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MY INDIA ADVENTURE – PART I  by Peter J. Leibert

Prevention of disability takes one to strange arenas - Brussels, Paris, Mexico City, Hong Kong, Vancouver, Italy, and even to Wailuku on the Sandwich island of Maui.  But one has to do what he or she has to do.  By the time you read these words, my latest adventure will have long before been completed - a trip to the mysterious and exciting India.  Any announcement of this new adventure brings one of three very distinct reactions - “Why India?”, OR “India!  Oh, I’ve always wanted to go there!”, OR “Oh Pete, you’ll get sick over there”.  The purpose for which I took such a trip to this Asian country was the “prevention of disability” as I was traveling to attend the International League of Societies for Persons with Mental Handicap (ILSMH) conference in the India capital city of New Delhi.  During this 1994 session, the ILSPMH organization had included a sub-program about primary prevention. 

I had been requested to participate in a number of sessions about preventing mental retardation.  One conference I attended concerned brain injury.  This meeting was held in the city of Bangalore in southern India, so I got to see different parts of India. 

I had been preparing for this challenging experience by reading a lot about India, both in books, and more recently within the press.  The writings within most of the books I had read leave you with the impression that India is swamped with health problems.  “Millions of their peoples have an extremely low standard of living, often are unable to afford nourishing food, can get little clean or pure water, and usually live in extremely poor housing”.   

The book authors report that there are limited education opportunities, job shortages, and natural disasters.  Some of the newer books do speak of projects to develop water and sewage systems, of building new housing and new hospitals, of developing modern technical training programs, of drives to eliminate mosquitoes, and to control contagious disease via vaccination programs. 

One textbook reported that during the early 1970’s, India had a high death rate of infants occurring in their first year of life. (This rate was about 150 per 1,000 live births.  Infant mortality was over 200 per 1,000 during the 1910-1915 period.)   

During the 1970’s, the death rate dropped rapidly to about 12.5 per 1,000 among one- to four-year-olds.  During that same time frame, the average Indian, when born, could be expected to live roughly 50 to 55 years.   

These authors saw this as a tremendous improvement as life expectancy had risen dramatically throughout the century from a scant 20 years in the 1910-1915 period.  There were a number of endemic communicable diseases that are continual public health hazards.  A variety of national prevention programs exist aimed at controlling or eradicating disease.   

The National Malaria Eradication Programme, the National Programme for the Control of Blindness, and the National Filaria Parasite Programme were examples.   

Other programs sought to limit the incidence of cholera, diarrheal disease, trachoma, goiter, and sexually transmitted diseases.  Government goals are to reduce the death rate to nine per 1,000, drop infant mortality below 60 per 1,000 live births, and raise life expectancy to 64 years by the year 2,000.  Health care facilities and personnel have increased substantially since the early 1950’s.  By the early 1980’s, there were approximately seven hospital beds and four physicians per 10,000 individuals. 

In today’s environment, the media has been reporting daily about the steps being taken in the panicked cities of India as pneumonic plague has stuck.  Pneumonic plague is one of the three forms of the feared pestilence known in the Middle Ages as the “Black Death”.  In the 14th century, plague killed about one-fourth the population of Europe. 

As a prevention advocate, this seems to be a wonderful opportunity to learn first hand about life in a country struggling with the many problems of basic survival.

MY INDIA A DVENTURE – PAR T II 

As I reported in the last issue, the World Health Organization had reported that pneumonic plague was taking a toll of human life in India.  This was occurring a few months before my departure for India.  One of two conferences I was scheduled to attend was canceled for about a week and then in mid October reinstated.  This is a continuing tale of my saga. 

Plague is spread to humans by fleas that have bitten rats infected with the bacillus Yersinia pestis (formerly called Pasteurella pestis).  It occurs in several forms.   

Bubonic plague, the most common, causes swollen lymph glands.  In its pneumonic form, the infection leads to high fever, the vomiting of blood and the filling of the lungs with fluid.  Without treatment, death almost always occurs within 2 to 4 days.  Even with treatment, mortality is still about 20%. 

The plague returned to India for the first time in 28 years this August when a village in the Bir district, in the state of Maharashtra, reported its first case of bubonic plague.  The outbreak was blamed on a surge in the rat population drawn by relief food meant to help victims of last year’s destructive earthquake.  Bir is about 200 miles east of Bombay which is midway on the west coast of India. 

More than 90 people were infected in the Bir area, but the bubonic outbreak was brought under control by insecticide spraying (DDT) and antibiotics (tetracycline, chloram-phenicol, or kanamycin). 

A month later, an outbreak of the more serious pneumonic plague occurred in the city of Surat.  Surat is located in the state of Gujarat about 120 miles north of Bombay.  About a week after the announcement of the plague being found in Surat, about 400,000 of the city’s 2 million people made a panicky exodus.    

Pneumonic plague symptoms usually develop within one to six days after exposure to the plague bacillus.  As symptoms develop, an infected individual can pass the plague-causing bacterium, Yersinia pestis, to others through droplets in the air from coughs or sneezes. 

Partly because of the Surat residents fleeing, fear that  the disease would scattered across India became widespread, and also impacted public health systems outside the borders of India.  A number of countries banned flights to and from the country. 

Within India, the government urged calm and stepped up efforts to find the sick, rush antibiotics to pharmacies, and spray insecticide to kill disease-carrying fleas and rats.  New Delhi, where the ILSMH conference is to be held, had about 20 suspected cases admitted to their hospitals.  Most of them had fled to New Delhi from Surat.  Two died.  Hospitals reported suspected plague cases in Maharashtra, Rajasthan, Uttar Pradesh, Madhya Pradesh, Orissa, and Tamil Nadu, some of the largest states in this nation of 900 million.  

To help prevent plague, the Indian officials are recommending that travelers avoid areas with recently reported human plague cases.  To prevent getting the plague, persons are being told to avoid rat-infested areas, apply insect repellents to ankles and legs, and apply repellents and insecticides to clothing and other bedding. 

MY INDIA ADVENTURE – PAR T III 

Traveling half way around the world is an experience in itself, especially with the jet lag effects upsetting your system and your plans.  India brings to one an expanded understanding of the struggles that many people are facing every day just to survive, but it also induces an excitement of learning about the beauty and happiness of a distinctive people and culture.  These words attempt to describe the fleeting impressions I have retained from my trip to the Indian cities of Bangalore, Mysore, New Delhi and Agra. 

After 36 hours of travel time, it does feel great to have your feet on the ground again.   Riding in any car in the city of Delhi brightens your senses.  There are no seat belts in any of the vehicles, and the drivers act like they don’t want to lose a race to somewhere.   

The drivers physically “take” the road apparently ignoring other cars, motorcycles, bicycles, pedestrians, and animals — yes, animals.  They are mostly the cattle-like Brahman.  Since my arrival was at two in the morning, these animals were seen resting at roadside, but sometimes their resting spot was in the middle of the street itself. 

Hazards, by my standards, include no tail lights, which I noticed on a large percentage of the vehicles.  This was typical for the three-wheeled autorickshaws that abound everywhere even at two AM in the morning.  In Delhi, bicycles are a frequently used means of transportation.  My early observations recorded no indications of lights nor reflectors on that type of vehicle.  Much to my surprise, the drivers of the numerous motorcycles and motor scooters  were wearing safety helmets on their heads.  However, their passengers were not.  

Quite noticeable was the smog.  I was informed that November was the peak of the smoggy season and that Delhi was the smoggiest city in the world.  Almost all of the vehicles use diesel fuel, and there does not seem to be any requirement for vehicle smog controls.  Faulty fuel injectors were very obvious to this former test engineer as I observed heavy black smoke being emitted from 90% of these diesel motors.  This is in addition to the smoke coming from burning leaves and trash, and to the dust.  Los Angeles was never like this with the exception of the times when they used to burn oil in our citrus smudge pots years ago. 

First impressions about the hotel were great as the marble-walled lobby was similar to the better class hotels found in the United States.  The elevator was a clue that all was not as it first seemed, since the operation of the hoisting machinery that Mr. Otis invented was marginal at best.  It did stop at the right floor, plus or minus a few inches.  “Lack of routine maintenance” was my judgment.  At the time, all I could think of was the elevator in the movie “Hotel”.   

My youngest son would have had a field day if he had seen the hallway carpets - he enjoys life by being a salesman for Philadelphia Carpets, a division of Shaw Industries (an unpaid advertisement).  I am certain Steve could have convinced the hotel owners that a new carpet would be a good investment and would increase repeat business.   (Perhaps not, as I later learned that the hotel was owned by the government and I hadn’t been in any of their bathrooms yet). 

The eloquent highlight of my emotions was reached when I realized that the bathroom plumbing in my room did not use what I consider to be a basic prevention tool for the drains of bathroom fixtures.  This was typical of all bathrooms and rest room’s I utilized while in the country.  Instead of the water trap below the sink, I found moth balls in the sink.   

Odors may be covered up and moths may be deterred by these little naphthalene balls, but small bugs are not.  Almost every evening I slew a cricket or some other small “bug” that had probably climbed the walls of the plumbing in order to reach my 9th floor room. 

It may seem that I am picking on the negatives from my trip, and perhaps I am.  This should not be what you use to judge whether or not to visit India.  I would probably do the same if I were to review my impressions of California.   

There were a lot positives.  The people of India proved to be a very friendly lot.  Most adults were very responsive to a smile or a wave or a camera, but the children were especially so.  On a couple of occasions I became surrounded by twenty-five or more school kids wanting their picture to be taken with the “strange” visitor.  While touring the Lodi Hindu temple in Delhi, I found myself in great demand as a model as part of family pictures with their white-bearded guest from the United States.  I and others received many personal invites to visit the homes of newly found friends. 

The food we received at our conferences was very,  very tasty, but a little too much sameness.  This  might have been caused by the curry-based sauces found on almost all of the “vegetarian” and “non-vegetarian” dishes.  Hindus do not eat meat, so vegetarian meals were found everywhere in the region including on the airlines coming to and fro.   

Whoever selected our convention menus must have loved ice cream.  It was offered at every meal.  It was also quite interesting that the meals were served in rooms that had no tables and very few places to sit down.  Fingers were the preferred utensil, it  appeared.   

I took a side trip to Agra.  Many people merely visit Delhi to reach Agra, which is the medieval home for the “famous” Taj Mahal.  Agra is 126 miles from Delhi which a trip that is another story in its own right.  (If you would like learn about this trip, send me an E-mail message and I’ll forward you everything you never wanted to hear about traveling to Agra).   

The Taj Mahal was worth taking that exciting trip.  The Taj Mahal is just like the postcards.  This must be India’s most loved tourist attraction and I agree that it is “a very enduring symbol of love and historic beauty”.  The structure was completed in 1659 after 21 years of construction by some 20,000 laborers.  Akbar The Great, made Agra great.   

Nearly all the world’s great monuments were the product of the religious fervor of a people or the vanity of a king.  But the Taj Mahal is an exception; it was built as a monument to love.  The woman was Arjuman Banu and the man was Shah Jahan.  They were married in 1621.   

Arjuman in the next nine years bore 14 children and it was in childbirth that she died in 1630.  Her husband was grief stricken.  He then vowed to build her a memorial surpassing anything the world had ever seen in beauty and in wild extravagance.  He brought in skilled craftsmen from France, Italy, Persia, and Turkey.  The cost of reproducing the Taj Mahal today has been estimated at nearly $70 million. 

A side trip in southern India was to see a district health center.  The site we visited was about 25 miles outside of Bangalore and was quite busy the day we were there.  It serves about 26,000 residents and many of them must have had a baby this year.  There was a long line of mothers carrying babies awaiting to get vaccinations for tuberculosis and measles.  We were told that rubella was unheard of in India. 

The center consisted of three buildings with very, very, little in the way of furniture or equipment.  Most of the examining tables were of the homemade variety.  Their pride and joy was a relatively new halfsize refrigerator which housed the vaccine.  

Records were displayed on some of the walls showing the numbers of people seen by month during the year 1993 and the 1994 year-to-date.  Their targets for 1994 included vaccinating 700 persons, and it appeared that they had already attained their annual targets.  India’s health department has a goal of achieving 100% immunity to the common childhood diseases by the year 2000. 

One feature of this health center program was their maternal nutrition education classes.  Small groups of these mothers are taken aside and given a short session on the need to eat a balanced diet.  This occurred each visit during pregnancy and continued as part of their well baby visits.  Samples of the recommended foods were displayed and various low cost, but nutritious, recipes were shared.    

Although India grows enough food for its population, making sure that low income pregnant women eat enough of the right types of foods is a major problem.  One third of the babies in India are born smaller that 2500 grams (low birth weight by US standards).  

In many “developed” countries, LBW runs less than 10% of live births and is closely linked to the babies that are delayed in their development.  At a later visit to the Victoria Hospital in Bangalore I saw dozens of VERY LBW babies, all weighing less than 1500 grams. 

From the poor sections, we went to the palaces where the royalty of old used to spend the peoples money.  Here, one week after my arrival in India, we were treated to our first sit down meal at the former Chamundi Hill palace, now a fancy hotel.  Mysore is a city of palaces, gardens, and Oriental splendor.   

In Mysore, there is little evidence of the crushing poverty so often associated with India.  The Maharaja’s palace is the most impressive building in the area and was built less than 100 years ago.  Pictures on its walls depict the pomp, grandeur, and ceremony that occurred there during the 1920’s and 30’s, not that long ago.   

On that side trip, we also had a stop at the Brindavan Gardens where we had High Tea on the hotel terrace near the Krishnarajasagar Dam and its enormous lake.  Below the dam lay the exquisitely designed gardens with bright flowers and silvery fountains.  We were at the gardens in time to overlook the lake during a beautiful sunset.  Later we strolled through the hundreds of illuminated fountains and pools.       -  That is 30!

 A TALE OF SUCCESS

Bangalore India Motorcycle Hemet Law  

This is a tale about how the state of Kamataka, India obtained their law to mandate the use of safety helmets for motorcycle drivers.  “It required getting fed up with the daily carnage we were seeing”, said Dr. R. M. Varma, a neurologist who lives in Banglaore, India.  “A group of us got together and wrote a proposed law which would require all motorcycle riders wear a second skull – a safety helmet”, Varma added. 

This group submitted their proposal to the state governor, where the proposal sat and gathered dust for over five years.  Varma and his associates kept gathering statistics about the observable facts of motorcycle use – the deaths and the injury that resulted from their use.  During their wait, the helmet-use advocates observed a 50% increase in the number of accidents. 

Eight to ten motorcycle riders were dying each month; 140 to 180 were being injured.  They also learned that the death rate for 2-wheeler riders who had received a head injury during an accident was 6.8% if wearing a helmet, and was twice that (13.5%) if they shunned the safety device. 

Bangalore is the capital of the state of Karnataka and has a population of about 4,000,000.  There are about 700,000 vehicles registered within the city.  “Two-wheelers”, as motorcycles are known in India, account for 75% of these vehicles. 

The proposed helmet law just sat there.  “No one wants to wear a helmet”, they were told.  Most of the police did not like it, the transportation department did not support it, and none of the politicians would touch it. 

In 1990, Dr. Varma and his family traveled to northern India for a vacation.  Upon arriving, he was greeted by the local police who carried an urgent message that he was needed back in Bangalore.  Their police convoy rushed the doctor to a nearby airport where he boarded a small plane for a flight to New Delhi. 

As he neared Delhi, he learned that the flight to Bangalore was being held, awaiting his arrival.  At Bangalore, he received another police escort to a hospital room where a young man lay with a cracked skull from a motorcycle accident. 

Varma lost no time in examining the injured lad and after completing his diagnosis, prescribed some additional treatment measures.  Then, doctor Varma mustered up the energy to face the hardest task of all, a task he had already performed dozens of other times that year.  He then retired to the adjoining room in order to speak to the parents of the young man.  The room this time was very crowded.  He recognized some of those present – the mayor of Bangalore, the chief police inspector, the state governor, and the Vice President of India.  This boy was the Vice President’s son. 

This time, Varma was able to tell the eager audience and the Vice President that his boy was stable, that he had a cracked skull, and numerous contusions, but he had been lucky.  The damage to his brain appeared to be minimal and with time he should fully recover.  As Varma prepared to leave, the Governor of the state come over to him and said,  “Doctor, Varma, is there anything I can do for you?” 

“Three things”,  Varma immediately blurted out.  “First!  Approve our proposal that all motorcycle riders be required to wear safety helmets.”  “Second”,  he continued, “build a trauma center here in Bangalore so that we may adequately treat persons with these types of injuries”.  “And third”, he said with a smile, “return me to my vacation with the same dispatch that you brought me here”. 

And six hours later Dr. Varma was again with his family, two months later the state government approved the law Varma cherished, and two years later Varma assisted in the opening of a trauma center within the city of Bangalore.  

RATS ARE KEY 

The deadly pneumonic plague in India is a health official’s nightmare.  This plague is known to be caused by a bacterium infection, and also to be transmitted by plague infected fleas that are transported around by infected rats.   

Like the venerated cows of India, rats are also treated as a god by  many of the country’s 740 million Hindus and are allowed free rein in many Indian households.  At some temples of the country, the effort to stifle the outbreak of pneumonic plague took a back seat to an old Hindu practice - rat worship.  It seems that according to Hindu whenever and wherever the god Ganesh travels.  Most Hindu worship services are not complete without an offering to Ganesh and his small friend. 

It has been estimated by numerous researchers that rats consume nearly one-quarter of the produce raised by India farmers.  If this is so, it would be  enough food to feed the entire 900 million population of India for three full months.  Yet rats are protected and rarely killed as it is considered by the Hindu religion to be a sin to kill an associate of their god.  It is not expected that even the pneumonic plague will change this ancient religion-based tradition of venerating rats in India.

November 1994