India trip 2025

 This trip has been difficult at the onset due to personal problems and I carried some emotional burden traveling with some unresolved issues from home. Sometimes we have to compartmentalise life and to leave our negative thoughts and emotions behind and as my 10 yr old says be in the moment. The past if it keeps coloring your affective immediate response to what you see will not allow you to experience the full range of response to current stimuli and sometimes makes you feel hopeless and cynical. With that in mind I will try to jot down things as I see them. Creative thought may be at an ebb, but will try what I can.

A winter snowstorm delayed take off from IAD. 

I am getting older -that’s a fact but the physical effect of that manifests when you start noting that your body seems to show signs that you associate with aging folk. My hip, knee and back made it abundantly clear of this on a 13 some hour flight to Dubai which got delayed in Dubai due to the snow storm. I took an Uber the night earlier so I could make it to the airport. Stayed at the Courtyard in Herndon, but could not catch much sleep. Woke up unrefreshed and thought maybe I can catch some sleep on the flight . Despite the flight not being full and an empty middle seat it was hard to catch 40 winks. Ended up watching Eisenhower, a doc series on Vegas and Barbie. Felt 3 meals was a bit too much and was bloated gassy and polyuric with a throbbing subliminal migraine.

Dubai airport was kitschy glitzy and felt like a upmarket fish market with gold and expensive perfume and watches peddled in your face like fish and vegetables by expat blue collar Asian employees who try to bring their sales smarts to high end goods. Transit was an Indian bank like experience with people jostling to get ahead. 3 more hours in a middle seat to Mumbai.

The best airport in the world was crowded but no complaints. They had people asking passengers to verify baggage tags on baggage claim, which may be a need perhaps in a crowded airport like Mumbai . Travelling back to Pune by KK travels was revisiting the old journey so often taken in the past. Being so physically exhausted though I just felt the jostling of the incessant traffic and blaring cacophony of car/scooter horns overwhelmed and inhibited the visual sensory flow and were an interlude I wished would end soon.

Traffic plaza on way to Pune at 11 PM

We parked for a cuppa chai at the truck stop but I had no cash to get any coffee/tea or snack. The parade of trucks on the Ghat section of the highway held us up and navigating the maze of parallelly arrayed trucks made for display of some interesting driving skills by our driver and it seemed at times I was seeing a video game player wielding a joystick and not a steering wheel. Everybody is trying to get ahead but there is no blood shed or teeth gnashed if a faster car flashes its blinkers and cuts you in your lane. If it were an occasional event you would but these things are passe.

Chatted with a ISKCON devotee who was an engineer in California but left his job for what he called a divine calling and was spending time at a meditation retreat in Mayapur. As the conversation moved ahead I sensed his tendency to frame everything in a God/religion/spiritualism context and promoting surrender to the Lord. I had my differences of opinion but was not in the mood for a debate. I let Krishna be the supreme omniescient being in that second row of car seats for that time.

Pavers on sidewalk uprooted by growing
roots of trees

Pune is very changed. I corrected that- it is evolving and I have been static in my view of what my home town looks like or should look like. It is perhaps evolving at break neck speed where the head keeps surging ahead and the body falls back not being able to keep pace. The road traffic spills over into the side walks,the uneven pavers on the sidewalk stick out like Lego pieces, the signage for luxury condos and garbage on the street share an uncomfortable live in relationship,the dust swept by the street cleaner and the vapors of the oil from the street vendors cart where Batata vadas swirl to a golden brown and multitudinous chatter sound frequencies between people and their paramours and their cellphones and the waves of 5G and LTE all intermingle into an unholy weather cloud that floats some 4-12 ft from the dusty sidewalk and envelops the pedestrian. With all the 2 wheelers and cars packing the road like an oversized pregnancy and carts and parked vehicles taking up the sidewalk real estate the pedestrian is the forgotten inhabitant of the street ecosystem. I say this not as a firang, but even for someone who has lived in Pune for years, crossing the street is not safe, let alone difficult. I feel for the safety of my elderly parents who may not be able to swerve or move quickly to avoid a motorcycle sensei who may be practising their motoGP skills while rushing for a client meeting somewhere in the high rise offices nearby or a delivery deadline for a Swiggy meal. My partners in trying to cross a crazy Kalyani nagar road were daily labourers at the end of their shift. They waited patiently for an opening in the constant tandem boluses of vehicles , we shared a silent stare stuck in this journey to the other side. When there was an opening, a raised hand to indicate their existence, a quick dart to the middle and a lather rinse repeat ritual performed at the Center divider while vehicles whizzed in front of you and behind you while you remained stationary waiting for your turn , except you had to take it than be given one. For them it was probably a daily dose of social deprivation. The ads for luxury condos starting 2.6 cr and the many expensive food joints stood on one side of the road. On the other side a street dweller just emerged with an empty pail from the bushes through a crack in the wall which ran along the sidewalk having relieved themselves with probably no other sanitary place nearby. Not far down the road on the wall is a peeling poster with an image of the supreme leader who had championed the cause of “swacch Bharat” .

This is a wheel that turns and turns. For an outside observer like me, with intermittent exposures to this place, time and its effect on space play out a drama of progressive revelation and the plot lines are linear and galloping along like bullet trains or the hyperloop and what was a snapshot in your past in this time space continuum is irrelevant now and your points of reference are always irrelevant. This is a Lagrangian frame of reference and not a Eulerian one.

Dust is like the Lord in India. It is everywhere. It is in the oil, 5G/LTE, chat cloud that sits in the odoriferous zone of the pedestrian. It is on window sills and scooter seats; it coats the leaves of the Champa tree and forms brown lines on the dorsa of your feet where the straps of the Hawaii chappal make contact, the soles of your feet when you are chappalless inside the house. It even makes your snot a dark black gob of putty . When it rains this dust becomes the earthy odor of petrichor, when COVID ravaged the country this dust carried spores of Mucorales which led to the surge of black fungus cases at the peak of the pandemic. The mother of the house sweeps and sweeps trying to control the dust but is playing a losing game. Like the Krishna the dust always has a trick up its sleeve or a place to hide and keeps coming back. The mother never tires. The post viral cough keeps persisting, the allergies don’t go away. The dusty bus spews exhaust burnt of sulfurated diesel into the suspended dust. Inside on a dusty seat I sit thinking of how to make peace. Perhaps we have already done that. The default defence mechanism is the Indian way of Chalta hai which through resignation assigns primacy to fate over action/change and engenders a passivity or subsumption to what happens around you. We have assigned the name of the object to the verb for cleaning up the object. We are formed of dust and we end in the dust.

Dust into dust and under the dust to lie…….. sans everything.

Mailboxes at H5 Mantri Aangan.
They are barely used and many of these tenants have since moved out

I have previously raved about the liberation by data revolution in India. Data is king. Data is cheap.Data is bhagya vidhata. Data has meant your Uber rickshaw wala can use google maps to take you to your destination while you look up menus of restaurants there and accept payment with no cash or cards exchanging hands and catch up on the cricket match live streaming on wireless. The elderly parent can pay bills on their phone, order cleaning supplies and WhatsApp call their children who are travelling in another country in another time zone and not worry about roaming rates. They make point of care interventions easy to deploy, text message communications efficient for implementation science and give real meaning to the idea of World Wide Web. Data in India is cheaper and more accessible with great penetration of cellphones in most urban and semi urban areas. This enables data equals knowledge and knowledge equals power process enabling social mobility. If only people stopped making TikToks !

I have eaten murungaka sambar, tomato rasam, rice( non basmati), mixed veg kootu, methi bhaji and idlis for brekkie, lunch and dinner for the last 3 days. Nothing to rave about but the contentment from eating the food you grew up with is unrivalled. I have often had arguments with my wife about where the usual theme is ‘ whose cooking is better or whose xxx dish is better-your mother’s or mine’. Get a culinary expert and they will probably rate my wife’s dish better probably. However you crave the experience of eating the sambar rasam or kootu you grew up eating, where you could fling your satchel after you got home and dig into some , that satisfied the hunger you came home with; or the pav bhaji which was awaited with bated breath on a Sunday because it was your treat and quenching the anticipation was the dominant feeling, not satiation of hunger; the water masala /bharli vaangi of Sunday morning brunches because it reminds you of the roti eating competitions with your sibling. It’s really not the taste but the experiences and emotions tied to the food. I only wish my wife would agree. I spent a significant time during my early school days at my grandmother’s place and her cooking was staple during my very early formative years , and the experiences from my time at 42 rasta peth have elevated paati’s cooking in my mind to my most craved ever. Was it unhealthy? Hell yeah. But was it fingerlickin fabulous!

Food that pleases still is also the street food of the previous years. This is bhel at Interval bhel house or samosa at Laxmi sweet home, beetroot cutlet at Priya restaurant."Aade taste irukku innum", the parents say. I don't disagree. They couldn't have improved it.

Pune has its share of amrututulyas which dispense sugary cups of cutting chai.
 I would never drink such a sugary concoction otherwise

Bhel at Interval Bhel house with amma/appa

When you travel home years apart the aging of your parents seems more apparent- you see it as the waddling gait, the very apparent kyphus, and their slow to get up and go responses , the coarse dry skin, bony knobbiness around their knees. You also see it in inattention to their physical health or vanity. Somewhere the minutes spent on daily morning walks has dropped, the flab around the belly has unavoidably grown, toenails are thick and overgrown, somewhere while walking together you realize your father is 10 steps behind and you wait for him to catch up. They cook the same delicious tasting food, but the utensils bear grime- their arthritic osteoporotic arms cannot scrub hard enough or sweep enough or dust enough. And the dust settles in. Also settling in is fatigue. With a limited set of things to do or accomplish, time expands and hours are sometimes spent looking at the roof imagining patterns or life pass by outside the windows or inane TV shows or reels forwarded by similarly bored folks. Time becomes morning to evening. You try to reason about why watch the hopeless shows full of loud melodrama- what is the point of it? But then they ask, is it better than having no point at all? While it is easy to fall prey to an us them framing of this, what I realize, in my fifth decade of life is that we are all on this curve somewhere - we are aging, they are aging, we all are aging. We just need to slow down. Sometimes this slowing down means slowing yourself to let your arthritic father walk alongwith, or spending more time with them.

Snap on day of departure

On the many early morning walks or bike rides my companions on sparsely peopled streets were street dogs. I had perhaps forgotten how ever present they are on streets in India. Or perhaps Pune has really had an increase in their numbers. I remember them as a menace when they would chase me as I used to bike down from Max Mueller Bhavan after late night German class along what used to be a very deserted North Main road/KP with only a graveyard and ABC farms along that stretch of road then. This was 30 some years ago. The roads now are littered with tall glass faced buildings with corporate offices, hotels, fancily named eateries, tea shops, pharmacies, 2 wheelers leaning on each other for every inch of roadside space. And dogs find their space on the sidewalks. When the shops are shuttered and the bikes and bikeriders have gone, they gather together lazing around. A mother will herd her litter. When you invade their zone, perhaps a pack will follow you. Perhaps if you get excited chase you. It reminds you of the travails of trying to figure out how to avoid the pack around the graveyard near NM road years back. But they seem more mellowed to this coexistence now. Or perhaps you don’t fear them as much now. Knowing how social these animals are you want to stare back at their inquiring eyes to say yes I can speak or give you a treat, but then you also don’t want that extra baggage. Having seen how scary rabies can be and having had a scary exposure to a patient with rabies and facing prospect of a fatal illness there is a healthy measure of hesitation. These dogs aren’t rabid and seem to want to be friends, but it seems to be one of those want to can’t do things. A litter of pups play along a sidewalk on magarpatta city. I try to snap a photo, but the mother comes at me aggressively trying to check what I am doing . I walk away making peace.

One of the evenings, I visited friends at DMH hospital. Some of them were able to find time to chat with me while grabbing a snack in the hospital canteen. We also met for dinner at a roof top restaurant later that week. These discussions eventually funnel into how things were in college, which batch who was in , weird habits of teachers, funny things that batch mates did, who had a fling on whom and where we are now, whose kids are doing how, how busy life is, new acquisitions etc. These are the brief stop growing moments. During that time everyone shared a joke and a laugh, was silly a bit and then went on about their lives.

The next day I met old friends for dinner
at a roof top restaurant in Erandawane

Traveled to Mumbai and visited Dhiraj at HN hospital
on Monday

I finally managed to submit my application for my Aadhar card - I had to travel to Nigdi because there were limited locations which accepted new applications. I took an early morning metro and thought I would be early and be done in an hour or so. However when I get there I realize there are people who have lined up since 7 AM to be the early bird. It seems there were only 10 new aadhar cards applications accepted per day. I was number 10 in that line. I thanked myself for making it just a few minutes early, taking the earlier train, choosing a rickshaw and not walking. While waiting interminably in line, I helped a couple who were of low literacy fill out their application forms. I was killing time awaiting my turn, but felt I did my bit of service. Job done.

The first weekend I managed to take the PMT bus from Shaniwarwada to Sinhagad. Was a good trek, but the place has become something of an outing for people on the weekend and I did not realize how crowded it would be. My mother freaked out because she could not reach me atop the hill due to poor network connectivity. I touched 24K steps that day which was my all time high.

Visuals of the metro from Shaniwarwada at dawn 

Had all sorts of company atop the hill

On the weekend we visited Bhajana madam. This was a regular on the weekly schedule growing up- either with tatha when the evenings were spent at 42 Rasta peth or early Maargazhai mornings after the bhajanai rounds singing and chanting touching base at temples around the Rasta peth area when I would be tasked with waving the ceremonial fan during Aarti and would get first dibs at piping hot ven pongal as prasad, or later in my life when ridden with angst and cynicism I would accompany my mother to Bhajana madam on Sat evenings trying to find meaning in faith while she performed archana in our names. This is a custom she carries out to date. I find peace in this small old temple that has been patched and refurbished many times over. ‘Madrasis’ who have stayed on in rasta peth make it their evening pit stop still. The locals may come for prasad or because of proximity. The kurukkal remembers me because my mother has had him perform archana in my name for so many years.

Visited St Vincent's on an early morning before school hours 

The small narrow lanes that lead to the temple were part of my evening loitering as and felt so big then. These streets where I have cycled aimlessly, eaten street food in, found corners to hide, and scavenged for matchbox labels and ice cream cup lids for tokens, got separated from family in during Shiralsheth and palkhi, fallen over and scraped a knee or elbow. Now shoe shops abound and old wadas have been replaced by concrete apartment buildings. I met Dileep and Kumar’s fathers at Bhajana madam. They are survivors while others from their generation and age have passed away. Perhaps their faith keeps them going. They looked shadows of their original selves, scrawny limbed with atrophied muscles. Their cataractous eyes search for sensory stimuli. People they don’t recognize or cannot make out entire faces of they assign names to what seem like Rorschach blots. And when a connection is made the joy emotion is undiminished and the mirthful smile, the drawing hug is unwavering. The temple is their workplace replacement. It gives them the social connection that becomes their purpose at this age.

The answer to the ultimate question of life, the universe and everything is 42. DA was probably high on pot when he wrote this, but I am going to be a bit bold here and frame my time at 42 RP in this context. The age 5-18 defines or frames perspectives or responses to stimuli, shapes ideas, aspirations. You evolve into being an external beings from the internal confines of the mother’s embrace and father’s bracing arm. How i respond to life’s questions is influenced by how i learnt to respond when we were first faced with being in that position. We define events in life based on firsts. Many of the firsts occurred during this time. The typhoid I had affected my metabolism for ever. The scar I have on my brow I carry for life. The trauma I faced from bullies to non Marathi speaking people lingers. The most effective teachers I have had has been Mrs Ramaswamy who taught us history and English during 7th and 8th grade and my grandfather who was somewhat of a role model for me for a long period during these formative years.

My grandparents were very closely involved in nurturing us during a phase when my working parents would not have time to watch us due to work commitments and daycare was not existent. These ontogenic experiences are recapitulated again and again and form the human experience. Hence.. proven.

The later part of the week I found my joy in biking. I was initially sceptical given the traffic and bad rides but the early morning predawn time period turned out to be perfect for pedaling through the streets of Pune. You cover more distance and see more sights than when you walk and even though the potholes and uneven surfacing make riding hell, with the lack of the smell of diesel exhaust and anyone jostling for space, I often ended rides feeling rejuvenated .

Time was fleeting. I could not accomplish many things I had marked as to dos for this trip. I don’t feel stressed about it though. I tried to make this trip about quality time with my parents. We often claim our memories for ourselves.We keep a bit of what events happen around us in our own personal reference framework of things for easy retrieval. Others have their own. They may not be the same.

326 Rastapeth today and our home on the 2nd floor and ghasargundi

Life as we remember is not a linear series of events but multiple snapshots. Events that define or linger in memory or are available for easy retrieval. Other events they pass. As we remember or narrate our history, the countless moments that are non descript or spent listlessly will not occur. My parents introduced me to a neighbor who many years ago had asked a favor and I had spent a few distracted moments helping him out. This was not etched in my memory for even forced recall. He remembered it vividly and so did my parents. Moments of joy, sadness, misery, great love, separation, grief linger. Images of events linger. I remember my grandmother’s passing as her lying on the ground dressed in my cousin’s dress because there were no other clothes readily available. I remember 326 Rasta peth as many images of us playing cricket on the terrace, biking on the linear connected balcony, sliding down the brick red bannisters, ducking to escape a kamikaze pigeon while entering the toilets, watching Wimbledon or a Sunday movie in the ‘2nd room’ , playing underarm cricket and table tennis on the small blue table with Ramu in the ‘1st room’ , the big pile of gray gravel next to the Sivan kovil and the joys of running up and down the mound, the red mud of the taalim with the big thick rope swing that swung from wall to wall and the fear I felt approaching the premises where the almost naked wrestlers dressed in langots idled on the benches twirling moustache and clubs admiring themselves; watching life go by from the balcony in the evenings, however silly it sounds in retrospect now- the cows gathered in a circle ruminating, the sardarji with his ice cream cart offering Rs 2 pista ice cream cones, dandia during navaratri, your cousins making their way over from grandparents place 2 blocks away, early morning Bhajana mandali singing and chanting and playing jalra and peti making rounds from temple to temple, the Panse having his tea, looking at you and looking away, on his balcony in Panse wada, your friend Parag whistling out to you to ask if you want to join him for some completely pointless activity. ….So many more memories. So many more images.

What images and memories my parents have of what our childhood was? I wish I could tap in. My dad calls them happy days and wishes we could go back to then. The fact is we won’t , but I need to give back some of togetherness we all felt growing up. These visits are just an attempt to

THE VITAL RESET

 
As the Tsunami of COVID cases in the Indian subcontinent shows signs of finally receding, what used to be a painful routine for many US residents of Indian origin like me, has thankfully become less common. We aren’t spending long hours every night checking on loved ones on WhatsApp, or calling family members in India, scrambling to coordinate oxygen procurement, medication or hospital beds for extended families, friends or acquaintances. I would worry about my parents, who live in India and are in their 70s, fearing that one of these nights, maybe I might receive a call that I dread. I had difficulty reconciling with the fact that survival and outcomes post hospitalization are based on the assumption that access to medical care was not an uncertainty, as it had become for many people in India. We still go over extreme rituals of non-pharmaceutical interventions, including likening using a mask like an undergarment- taking it off only in privacy of seclusion. We try to estimate exposure based on who was around who else, for how long, how close, hoping details are not lost in translation. I sigh sometimes, aware that the virus is unforgiving, and I may be clutching at straws. I would feel helpless in my inability to influence things, insulated myself in a cocoon, vaccinated, surrounded by things resuming to normalcy. My 80 year old father himself, received his vaccine 3 months after I did, due to shortages in India.

I am aware that the privilege of knowing physician colleagues would have assured reasonably good care for my parents in another time. The severe shortage of acute medical care on ground made me feel more deeply aware of what a disadvantage the common folk of meagre means in India face. The reason this pandemic has become such a pestilence is because it has exposed deeply pervasive inadequacies and inequities of healthcare system in India.

The moral test for a government is how the country treats its most vulnerable. The underprivileged in India seek healthcare primarily through government run hospitals, and cannot access care in more expensive private hospitals. These facilities are chronically underfunded, plagued by poor staffing and lack of supplies and infrastructure. Yet the smartest medical students and residents train at these institutions. The National Health protection scheme seems to be focused on supporting care in private medical facilities. In India, access to care in private sector does not necessarily result in better care for a large majority of rural and urban Indian people .

India spends a mere 1% of its GDP on healthcare expenditure. The domestic government health expenditure per capita is $74 in India at PPP, and India has 0.53 beds per 1000 people. Reports at different times estimate that there are around 80,000–100,000 ICU beds and approximately half that number of ventilators in the country. With the current number of COVID infections, a simple back of the envelope calculation shows that even if a fraction of those infections ends up needing intensive care, the country is in no position to provide the level of care they need. The healthcare system was clearly duct taped and arthritic even before the pandemic. The pandemic has just pulled the plug on whatever threads were holding this creaky system together. The truth has been staring at us, but we had chosen to look away. I looked away when as an ICU registrar I was tasked with triaging ventilators in a large municipal hospital in Mumbai during a post monsoon leptospirosis epidemic. I felt thoroughly exposed as inadequate in making such vital go/no-go decisions, and the experience left me hollowed out at an emotional level. I looked away when I was unable to resuscitate a stuporous young male with cerebral malaria who coded waiting outside the CT scanner because the bulb on the only laryngoscope for a medical ward with 50+ patients did not work, while people hurried along the crowded hospital corridor during evening visiting hour. We all looked away when we were given the task of treating an unending line of patients who came in during the monsoon admission surge, willfully accepting to lay on floor beds, with family members holding an IV set when poles ran out and even bagging their intubated family member when ventilators were unavailable. How did I, and other people, allow ourselves to be desensitized to such a travesty, when we were exposed to this all along?

Resident doctors who provide most of the clinical care at government run medical college hospitals. They are often re overworked, underpaid and face enormous stressors including inhumane working hours, and patient caseloads. What I chose to accept during this period when I was a resident was that submissiveness to adverse circumstances helps disconnect from the stress of the immediate situation. Over time this becomes an ingrained habit- if we cannot change things, we become used to it.

The dramatic scenes of patients dying due to lack of oxygen remind us that there is an Infection Fatality Rate with oxygen and one without oxygen for COVID. What we have witnessed in this period of oxygen shortage is a grotesque natural course of illness revelation with system too paralyzed or dysfunctional to be able to grapple with what it was dealt with. The visuals of helpless family members and medical staff trying to do what they can, remind me however that we have been there, in smaller measures in the past.

Pandemics hold up a mirror to human beings to show who we really are. They are inflection points to reset our trajectories. Inaction at this time is accession. While the pandemic surge numbers show signs of initial decline, this is not a time to introspect deeply, and to organize and plan for the future. As physicians we need to use our position to voice our concerns, to advocate for our patients and to pressure governments to invest more into healthcare, including critical access to the most vulnerable.

Peregrination Diwali 2019

Random Observations for posterity: India trip 10/22-11/4/2019

This was an India trip after 8 years. In some ways it was an eye re-opener for me. I had quaint ideas of how things might be despite the build up of expectations before the trip, and did not realize my ideas and expectations were quite amiss. Quite often we get stuck in a snapshot of what things should be like and do not realize that times and rituals change, and our frame of reference has not. However, I found this trip quite refreshing and instead of getting stuck on lingering on the memory of the moment, due to the constant sensory overload, I made an attempt to experience the moment and move on. This was also because I had limited time and my attention was divided between family in India and checking back on family in the US. This is a a set of random observations that I have tried to document in no specific order or pattern, taking things as they come.

One very striking thing that hit me the very moment I stepped out of the airport was the sense of needing to define our space and time you occupied that space as a vehicle driver or pedestrian on the road. It was that few inches of space and for those few moments that belonged to you. You had to move to let another person occupy it or else you would be colliding into each other. It was as if I was the culprit if I did not move in this Brownian movement of orderly chaos. There was no anger at being pushed out or being honked at. It was an understood transaction with implicit rules, that there were no rules! And for this reason, somehow, strangely, everything seemed very small. This is hard to explain- it is as if the streets were smaller- the landmarks you grew up with looked petite sized and stunted. Because their being big was defined by the moment being longer. With so many people on the road, the moment was smaller, shared.

Driving in India was something I looked forward to, but riding on the a rickshaw, I began to feel a sinking pessimism about the prospect. My days in Mumbai I had relished at being able to get on my bike and get to Regal Cinema for a late-night show or BTC for a sinful lunch or the Worli Seaface or Bandra for a breather at the spur of the moment. However, there are so many more cars and 2 wheelers, and so much lesser space on the road, with the Indian penchant for the elastic waisting of the underbelly, the disregard for traffic rules and order in street is not unexpected. Driving on 2 lanes is not frowned upon. It is a way to claim your space.

Uber, especially Uber rickshaw became my go to way of getting around. In some ways it is such a democratic equalizer. I fell in love with the ease of being able to summon a rickshaw without having to deal with a dismissive “nai” for your pleas of “rickshaw aata hai kya?”. It is also less displeasing to allow the driver from ‘8 drivers nearby’ to refuse your ride through the app without you seeing it as a dismissive brush-off.  There is no haggling over fare, demand for return fare, or meter “nahi chalu”,” kab chalu kiya”. The security feature is an important addition and most welcome.

I was also impressed at how good google maps was at locating the best route to your destination despite landmarks being random/non-orderly like the Maruti mandir on your street corner or near the chakki mill en route to the talao.

Getting through a day of work with many distracting demands of your attention can often make you frustrated, unfocused. I would imagine the job of a bank teller clerk would be an example of such a job profile. Many people of diverse backgrounds, profiles and interests making demands, asking questions, trying to eke a shekel extra here or there. On a humid hot day we were witness to a bank officer at the SBI branch at Thane be the epitome of imperturbation. She was quite being harassed at around closing time on a Saturday afternoon at the bank. The air conditioning was off, the room was hot and sweaty. A novice businessman kept demanding that she process a transaction which seemed poorly defined, or detailed. Another rotund pan chewing hombre wanted his transfer of money done before Diwali. I wanted an internet banking password reset. An elderly gent needed his withdrawal approved. This lady seemed able to attend to everyone, without losing her patience, in a Buddha like calm. It was as if the travails of demonetization had given them the inner peace of being able to dissociate the affective response from the work to be done. Within those few moments I learnt a lot about how one can decide how much the environment around them affect them negatively by making a conscious choice about how to react. Eventually we will get from point A in time to point B. It is all about what state we are in when we arrive at point B.

Sample of a menu from a vegetarian restaurant in Thane

If it’s India trip you have to talk about food. Of course it was Diwali, but still, I kid you not, in a street in Thane, which is less than 500 yds long, there are 11 pastry/sweet shops. Sugar has sweetened the tongue, fattened the underbelly, raised the A1c, and expectations, enhanced the creativity and the appetite of the Indian middle class. I would like to propose that like hoarding gold, pigging on sugar can be called a defining characteristic of the Indian middle class.

Meeting with friends at a barbeque style restaurant in Pune

I had thought that I would run amok on treating myself to Indian culinary treats this visit, but strangely found my appetite for Indian food lacking and in need of some juice. Maybe it was the concern of calories or maybe my gastrointestinal tract has become more blasé and unadventurous with age and lack of stimulation. All said and done, I tasted everything I wanted to, but thankfully did not pillage on the offerings.

Before Lonavla

I had quaint memories of riding on the expressway from Mumbai to Pune on the Shivneri buses from my days in Mumbai. I thought that with the October rains, the wholesome weather, my ride through the ghats would be memorable. I think I let my expectations rise too high. 

The romance of the ghats was lost on me. It was like an orgasm that did not come. There were signs galore- ‘India’s biggest amazement park’, ‘ baghtoys kaay raagana, linen ghatlay vaghana’. Big FM was playing on the car radio- “Jaadu hai nasha hai”. 

After Lonavla

The clouds covered the mountain tops, the weather was misty, the mood languid and peaceful. But the magic wasn’t there. I cannot explain it- maybe it is the same idea- we get caught up in a frame of reference but the frame itself moves.

               

The road to Pune is littered with banners like this

Ghats

70 Mercedes cars booked on Dhanteras!. So the papers screamed. There were Porsches, Range Rovers and Ford SUVs on the Pune roads. However, there is no space for all these cars. The traffic exchanges are torturous, especially in evenings when the vehicle traffic is heavy. There is a heavy diesel odor which dries up your throat and makes you want to rinse and gavage when you get home. People wearing surgical masks while driving solo on their 2 wheelers is ironic! I will still drive and contribute to the pollution, even if I have to wear a mask for it. It is like a fat man not cutting down on intake and taking an obesity pill for weight loss.

Despite the pollution, the concept of an evening stroll is something which I cherish and thoroughly miss in the United States At 9 PM I can get out of the house and find people getting some tea at a local amrutatulya shop, shopping at a grocery store or pharmacy or visiting the local Ganesh temple, or just taking a stroll. Life shuts down on the streets in the US after 8 PM, at least in the residential neighborhoods. The streets in India are buzzing till late. The day begins late – 9 AM is when people saunter into their offices, the senior staff afforded the luxury of arriving even later- and ends late. I can put on my Hawaii chappals and go gallivanting around at 9 PM and have a lot of post Sylvian stimulation. This is something I sorely miss and will miss.

The biggest revolution IMO in India is of mobile telephony and the deluge of mobile data. I get a puny 4.5GB per month and a Jio customer in India pays a tenth of what I pay and gets 10 times more data. It was mind blowing to be able to do video calls on the go, not being tethered to a Wi Fi zone. Or to use Google maps to get around, Whatsapp to call/text/communicate. Data lines have walked over voice telephony with heavy boots. You can call anyone anywhere anyhow. You can be a vadari hanging on to a Local train door bar, watching Bhojpuri hits on YouTube or keep your kids occupied on the backseat while you drive with Netflix streaming on data. The whole concept of limits has been blown to smithereens. It was unlike anything I expected. The opportunities out of this data revolution are so infinite, that it is benumbing.

Diwali killa

Sinhagad on the way up

Sinhagad on top

All this packaged within 2 weeks was all I could ask for. I was happy-sad to be back with family, but we live life based on the choices we make. Being an immigrant is a hard one and every immigrant can relate to this. There is a cognitive dissonance about where home is. People say the longer you stay away from where you grew up, this ego-dystonicity dilutes into a hybridoma you yourself evolve into. You cling to cultural things, glitzy Diwali/garba functions locally, dressed in gaudy ethnic wear, cooking imitations of your mother or grandmother’s best confections, that help you remind of what you grew up with. The childhood friends age into their own routines of domestication , your parents age into fading resemblences of what you remember them as- diffident, with physical frailties, hoarding like they themselves want to cling to memories of when you were with them, with opinions which seem strangely extraneous to your priorities and values, though they helped shape some of yours. There is a languorousness to the cold snowy Saturday afternoons which were foreign to you but you have allowed to become part of our life, just as you have allowed things you grew up with you drift away from your time and space. That’s why such trips are refreshing, and you need to cling to them like a warm hug and enjoy it while it lasts.

INFECTIOUS DISEASES AND MORTALITY

Infectious Diseases mortality trends

Crude Mortality Rates (per 100 000 Population) in the United States Over TimeThe x-axis and y-axis scale is different for each panel. In panel D, vaccine-preventable diseases for which vaccines are routinely provided in the United States include measles, mumps, rubella, varicella, diphtheria, tetanus, pertussis, polio, Streptococcus pneumoniae infection, hepatitis A, hepatitis B, and meningococcal infection.

' Action without reflection is mere experimentation'. This timeline encompasses the time when we entered medical school- 1996.  HIV mortality was at its peak and witnessing this peak period of so called medical helplessness had influenced me profoundly with respect to what I wanted to specialize in eventually. Much has come to pass since, and now we learn about an ab and an ib every week in the ever increasing advert pages of once venerated journals. HCV is the NKOTB but for those who have seen the pestilence of AIDS and associated OIs, Kochs included, the munificence of payors for Harvonizepatierepclusa seems too generous, considering that companies make a 1000% profit on these. The lumping of all infections is an oversimplified agnosia and does little justice to individual conditions, just like 'cancer' is not one condition and terms like cancer moonshot and 'beat 'cancer' a la CTCA seem as spurious as they are naive. However snapshots like these give opportunity to reflect - they are like a K Park's PSM perspective to a reading of  Harrisons. One without the other is going to leave you either a myopic or an out of context Frequentist

Ref
Hansen V, Oren E, Dennis LK, Brown HE. Infectious Disease Mortality Trends in the United States, 1980-2014. JAMA. 2016;316(20):2149-2151. doi:10.1001/jama.2016.12423

Pratikriya

Everyone is the sum total of his reactions to prior experience. As your experiences expand and vary,, you become a different person, your perspective on things evolves.. Every reaction thence is a learned conditioned one; every significant experience alters your ability to reflect/react and shape your next esperience. . This is a perennial and iterative process,  until perhaps dementia sets in. ( प्रतिक्रिया ही जीवन है और जीवन ही प्रतिक्रिया - वोह प्रतिक्रिया है जिसने चम्पू को दीन , गोकुल को धूर्त , और बंशी को विद्रोही बना दिया )

So it would seem foolish,  to adjust our lives to the demands of a goal we see from a different angle every day? How could we ever hope to accomplish anything other than becoming neurotic idiots who serve our neuroticism with to do lists, and a skewed frozen perspective which defeats the freshness of perspective.(दास्वीदानिया movie देखी ?)

Goals hence are meaningless. They make you arrogant when you achieve them, or restless when you stray. They give a linearity to a frame of learning which ought to me more circumferential or spiralling. They stunt life into meaningless non-memorable routines.Life actually happens to us in between getting from point A to point B. We laugh, cry, tense up, let go, sigh, exult and go through various other consuetudines of existence. In the interim we build various comfort zones to ward off solitude- family, love, career, hobbies. We mistake these to be life, yet when the gray cells age and company and productivity abandon us to solituide, we fear it instead of accepting it as the way you entered this world. All alone, naked and unendowed of anything but the ability to observe, react and evolve. 

Review of systems

Gen: hot and cold. Like ants in my brain. I am chill.lets see I lost weight when I was on a diet. Then I

         ate and regained. What's the difference between malaise and fatigue? 

HEENT: stop the nose, it runs. Away. I hear a symphony, not ringing in my ears. Does an itch in my ears count? I hid a babycorn in my nose when I was 3 and it just came out. Bad breath. Well, I fart the wrong way, will my mouth not be sore?
Eyes- when the joints creak, and vision fades,and calcium deposits in the arteries, a fine arc forms around the eye, want to see?

Cardiovascular: chest pain?- huh sometimes- fit me in your diagnostic model; palpitations- you mean heartthrobbin? ; yes, always with 3 pillows under my head; nah woke up to pee, not to breathe; If I don't breathe I expire, ain't I? If I do, I inspire?
Respiratory- Smoker's cough- always do, more of a hack I call it , sailor; blood - why would I have any blood in it; 2 blocks? I stay in the countryside; Nah , my cat wheezes......yeah shit she does....asthmatic feline
Gastrointestinal- Whaddya say? Noshia? Where are you from? No, I mean originally....you ain't born here were you? WTF is reflux? Heartburn? no, I get a sour taste sometimes. Lots of gas!!! Like I need to fart or belch. I like to have a 8 inch turd every 2 days or so. Not black, I make green shit. I wipe really carefully.No blood. Pooptube- nope, don't want one. Why don't you get one instead. Yellow eyes? Won't I look like a zombie?
Genitourinary- Quite a lot. I take an hour sometimes.No I don't have accidents, but wear them depends just in case. Burns in the tip. I shoot small and slow.I am pissing razor blades outta my pecker.Yeah, wake up 3-4 times to pee.
Musculoskeletal- Yeah my L4 and L5 is shot. Knees hurt when I run.Yes I have some disc problem. Spondolysis something. Yeah I got plates and screws in my back
Endocrine- Hot flashes, no I don't have them since I manopaused.I get hot and cold all the time. I eat like a pig. Don't drink as much I think. I am always getting dehydrated.
Integumentary- Have some sun spots. No lumps or bumps. No no...
Neurologic- I get migraines. I get numb, like my feet are asleep. No they feel numb. Isn't it the same- tingling or numbness? Yeah, I forget. No, I don't forget , I am pretty sharp.
Psychiatric- You think I am mad? Yes, I get anxious when I am taking a test.NO I am pretty upbeat.

Now why are you asking me all these questions? I just came with a urine infection.
You mean you want to cover your ass?
You mean you will miss things? I better get another doctor
I think you are very thorough. 
I think you ask too many questions. 
Why does everyone ask so many questions? I am tired. Let me sleep will you.
What? 
Everything hurts!! EVERYTHING hurts... period...
Jiyara ghabravat hai....phadphadavat hai, udat hai, magaj ma jhunjhunaut hot hai
Kaleja ma meetha dard hota hai
Kachu samajh nahi avat babu....bada ajeeb sa lagta hai....tum daktar hai na, pata lagav ke kahe hot hai

Haazir hoon............

The VA on weekends can be eerily desolate with hardly a soul in its vacant corridors. You could get mugged and no one would know till hours later maybe. I am making my way to the fellows' office hearing my own squeaky shoes as I trundle more than walk, unsure of what to do next , except carrying out the ritual that i have unfailingly indulged in every day. Unfailingly perhaps out of meekishness, and fear of the unfamiliar if I did not. 

Of looking up labs, heading to patient rooms to see tired, unfrustrated veterans who have resigned to what may happen, almost fatalistically, also thankfully that they get healthcare amongst a paucity of other privileges. Of heading back to the office, reading the NY times, dreading a page for a new consult in the minutes before I decide to drive back home. What gives? 

I trundle, unplanned for the unplanned. If a UFO crashed in my path, I may not recognize the need to run to safety. Oh really! You critters are aliens. How bout that , eh. Mind if I get along? 

A new batch of interns, on the floors below, performs in Brownian randomness. Some misdirectedly over enthusiastic, some glad not to goof up. They are learning the right wrongs from their peers, speaking the phraseology, diuresing the dry, walking troponin plateaus, smelling the diabetic feet, getting high on nebs and vanco, smiling goofily at strangers who look on as they run athletically gracefully for code blues, in scrubs, green pixie shoes and dirty loaded lab coats and all, thinking for the moment , that this is it.....what I became a doctor for. 

Invariably, the final year resident/fellows are a more pessimistic lot. They have known the shibboleth, learnt from mismanaged codes and perfectas gone snafus, raked through piddleshit, got scutted out, had an inspiring encounter, and an insipid one, lost and redeemed themselves over and over. They know to locate the vocal cords, the subclavians, Mr Babinski's erection, flutters with 2:1, spectra of beta-lact-amazes, the right words to discuss end of life care, SIRSies and dopies. And this becomes a learnt exercise. Notes become less verbose, patients become lists, time off becomes more important than time on, and the present gives way to planning for future. 

They were once interns. 

The current interns will be residents and fellows later. This cycle goes on. At least for the observer. For the passenger on this conveyer belt, this training time will never come back. What started as passion becomes a profession. Notes become codified billing sheets, processes become bulletted problem lists, pathogeneses become DRGs, recoveries become hospital stays. Families expand, priorities change, anxieties are decentered. The angst at aimlessness is now felt to be a wasteful frustration. 

Get off the gas, clutch, lower the gear, drive on.

Times of changing gears are weirdly surreal. The knowledge of going into an unknown time mass feels like someone deafferented your gracile and cuneate nuclei.  I am sure all the interns felt this way leaving med school going into the real world. When I moved out of home, bag and baggage into the mosquito infested room in the KEM resident  quarters where 9 tired house men bodies competed for aedes aegypti lullabies and dry bath towels, among other things, I was as just as random, kibitzing around. I made my mistakes. I learnt. 

Times of change are good for stress testing a growth reserve as well. It is a good stimulus for the senses also. I think this country offers the opportunity to do this. At some point, you can clutch, raise your gear , and drive on. Along one of the long interstates.....someplace else.

Btw "htiu#" : that was the text of my 14 month old daughter's first tweet. Figuring out what it means...