an actor and owns an outdoor billboard company. Since joining the Rotary five years ago, he's been providing free advertising space for charitable causes. The other member owns a business that transforms molybdenum into a salt. It turns out that China is the largest producer of molybdenum, which is one of those chemicals you don't know much about but is in everything. The US is second in production. This fellow will be off to China in a couple of months.

Oh, I do need to say that while we were out today they paved the road in front of our hotel, and the local cow was no where to be seen. And the equivalent of Fox news is alive and well on Indian TV.