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...

Random phraseology, that colored my growing up with pati

In no specific order. Am decanting here from memory, lest these were to disappear from recollection.No one would know what they mean, without having heard them uttered/seen.....

Aing oyang....
Pillapapiah / jemmy doctor
Balakka
Lalla won Kulla enakku taa
Summa irukkaya swaroopata kattama
Pant doctor
Melleril/ Largactil/ serenace in a red white Fargo lantern box
Marwadi sainyam
Rajanna/Bebanna/Mani anna
Thanga taatha
Nandiyaal thelu
Aise chandrabhaaga aise bhimateer aisa vithevaara "Devakottai"
The swinging hips dance
"Jaala setthu poi lorry le eduthindu poghara"
"Kudu"
"Ennadhu idhu"
The times Poona taatha would drop in at 3 PM to read the TOI and paati would make tea for "Maama"
"Mookannadi vizha terunjiduuuu"
Mriganayani
Aadivaram aviyal chestaana
Oosipullaaan
Madaraas ki jao
Mischief rascal
Nallavan kadai
Torchlight and all other small collectibles
Aadum maadum kolam kolam, amayaar paati um kolam kolam
Deepa Jyoti parabhrama.....
Ucchipulayaare mahaganesa
Durgalakshmisaraswati thaaye
Chidbambara ragasyam
Chakravarti thirumaghan
Poooo....malaaaii....pottu kalyanam
Ungalukku ellam ennai mami.....neenga ellam romba jolly aha iruppel

The last I heard of her, she was a frail shrunken form of her previous self...staring into the webcam on Skype....muttering unintelligibly like a child , trying to sing her remarks....the image quality was not very good, she did not recognize me I think......

This was the last grandparent of mine who was alive.
A generation has passed..........

Lime and lemony Limca!!!!