Let's cure malaria using Integrated Pest Management!!

Once upon a time there was a pretty green frog named Swati. Swati liked to eat so many things in her pond, but her favorite snack was mosquito larvae. Then one day, old farmer Chatterjee decided to use pesticides in his rice paddy. When Swati’s babies were born, the tadpoles each had 2 heads and died. Swati was so sad. Then she got a headache and died too.
Now who was there to eat the mosquito larvae?
Was it the mud fish?
Well, the mud fish would be happy to eat the mosquito larvae, but he’s not feeling very well. The pesticides make him sick too!
No one was left to eat the larvae and the mosquitoes increased too much.
Then old farmer Chatterjee’s granddaughter got a fever with great body pains. Suddenly she had a seizure was brought to hospital in Srikakulam. The doctors say she has cerebral malaria! This is too, too bad.


Oh the tangled web we weave. So, the frogs and this certain mudfish used to keep the malaria mosquitoes under control by eating the mosquito larvae. But then agricultural pesticides came into use, and destroyed many of these larvivorous species. Without these natural control mechanisms, malaria became rampant. So the government mounted a DDT spray campaign, which worked well… for a while. But what we see often in this situation is a rebound mosquito population even bigger than the original. We also see that mosquitoes develop resistance to the effects of DDT.

And DDT has effects on creatures besides mosquitoes. Birds and fish, for instance. It tends to kill them. Rachel Carson wrote about all this back in 1962, in her landmark book Silent Spring. Since then, evidence is accumulating that DDT has serious effects in humans, as well. DDT is one of the POP's (persistent organic pesticide) we hear about in the news. It is a fat-soluble organochlorine insecticide and it accumulates in fat tissue, such as the breast, and becomes concentrated in mother’s milk. It can have neurotoxic effects in children, and increases risk of breast cancer 5 fold, according to some studies.

Worldwide, malaria kills about 3 million people every year. The statistics alone are impressive, but there’s so much that they just don’t convey. A pretty common scenario is for somebody in a family to get sick with fever at least every couple of months. The fever may be malaria or not, but usually the doctor treats any fever lasting more than a few days because the odds are so high. The fever is incredibly painful to experience, and scary to witness. You feel so helpless. Children miss school, adults miss work. The financial burden of missed work and medical expenses is really significant. This is the kind of ongoing drain on the time and health and capacity of people here that’s difficult to quantify.

The proportions of the tragedy definitely warrant some risks, possibly even the use of toxins like DDT, but we get stuck in these arguments without seeing that entirely different approaches are possible. The other major intervention advocated by groups like the World Health Organization is pesticide-impregnated mosquito nets. They sound like a great idea, but here, you just suffocate inside them. It’s impossible to sleep under these nets (and breath at the same time), and so nobody would use them, even if they were supplied free of charge.
So what CAN we do?

Integrated pest management makes sense to me. This is a system based on the understanding that living systems are complicated and the fundamental principle of life is BALANCE. Generally, it doesn’t work to eliminate a species, even if it is a dastardly one like the mosquito. Instead we work with the natural systems that maintain a favorable equilibrium. This way, we’re less likely to mess up big and do something like feed DDT to babies.

There are lots of methods at our disposal -- natural predators and parasites, complementary crops that increase pest-resistance, physical techniques like mulch and compost, cultural practices, etc. All the principles of permaculture are relevant. We can shift our paradigm from the false binary thinking of good/evil, kill/be killed, and instead use our ecological wisdom to increase the strength of the whole system, and reduce or eliminate the use of chemical inputs.

I found an interesting article about a project in Karnataka where they actually eliminated Anopheles mosquitoes from the community within a year of introducing Poecilia reticulata fish into the wells and streams. Of course this needs to be done carefully because these are non-native species. I’ll be talking about these ideas when I give the infectious disease training module. Hopefully it will spark some enthusiasm in the field workers and we can start to develop a project of our own in this area.

Sometimes, the most powerful ways of affecting health don’t have much to do with medicine.

I’m going to Hyderabad soon for a visit, hopefully I’ll have some nice pictures for the next entry.

Comfort Foods

I grew up on an interesting mix of comfort foods: rice and beans on the one hand, cholent and chicken soup on the other. The other night I literally dreamt about (California style) Mexican food with heaps of sweet and juicy heirloom tomato cubes and gorgeous green chunks of velvety ripe avocado. Steaming handmade tortillas with frijoles and melted salty cheese ….

Now I’ve discovered a new comfort food: pongal. It’s a breakfast food that’s relatively mild. Usually breakfast food in the South includes pungent chutneys and spicy curries. They’re served with some kind of bread, like idli (steamed cake of fermented rice flour), dosa (crispy over-sized crepe made from gram flour) or puri (flaky chewy fried little round). Lunch and dinner always include rice and dhal, along with some kind of vegetable curry.

So what’s my new favorite food made from? Well, rice and dhal, of course. But in pongal they’re cooked together so it has this texture that’s like… baby food. In fact, it’s just like kichedee, which is the first food that Indian mothers give to their babies. I love it. Madam cooks it with garlic, mustard seed, curry leaves and only a little chili. I like it mixed with curd (but then, what don’t I like topped with yogurt?)

Well, as much as I love pongal, I was getting ready to join a cult after so many days of rice and dhal (with the occasional garnish of banana curry, egg curry, curry curry) when I was unexpectedly served some very interesting food. First, was mutton. That just means meat. No idea what kind, probably goat. Hopefully goat. I was honestly afraid to ask.

Then, madam kept wanting me to try this other dish called junnu. It looked so odd. Spongy and tan. I asked if it was sweet and she said no. But it was, so I saved it for dessert and ended up really liking it. Turns out, it’s colostrum! It comes from a cow in the first 3 days after she’s calved. It’s cooked by steaming so it’s like a flan, and it’s flavored with jaggery (that reduced cane juice). So it’s like a super-food! Packed with nutrition. And it’s tastes really nice.

I’m still preparing the teaching modules which means a lot of time at the computer. I loaded my mac with podcasts before I came, so while I wait for the internet, I listen to Science Friday with Ira Flato, Visionary Activist with Caroline Casey, and KQED’s Forum with the brilliant Michael Krazny. Good thing I loaded up because the internet is too slow to download any new ones.

My room at the girl’s hostel is great, but things get very loud around here at midnight. I’m not sure why, but it happens every night! I think it’s when they put away their books and just relax for a while before bed. The building is all concrete block, open hallways around a central courtyard, so noises resonate and there’s no way to sleep through it, and I hear them shouting to each other, "Puspa!! Aparna!!". Here’s a picture of my stuff in my room at the hostel (Jana, notice your pillow – I use it every night!), and some pictures from a recent excursion into Parlakmendhi, where I bought my train ticket to Hyderabad. There’s a shot of the pan wallah, the juice wallah, and the Gokul ad and the King’s house are especially for D. The king was in town, and I was issued an invitation to visit him the next day, but it rained and I couldn’t make it.

AND…. A big shout out to Clara Dorothy. Well done little girl (Man, that was fast!), and Happy, Happy Birthday! We’re all SO glad you’re here.

Back to School

I’ve been staying at the BREDS office, which has been pretty nice. It’s a simple room with a view of the rice paddies out the window. There’s a TV and an air conditioner. Neither of them work, but they’re big and make for good furniture. A few species of lizards to keep me company and some dogs to steal my chappals (flip flops) every now and then (no shoes indoors). Chinnamuru manages to make the curries spicy even though I say no chili, and I get to practice my Telegu greetings with BREDS staffers daily. I’ve never seen brighter smiles or more graceful greetings than here.

One day, Sir told me I am moving to the girl’s hostel at JITM, a small college across the border in Orissa. (Sir is Ramakrishna Raju, the head of BREDS. Everyone just calls him Sir). And the next day I ‘shifted’. Sir lives on campus at the faculty housing (he lectures at the CSREM college next door) and his wife is in their apartment all day, cooking 3 meals. Both their boys are away at school, so I expect she’s a little bored. She doesn’t speak any English, but somehow we manage to communicate a little, I treat her herniated lumbar disc with Su Jok, and we laugh over the hammy Hindi TV serials (soap operas).

When I first moved in, they were constructing a building behind the hostel, but no road reached there, so they had to carry bricks and plaster and rebar through the girl’s hostel. Most of the workers were females who carried their loads in wide, shallow bowls on their heads. Lines of ladies in sarees, heads loaded high, would wend their way through the ground floor of the building. They seemed very interested in looking at me and despite their loads, would step out of the way to watch me go by. One even managed a head wobble greeting from under a huge sack of cement.

There is internet available more frequently here, so I can use some online resources to research and prepare the trainings, and correspond with some experts who may be able to help future projects. The plan is basically to save the environment, rescue humanity from poverty and disease. I should be done in another few weeks.

Here are pictures of the local laundromat and the ox-wash.
Soundtrack: Khaled and KanYe this week!

Fever dreams and Molish

Hmmmm….. How can I describe the despair of delirium and fever when you are isolated in the middle of rice paddies, no reliable medical services for at least 5 tortuous hours in a jeep, no one who speaks English to understand why you’re sobbing, and of course you’re in the tropics and have a medical education so the differential diagnosis running through your clammy brain is … prodigous?

Finally Asha arrived, and was kind of shocked to find me in this state. I had just been in bed all day, so no one realized! She was fantastic and cared for me, forcing me to eat, drink tea, and doing molish (I guess it means massage, mostly it was just a pressing/rubbing on my sweaty skin) for a couple of days, until she took ill herself. Then her daughter caught it from her. I felt awful to have spread my contagion so far. They both have recovered fully, but Asha took Suni to the doctor. He gave her a couple of shots of who-knows-what and that cost her 100 Rs (about $2.50). It’s a lot for her.

When Asha couldn’t come, Chinnamuru (the cook), and Parathi, (the wife of the handyman) would show up 3 times a day, cluck over me in Telegu, make me eat a few bites, and do some molish on me. I can’t express how even though being touched felt kind of icky, it was mostly just profoundly healing. It was such an incredibly pure expression of concern and desire to do something to help. Thank goodness for the ladies.

People always think it’s ironic when “the doctor” is sick. I think it’s an important reminder for us, and helps renew our compassion. I know I’m feeling very compassionate right about now! It was interesting, in a way, to observe my own symptoms – fever, pain, weakness, anorexia, maybe a touch of delirium. I felt the illness leave my body pretty abruptly. One day I just could walk steady. Two days later I actually had an appetite. The first time I ate a decent meal, Asha glowed with pride (and some relief, I think).

Now that I’m feeling better, I’m ready to start preparing the teaching modules. I don’t think there will be any more field visits. :[ They’ve been really interesting. Sambamurthi asked me, “Madam, how was field today?” I told him “It was fun.” He nodded and said “Fine.” I had to clarify, “No not ‘fine’, it was ‘FUN.’” First he looked confused, then bemused. He's a very serious man, so it was nice to get a smile out of him.

Here are some last pictures from the field, and one of my Molish Team.
Songs for fever (sangitam oka jwaram): a dreamy mix of iron and wine, Dead Can Dance, Mazzy Star, Sufjan Stevens, Joshua Radin, Sia, Nick Drake.

P.S.
I want to send a shout out to everyone at the Petaluma Health Center. I miss you!
And a huge Happy Birthday to Sadie!! 8 pounds 8 ounces and a head full of hair. Jena, you're a star.

Mysteries of India

We had an overnight at the coast. It was a long drive to get there, but Asha insisted we stop at the Akulamma Talli temple. She is Ammavaru -- mother to the whole world. Here is a picture of her feet. Asha is Muslim, but she likes all the female goddesses, especially. Indians seems pretty flexible that way. I see her giving money to beggars all the time, especially if they’re women. She also likes Sai Baba (not the current fuzzy headed one, the old skinny bandana’d one) and does this kiss your finger touch it to your forehead thing whenever she sees a picture of him. He’s really popular and there are pictures of him painted on buildings everywhere!

We stayed in Palassa. It’s a bigger city with a train station, major cashew processing industry and lots and lots of mosquitoes (doma). We visited a few coastal villages: Baruva, Sompeta, Baipali and Kunduvanpeta. One issue that keeps coming up is “over-bleeding” (menorrhagia). (Very) informal survey reveals at least 50% incidence and 30% of all women ultimately getting a hysterectomy.

So it goes like this: you get married in your early 20’s, have your two babies, usually within 5 years, then you get your tubal by the time you are in your 30's. By your 40's, you start “overbleeding”. Menopause is around 45 years here. So the doctor might treat you with hormones for a few months, but then they explain that without a hysterectomy, you will develop cancer. Sometimes an endometrial biopsy is done that confirms this. The women are scared, and get the surgery, which they pay for out of pocket. It costs about 10,000 Rs, which puts these women into debt. After the surgery, many women feel chronic "loss of energy", knee pain and back pain too.

What in the world is going on here?! It has been suggested by some that the surgeons deliberately 'overstate the problem' for personal gain. There seem to be a lot of unethical aspects to medical practice here. For instance, whenever a doctor orders a lab test or an x-ray, he gets a cut of the fee! The prices of course are highly inflated because of this. I can't say how shocked I was to hear of this practice. I think it's 10 kinds of illegal in the states.

More Indian mysteries: Why the 6 year old boy who was cinnamon color 1 year ago is now 6 shades darker? What kind of water contamination is going on to cause all the kidney disease concentrated in these coastal villages? What is it about cashew processing that causes asthma? Is there really a 5% incidence of breast cancer in some of these coastal villages, as I’ve been told?

We passed another herd of goats on the road and they’re such a lovely breed (I *really* like goats). I asked Asha “Do people keep goats just for meat, or also for milk?” She said, “No, no. Men and also children. They get it from the forest.”

I guess some Indian mysteries will never be solved….

Caste feelings

I went to a huge meeting in Kotturu of all the angan wari teachers in the district. These ladies are incredible. They are on the frontlines, in the most remote villages, giving basic education to kids who would otherwise have no access, giving midday meals where kids would otherwise go hungry, monitoring children for malnutrition, etc. I asked them about some of their accomplishments and they told me about increased school attendance, improved immunization rates, increased prenatal care. I heard a story about a child whose mother died in childbirth. The teacher was so proud that although the baby was a little undernourished, he was actually surviving and developing well.

I asked what one thing they would do if they had a magic wand. They got excited, and mostly said they would build more angan wari centers. I asked if they like what they do, and YES, they started beaming. It was so inspiring! When I asked about some of the challenges, one of the things they mentioned was “caste feelings”. Some of the teachers are lower caste and parents in the community don’t want to send their children because of that. Never mind that the kids can’t get education anywhere else. Never mind that they’re all equally poor! The caste thing….. I don’t even know what to say. The teachers’ union is having a meeting soon, trying to get guaranteed salaries. I told them I hope they get it and everyone cheered.

They had great questions for me, too. They asked why do newborns sometimes turn yellow? Why do they sometimes have trouble breathing? It was fun to give an impromptu talk about neonatal jaundice, and causes of respiratory distress. We finished up with the surya namaskar, and they got totally got into it!

In the next village, I was approached by the panchayat sarpanch (president of the village). “Shoulder pain,” he said. After some questions, I asked him to take his shirt off for an exam, and actually had to insist cause he was acting shy. I didn’t get it – village guys go around mostly naked all the time! In the jeep ride home, in the middle of all the Telegu chatter, everyone started cracking up. Eventually they told me, he didn’t mind having his shirt off, but he was afraid my range of motion testing would make his panchi (man-skirt) fall down, and he wasn’t wearing any underwear!

Here’s a picture of a lady holding a piece of bellam. It’s an iron rich food, good for pregnant ladies. I tasted it – it’s canela! Yummy cane juice before the molasses is extracted and it’s turned into sugar. In Hindi it’s called jaggery.

My Caste

The other day, I wore some silver anklets like all the ladies here do. Today, before we left my room, Asha held them out for me to put on again. "Compulsory".

We visited a really nice angan wari center in the village of Navatala. Kaluamma is the teacher there. My friend Rachael in Petaluma is an Orf-trained music teacher with a special interest in world music and she’s asked me to bring home a children’s song. Kaluamma taught me the yenegu (elephant) song while we waited for community members to arrive.
Yenegu yenegu nallana,
Yenegu kommalu tellana.
Yenegu meeda Ramudu,
Yetto chakkani devudu!
How beautiful is Lord Rama sitting on the elephant’s back!

This day we met with pregnant ladies. It was so sweet! One woman in particular was just beaming and pleased to be in the 8th month of her first pregnancy. You know her labor will be lovely. Another woman with disheveled hair and sari had sallow skin and such an obviously anxious expression on her face. It was heartbreaking. She looked anemic and neglected. We spent time talking about how important nutrition is, for baby’s development, and for her health. She’s at increased risk for infections like malaria and severe complications at delivery. We tried to make a plan, who was going to help her with food, and care for her. I just wanted to be there with each of them at time of delivery.
**But mostly, Jena, I wish I could be with you! Good luck and make sure Denise is your nurse!**

We talked about how you know when labor begins, and what to expect during labor. We also reiterated that babies need colostrum until mother’s milk comes in. There was a common belief that babies should not eat the first 3 days of life. Sometimes they were given water or cow’s milk, but colostrum was devalued. How can such ideas persist when they so clearly compromise survival? Infant and maternal mortality rates have been so high in this area, there is a big push for institutional (hospital) deliveries. Women are even given cash money (1000 Rs!) if they deliver in the hospital. The program has been very successful and the mortality rates have dropped significantly in the past 2 years.

The government had a similar strategy to address family planning. They gave every woman who (voluntarily) underwent tubal ligation a free sari. (I emphasize voluntary because India has a horrible history of enforced sterilization campaigns, fictionalized memorably in Rohinton Mistry's incredible book A Fine Balance.) Now, most women get the tubal after babies, even without the incentive, but it really makes you think what someone’s life is like when a decision like that can be influenced by the price of one sari.

The first picture is me eating nuvulu (sesame seeds) while the telegas grinds them in the press used by his father, grandfather, etc. The telegas have their own caste even! I decided I'm in the 'field worker' caste with people like Asha and Nell. There's also one of me and "Sir", A. Ramakrishna Raju, the head of BREDS.