Into the Deep End

For those of you who may be following, I apologize for the delay in writing. These last few days have been very busy to say the least.

I don't think that it is possible to become completely inured to the level of poverty here. India has made great strides in recent years, and, ostensibly, Mumbai is an already vibrant city now growing exponentially. Skyscrapers are being built everywhere you look. But, next to these skyscrapers are slums. Despite India's enormous economic development over the last few years, this hasn't changed. I'll have to describe these in detail in a later blog. Onto the burn mission for now:

Saturday was out screening day. We saw approximately 70 patients, which took up most of the day. Its hard to describe the morbidity of their contractures. The severity seen in India is so much more than I expected based on my experienced in Burn rotations in the US. The majority of the patients were women. Many of them had necks with necks fused to their shoulders. Wrists were fused to shoulders, ankles to thighs. I can't imagine how people get through their day. I wish I could post some pictures, because I don't think that words can do justice to their level of deformity.

Operations have just started. But, it's time to start another day, so I'll have to write more later...

Thanks for reading,

Indranil

An Enviable Problem

Our team has landed in Mumbai just fine. I never sleep well on planes. I have tried numerous times, but I've always failed. At this point, I've given up. But, I've started to look forward to flights. It's perhaps the only moments where my time is entirely protected. There's nothing to do but sit. And, at least, it gives me moments to think.

I flipped through old New Yorker's on the flight (they've been collecting dust on my desk for so long- guilt goaded me to bring them along). I read through the article: "Testing, Testing" in the December 2009 issue. It discusses the necessity of overhauling the current American health care system and critiques the current proposal on not substantially changing the nationwide healthcare structure so that it curbs costs and raises quality. It really cannot be argued that "the [proposed healthcare] bill doesn't even meet the basic goal that the American people had in mind and thought this debate was about: to lower costs". This quote was said by Senate Minority Leader Mitch McConnell, and noted in the "Testing, Testing" New Yorker article by author Dr. Gawande.

I won't deny that the U.S. healthcare system threatens this nation's financial solvency, nor do I argue that it is in major need of change to curbs costs. But at least there can be reasonable discussion over this. In contrast, India, as far as I understand it, has very little health care to even speak of. It would be a wonderful boon were India to be able to participate in the same discussions. India's health care system is instead much simpler; those who have money receive excellent care, and those who don't, don't.

Arivand Adiga's White Tiger was perhaps one of the novels that best described the struggles of India's abjectly poor class. In the novel, under the guise of government aid, hospitals would open to treat those who couldn't otherwise pay, but these were empty promises. Physicians didn't staff these buildings, as economically, it makes very little sense to treat India's truly poor. But these aren't just stories from novels. My cousins, who live in India still, have relayed many similar stories as well.

Even for my Aunt in India, medical care was hard to come by. She was middle class, but found medical care poor at best after being diagnoses with small cell lung cancer. Routinely, she would make a four hour trip on train to be treated, only to find that there was no chemotherapy still available. Without financial aid from others, even when treatment was available, it still would not have been available. My aunt passed away from complications of her cancer three years ago now. Although her passing from this aggressive malignancy was pre-ordained, there were many steps where the rudimentary medical structure in India failed her along the way. For what it must be like for the abject poor, I cannon even begin to imagine. I an only glimpse at it through aforementioned works of fiction. But I know that fiction is only an extension of actual medical problems.

So, while the U.S. focuses on cutting health care costs, I think that India would be so fortunate to have such a problem. So much is there to be done. Clean water, a trauma response system, and further outreach to the poor would just be a start. Regarding burns, simply the initiation of a central registry would dramatically improve the ability to identify at risk individuals and work on methods by which to educate these groups.

The flight's over, and it's time to get to work! As mentioned, there's much to do.

Patient screening starts today. Thank you very much for reading.

Indranil

Away We Go

On the brink of embarking on something that I've wanted to do for so long, I'm more apprehensive than anything else. There is so much to do.

My name is Indranil and I'm one of the Plastic Surgery residents at Brigham and Women's Hospital in Boston. One of the core reasons for which I entered into a Plastic Surgery residency was to be able to aid patients internationally. I knew before of Operation Smile and their history of significant international outreach- it's a non-profit company that treats cleft lip/palate around the world. But my interest has always been in burns, and India needs all the help that it can get. Thankfully, due to the tremendous generosity of both Operation Smile and Cents of Relief in sponsoring this Burn Surgery mission to Mumbai, I'll have a chance to do my part.

India is the only country in the world in which burns are classified as one of the top fifteen causes of death. This is a staggering finding considering many burn injuries and fatalities may go unreported when occurring in a rural setting and, thus, significantly underestimates the incidence of burn injuries. Therefore, burn care is of great concern now in India. This is especially true given underdeveloped trauma care, which magnifies the morbidity and mortality associated with burn injury. The lack of pre-hospital care, inadequate emergency transport systems, and low rates of Advanced Trauma Life Support (ATLS) training amongst surgeons are all contributing factors. In some states, such as Punjab and Haryana, burns are even reported to be within the top five most common causes of death.

Multiple factors account for India’s high rate of burn incidence and morbidity. Firstly, cooking, particularly in rural areas, is still performed over open-kerosene burners leading to an increased number of accidental burns, which overwhelmingly occur in the pediatric and the female population. Dowry deaths, which constitute women being burned for disputes over dowry, and bride burning, in which a wife is burned for suspected infidelity or other transgressions against the marriage, still account for a number of cases of burn-induced mortality. Although the Indian Government has taken legal steps towards outlawing these procedures, which can loosely be traced to cultural and religious origins, the number of these deaths may still be on the rise and the issue of exchange of dowries in marriage remains an issue remains to be effectively addressed. These aforementioned factors only add to both the number and extent of accidental and traumatic burn injuries.

This is the first time a major mission focusing on burns in India is being undertaken by Operation Smile. Being the first, it will be simple. The plans call for approximately fifty operations over the course of one week, screening of one-hundred patients, and an education day in which physicians of both India and America can share their ideas on ways by which to improve care. While there, research will be conducted on why patients don't immediately present following burn injury and ways to improve proposals for burn intervention. I'll be blogging everyday along the way.

I'm apprehensive, but excited. The first step really is the hardest. Thanks to everyone who has made this possible. Thanks most of all to my wife, who reminds me always what is most important.

Kolkata December 2009

Christy Garg of Cents of Relief just returned from her visit to our partners in Kolkata. Read more about Christy's visit below.

I just returned from Kolkata, which was amazing. Not only did I get to surprise the girls we have worked with in the past, but I also visited two nonprofits we plan to partner with.

First, the surprise visit. The girls of Apne Aap have been training in Indian classical dance, and put on a beautiful performance "Dancing with Shiva" in the auditorium across from the U.S. Consulate in Kolkata. It fused Indian classical dance with a traditional Spanish dance. The event received a lot of publicity, and had some high profile guests -- I saw a billboard in Kolkata advertising the event (didn't have my camera that day) and met the Japanese consulate at the dinner reception. I was lucky to be able to attend on short notice, and went backstage after the performance to meet the girls. As I walked through the long hallway to back stage, I was greeted with screams of "Christy Didi," followed by a swarm of hugs and questions. Soon after, the girls realized that they were still halfway in their costumes with full dance makeup and become quickly embarrassed. The girls are growing up so fast, and most seem to be doing very well. They are attending school, practicing English, and full of aspiration. It was a bit sad when I asked where a few of the children were, and they responded that they went away to a hostile and did not come back. While I hope that those children did not fall to the same fate of their mothers, deep down I had a bad feeling about it.

I also had the chance to visit a nonprofit we plan to partner with, called New Light. The center was located in Kali Ghat, a red-light area near the famous Kali Mandir (temple). New Light had a Christmas party for all the children they work with. After navigating through a busy red light area past men soliciting and women selling sex, and the many vendors along with way, a small gully led to a cheery mix of Christmas music coupled with random tunes of Britney Spears, beautiful strings of lights above the buildings, and children running everywhere with several Western volunteers. The children boldly walked up to me, offering an extended hand with a kind "hello madam, my name is..." I chatted with the director Urmi for some time, a vibrant woman who works tirelessly at the center and is passionate about making a difference. We discussed their needs, goals, and current programs. New Light has many facilities and programs, such as a health clinic, legal clinic, shelter homes, and computer training. It was fascinating to hear the legal issues that arise just trying to get women a voter identification card. With no birth record, and a life in a brothel, it is quite difficult to establish one's identity. We plan to work to provide plastic surgery to women who are victims of acid burns. Urmi explained that it is often times framed as a "cooking accident," although from the place of the burns (usually the face and neck) and the fact that no one who tried to help suffered from any similar burns, it is all too commonly a suicide attempt or an attack.

My final visit was to Destiny, a nonprofit formed by a dedicated women Smarita, whom we worked with previously on programs in Kolkata. At Destiny, the children who live in nearby shelter homes come to learn sustainable handicrafts, most commonly embroidery. Smarita is planning to next work on employment placement programs with red-light area young adults who are just finishing school and ready to enter the workplace. With about 8 sewing machines in a bright second floor space, the children at Destiny do not yet go to formal school , but escaped the red light areas to come here daily instead. I visited the center for a couple hours, and saw many of the handicrafts made, offered suggestions for what would be popular in America. We hope to partner with Destiny and offer some of their products for sale -- including greeting cards, yoga bags, blankets, and reusable shopping bags.

Photos and videos to come in the next post. Wishing everyone a Happy New Year!