#pharmacyrotation

Leonard and I were given the amazing opportunity to take part in a multi-diagnostic camp on the Sunday before last (20/07). The Institute’s dermatology, ENT (ears, nose, throat), general medicine, dentistry, ophthalmology, internal medicine, gynecologic, orthopedic, and physiotherapy departments set up makeshift OPDs at these camps in prearranged villages every month or so.

We were on board… on one of two packed buses at 7:30 AM, taking care to sit at the very front to avoid a rollercoaster ride at the back. The most obnoxious horn you could imagine blasted an unsuspecting me while Leonard drifted to sleep. I was pleasantly surprised when we arrived at the village of Nepani Vadgaon after only fifteen cacophonous kilometers, having been briefed about a 100-kilometer trip.  Our nutella and kayli (banana)-filled selves were also not expecting a breakfast of carb-heavy pohe to be provided. The only thing I've come to expect is discrepancy here. I'm improving my flexibility sans yoga.

Twenty minutes later, flocks of nurses, residents, and department heads were buzzing on breakfast while I stood with Leonard and Mangesh (of the CSM) to the side—but not for long. I approached the nursing students who were obviously laughing at us, and spoke infantile Marathi at them. They ushered me to a masala tea party where I tried to add to my growing Marathi dictionary, but their foreign phrases were left untranslated. I’ve found that, as a rule, the nursing students of Pravara are not fluent in English.

In the ladies’ restroom of Nepani Vadgaon I finally experienced a squat toilet. Look at the not-so-private stalls that changed my life:

Before long, the camp was inaugurated. Villagers sat Indian style (naturally) and watched as the hospital’s department heads were presented with coconuts and bouquets. Mangesh pointed out the sarpanch (head of the village)—a woman dressed in a yellow sari. Many of the towns in the district of Ahmednagar are headed by women.

Once the clinics were opened up in the surrounding schoolhouses, the villagers lined up outside to be seen. I dropped by the skin clinic first, where I saw cases of tinea corporis (ringworm), lipomas (fat tumors), allergic reactions to kumkum (a powder used to mark the forehead), hyperpigmentation, eczema, vitiligo, and neurofibromatosis. I asked the residents what treatments these patients had tried for their skin conditions, and learned of the population’s lack of health literacy. Medical records are not maintained. Prescribed treatments are blindly taken, if at all. Non-adherence commonly leads to fulminant and recurrent disease patterns.

In the ENT department, we observed a patient whose right tympanic membrane was perforated from a recurrent upper respiratory tract infection that had migrated via Eustachian tube. Surgical reconstruction was in order, but first the infection would need to be controlled with antibiotics.

In the mobile dental clinic, basic minor procedures were under way, including scaling (deep cleaning) and uncomplicated tooth extractions. ‘Mishri’ is a form of tobacco that is rubbed on the teeth and gums, while ‘bidi’ is smoked. These habits lead to teeth staining and palate issues in this population.

To manage illiteracy, the ophthalmology department assesses patients’ abilities to count circles from a distance in contrast to the traditional Snellen letter recognition.

In the pediatric department we heard about children who suffered pesticide or kerosene poisoning. During monsoon season, poisonous snake bites surge as burrows become uninhabitable. Snakes are regarded as the “farmer’s friend,” but venom can be neurotoxic or hematotoxic from a provoked krait or viper.

At lunch, the locals ran around offering jalebi—sweet rings of deep-fried flour. I asked one of the internal med residents how I might say ‘no, thank you,’ and he was dumbfounded. He explained that there is no need, that there is a mutual understanding. These patients do not thank him for the services he provides.

In the orthopedics department, the residents were worn down by the many knee osteoarthritis cases, and so I enthusiastically counted exercises out for patients (ek, don, tin, char, panch...).

On Tuesday Leonard and I visited the Rural Health Center in Rahata. The clinic is operated by two nurses (designated brothers or sisters), a doctor (called a medical officer), a medical intern, and a lab technician. Dr. Arsude, the medical officer, provides both Ayurvedic and allopathic medicine to patients depending on their preferences. Observation soon reveals the immense amount of trust and admiration that patients bestow upon her. The patient-provider interaction is completely and wonderfully forthright.

The medical intern, Sorabh, described the drugs commonly used at the clinic. Anti-helminthic (anti-parasitic) drugs are frequently prescribed in this rural population: tinidazole is available in a fixed-dosed combination with the antibiotic norfloxacin to treat dysentery. Labendazole is used to treat neurocysticercosis, a parasitic infection caused by the ingestion of infected pork.

We were introduced to Rajesh, the project manager for the Targeted Intervention to Migratory Workers for the Prevention of HIV/AIDS. These migrants from other states or districts are glad to occupy jobs which locals are too proud to accept as custodians, hotel workers, or construction workers. The Targeted Intervention is aimed at five surrounding towns, each estimated to take in 10,000 migratory workers. Only those at high risk were tested, including men who have sex with men (MSM), sex workers, and battered women. IV drug use is not very common due to poverty. Patients at risk are interestingly identified via body mapping—behavioral changes, itching, and anorexia are all red flags. Of the 50,000 migratory workers, 30,000 were registered, 6,000 were tested, and 8 cases of HIV/AIDS were detected. While this number may seem small, these patients can have exponential effects on the region. These patients are provided with anti-retroviral therapy at no cost with a government-authorized report from a testing center. Here you'll find me cheesing with the nurse, Sorabh, Rajesh, the lab technician, Leonard, and a social worker:

We traveled by tum-tum (rickshaw) to the local Anganwadi where 3-to-6 year-olds receive health care in addition to standard pre-schooling at absolutely no cost. The height, weight, arm span, chest circumference, and head circumference are continuously assessed. Most importantly, weight-for-height is compared to a growth chart, and nutrition supplementation is given if necessary. The Indian government started these pre-school-cum-clinics to combat child malnutrition. Because farmers in these rural areas do not prioritize health care, the government provides services such as these. The children were all so well-behaved, and a couple boys recited numbers and poems for the class.

Back at the rural clinic, I developed an understanding of some common disease states in the rural population. Malnutrition and poor hygiene are the most common sources of concern. A pregnant woman presented with anemia as evidenced by lower palpebral (eyelid) conjunctival (white part of the eye) pallor. A reference sheet will allow her to be seen at the hospital at no cost. Pica is a common illness as a result of iron deficiency, usually involving an appetite for sand, chalk, soil, or lead. A 3 year-old child was brought to the clinic due to soil-eating. His iron deficiency may or may not be related to minute, continuous blood loss from an intestinal hookworm (Ancylostoma duodenale), and so anti-helminthic drugs were prescribed in addition to iron supplementation. Other common pediatric diagnoses include nocturnal enuresis (bed-wetting) and breath-holding spells (the cessation of breathing to seek attention from caregivers, often associated with cyanosis).

On Monday morning Leonard and I were de-sandaled, presented with bouquets, and ushered to the golden statue of Dr. Vitthalrao Vikhe Pathil. We offered dried flowers with a sign of prayer at the base of the statue with incense smoldering in the background. From there, we visited the illustrious sugar (sakhar) factory which this revered man worked so hard to establish.

This factory tour is not for the unwary: every step requires care, beginning with the sparks that rain down spectacular on the pathway. Though sugarcane is harvested from November until March, the place was teeming with workers involved in maintenance. Come November, sugarcane will be transported to the factory by the truckload. The shoots will be compressed to produce a juice and a powder. The powder will be sent to a furnace to be used for energy, while the juice will be sent upward to be refined. The molasses will be mixed with sulfur and limestone, and then heated to produce red crystals. From there, these granules will be categorized from smallest and least sweet (1) to largest and sweetest (3). Mr. Jana reflected that perhaps grade one is for the diabetic. These raw granules will be further refined to give white sugar!

Outside of the factory a couple of men requested a picture with me and Leonard. “Five rupees,” I muttered to them before we assumed our poses. Turns out we’re not worth that much.

We then visited the distillery where the byproduct of molasses is processed for sale as ‘country wine’ (deshi daru). The bottling process is both a manual and a mechanical process that enthralls. The resulting product is largely banned. I was told that it is 60% methyl alcohol and 40% ethyl alcohol.

We took things down a notch at the Pravara Public School. The goddess of knowledge, Saraswati, may be found outside every school in India. We were given the opportunity to question a classroom full of students. We learned that their favorite subject is computer science and they are all feeling happy.

We then visited a special needs school, first stopping at a classroom occupied by ten blind students, all boys. One English-speaking student printed our names in Braille, and yet another student recited a beautiful song for us.

In the next room, deaf girls adorned with pink sashes were holding class. The crafts that they had woven were astoundingly lovely, and so I linked my thumb and forefinger to demonstrate my compliments. One student wondered what my name was, chalking on her personal board “what name why.” I chalked, "What is your name? Rachel." Her name? Neetan (far left).

That afternoon we visited Pravara’s satellite colleges. The Krishi Vegan Kendra (KVK, Farm Science Center) caters to farmers in every possible way. The center treats plants as patients. The lab where farmers’ diseased plants receive treatment is actually referred to as an OPD (outpatient department). The KVK finds solutions for plants in addition to finding plants for solutions: the drumstick tree (Moringa oleifera, pictured below) is rich in iron, thus valuable for anemics, pregnant women, and children. The protein-rich azola is used to supplement animal feed. We found spirolina, the only algae with single-cell protein, at a pH of 11 in pools requiring constant agitation for oxygenation. This algae is dried for supplementation, potentially in cancer patients and astronauts.

From there we re-entered the center to check out the various strains of fungi which the KVK cultivates due to their high specificity for pests. Packets of sex pheromones are valued for their ability to trap insects of the opposite sex. The KVK also serves farmers through a radio program that broadcasts answers from experts twice daily, reaching farmers up to 30 kilometers away.

Eventually we entered my domain at the Pravara Rural College of Pharmacy. The pharmaceutics professor kindly showed me the various instruments used in their heavily practical curriculum. The students here actually prepare pharmaceutical products. I was first shown the compression device used to fashion tablets (pictured below). The final products are tested for friability, dissolution, pH, viscosity, and other properties in the adjacent room. The autoclave on site is used to sterilize parenteral products. Compatibility of drugs and excipients is assessed at varying temperatures over time using a stability chamber.

In the pharmacology lab, animal subjects are assessed using photoactometer (measures movement), analgesiometer (measures pain in response to increasing temperatures), spirometer (measures respiratory function), rotarod (measures muscle strength), metabolic cage (measures urine output), and kymograph (measures blood pressure) among other devices. 

I learned of the College’s work with pharmacognosy—the extraction, evaluation, and preparation of plants. At the conclusion of my tour, my guide plucked a flower for me: the Madagascar periwinkle is the main source of anti-cancer vinca alkaloid drugs. It is beautiful, but smells cancerous.

Believe it or not they do things a little bit differently 8,445 miles from Chicago. I am exceedingly grateful to the driver accompanied by a Mr. Jori (of Pravara) who delivered me and Leonard (Drake health sciences student) from Mumbai to Loni unscathed, because the roadways here lack both rhyme and reason. Lane markings? Mere guidelines. Honking? Yes, please ("Please OK horn" is actually posted on the back of "goods carriers"). Not only is honking a frequent and seemingly random occurrence, but the spectrum of tones blared from these technicolor vehicles is astonishing. Buzzing rickshaws may gravitate within inches of pedestrians. All very exciting.

On Friday, Mr. Jana introduced me and Leonard to the campus, starting with the mess hall. The food is less spicy than I imagined. Conversely, finding out the names of the items has proven to be more difficult than I would have expected. My attempts at this have only gotten me additional portions from staff: I guess you could say these were both successes and failures.

The Pravara Institute of Medical Sciences (Deemed University) is comprised of a Medical College, a Dental College, a College of Physiotherapy, a College of Nursing, a Center for Social Medicine, and a Center for Biotechnology. The beautiful campus is bordered by plant life at every turn. And I can't omit the fauna: cats, dogs, and peacocks pay us no mind.

We were introduced to Mr. Sanjeev Kulkarni, Pravara's International Coordinator and Associate Professor in Microbiology. He shared Pravara's history with us: at a time when Loni boasted a flourishing sugarcane industry, much of farmers' profits were being lost to outside distributors... until a visionary, Mr. Vitthalrao Vikhe Patil, proposed a radical scheme within which farmers would operate a sugar factory of their own. The Indian government agreed to satisfy 85% of factory costs, and Mr. Patil petitioned the people of Loni to raise the remaining funds through money, gold jewelry, or any other valuables that they could spare. Once erected, this factory gave Loni the means to establish Pravara Hospital in 1972 with 100 beds to provide health care to a community in need. The Medical College was introduced thereafter to train the locals, ultimately supplying the area with health care providers.

From there, we were introduced to Mr. Soma, the Director of the Centre for Social Medicine (CSM). He oversees a Center that upholds a mission “to support and encourage interdisciplinary research, training, and services in the field of social medicine and community development for the benefit of students, faculty and the needy community at large.” The CSM provides community-oriented primary health care for underserved, remote villages through mobile and remote clinics; advocates for at-risk groups; and empowers community members for their health and development. I believe that everyone is entitled to good health and am eager to explore my interest in social medicine with the CSM! The Center’s work provides a forum to advocate social justice. I look forward to cooperating with other professionals to solve health problems in vulnerable populations!

Three fellow International students (one nursing, two public health) are here from Oregon, and they introduced us to the local shops which I basically ravaged in search of traditional Indian garb. It was an awkward process: shopkeepers pried the packaging of garments open to unfold and lay out an array of blouses, and then looked to me for answers that I was reluctant to voice. After leaving a wake of kurta destruction, I maybe had a taste for one or two selections. The assimilation process can be difficult, and you can bet I still draw attention from locals even with my new kurtas.

I had exchanged 149 USD for 7717 RPS at the airport. This is a small fortune. To give you an idea of the local economy, a pack of twelve 1L water bottles, five kurtas, two electronic adapters, a small tupperware set, Tide soap, mosquito repellant cream, a strawberry swiss roll, an apple, two oranges, three bananas, an ice cream cone, a scarf, and two pastries later I have $31 (1630 RPS) less to my name and, now that I mention it, significantly higher blood sugars. Worth it.

While breakfast and lunch went over swimmingly, I couldn’t stomach dinner. I had been feeling dazed and confused, dizzy, tired, not myself. And so I laid down for a minute. Burned through Wi-Fi hours. At a reasonable bedtime I found myself surprisingly stimulated. Nonetheless, I laid down for bed and within an hour woke up reeling from an emotionally disturbing experience of a dream with mild visual hallucinations and a heart rate up to 100 BPM. The dream weighed so heavy on me that I found myself in tears. I didn’t mind using some of my precious international cell phone minutes just to hear a familiar voice.

At this time my weekly anti-malarial medication, mefloquine was at its peak concentration in my blood. Yes, as any self-respecting pharmacy student would have, I had perused the drug information before taking it. There is an FDA Black Box Warning that mefloquine may cause neuropsychiatric adverse reactions that can persist after the drug has been discontinued: for this reason, it is not to be prescribed in patients with major psychiatric disorders, and should be substituted if symptoms develop. Because I usually consider myself to be free of major psychiatric disorders (though I can’t be too sure about minor disorders ha) I assumed the drug to be safe. Never assume though, you know. So now I have a drug in my system from which people have reported such casual side effects as aggression, agitation, restlessness, anxiety, confusion, convulsions, depression, encephalopathy, hallucinations, memory impairment, mood swings, panic attacks, psychotic or paranoid reactions, sensory and motor neuropathies, suicidal ideation, and suicide. I plan on submitting an adverse event report to FDA MedWatch and finding an alternative, and I guess you could say that I strongly discourage use of the drug in situations when other options are acceptable.