Community Medicine and other updates

Alright so lets start from Monday last week where I left off…

On Monday, we had a journal club about nephrotic syndrome. I presented the US guidelines for management while the registrars presented the Sri Lankan guidelines. It was different from American journal club meeting because we were told to mainly use review articles rather than critically analyzing one article. But it was an interesting discussion, and I learned a lot about nephrotic syndrome which I have not previously managed. 

On Tuesday and Wednesday, I participated in the community rotation. It is supposed to be more structured and longer than two days but that is when medical students are there too. Without medical students there is less formal learning involved. But it was still a great experience. I don’t think I have previously explained Sri Lanka’s health system so let me start there…

So Sri Lanka has free, universal health care. There are some recent private hospitals popping up but most everyone goes to the public hospitals and only the public hospitals have an emergency room and trauma area. Every testing, medication, and surgeries available at the public hospital are free. This includes things like MRIs, chemotherapy, and open heart surgery. And the smartest, most trained physicians are at these public hospitals. So despite how some of them look, it is the best care available in Sri Lanka and it is quite complete. What it lacks (for free but is available if willing to pay) are certain medications (for example ceftriaxone is not available for free but cefotaxime is), specialized lab testing (like gene testing), and certain surgeries (like bone marrow transplant). The doctors told me that if they or their children were sick then they would take them to take a public hospital, which I think speaks volumes, and is not something other countries like India can boast.  With this system they have an infant mortality rate equal to many developed countries. It also helps that >90% of the country is literate thanks to their free public school system that basically everyone goes to. Private schools are rare and many public schools are better than private. I also think that’s very impressive! 

Part of this system is a great rural health care structure. Areas in each state are divided into MOH areas that one doctor (the MOH) supervises. Within these MOH areas are multiple small clinics spread out throughout the community that different medical officers (called Demonstrators) visit each day for different clnics. For example, one day it is the antenatal and immunization clinic and another day it is a children’s clinic. This allows the locals nearly daily access to doctors without going too far. It also ensures that everyone is cared for and looked after on a regular basis. There are also smaller hospitals for about every 2-3 MOH areas. Parents can be transferred from these hospitals to one of the five or six larger tertiary care hospitals in the country if needed for free. 

Seeing how much the US has struggled in controlling health care costs, I am impressed with how the Sri Lankan system works. There is a deficiency in quality and often delays in testing, but they have the same eventual outcomes. The Sri Lankan government wants healthcare to become more privatized because they feel they are spending too much money on healthcare. I have had many discussions with the doctors here on the future of Sri Lankan healthcare. They feel excited about privatization, but I am wary of the discrepancy in care that will develop-- not just in the quality of hospitals but the doctors who work there. Right now the government doctors (which is most of them) must move to different hospitals every 4 years with doctors who are more senior having priority over where they end up. This is a way to ensure that there are doctors in rural areas. It is less than ideal for the doctors many of whom must move hours away from their family but great for the patients. It's an interesting, never ending discussion so let me go back to my community medicine rotation...

I went to a couple of the clinics, seeing primarily antenatal patients but also going into the immunization area where kids were getting necessary vaccines and having their weight and head circumference checked. It was interesting because they don’t have dopplers to listen to the fetus’s heart beat. Instead they use something called a pinard. I had a really hard time hearing anything with it and probably only heard fetal heart tones twice. Here is a picture of what they look like: http://en.wikipedia.org/wiki/Pinard_horn

One of the clinics was held at an orphanage created by an Austrian doctor. It was a very well developed and maintained orphanage. They gave me tour of the place. Most of the kids are actually there due to court sanctions to get away from abusive parents, which is super sad. But the children looked very happy and content there! Unfortunately I did not have my camera but this is the website for the orphanage: http://soschildrensvillages.lk/

On Friday, I presented a case at their Clinical Lecture Discussion. The CLD is their version of Morning Report that they have once a week. But it is much more intense because only the pediatric registrars participate. They are ones on the “hot seat” and ask all the questions and form a differential. I presented the case I presented at Chair’s Conference: the girl with Hemophagocytic Lymphohistiocytosis. It was a hard case, but they got pretty close!

This past weekend, I spent time doing some final souvenir shopping and attending a peace concert! It was held at a Japanese Buddhist temple and featured people from Europe, India, Japan, and of course Sri Lanka. The point of the concert was to promote peace and understanding through music. The Japanese Ambassador was there too! It was nicely executed in a beautiful area. Here are some pictures from the event:

 A sitar player from India

 The crowd in the area

 A view of the beautiful sunset we watched there

The pagoda light up at night!

Speaking of going tourist shopping, let me tell you about experiencing what I call the “Tourist Tax”. When traveling to a developing country, foreigners often pay more than locals for many different reasons, primarily being that the locals charge more knowing the foreigners will pay. I have been charged more for that reason but can often haggle it down to a reasonable rate  that is still more than the local rate. But I have not had people jack up the price so much as when I am traveling with Anna, our new Japanese friend! I actually met some rude Sri Lankans for the first time when trying to negotiate a bus fare! 

Relatedly, I may have mentioned that people are very curious about me being Indian and enjoy talking to me. But I don’t actually stand out too much usually unless I start talking, especially now that I have gotten darker. Most people here assume I am Sri Lankan! And I really enjoy not getting unnecessary attention. But walking around with Anna, people are constantly staring and commenting! I feel like I am experiencing a different part of Sri Lanka being around her. The Japanese government has put in a lot of money into the Sri Lanka infrastructure so they are very well respected here.

I wrote this blog post while going to pick up Dhaval from the airport on Wednesday but unfortunately am just getting around to posting it now. Pictures take so long to upload! I will provide details of the rest of the week in a different post!

This post had a lot of writing so let me end with pictures of different Sri Lankan fruit and food that I tried:

Hopper and Egg Hoppers. Super yummy and cheap. It is basically a South Indian Dosa made in a small skillet. So the edges are very crispy while the center is thicker and softer. The egg hopper just has an egg broken in the middle. It is super yummy especially with their different chutneys.

Wood apple. I really didn't like this. I thought it would be more like an apple but the name only describes the appearance. The taste is not so bad; it is very tangy. But the smell and appearance prevented me from being able to eat it.

 Our version of High Tea! We meant to go to the Fort to have high tea but kept forgetting/not getting time together. But we bought amazing tea in Hikkaduwa and some local cake and made our own high tea!. The little brown things in the back are another fruit that is also very tangy. Sorry I don't remember the name of it!

Yala!

So last weekend we went to Yala National Park (not this weekend because as usually I am behind!) as I had mentioned in my last post. We actually stayed outside the park in an area called Tissamaharama (Tissa for short). This is where one of the secretaries in the Duke research office lives (Ruvini). Well to be more correct this is where her family lives as she leaves in Galle with her husband and son. But anyways, I mention her because she really helped to make our trip special!

She was planning on going home this weekend and so we hitched a ride with her family in their very large van, which saved us the tiring 6 hour bus ride. She also helped us find a nice guesthouse which was basically across the street from her home so that she could feed us every single meal! It was so sweet and completely unexpected. Her family was very welcoming.

We went on a safari early Friday morning (5am!) and her brother woke up to go with us to make sure we would have a good trip. We did not see too many exciting animals but saw an elephant and many beautiful peacocks. I did not realize that elephants with tusks (called Tuskers here. Brilliant!) are only native to Africa. But there is a small pack (are they called packs?) of them here at Yala. Here are a few of the many pictures I took:

 Beautiful male peacock. We saw one put up his feathers and do the mating call, which normally they only do in the evenings! My picture did not turn out well of it but it was pretty!

 A baby crocodile. There are many of these here!

 The baby Tusker we saw! He was so cute eating some hay :o)

Deer and buffalo. The scenery really reminded me of my Africa safari.

After the safari we went to Kataragama, which is a famous religious site. But it is actually known more for the Hindu God it is named after rather than the Buddhist temple that is there. I think I mentioned in old posts that many of the Buddhists here also pray to Hindu Gods. This is a popular time in Kataragama because it is the time of their annual festival. Religious people often make 45 day on foot pilgrimages from northern Sri Lanka (where most of the Hindus are) to come to this festival. Because of the festival, we got lucky enough to see a Perahera. A Perahera is this processional of dances and music from different areas along with many elephants that honors the God of the temple. The Kandy Perahera is the most famous and is occurring right now but is unfortunately a bit above our price range to go to right now. Luckily we got to see this one and got really awesome seats for it thanks to our hosts! Here are a few pictures:

 The bright decorations at the temple

 Some fire dancers

 They start with the small elephants first...

 Some of the beautiful and different dancing

The finale with the large Tusker elephant carrying Kataragama's idol.

 Beautiful Bodhi Tree all light up

 The Sri Lankan national flower! I forget the name now though

The Buddhist temple in Kataragama

Ruvini's family actually owns a bakery so we go to eat some awesome bread and get a tour of the place! Very cool. Here are pictures of that and Ruvini's family:

 This actually home made yogurt, which Tissa is famous for. They eat it with this sweet and tangy sauce.

 The bread ovens!

 Dough ready to go in!

 Yummy dough that is baking!

 Us in front of Ruvini's house with her and her son. I am eating some yummy bread :o)

 Traveling the Sri Lankan way: in style!

Ruvini's family and us! The children are super cute! Ruvini's son is 15 months while his cousin is 9 months but they look near the same age! His cousin went to everyone, and so I had lots of fun holding him :o)

Our final day we went bird watching but the location did not seem too ideal to actual see birds. As Xiao said "there is more s*** here than birds"and literally it was true! haha. There are some awesome quote from this trip, and I will take a moment to digress and mention two of my favorite. I am not sure if you find them funny but they still bring tears to my eyes from laughing:

1. Xiao: as we (aka everyone but Xiao) are trying to split the check at a restaurant but keep getting the math wrong, Xiao says: "Next time let the Chinese guy do the math"
2. Sean: as we are freshening up to go to Ruvini's family's home for dinner, Sean comes to Gayani and me and asks "hey guys, should I wear pants to be more conservative?"
haha, this one still kills me. We reassured him that it was okay for him to show leg ;o)

There have been many changes in the people here at Leijay. I don't think I mentioned that Mirna left a couple of weeks back. We also briefly had 3 Duke undergraduate students who were returning to Leijay after teaching English in the mountains of Deniyaya. Gayani is not staying at Leijay. She is a Global Health Fellow (aka she is already a doctor and actually an adult infectious disease subspecialist) doing research here for a year. She is a native Sri Lankan, and it is awesome to have the perks of the getting the local rate when she is around! Though not as awesome as her company :o) Finally, now we have a Duke Global Health Masters student (like Mirna) here to do some research. Her name is Anna, and she is Japanese. I love all the diverse people I have met here! Global Health draws a like-minded crowd from around the world. I am learning so much about so many different cultures and histories while in Sri Lanka!

So I am ranting a bit. I will stop for now but will try to put more posts up as my days near an end in Sri Lanka. This has been a great way to chronicle my time here, and I want to put in everything before I forget! You guys are now updated from a week ago but more has happened since that I will share tomorrow!

Many updates

Okay so it has been over two weeks since I updated this blog. I don't know if you remember but in the beginning I said that I am not much of a blog writer :oP Though to be fair, the first 1.5 weeks of my blog hiatus was very uneventful; I was just working and becoming very irritated with my abysmal internet connection. The guest house I stay in has a quota of internet that can be used within the month so by the end of the month it always gets very slow. Apparently, though, last month was worse than most. I guess I shouldn't complain too much because it gave me time to get into the Fire and Ice series (aka Game of Thrones), which is really good!

But the last week has been quite eventful so I will update everyone on this last week.

This past weekend, I went to Mumbai, India. I am going to India at the end of my Sri Lanka trip, but I do not have enough time to go to Mumbai, and it was really important for me to see my family. I actually have not been to Mumbai in about 5-6 years so I was very excited to see how the city had changed. I only had essentially 48 hours to see as much family and as much Mumbai as I could, because I did not want to take off extra days of work. But the trip was immediately worthwhile because on my flight to Sri Lanka I met RANBIR KAPOOR.

For those of you who don't know him, you may google and ogle over him now. He is essentially the number one Indian actor in Bollywood and super super cute. I was so shocked to see him on the plane I was literally not thinking straight. My heart rate definitely jumped up 50 points. I obtained his autograph and later thought about getting a picture with him but became too shy. I know it's stupid because he was so super nice and would totally have obliged, but I became a silly school girl around him! Here is my stalker picture of him and his autograph where he said he LOVED ME! haha j/k

 LOVE

In more seriousness, my trip to India was wonderful otherwise as well. My aunt really showed me around to places I had been and places I had not been before, which was really nice. I was surprised to see how much cleaner the streets of Bombay looked because I really expected the opposite. I also got to enjoy some Indian food! Sri Lankan food is good but nothing beats Indian food in my opinion. I especially love chapatis, which are hard to find in this rice-centric country. Here a few pictures from my India trip (warning many of them are of delicious food so be wary if you are hungry!):

 Delicious Rajisthani Thali

 Gateway of India! Another thing I love about Bombay: I don't have to worry about what I am wearing!

Butha (phonetic spelling) aka roasted Indian corn = yummy!

My aunt and me along the Worli Shore

With my aunts and cousin at a little known but really nice beach in Bombay!

Part of the benefit of me going to India was to save time not having to renew my Sri Lankan VISA as I could just obtain a new one on arrival back to Sri Lanka, but India never makes anything easy. After arguing for 1.5 hours and begging people to let me use the internet on their phone, I finally boarded my flight to Colombo. Of note, there were no issues in Sri Lanka. India is great but has much room for improvement.

I got to Colombo early Monday morning to attend the National Pediatric Conference being held on Monday and Tuesday. It was a great experience! I definitely learned a lot, such as the similarities  (pharmaceutical vendors giving out freebies outside the conference) and differences (no one asked questions when a speaker was done talking! Just shocking!) between American and Sri Lankan conferences. I also noticed how much more research driven and evidenced based the US is by the paucity of poster presentations and somewhat lacking research presentations. It was a really great experience though! And I enjoy the luxury of getting an upgraded room at the hotel since I was a doctor at the conference. The room itself was not as impressive as being able to say that I have stayed in the Penthouse of a 5 star hotel! I also took some time to tour around Colombo so here are some pictures of all of that:

 The view from my room!

 A beautiful church

A cool Hindu temple

 A large, really nice Buddhist temple that I took many pictures of but could not quite capture it.

 An elephant getting a bath at the temple!

 The President's office by my hotel. I got in trouble for taking this picture because the president is inside!

A picture from the conference

Dinesha and me posing with the mascot for a cream for eczema. This is one of the many outfits I bought in India!

Ok now I am super tired so I am sorry if this was not proofread well. Tomorrow after work I am going to Yala! It's a three day weekend because of Eid so I am sure I will much more to tell you all about in a few days.

Poya Day!

Hey guys!  As promised I wanted to share pictures with you from Poya Day.

Poya Day is considered very auspicious by Buddhists. As I said before it is celebrated during the full moon. This is a day of prayers, beautiful lighting, and a day to refrain from drinking and eating meat. Each Poya Day has a different name and some are celebrated in grander ways than others. In Kandy (the cultural center of Sri Lanka) there is going to be many celebrations leading up to the Poya Day in August.

Currently, in Unawatuna (a city about 15 min car ride from me) there is a 7 day festival going on that started yesterday. I am not sure what the festival is for exactly but I know it culminates with a visit from the Sri Lankan President on Monday.

Anyways, here are some pictures and a video from the celebrations!

Leading up to the temple are multiple little shops selling anything from shoes to plastic buckets to decoration for the home to food. These are beautiful clay pots.

These are like wind chimes minus the chiming. I think they are suppose to bring peace.

There are many coffee places around Sri Lanka using the Starbucks logo and fooling me into thinking I may get a delicious mocha! They have various different names.

 My friends! You met Mirna in my other posts; her family is originally from Bosnia. Sean is in the middle: he is an undergraduate student at Hopkins who is thinking about going into Medicine. Xiao is on the left and he is a Global Health graduate student at Hopkins who is originally from China. We are a very diverse group!

 The first smaller temple we passed. They have Buddha on the right (not seen in this picture) and some Hindu Gods that they worship as well. See the video below.

The larger temple on the beach that we walked to. So pretty!

 Drummers lead people carrying rice and sweets to the big temple.

 We stopped for a delicious bite. This is vegetable kottu- vegetables and roti minced on the stove.

 The beautiful temple by the water with Buddha at the top on the right.

Large, simple Buddha statue at the top of the mountain

Finally to end here is a video of the praying a the smaller temple. I don't know if you can tell from the video but the priest (? I think he's a priest) is dancing to the drums while doing prayers. I've never seen that before. Very interesting!

But the video is not loading! Sorry! I tried for 2 hours, and I am sleepy. Will try again later.