PINCC's Blog

Uganda. Our first week in Gombe

2012-01-28T06:30:00.001-08:00

Monday, 20 patients

Tuesday, 25 patients

Wednesday, 26 patients

Thursday, 25 patients

Friday, 15 patients

Our first week at work in Uganda and we are in Gombe, a small rural village about 2 hours west of Kampala, 45 minutes of the journey on a bumpy dirt road. It is small community, with a hospital, but with only intermittent power and untreated water from the well. It is a one road, agricultural community (banana and ginger) that appears to be out in the middle of nowhere. PINCC was found by it's incredible administrator, Dr. Lule Haruna, a very savvy man who is finding any way he can to fulfill the needs in his community.

We are staying with Janet, a retired social worker who lives in both Gombe and Kampala. She is around 60 years of age and has been married to her husband for 40 years. She has five children, the last of which just graduated from college. She is an open, loving woman who has been a champion for women's rights all of her life. During Idi Amin's reign, she and her family were refugees in Kenya but upon their return, they were able to repossess their banana plantation and she lives here now, part time, and employees several people to work it. A week of bucket baths and power when it came on, possibly twice the entire week for only a few hours at best, breakfast by candlelight, incredible sunrises and sunsets, evening spent sitting on the steps of the veranda, living with Janet, her best friend and sister-in-law Mary, and Hope has been a joy. Our days were filled. In the week we were in Gombe, the doctors saw 111 patients, performed 22 Pap smears, eleven biopsies and five cervical cancers were diagnosed.

We worked with eight trainees, all but one of who had been trained on one of the two previous visits PINCC has made to this community. All of the trainee's skills were sharp and efficient, and Melissa concluded that they have all completed their classroom training, including Josephine, the one trainee who had not yet met with PINCC. We were able to set up the cyrotherapy lab and the trainees were able to practice; we were able to start the community outreach education program and we began working with the community health educators for the district of Gombe; we successfully facilitated a training for trainers workshop on women's health; we were very busy, and we had a wonderful time.

As for Arlayne and I, we followed our job descriptions and got it done! We inputted our findings in the computer, having to charge the computer batteries off of the jenny the hospital has for the OR, cleaned speculums, facilitated patient registration and made sure every patient was interviewed, kept record of every woman's name and contact who stated they had been in an abusive relationship for the community social worker to contact later, made sure the treatment rooms were stocked and ready to go, and got the things for the medical staff asked for. And I? I saw my first cervix, a prolapsed uterus, am fairly confident I can now perform a successful VIA on a cervix for cancer, although I have yet to do one, performed two HIV tests, two pregnancy tests, trained women waiting to be seen by the doctors on women's health, and began the facilitation of the Training of Trainers Workshop. It was a full week, and one where I for one learned more that I ever thought I would. It has been amazing.

The team is fantastic and we are working as though we have done so for years. The three clinicians are such good teachers that the trainees are learning anything and everything they want to. Arlayne keeps us all laughing and Carol makes sure everything is where it is supposed to be. Everyone has commented as to how well it is going and we are all thankful. Again, it is a privilege to be on this team.

We are in Jinja now, our one day off (kind of, I am doing the blog…) awaiting Mike, our Kenyan driver to arrive so that we may be on our way to Kenya. A successful week complete; our next week before us. On to Kenya…

Amelia T. Hambrecht

On to Gombe...

2012-01-28T05:15:00.001-08:00

Endebee

January 21, 2012

Have you ever heard a lion purr? At the reserve, there are three lions, one male and two female. One of the females is in heat. I am watching the lions in their enclosure. One female laying on a platform, and the male is sleeping under a tree. The female in heat is pacing around in the enclosure, a large space I would guess to be around the size of a small city block. I would be unable to see the loins if they were in most of the other areas of the enclosure. After she tires of pacing, she walks up to the male and snuggles up to him, rubs her face into his mane and purrs. The purr is the purr of a cat, however it is as loud as an engine, and vibrates to my bones. It is pure music.

Our team has congregated and we are preparing to leave. We are lead by an obstetrician, Dr. Melissa Miskell from Texas. She has been a volunteer on PINCC trips, twice a year for the last six or seven years, and just loves what she does. A straight shooter with a wonderful Texas twang, she is the perfect leader for the team. Our second doc is Dr. Sharry Kreitlow, an OBGYN from Wisconsin who is also fantastic. She has done similar work in Haiti and is scheduled for a trip in Guatemala this summer. This is her first trip with PINCC. Our third medical staff is Eva Bryer, is a nurse midwife who, when not on PINCC trips, volunteers in a free clinic in the South Bay. Arlayne Mandell, a friend of Melissa's who is living in Holland when not wit PINCC and myself are the support staff whose job description is basically: get it done! And lastly Carol, our coordinator, our MC who rounds out our team, a random mix of six people, six backgrounds with six personalities, all coming together because we all share one thing in common: a need to balance the abundance in our lives with the realities in our world; a need to share our talents and knowledge with those that do not have access to them; a need to help. It is an honor to be a part of this team.

Tomorrow we leave to our first site, Gombe. We will spend a week in very rural Uganda. Although everyone but Sharry and myself have been on PINCC trips before, this is the first trip to Uganda for all of us but Carol. We are excited, and looking forward to the days that come. Gombe, here we come!

Amelia T. Hambrecht

Thanjavur Report – PINCC Consults to a sister organization for Quality Improvement

2012-01-27T10:02:00.001-08:00

Dr. Aarti and Dr. Rhoda reviewing the ICTPH Screening Program

On Monday, January 16, 2012 we were driven after breakfast from READ, in Andimadam, down to Thanjavur for our consulting visit to the IKP Centre for Technologies in Public Health (ICTPH). The drive was a pleasant roll through countryside and small villages – to the extent that any drive can be pleasant in India! After two hours we arrived at our hotel in Thanjavur, and had the rest of the day for site seeing.

When we got settled into our rooms, we went for lunch and then some of our team got massages at the hotel spa. (In spite of having a spa, this hotel is NOT a nice place to stay, and the next morning we moved across the street to a slightly less not nice place to stay.)

After the spa visit we all five piled into an auto-rickshaw and went to the Chola Palace (built about 1200 CE) to see ancient bronze statues of deities and to climb up the eight level breeze tower to look out over the city. The Palace itself is a bit the worse for wear, but is still owned and operated by descendants of the original ruling family. The various museum rooms contained incredible old statues, jewelry, artifacts and artwork.

From the Palace, we hired another "auto" to take us to the "Big Temple" – also a 1200 CE period Chola dynasty Hindu temple. The Temple is in excellent condition and is protected as a world heritage site. January 16 was at the end of Pongal, so there was much celebrating and exchanging of best wishes with strangers! After dark, we sat on the ground and watched a recital of young girls playing traditional Indian stringed instruments and troupes of young girls doing traditional Indian Nataraj dances.

After breakfast on Tuesday morning, we hauled our gear across the road to the PL.A Residency Hotel – a small cut above the one we left, but right on the RR tracks and next to the station, so very little real advantage – we traded darkness and dinginess for immense noise pollution. At least there was hot water!

At 11:00, a driver from ICTPH picked us up and we spent a few hours with Dr. Aarti Sahasranaman, VP for Interventions (which means health programs like vision, dentistry, cardiovascular and women's health), and the ICTPH Research Analyst Ms. Vani Priya. We learned about the history of ICTPH (4 years) and the women's health program, where their screening work is located (about 3 months). VIA and VILI screenings are presently carried out opportunistically at two of their first four Regional Micro Health Centres.

After a nice lunch at a really good hotel restaurant nearby, we went out to visit one of the RMHCs, about an hour's ride out of town, where VIA and VILI are being carried out whenever women who come in for other reasons agree to be screened. We were all exceptionally impressed with the quality of the physical space and also the supplies and equipment – for all their programs, including VIA and VILI. For example, the have locally designed and built gyne tables with built-in lighting and foot rests that are very innovative. When we got back to the hotel, all were pretty tired, so Joy, Liz and Janis went to eat snacks in their rooms while Rhoda and John went to the hotel restaurant for soup and "Chicken 65" – a new to us menu item that presents chunks of deep fried boneless chicken marinated in a similar manner to Chicken Tikka – garnished with red onion rings and cut limes.

Wednesday morning, we got picked up at 9:30 and spent the whole day at ICTPH. Joy and John interviewed Vani, Dr. Aarti, Kartik (AVP for Finance and newly appointed ICTPH COO), and Zeena Johar, President of ICTPH. The focus of these explorations was on the organization and administration. All of these folks are young and full of energy and passion for their project – which is to ultimately build a Kaiser Permanente-like prepaid health network of 10 RMHCs that each offer comprehensive care. Most impressive!

Rhoda, Janis and Liz went to the second clinic that is currently offering screening and met with the people trained to carry out the screening at that clinic. In the afternoon, they returned to town along with some of the clinic staff and met further in the ICTPH conference room.

Wednesday evening was Joy's last night with the team, so we went back to the nice hotel dining room for an exquisite celebration dinner. As we were tucking in to appetizers, Zeena, Kartik and a few other ICTPH senior staff came in for their own dinner party. Not really a surprise, according to Kartik, since there are so few acceptable restaurants in Thanjavur!

Thursday morning we saw Joy off to Chennai and Delhi for her holiday tour, and then went to ICTPH at about 11:00 for a feedback session to the entire ICTPH staff about what we had learned from our meetings and interviews. They were most eager to learn, since most are new to ICTPH, and especially since the VIA & VILI screening program, the focus of our visit, is just getting off the ground.

Both the organizational and the clinical interviews and observations converged on the same four areas for improvement recommendations:

1. Community engagement and public education

2. Training and continuous learning of screeners

3. Documentation

4. Referral system

We felt that little cervical cancer reduction can take place in the region under the current model, which again is just getting started. Relatively few orientation sessions have been held with community women's self help groups. These sessions to date stay away from mentioning cancer, so there is little compelling reason for an asymptomatic woman to choose to come to the clinic for such an invasive procedure for no reason that she understands as urgent. Also, the screenings do not account for inadequate screenings and when they see lesions, the do not do Paps or biopsies, but refer the women to the city cancer hospital for having these procedures done – another invasive process for reasons still not clearly understood by the women.

Not surprisingly only a couple of women have actually gone for Paps and biopsies. So we made several recommendations about how they could engage the community more realistically, how they need to move towards doing their own Paps and biopsies (and ultimately to single visit see and treat).

We also recommended creating a system for proctoring and supporting the continuous learning of the existing screeners and, as they scale up to 10 RMHCs, new screeners. Certain shortcomings were pointed out in their documentation system, which is an in-house created software program that is over-all very impressive! We also recommended that when the bugs are worked out, their record keeping system would be a commercial success that could generate more income for the ICTPH.

Finally we attempted to show how their present referral system would not ever be viable and that with the implementation of the above recommendations (plus a few more referral-specific ones) their overall operation could be built into a successful and important contribution to local women's well-being.

Our team went out to a final night dinner at another of the "acceptable" restaurants in Thanjavur for a veritable vegetarian south Indian feast – one of the best meals of the entire trip! On Friday morning, we went to the train station to go to Chennai, on our way home!!!

After a lovely evening in Chennai, we took off on time and landed at SFO a few minutes early.

2012-01-21T04:15:00.001-08:00

Amelia T. Hambrecht

Monkeys and Malaria

2012-01-21T03:53:00.001-08:00

SFO to Dubai 15 + hours. 12 hour layover in Dubai. Dubai to Addis Ababa 3 ½ hours. I hour layover in Addis. Addis Ababa to Kampala 2 hours and we are finally here. Carol and I left San Francisco at 3:30 Tuesday afternoon and arrived in Entebbe around 4pm Thursday. Uganda takes some serious effort to get to.

We arrive at our accommodations and they are fantastic. They are funky, very funky, but entirely magical. We are staying at the Uganda Wildlife Education Center, a nature preserve where animals that cannot return to wild for whatever reason are cared for. They have rhinos, and lions, giraffes and water buffalo, zebras and crocodiles, beautiful birds and monkeys. Do they have monkeys…

Monkeys, we have decided, must be an indigenous species for this area. They are everywhere. A cute grey little thing with black faces, they scamper around in packs. It also appears that, what ever their natural predator was, no longer resides in the area. I would estimate there are a thousand monkeys here, and do they have a mind of their own!

The café where we go for meals is a circular cinderblock open air building overlooking Lake Victoria. Funky and magical. We meet some visitors, a pilot from Ohio via Turkey, a tour guide from Iran, have a beer and collect some things for the room, namely, a few bananas and some mantaz, also known as half-cake, a fried bread donut type thing that looks really good. On our walk back to the room, we travel through a path that is canopied by trees where out of nowhere, a monkey runs up and leaps to grab our bag of goodies. Unsuccessful, he runs off but another attacks from different angle. Carol and I are trying to get though this gauntlet with our bounty but these monkeys know what they are doing. The second monkey got a hold of the plastic and tore the bag. Donuts and bananas cascade to the ground and monkeys are immediately on deck to pick up their loot. We carry on down the path schooled in the behavior of Ugandan Monkeys.

We return to the café the following morning for breakfast. It is a spectacular morning. The blue mist rising on the flat still lake, a few scattered boats fish for their daily catch, it is a lovely place to sit and read while waiting for the café to open. Carol forgot some things so she returned to our room while I stayed to enjoy the moment; she left her malaria meds on the table with me, sealed in their child protected pill bottle. The café opens and I go to order some tea and unbeknownst to me, a monkey scampers by and grabs Carol's malaria meds. I return to the table, pick up my kindle, and start to read but out of the corner of my eye, I see something. I look up and there is a monkey, looking straight at me, holding Carol's pill bottle, chewing the label. I yell and go after the little thief, hoping he would just drop them but he scampers up to the roof, pills and all. One of the young gentlemen who work at the cafe came to help and we walked around the building, trying to find the offending monkey to see if we could get the meds back. We find him, chewing the label happily, and the child protective top no longer on the bottle.

With the pills no longer in the bottle, I left the monkey to enjoy his prize and I looked around the grass, hoping to find at least a few pills. I personally only travel with the amount of pills I need and I didn't know if Carol did the same. This could be a problem. We had already learned that we were on two different medications so I could not share. I did do a quick calculation and we could have someone call in a new script and have them picked up by Eva before she got on her flight that afternoon but what to do for today? I found some, a few pills lying on the grass. I picked them up. One looked completely untouched. It will be up to Carol…

I return to my kindle and this blissful morning scene where out of the corner of my eye, I see the pill bottle flying from the roof on to the ground. At least I now have some evidence as to the happenings of Carol's medication and the monkey.

Carol returns and we have a laugh. Fortunately, she has some extras in another bottle so there is no concern. Breakfast is delivered and we are given plates of beautiful fresh fruit and hard-boiled eggs. We are just ready to begin eating when another monkey comes racing towards Carol and attacks her fruit! What is it about Carol's monkey Karma? She was holding the bag the evening before, so she was the one who was attacked. It is her Malaria medication, and now her plate of fruit! The wait staff did have a quick solution. The young waiter who assisted me earlier sat with us as we ate, a long wooden stick in his hand that he waived it at any monkey who considered coming near.

As we left the café to go out for our day, Carol to do her thousand's of errands before we go and I to explore Kampala, I heard a drop and looked. The child protective top had landed on the path just behind us. Apparently, the monkey thought we should take it with us…

Our first 12 hours in Uganda, funky and magical.

Amelia T. Hambrecht

Rural Education and Action Development, Andimadam, Tamil Nadu

2012-01-17T21:55:00.001-08:00

Dr. Rhoda speaking to the local medical association group in Jayagondam in the Ariyala district of Tamil Nadu.

John Adams

16 January 2012

We took an overnight train from Mysore to Kumbanakom on 10-11 January, 2012 to visit the Rural Education and Action Development (READ) NGO that is a sister NGO to our Mysore hosts, PHRII. D. Selvam has created a wonderful set of institutions in the town of Andimadam, including an HIV+ women's program, school, disabled school, and craft programs. READ also coordinates over 900 women's self help groups.

We arrived just a the start of Pongal, the biggest festival of the year in Tamil Nadu – a merry-making harvest festival that brings Tamil natives home each year from all over the world. The first morning (Wednesday) of our visit, we observed the making of Pongal Rice and visited the school. We also visited a beautiful old Chola Dynasty temple that dates back nearly 1000 years.

On Thursday, there were more READ institution visits and then Dr. Rhoda spoke to the local Indian Medical Association chapter about PINCC, HPV, and VIA. The group greatly appreciated the talk and spoke eagerly about getting the training brought here. See the picture above.

We spent Friday morning at the local Public Health Center in Andimadam, where some of the doctors from Thursday's talk work. The PHC doctors spoke of training they received in the now defunct VIA program instituted by the state a few years ago and proudly proclaimed that they have a Cryo gun from that program – however they don't use it! One of the nurses stated that she does 3-4 VIAs a month, but was unclear what happens when a positive case is found. We are just a tad skeptical about what is going on here, but they invited us to bring our PINCC training to the PHC if they can get approvals up the state bureaucracy line. It would be a perfect venue, and the 100 or so HIV+ women in the READ program would be an ideal group to start the trainings with. We gave Selvam the PINCC commitment letter and he will be working with the PHC to get the needed approvals.

On Friday afternoon, we went to a Tamil "Backwater" area and took rowboats through a mangrove area that eventually led to a gorgeous and totally deserted ocean beach! It was an incredibly wonderful experience.

Saturday was a day of further meetings around READ and many hours of finalizing the Tata proposal with Mr. Selvam to fund our envisioned Centre of Excellence for Cancer Prevention in Women in Mysore, that intends to train 320 doctors, nurses and midwives a year in the PINCC methods by the fifth year of its operation. On Sunday, the PINCC team's three Christians went to a catholic mass in Andimadam, and afterwards, in conversation with the priest, learned of his social and community missions in eco-developments. He is sponsoring a number of "green" local programs for tree planting, organic gardening, and so on. Very impressive service and we really were excited by the community focus. We spent Sunday afternoon visiting Selvam's home and meeting his family.

Monday morning we traveled by car to Thanjavur, the last stop on this trip, for three days of Quality Improvement consultations with an NGO that sponsors a clinic where three staff have received VIA training at Adyar Cancer Hospital in Chennai.

Mysore activities January 02-10, 2012

2012-01-09T04:25:00.001-08:00

John Adams

MYSORE -- 02 – 10 2012

SUMMARY OF FOUR SCREENING TRAINING CLINICS IN MYSORE

DATE

HOSPITAL

DAYS

VIA

PAP

BIOPSY

CRYO

LEEP

CANCER

MD / RN TRAINEES

08/2010

St. Josephs

159

12/2010

Cheluvamba

202

(1 as co-teacher)

07/2011

JSS

263

01/2012

St. Josephs

198

(Broken Cryo gun)

TOTAL

822

193

146

We completed our fourth four-day VIA screening and training clinic in Mysore on 07 January. Once again, we were highly impressed with the organizational support provided by all the staff at the Public Health Research Institute of India. They provided a total of 21 staff for patient education, registration, informed consent, record keeping, nursing and patient flow management. We had to make a late switch from JSS Hospital to St. Josephs Hospital due to a government mandated polio vaccination program that was announce just before we departed for India.

During the camp, we saw a total of 198 women. 58 of the screenings were inadequate and Pap smears were sent to JSS Medical College Pathology Department. 53 patients were judged positive and 50 biopsies of the possibly affected areas of these women were also sent to JSS. Eight Cryotherapy treatments were performed for moderate lesions and seven LEEPs were performed for more severe lesions. We saw one "definite" case of cervical cancer and one possible case.

The original intention on day four was to bring in a large cohort of HIV+ women. Unfortunately there was a late glitch and so we only got to see a handful of HIV+ cases. As a result, Day four was shortened and we saw about half as many patients as on the other three days.

At the end of the camp, we certified five of the trainee doctors as qualified to perform and to teach VIA and Cryotherapy. We concluded that a fifth camp is necessary in order to certify any of the doctors in LEEP.

In our follow up meetings at PHRII after the camp, they reaffirmed their intention to continue to develop the VIA screening camps on a monthly basis in the Mysore area. We also held a "pluses and deltas" review of the camp with all staff at PHRII and identified several areas for clarifications and improvements. In another meeting of the PHRII management and clinical group (nurses, trainee doctors, administration), we focused on planning for the development of a longer-term cervical cancer screening and prevention program – with the vision of making Mysore the "capital" of cervical cancer prevention in all of India.

On 09 January, Dr. Rhoda Nussbaum, PINCC-India Medical Director, gave an excellent CME presentation on cervical cancer, which included an actual colposcopy demonstration on three patients back stage, with video coverage into the auditorium. A first for PINCC-India to be sure!

9 days and counting! Readying for Africa

2012-01-08T09:41:00.001-08:00

The bags are (almost) packed! Shots and meds on Wednesday, first aide kit replenished, camera batteries and kindle charged, mosquito repellent and skin so soft purchased… got to pick up a mosquito net.

My name is Amelia, and this is my first trip with PINCC. I became acquainted with the organization last May, helped in the fundraiser in June, and waited until there was a trip that fit in my schedule. I will be going to Uganda and Kenya in two weeks. I am not a nurse or a doctor, I am a former teacher now nursing school candidate who will act as a community educator and all around support for the team while they train the host country medical staff on the identification and treatment of cervical cancer.

Today the team met in Oakland to prepare for the trip. At least 8 suitcases bigger than I have ever owned were packed with gauze, small cotton swabs, large cotton swabs, gloves, gloves and more gloves, pregnancy tests, LEEP machines and materials, exam kits that we put together, headlamps, alcohol solution, cytobrushes, pap sticks, syringes, loops, silver nitrate, lidocaine, and all kinds of instruments that I am only fairly familiar. Each suitcase had a packing list, each carefully thought out so that everything that was needed would be with us yet none would be over 50lbs, so no one would have to pay over sized luggage fees.

And what fun the day was! These are some terrific people going on this trip. Our fearless leader, Carol, has a Zen like quality that, regardless as to what is going on around her, keeps everyone calm and unfretted. Art, a retired OBGYN who plays drums and is studying Jazz piano has an elfish sparkle in his eyes, a joy of life seen in many people who are readying to embark on an adventure. Another Carol and Eva, two lively and cheerful nurses who have been to South America with PINCC, round out our team to Africa. The day went fast as we filled the suitcases, smiled and giggled at the stories and perused a book Barbara and John made of the last trip to Africa.

Many thanks to Kay, Pat, Carol, Art, Carol, Eva, Mitra, John, Barbara, Cheryl, Renee, Sujata and Karen for giving of their time in helping us prepare for this trip.

The bags are nearly packed. We are just about ready to go. For me, nine days and counting…

Amelia T. Hambrecht

Arrival of PINCC INDIA

2012-01-04T18:37:00.001-08:00

John Adams

ARRIVAL IN INDIA: 02-03 January 2012

Our PINCC-India team of five departed from SFO new year's eve on time on an Emirates flight that is the longest non-stop flight coming out of San Francisco – nearly 16 hours! With suitable drug therapy we all got enough sleep to get off the plane in Dubai, walk around for an hour, and then board another three-hour flight to Bengaluru. For once, we actually arrived at our destination in India a few minutes early – unheard of in the annals of modern flight!

In the picture, from left to right, Janis Luft, Liz Armstrong, Joy Carlson and Rhoda Nussbaum, waiting for our car at Bengaluru Airport at 4:00 am Monday morning 02 January.

Our team consists of Dr. Rhoda Nussbaum, Medical Director, PINCC-India; Janis Luft, NP; Joy Carlson, and Liz Armstrong; and your trusty blogger and Administrative Director for PINCC-India, John Adams.

Our regular driver, Mr. Khan, met us at the airport and drove us safely to Mysore, where we arrived at 7:00 am on 02 January, and checked into our regular hotel. For Rhoda and me it is always like coming home! We spent the morning going to the bank to exchange money, shopping for room necessities, and getting our telephone SIM card charged up. We spent the afternoon at PHRII coordinating the week.

On Tuesday we had a wonderful meeting at the government hospital, where we worked during our second visit to Mysore, with the Radiation Oncology doctors, who are most interested in learning VIA and setting up clinics to screen for and prevent cervical cancer in the villages. They both declared they'd come to see our clinic set up on Wednesday to get an idea of what it takes. We may well be doing further PINCC camps in Mysore with new populations of doctors!

Next we went to the JSS Medical College and got a tour. During our July 2012 visit, the JSS Swamiji (Holy Man) blessed our project and invited us to make JSS hospital our home. When we were introduced to the JSS Medical College Principal, he told us that the Swamiji had spoken highly of our project. He invited us to submit a proposal for incorporating VIA, Cryo and LEEP training into their medical school curriculum. If it is successful, they would advocate to the National Medical Council, which controls all medical school curricula, to add VIA, Cryo and LEEP to all gynecology programs across the country. We continue to dream big and find progress!

Tomorrow we stat our fourth PINCC clinic hosted by The Public Health Research Institute of India and held at St. Joseph's Hospital (JSS not being available at the last second due to a government mandated national polio program – if only they'd take HPV as seriously as polio!).

209 728 9432

415 385 8388 (Mobile)

www.home.comcast.net/~jadams2212/

The rise of economics as a profession has not been accompanied by any noticeable improvement in the ability of societies to manage their economic affairs (John Michael Greer)

PERU!

2011-11-10T14:49:00.000-08:00

Last Saturday we held classes for willing Salvadorenos that came in voluntarily on the national Bicentenial holiday to complete their training with PINCC. Dra. Patricia de Banos, the person who "put it all together in El Salvador" is pictured in the first attached photo. The PINCC team then dispersed and Kay, Carol, Samantha and Lyell continued to Lima and met up with Nancy Levine, Janet Wiese, and Natalia Tocino and headed north to Huaral at 5am Monday morning. Huaral proved to be challenging in many ways, but PINCC's training there will definitely benefit the women of Huaral and surrounding areas as there is MUCH need for cervical cancer screening there---sadly, we had to turn away women each of the three days we were there as there were still women waiting in line after 5 pm each day. The stats for El Salvador and for Huaral, our first 3 days in Peru are as follows:

El Salvador:

Total Patients seen for IVAA: 236

Cryo's: 22

LEEP's: 7

Huaral, Peru:

Total Patients seen for IVAA: 268

Cryo's: 6

LEEP's: 9

In order, the next photos show Natalia teaching women's health to the women waiting for their IVAA exams, photo 3 is Nancy teaching the midwives how to identify lesions, Janet teaching beginning students IVAA exam techniques, next is Noris, the midwife who coordinated the PINCC training, and, last but not least, the PINCC team shortly before departing Huaral. Tomorrow is the first of our 2 days working in Lima and we will try to blog one more time before heading home. All the volunteers send love to all their friends, families and supporters. Buenas noches, Lyell Fox

San Salvador

2011-11-07T11:47:00.000-08:00

Saturday, 5 Nov 2011, by Kay Taylor, MD
Today we completed a terrific training week in cooperation with the El Salvador Ministry of Health. We have been working to train and certify teachers, who are already performing screening and treatment for cervical dysplasia in 5 health centers in the huge San Salvador metropolitan area. Each day, we drove for half an hour or more to a different clinic, some associated with hospitals. Our team of gynecologists, nurse practitioners and support people included two mid-teen girls, one of whom had her 14th birthday on Thursday. She received ice cream and cake from the health center with a lovely party after work was finished, then more ice-cream cake at dinner followed by singing and dancing at a local restaurant. She looked so cute in a huge caballero sombrero, with the MC leading singing of 'Felicidades' and Happy Birthday! They've been a great help, sorting charts and stocking exam rooms for us.

The rest of the team was kept very busy, teaching and proctoring examinations for 15 doctors, 4 gynecologists, and 25 nurse specialists, all of whom are in various stages of training, from just beginning to training their colleagues. We have certified 2 more gynecologists in all procedures, as well as 4 other doctors as trainers for examination and cryotherapy, and several more doctors and nurses certified to perform these techniques in their health centers. How proud they are of their certificates! The trainers will hold another training session in 3 months, so when we return, the remainder of these students should be ready for certification. There are 41 health centers in the metropolitan area. Now, 5 of them are equipped to perform treatments, and 14 to do screening and referrals. We hope to have this densely populated part of the public health system completely covered after May's visit!

We also trained 5 community health workers who lead health education efforts in the use of our new flipbooks for teaching women about their bodies and cancer prevention. They were very enthusiastic about the flipbooks we gave them, and are going to field-test them and train others with them. We'll get their feedback in May. We are told that only 1/3 of women have had cervical screening more than one time, because of lack of education as much as lack of opportunity. We hope to help change that!

Tired but satisfied, our team will be celebrating tonight with the Salvadoreans. Today is the 200th anniversary of their independence from Spain and Mexico, and the streets will be filled with music, dancing and fireworks. We really feel a part of their celebrations today!

(To watch Dr. Eve Yalom interview a patient that was treated by the PINCC team CLICK HERE)

Nejapa

2011-11-04T05:25:00.001-07:00

Another special day with the pincc team alongside representatives from
the Ministry of Health and at least my favorite clinic yet.

Today we worked at a a clinic in Nejapa called ProVida. This was one
of the fist sites PINCC ever worked at and there{s a strong connection
and mutual respect.

ProVida is a community clinic, and those of us who{ve worked in then
even in the US know that there is a kinship in them that is different
from most other healthcare delivery sites. This clinic has worked
very hard to build itself from the ground up - literally as we arrived
to even new contruction since PINCC was there last.

Nejapa is a more rural community about 40 minutes outside of San
Salvador. Again, nurses and doctors from clinics and healh sites all
around San Salvador came to work today to learn VIA, sharpen their
skills, or become certified. We ran 6 rooms yesterday very smoothly
seeing patients for VIA exams while teaching new participants the
process and doing LEEP and cryo for new and prescreened patients.

Yesterday was extra-special. Soukeyna, my daughter, also turned 14
yesterday. The staff sang Las Mañanitos to her in the morning
introduction and, after clinic, we had a little party for her with
cake, singing and dancing with the clinic staff and participants. One
of the best days by far! Pictures to come...Michele Bunker-Alberts

day one El Salvador

2011-11-01T20:24:00.001-07:00

picture from day one El Salvador

2011-11-01T20:20:00.001-07:00

blogggg

2011-11-01T20:16:00.001-07:00

Train-the-Trainer is in my life for good, I think.

After just completing a series at work in the US, I was looking forward to
seeing what this one would be like here. From last week, teaching and
collaborating with health workers of various levels to do VIA, biopsy,
cryo, and LEEP every day, it was a nice contrast to focus on
Train-the-Trainer. Each first day starts out chaotic, as Carol has said in
setting that tone in he usual infectiously calm way, but it's always fine.
Yesterday, we started with a new trainee in VIA, an experienced examiner,
and a trainer. I started with a group of una medica, who was the trainer,
y dos enfermeras. who were learning VIA. My part was to answer questions
and support the trainer. Pretty quickly, we started talking about "tough"
cases, incorporating biopsies with treatment and the role of a Pap here.
More to come there...

El Salvador is so beautiful! -Michele Bunker-Alberts

Tonight after clinic, we said goodbye to another one of our group. It's only been a little over a week, but, after a few days of this, the group actually becomes pretty familiar and ours works really well together. I'm going to miss Eve. We taught her final session this trip together this afternoon, but it has been really fun to have been here with her, learn from her, and get lost walking in Leon with her and Jaynia. Next trip, when she brings her daughter too, my daughters can show her daughter "the ropes" of PINCC support...

Today we had another busy city clinic. Things are very well-organized in El Salvador in terms of our group sessions and the support it requires for municipal clinics without many resources to encourage their doctors and nurses to both learn and practice IVAA. Further, our participants are all enthusiastic about womens' health and providing appropriate care. Our groups today did many exams - about 75 patients and several cryotherapies and LEEPs. During the patient sessions, the examiners educated women about HPV and cervical cancer, the importance of screening, and more generally about their health, contraception, breast care, negotiating safer sex with partners, about reducing sexual violence and how to connect to support around all of those issues. El Salvador's epidemiologic data, including cases of Dengue by neighborhood - which there's been an increase in this year with the rains, immunizations, even morbidity reports are posted throughout its clinics and in every exam room are posters about breastfeeding, nutrition, hypertension, and the steps of prenatal care by gestational age.

Okay, so back to us.

Today we did more Train-the-Trainer and each of us worked as "group advisors" and were there to both offer additional learning and to support the trainers as they taught IVAA. The group I worked with asked lots of questions about Pap diagnoses, cytobrushes, biopsies, and distinguishing lesions - all very rich discussions with a lot of detail.

Tomorrow is Dia de los Muertos. We're heading out to a few cemetaries and then to the beach for a few hours. Again, El Salvador is an amazing country and it's nice to be doing work that people are really excited to be learning. More to come, keep reading. -Michele Bunker-Alberts

day one El Salvador

2011-11-01T05:23:00.001-07:00

we were off to a flyimg start in El Salvador with another stellar
PINCC group - all extremely hard-working and always maintaininh a
sense of humor. We spent our first day at a clinic in San Martin that
previous vounteers will remember as very busy with a BIG patient
volume. Alongside the Trainers and Trainees - the site is a new
´TrainñtheñTrainer´site, we saw 80-90 patients, 4 cryos and a LEEP.
-Lyell Fox, photos to follow

Saludos de Leon!

2011-10-29T12:11:00.001-07:00

We are getting ready to leave Nicaragua, everyone but myself is going on to El Salvador. It has been a wonderful week here in Nicaragua.

Monday and Tuesday we were in El Sauce at a hospital that's been up and running for 1 year. There was a full waiting room when we arrived at 7am with many women coming from far away homes to be examined. In total, we saw 50 patients over the 2 days, all very grateful for us being there.

Tuesday night we headed back to Leon, and have spent the rest of the week at HEODRA, the hospital here. We had wonderful trainees and worked with wonderful people that helped coordinate the program. I got to see a few exams and procedures and it was very clear that every single one of the women that we saw were extremely grateful for us, even when there are several people crowded around and looking at their cervix. One thing we made sure to do was to get the patients who had a history of sexual abuse an opportunity to speak with a psychologist, this was very important as many of these women don't get a chance to do this and many of them have had such difficult lives. It's great to actually see all of the wonderful things PINCC is doing for these women.

It was a successful week for PINCC and an incredible experience to have.

A video of the trainees singing the Nicaraguan birthday song to me, which was so sweet

http://www.youtube.com/watch?v=-ybdn6ZHwp8

A video of Carol's longtime friend Carola singing at her restaurant La Olla Quemada where we had dinner on Friday night

http://www.youtube.com/watch?v=wz39I8T-vIQ

Jaynia Anderson

PINCC at Mills College Health and Wellness Fair

2011-09-30T10:52:00.001-07:00

Yesterday PINCC happily participated at Mills College Health and Wellness fair! Although it was so windy our banner was almost carried away, the women at Mills had a spirit of community involvement and concern for the conditions of women extending across the globe. Several students from Mills Nursing Honor Society eagerly greeted me with excited voices proud to have been a part of fundraising and participating in PINCC's walkathon.

New York Times

2011-09-28T12:30:00.000-07:00

On September 26, 2011 The New York Times published an article entitled “Fighting a Cancer with Vinegar and Ingenuity. The article discusses how doctors in Thailand use the same method as PINCC to save women from dying of cervical cancer and praises them for their resourcefulness and cost effective methods. To read the full article Please go to http://www.nytimes.com/2011/09/27/health/27cancer.html?_r=1

Dr. Kay Taylor sent the following letter to the editor:

"Donald McNeil’s article (Sept. 27: A little vinegar and ingenuity) on cervical cancer prevention services shed an important light on a hardly-covered issue. The cervical cancer epidemic in the southern hemisphere has been given little support or attention, despite the death rate in Africa and Latin America being almost as high as maternal mortality. Yet cervical cancer – unlike other cancers -- is completely preventable.

PINCC (Prevention International: No Cervical Cancer) is an organization that brings American volunteer doctors to train local medical personnel in Africa, India and Latin America. We then donate the needed equipment to create self-sufficient centers for diagnosis and treatment. The unsung heroes of this movement are the many doctors, mid-levels, and lay people who pay their own way and donate their time to help the poor and high-risk women ignored by many countries’ health systems. However, funding for this work is difficult to obtain, unlike maternal/ child health or HIV/AIDS.

I applaud the George W. Bush Presidential Center for its recently announced “Pink Ribbon/ Red Ribbon” program to help defeat cervical cancer in Africa and Asia. They will work with PEPFAR programs, so that cervical screening will finally be included in HIV/AIDS care. At last, public health programs are recognizing this neglected public health epidemic. We can save so many women from a terrible death, with such simple tools and the great hearts of our volunteers! "

PINCC encourages our supporters to send similar letters of their experience with PINCC to New York Times' editor at letters@nytimes.com

An African Urban Pilgrimage

2011-09-19T07:40:00.000-07:00

Our fall East Africa Campaign is over, and all our great volunteers are off on safaris or heading home. It's been so heartwarming and thrilling to watch our 3 continuing sites grow and become independent! The biggest thrill, though, was going out to a small rural hospital on the lower slopes of Mt. Elgon, in far western Kenya, to start a training of health workers from 5 very rural sites. This group was recruited by three of our trainees in Kitale and Kapenguria, They have gone out to these sites, doing one-day screenings and bringing women with abnormal results in for treatment. The doctors, nurses, and clinical officers were very excited about the techniques, and asked to be trained. We had 12 new people begin training, and 3 observers from other programs, as well as 4 of our graduates there to help start the new ones out. They came from many miles away, traveling since dawn in small buses called matatus. All had read the material sent, and were most enthusiastic students. The word had spread among the communities as well, and every day the waiting room filled to overflowing in the morning. We could only see about half the women; but the others were booked to come back to our centers during the next weeks. We left screening kits for the 5 hospitals and dispensaries to continue screening women during the 6 months until our return, when we will see and treat any positive cases. The wonderful outreach team is organizing a non-profit to continue spreading this work over the entire area, and we are assisting them to find funding and equipment, and donating much of it ourselves. We'll be showing a map of how much of the country is now getting care at our Walkathon on Sept. 24, and will then have it on the website. Watch for more great pictures as well! Today, Monday Sept. 12, Pat Sax and I (Kay Taylor) took a walking pilgrimage towards fulfilling a dream held since 2006, when we first came to Kenya. Ever since our first visit to the Kibera slums, second largest slum in the world, we have wanted to establish a cervical cancer screening and treatment site for these women who struggle daily for the bare essentials of life. One million people live in 700 acres here, on unimproved dirt in squalid mud rooms with tin roofs. Each little cubicle holds a family of 2, 3, 4 or more, with an open window and door covered by a piece of cloth. There is no water, electricity, or sewers; the rutted paths are strewn with garbage and plastic bags used as toilets. Small fires burn between structures and along the fronts, for heat, cooking and trash destruction. In a misting rain, we carefully picked our way through the mud and rocks for about half a mile from the dirt road which ended at defunct railroad tracks, along with hundreds of other people carrying food, water, bags, pushing wheelbarrows, or just kids going to and from school in uniform. We kept our eyes mostly on the path to keep from slipping into the streaming gutters of oily filth. At last, we reached our goal: Shining Hope School and Clinic, on the far side of the slum from the road. This will be our third clinic in Kibera to attempt a permanent program. The previous ones failed to stay in business. The enthusiastic group of Kenyans and Americans who built this 2-story clinic of cement, rock and wood greeted us happily. We were shown around the facility, meeting teachers, nurses, lab workers, a clinical officer and Dr. Henry, who tend to men, women and children from this desperate camp every day. They proudly tell us of their HIV screening program and the soon-to-be-established ARV treatment program; the 400 women they have in prenatal and family planning; and the immunization program for the babies and children. It only costs 150 shillings (about $1.60) for a person to receive all health care services for a week, including lab tests, procedures and medicines. We discussed our cervical cancer screening and treatment training program with Dr. Henry and two administrators from the USA, explaining our goal of helping them to have a cervical screening and treatment program independently functioning and fully equipped within 2 years. We all knew there would be problems to overcome, but felt they could be worked through, and left with the intent to start training in February of 2012. We were waved off by some of the 64 primary schoolgirls who attend school here. As we walked back across the crowded, slippery paths, I thought about bringing our team of American doctors, nurses and other volunteers along this walk twice a day, and moving in our equipment suitcases on the carts and wheelbarrows navigating the trails around us. Would they tolerate it? It reminded me of the famous pilgrimage in Spain through the Pyrenees to the sea in Portugal: self-denial and deprivation of our comfortable, clean way of life for the week of work, if not the months that journey requires. We will need to prepare our team carefully. But when I see a mother welcome her neatly uniformed children back from school with a smile, I'm awed by the amount of planning, work and love that this daily routine requires. I think our group will thrive on the challenge, and be invigorated by the hope and healing our training will bring. These are mothers and grandmothers motivated not only to survive, but to help their children to rise to better things. Surely we can spend a few uncomfortable days to give them the chance to avoid this silent killer, and live to see the children graduate and thrive. The gratitude we receive is certainly its own reward!

PINCC at Bishop O' Dowd

2011-08-30T16:47:00.000-07:00

Today I did a presentation at my alma mater, Bishop O' Dowd for one of their clubs called "Sisters of Success" (SOS). It was my first PINCC presentation, and went better then I could have asked. SOS supports the young women at Bishop O' Dowd by discussing goal-setting, self-esteem, etiquette and other topics of interests to young women including PINCC.

The SOS girls were engaged and enthusiastic about our organization and our upcoming walkathon. They are planning to get a team together to fund raise for "Walk For Women Of Africa". It is really encouraging to see young women excited and getting involved in their community. Go Dragons!!!

By Tenay Woodard, Assistant Administrator for PINCC

Update from Africa

2011-08-29T12:22:00.000-07:00

As usual, Africa is somewhat chaotic, and we struggle with spotty electricity, overworked staff, inability to hook up the cryotank, scant resources; but we have made major strides despite all this in our Gombe, Uganda clinic. The health workers are very excited and enthusiastic, both clinical and community workers. The Chief Medical Officer, Dr. Lule Haruna, has been given responsibility as District Health Officer as well, and 2 of his doctors were sent for further training, so they were really tight on doctors. But he is so committed, he found time to study the techniques in the evenings, and came for training in LEEP; he scored only one part wrong answer on our post-test, and is excellent at teaching. The community health team has started insisting the HIV+ women come for screening, and we did 5 LEEPs, saving these lives. There were 4 other LEEPs as well. I think Gombe will be a very successful program!

PINCC - India in Mysore

2011-07-13T20:22:00.001-07:00

Lighting the lamp to open the third VIA camp in Mysore

PINCC India in Mysore

2011-07-13T19:27:00.000-07:00

July 14 2011

John Adams

We have seen a huge number of women here in Mysore – over 200 in the first three days – with pretty much the same percentages of positives and pap smears as usual in India.

The big news here is that last evening (Tuesday, July 12) we were taken to meet the Swamiji (god-man) of the JSS system. He is head of many health care and educational institutions all over the greater Mysore area, and is reputed to have a huge amount of power and ability to get things done. Our host hospital for this visit is JSS Hospital, by far the largest hospital in Mysore. The connection was made by Mr. V. Bhat, who is a leader in the local Rotary and a devotee of the Swamiji.

Our visit with the Swamiji seemed to be very successful, and he told us we should meet with the Karnataka State Minister of Medical Education. He also acknowledged how important our work is. We then went into a small dining room inside the ashram and were given dinner and tea. As we ate, Mr. Bhat called the Minister and set a meeting for Wednesday at 5:00.

During the night, Dr. Rashmi became quite ill and had to be taken to a nearby hospital emergency room. There are not easy ways to get transport at 2:00 am in India, so the young man on the hotel desk woke up another guest with a car and got the owner to take us. The young man also came along because he knew where to find the hospital. With Rhoda and Rashmi and her mother Mytree that made a really full car!

This hospital had an excellently stocked and fully staffed emergency room and no waiting patients, so Rashmi got seen immediately. Unfortunately, they could not find the cause of her pain and nausea, but gave her an injection to ease the cramps. In the morning, Rashmi and Mytree left us and returned to their family in Bangalore. Later in the day we found she was feeling better, but still unsure of the cause.

So Rhoda was on her own with the volunteer docs, and as luck would have it, we had 81 women to see, and carried out 2 LEEP, many cryos and biopsys, and worked over an extra hour to get everyone seen. It's hard to turn women away when they've been bussed in from a remote village for the screening. Dr. Shobha Krishnan, a Columbia Univ. professor with her own HPV NGO in Chennai and Gujurat, is visiting to explore collabortions, and she pitched in with background stuff in the medical area. I was inundated with registrations, clinical reports, and a spreadsheet that crashes every few minutes – but we got through it all!

Unfortunately the minister could not meet with us, so we are carrying on with whatever connections we can make and focusing on building a network of solid relationships for the future. Given all this, we were glad the Minister of Health Education was unable to see us!

One more day of camp and then we head for home – quite happy with the progress in both our sites, appreciative of the great organizational support both sites present, and confident that we will be able to scale up our operations in the Mysore

One of Infosys's buildings in India

2011-07-08T00:32:00.001-07:00

July 7 2011

Reporter filming the press conference

2011-07-08T00:30:00.001-07:00

July 8 2011

Dr. Vijaya introducing Rhoda at the press conference

2011-07-08T00:28:00.001-07:00

July 8 2011

Dr. Vijaya is our lead trainee in Mysore

Dr. Rhoda Delivers a Wonderful Message in the Mysore Press Conference

2011-07-08T00:27:00.001-07:00

July 8 2011

Mysore Report

2011-07-08T00:24:00.001-07:00

John Adams

July 8 2011

We departed Puttaparthi at 7:00 am yesterday and were in the offices of the Infosys CEO Kris Gopalakrishnan in Bangalore by 11:00. Kris spent a full hour with us and was highly interested in what we are doing. We proposed that Infosys support our intention to scale up our PINCC efforts in India, through our collaboration with PHRII, to establish a Centre of Excellence for Cancer Prevention in Women. We are expecting that Infosys will send a manager of the Infosys Foundation to our clinic here in Mysore during 11-14 July.

Initially we would create a more established centre for our work in India, with Indian management and an Indian lead trainer (whom we would train). As growth occurs we would anticipate establishing VIA screening and training collaborations with other NGOs who are working at micro-scale around the country.

We are also working on a proposal for the Tata Family Trust to support our work here. Since PINCC has no legal basis in India, the proposal will come through PHRII.

With 25% of global cervical cancer cases and 27% of cervical cancer deaths world-wide, India is an overwhelmingly large and intense place for the present PINCC model to make a difference. Fully 10% of the global population lives in Indian villages! The government continues to ignore this disease and its prevention, so we will have to shame them into attention through Public Private Partnerships to get our work to scale. PHRII continues to be an extremely reliable, competent and committed partner in this venture. When polio re-appeared a few years ago, the Indian Government proved it could mount a nation-wide universal vaccination program overnight, so it is just a question of challenging the society's will to save 73,000 lives a year (one every 7 minutes) that are lost needlessly. Presently only 2.6% of Indian women ever have a single screening (2.3% in villages, 4.6% in cities). The opportunity is huge for harvesting this low-hanging fruit!!!

Dr. Rhoda just completed a press conference here at PHRII headquarters, attended by about 20 local reporters. We will be looking for great coverage in the local English language and Kannada language papers tomorrow! Also tomorrow, Dr. Rhoda will be presenting a CME lecture at JSS Medical College, which is also our venue for next week's VIA clinic. JSSMC will be sending some new trainees and so far appear to be eager to become a central partner in the Mysore PINCC work going forward. Rhoda and I are scheduled to meet the spiritual leader of the organization that sponsors JSS to pray for his support next Thursday at the end of our fourth day of screening / training.

More to come!

Kay may remember this woman from two years ago when she gave padnamaskar following her LEEP procedure

2011-07-05T04:29:00.001-07:00

PINCC India completes fifth clinic at SSSMH

2011-07-05T04:26:00.001-07:00

A typical SSSMH clinic scene: Arithmetic, English, Telugu, the Goddess Lakshmi, and the Gynecology section!

July 5 2010

John Adams

We were overjoyed at how excellently the SSSMH team of gynecologists have developed and made this program their own. Duirng the six months since our last visit in December, they racked up the following numbers:

VIA -- 1276

Pap -- 16

Biopsy -- 260

Cryo -- 40

LEEP -- 8

They also referred 12 women with cervical cancer to various cancer treatment centers.

We had two wonderful visits from earlier patients. A woman who was referred with cancer two years ago stopped by to thank PINCC and to get rescreened -- she is completely healthy! Another woman who had a LEEP done two years ago also stopped by for rescreening and expressed her gratitude as well.

During the just completed five day camp, we saw 225 women, performed 4 LEEPS and 6 cryos.

We will not need to bring PINCC-India back to this site. When we come to be at the ashram, we may go along for a day or two, but only to check in and exchange greetings.

Amidst the rewards, some sadness, too

2011-07-03T15:03:00.001-07:00

LEON, Nicaragua -- Working with PINCC in Central America has always been richly rewarding and fulfilling, especially since the screen-and-treat protocol being taught serves mostly poor women who otherwise would have no care at all.

But sadness and frustration come with the experience as well.

For me, having just returned from my third trip, two things have affected me profoundly.

The first is the realization that I get to drive away from Jalapa, Nicaragua -- a profoundly poor place -- and escape the misery I see around me. Not an option for the people we serve there.

The second is the unexpected and completely shocking experience we just had in Leon: while her mother was being examined, we played with a little girl of about 7 years old, who seemed entirely happy and normal. But I'll always feel helpless when I think of her. We learned that she has been treated repeatedly for a common sexually transmitted disease, apparently from abuse by her mother's husband or boyfriend.

In the United States, we would have called the authorities. She would have been protected somehow.

No such thing in Leon. We had to watch her leave with the adults in her life, and there was nothing we could do to intervene.

-- Larry Shushan, PINCC volunteer in Central America

PINCC-India at Sri Sathya Sai Mobile Hospital

2011-07-01T07:54:00.002-07:00

SSSMH Patient Record Format

PINCC-India at Sri Sathya Sai Mobile Hospital

2011-07-01T07:54:00.001-07:00

Dr. Rhoda preparing to begin the day's screening

PINCC-India at Sri Sathya Sai Mobile Hospital

2011-07-01T07:53:00.000-07:00

From John Adams

July 1, 2010

We opened our fifth camp at the Sri Sathya Sai Mobile Hospital, based in Puttaparthi, Andhra Pradesh, today. What we found when we got to today's venue, Rachuvarapalli Village, was most heartening. The gynecology section administrator presented us with summary statistics for their VIA work during the six months since we were last here.

During their regular 12 day camps each month January through June, they have conducted 1276 VIA screenings and carried out 40 cryotherapy and 4 LEEP procedures. Three LEEPs were brought back to be done while Dr. Rhoda is here.

Their record keeping is very good and the lead VIA doctors are performing with confidence and competence. We introduced our QA materials today, and these were heartily welcomed, along with the idea of making one improvement every day. Our primary focus now at this location, in addition to reviewing quality items and procedures is to work towards increased "bench strength" of doctors who can capably carry out LEEP.

Unprecedented!

2011-06-29T10:32:00.001-07:00

Two PINCC campaigns are underway simultaneously, one in India and one wrapping up in Nicaragua!

Re: PINCC-India At work Again

2011-06-28T23:45:00.001-07:00

An Indian child waiting for her mother to be screened

PINCC-India At work Again

2011-06-28T23:38:00.001-07:00

From John Adams

June 29, 2011

Rhoda and John arrived back in India on June 26, and immediately began preparations for the two very important cervical cancer initiatives here in Puttaparthi (Andhra Pradesh) and in Mysore. It is a little strange to be in Puttaparthi, now that Sri Sathya Sai Baba has left the body (April 24). There are very few people around and the shopkeepers, porters, and others who rely on a steady coming and going of devotees are becoming desperate! The owner of Sai Towers Hotel tells us that his bookings are picking up again from about the middle of July, when Gurupurnima, a major Hindu holiday, takes place. By then, the tomb being built for Sai Baba's remains in the main darshan hall will be completed and the theme of "continuity" will ensure that all programs and rituals will be carried out as before. We all assume that the ashram, Prasanthi Nilayam, will become a major pilgrimage site for spiritual seekers of all kinds.

The Sri Sathya Sai Mobile Hospital gynecology section has already been certified in the PINCC VIA protocols and in use of Cryo and LEEP procedures. During this camp (1-5 July) Dr. Rhoda will be reviewing and helping the certified physicians to "brush up" on their knowledge and skills, and also begin the training for some additional SSSMH volunteer physicians. John will be inaugurating a quality assurance process for this program, so that they can self monitor and engage in continuous learning and continuous improvement.

On the drive down from Puttaparthi to Mysore for the third PHRII (Public Health Research Institute of India) cervical cancer camp, we will be stopping in Bengaluru to meet the CEO of Infosys. We hope to get his company's involvement and support in the "The Centre of Excellence for Cancer Prevention in Women" that we want to create through our collaboration with PHRII. During our stay in Mysore, we will also be meeting with the local Rotary club for the second time, seeking their support. We are also attempting to get the Rotary Wives Club involved to advocate for cervical cancer screening for all women in the area. Less than 5% of all Indian women (2.3% in the villages) ever have a single cervical cancer screening in their lifetimes.

While Rhoda is engaged in the third clinic with our Mysore trainees, John will begin rolling out our QA process here as well. (Contact John if you would like to see the items we are going to be investigating for quality assurance). This third camp is to be held at the JSS Hospital / Medical College -- our third venue in Mysore. By the end of this visit, we will have carried out PINCC clinics in a catholic hospital, a government hospital, and a private hospital. More networking for the future!

Also in Mysore, we will be meeting with the District Health Officer and other key stakeholders at the various Mysore medical colleges and teaching hospitals and will once again be hosting a Stakeholders' Dinner on our last evening in town. Our vision is to create a network of involvement that includes the local medical colleges, civic associations, and health-related government agencies.

Our volunteers on this trip are Dr. Rashmi Murthy, who volunteered previously on a PINCC Central America camp, and her mother Mytri Murthy. Dr. Shobha Krishnan, a professor at Columbia University, will also join us in Mysore. She has been engaged in VIA screening through her own program in northern India and also in Chennai. We are looking forward to also finding ways to synergize our programs with hers during this trip. India is so huge, and the need is so great, that we need to rapidly find ways to scale up before the cost of coming here becomes too high! 25% of all cervical cancer deaths in the world each year are in India (Globocan 2008), and there is at present no coordination of efforts and no center for rapidly building local capacities to address this huge challenge.

So all in all, we have a lot on our plates beyond running two PINCC-India camps. We will be much clearer by the time we leave about the future directions of PINCC-India! Progress reports will follow! Everyone who reads this -- please send good thoughts for successes!

Waiting room outside our exam rooms

2011-06-28T07:24:00.001-07:00

At the hospital in Leon yesterday morning. Training is going great.

View from our hotel roof last night

2011-06-28T07:22:00.001-07:00

This was before the spectacular lightning show that we had walking home from dinner in Leon!

Parking outside the hospital in Leon

2011-06-28T07:21:00.001-07:00

No hitching post for the horsecarts, and no parking lot for the few cars. Main transportation: feet or two-wheeled vehicles (or buses).

Team PINCC on a day off on Sunday

2011-06-28T07:18:00.000-07:00

At a nature preserve near the beach outside Leon. A much needed break!

Some of Team PINCC right now in Leon

2011-06-24T12:11:00.001-07:00

Lunchtime in Leon! From left: Hayley Miller, Dr. Tara Hulbert, Dr. Pratima Gupta and Emily Riggs.

Guess what this is?

2011-06-24T09:26:00.001-07:00

A bottle of orange soda left for the occupants of this house (which is in Leon en route to the hospital)? No! But if you said "a papaya", you're right!

Desvios, Puentes y 'Policias Acostado', Oh My!

2011-06-23T12:58:00.001-07:00

SOMEWHERE BETWEEN JALAPA AND LEON, Nicaragua -- So I found myself yesterday engaged in one of the more adrenaline-pumping, sometimes-terrifying and certainly adventurous drives I've ever performed from behind the wheel. With a vanload of innocent people relying on me to get them to their destination safely. (Why me? Because I volunteered to drive when our usual Nicaraguan driver was unable to join us for the trip. We later joked that he chose not to join us because he checked on the road conditions for the portion of the trip I'm about to describe.)

We got out of Jalapa later than expected, which meant we'd roll into Leon -- at least a 6-hour drive -- after dark. That's never good in an underdeveloped country, especially one where pedestrians (or groups thereof), loose livestock, bicyclists, motorcyclists, trucks and dogs all occupy major highways at unpredictable times and locations, and, depending on which of these you're talking about, without warning, lights, reflectors, consideration, caution or apparent concern.

The first part of the trip was predictable. Jalapa to Ocotal is a known quantity. It's a trying, winding road with the usual asortment of men on horseback, small children playing on the shoulder and -- best of all -- a series of "puentes," narrow bridges across rushing water where the approach is partly washed away, the ability of the bridge to carry our vehicle safely is questionable and the width of the bridge is just enough to drive across. But it was during daylight hours; in other words, no big deal.

We got through without incident.

Then we got to the highway (loosely termed) where you turn toward Leon. Of the options to Leon, we had been told that this was the best one in terms of road conditions. And the presence of major commercial trucks confirmed that. In other words, if there was a better way to go, they'd surely be going that way.

Very quickly, we encountered a "DESVIO" -- known in the United States as a "DETOUR". Detours where I live consist of a sign with an arrow followed by a series of signs keeping you on the right route. Here, however, a DESVIO simply signifies that you don't go the way you thought you'd be going.

If it's dark (which it was by the time we saw our first DESVIO sign), you look to the right or left for a very bumpy, lumpy dirt road down in the gully alongside the highway where your vehicle MAY be able to pass if it's not raining. And if there's no major truck (or herd of cattle) either coming the other way or stuck.

We got used to this because we encountered at least a dozen of these always interesting one-way DESVIOS. That's right: one way. Nobody handles the duties handled in the United States by a person with a flag and radio, signaling someone at the other end to either stop traffic or let people pass. Here, you take your chances. Part way through, you may encounter someone coming the other way who also has taken their chances. There's nowhere to turn around. There's no way to back up.

Once, the pavement abruptly changed from old pavement to new in our lane (with an 8-inch change in elevation) without warning. Coming the other way, in my lane, was a huge truck. When we got close to each other we both stopped. The driver of the big truck leaned out of his window and motioned for me to drive off the edge of the new pavement onto the old pavement in the oncoming lane so he could pass. I quickly thought this through. He couldn't do what he was asking me to do because of the kind of vehicle he was driving. So I veered gently down to the oncoming lane. Fortunately for all of us, nobody was there. The big truck passed and honked his air horn in kind of a "Spanglish" thank you. I returned the signal, got back into my own lane and continued on to the next DESVIO sign I knew must lie ahead. I wasn't disappointed.

Of all the DESVIOS we encountered, only one was so deeply rutted that the entire undercarriage of our van scraped along the center part of the dirt road with a pronounced sort of grinding sound, punctuated by abrupt stops and more pronounced sounds. It felt and sounded really awful. We envisioned u-joint parts, the oil pan and other essentials being ripped from beneath us.

After many more DESVIOS, we finally concluded we were through the section being worked on. Not because there were signs indicating "End Construction Zone," but because of the lack of any more DESVIO signs.

But now we faced a new phenomenon. We called them "random strips of missing pavement."

These were sections where, apparently, new, huge concrete culvert pipes had been installed across the road, with the opening then filled in with dirt and rocks to be paved later. No care had been taken to ensure the level of the unpaved space was anywhere near that of the highway. So, at 80 or 100 kph (that's kilometers per hour to those who have never left the mph world), you'd come to one of these strips and struggle to slow down enough to keep the car intact as you passed over the patch.

We got through all of these, as well.

Soon we were in total darkness, but with ominous lightning occasionally flashing in the sky to our right or just ahead. Now came the really fun part. Apparently, in Nicaragua, the place for people in tiny villages to hang out just after dark is along the side of the road. Once in a while, they hang out by themselves. Mostly, though, they hang out in groups ranging from 3 to 20. The custom I was most surprised at was the one where they hang out as close to the pavement as possible, or, in many cases, on the pavement where vehicles are traveling at what we in the U.S. would describe as "freeway speeds."

Sometimes, they'd be sitting or even lying down perpendicular to the pavement. One young man remained in this position, with his body from the waist up on the road and the rest of his body on the shoulder. As I came speeding along, just about when the limit of my high beams brought him to my attention, he did a very slow and controlled situp -- just in time.

One of my favorite experiences, though, involved my encounters with people on bicycles, motorbikes, horsecarts and other vehicles with no lights or reflectors whatsoever. They weren't moving along on the side of the road. They were in the road. In the dark. Mostly, if they were people either on foot or on bikes, they wore very dark clothing. Sometimes, I'd catch a momentary glint of a reflector strip on the pedal of a bike. These made me feel lucky.

I also felt lucky to have Carol Cruickshank, our trip director and a one-time Nicaragua resident, as my co-pilot and navigator. From time-to-time, she would quietly alert me to a barely visible pedestrian or bicyclist. Carol's voice is almost always perfectly calm. Her voice remained so as the rest of the passengers sat behind me in abject terror.

And then, once we got to Leon and my body had more adrenaline coursing through its veins than blood, I learned about "policias acostado." In the United States, we call these "speed bumps." Here, they're called "sleeping policemen." If they're really large and challenging to drive over, they're called "policias acostados con su mujer," which means they're nearly twice as high. I'll leave it at that since this is a family blog.

After nearly seven hours, we rolled into Leon without incident. In fact, there actually were no true INCIDENTS on the whole drive. Only the constant, nagging sense that an INCIDENT -- or worse -- would happen at any second. There are a lot of seconds in nearly 7 hours. What if we had a flat out there in the middle of nowhere and had no way to drive to a non-existent shoulder? What if the oil pan had truly been pulled from the bottom of the engine on that one DESVIO where the center section of the dirt road was higher than the van's clearance? What if a child on a bike had randomly chosen the moment we were careening past to cross the road? What if, what if, what if (fill in the blank)?

My mind reeled as to what may have happened but -- thankfully -- didn't. We got to the hotel safely. The longest, toughest part of our trip was finally over.

-- Larry Shushan, PINCC volunteer in Central America

Success in Jalapa, Nicaragua

2011-06-23T10:01:00.001-07:00

JALAPA, Nicaragua -- Seven PINCC-trained medicos yesterday were certified to perform screenings and treatments on their own, which is a tremendous accomplishment, both for the trainees and for PINCC.

But it's an especially significant development for the women of Jalapa and the surrounding area, because now there are trained medical personnel who know how to screen for the precursors of cervical cancer and provide immediate, effective treatment. And Jalapa's clinic now has a gynecologist assigned there -- for the first time ever -- by the Department of Nuevo Segovia (the equivalent of a state in the United States).

Lives were saved while we were there, and lives will be saved in the future. "Brigades" of medical teams will now be able to visit outlying areas -- trained and equipped by PINCC -- and screen and treat women. It's a profound experience to contribute to this kind of progress because one knows that lives will be changed for the better.

Jalapa is the poorest place I've ever seen. I acknowledge that I have not been to some of the world's areas most well known for poverty.

That said, however, I and others on the trip were deeply affected by our experience. If you live in the United States, even the poorest areas we see have an infrastructure that provides basics -- from toilets to running water and from electricity to protection from most public health hazards.

In Jalapa, life is a grind, plain and simple. At first glance, it's quaint and charming to watch people ride around on bikes and horseback, or to see people walking from place to place -- except these people are using these methods of transport for lack of any other way to get around. There are almost no private cars, and public transportation is only from town to town, not within a particular town or village. They're unprotected in the rain. They're in sandals in the mud. And they have no protection from the blazing sun or suffocating heat.

Unlike patients we saw in San Salvador, where people of limited means showed vibrancy and interacted with energy, the people in Jalapa were blank, extremely stoic and flat. There are few smiles.

Dogs are treated like, well, dogs. Not the way dogs are treated in the U.S. Here, they wander the streets and look skeletal and desperate. They're shooed away; sometimes even kicked. They wander through the clinic and scrounge for crumbs. I didn't see any that were "pets" in the U.S. sense of the word. Black vultures circle and, frequently, descend for a meal on the side of the dirt road.

Some streets are paved with interlocking concrete blocks. Many are dirt. Some are formerly paved streets whose pavement has been destroyed by the elements, vehicles and time -- apparently never to be repaired because there are no resources available.

As I said in a previous blog entry: One can only focus on the positive -- that people are being helped now and in the future because of PINCC's work. But I couldn't wait to leave Jalapa, which I'm almost ashamed to say. At least I had the option to leave.

-- Larry Shushan, PINCC volunteer in Central America

A much different kind of day

2011-06-20T17:02:00.001-07:00

From the urban center of San Salvador, where clinics are relatively efficient, and patients and trainees are plentiful, PINCC's team has moved on to an extremely remote location in Nicaragua -- Jalapa. This is PINCC's fourth trip here.

At this clinic, where women travel sometimes for two days on foot or by bus from even more distant villages, there are more positive screenings and the need for more treatments.

Poverty is grinding and ubiquitous. The team is affected by what we see and experience. We went from celebrating success in the big city to sitting through hours of travel to come to a place where what we see is sobering (a huge understatement) and saddening.

Women wait patiently for screening exams, some of which are the first on their lives. Children wait with a patience unseen in the United States.

Here, where waiting is frequent and almost always lengthy, children occupy themselves without complaint or fuss. They wait for hours and say it's their duty to wait for their mothers. This phenomenon is utterly different from what we see in the United States. No video games, no books, no coloring books -- just waiting patiently.

Tomorrow is a new day in Jalapa. Today we saw 25 women. Tomorrow will bring whomever and however many it brings.

-- Larry Shushan, PINCC volunteer in Central America

Team PINCC heading for Nicaragua

2011-06-18T06:21:00.001-07:00

...and so we say goodbye to El Salvador for this trip. We're heading for Jalapa, a tiny village in Nicaragua for PINCC's 4th visit. Then it'll be on to Leon, where we're training doctors to enable them to train others and to head to outlying areas to screen and treat women for the precursors of cervical cancer.

An amazing trip so far, with more to come.

Stay tuned ...

-- Larry Shushan, PINCC volunteer

Former PINCC trainees now doing the training

2011-06-17T21:43:00.001-07:00

One of the most rewarding things about this trip so far has been seeing El Salvadoran doctors I watched being trained two years ago by PINCC now training their own colleagues. That means PINCC is accomplishing its objective of creating sustainable programs to stop cervical cancer.

Here, Dr. Julio Rosales trains doctors and nurses after a long day of working with about 4 dozen patients at the San Jacinto clinic in central San Salvador.

PINCC donates biopsy tools to El Salvador Ministry of Health

2011-06-17T21:14:00.001-07:00

PINCC Board President Deborah Shefler (in red) signs documents with Vice Health Minister Violetta Menjivar marking the donation of gynecological biopsy tools for use in San Salvador clinics. The PINCC medical team of volunteers moves on to Nicaragua in the morning after spending five days of work saving lives and training local doctors and nurses in three San Salvador clinics.

One has to focus on the positive

2011-06-16T19:01:00.001-07:00

NEJAPA, El Salvador -- Three trips to Central America with PINCC, and I still struggle with this inevitable conflict of emotions: Cervical cancer is always found during a trip, and as the guy handling all the paperwork, I am aware of all the details. This time, it was two in one day (out of 60 women) -- one that's certain, the other probable. Always sad because this cancer is totally preventable. (Some American gynecologists see it maybe twice in their whole careers, by the way.)

On the other hand, how many lives were saved because the medical team (PINCC volunteers and Salvadoran medicos alike) successfully identified pre-cancerous lesions that were treated and which otherwise would have gone unnoticed and untreated until it was too late? Nearly a couple of dozen, and it's incredibly gratifying to be part of a team doing this work.

One more work day here, and then on to Nicaragua for two weeks in two communities.

-- Larry Shushan, PINCC volunteer in El Salvador

Scenes from our day at Zacamil

2011-06-15T19:59:00.001-07:00

Salvadoran doctors training Salvadoran doctors and nurses

2011-06-15T19:50:00.000-07:00

By Larry Shushan, PINCC volunteer

SAN SALVADOR -- Today in San Salvador, we saw the tangible results of PINCC's sustainability-centric focus: after years of partnership with the national health infrastructure in this small Central American country, the training and certification of local doctors is going beyond merely enabling them to perform cervical cancer screening and treatment on their own. Now, Salvadoran doctors are doing the training, creating an incredible multiplier effect from PINCC's work here.

In this photo, doctors at the Zacamil clinic are training other doctors and nurses to recognize lesions on the cervix that become visible when vinegar is applied. Flashcards and discussion are used to prepare for actual visualization, followed by practice on patients. The experts -- already certified by PINCC -- supervise the work of those not yet certified.

At Zacamil, 140 women were seen in two days. Several tested "positive" for pre-cancerous lesions, then treated on the spot with cryotherapy, a technique using a special tool that freezes the lesions, effectively destroying them. The single treatment has a 95 to 98 percent cure rate, essentially eliminating the risk of the deadly disease for the rest of a woman's life.

Some of the doctors and nurses who saw 60 patients today

2011-06-14T21:19:00.000-07:00

At the Zacamil clinic in San Salvador, where Dr. Melissa Miskell of PINCC (center) is leading this phase of the trip. Yesterday we saw 89 patients at San Martin, and more than 15 local doctors and nurses received training there in screening and treatment techniques to prevent cervical cancer.

Today at Zacamil

2011-06-14T20:05:00.001-07:00

I sit in a tiny room at a beat-up metal desk typing patient information into a laptop while a woman is examined on the other side of the partition.

It's tedious, repetitive work requiring utter accuracy. I sense a stare: To my right, just outside the metal-barred open glass-slatted window is a sweet, smiling face with big brown eyes that watch my every move. The face belongs to a Salvadoran girl of maybe 10, whose mother is on the exam table. The eyes epitomize innocence and shyness being overpowered by curiosity about the unusual white-haired American man performing mysterious work with fingers on a keyboard. I try to imagine how to connect without a shared language and beyond just returning the smile.

I remember a toy my grandchildren gave me to share, a simple number puzzle square like I had as a kid -- a toy whose language isn't exclusive to my world or hers. I grab it and walk it out to the girl, who is overjoyed by the attention and the gift. She beams and quietly says 'gracias.' When she is leaving, she first stops by and waves goodbye with the puzzle, still smiling ear to ear.

-- Larry Shushan, PINCC volunteer in Central America

2011-06-13T12:09:00.001-07:00

This is Deborah Shefler writing from San Salvador, having just completed our third visit to Medisol, a well organized clinic in Lima that is a big fan of PINCC. We were able to certify 3 gynecologists in VIA, cryotherapy and LEEP, and 2 midwives in VIA and cryo, so the trip was a success just from that perspective. We screened 220 women!

The Medisol clinic is in a stand alone building in a poor, run down section of the huge city of Lima (I heard variously 8 to 10 million). We stayed in a very safe touristed area full of glittery shops and outdoor restaurants called Miraflores, in a simple but beautiful little flower bedecked hotel, Hostal El Patio, PINCC discovered a couple of trips ago. It´s a budget gem.

It´s about a 40 minute drive from Miraflores to the area where we worked. The contrast between Miraflores and the clinic area is stark. Nothing glitters, the shops are tiny and basic, the building construction is one to two story brick and concrete, and the streets are full of little microtaxies rather than buses and cars. I quickly realized that the microtaxies are essential because they are the only vehicles that can make it up the steep streets of the neighborhood. This area is filled with seemingly ad hoc slums that ascend the hills in switch back fashion. There seems to be at least some electricity, but the plumbing is unclear. By the time you get to the top of the hill the housing is more like camping out. The city is full of these ascending slums. I´m told that in recent years the government has invested in infrastructure in these areas.

I spent a few days in Lima before the group arrived. I stayed in 3B Barranco, a fine small and inexpensive hotel with a friendly staff. The best experience I had was the world class Larco Museum. http://ping.fm/CauKV Check out the beautiful objects, particularly the ceramics, which are extraordinary. Also check out the restaurant, which is quite posh but not expensive. It was filled with French tourists while I was there. I had a pisco sour and a peruvian sampler. Delicious all. It is a private museum with exquisite, well maintained grounds, colorful flowers abounding, quiet ambiance. Some of the art is astounding, particularly the ancient Moche pottery, which was mostly found in perfect condition in tombs. The pre-Colombians in Peru practiced a cult of the dead, something like in Egypt. The pottery therefore depicts all aspects of ancient life, including the pornographic.

I also went to the national cultural archaeological museum, http://ping.fm/yFzsd Very extensive museum of everything about Peru. Again, the Moche ceramics from the north are worth the visit in themselves. It's among the most inventive, beautiful and entertaining art work I've ever seen. It's the vessels with the curved handle and spout coming out of the top of the handle. But what we've seen in the states is nothing compared to the work on display here and in the Larco. Unlike Museo Larco, little of this museum was in English, but I got along fine. Finished with a delicious grilled fish with sauteed veggies in a big, open air restaurant.

There was (supposedly) no alcohol served in Peru for several days leading up to last Sunday´s run off election. Also, it is compulsory to vote in Peru. Some people predicted the election would be very close and the results not available for some time, given the remote rural situation of many voters. But that turned out not to be the case and one candidate conceded within a day. It seemed most people in Lima preferred the more conservative candidate, the daughter of a former president now in prison, but she was defeated by someone who has sometimes identified himself with Hugo Chavez.

I drove through some of the nicer parts of town in taxis, particularly San Isidro and Miraflores, which is next to Barranco, where I'm staying. Lots of attractive stucco housing, some colonial buildings, Spanish churches, flowers everywhere, lots of walls and attendants, low buildings and luxury high rise towers with expansive views of the ocean. These parts of town look well taken care of and very clean. There was some graffiti, but few signs of poverty.

I walked alone down the main drag in Barranco several times, feeling very safe. This area used to be a town in itself, but has been absorbed into greater Lima. It's a middle class neighborhood. No international chains, only local businesses. Not even Starbucks, and nothing even close to Benetton. Some shops are quite small and simple, like in Morocco or Turkey. The nicest businesses are white table cloth restaurants, and some look nice indeed. It is safe for me to walk here after dark, and indeed you see lots of police and guards, certainly around all the banks. If you eat before 8 or so, you'll be eating alone. Street food looks good but not sufficiently tempting to take a chance. Streets are relatively clean, much better than India but there is some litter. Traffic is relatively courteous, with lights, sidewalk slots for persons with disabilities, and pedestrian crossings. Sidewalks are normal and walkable, much better than in India, at least in these areas. No hassles whatsoever on the street. In fact, it felt like not a single person bothered, or even looked at me. People are conservatively and simply dressed, with young women almost universally in tight jeans. ATM worked perfectly. Super market well stocked.

I spent a day with a prearranged guide named Arturo, visiting downtown Lima. There are two squares in particular that are world class. The buildings are consistent in size, period and color, and exquisite, clean and well maintained, mostly from late 19th century. The oldest church is 17th century. Lima is a relatively new city. Someone from Spain would be right at home with the civic and ecclesiastical architecture. The weirdest thing is the catacombs under St. Francis church, which is now a museum. It's really an ossuary, full of piles of bones separated by type, femurs, tibias, etc. It's completely anonymous, just bones, all looking exactly alike and undifferentiated in any way.

We took public transportation, a first for me, so I got to see more parts of the city, for better or worse. We took a bus with a dedicated lane, a massive public works project that is only a couple of years old. I'm told it's like a system in Mexico City. It goes above and below ground and was a big deal project here that took several years to complete. On the other extreme, I got my first look, from afar, of one of Lima's infamous slums, little houses built up a steep hill.

Had ceviche, sliced raw fish in a lemon, yellow pepper sauce about the consistency of lemon juice. It was served with corn and sweet potato, and delicious. This was my third fish dish in a row. Fish is the thing to have here. Chinese food is big here too, on virtually every block, but it is made with Peruvian ingredients so should be a little special. Peruvian ingredients generally means potatoes (there are hundreds of types here, in all colors and sizes), rice, and corn (also all colors and sizes). Cooked veggies are a little hard to come by.

Arturo is a nice, 34 year old single man who is thinking about getting married (or not) and having children, or not, or moving to the US, or not. His father lives in NYC, but he seems more attracted to Miami or San Diego, where he'd like to have a travel agency. He says that Peruvian young people generally do not get married, they just live together and have children. His brother did get married, but that's because he's a Jehovah's Witness. This is strange because although people tend not to get married, they are religious, overwhelmingly Catholic. There's a real dichotomy in my experience here. The museums are all about pre-Colombian pagan polytheists, and the architecture is all about Spanish colonialism. It's interesting to compare how the ancient civilizations imposed order, and how the Catholic church and its secular political/military arms did something similar. Two different ways of accomplishing oppression.

On Sunday I took my last walk in Barranco. It is an up and coming neighborhood with small luxury high rises that I didn't see on my prior evening walks. Everything, however, is behind formidable doors, gates, bars and walls. I transferred by taxi to the Miraflores neighborhood around noon and checked into Hostel El Patio. There are big markets or bazaars nearby that are full of little shops, like the souks in Istanbul or Morocco. Some of the stuff is really nice, particularly the alpaca items, which are highly recommended.

Once the whole group of 8 had arrived, we met for 2 hours to go over what we'll be doing for the next week. Carol is very well organized and has seemingly thought of everything. Indeed, the week went smoothly, showing what planning and experience can accomplish.

2011-06-02T10:34:00.001-07:00

Deborah Shefler and I arrived in Lima last night, with two medical suitcases, after easy but full flights. Lima is showing off with beautiful weather today and it is lovely to be here.

Saludos, Carol

Carol Cruickshank, CNM, PINCC Program Director

2011-06-01T13:22:00.001-07:00

PINCC is getting ready for our June trip to Latin America.

The end draws near

2011-02-17T08:36:00.001-08:00

Sadly this is the first time I'm blogging as this glorious trip is
coming to an end. However today was definitely something to write home
about.

For the last week we've been in Kapenguria, which is much more rural
than our previous week in Kisii. Oddly we had relatively few clients
for the first three days and then today, everyone and their mother
showed up. So in the midst of the chaos Carol convinced my fellow
support staff friend Jessie to play the flute, which in turn inspired
the line of 40 or so women waiting for their exams to burst into song.
It was awesome to say the least.

Also it was really sad to say goodbye to Silvester, a young child with
severe burns on his legs who had been cruising around on his walker,
and playing with the lot of this for this last week. He was the best
part of this trip for me so far.

From PINCC in Uganda, Feb. 2011

2011-02-14T09:24:00.000-08:00

Hello to all you fans in the USA! This is Kay Taylor, blogger of the month. PINCC is working this month in East Africa. Our first site is Gombe,Uganda: a small town about 2 hours from the capitol of Kampala. Uganda is a very beautiful place, full of green rolling hills, farms, woods, streams, and a huge lake, which is its southern border, bigger than Lake Tahoe, . The Nile river has its start in this lake, and flows north to the Mediterranean. After our week of training, we have driven to Jinja, the town at the source of the Nile, where it leaves the lake. It's a really spectacular place, with rapids and waterfalls, a wide river and lakeshore, and LOADS of birds. I was so excited to watch them this evening after we checked in to our lovely guest house. We will stay here 2 nights, and get to rest and do fun things tomorrow, before driving on Sunday for another 6 or 7 hours to reach Kisii, Kenya, where we'll work next week.

This has been a wonderful week. We were the guests of 2 delightful grandmothers in their very nice home, surrounded by a banana plantation that grows at least 5 different kinds of bananas, from tiny sweet ones to large, thick plantains. We ate them in many ways: steamed and mashed, called matoke; little ones for breakfast and snacks; ripe plantains, boiled and sliced, with a lemony sweet flavor; and more. We've also had peanuts in several ways. They are ground and cooked into a sauce without roasting, and served over the matoke; roasted whole over charcoal (barbecued peanuts-yum!); roasted and ground coarse in vegetables and rice; but no peanut butter...they don't like it! Anyway, they have fed us 7 or 8 dishes every meal, with tea in the midmorning and late afternoon served with a snack. We are not going hungry, for sure!

There are five of us on the team this week: myself and a resident doctor in OB/GYN from Baltimore (Katie); 2 nurse/midwives, Carol and Mary Fitz, and Mary L., a teacher and administrator from Denver. We have trained a group of 7 doctors, clinical officers, and midwives at Gombe Hospital, which is in a rural farming area west of Kampala, the capitol. When we arrived, it was hot and dusty, as they had a drought going on; everyone was worried about the corn/maize crop failing and widespread hunger. Well, on Monday, the President came by helicopter to campaign as the election is in 2 weeks, and that night, it started to rain. It went on for 2 days, and now everyone thinks he brought the rain, and he'll probably win. I think he would anyway, as he's been re-elected every 5 years for 25 years now. But the rain was spectacular, with lots of thunder and lightning all night long, and the dust is all gone.

Women here wear their traditional formal dresses to come to see the doctor, beautiful, colorful long dresses with puffed sleeves and a heavy satin sash. The waiting room looks like it's full of butterflies! The training went spectacularly well. The hospital is very well-run, with several teaching and quality improvement programs going on while we were there. The group of 9 nurse/midwives and doctors we trained was enthusiastic and hard-working, and were doing screening exams very well within 2 days. They are about the best group we've ever trained. They have already established a weekly clinic to continue screening and find women who need treatment. They will bring them back to see us when we return in August. Then we'll teach treatment, and leave cryotherapy equipment so they can do it on their own. We gave the hospital equipment and supplies for exams to last till we return. We were lucky this trip: we only saw one lady with invasive cancer, and got her to the treatment center in Kampala. We saw 118 women this week, and found 7 abnormal cases, treating 5 with LEEP removal. We did another 49 Paps and some biopsies, and the staff has many more women scheduled to be examined in the next 2 weeks. The demand grew every day, as word spread. I think this hospital will be a regional referral center for women's health care when we finish their training!

Day 13 - Last Village and end of mission

2011-01-10T12:06:00.001-08:00

The opening ceremony before the assembled villagers featured an exhortation by swami, via laptop, to not smoke or eat meat. He spoke, and his words were translated into English, so I got the message, as did all the villagers. This is part of the public education program sponsored by the mobile hospital. BTW, I have seen very little smoking in the villages or in Puttaparthi itself. There was also a special fire ceremony in which John, much to his obvious delight, officiated, with cues from the other doctors.

Dr. Susheela told me that if I ever needed help or wanted something to happen, all I had to do was write a letter to swami. I could write it on paper or on my hand, and there would be no need to post it. Swami gets everything you "send" him. It's up to you, however, to interpret his reaction, connect the dots so to speak. For example, something will happen, and you will have to realize it is his doing. She also told me that I was fortunate to be able to come to the ashram because swami does not permit all to come. Bill Clinton wanted to come but swami would not allow it. Obviously, I have something going for me that Clinton doesn't.

One of swami's miracles is completion of a $63 million water system bringing treated water to 900,000 people in 700 villages in Andra Pradesh. The claim is that it was financed without solicitation, which probably means Tata funded it. Normally projects in India are delayed, never completed, for instance because of changes in the administration, poorly maintained, etc. This one was completed in record time and apparently works. That may truly be a miracle. I was told about a separate water project that saved Chennai, a city of 7 million officially and probably much more unofficially, from having to rely on water trucks for delivery. But this was also explained to me as a desalinization project, and/or as negotiation of a water sharing agreement among several jurisdictions, so it is not clear to me what swami's role was. But he does seem able to get things done.

A few of the doctors, such as Dr. Susheela, come every month to the mobile clinic, but most are new each month. The doctors have to be practicing in Andre Pradesh state. They are also all devotees. This is a very popular activity, and there is a 3 month waiting list of doctors who want to come. They all work for free and from the heart, so they seem to be instantly cohesive. There is a great deal of camaraderie among them, and they love to tell swami stories. A particularly charming moment was one morning when one of the doctors passed out little sweets to everyone on the bus because it was his birthday. It is a tradition in this area to give small presents to others on your birthday.

The last village specializes in pokuri and they make them for the doctors each month. Some have chilies in them, or other types of vegetables, They are delicious, and the doctors look forward to them.

I spoke with one of the doctors in the general surgery clinic. Much of what they do with the mobile hospital is remove sebaceous cysts, give steroid injections, and set closed fractures. As I mentioned earlier, procedures requiring general anesthesia, including knee replacements, are referred to the swami's hospitals, including the new super specialty hospital, the one shaped like Om. Everything is free at these hospitals. That is supposed to be the case at the government hospitals for the poor, but in fact it often isn't. For example, the hospital may claim not to have certain medicines so that the patient has to buy them elsewhere. Or the hospital won't provide certain services. Also, the service at the government hospitals is poor, with people waiting around for hours. Apparently none of this happens at the swami's facilities, which are all funded by his trusts.

The ENT doctor I spoke with told me he has two sons and three brothers in the US, in five different cities -- someplace in NJ, Tennessee, St. Louis, D.C., and Greensboro, NC. He has been to visit all or some of them, and in particular likes Greensboro. These relatives are all engineers, the brothers mechanical and electrical, the sons in computers. None of them has any intention of returning to India.

Our work with the mobile hospital was very rewarding because the trainees have had opportunities to do LEEP procedures and are already improving their skills. This was a terrific experience, something truly wonderful to see. The mobile hospital is known about all over, perhaps all over India, It would be great is similar efforts took place elsewhere.

One last comment before I start the tourist part of my journey. At dinner the last night flocks of fruit bats, which look to be about the size of sea gulls with wings spread, flew in loose formation over our outdoor cafe. The show lasted for about a half hour, with what seemed like thousands of bats circling around the town as the sun set. It looked like special effects in a film.

The next activity was my overnight train ride to Chennai to meet up with Stephen. It was uneventful and I was even able to sleep for several hours. Deborah

Days 10-12 - Villages with Mobile Hospital

2011-01-10T12:04:00.001-08:00

Each of these days we visited a different village. The 12 nodal villages provide services for 96 villages in all. I saw little of the first village except the school where we held the clinics. The uniformed children had their lessons that day under trees behind the school buildings. I spent some time walking around the second village, which surrounded the school so was easy to access. It was picturesque in a rural way, with women talking together while they drew water at the communal pump, old people sitting in open doorways, women on porches preparing food. Today's clinic was in a school facility outside the village, which is the more modern way of building schools, but means I saw nothing of the village itself.

Village buildings here tend to be build of concrete as there is little wood available on the Deccan Plateau, which is where we are. Many have thatched roofs. Utility poles are concrete and fences tend to be slabs of concrete or stone set upright like a line of tombstones. Travel is by motor rickshaw and I saw almost no cars. The schools are bare concrete, drab and in poor condition, but they may have stone floors. The children sit on long metal benches attached to long metal tables. The central square usually contains a shrine and is unpaved. The streets tend to be packed dirt, but there is very little trash around, refreshing for India. (The trash problem is of course serious and well known. Even the doctors will toss trash out the window rather than get up to put it in the trash bin. There needs to be a national campaign.) The area is richly endowed with communication towers and surprising numbers of people have mobile phones. Some people may have TVs. As I've mentioned, both Muslims and Hindus live in these villages, but we have been told that the groups seldom socialize together. All the children are adorable, full of energy and curiosity, run around all over the place, peek in at the clinic windows, and smile readily. The little girls are giggly and shy. While there are some small trees and shrubs, the women's saris provide most of the color in the villages, something else to be said in favor of this mode of dress. As Rhoda pointed out, you never see the same sari twice. There are scruffy dogs all over (in Puttaparthi too, along with fruit bats and monkeys) that do not seem to belong to anyone. You would not want to touch them, but you are advised not to do so because they have fleas and worse. Curiously, all the dogs look alike. They are medium sized, trim, beige, with long tails. Perhaps there is inbreeding going on. There are occasional sounds of bellowing oxen, wooden ox carts being the chief means of moving goods from place to place.

My job all three days was to keep track of PAP smear slides and biopsies. This was a step up from washing the equipment. I would make sure the doctors completed the reports for the pathologist. Then I would wrap up the slides with proper identification, label the biopsy bottles, and place matching reports and samples into little zip lock bags destined for the pathologist, an amazing man who donates days and evenings to the mobile hospital. We did a lot of smears and biopsies, so this kept me reasonably busy. The first day was a little chaotic until we developed a system, which from my perspective involved bothering people until I got what I needed to fill up the little bags. Dr. Rhoda of course taught the five trainee doctors about VIA, cryo and LEEP. We did 2 cryos and 2 LEEPS I believe. We saw many women, but I don't yet have the total. Sadly, we found one tiny 68 year old woman with cervical cancer, and I was invited to look through the speculum to see what it looks like. Quite disturbing. This woman had never been screened. The insidiousness of the disease is that it is asymptomatic until it's too late, which is why screening is so critical. We told this woman to go to the hospital, but she is just as likely to go home and die. We also saw a woman with a completely prolapsed uterus, which means it had inverted through the vagina and was hanging down outside her body. You could push it back in, but it would just fall out again. This must be very uncomfortable for her, to say the least. She was of course referred to the hospital too, for reconstructive surgery. One woman fainted after her procedure, but was ok again within minutes.

There was a very moving moment on day 11 when a young woman who had had a LEEP procedure come to the clinic to personally thank Dr. Rhoda for saving her life. She brought her daughter and introduced us to her. If there is one memory that will epitomize for me the good we are doing, it was this moment, when the young woman took hold of both of Rhoda's hands and wouldn't let go.

There is some wealth in the villages. We saw one 22 year old woman who wanted to be examined for infertility. Her mother brought her in. She was beautiful and had quite a bit of gold around her neck, and about 10 gold bangles on each wrist. She definitely stood out. We had a lunch in the home of the head of one of the villages. The front of the house was indistinguishable from all the other cracked concrete structures. A third of the front room was full of sacks of rice to be sold. There was little furniture or modern conveniences. There were, however, several rooms, whereas most of the houses look quite small, maybe a room or two.

I had a chat with the Hyderabad pediatrician on duty and learned that village children do not wear diapers, ever. Nor are they wiped. As a result they get frequent urinary track infections. At least they are not creating landfill problems. Many kids have mottled teach, perhaps from the excess fluoride I previously referred to. There is a lot of anemia.

I previously reported that birth control consists of two children followed by tubal ligation. Of course, it's not that simple. Mother Theresa, a good Catholic, opposed family planning and was quite influential in India, so that's part of the challenge. However, there have been inroads in some of the villages. In her area Muslim men are allowed to have up to four wives. Each of those wives may have 10 children, for a total of 40. She saw one 40 year old woman who had 22 kids, and only stopped because her husband died (one wonders why he went first). Mother in laws have a lot of power, and if she wants her daughter in law to have more children, the woman probably will. She sees a lot of children with birth defects, not clear why. It could have to do with consanguinity among marriages in villages.

Rhoda was asked to address the cervical cancer vaccine several times. India tried it a few years ago and there were six deaths of women who had been vaccinated. All of those deaths were for documented reasons other than the vaccine. Nevertheless, it caused the program to come to a halt. It will probably be reintroduced, but with better outreach and education. (Reminds me a bit of the uproar in California over smart meters.) It is not a complete shield, however, so screening will still be necessary. Also, it won't be of much use to the millions of older women who are the main victims of this disease. Deborah

Day 8 - Puttaparthi

2011-01-10T11:56:00.001-08:00

Rhoda and I spent the morning walking around the area, in part for exercise and in part to see the sights. I can report that yesterday I was the only woman in town wearing jeans, the first day I didn't wear Indian clothing. Puttaparthi has about 8,000 regular residents, about 900 of whom live in the ashram, and a varying floating population. During the recent 10 day celebration of the swami's 85th birthday, there were a total of 1.8 million people here, perhaps 250,000 at one time. Many would have stayed in the concrete warehouses I described yesterday, some of which were built for the occasion.

We visited the old museum of religions that is outside the ashram, as distinguished from the new museum built for Swami's 75th Birthday, which I have not yet seen. The old museum is well done without being glitzy. It is three stories and takes about 45 minutes to walk through. There are dioramas depicting significant aspects of various religions that illiterate people can understand. The individual religious groups come and arrange their own exhibits, which they presumably pay for themselves. There are exhibits about Buddhists, Muslims, Jews, Jains, ancient Greece, Confucians, Christians, of course Hindus, etc., even a little exhibit about Maoris. The message is that devotees of the swami come from all religions and countries and continue to practice their own faiths while following his precepts of doing good and loving. There are models of several temples, including of one of the beautiful wooden Buddhist temples that Stephen and I saw on a previous trip in one of the UNESCO heritage squares in Kathmandu. The main road leading into Puttaparthi is lined with buildings the Sai Baba's trusts have built: a large hospital in the shape (from above) of Om, a music school for traditional music, a separate school for other music, a sports complex including a stadium, a large school for boys, a large school for girls, a graduate school & business college (where John has taught), and a structure for the swami's pet baby elephant. The road is lined with his sayings, in several languages (think Burma Shave). There are no statues of the Sai Baba, but photos are, as I've noted, EVERYWHERE. We walked back to town on a side road that was only recently paved. It runs through a wetlands, or at least land that is now full of little ponds because of the plentiful monsoon this year. This is where the laundry is done. Think industrial level hand washing, drying and ironing. Every morning the laundry is collected from the town. Men carry out huge loads on their heads or on vehicles of some sort. It is washed in concrete vats. It is not clear whether they use soap, and instead of agitation they repeatedly bang the fabric against rocks or the sides of the vats, very hard work. The lines of drying items stretch for perhaps 1/4 mile, row after row. Somehow they are all returned to their rightful owners the next morning, dry and ironed if appropriate. There is of course a separate caste that performs this miracle. I have also heard of the tiffin collectors in Mumbai. Each morning the wife puts her husband's lunch into a stack of metal dishes, which are picked up. Somehow they are delivered hot to the right husbands at work around lunchtime. Another caste performs this miracle. These sorts of labor intensive arrangements, plus having 85 percent of the population involved in agriculture, is how India keeps most of its citizens employed. We visited some American friends of Rhoda and John, Debra and William, who have lived on the ashram full time for 11 years. The have a bit larger room than Rhoda and John are in, but it is still only one room, bath and kitchen. They love living here and don't want to be anywhere else. They are both human resources management consultants, and they are developing a business plan for an on-line values-based product to assess and encourage innovation among all employees of a company, regardless of level. The idea is that everyone can be innovative, they just may approach it in different ways, and if the company understands and properly leverages these talents it can be more innovative generally. They are super enthusiastic about this project, and have already written 300 pages in their business plan. Twice a week they offer western devotees to seminars to discuss the swami's precepts for living. The main event of the day was attending darshan in the evening. I have referred to this before but now I can provide some detail. I went with Rhoda. It is held in a large covered space almost the size of a football field, with crystal chandeliers, a coffered ceiling lined in gold, a marble floor and open sides attached to a spacious performance area up front. Darshan occurs twice a day. Anyone may come, but you are searched thoroughly and can't bring in much other than tissue and money. You leave your shoes outside. Each time about 15,000 people attend. They sit on the floor in designated places. You have to bring a mat or pillow to sit on. There are places designated for VIPs, doctors (up front, which is where we sat), professors, relatives of the swami (he has no offspring or wife, but does have other relatives), etc. There are many westerners in attendance, perhaps 10 percent. A lot of them are older and have clearly "gone native." People are packed in and it is very uncomfortable, at least for me and Rhoda. Men sit on one side and women on the other. There are many security personnel. For the first half hour or so of the ceremony singers perform ancient vedic chants, i.e., pre-Hindu. The sound system is excellent, but I can't tell you if there is instrumental accompaniment because we arrived after that. People come and go. Then they do a couple of hours of bhajans, which are spiritual chants of the call and response type. They are highly rhythmic, and are accompanied by percussion, some sort of baffled keyboard, a flute, and drums. At some point the swami is supposed to be wheeled in and take his seat on a throne in the front with two gold (I'm told real gold) lions by his side. Unfortunately, we left before he came last night. Sometimes he doesn't come, and when he does you never know when. I had been looking forward to this ceremony because I thought I would be able to practice yogic breathing and enter some sort of trance state. However, I only felt uncomfortable.

Deborah

Great Success and New Directions!

2010-12-14T06:13:00.001-08:00

John Adams

14 December 2010

We have had a hugely successful pair of camps and have also just returned from a very wonderful 48 hour trip to Visakhapatnam and back. In the two camps, in Mysore (#2) and Puttaparthi (#4), we screened about 360 women and also had some very important meetings about the future of PINCC-India. We carried out about 8 LEEPS and as many Cryos.

The Vizag Steel Plant in Visakhapatnam is a government run facility that looks exactly like the huge steel plants we used to have in the USA. If you ever wonder where 41,000 steel worker jobs went, we found them. Vizag Steel is a government owned plant that is just huge -- it dominates the region on the edge of the city. On the leeward side of the plant (we are green and clean, our smoke is blown out over the sea) is a 22,500 Acre township where the workers live. It is a completely self contained company town, complete with temples, hospital, shopping etc. What makes this township stand out is the 10s of thousands of trees that they have planted that make the whole area into a forest. There is little traffic or congestion, as most workers bike to work. Very beautiful and very clean.

Rhoda and I (minor role for me) gave two presentations -- one to the general public (of the township) and one to community leaders, and another to senior officials. Rhoda got her picture in this morning's Telegu language local paper. They would dearly love us to come and open up a PINCC VIA training program here -- we aren't sure yet if it will work out, but we certainly enjoyed the hospitality. If it does happen, the local Sai Baba Temple members will provide all the infrastructure support. This morning before going back to the airport, we visited three villages that would be served -- the most primitive we have yet seen, with thatched roofs, and then toured a huge rolling mill where all they do is create rebar for the world -- tons and tons of rebar!

I am currently putting the finishing touches on a proposal for Rotary International in Mysore and in the Bay area. They were very encouraging about supporting our vision of creating a locally operated VIA centre in Mysore by the end of 2013. Once the proposal has been reviewed by all the important eyes, we will get it submitted and see what happens. I am writing it so that it might also be submitted to other agencies.

It was a joy having Deborah Shefler with us for the two camps. We are hoping that her trip with Stephen around south India is proceeding well.

Day 9 - First village visit with Mobile Hospital

2010-12-11T16:36:00.001-08:00

The day started auspiciously with granola on the breakfast buffet. My tolerance for Indian food for breakfast is by now non-existent. As a matter of fact, I am having trouble eating the Indian lunches that are provided in the field. First, it's all vegetarian, even vegan as there is no cheese or eggs. Second, the quality is poor, not like the delicious northern Indian food and dosas we get at home. Third, I can't stand watching the Indians eat with their hands. Particularly disturbing is what they do with the second course of white rice and curd, or yogurt. They swish it around and around with their fingers and then pop a big bundle into their mouths. Just thinking about it makes me slightly sick. To avoid having to see this, I have been eating by myself at lunch. I would like to avoid lunch all together, but everyone is very solicitous of my welfare so it would be rude to take nothing. They pass milky, sugary coffee or tea around twice a day, and I do enjoy that.

Today was our first day seeing patients with the swami's mobile hospital. The mobile hospital travels 12 day/month, visiting 12 villages, which swami designated. They are nodal points for other villages in the areas from which people come, usually in 3-wheel motor rickshaws. These rickshaws are designed to carry 2 or 3 people. I've seen them carry as many as a dozen, with a couple on the roof. Stephen will recall the problem we had in Fes trying to convince one of these drivers to take 4 of us after dinner one night. The mobile hospital staff sees about 67,000 patients/month, providing health care service to about 250,000 people in the villages around Puttaparthi.

We all boarded an old bus a little after 8 am and drove to a small village about a half hour away. The roads are paved until you get close to the village, when it might turn into a narrow dirt path. Two vehicles meeting makes a good photo. There are about 25 doctors on the bus (many with friends and relatives in the US). All the way to the village they chant and sing responsively. One doctor volunteers as the leader, and later another takes over. They all are familiar with the music and clap and have a great time.

The landscape is quite beautiful in parts, with paddies and mango orchards close to the narrow road, and hills in the distance, some with interesting rock formations toward their crests. This is a good year because of the heavy monsoon rains, but there are also drought years when it's hard to see how the farmers get by. It used to be that virtually all the land was owned by one or two families in a village, and the villagers worked for them. Now there seems to have been some land redistribution and many of the villagers work for themselves. The road is dotted with small cemeteries. It seems that young people not yet married are buried rather than cremated, and sometimes a family will put up a slab monument to someone who was cremated. I have yet to get a picture of the heavily laden ox carts that pass by. The fields are full of big stacks of what looks like wheat but is in fact rice. The stacks are the size and shape of Quonset huts and are usually covered with blue plastic tarps because of the rain.

The village we worked in this day had a population of about 1,000, which may be typical. As is often the case, we took over the school rooms for the clinics. Everything was already set up by the time we got there. As with everything in India, the clinic starts with something spiritual. In this case we all lined up, men on one side and women on the other, for a short ceremony that seemed to involve asking swami to bless the endeavor. Between the two rows of doctors there were about 100 patients sitting on a ground cloth, in this village all women. There are Muslims and Hindus, living together in apparent harmony. Everyone gives thanks and then some ash is distributed to the doctors, who put some on their throats and foreheads and eat the rest. I was included in this. The ash is blessed and/or made by swami. All the doctors are completely devoted to swami and feel that he is watching over their work.

The mobile hospital is astounding. All these doctors work for free. Some have even retired early from paid jobs to volunteer their services for swami's hospital. Others have practices but devote volunteer time too. The Sai Baba specifically asked the mobile hospital director to take the job. He seems like a charismatic and caring person. Another man got a green card to work in the US, but returned here because he preferred to work for free for swami. They talk all the time about how the spirit and blessings of the Sai Baba are with them and have made all this possible. For example, they claim that there was no bleeding in the case of some LEEPs they have done, which would be most unusual for this as all surgery. The explanation is that the swami made this possible. Besides the gynecological clinic, there is a well stocked pharmacy, general surgery (they do anything that does not require general anesthesia), dentistry, cardiology, general medicine, opthamology, etc. The mobile unit itself has an X-ray machine with dark room, some sort of scanner or sonogram, and a well equipped pathology lab that does cytology and histology (I think I have that right). They would like to do more health education consistent with a philosophy of treatment and prevention guided by spirit.

They are only just getting into maintaining medical records from which epidemiological studies could be done, e.g., determining the population subject to certain diseases and the penetration of the mobile hospital's services. The general practice is that medical records aren't even maintained by the hospital. Rather, each patient has a little notebook in which things are written, and/or they get a little slip of paper telling them when to return. The patient is responsible for maintaining the record, in other words.

In the US we throw out needles after use. That is not necessarily the case here, so health care workers are still subject to needle sticks and all that goes along with that.

Rhoda saw patients but I observed this day because we were not originally scheduled to come. Many of the old people have very skinny legs and need walkers, which is most evident on the men because they wear dotis (like Gandhi). This apparently comes from eating not much other than white rice all their lives. Many have poor teeth and brittle bones because there is too much fluoride in the local water. They are also subject to loss of pigmentation; I saw one women whose face was completely white. A man or woman who is 65 is considered pretty old, and it was generally observed that Rhoda and I did not look like we were so old (Rhoda is 63). Indeed, in shape older Americans are doing and looking much better than Indians. The young people, particularly the women, are thin and graceful, some even strikingly beautiful. But they do not age well. After childbirth their bodies lose their shape and they seem to do nothing to get their figures back. They do no exercise other than what their lives demand. This is true with middle class Indians also. All the village women have gold earrings, a marriage necklace usually with some gold in it, a gold nose pin with little diamonds, perhaps a gold bangle, and lots of plastic bangles.

I want to say something in favor of saris. All the village women wear them. First, they are one size fits all. They can be inexpensive yet look great on the village women. The more sequins the better. They are flattering to most shapes. They are perfect for pregnancy, you just wrap yourself a little looser. Depending on the weather, they can be warm or cool. One doctor told me that although she sometimes wears western chothing, she prefers saris. The Muslim village women wear black caftans, under which they wear bright saris. Without the caftans they are indistinguishable from the Hindus. Village women do not wear underwear. When they have their period they bleed down their legs or onto the petticoat that is worn under the sari.

The primary means of birth control is having a tubectomy after two children, although there are exceptions, e.g., for some people who do not conceive a son. If there is anything wrong with the reproductive organs the first option is usually to have a hysterectomy. The doctors I am with believe this is because of the money private doctors get to do these operations. One of the things we are trying to do with the cryo and LEEP procedures is to discourage hysterectomies in favor of much more conservative treatment.

I will have some wonderful pictures of the villages because no one minds photos. In fact, everyone wants to be in them. I took a photo of some adorable children and it seemed like every child in the village suddenly materialized to be part of the picture. I showed the photo around with my camera to great hilarity. The kids mobbed me and all wanted to shake hands and say "sairam," the general greeting around here that always gets a response, especially if you put your hand to your heart or put both hands in prayer position in front of your chest. I ended up shaking about 30 tiny hands.

People chatted happily on the bus ride back. Deborah

What's news in India

2010-12-11T16:34:00.001-08:00

One of the pleasures of being in India is reading the newspaper. While they did report the attack on the ghat in Varanasi earlier this week, mostly they report about corruption, which seems to be rampant, well known, and mostly ignored, except by the newspaper. Here are a few tidbits from the last couple of days I just can't resist sharing with you. Truly, I am not making this up, and several items are right out of Slumdog Millionaire.

Villagers who are jubilant about getting 24/7 power for the past couple of weeks fear they will be back in the dark after local elections. Reliable power would allow them to harvest a second, summer crop. But they are afraid to make that investment because they will suffer a financial loss if the power is curtailed after the election, which has happened in the past.
The principal of a Catholic girls school ordered about 50 students to clean wooden tables and benches they had allegedly defaced. But instead of giving them cleaning liquids, the girls were provided with concentrated nitric acid and small cloths. Students were burnt within seconds and admitted to a hospital. They may have severe and permanent injuries. The school would not permit the girls to tell their parents what had happened for hours. The administrator of the Archdiocese of Hyderabad has denied that the incident occurred.
A former state chief minister and his cronies pocketed 60 million rupees, which his son is trying to turn into political power by using it to set up a new party.
Fake Naxalites (Communists I think) have been extorting money and killing people with weapons procured in Bihar. I guess they thought revolutionaries had a good thing going.
Two students drowned in a cesspool caused by deep mining in the area.
The new chair of rehabilitation centers in the state plans to tackle organized beggary, which is run by goons in collusion with law enforcement. Gang leaders pay beggars daily wages and receive the day's collection. They operate in - you guessed it - railroad stations, traffic junctions, temples, and markets. Existing rehabilitation centers are being used by people from well to do families. His goal is to eradicate beggary. Good luck.
It has been discovered that millions are being misappropriated each month by 6,000 welfare hostels that inflate student strength in order to collect extra meal expenses. Meanwhile, the food is of poor quality and hostel maintenance is unsatisfactory.
21 teachers have been dismissed for failing to show up at work for more than a year without good cause or permission.
The health department has ordered compulsory retirement for the president of the employees' association, who was found guilty of misappropriating money meant for life saving drugs.

Deborah

John Adams re PINCC developments this trip in India

2010-12-11T16:33:00.001-08:00

Greetings from 'Parthi in AndhraPradesh

First the important news -- Deborah looked smashing in a sari yesterday! She borrowed one from Rhoda and wore it to our village of the day.

We are receiving much support and encouragement to continue building towards a sustainable, locally operated train the trainer centre in Mysore. We spent an evening with Rotary International leaders in Mysore, and they were quite encouraging of us to send them a proposal for local support of various kinds -- I am working on that proposal now. The next evening, we hosted a dinner for 30 of the most senior members of the gynecology community in Mysore -- Senior professors from the two primary medical schools, senior administrators from the Cheluvamba Women's Hospital, senior physicians, our wonderful trainees, and even the District Health Officer (DHO). We shared our goal of a locally operated centre for training health care workers to carry out VIA and preventive treatments -- to be established by 2013. They were also quite encouraging.

We will spend Monday and Tuesday in Vishakapatnam (NE Andhra) exploring possible PINCC-India involvement there. There is a large steel company there that operates a general hospital. The Sai Seva organization would coordinate outreach and patient education and bring village women to the hospital for VIA etc. The doctor there (Dr. Suryaprabha) has been trained by Rhoda and Kay at the SSSMH.

John Adams, Ph.D.

Day 7- Puttaparthi

2010-12-11T16:28:00.001-08:00

One thing I forgot to include in Day 4 was Dr. Susshela's belief that there are 500 year old men living in hundreds of caves in the Himalayas praying for good. They help to keep the world on an even keel, or something like that. She has never seen one of these 500 year old people, but she knows they are there, doing their thing.

I also forgot to mention something that will be of interest to Anna: on the last day of the camp they brought us a cervical fibroid cyst they had just removed from a woman. It was the size and apparent consistency of a coconut! I think they said they'd had to do the surgery in two stages, first to deal with circulatory issues, and then to remove the "coconut," but I'm not sure about that. They had had her in the hospital under observation for several days while they prepped and figured out what to do. Obviously there was no cervix left. It had probably been growing inside this woman for years.

After breakfast Dr. Rhoda and John took me on a tour of the ashram. Warning -- if you read further you are going to learn way more about the ashram and Sai Baba than you ever need to know. It is very big, perhaps bigger than the old city of Jerusalem. It seems to be funded by a variety of trusts and sub-trusts, about which Rhoda and John know little. They do know that the guy who owned Hard Rock Cafe donated $25 million fairly recently. Someone in the TATA family is also a big supporter.

There must be at least 100 buildings, more every year. Nice gardens, meditation areas and little shrines pop up here and there, but one wonders whether eventually they will cover everything with buildings. There are at least 2 massive buildings for ceremonial gatherings of thousands of people, such as the darshan. There is a book store that sells only books about Sai Baba, in about 60 languages. Devotees are encouraged to write books about their personal spiritual experience here, and there is an in-house press that prints them. One of the nicest buildings is the book depository across from the book store. There is a shopping center that sells food and clothing. There are separate hours for men and women to shop. Even the entrance to the ashram has separate lanes for men and women. There is a museum of religion and a fairly powerful radio station. There is a medical clinic for women named for the Sai's mother, a hospital, and of course the mobile hospital vehicles that we will be using when we go to the villages to deliver our screening services.

There are three places to eat: the western canteen, the north Indian canteen, and the south Indian canteen. Everything is vegetarian. We ate lunch at the western canteen. I had a bean dish, fried veggies and pasta. The pasta was terrible. The kifir drink was delicious. It all cost about $1, and this is the most expensive of the three canteens.

There are many 3 story concrete accommodation buildings. Rhoda and John borrow a unit from friends who have fixed it up nicely. They pay 40 rupees/day, which equals about $1. The units are allotted to people in some fashion, not owned in fee. Perhaps there is some "ownership" arrangement like in assisted living, but I don't know. There is A/C in their unit, which is rare. It is one room about the size of a large hotel room, western bathroom, plus a little western kitchen. They have had the walls paneled in a varnished wood, into which are built closets and drawers, very tidy. The units come originally quite basic, with only cold water, but you can fix yours up as you like. Their unit has all the creature comforts, including a cleaning lady whose two children are being put through schools by the owners of the unit. They have also set up a savings account for her into which they regularly deposit part of her wages.

The accommodations run from palatial for VIPs such as the Prime Minister to open concrete warehouse structures with bunk beds and mats on the floor. There is a fancy hotel on the grounds for important people; Goldy Hahn stayed there, but people like us could not. The Sai himself lives in a large, decorated, multi-story building with terraces; looks real nice. Several of these warehouse type accommodations were build this year for the celebration of the Sai's 85th birthday, to which certainly 100's of thousands of people came. The Sai discourages belief in the caste system, but as you can see the housing here is very hierarchical. Or you could interpret it as creating availability for all people, regardless of income level.

There are designated living units for volunteer pilgrims who come from all over to work at the ashram for 2 week stints. Many of these people seem to be Nepalese at the moment. They perform mostly security services, standing and sitting guard in the buildings, greeting everyone with a "sairam," and touching their hand to their heart. There is a lot of security all around and in the ashram. I had to go through a metal detector to enter and they did a very thorough manual search of my purse, probably because I was carrying a metal spoon. As I've mentioned, I don't like eating with my hands. Everything is painted yellow, Pepto Bismal pink and light blue.

The ashram is here because this is where the Sai Baba was born. He is the reincarnation of the prior Baba, who died eight years before Sai Baba was born. That avatar was born south of Mumbai, so that is where his headquarters remain, and he still has many devoted followers, perhaps more than Sai Baba. Eight years after the Sai Baba dies there will be another incarnation, which will usher in a period of love and peace on earth. It is a little like the Tibetan system for selecting Dali Lamas, except that the Sai Baba designated himself as the avatar of god, whereas others identify the Dali Lama as a child. His birth story is similar to the story of Christ. When his mother was pregnant she was hit by a bolt of lightning. Although she gave birth to him, he is not her child, but a god being. He acted differently from early childhood. At about the age of 9 he revealed that he was the avatar of god and incarnation of the earlier Baba. The Sai Baba is regarded as at the same level in the spiritual cosmos as Krishna, or perhaps even Jesus. The way of life he espouses is about doing good, doing no harm and loving. It is not seen as a separate religion, but is welcoming to all religions. In other words, you can be a devotee and still practice your own religion. There is great concern about what will come of his movement when he dies.

I spent much of the rest of the afternoon writing up the three days I sent to you yesterday, sitting in the western cafe I described. It was very pleasant. We ate dinner there. Before dinner I went back to my hotel and managed to get my laptop fixed so I could use the Internet in my room. A very nice fellow changed the IP address and that seemed to do the trick. They also sent up a TV technician to check why I cannot get English language stations. He fooled around with it for a while, but the truth is the hotel has not invested in the package that includes such stations. One wonders why they didn't tell me that to begin with. Anyway, dinner was delicious. I had salad (this may be the only place in town that for sure washes veggies in filtered water) and pizza, and a tiny, first rate chocolate mousse. The restaurant features what may be the nicest western toilet in rural India, a separate reason to hang out here. The meal was relatively expensive - about $6. Deborah

Day 6 - Mysore to Puttaparthi

2010-12-11T16:27:00.001-08:00

The drive from Mysore, through Bangalore, to Puttaparthi took about six hours, but that included two stops. The SUV was comfortable, with room for 6. We were five, including the driver (who has died parts of his hair and beard orange, quite handsome) and Dr. Vijaya, the medical director of PHRII, who wanted to come to see the Sai Baba at darshan. We picked her up at her home and were invited inside. This was my first time in an Indian home. She lives there with her husband, also a doctor, her two sons and their wives, and one grandchild, an adorable one-year old girl. This is the Indian custom: when sons marry they bring their wives to live with his parents. One of the sons had an arranged marriage, the other married for love - but only after obtaining parental approval. Dr. Vijaya is open to her sons living separately, but that has not happened. The home did not look very spacious. It was constructed of concrete and not attractive, although there was a lush garden in front. (The monsoon this year was plentiful, so there is lots of green.) The furnishing in the reception room where we were was decidedly non-western. There was a wooden couch and chairs, not really comfy. The main furnishing was display cases with family pictures and personal mementos from trips, awards, etc. You could tell the whole story of this family were you to be talked through these display cases. We were of course served sweet tea and cookies. They give Rhoda a bead necklace that is supposed to deflect heat from the body, and later a moonstone ring. They even gave me a little silver ring with a purple stone. They were in all ways incredibly warm and hospitable.

The highways we were on were excellent - totally unlike what we experienced in the north five years ago. In many areas they were two way, with two lanes in each direction separated by a median. The only delay was in Bangalore. There is no highway bypass so we are tangled up in city traffic for some time. At each stop light (yes, Bangalore has stop lights, which are rare in Mysore) beggars would approach our vehicle, sometimes selling something, sometimes just thrusting their small child at the window. Once a little girl did a hand stand and then a double somersault with a little boy before asking for money.

We took a morning break at a western type cafe where I was able to get coffee without sugar. Usually the tea and coffee comes with whole milk and sugar already in it, which I don't like. They also had sandwiches, something that is increasingly attractive to me, except for the ubiquitous white bread. At this site one can chose between an Indian and western toilet. The Indian toilet is a stand astride the hole sort of thing, hard to get used to.

We ate lunch at an outdoor place with cows browsing in front. Rhoda and John had been here many times. We again had different types of dosas, set, raga, and paper I think, with condiments and chutneys. Dosas are a good choice almost any time. They come in incredible numbers of varieties made of different types of grain and in different shapes and sizes.

I had a chance to read some of the local newspaper. There was an article about the plight of Indian widows, including a 9 year old who had no memory of ever meeting her "husband" yet had been living in poverty on the fringes of society for decades because she was technically a widow. This reminded me of the trilogy of films we saw, Earth, Water and Fire as I recall. One involved this very problem. The paper is full of stories about corruption and scams. So it's well known, yet persists.

We arrived in Puttaparthi around 4 pm. I got installed in my hotel, the Sai Towers. It is fine, but lacks the amenities of the Urban Oasis in Mysore, a true gem. For instance, the wifi supposedly exists, but you have to have a technician set it up for you, whereas it was hassle free in Mysore. (I'm writing this from a wonderful western type cafe called the Hanaman Hillside Cafe, which features free Wifi that works well.) The English language TV stations are unavailable at the hotel, again unlike in Mysore. They claim they can adjust the programming to bring in these stations, but I have asked twice already and it just doesn't seem to be happening. Jeremy and Anna may appreciate my frustration. On the other hand, the breakfast has greater variety, although the variety is mostly dosas with various veggie accompaniments. I had fresh fruit and corn flakes. I've discovered that ordering black coffee with a side of milk is the way to get what I want. There is a nice, quiet shop in the hotel where I bought a silver and "emerald" ring for $22.

Puttapatri is all about the Sai Baba and his ashram. Pictures of the Sai Baba are omnipresent, and I mean omni. It would probably be close to impossible to take a picture here without some image of him being in it. There is the town outside the ashram and the inside of the ashram. Rhoda and John are staying inside, I'm outside. The outside consists of a few streets lined with little shops. There is no Starbucks, don't even think about it. Restaurants are often on the 2d or 3d floors of nondescript buildings. We ate dinner, for instance, in the German Bakery, which is staffed by fetching male Nepalese refugees. There is a Nepalese shop next door with felted wool hats and other products, and tonkas. The food was great. I was able to have lightly sauteed vegetables with hummus and dense German bread, totally satisfying. I had dinner with John, and a nice conversation, as Rhoda was still working on getting Dr. Vijaya into darshan and a room for overnight. They showed up at the restaurant at about 8:30, but since the ashram gates close at 9 pm, they weren't able to eat. After dinner they all went back to the ashram and I walked around the town. The weather is again perfection, even in the evening. There are many pilgrims here, in particular a group of men wearing black and gold outfits, and many women wearing red saris. There are some serious hippies, many of them Russians. The atmosphere is mellow and non-threatening. While there are beggars on the walk ways in front of the shops, the town itself seems relatively prosperous, probably because of all the pilgrims coming through. The shopkeepers are as "inviting" as you'd expect, very much like in Morocco. There are many westerners, but few of them are obviously American. More often they are German or eastern European. There are also Italians and South Americans. I have already made friends with two chatty women from Vancouver, former telephone company employees, who are not devotees of the Sai Baba but nevertheless come here often to hang out, meditate, take treatments and, apparently, be happy. One was formerly an Olympic kayaker. Both have shoulder injuries. They are staying in my hotel. Deborah

Day 5 - Mysore

2010-12-11T16:23:00.001-08:00

Our fourth and final day at the clinic again went smoothly. The trainees are doing well. We were able to do one more LEEP procedure, but that was only two for the whole four days. I was much busier cycling the instruments through the sterilization process because we saw 73 patients, quite a few more than on other days. This increase was in part due to several women still in their 20's coming in. Our target group is women older than 30, since the cancer takes years to develop and the signs rarely show up in young women. At any rate, I felt better utilized and that was a good feeling. Dr. Rhoda volunteered that the instrument cycling went well throughout the camp days. The only real hang up was having only two biopsy tools. We seem to have done an especially large number of biopsies. At the end of the day we met with the doctors and director of PHRII to discuss preparation for the next camp when Dr. Rhoda and John return summer 2011.

Sister/nurse Mary brought me a gift of a Gideon New Testament and a couple of booklets of guidance so I can spend at least a half hour each day improving my soul. As with Dr. Susshela, this is an example of how being in India can be a highly spiritual experience if you are open to it. I'm afraid I'm not, but I do respect the sincere beliefs of the devoted, especially if they motivate good works, as seems to be the case with these health care professionals.

I mentioned before how the washer woman kept trying to communicate with me. As I realize now, she was actually begging, asking me for money to feed herself and family. Funny, but it did not at the time occur to me that that was what she was doing, unaccustomed as I am to having workers beg while on duty. I have her a kiss at the end of the day, but that's all she got from me.

In the evening we went to see the Mysore Palace lit up. It is lit for a half hour on Saturday nights, and one hour on Sunday nights. The grounds and gardens are extensive, circumscribed by a high wall. The open entrance changes from time to time, so we were left off by our motor rickshaw two kilometers from the gate open this night. The walk was good after sitting all day. It is impossible to describe what that Palace looks like with every architectural element picked out in lights. It's a bit Disney-like, but dazzling and impressive. This was the first time I'd seen westerners in several days; there were almost none in our neighborhood, and absolutely none at the hospital. I felt somehow different from the regular tourists, probably because I was having special experiences unavailable to the casual traveler. The maharajah build this palace about 100 years ago, using British contractors - you can see how colonialism benefited Great Britain in many ways. I hope Stephen and I will have time to visit the inside, a museum, during our one day in Mysore. There is also a famous shrine on a hilltop just outside town.

We ate dinner in a popular hotel restaurant called the Park Lane. The food was better than average and there was live Indian music. There was also a clean western toilet with toilet paper, quite an oddity and very much welcome.

I must say that I am already getting tired of eating Indian food all the time. It of course varies in quality. For example, I just couldn't eat the lunch at the hospital today. I ate the sweet, but not much else. Dinner was much better in quality, but a little good Thai or Chinese would be welcome. There are Chinese dishes on some of the menus, but I can't imagine they would match my requirements.

I am sorry to be leaving Mysore. It seems like a relatively livable place, without massive crowds or choking traffic. I'm likely also influenced by our embracing reception here and by the warm and lovely people we have met. Deborah

Day 4 - Mysore

2010-12-11T16:21:00.001-08:00

Yesterday was the third day of our four day camp. I've got the instrument sterilization routine down pat now.

It turns out that the bible does say that god wants the Israelites to remove their "adornment," just as sister said. However, if you read the passage in context, it is clear that what god really wants is for the people to put aside their pride - god calls them a "stiff-necked" people - so he can see who they really are. I think this woman could safely wear jewelry without jeopardizing the purity of her soul. She brought her younger 16 year old daughter to meet me because she thought I was "so good." This was quite touching. Both of sister's daughters will go to college, studying computer science and engineering.

The clinic went very smoothly again. We saw 40 women. Unfortunately, we were unable to do a LEEP procedure. This is unfortunate because it makes it impossible to train the trainees on the procedure on a real woman. Training on a piece of meat is not quite the same. We have our fingers crossed that there will be opportunities tomorrow.

The special event of the day was an appreciation/networking buffet dinner PINCC sponsored for the trainees, supporting doctors, and health department officials. About 30 people came and we did the best we could to encourage the development of an in-country screening program based on our protocol.

I had two fascinating conversations during this event. The first was with a mother and daughter whose husband/father is one of the health officials. The mother had a professional job and the daughter was still in high school. This young woman was extraordinary. She spoke English as if she'd lived in England half her life, although her facility was all the result of Indian schooling. She has won several regional contests testing general knowledge, sort of like the kids in the spelling bee documentary. She has incredible poise. She plans to study physics or some other heavy science in college. At the end of the conversation her mom invited me to come visit her home, but alas there will be no time.

The second conversation was with one of the doctor trainees, Dr. Susshela. This woman was already trained in Puttaparthi, so she was able to assist Dr. Rhoda with the training in Mysore. She is devoted to the Sai Baba and volunteers every month at the hospital at the ashram, although she lives in Bangalore, a couple of hours away. She is a lovely woman very much at peace with herself. She explained that all the Hindu gods are aspects of one god, which I've heard before. She believes that the Sai Baba is an avatar of god. While we all have aspects of god in us, god comes through him as through a fire hose. He is 85 years old. Some years after he dies another avatar of god will be born and identified. A main event at the ashram is darshan, when the devoted gather in a covered space and wait for the Sai Baba to come among them. Sometimes he does and sometimes he doesn't, as he is quite frail now. It is very important to see him and be in his presence so that you can feel his spirit. He can perform miracles, many of which involve getting roads, clinics and educational centers built. One should not wear black to darshan because black clothing blocks the spirit. Much of her motivation to service seems to come from her devotion. It was clear that she felt I could benefit by being receptive to the spirit of the Sai Baba. Deborah

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

2010-12-03T19:06:00.001-08:00

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.

PINCC Latin America Updates

2010-11-27T13:05:00.000-08:00

You can find Mai's report on the latest PINCC voyage to Latin America at http://mai-pincc.blogspot.com/.