Down the Rabbit Hole: epilepsy in Tanzania

Epilepsy.  The Swahili word is kifaafaa, origins possibly from the verb “kufaa” meaning “to die”.  Although overshadowed by diseases such as AIDS, tuberculosis, and malaria, most of the same diseases and conditions present in the United States are also present in East Africa.

My interest in epilepsy in Tanzania was sparked over a pot of chocolate fondue in Arusha town.  I had met with my election buddy, founder of “Mwangaza” (www.mwangaza.com) who is working on an epilepsy initiative that will tackle multiple facets of the epilepsy problem within Tanzania over a 2 year time span.

Although the exact prevalence of epilepsy is unknown in Tanzania, it is estimated to be higher than that of western countries, ranging from 5 to 75 cases per 1000 patients (Foresgren, Winkler).  There are many theories, including increased incidences of diseases such as neurocystocercosis, cerebral malaria, and meningitis, head trauma, or toxins.  While there is a growing body of evidence regarding prevalence of epilepsy in sub-Saharan Africa, we have not even begun to go down the rabbit hole.

Cerebral Malaria

Of the four species of plasmodium known to cause malaria, Plasmodium falciparum causes the most severe illness.  Although many cases will remain as simple malaria, complicated malaria can cause acute renal failure, acute respiratory distress syndrome, changes in blood homeostatis, and cerebral malaria.  Cerebral malaria carries a drastically increased risk of mortality and is often characterized by seizures.

As diseased erythrocytes flow through the vasculature of the brain, they begin to stick to the endothelium and disrupt blood flow.  Cytokines are released to fight the disease, but, also do harm to the brain tissue.  Despite treatment, neurological damage may persist.  It is hypothesized that CNS infections, such as cerebral malaria and meningitis, may play a role in epileptigenesis for some patients living with epilepsy in sub-Saharan Africa.

While many questions remain to be answered, undoubtably many patients would benefit from rapid malaria treatment to reduce the risk of progression to complicated malaria.

Neurocysticerosis

Pigs are filthy animals.  Cysticercosis results from infection by Taenia solium, a parasitic worm that is acquired from undercooked pig meat.  Infection with the adult worm causes taeniosis, tapeworm infection.  The worm grows and begins to shed eggs which are released into the host’s feces.

The eggs can then be potentially ingested by other pigs, other humans, or auto-infect the original host.  These hatched worms will never leave the larval stage, but are deposited into the host’s tissue where they develop into cysts capable of causing an immune response.  Inflammation from the host’s immune system attacking the parasite results in the clinical symptoms of cysticercosis.  Eventually the legion will calcify and the inflammation will disappear.

Neurocysticercosis results when the parasite has penetrated the blood brain barrier and forms lesions in the brain tissue.  It is possible that the lesions will be asymptomatic, but there is a growing body of evidence to support high incidences of epilepsy or recurrent seizures in patients with neurocysticercosis (NCC), especially during the phase of intense inflammation.

Without access to neuroimaging technology, it is important for physicians in areas of endemic NCC to be able to identify symptoms.  Cysticercosis can be treated with anti-parasitic medication, such as albendazole and praziquantel, and steroids.  Additionally, anti-epileptic medications are helpful in symptomatically managing the disease.

Neurocysticercosis is the leading cause of adult onset epilepsy in the world, and it is completely preventable.  Increased education on proper hand-washing techniques and the dangers of ingesting undercooked pig meat could significantly reduce the prevalence of seizures and epilepsy in sub-Saharan Africa.

The majority of patients living with epilepsy in sub-Saharan Africa are untreated.  WHO estimates that over 80% of patients with epilepsy in Africa do not receive any treatment.  Untreated epilepsy leads to progressive brain damage, and patients are at risk of physical harm when they seize.  Major obstacles to successfully manage patients with epilepsy include a lack of resources, lack of experience in treating epilepsy among health care professionals, a lack of understanding of the disease for patients living with epilepsy, and cultural barriers. 

Resources

A simple lack of resource is the most obvious reason for the treatment gap.  The only medications I was aware of that were being used to treat epilepsy in Tanzania are phenobarbital, phenytoin, and carbamazepine.  Valproic acid seems to also be a common treatment in third world countries.

In Tanzania, phenobarbital is the most frequently used medication.  It is far from being first line treatment of epilepsy in the United States for the simple reason that many patients taking it turn into a sort of zombie.  It is very difficult, if not impossible, to be high functioning while taking large daily doses of phenobarb to control seizures.  However, it is very effective in controlling seizures and patients can safely take it without needing blood draws.

There is a shortage of neurologists in Tanzania, and with this, there is less understanding in how to effectively manage the disease and manage the medications.  Many health care facilities may not have labs with the capacity to monitor serum levels of carbamazepine or phenytoin, essential to avoid blood dyscrasias and seizures that can result from high phenytoin levels.  Additionally, many patients with epilepsy live in very rural areas, where seeking any kind of medical care is a challenge let alone getting to a larger facility with the capacity to determine serum drug levels.

Carbamazepine is available in Tanzania, but it is only available in larger urban areas.  A challenge for my friend, that is developing the epilepsy initiative, is not only to find patients and get them started on an antiepileptic medication, but also to keep them on that medication.  As she goes out into the villages, she not only has to provide medication on this visit, but ensure that systems are in place for the patient to continue their therapy.  The wider availability of phenobarbital again makes it a more desirable choice for this reason.

Culture

Epilepsy is known as “kifaafaa” in Swahili, which may be translated as “deathdeath”.  The disease is not understood well by the majority of the population and is surrounded by a number of superstitions.  Learning about these was one of the most interesting aspects of the disease; to treat the epileptics of East Africa, these beliefs must also be confronted.

Many people believe that epileptics have been cursed or that they are being possessed.  Under this belief, a person that is seizing is less likely to be helped, even if they fall into the cooking fire.  Many people that have been living with epilepsy for a long time have been badly burned.  Poorly controlled epilepsy also results in decreased brain function, as a result from a lack of oxygen delivered to the brain during seizures.  Epileptics are the victims of social stigma, increased physical risk, and risk of neurological damage. 

Another friend of mine was working to set up a homeless shelter for women in Usa River Village.  He wandered the streets with Ibra, a former student, as an interpreter and met women in the worst situations of life and listened to their stories.  One woman who was of great interest to me, was covered in burns.  She told him she had a “fainting problem”.  She also exhibited neurological damage; she was not really all there.  Her strangeness drew neighbors out of their homes, who in turn laughed at her.  She had virtually no support system, and neither she nor her neighbors understood that her condition could be treated with medication.

Given these stories, my heart goes out to Mwangaza.  I have only begun to go down the rabbit hole, but Mwangaza is already in action, setting out to tackle a disease state that is not only misunderstood by the general population, but also has little scientific research behind the prevalence, origins, and treatment in this geographical area.  If given the opportunity to go back and make myself useful to Mwangaza’s initiative, I would do so in heartbeat.  

References:

Winkler AS et al.  Prevalence, incidence, and clinical characteristics of epilepsy- a community based door-to-door study in northern Tanzania.  Epilepsia 2009; 50(10):2310-2313.

Mbuba CK et al.  The epilepsy treatment gap in developing countries: a systematic review of the magnitude, causes, and intervention strategies.  Epilepsia 2008; 49(9):1491-1503.

Ngoungou EB et al.  Cerebral malaria and epilepsy.  Epilepsia 2008; 49(Suppl. 6): 29-24.

Zafar MJ. Neurocysticercosis.  eMedicine Medscape 2009.  Taken from http://emedicine.medscape.com/article/1168656-overview  on 1 November 2010.

Winkler AS et al.  Epilepsy and neurocysticercosis in sub-Saharan Africa.  Wien Klin Wochenschr 2009; 121(Suppl. 3): 3-12.

Quet F et al.  Meta-analysis of the association between cysticercosis and epilepsy in Africa.  Epilepsia 2010; 51(5):830-837.

An Indian Wedding

"It's not what you are that counts.  It's what they think you are."
-Andy Warhol

I learned the first time I traveled in Tanzania in 2008 that if a man asks you if you are married, you say yes.  It was all too easy to meet handsome young bachelors in East Africa, but easiest to avoid the Borat question- so when we have the sexy time?; and yes, I have been asked this multiple times by men I had been speaking with for more than 5 minutes- if I said that I had left the old ball and chain at home- and even better if I said the hubby was an Arab.

I encountered a similar problem in India, but in general, men were more aggressive in trying to convince me to marry them then just to have sex with them.  I suppose that in addition to sleeping with them, they also hoped that I would fold their laundry for the rest of my life.  Aim high.

I would make up all sorts of stories.  Usually whichever male friend I had been thinking about most recently became the victim of my marriage fantasies.  I would give us all different types of jobs, talk about our plans for children or no children, and invent the histories of our relationship.  I would invent the perfect husband.  On any given day, he could be of any nationality, hold any job or position, and be a perfect scramble of all the best traits I have discovered in the men I know.

My imaginary marital life really blossomed in Pushkar, the first place I went after leaving Ajmer.

After checking into a guest house, I went to see the lake.  Pushkar is a holy city.  It is the one of two places in India with a temple to Brahma.  It is said that Brahma dropped a lotus flower to earth, and where it landed, became Pushkar.  The tourist pocket book is also highly revered.

I was awestruck by the beauty of the the lake and approached the ghat, then led down to the water's edge by holy men for my puja, a sort of Hindu baptism.  I informed the holy man of my family dynamics, instinctively saying that I was married.

Lonely Planet had already warned me to ask a price before starting.

No no.  This is holy.  We do not talk about money.

After I had poured pond juice over my head, I was asked to give money as the blessing for the health and wellness of my family.

I will give 100 rupees.

No no no.  Not even the poorest of peoples gives this amount.  Ok 100 rupees each family member.  This is good price.

I will give 100 rupees.

Imagine my shame a month later, when I returned home, and had to tell the friend  I had named as my life-partner that I had only given 20 rupees for his health and wellness... but what a bargain!

I moved on from Pushkar to Jodhpur, the blue city.  Jodhpur is my favorite place that I stayed in India.  I stayed in the Hare Krishna guest house, which was a dream in itself.  Which undoubtedly influenced my opinion of Jodhpur for the better.

I was there two nights.  The second night was Christmas.  Both nights there was a wedding celebration for our neighbor held next door.  Christmas night was the actual wedding ceremony.

Hearing music, we ran downstairs to see a terrified groom on a horse surrounded by dancing family members and friends.  The wedding was to be held 2 kilometers away.

Manou, a member of the family that ran the guest house, was going and asked who wanted a ride over on his motorcycle.  I can never turn a free motorcycle ride down.  I got on with a 30 year old veteran traveler from Belgium and we were whisked away.

Unlike American weddings, food is served to the guests buffet style (Indians love a good buffet) before the bride and groom even enter for the ceremony.  Half of the guests were dressed in the finest saris and the other half wore jeans and a sweatshirt.  The Belgian woman and I were making some small talk with guests and children and were led backstage to meet the bride by the children.

She was absolutely beautiful.  She was 24 years old, covered in henna, adorned with heavy gold jewelery and jewels and wearing a heavy looking bedazzled red sari.  She spoke good English.  She told us she was nervous.  She had never met her future husband.  We assured her that he was very good looking.

He has kind eyes, I offered.

We took pictures with her and wished her luck.  Back outside, Manou was eager to go.  He had finished eating and it was cold.  We waited until the bride and groom came out to the stage for the ceremony then left.  They are not supposed to look at each other until the wedding night, but they stole glances of each other from the corners of their eyes.  Manou told us that he was married a year ago.  He showed us pictures of him with his wife.  They looked happier together than I could ever hope to be.

She is beauuuutiful! You are very lucky.  We gushed.

She is lucky.  He corrected us.

He explained,
In America, you love first, then live together.  In India, the opposite- first you live together, then you love each other.

Its a leap of faith.

Experiencing the wedding in Jodhpur wasn't the last time in India that I would consider what I wanted from relationships in my life.  However, I'll save my marriage proposal in Khajuraho for another entry.

Women

The black dress seemed excessively revealing- because it was astonishing to discover that the lines of her shoulder were fragile and beautiful, and that the diamond band on the wrist of her naked arm gave her the most feminine of all aspects: the look of being chained.

-- Ayn Rand, Atlas Shrugged

Vatsalya's clinic in Jaipur dealt exclusively with truck drivers.  Since the 1990s, HIV awareness in India has been on the rise, but it is still a somewhat taboo topic.  A man and woman should remain virgin until their wedding night, when they are bound to love and honor their partner that they have most likely met for the first time this night.  It seems crazy, but so is the American divorce rate.

Long distance truck drivers leave their homes for days at a time to deliver goods across India, leaving their wives and families behind.

"These men have needs," Doctor Rahul explained.

As a result, there is a lot of prostitution near the rest stops.  The men bring home HIV, gonorrhea, and chlamydia to their wives who often feel to ashamed to tell their husband of their ailment or to seek medical help.  Vatsalya's aim is to fulfill the need for treatment and education in this population.

One day at a extension clinic, one of the male nurses invited us to see a female sex worker.  As we walked out toward the main road, he explained to me:

Female sex worker has four qualities
1: She has other job.  She shines the shoes or sells the things in her area of prostitution.
2: Her husband he travels.
3: She is very wealthy so she can pay the men for sex.
4: She likes the sex.

Wait.  I'm sorry I misunderstood.  You mean to say that her husband left her and that she is so impoverished the only thing left she has to sell is her body, correct?

No.  Female sex worker is very wealthy.  Unless she pays the men they do not wish to cheat on the wife.

I really hope that he was kidding.  I also know that he was completely serious in telling me this.

We found the women sitting on the side of the road in front of their shoe shining stations.  Some were probably female sex workers.  Maybe others weren't.  The nurse said that a man would approach and signal to them.  If they responded to the signal, they were a sex worker and they would work out their deal.  I decided that I needed to go to Ajmer to see the project dealing with female sex workers.  I needed a more complete picture of the problems.

Ajmer.

I woke up early to get there as soon as possible, in hopes of starting work that day.  I arrived and the coordinator was away for a meeting.  Tomorrow you will start.  So I spent the day exploring.

The next day I got up, refreshed, eager to start.  I met the coordinator when he came in the night before and we had arranged for me to shadow some of the educators to female sex worker hot spots.  Again it did not work out to go.  I made the decision to leave that day for Pushkar and start traveling.

It was interesting to have that little glimpse of the project in Ajmer.  Unlike the Jaipur project, it was solely an awareness and condom use program.  Women were not tested for sexually transmitted infections, although they were often taken to sites where they could be tested.  Women who were already HIV positive did not fall into the targeted patient population.  These women were taken care of by other organizations or by the government run HIV clinics.

Education goes a long way.  Although many women knew that sex with a condom was safe sex, men would often offer to pay extra to have sex without one.  Vatsalya's projects were so interesting because they educated both sides of the problem.  Educating sex workers and educating their clientele were equally important in reducing the spread of HIV and sexually transmitted infections.  Prevention is the best cure.

A ride in an Indian helicopter

I think everybody should be nice to everybody.
    -- Andy Warhol


My second week of volunteering, a third volunteer arrived.  A Canadian girl who had been living in South Korea (teaching English naturally) for the past 4 years.  She was pretty cool.  We had the same sense of humor and definitely the same travel style.  I could have easily traveled around the country with her.  But our timing didn't match up.  And maybe she thought I was boring.  You can never really tell.  Anyway

We heard that there was a Pizza Hut at Crystal Palm mall at Go-Down Circle (how can you forget names like these?) so decided to make a day of it.  We got there too early and nothing was open yet, except this one ice cream shop that also served coffee.  


Coffee.


My biggest regrets about not learning enough Hindi was not knowing how to say "Please get me a big pot of strong black coffee".  Essential.  This phrase would have significantly improved my travel experience.


The coffee making process was so painfully slow that it was funny.  I was trying to look away and not watch because I was about ready to climb over the counter and make it myself.  

We sipped our western coffee at the edge of a fountain in front of a westernized mall talking about goals in life and I look to my side and there is a woman on the other edge of the fence surrounding the building.  Dirty.  Hair messy.  With a baby, without pants.  She is begging for change.  


That brought me down pretty quick.  It is true that there is a lot of poverty in India.  But there is also a lot of poverty in East Africa.  There is poverty in the United States.  It just seems so much worse in India because it is easy to forget where I am, enjoy my western luxuries, then suddenly realize how many people are desperate to feed themselves with the money that I just spent on coffee.  And unlike the U.S., there is no support system for people who are unable to make enough wages to support themselves, and their families.  


I later forgot about them, enjoyed my mall window shopping and ate an entire personal pizza at Pizza Hut.  Only to again return outside and see her with her other children.  This time I felt worse.  All I could think

I didn't need to eat the whole thing.


I worked at a summer camp in the summer of 2006.  A girl I had known previously as a camper was also on staff.  But she was different.  She was maybe close to 100 lbs lighter.  Her eyes were dull.  She had no energy.  She lost her spirit.  She had spent a semester in India and had been so touched by the poverty she encountered that she decided that she too must suffer.  


Well that's sweet.  I'm sure all the impoverished people in India really appreciated the efforts of this upper-middle class American girl to starve along side them.


Why?

There really is no reason.  No matter how much you want to help other people you should always put yourself first.  If you are not helping yourself, you aren't helping anyone.  I honestly have no qualms about spending money on myself.  Maybe I've been reading too much Ayn Rand.  But still


I didn't need to eat the whole thing.

We spent the rest of the day at Galta Temple (aka Monkey Temple) and I fed monkeys... so great!  Just some advice; Don't feed baby monkey while mama monkey is watching.  It was bad news bears (or just bad news macaques, but either way, just don't do it).

The following day we went to Amber Fort, also awesome.  Many people living around tourist sites rely on tourists to make their living.  Needless to say, we encountered several unrelenting salesmen.






200 rupees! 200 rupees!


I wouldn't take it if it were free.


Alright, 100 rupees, I give you 10!


I really can't help but admire the determination.  


It's the Indian "no".  You say "no" three times and on the forth time, you have no choice but to say yes.  The majority of chotchkies I brought home were results of the Indian "no", and, in retrospect, I am completely satisfied with everything I bought.  So the Indian "no" really does pay off in its own way.




Another daily favorite, a man was trying to lure us into his took took... "come take a ride in an Indian helicopter"


Now, that's a way to get a girl's attention.

Luxury and Love

An artist is somebody who produces things that people don't need to have.
   -- Andy Warhol


If I had planned my trip knowing what I know now, I would have done it in reverse.  I was excited about volunteering, but even more excited about getting to see India.  I enjoyed my days at the clinic, but it was hard to concentrate on anything other than planning my weekend adventures.  

My first weekend in India I traveled with the other volunteer.  He had come with a friend from college who was working with disabled children in Delhi so on Friday evening, the two of us took a bus to Bharatpur where we met up with the friend at a guest house.  In the morning, we made friends with 2 German guys who were also there to see the Keoladeo Ghana National Park, home to over 230 species of birds.


I've never been much of a bird watcher but was honestly sold on the fact that bicycles could be rented inside the park.  Also, Bharatpur is about an hour away from Agra so it was an easy day stop before going to see the Taj Mahal the next day.

The five of us hired a guide from the guest house and set out on bicycles to explore.  Since the 1700s, Keoladeo had been a popular hunting ground for maharajas.  There was even a monument commemorating the number of birds killed on an annual duck hunt day, which was in the thousands for some years.  In 1972, Keoladeo became a national park and the annual duck hunts ended.  We also explored some downtown and saw the fort.

No matter how seemingly small the towns I visited seemed, they all had forts.  It took less than 15 minutes to walk through downtown Bharatpur and as we came to the other edge of town, we "found" a massive fort and moat.  Surreal.  When I moved to Boston, I was amazed at how old the buildings were.  Paled in comparison to India.   


We took a bus to Agra that night.  We started waiting at a smaller bus stop.  After an hour of waiting on the side of the road in the cold as buses passed us by I was insisting that we needed to get to the official bus stand despite the other guys insisting that we didn't need to waste 50 rupees (about $1) on a took took.


Get into the took took! I'm paying!


Its easy to get carried away with budgeting while traveling but I'm all about paying the extra dollar for the extra luxury.  Just because I'm budgeting doesn't mean I have to torture myself.

We ended up waiting another hour + at the bus stop, so by the time we got to the guest house in Agra, it was past midnight and freezing.  I was tired but ran up the steps to the roof top and could see the Taj illuminated in the distance by the moonlight and city light.

Despite being tired, I woke up early to see the sunrise around the Taj.  The sun came up opposite the Taj, but it was still beautiful in the morning light.  The Taj Mahal is one of those monuments that is so characteristically touristy of India but still everyone really should see it.  It is easy to take a good picture of the Taj because it is absolutely impossible to make it look bad.  Conversely, no picture really does it justice.  Seeing it was like a dream.


The Taj Mahal was built by Shah Jahan, for his second wife, Mumtaz.  Mumtaz was the favored wife despite being second.  She was Persian and very beautiful.  She also had 14 children, while the other wives had none.  


During her life, Shah Jahan told her that he would build a monument to their love, so that people thousands of years later could look upon it and remember the love that they had for each other.  It was intended to be a palace for her, but she died during childbirth #14.  He started construction the same year, but as a mausoleum.  It took 22 years to build, completed in 1653 and is made of marble, inlaid with semi-precious stones.

While I am touched by this story of love, Shah Jahan must have loved himself just as much.  After completion of the Taj Mahal, Shah Jahan started construction on a black "Taj Mahal" across the river from the site of his wife's grave.  Plans for the construction exceeded the costs of the first monument, and Shah Jahan's own son had him "imprisoned" in Agra fort.  


Just saying, but I saw where he was "imprisoned" and they can "imprison" me there any day.  Just saying.


From the fort, Shah Jahan was able to see his beautiful monument down the river.  He died in the fort and his son had his body floated down the river where it was buried alongside Mumtaz. 


Shah Jahan's body is the only non-symetrical aspect to the Taj Mahal.


In India, they do luxury right.

Clinic in Jaipur

Everything has its beauty but not everyone sees it
    -- Andy Warhol

Jaipur.  Capital of the state of Rajasthan.  Not the finest city in Rajasthan, but definitely a hub.  The best way to describe Jaipur (and India in general) is as the most beautiful and most filthy place I've ever seen.  We spent Wednesday exploring then started at the clinic the following day.

The clinic was on the outskirts of town, where all the trucks stopped to load or to rest. Every morning I watched the cook sweep piles of rat droppings of the floor.  There was no lab, but there was a kitchen so chai was served as often as possible to keep us warm.  Awareness workers on the street conducted educational seminars and games then informed truck drivers of the clinic.  Daily, there were also "extension clinics", which ended up being the doctor, the counselor, and us sitting in one of the winding alley ways or in an empty shop with a make-shift room concealed by curtains where the doctor could examine the patient.


Although patients were understandably not receptive to having a 23 year old white girl accompany the doctor to examine them, the doctor discussed with us the patient case in English after the patient had left.  Most times it was ghonorrhea.  I'm actually struggling to think of a patient that came that did not have ghonorrhea.  I can think of one.   I got to see a hernia.  Unfortunately, we could not treat so we referred out for surgery.

The American boy and I were under the care of Doctor Rahul.  Doctor Rahul wore glasses and sweaters knit by his wife (everyone at the clinic proudly wore sweaters that their wives had made for them) and frequently would softly start to sing love songs.  A father or grandfather character, so warm and welcoming.  My favorite memory of him is the first Friday at the clinic, we discussed our plans for the weekend.  He insisted that we must see the zoo and offered to drive us back to the guesthouse after work, but needed to make a stop along the way near to the zoo.


ok fine, sounds good.

We pull over to a spot near the Albert Hall and get out of the car.  Like many other parts of Jaipur, there is trash everywhere.  Most of it is foodstuff.  And so many crows sitting on a fence crowing and pecking through the trash.  Our good Doctor Rahul takes out little bowls and proceeds to fill the bowls with rice and curd.


So... we are having lunch here? or a snack?


No.  The doctor places the bowls on the ground and chuckles to himself as the crows peck through the rice.  So we went out of our way to make a stop on the way home for him to feed the crows.  I asked about it.  He said in Hindu belief, crows are the ancestors so everyone takes time every week to come feed the crows.


That makes more sense.


I spent about 2 weeks at the clinic.  We were really limited in what we were able to do (my Hindi is not so good, in fact not good at all) but I asked a lot of questions and learned a lot from the doctor and other clinic members.  I also made a medication guide of the antibiotics used, which Hitesh (the other founder of Vatsalya) has promised to translate to Hindi so that this can be handed out with the medications (I still have to look it over and send back the final edition).  I also had the opportunity to see a lot of Jaipur.

Rajasthan is a typical Indian destination for tourists because the maharajas squandered the money of their state to live in luxury and build beautiful monuments, while allowing their state and citizens to collapse into poverty.  It was the last state to agree to separate from British rule for Indian independence, I presume because the maharajas didn't want to lose their power to a national Indian government.  The Singh's were the last ruling power in Rajasthan.  Jaipur is known as the pink city, because old town is all painted this really terrible salmon color.

The first week, I saw the City Palace (beautiful, but not as good as the one in Udaipur) also Jantar Mantar.  On display at the city palace are 2 massive jugs made of silver, the largest items ever made of silver.  The maharaja had them made for a visit to England.  He didn't trust the water quality of the United Kingdom so brought along polluted holy water from the Ganges in these jugs for drinking.  I can't resist a good self portrait in a reflective surface.

Jantar Mantar was built by Jai Singh in the 1700s designed for astronomy observation.  As this is not my area of expertise, I appreciated all the interesting shapes and structures without real understanding of their meaning.  The massive sundial, samrat yantra, tells the time in Jaipur to an accuracy of 2 seconds.  There were also special structures, resembling sun dials, for each of the astrological signs.  It was surreal just being there.

Vatsalya

And your own life while its happening to you never has any atmosphere until it becomes a memory.
       -- Andy Warhol

I was paired with Vatsalya, www.vatsalya.org.  The organization was initially created to help street children but has since expanded to other projects as well.  The organization runs a clinic around the truck rest stop in Jaipur, where doctors test long distance truck drivers for STIs (sexually transmitted infections).  Although HIV awareness activities are conducted around the area outside the clinic, the clinic does not have a lab so patients are referred to government facilities for testing.  Vatsalya also runs a "sex workers project" in Ajmer, 3 hours west of Jaipur.  This project is more awareness oriented, as educators go out to sex worker hot spots and teach prostitutes to protect themselves from HIV and other sexually transmitted infections.


The other volunteer and I were first taken to the orphanage in Acherol, called "Udayan".  Both middle men had failed to inform the parent organization that we would be coming, so we kind of just showed up.


It was cold.  The orphanage was placed far back from the main road.  It was peaceful and quiet.  We arrived right before prayer time and met another volunteer who was on her way out, also American.  We watched the children say prayer.  Beautiful.  Singing and lots of repetition of the word "shanti", peace in Hindi.

After dinner we went into the kitchen to get chai.  The kitchen staff mostly just spoke Hindi, but we stayed and socialized.  The big aunty in the kitchen said something in Hindi about me being a boy, or boy hair (my Hindi isn't good enough to really know) and I replied indignantly, "Meh lerki hu!"... "I'm a girl!" and pretended to look upset, which they all thought was hilarious.  I started talking with one boy putting ghee on chapati.  He told me he was from South Africa.  Apparently, there are no elephants there, but dinosaurs are a common sight.


Both nights I stayed there there was a traveling group of musicians.  Good evening entertainment, but I was so jet-lagged I fell asleep and the singer was making fun of me in Hindi and Urdu.  oops.  


From the other volunteer, we learned more about the organization and got some useful tips.  She had a lot of pent up frustrations and most of what she said was pretty negative.  I told her that night


You are going to get home and find out that you experienced a lot more than you think


After that she had a much better attitude and realized, despite how awful and frustrating some things were, she really had experienced India.  Some things, the only thing you can do is laugh.

I only stayed at Udayan for 2 nights.  Most of what I saw was all smiles.  Playing with the kids and trying to learn Hindi from them at meal times.  I picked up a book in the dorm I was staying in, written by Jaimala, one of the founders of Vatsalya, "Eighteen million question marks: The street children of India".  She had written about the children of Vatsalya, changing their names.  It was hard to believe what these children had been through before coming. 


In particular, I learned of one little girl who was less than 12 years old but had learned how to take care of herself on the streets by giving sexual favors.  Mistaking this for love, she continued to "sex play" and to try to get the other children to engage.  As a result, she lived separate from the other children and had special counseling.

Despite their pasts, children are children.  They have the same needs for attention and my interactions had been the same as those with American children and the children of Tanzania.  My favorite memory is ballroom dancing to Hindi music with some of the little girls on my last morning before they went off to school.


We met the founders of Vatsalya on the second night who had come to see the music group and discussed our goals for volunteering.  Despite not knowing about us until we had showed up, they were very accommodating and we arranged to go to Jaipur the next day.

Love Affair

I wonder if its possible to have a love affair that lasts forever
    -- Andy Warhol


I returned from spending 4 1/2 weeks in India last night and have been reviewing my journal, trying to make sense of the things that I experienced.  Despite how quickly that time went by, I think of my first few days and the things that I felt and experienced and it just seems lightyears away.


I arrived in Delhi on December 6, at 2 am Indian time, which was 1 pm Boston time.  Flight was without incidence and, despite my insecurities, someone from my volunteer organization had sent a driver to get me.


I struggled to make conversation (I'm sure the driver just wanted to sleep) and gazed out the window, trying to catch a glimpse of the city which was covered in thick white fog or smoke.


"Has there been a fire recently?" I naively asked.


Actually Delhi, as well as many other Indian cities, is just so polluted that it is always densely covered in smog.  Lucky for me, when photographed it kind of just looks like a mystical mist.  Unlucky, it was a struggle to breathe and I developed an upper respiratory infection during my second week (which I treated with azithromycin, Indian regimen 500 mg for 3 days).


Back at volunteer headquarters, I immediately fell asleep.  I struggled to wake up the next morning and met the other volunteers.  After socializing, we were given a 30 minute introduction to India, Hinduism, and Hindi.  I had unknowingly went through 2 middle men for the volunteer placement, so all of us were to be split up into separate projects.  Only one other volunteer, a 20 year old American male, and I were doing the HIV program, which was based out of Jaipur.  We went with the coordinator afterwards to get a bus.


After 10 minutes of waiting for a bus, the coordinator decided his time was not to be wasted and started to arrange for us to go by cab.  I saw a man approaching.  He was covered in white and red face paint, adorned with jewelry, and while his chest was bare, he had cloth hanging about his neck.  I looked down and noticed he had a decorative dagger on a belt about his waist... and nothing else on.


I averted my gaze so as not to see his unholy genitals.  He came right to my face and was muttering something in, most likely, Hindi.  He showed me a sixth finger growing out of the side of each pinkie and wiggled them for me.  This must be where he got his holy powers.  He then moved on to the other American and proceeded to bless him.  


We were thankfully saved by the coordinator who had finished arranging the cab and jumped into the car.  The holy man kept his head pressed close to the car window, still chanting, but thankfully the car door blocked view of his genitals.


"I just saw that man's penis."  the American said.


Welcome to India.  This is going to be an adventure.