The End. Sort of.

So, it's my last day here at The Leprosy Mission Hospital in Naini. I have mixed emotions about leaving. I've had a fantastic time here, made some great friends and would gladly stay longer (though maybe not into the monsoon season) but will be seeing Ryan for the first time in 8 weeks tomorrow for an explore of North Western India together.

Here are 5 points that I could have written about but didn't have the time:-

1. Surgery
I've undoubtedly spent more time in operation theatres seeing surgery here than in my entire 5 years of medical school in the UK. Dr Premal Das is the only surgeon so has a huge range of skills which I find very impressive. I've also had the chance to carry out some of the surgery myself, notably skin grafts to cover ulcers, caesarean sections, and the removal of various lumps. This has usually meant that everyone's gone home half an hour later than usual but I really appreciate their patience. This Tuesday I was left to do some stitches while Dr Das moved on to the next surgery so I'd like to think that I finally saved a bit of time, though my slow excision of a lipoma earlier that day probably made up for it! I may never see the inside of an operation theatre again so am delighted that after so long in medical school someone has finally inspired me to appreciate that surgery can be amazing and not boring.

Ooo, gory photo of surgery

2. Chapel.
I've been to church every day since Easter, wow! I hope this makes up for the fact that I was on a plane during the Good Friday service. Morning Church of Northern India chapel services have been a brilliant way to start each day. Although I couldn't understand most of the time, I could follow the daily Bible reading in English as well as the daily devotional prayers said all over TLM centres in India that are also written in English. These 20 minutes each morning gave me a chance to rest, put my trust in God, and prepare for the day ahead of me. On Wednesday I led the service with a talk about my faith and a reading that I'd chosen - Pslam 25 verses 1-5 if you're interested. Daily chapel offered comfort in the first couple of weeks while I was settling in, and more recently have been a place where I catch up with friends over a cup of chai and biscuits afterwards. I made the right choice in carrying out my elective in a Mission hospital.

3. Sightseeing.

One of my favourite moments was when I went on a boat trip to the Sangam with the CMCV students and junior doctors. The Sangam is a very holy point for Hindus where the rivers Ganges and Yamuna meet, as well as a mythical river. It was the site of the huge Kumbh Mela earlier this year - the biggest religious gathering in the world, ever. As well as this, we visited Anand Bhavan - the home of the Nehru family that provided India with its first Prime Minister when it gained independence.

I'm proud of this photo!

4. The rabid monkey.

So there was a money on the loose within the campus that was biting people. It was costing staff and patients a lot of money. Children were not allowed out alone, and I stayed indoors at night to eat my bread and jam rather than venture to the dining hall. It bit a total of 5 people - 2 staff members, 1 staff child, and 2 patients. Patients were moved wards, and cottage patients were feeding it breakfast so that it wouldn't eat the bananas in the trap set for it. A week after the first bite, the monkey was caught by a monkey-catcher with a cork hat called Tarzan. The hospital breathed a sigh of relief.

5. The weather.
Such a huge topic! So when I arrived on March 31st it was a hot but bearable 38 degrees C. I was told "Wait until April." In April a desert cooler had to be installed in my room (an ugly device that requires electricity and a tub of water) and my fan turned up to full in order to sleep at night, with temperatures averaging 42 C. I was told "Wait until May." May has been consistently hot with a maximum of 46 C, and this week it's also become humid. I didn't understand the importance of humidity before Monday, the first day when I thought "Take me back to the UK right now!" - it was that bad. I walked the 3 minutes back from eating dinner at 9pm at night and was sweating all over. Thankfully it's become less since then. I've been told "It'll get worse in June" - I'm pleased that in June I'll be mainly in the Himalayas or in the UK!

42.6 C is a low point here...

I want to say a big thank you to everyone who has helped me with this trip. A year or so ago I emailed the TLM England and Wales office and without Alisia's reply and my crazy day trip from Bristol to Peterborough I wouldn't be here. Thank you.
Thanks to everyone here in Naini who has made me feel so welcome. I think that this has played a big part in my happiness here. I'm going to remember you all fondly.

Random mention - This is the first time that I've spent 8 weeks sleeping in the same bed for about 5 years! I hope I don't have to wait another 5 years for that luxury, or have to travel as far to get it.

Next stop(s): Delhi -> Agra -> Jaipur -> Shimla -> Delhi -> U.K.

Thanks for reading: This blog's had 562 page views at time of typing.
Becky :)

(I may put up some photos of our travels if you're lucky and we have internet access!)

Leprosy:- 10 Things That You Probably Didn't Know

So unless you work for TLM, you probably don't know an awful lot about leprosy. Neither did I. After 7 weeks here I am finally going to educate you!

1. Leprosy still exists. 
You probably do know this, but I'd like to re-enforce the point. The World Health Organisation stated a few years ago that leprosy had been eliminated from India. So how is it that every day this hospital diagnoses several new patients? "Eliminated" is a term used when the prevalence of disease in a population is less than 1 in 10,000. This may well be the case over the whole of India but within the region of Uttar Pradesh it is not.

2. Leprosy is curable. 
Dapsone was introduced in the 1950s which helped to control the disease to some extend, but it wasn't until the 1980s that multi-drug therapy (MDT) was introduced. It combined dapsone with other drugs such as rifampcin and clofazimine. It's taken for a minimum of 6 months, depending on the type of disease and after completion of the course the person is cured.

3. It is not very contagious. 
It's classed as a communicable disease but the chances of me or any other member of staff catching leprosy is extremely rare. It's transmitted by droplets in the air but a strong immune system can fight it off fairly easily, and over 90% of the population are naturally immune. This means that the majority of people have had prolonged contact with a family or friend with the disease and they are usually from poor backgrounds. After taking just 1 month of MDT that person is no longer contagious.

Male Ulcer Ward 1 of 2

4. Some people see it as a curse.
Stemming back thousands of years societies have shunned people with leprosy. Here I have met a man who decided that his disease must be a punishment of some kind from God. He left his family and has spent the past 15 years of his life in a monastery serving penance, as he feels that he must have wronged God. I have also met a man who was left here by his children. They told him that they would collect him in 2 days, yet they didn't return. Lastly I met a girl younger than myself who will never be able to marry anyone in her village because they believe that she is cursed. "If she marries at all, her husband will likely be a cripple."

5 It affects the nerves. 
Before my arrival here I thought that leprosy was purely a skin disease. It isn't. It causes nerve thickening and can have effects on the motor, sensory or autonomic functions. This causes loss of sensation over the hands and feet, loss of sweating leading to dry skin, and deformities.

6. It can cause permanent deformities. 
Following on from the above, the disease can cause 'absorption' of fingers and toes. These can't be grown back again. It can also lead to a clawed hand, making daily functions very difficult. It can cause a foot drop. These can be treated with reconstructive surgery, requiring persistent physio care.

Loss of toes: a patient in the female ulcer ward

7. It can result in horrific ulcers.
Due to a sensory loss on the feet, people with leprosy don't notice that stone inside their sandal, or that nail that they stood on when walking barefoot. The skin becomes damaged but they don't realise it - how often do YOU look closely at the bottom of your feet? This worsens and develops into an ulcer. I don't mean a teeny little ulcer, I mean a big three-quarters-of-your-foot ulcer in some cases. Some of the worst ones have maggots crawling in them after flies have laid their eggs in them. Ew. Diabetic ulcers in the UK will be nothing compared to what I have seen here. Ulcers take a very long time to heal and are difficult to treat, requiring dressing changes twice a day by the dedicated nursing team. One ulcer patient has been here for over 390 days.

8. A patient can become acutely unwell due to one of two types of reactions. 
A reaction can occur before, during or after treatment and will involve a flare up of symptoms. They can cause nerve or nodule pain, and damage to the peripheral nerves as well as those related to the eye. Treatment needs to be prompt and aggressive often with immunosuppressant steroids and sometimes with thalidomide, in which case the patient will have to stay in the hospital for about 4 months.

9. There are 14 patients who live here full-time. 
They're called Snehalaya ('mercy home')patients, and most of them have lived here for the majority of their lives, moving in decades ago. Thrown out by their families because they had leprosy, they had nowhere to go and so the hospital took them in and looks after them to this day. What is just an outpatient department for most is a home to these 14 and without Snehalaya they would have been destined to a life of begging.

10. In India, you can divorce someone because they have leprosy. 
In the Special Marriage Act of 1954 (before the dawn of MDT) it is stated that if your wife is has leprosy, this is suitable grounds for divorce because the disease is "incurable". The law hasn't been changed. Similar laws mean that a patient with leprosy cannot board a train or hold a driving licence.

Point 11? It can affect any age. Teenage surgical patients.

Sugar and Spice

A bit about what I've been eating since Easter day, aside from my two a day rationed mini eggs.
Everything contains either sugar or spice.

Sonia and Manjula fashioning 'Panipuri' - crispy shells filled with spicey liquid that you put whole in your mouth

Breakfast:
Two days a week we get jam and proper real full-fat butter on toast. This was previously my favourite breakfast as it was well known but lately it's been overtaken by...
Puri and paratha. Chapatis with added oil, what could possibly go wrong? These breads are really delicious and are always served with an aloo masala - potato curry
Igli - A southern dish that apparently tastes better in the south. Either the cooks can't get it right here or I just don't like it. A day of cereal bars instead!

Puri or paratha? Depends on who you ask. Either way they're lovely.
Image taken from Google.

Lunch and dinner:
There is always chapati, rice and dhal (lentil curry) on offer. As well as these regulars there's always a vegetable dish of some kind. Special days:-
Two days a week we get a chicken curry.
Two days a week we get an egg curry.
One-two days a week we get a paneer curry. Paneer's a soft cheese that doesn't really taste of much, usually served with peas.
The remaining days are pure veg days.

"Mattar paneer" - tastes slightly better than it looks.
Image from Google.

On top of this there's morning coffee served with samosas or other savoury nibbles, and afternoon tea served with biscuits.

My journey with food in the training unit mess:-

Week 1-2: Novelty of curry still exists, can't possibly stomach eating spice for breakfast, being a bit picky about what veg I'm eating and don't like eggs.
Week 3-4: Getting really fed up of curry, craving anything else, buy myself bread, jam and cheese spread.
Week 5-6: I love the food. By now I'm eating the aloo masala at breakfast too; I look forward to every meal.
Week 7: I'm eating eggs.

My not-so healthy fridge! There are grapes at the back...
 Taken a few weeks ago, though I'm still working my way through the biscuits

As well as mess food I've been enjoying Western luxuries when out and about. I've had two trips to Dominos and a trip to Pizza Hut - my favourite restaurant back in the UK. I've also been to a coffee shop chain which serves cold coffee mixed with chocolate sauce and ice cream. Yum! I've eaten a lot of ice cream including the local 'kulfi' made with frozen milk, nuts and fruit.

Look! A Pizza Hut map!

Drinks? Water, cold water and frozen water! There's an on-campus shop that sells glass bottles of fizzy drinks for the equivalent of 16p. There are 3 different companies all fighting for the mango juice market and I've loved them all. Tea ("chai") and coffee are served in small cups with a LOT of sugar and milk. I still can't tell the difference between the two as I just taste it as a warm sugary milky yumminess. I tried to make myself a 'normal' cup of coffee but it didn't taste very nice. I'm a bit worried that this means that I've become converted to the way of chai and will need to take my coffee with 6 sugars when I return home.

The gang at Coffee Cafe Day.
Image thanks to Manjula's camera/randomer who took it

Needless to say, I'm not starving and in fact am probably gaining weight! So much for the expected Delhi-belly diet.

My one craving? Pasta.

Shout out to my sister Jenny who's flying tomorrow to watch Eurovision, have a safe trip :)
And to my parents who are going to be just a teeny bit worried with both children out of the country...

Trips to the Villages

Time for another work, ish, blog entry.

Once a week Pavan, the social worker and one of the paramedical workers at TLM Naini, takes a doctor into one of the surrounding villages to spread awareness about leprosy.

Villages are very different to cities in India. During my first week here I'd been shocked by a newspaper article (Times of India, of course) that stated that those living in slums were in a better position than those living in the villages. In the media we regularly see films and images of Indian slums and I think we can all agree that they look very dire. The article explained that at least in these slums there is a nearby hub of activity and many entrepreneurs can arise due to the massive possibilities of trade and business that can be found in cities. 

In the fields. Photo thanks to Pavan/Manjula

Villages, however, are far from the beaten track. On the first trip I joined Pavan and we had to walk for about a mile because there was no road for our vehicle. Village inhabitants earn a poor living by working on farms. A few of the men will make a weekly trip to the nearest market for food, but there's little in the way of hope for the children here. The government has in recent years given free education for all children so they do go to school, but even the most ambitious would find it difficult to escape their surroundings.

Spreading awareness. Photo thanks to James/Manjula

I was amazed by the generosity and hospitality of the people who lived in this first village (I imagine that they do have names but most people refer to them as 'the villages' no matter which village you mean...). On arrival we were given chairs and offered water, tea and biscuits. It's unwise to drink water from unknown locations but the custard cream style biscuits are harmless so I helped myself to a few! We were made to feel very welcome and comfortable. Soon we had an audience, mainly women as the men were working in the fields. Manjula and Pavan explained to them the signs and symptoms of leprosy and I observed, picking up a few of the Hindi words and contemplating how people managed in 40 degree heat without ceiling fans.

Our audience. Photo thanks to James/Manjula

Secondly, when the students from CMC Vellore visited we paid another trip to a larger village. Their task was to ask about ration cards and to measure the BMIs of the members of twenty families. Most of the students had never been to so remote a location and it is a wonder how these villages were started so far from the beaten track. 

Me and the CMC Vellore med students. Photo thanks to Pavan/Praneet

The government supposedly issue ration cards to each family though the survery found that 50% did not own one. In theory, they can use this to buy supplies of rice, sugar, oil and wheat. BUT, there currently is no ration shop in the area as the owner has been suspended because he sold products on the black market. It is right that he should be punished, but now each family has to suffer too as there is no food source. 

It was a long day out and we were all relieved to return to the friendly campus.

Home sweet home.
View from the mess, past the training unit on the right, to the wards.
 Photo courtesy of Praneet.

So I went to a wedding reception...!

This week has been extremely busy and contained a lot of fun, as 8 medical students from the Christian Medical College Vellore in Southern India were here for an annual mission hospital placement. Consequently there are many stories that I could tell from the past week here but I'm going to focus on a very unexpected event!

It was Monday and I was on morning tea break with the other junior doctors when I overhead my name being discussed. The next thing I knew, I was handed this:-

Envelope and inside card

Translation, anyone?

It was an invitation to the wedding reception of the son of one of the vehicle drivers of the hospital! Needless to say that in my thoughts of what I'd be getting up to on my elective I'd never considered this to be a possibility. I was very excited. First thoughts - What do I wear?!

The event was held on Thursday evening (you can make out the 02 and 2013 on the invite). Almost everyone who works in the hospital came along, which made me feel even more part of the family that is TLM Naini. I wondered what would have happened if a patient became very ill in those few hours but was reassured that there were a couple of nurses staying behind and Drs Premal and Loretta Das who are in charge were also still on campus. The patients were in safe hands!

Me with some of the staff

It was a Hindu marriage, and the wedding ceremony had already happened on Tuesday. On Wednesday there had been the bride's celebrations and so Thursday was the groom's celebrations. I think that having a party that goes on for several days is a great idea!

In true Indian style the event began an hour later than expected but we were served Nescafe and nibbles in the meantime. Then, the bride and groom walked down the aisle to sit upon their throne. I have to say that neither of them looked very happy. Maybe this is normal in arranged marriages, maybe after three days of entertaining they were really fed up, or maybe if I didn't know half of the guests at my own wedding reception I'd be miserable too.

A not-very-good photo of the couple (me not knowing the etiquette of photo taking)

Next, we all went up to the stage and shook hands with the bride and groom, offering congratulations and handing over gifts.

Next stop - food! And there was a LOT. But there were a LOT of guests! A few hundred hungry mouths to feed, and this was day 3. I enjoyed some spicey noodles as an alternative to my usual diet, but managed to fit in some traditional curry and rice too. Some guests had even begun eating before the bride and groom had arrived, ignoring them as they made their way down the aisle. Maybe these guests had already done days 1 and 2, or maybe they were college students crashing the events for free food - I was told that this happened. With so many people and the fact that apparently you don't have to know either member of the couple to be invited this would be fairly easy to do.

Below is a video that sums up the atmosphere before we left, which may or may not work... in case that it doesn't work I'll post a couple of photos too!

A couple of hours later we arrived home. The junior doctors and I, being girls, then spent half an hour in the dark trying to get a good group picture of ourselves looking all dressed up. 

Manjula, Sonia, Swati and Anila back at the campus.

Conclusion - a fantastic experience and an amazing feeling to be included in such an event.