15 apr 2006 - growing pains

mumbai is the epitome of an overpopulated city. it continues to push the constraints of its geography, yet manages somehow to always find room for more people. the slums are the smoke and mirrors with which a finite area--its capacity long since exhausted--is made to accomodate still more. people are crammed beside each other and stacked upon each other in what precious little space there is. while population density estimates are often wildly disparate, simply dividing population (~18,000,000 by a 2005 estimate) by land area (437 sq km) puts mumbai's density at ~40,000/sq km. many of the slums have a much higher density, though i won't hazard a guess to try to quantify exactly how much more. i also personally think the population is greater than the official estimate given the difficulty in accurately counting the number of slum residents, a demographic that makes up ~40% of mumbai's population. manhattan, by comparison, has a population density of ~25,000/sq km. finding consistent figures for population density of other populous cities of the world is very difficult, but they are almost without exception significantly less than mumbai's. in any case, superlatives aren't necessary to make my basic point: there are a lot of people here in a small amount of space.

i promised more stories and less commentary this time. here are a few selected details about some of the children i spent time with this past week.


nargis is a 14-year-old girl who came up to me on three separate occasions asking for an examination. she complained of body aches all three times and wanted medicine from me. i found nothing significant on her exam (all three of them) and explained to her that her body aches because every morning she has to go fetch water for her house in several heavy containers and drag it back about 2.5 km. all three times i told her that i really couldn't give her any medication for that, and all three times she frowned at me and walked away.

shyam is a 14-year-old boy who is tall for his age and could be called lanky. he is in fact skinny--too skinny--and he told me he wants to gain weight and build muscle mass as he lifted up his shirt and showed me his sunken pecs. i told him he needs to eat more (he is malnourished) but i don't know if it's possible.

elsie is an 11-year-old girl with asthma. she has never previously been told she is an asthmatic, though she's been having almost nightly symptoms for years. we classify asthma into four groups: mild intermittent, mild persistent, moderate persistent, and severe persistent, based on the characteristics and frequency of attacks. by history she falls into the moderate persistent category, and she was wheezing when i listened to her during my exam. so i bought her a bronchodilator to use when she has attacks and spent some time the next day showing her how to use it properly. i noticed a reluctance on her part to take the inhaler from me and show me that she understood how to use it, but i didn't think much of it. about 20 minutes later, though, i found her outside in the hallway crying. she didn't want the inhaler because it made her different from everyone else. i explained to her that she could keep it hidden in her pocket or under her pillow at home, and that no one had to know she has it. but i'm still not sure she will ever use it.


kajal is a 13-year-old girl who refused to tell me her age. 'i don't tell my age to anyone,' she replied when i asked. 'i need to know,' i said. 'nope,' she said. i persevered, and finally she relented by writing it in pencil on the table and then quickly erasing it. i usually walk over to the slum in which the children reside and then ride the bus with them to the akanksha center to which they go for their after school program. on tuesday, kajal comes and sits next to me on the bus with a big smile on her face. 'i have your number!' she proclaims triumphantly. 'what do you mean you have my number?' i ask. 'i have it!' she says, beaming. 'which number?' i asked. 'i don't have it memorized yet,' she says, 'but i have it written down at home.' 'where did you get it?' i asked. and she pointed to the luggage tag on my messenger bag, in which i carry my stethoscope, flashlight, and some medications and dressings. 'that's my number in the u.s.,' i tell her. her hand goes up to her mouth in a look of shock. 'what's your number here?' she asks me, and demands i take out the mobile phone i carry with me. she then proceeds to take my pen from my shirt pocket and write down my mumbai number on her hand (that never happens to me). she hasn't called me yet (that's more familiar territory).

jyoti is a 12-year-old girl who lost her father last june to tuberculosis. she has two younger brothers whom she looks after with a lot of love. her mother, parvati, is actively involved with akanksha, and comes to the center most days with the kids from their slum and serves as a sort of liaison between akanksha and the other children's parents. jyoti has trouble with her vision at night and itches all over her body most nights, too, both signs of vitamin a deficiency, which many of the children have. she's goofy, she loves to play with my medical equipment, and on several separate occasions took my stethoscope and flashlight and tried to examine me. she concluded that while my eyes and throat looked fine, i did not have a heart.

jeetendra is a 13-year-old boy who's a fantastic cricket player and a genuinely good kid. he is the humble captain of his cricket team, comprised of kids from his slum, and last month led them to the championship of a tournament between the teams from multiple slums around mumbai. thursday when we were playing cricket outside while waiting for the bus to come take us back to the slum, he smacked a ball so hard it literally split at its seams into two, ending the game (there was only one ball). jeetendra first came to me complaining of some chest pain on his left side which appeared to be a muscle strain in his rib cage. 'just take it easy with the swings for a few days,' i told him, then got distracted with some other kids and wasn't able to complete his exam. the next day i found him and said let me just finish with you, and that's when i discovered the striking difference in size between his right and left thighs. the quadriceps muscles on his right leg had wasted away almost completely, and he had significant weakness there compared with his left leg. the process had taken place over about a year, he said. he doesn't wear shorts anymore, he told me, because he's embarrassed by it. i suspected this was a consequence of polio, and after reading on it that night, i think he has something called post-polio syndrome, in which the virus (which he must've had and survived when he was younger, though he couldn't recall) reactivates and affects focal muscle groups innervated by common nerves. there isn't an effective treatment from what i could gather, all you can do is hope it is self-limited.

pankaj is one of the children i'll never meet. by all accounts, though, he was beloved by his peers. he was a 13-year-old boy who died a few months ago when he was hit by a train after he unwittingly ran onto the railroad tracks while chasing a kite near his home. pankaj also loved to play cricket and so the other kids from his slum, in tribute, spent two days clearing a parcel of land that had essentially become a dumping ground, turning it into a cricket field. they proceeded to designate it 'pankaj's cricket club,' etching his name into a stone wall at its edge, in a touching monument to their deceased friend.

as i've said before, these children give me extraordinary access into their lives. they trust me. they show me their homes and communities, introduce me to their parents, and share their dreams with me. they show a fondness for me that i can't help feeling that i don't deserve--not so soon. but in truth, i reciprocate their adulation and become attached to them quite quickly myself. as a result, i find it exceedingly difficult to leave each center and move on to the next.

i've posted some more of my favorite pictures from the past two weeks at the following locations. check them out, as they are worth much more than my words could ever convey:

more mumbai photos (smaller files for slower connections & smaller monitors)

more mumbai photos (larger files for faster connections & larger monitors)

much love from mumbai,
sachin

8 apr 2006 - the audacity of hope

i've been in india a week now, for those of you who didn't know i was here (sorry). i came to help a nongovernmental organization (ngo) called akanksha (www.akanksha.org) that works with slum children here in bombay. read about them on their website (which is excellent, i'd really encourage you to read some of the kids' quotes under the 'i am here for me' part, they're beautiful) if you're interested, they do incredible work providing educational opportunities for these kids. akanksha runs programs after school at spaces near each of the slums in which the children reside. often they bus them from their slums everyday before or after school to the nearby spaces and then spend ~3 hours on additional educational and extracurricular activities.

there are lots of problems, as you might imagine, that come with living in the slums. sanitation, hygiene, clean water, for example. access to health care is also a big one. i'm here to modestly assist on that front, as i'm doing medical checkups on all of the kids in each of as many centers as i can get to in the time i'm here. i'm unfortunately on my own, though, as there is no supervising doctor, and we are very resource poor. i have my stethoscope and a penlight in need of new batteries. i usually take the kids to the corner of the classroom and talk to them a while and then do a basic physical exam. for the girls, i usually take them to a stairwell landing upstairs, and have them lie on a mat on the ground to complete my exam on them -- it's as much of a private space as we have. i'm seeing a lot of dermatological problems like impetigo and pyodermas, malaria, ascariasis (worms), anemia, lice, ringworm, vision problems, diarrheal diseases, the occasional TB, and a host of others. for the diagnoses that i am confident about that are treatable with meds, i'll write the name of the drug, the dose, and duration, and either the teacher, the social worker, or i will go to the chemist (pharmacy) and buy them for the child. it's pretty informal here, if you want mefloquine for malaria, just ask for it and they'll give it to you, no prescription necessary.

i'm hindered, of course, by my inexperience, but i'm doing my best. the kids that absolutely require lab tests (a girl that i think has malaria needed a peripheral blood smear yesterday), and those that are more complicated or serious, i send to the government hospital. but the parents hate taking their kids there and often don't, so i try to do as much as i can, because they trust me. that means i make some presumptive diagnoses that i can't prove with lab tests that would normally be routine at home, but that i have a high clinical suspicion for. i am able to connect to a really powerful medical reference resource called 'up to date,' which i have access to remotely from my medical center's computer network in detroit, and i'm relying on it for a lot of guidance -- it's basically my attending right now.

so that's the means by which i am getting to my end of interacting with these kids. they are inspiring to their very core. they live in the most difficult of circumstances: small, cramped, makeshift homes of concrete floors and corrugated roofs no larger than many of our bathrooms or closets. they are shoehorned into spaces that are chosen based solely on their availability in this teeming, overflowing city -- alongside railroad tracks, on pavements beside main roads, under bridges and overpasses. they are subjected to dirt, pollution, heat, disease, and hunger. they must drink unclean water and defecate by the railroad tracks. they must withstand abuse--verbal, physical, sexual--from society and often their own parents. many fathers have left their homes, having squandered what little money they had on alcohol and gambling, leaving them with only their mothers or as orphans. they are shunned by the government, condescended to by society, and written off by virtually everyone. they are regarded as worthless nuisances, parasitic products of the bottom rung of society. they are looked down upon as poverty's contemptible procreation.

in reality, the slum dwellers make the city run. they are the rickshaw drivers, the vegetable vendors, and the servants. they collect the trash, sweep the floors, and deliver the tiffins at lunch time. without them, the city would be brought to its knees. they deserve a place to live and a certain standard of living, both of which they are mostly denied. many of the adults have given up, they have been defeated by a life of suffering and hopelessness.

yet the children persevere. if only you could meet them, believe me, your heart would be buoyed by their spirit. they are young, and they have known no other life than that of the slums, but with the help of akanksha, they believe in themselves. they desperately want an opportunity, and they dare to dream big, of improving their lives, of achieving and advancing themselves through education. how they personify the audacity of hope.

they are beautiful, they are curious, and there are many that are incredibly gifted. take 14 year old hina, for example, who came up to me the first day and asked me if it was hard to become a doctor. i asked her if that's what she wanted to do, and she smiled with self assurance and said, 'yes, that is my dream.' i watch her sometimes at the center, the way she furrows her brow in concentration when she thinks, when she seeks to understand; the way she explains complex concepts to her peers, and the passion she has for learning. i believe she will be a doctor some day, but more importantly, she does, too. these children will be given an opportunity--thanks to akanksha, especially--small though it may be, and i believe (i hope?) many of them will seize upon it and succeed, despite intimidating odds and a deck stacked squarely against them. this, to me, is a fairer application of the concept of personal responsibility.

i've already grown close to many of them. they accepted and embraced me immediately, and they make my day everyday. they've given me tremendous access into their lives, as well, and i'll share some stories and photos from my time with them in my future writings.

their city, bombay, is full of contradictions, of a stunning juxtaposition of poverty and wealth; there are no protected pockets, no sheltered areas. the staggering dichotomy between the haves and the have nots is evident everywhere you look. it is the legless beggar sitting below the louis vuitton display window, asking for money, at the taj hotel by the gateway of india in colaba in south bombay. it's the barefoot, naked, 5 year old ragpicker boy, scavenging for anything of value in a pile of garbage beside the railway station as a wealthy, 17 year old girl with gucci jeans, driven by her driver in her air conditioned toyota qualis suv, passes by. the poverty is so pervasive, that most mumbaikars (residents of the city) don't even see it. they look right past. it's not a criticism, it's an observation. i don't know how you could do much else, quite honestly, given the scope.

i have been placed in a flat near one of the slums (called dharavi), in a part of bombay called sion. it's centrally located, buried in a crowded, easily disguised maze of lanes. but i've grown accustomed to the area and have carved out in my mind the pockets of recognition that get me home each night, despite often coming from different directions. i ride the local trains to all the slum sites, and i'll be sure to write about riding the central line, for instance, during rush hour here sometime. space, including personal space, is at a premium always. it's been great learning and exploring the city for myself. staying with family, as i normally do when i'm here, shelters me from most of what i've been seeing and doing here this time. but i also get to spend time with my extended family when i'm free, as most of them live right here in bombay, so it's the best of both worlds.

so that's my intro. i'll write mostly stories and anecdotes in my future posts, but wanted to start with a frame of reference. i hope you're all doing well, and that life is good.

much love from mumbai,
sachin