Fires, fires and fires

Yesterday, many women…over 2 million in fact, celebrated the Attukal Pongala festival in Trivandrum, Kerala where I just spent just over 2 months.  I do not fully understand the story of the goddess who is being celebrated.  The largest impact is that huge numbers of women line the streets of Trivandrum, Kerala in a large radius around the Attukal temple. Each woman has set up a cooking fire with a terra cotta pot, with bricks supplied by the temple.

She has brought the raw ingredients for payasam– rice, jaggery (unrefined sugar in blocks), coconut, cardamom powder, cashews, raisins, ghee (and maybe bananas).  Each woman waits for the flame, which is delivered from the  from the temple.

Then the ingredients are added in step-wise fashion, and boiled until a certain consistency.  This is most notable because 2 million other women are doing it at the same time.  And for a week after this festival, Malayali men will offer visitors and work mates their mother’s payasam as the best in the district.


These fires and the sheer quantity of them, and the image of 2 million women bent over these cook fires prompts me to write about other fires that affect the health of Indians.  Women still cook with firewood in India, more in the rural areas than in urban areas.  More concerning is the disposal of household waste (including plastics) and brush from plants and trees with burning.  It would not be unusual to have a brush fire going around the hospital where patients already have difficulty breathing.  Walking the 3 blocks from yoga to the hospital, I notice all the street sanitation workers who are burning the leaves that they have collected in a small pile.

India has a rapidly increasing difficulty with smogRecent recommendations have suggested vitamin D supplementation for India’s population because people cannot get the 10 minutes of sunshine needed to make vitamin D in the skin.  What would happen if households or districts used composting–using either worms  or microbes to accelerate the decomposition of household and yard waste to fertilizer…without burning?  Could this be an employment  project with an district entrepreneur paid by neighbors to take the household non-plastic waste and yard waste and make fertilizer?

Burning as a method of waste disposal is a health issue.  Some day, the Attukal Pongala festival could also be a celebration of the triumph over smog and will be one of the few  times open air  fires are used.

There are people in Kerala who are champions for composting. I did not get a chance to visit with the Kerala compost champions on my recent trip.    Next time!

For now, I will just go back to Iowa and love my pet worms in my composter.

And now for your moment of Zen:


Barrier Free Trivandrum Mural, painted by Pallium patients and staff



By the skin of my teeth

Now in New York City, fighting jet lag….and missing a Nor’easter)

I almost missed the inauguration of the Oral Health Clinic at Pallium India. This clinic will fill an important need for rehabilitation patients, patients who are chronically ill, and the patients who are terminally ill with painful dental problems. Little did I know that I was selected to cut the ribbon!


Dr. Sreedevi in red sari, as we inaugurate the clinic.

The faculty and staff at the College of Dentistry, specifically Dr Dan Caplan and Marilyn Wessels-Evers were especially generous to gather surgical dental equipment and fluoride that they thought would be helpful. And Dr. Satish Khera donated 20 dozen pediatric toothbrushes and 20 dozen adult toothbrushes. TEAM IOWA-a group of 15 health science students- collaborated by packing all the instruments, the fluoride packets and the toothbrushes in their luggage for their 3 week course at Pallium India. Luckily we did not get stopped at customs. (We had a story all ready about compulsive Iowa toothbrushers.)

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Sr. Sandhya instructs young patients on the use of the donated toothbrushes.

We wish Dr. Sreedevi and Dr. Amirtha great success for the clinic! It will be great to have this resource for Pallium patients.


Dr. Sreedevi and Dr. Amirtha checking out the dental hygiene on a patient

Oral health is one area that is not covered well in the medical school curriculum. (I have felt grossly deficient in wound management as well). In my practice in an academic center in Iowa,  I frequently “outsource” medical care to other specialties.  I refer all wounds to the wound nurses, all oncology to oncologists, all oral health concerns to dentists, and rehab concerns to physiatrists.

Outsourcing medical care is not always an option in a low resource country. Referrals to specialists may be logistically or financially impossible in a system where patients pay cash for care, and live at a distance from specialty care.   While I am grateful for the new Oral Health Clinic, it reminds me how much I want to ramp up my knowledge base in wound care, mouth pathology and basic oncologic care.

Perhaps, in my return to a high resource country, I can simply ask the question: What would I do if I did not have a specialist to ask?
I am a general internist after all.

And now for the moment of beauty: (I thought I worked for a living until I saw these fisherman pull in the nets at Samudra Beach).


Getting from here to there in Trivandrum

One of the greatest day to day challenges of getting to the hospital to volunteer was transportation to and from the guest apartment. There was not really the option to walk, or bike for 8 kilometers. I tried auto rickshaws,IMG_5384 an easily maneuverable three wheeled vehicle—it is quick but usually requires price negotiation with the drivers. My apartment mate, Anne, was good to take me on the buses when she was in town or when we left the hospital at the same time. The bus is clearly my preference.

But how to determine which bus is mine when Anne is not with me? The buses are not numbered, and Malayalam bus placards did not have a recognizable word for me.


Malayalam, Hindi and English script

At first, I just got on the buses with a notebook –with my destination written in Malayalam. That did not work, as I usually got on the wrong bus. The conductor sucked his teeth (a universal communication tool) and had me get off at the next stop.

The next strategy worked like a charm. I should have known that “relationship” is the key. Anne had been very social at the bus stop.  I smiled at these bus friends at the bus stop and asked them, with my destination written down in Malayalam to make sure that I got on the right bus.  As long as I am out there by the 8:05 AM bus, I was in the chips.


Inbound bus friends: Dhanya, Punyia, Anne, and Revi

It worked well. One time, the conductor tapped my shoulder to have me get off at a hospital on the way, and there was a chorus from my bus friends seated distantly from me that he was mistaken about my stop. Then Revi looked for me every morning.

Getting home was more challenging but equally charming. Chaithanya Mohandas, (a web designer with Leonine Info Solution located right at West Fort) was very happy to help me get on the crowded 5:15 bus. Once, through mass motion only understood by a bus passenger, I got moved toward the front of the bus away from the door. When it was approaching time for me to get off, I started to move toward the door with my yoga mat catching on everyone’s clothes and purses. Amazingly I got off that bus, rumpled but intact. The next time I got the bus with Chaithanya, she parked me right where she could guard me against movement down the bus aisle.


Outbound bus stop friend, Chaithanya

Why do I prefer to take the bus? In part, it is the higher viewpoint, away from the exhaust. But more important, it is the connection with the every day, the unexpected, the hilarious. I am more apt to see the fruit stand, the cricket game, bananas sticking out of a rickshaw, regular people on their way to work looking fresh in saris…6 days a week. From that vantage point, I see whole families on motorcycles (not hilarious). And then there is the time that an elephant went by in a truck.

It is a little restrictive to ONLY know how to travel back and forth at a certain time. I decided to take yoga-which is only offered at 6:15 AM and 6:15 PM. I like the 6:15AM yoga-doing the sun salutation with 30 Keralites on a rooftop is a peaceful way to start the day. Along came Vijay-a rickshaw driver who was willing to come at early hours to get me to yoga on time or pick me up at night. No haggling—he had a set price for going the 8 kilometres—a price that was worth it to make it to yoga.


Vijay drives so smoothly that I can drink coffee

In international stays, it takes a while to make life work. Sometimes it starts working just before it is time to leave. Which means I will have to come back!

Thank you to my friends—Anne, Dhanya, Punyia, Chaitanya, Revi and Vijay. You made life work.

Oh, and happy leap day birthday to my childhood friend, Andy Tuthill, who has had 15 birthdays.



Yoga at Kovallum Beach (I am not there…yet)


Above the sound of the call to prayer in Murukkumpuzha, a group gathers and chats in the public library on the second floor. Wednesday is outpatient day and those who can climb the stairs come and visit with the Pallium team– nurse, doctor, social worker and volunteer. Here, they will get an assessment of their social situation, their symptoms and refills of their medications.


Sarath takes a social history


Dhanya, a geriatric trainee, looks up during a break

Many healthy appearing women are in clinic on this day. Their husbands or fathers have been injured through accidents either in India or in Gulf countries. Or the menfolk have had strokes and cannot make the trip to clinic. The women serve as “proxies”—reporting symptoms and getting some support for the hard work that they do at home, in addition to their wage earning jobs.IMG_5319

The volunteer, Francis Ernest, bustles about the library , answering his cell phone and talking to patients and families while they wait. About 8 years ago, he retired from his


Mr. Ernest

government job. In retirement, he saw a need for a community organization to meet the health needs of home-bound patients. He asked Dr. MR Rajagopal, the Chairman at Pallium India for some training for 20 interested community members. At Pallium India, the volunteers receive training to be the case managers and frequently the first contact for patients and potential patients in the community. They learn to do follow up for patients who are seen in clinic, receive referrals for Pallium India, and do initial visits after referrals.

Those 20 volunteers, under the leadership of Francis Ernest and Patricia Paul started the SNEHA Palliative Care Society for Murukkumpuzha. “Sneha” means love in Sanskit, very close to the word in Malayalam for love-“sneham”. Now, 8 years later, 4-5 of the original volunteers are still strongly involved.

There was another striking part of this morning’s clinic. A quiet and dignified man sat in his dhoti next to his daughter waiting for his turn to visit with the doctor. His diagnosis is motor neuron disease, which is amyotrophic lateral sclerosis. (I wondered how he possibly made it up the flight of stairs). He was having increasing problems with swallowing and has some regurgitation through his nose. He was losing weight and feeling short of breath. His fingers were developing contractures. He had pain. His daughter, a nurse, elaborated on his narrative. Everyone listening, including this patient with his erect posture, knew that his disease was progressing. Pallium India provided medications for his pain and shortness of breath and he and his daughter went down the flight of stairs…slowly.

My admiration may have ended right there for this patient, except that I peeked out of the second story window and saw him climbing on the back of his daughter’s scooter, his contracted fingers on her shoulders. They must have felt me looking, because they looked up. My hand went to my heart-and we smiled together. They seemed to enjoy my surprise. A week later, he is still in my heart.

And for your eye candy…


Black pepper roasting in the sun at the side of the road


Sindhu is a mother of one who fell into a well about 7 years ago and developed weakness in the lower extremities. She had tried using arm crutches but found it was not functional for the distances and given her need to have free hands to do her housework. Amazingly, due to the work of a volunteer physiatrist (rehab doctor) and his colleagues, her kitchen and bedroom has been adapted to her use.


Sindhu at her wood stove

Until recently, this was her wheelchair:


Due to the generosity of Vince Wolrab and Jason at JVA Mobility (this link will allow you to thank them), Sindhu received a narrow manual wheelchair with removable arm rests and foot rests, and a seat cushion that will certainly make a difference to prevent a pressure sore. (She has already healed one already). Here is the first transfer with an extra hoist to get over the back wheel:
Here is Sindhu saying thank you (pronounced na-KNEE) in Malayalam and in English:


Guess who tried NOT to cry when she blew me a kiss at the doorway.

And thank you to Sr. Aswathy for sitting in the way back of the van with the wheelchair and the suitcases full of supplies.


And here is your moment of Zen: