On a lighter note, I got the opportunity to go visit a few on the nearby Hindu Temples.  My Tucson friend joined me which was wonderful because she served as a translator and guide.  She practices the Hindu faith giving me insight to the rituals and significance of the temples, offering, etc. The first temple was located in the hillside overlooking the city below.  We arrived as the priests were performing one of the daily rituals which included providing offerings, food, and then cleaning the God.  Once that was complete we were allowed to enter and visit the God.  The God was stunning presented in all gold, covered with flowers and radiating in the candle light.  The God was smaller than I expected, only about 12 inches x 12 inches.  The ritual was performed, a blessing was spoken, and it was finished with giving us coconut water poured in our hands to drink.  I felt awful but I did not drink the water, I dabbed it on my cheek!  That just seemed like a raging case of bacteria to expose to my gut to since I am not used to the local bacteria here.  After visiting the God we went outside where my Tuscan friend lit a fire and placed it outside the alter.  We then walked three laps around the alter to solidify her prayer.  She prayed for health and strength for her Dad who is hospitalized. I have to say I admire the spirituality, devotion, and dedication of the Hindu faith.  The faith of the followers is inspiring. 

We finished our evening with a trip to the local street market. This was fun for me because it gives me the opportunity to see a piece of the local life. Where do the people go to get shampoo? Where do they do their grocery shopping and get their hair cut, the everyday events of life.  There was the main dirt road lined with fruit venders, retail shops, and moto repair shops. There were children, chickens, and pigs running around amongst the locals doing their every day shopping.  It was the hustle and bustle of the village.  I even did a bit of shopping myself. 

Today I had the opportunity to review x-rays with one of the chest doctors. The chest x-rays were of patients who were admitted with tuberculosis and currently receiving treatment. There were classic cavitary lesions and even an image of miliary tuberculosis on the x-rays. I found it pretty cool to see in real life what I have studied in the textbooks. We then went to the microbiology lab across the hall to see an acid fast stain. There were a ton of the bacillus all over the slide, lighting up like green fluoresant stars in the sky!  Next, we attempted to go to the dermatology clinic and see skin cases but the afternoons are pretty slow in the clinics. The way it works here is most patients come in the morning, get seen by the doctor on a first come first serve basis, tests and labs are ordered, the patients leaves to get them done, then returns to the doctor with the results. Only then is the treatment determined. There is no MyWakeOne or I will call you with the results here.

What I was hoping to see in the dermatology clinic was a case of leprosy, the clinic sees several cases each week. The dermatologist was telling me the cases have increased to roughly 50 cases per 10,000 people which is a significant amount. The reason for the surge is several years ago Indian declared that leprosy was eradicated in the country, only 1 case per 10,000 people. What happened then was suppliers, such as aid organizations and pharmaceutical companies, quit providing the medication to treat leprosy. If leprosy was supposedly gone there was no need to keep spending money on distributing the medication. That would have been the ideal situation but that was not the case. So now several years later you are seeing a spike because people who were infected didn't have treatment options available allowing the disease cycle to continue.

We also talked about government programs to ensure tuberculosis and HIV get treated. There are programs to provide the medications free for both diseases and the tuberculosis treatment is even observed improving the compliance rate.  This has decreased the incidence of TB significantly and decreased drug resistance cases. There still a few cases each month of extensively drug-resistant tuberculosis (XDR-TB). Those cases require hospitalization to ensure the patient receives adequate treatment. In regards to HIV, there is still great stigma attached to the diagnosis. Employers fire people with the diagnosis, families excommunicate the individuals, and they are socially ostracized. This has lead to a dangerous environment for hospital employees and other patients. It is not uncommon for HIV positive patients to be admitted to the hospital and not disclose their positive status perhaps due to social pressures. This becomes very dangerous in a setting where medical supplies are often sterilized and reused. What is the ethical action to take? You have the patient's right to determine what tests they undergo on one side and on the other side you have the patients and staff who could potentially be exposed. This seems to be a tough decision.

Below are pictures of the typical outpatient clinic. The attending sits at the desk with the patient who is currently being seen sitting on the silver stool. Additional patients waiting to be seen are first checked in then sit in the blue plastic chairs to wait their turn.  Most patients admitted to the hospital are admitted through the outpatient clinic. The outpatient clinics here function similar to an Urgent Care Clinic in the US. 

"This town is so small" is a phrase I have heard over and over again since arriving at the hospital. The population of Vijayawada is only 1,491,202 people. This shows how perspective matters.  Winston-Salem, NC where I am currently settled is the largest city I have lived in. The population of Winston is 234, 349.  Imagine how small that city would seem to the people here. Even smaller is the town where I grew up, Washington, MO a thriving metropolis of 13,918.  Yet I wonder if using population is not a reasonable comparison between the two cities. Yes Vijayawada may  have six times the amount of people as Winston-Salem but that doesn't mean the cities have comparable resources or amenities.  Take the average population density of India (364 people per sq km) compared to the US (34 people per sq km).  It seems India has 10 times as many people living in the same sq km as America.  No wonder a town can be labeled small but still have a population over a million.

The population of India is booming and has been one of the assets and pitfalls to the county as a whole.  The population is diverse with a robust culture and traditions leading to an undeniable pride in their country. However, the enormity of the Indian population also results in limited resources with a majority of the people living in utter poverty.  According to the World Bank report in 2010, 32.7% of the Indian population falls below the international poverty line of making less than $1.25 USD a day, while 68.7% of the population lives on less than $2.00 USD a day.   A majority of the people in the area here including the city and surrounding area fall in the category of making less than $2 USD a day.  They are daily wage workers in the agriculture industry, domestic helpers, or stay at home to while the husband works.  That makes affording hospitalizations, medical tests, and treatments difficult, frequently draining the families savings.  Below is a breakdown of just a few of the costs for medical tests:

CBC                                            180 Rupees    $2.91 USD
Renal Profile (Na, K, BUN, Cr)   225 Rupees    $3.64 USD
Liver function test                       300 Rupees    $4.85 USD
Finger stick blood sugar               30 Rupees    $0.48 USD
Urine analysis                               80 Rupees    $1.29 USD
Lipid profile                                 250 Rupees    $4.04 USD
Chest X-Ray                               125 Rupees    $2.02 USD
Abdominal Ultrasound                500 Rupees    $8.09 USD
MRI Brain with DWI                 2,800 Rupees    $45.24 USD

It is a struggle for both the families and the hospital, the hospital gives charitable care but has its limits.  In the end the hospital has to be fiscally sound to keep operating and delivering care.  When a family can not afford the care here at this private hospital their other option is the government run hospitals.  However, I have been told by numerous people on separate occasions these are less than stellar.  At times there are not enough beds for patients so they are sleeping on the floor. Treatments are not available and evidence based medicine is an afterthought.  I'm not saying all are like this but the nearest one here falls into that category.  I guess that is perhaps where I tend to get discouraged.  There are needs that need to be met around every corner and how do you say one is more important that another.  How do you pick and choose? The amount of need is overwhelming and at times can seem like no matter what action is taken is there really a difference being made?  When the medical team receives a smile from a mother who's 16 year daughter has recovered from high fevers and low blood counts I answer yes, a difference has be made.   There may be no definitive diagnosis of which virus caused her symptoms but for that family they have their daughter.  Major change is happening at this institution but perhaps like a ripple in the water we are in the early stages and the difference will take many years to manifest.  That is my attitude, that is my hope and that is my motivation.