Dialing into the Chicken Internet

Another busy day here in Kolkata! Our first stop of the day was the Institute of Hygiene and Public Health.

The institute is the oldest public health center in the country. Kolkata was the capital of British India and so a lot of the infrastructure dates from back when it was under their rule. They were actually doing some remodeling of the interior which Marton experienced first hand…

After meeting with the director of the public health center, we were off to the Urban Health Center. But first we stopped at a local bakery to pick up some lunch.

They had a ton of stuff there, ranging from veggie pizzas to chicken masala sandwiches, but my favorite was the chicken internet.

For only 18 Indian Rupees (or 40 cents), I couldn’t pass it up!

Once our party had restocked, we arrived at the health center.

We attended a educational lecture on breast milk composition that was being given to the health care workers. We had the chance to introduce ourselves to the group and explain our purpose.

To get a better idea of the conditions in which the poor live, we were taken on a tour of the surrounding slums. While walking by one of the massive concrete buildings that house a portion of the 100,000+ residents of the slum, a mother invited us up to see her one room house.

Our guide from the health center also took us to one of the local primary schools. We had the chance to interact with some of the children and help them practice their English.

It was really touching to see the children who lived in the slum. Despite the rough conditions, they still were really happy and playful.

While on the tour, we came across a woman creating homemade charcoal. The briquettes were made out of cow dung and some type of rock. The two ingredients were combined by hand and left to dry in the sun.

The women in the slums are the ones who typically have the steady jobs and bring home a consistent paycheck for the family. These women were creating food bags out of old news papers.

Our tour concluded with a meeting back at the urban health center where we talked with doctors from the epidemiology department, education, and maternal/child health departments.

In the evening, we journeyed out to Salt Lake city and went on a tour of an up scale corporate hospital. The building was 7 stories tall and was on par with the hospitals in the US.

Let Freedom Ring!

Today was India’s Independence Day. Brian, Paulina, and I took the metro to the markets where we shopped for a bit before going up to the rooftops to watch the stage performance going on. We got invited up by the locals who sent down a young lad to guide us up.

Then we went to the Victoria Memorial where people were hanging out in the gardens (an interesting juxtaposition considering they were celebrating cutting ties with the British).

In the picture below Anastasia and I are showing off our new Indian threads. We’re off to dinner now to feed our bodies, tomorrow is back to work.

Rakhi

Today was Rakhi – a Hindu holiday which celebrates the love between a brother and a sister.  Traditionally, the sister ties a bracelet onto the wrist of her brother, and the brother promises to protect her.  Also, gifts are generally exchanged during this interaction.  Dr. Dam (pictured below in the pink sari) decided to include Marton, Brian, and Geoff during this holiday, and gave them some sweet beaded bracelets!  The boys and their bling are pictured below.

Here’s the crew before we started observing for the day.  Since it was our last scheduled day in the department, they presented us with gifts, which was really nice!  The guys got these cool sculptures, and Paulina and I got carved wooden flowers.

During the day, Paulina and I saw four gyno procedures in the span of about an hour and a half (the volume of patients some of these government hospitals see is ridiculously large) – the ORs here (or OT’s as they call them – “operating theatres”) are run like well-oiled machines.  Also, Geoff, Brian, and Marton apparently got to see a Laerdal penguin (one we had given as a gift a few days back) in use during a C-section delivery today!

 

Since it’s Saturday, the workday ends after lunch, instead of continuing through to the evening.  Paulina and I perched out a window so we could get a better view of the city.  Here’s a view of the street below Dr. Tripathi’s office:

And here’s Paulina using her awesome camera.

It has proved to be near impossible to find a landromat-type place here in Kolkata.  If you don’t wash your clothes at home and pay to have it done instead, someone else not only washes your clothes for you, but also to fold them and stick paper in between the folds to keep the creases fresh. Brian, Geoff, and I got the laundry back that we had sent in – it looks really professional.

Better Late Than Never

Every morning at our hotel we have this awesome breakfast spread. Dishes range from pancakes to Indian samosas to fresh cut fruit.

The picture above is only half of the spread! As part of the meals, we always get coffee and unlimited fresh fruit juice. I have just discovered a great morning combination. Croissant + chocolate sauce. If there is a better way to start of the mornings here, I haven’t found it.

This morning we went to NRS medical college and were given a tour of the facility by Dr. Jhanavi Das. Dr. Sood of Jhpiego came with us on the visit and gave her prospective. The focus of the visit was again on OB/GYN and it was interesting to see the practices in another setting. We got to see everything from labor (or labour here) and delivery to GYN surgery.

As part of the tour of the hospital, we went to the nurse teaching college on the campus. The student association was having a celebration that we watched for a few minutes. It was great to see the traditional dance and costumes worn by the people.

This is some old news but I think the picture is too good to pass up. When we were at the Gateway of India a couple of days ago I was approached by a man dressed in traditional clothing. I thought he was trying to get me to pay him to take my picture in front of the Gateway or to take a picture with him. I did what I had been trained to do, I ignored the man despite him tapping me on the shoulder and trying to grab my hand. The man was really persistent and ended up going over to talk to Dr. Acharya. As it turned out, he didn’t want to be my personal hired photographer, he simply wanted a picture of the giant white man walking in the crowd.

Not only did he and his family take a picture of me home, but so did about 10 other people as they passed by.

The OB/GYN Dept, The Lecturer, and The Nursing Home, oh my

It’s been a long and dense day of learning and immersion. We started off the morning by visiting the OB/GYN dept to talk with Dr. Chakravorty who is the director of the department. We had already met with him before so we quickly split ourselves into 3 groups of 2 to visit each of the three sections (Out-patient dept (OPD), the Operating Theater (OT), and the Labor and Delivery area) for an hour each. Geoff and I went with Dr. Chakravorty to the OPD to start the day. We observed how the patients check in, where they get their clinical examination and where they get their labs drawn up. The way he explained it to us is that with each phase of the OPD check up you are trying to divide the expectant mothers in a way to identify those with the highest risk pregnancies. We also learned of the immense patient load that the OPD is under, each physician does a clinical exam of approximately 200-300 patients/day. One of the biggest problems that they face however is that it usually requires at least 4-5 check ups during the pregnancy to fully evaluate and identify the risks that might be involved but many times the mothers come in for only 1 or 2. Over the last few days we’ve heard a lot about the problem of postpartum hemorrhage and it came up a few times today as well. One of things that ends up happening is that the hemorrhage will start in a peripheral hospital where they are unable to control it and at that point the decision is made to send the patient to major city hospital like this one (Medical College). One of the the problems is that transit times are typically long and the mother really only has about 2 hours or so before the hemorrhaging has to be stopped; this leads to as many as 1/2 the mothers dying in transit. Geoff and I then saw a public health education seminar that was being set up by the nurses to teach people how to avoid infections and we got a chance for a photo with them.

Geoff and I then went to the Gynecology surgery department where we saw a D & C / polypectomy. It was our first observed procedure of the trip. Unlike in the US there is a huge focus on keeping everything reusable here (as far as possible; obviously not needles and syringes), so we put on cloth caps and masks for the surgery. Similarly we saw that drapes are also cloth and are sterilized and reused; for me it was kind of nice to see that surgeries can be performed without the enormous amount of waste being generated that we got used to seeing in the US. We then moved on to the labor and delivery ward where we got a brief tour of the multiple stages of the delivery rooms that the mothers get divided into. Geoff and I didn’t see any deliveries today but not for lack of deliveries but because Dr. Dasghapta gave us a very detailed overview of the delivery process. Between midnight and noon today the delivery room saw 27 deliveries, Anastasia and Paulina saw 4 in their one hour on the ward. We then ate lunch at the Food Station again which is place just down the street from Medical College. In the early afternoon we saw Dr. Acharya give a lecture describing what our program is all about including both global health projects and developed world health projects: the takeaway point is that none of these projects would be anywhere if they didn’t have the collaborative efforts of the very enthusiastic clinicians we graduate students have the unique opportunity to work with. So far we seem to have avoided any major faux paus and all of the clinicians and professionals we’ve interacted with have been very warm, welcoming, and most importantly incredibly enthusiastic with plenty of ideas on how we can be of use to make people’s lives better.

We then visited and interacted with the director of one of the oldest nursing homes in the country, North Calcutta Nursing Home. Founded in 1950 this institution started off as strictly an Obstetrics and Gynecology facility. It caters to a unique subset of the population which cannot afford the private large hospital costs but that can still afford to pay for their medical expenses. Unlike in the US, Nursing Homes in India are not old people homes; these are more like mini hospitals which perform surgeries up to a certain level of technical difficulty. We had a long discussion about the specific problems and challenges that these physician entrepreneur face as they own these nursing homes. Some of these challenges are unique to them but a lot of the solutions to their challenges could revolutionize the healthcare industry.

Intro to Calcutta Medical College and the School of Tropical Medicine

Last night we got a late call from Paulina from Laerdal (a Global Health Company that we are extremely excited to be working with!) saying she had just arrived.  Paulina was the inventor of a low-cost birthing simulator for developing countries which has outperformed multi-thousand dollar simulators at Hopkins studies.  She was kind enough to have us all over to her room for tea and a chance for introductions.  Clearly passionate for her work, we’re lucky to have her accompanying us for the rest of our trip.

The next morning the five of us (4 CBID students and Paulina) met up with Dr. Tripathi in the hotel coffee lounge for breakfast and for more introductions. Dr. Tripathi is a long time associate of Dr. Acharya (our graduate program director who has accompanied us so far).  At lunch we got to hear stories of our fearless leader tinkering with electronics in highschool to produce simple medical devices which Dr. Tripathi was able to submit to a conference, but that’s getting ahead of ourselves with the days events.

 

Next we made our way to Calcutta Medical College and met with the Principle, Dr. Gutta, who was a most interesting character who seemed very eager to see us get into clinical immersion and make the most of our experience.  There was some discussion of plans for our time at the hospital as well as a quick history lesson of the institution which has been around since 1835!

 

We made our way to meet with Dr. Ray, the director of the School of Tropical Medicine.  Dr. Ray was Dr. Acharya’s pharmacology professor back in medical school, and more good stories were told!

Continuing our initial exposure to the faculty and facilities, we met with Dr.Chakraborty.  Clearly excited to have us around, Dr. Chakraborty was able to quickly get us oriented in the Ob/Gyn department with a quick orientation, followed by a short trip to Labor and Delivery.  Here we witnessed the bond between patient and doctor as Dr.Chakraborty  talked to patients who either just delivered or were about to, reassuring them and obviously using a bond of trust to reassure the patients that they were getting the best care that could be provided, which he undoubtedly provides.

 

Our day continued during a meeting with the entire pediatric department to talk about possible areas they see that may be helped through our program and the projects we develop. We’re all very excited to be counted on by these people to have an impact and will most certainly give it our all especially having such caring peoples faces assigned to the task.

Mumbai to Kolkata

Hey everyone!

Today was a busy day, starting with another visit to J & J.  After a buffet breakfast at the hotel, we went back to the J & J research and development center in Mumbai.  There, we learned more about the structure of the healthcare system in India.  Afterwards, we took a couple of vans and went to the administrative headquarters of J & J in Mumbai, where the Managing Director talked about the things that can affect the success of an innovation other than just its design – namely inefficiencies in the supply chain.  40-60% of a product’s price point can be wrapped up in supply chain expenditures, so understanding how to minimize that spending is crucial when innovation is occurring in developing countries. Being able to have meetings with these people is fantastic – we’re gathering a lot of relevant information regarding the context of the Indian healthcare system.  Having a grasp on the background of what we’re diving into before we actually do is helpful, as it allows us to understand how the chain of command within a hospital, the supply chain, or the public mentality of healthcare may influence the success of a new technology.

 

All of us at J & J

Driving in India, if you haven’t already gathered from prior posts, is NUTS. That might be an understatement.  There are no lanes, no discretion regarding horn use, and, by my observations, probably no traffic laws either.  The thought of having to drive in India myself is almost as scary as crossing a Mumbai street.  However, the nice thing about traveling by taxivan all the time is that we all can pass out in the car in an effort to rid ourselves of jetlag.  There have definitely been times during the past few days where all five of us in a van are close to comatose. 

Typical day of driving in Mumbai

After meeting at the administrative headquarters of J & J, we went back to the research and development center, where we were fed a fantastic lunch and learned the importance of the India-Pakistan cricket games.  The way Dr. Acharya described the amount of viewers for that game makes it seem equivalent to the American Superbowl.

Discussing the finer points of cricket over lunch

We had to say goodbye to the other half of the students we were  traveling with today (well, only for two weeks – until we meet up in Norway).  Shuja, Luis, Omid and John are flying to Kathmandu tomorrow, and Marton, Brian, Geoff and I (Anastasia) just landed in Kolkata.  Here, we’ll start our field work, which will include meeting with hospital administrators and shadowing clinicians (similar to our summer rotations in the Hopkins hospital).

 

Our hotel driver welcoming us at the Kolkata airport.  Apparently I am a man.

Be Great in Sport.

Today was our first day of of work here in India! We met with the Johnson and Johnson India team at one of their Asia-Pacific research and development centers.

We talked about the differences between the US  and the Asia-Pacific healthcare market. Here pure volume drives sales (over 1/3 of the world’s population lives in India and China alone) so profit margins can be razor thin and still make a product sustainable. We also discussed the various types of healthcare services available to Indians and what it takes for a medical device product to succeed. A product needs to conform to the three A’s; it must be accessible, available, and affordable. After our morning discussions, we broke to eat delicious Indian food in the J&J cafeteria.

Next, J&J had arranged a tour of one of the local government run cancer hospitals called Tata Memorial Hospital. This hospital mainly caters to the poorer segments of the population and attracts patients from all over India and even neighboring countries. Here, treatment is deeply subsidized for those below the poverty line and made affordable for those above. It was extremely crowded inside and during the tour we were afraid of loosing each other in the crowd (luckily I’m about a head taller than everyone else so we were ok ). We also had the chance to briefly speak with the hospital director ( Dr. Rajendra Badwe ) about what influences device purchasing decisions and also get some advice on what to see in the city.

Thank you to Dr. Sumit Misra and the rest of the team for helping to coordinate this visit! We’re looking forward to coming back tomorrow.

After returning to the Sea Princess and all of us had recovered, we met Dr. Acharya at a local seafood place called the Mahesh Lunch Home. We had some gigantic prawns and some crazy looking local fish called the pomfret (see picture below).

We have been eating so well here! Some people are actually complaining of having too much…I’m loving it!  

On our way back home from dinner, I discovered a great way to deal with beggars! Give them Purell. I have been telling all of them no to requests for money and just continuing to walk. Tonight, as soon as they saw the bottle of Purell on my backpack they start pointing at it and asking for some. Once I gave them a big glob, they began to play with it and went on their own way! They seem to love the stuff!

Until next time!

Education and a Bit of Sightseeing

Brian attended Dr. Sangvhi’s lecture on contraception and abortion this morning. What he found most interesting was that there have been studies to show that when women have a choice in the contraception form they use they are more compliant and the effectiveness of the therapy is greatly increased. The morning also consisted of a delicious buffet style breakfast. In the afternoon we met up with Dr. Acharya went to the Phoenix Mall for lunch; it used to be called the Phoenix Mill because it used to be a cotton mill. We ate at the Punjab Grill which was really delicious and filling; they also had a setup where you could see cooking going on through a big glass window. We then visited the Gateway of India. This is a monument that was erected in 1911 to commemorate the visit of King George V. Right behind the monument are the Taj Mahal hotel and the Taj Towers. At monument there is also a statue of Chatrapati Shivaji who was as Dr. Acharya put it, the George Washington of India. As I learned on wikipedia Shivaji led the resistance to free the Maratha kingdom and later he defended his kingdom from the Mughals. One thing that has been a bit shocking is the controlled chaos which controls the flow of traffic through the bustling streets. Honking is necessary and even encouraged (based on the signs on the backs of cars) to let people know that you are passing them. Crossing the streets is a bit like playing frogger. Dr. Acharya pointed that around 95% of traffic fatalities in India are pedestrians. I found an article from 2010 in the NY Times that states that in 2008 there were 118,000 traffic fatalities in India which was a 40% increase from the previous 5 years. The article points to causes such as bad roads without crossing abilities, lack of police enforcement, and lack of safety education. I tried my my hand at bartering today and unfortunately I think I lost; but I won a sweet hand drum. Well anyway we’re off to meet with J&J tomorrow morning; we’ll keep you updated on how things are going in the next installment.

Mumbai Van Ride

Untitled from Brian Ray on Vimeo.