The Gift of Pain

After our rude awakening with the accident our last week in Vellore was a little disturbed. We took about a day to recover from our bumps and bruises before returning to work. I ended up visiting the Paul Brand Leprosy Clinic this week seeing as that is the namesake of the scholarship I received and what originally made this area well known in the medical field. Dr. Brand was an English surgeon working at CMC in Vellore in the 50s and 60s. He would research patients with leprosy at the end of each day to try and piece together the reason the patients had such severe deformities. What they discovered was that even in mangled extremities there remained normal, healthy tissue. Because of this discovery Dr. Brand was able to perform highly successful reconstructive surgery and subsequently also revolutionized the way the world thought about healing ulcers. We now use a number of similar techniques for our diabetes patients in the US, believing that tissue can, in fact, heal if given enough time and if the insult to the tissue is stopped.

With the discoveryabout the tissue Dr. Brand had a huge influx of patients coming for reconstructive surgery and treatment, flooding the CMC hospital and causing problems with the other patients. Leprosy was a highly misunderstood disease with most people believing it occurred due to a curse from God for unpardonable and unmentionable sins. To make matters worse the disfigurement that ensued from the damage was horrific. With necrotic ulcers, missing appendages, and a hole in the middle of the face after losing a nose no one wanted to come close to a leprosy patient. So in conjunction with the help of Dr. Robert Cochrane CMC was given a large piece of land, about 250 acres, near Karigiri Village (30-45 minutes from Vellore by rickshaw and many bumpy roads, not so much fun when you have to go to the bathroom).
The men's ward.
At the time of the purchase, the property was a vast wasteland, something the government found to be suitable for leprosy patients (sarcasm) and figured no one would want to live in that area thereby completely avoiding the social stigma attached to the disease. What developed after obtaining the property and what one see today is absolutely incredbile. As we arrived on our autorickshaw we drove up to a lush paradise with green trees, flowers blooming and an overall peacefulness, rarely found elsewhere in India. We met up with Ms. Koshi, the public relations person, who kindly took time out of her day to give us a private tour aorund the facilities. The design of the center was to fully treat leprosy patients, perform research to further improve care and provide support for the patients and families (physicially and spiritually).

The disease is caused by bacilli that infiltrate nerves causing severe damage causing patients to lose sensation. The bacilli preferred cooler climates and would thus migrate to the coolest areas of the body: the hands, feet, nose, ears, etc, making these locations the site of the most injuries. In turn, individuals would develop deformities from repetitive damage followed by healing or ulcerations, all due to a lack of sensation. To give an example, in Paul Brand's book The Gift of Pain he describes what happens when someone twists their ankle. A healthy person, like you and me, has a signaling mechanism for when you step on the edge of a sidewalk. In the split second you lose your balance a message goes to your brain telling you that you are about to fall on your face or break a tendon or bone. Your brain sends a signal to the appropriate part of the body telling it to compensate for the fall and therefore not injure yourself. A leprosy patient has none of this. Upon stepping on the edge of a curb a leprosy patient will continue to put his or her entire weight on the foot providing enough force to snap a tendon then continue walking as if nothing happened.

You may wonder why this clinic is still around seeing as we have treatment for leprosy now but Ms Koshi informed us that the definition of an eradiacted disease is 1:10,000 (something I have to check is correct but you will see my point in a sec) therefore by definition leprosy is eradicated but due to India's population being so humongous that comes down to about 20-25 new leprosy diagnoses per month (yes I said month)! In addition, the clinic has turned into a large treatment center for diabetes, particularly the treatment of ulceration with the use of casts, new shoes, antibiotic treatment, education and proper dressing changes.

One other interesting note is that we met a beautiful young girl who completely lacked any sensation of pain. She was being treated for a recent foot ulcer and was scooting herself around the hospital in her little wheelchair behind our group. Dr. Brand talks about a similar case in his book where the little girl would bite the tips off of her fingers and use her blood to paint on the walls, fingerpainting quite literally!

The young girl is in the wheelchair.
Now the medical staff knows so much more about these diseases they focus largely on prevention and protection. There is a shoe factory on site that makes the soles of the shoes with special rubber and each pair is specifically made for each patient. They also designed gadgets to assist with everyday activities: fastening a button, combing hair, brushing teeth, writing, etc. All of these things we take for granted, do not even think about having to do each day but each task is a challenge for each of these patients. Another wonderful aspect of the center is they taught weaving techniques and designed tools so that even those patients missing fingers could still participate in the design and creation of something. This reminded me a lot of the women's prison in Nicaragua; the simple act of believing an individual can do something and contribute to society makes such a huge difference in peoples lives. They currently make wavings and do block printing, a very popular Indian art. The blocks are made out of wood and carved into different shapes then dipped in ink and stamped onto fabric. They can then leave the fabric in its natural creme color or they dip it into a liquid (what that liquid is I don't know, we will call is magic liquid) that changes the colors, the fabric and the ink prints. All in all this is quite impressive because they do all this without any fingers.
Making protheses.
We also got to visit the wards to talk with the leprosy patients currently being treated. I often times feel bad being an observer of sick indivuals and especially felt this way with the leprosy patients. Yes, I enjoyed meeting them and talking to them and yes, I learned a great deal from them but I can not help but feel I was invading their privacy in some way or making them feel like they were on display. However, I must say the patients did not seem to mind and actually seemed thankful to have us around after we told them we were medical students from the US. They were willing to talk about their treatment and their ulcers and let us take some photos. The patients on the male ward actually reminded me of VA patients, talking about how long their ulcers have been around and their various ailments, but I also have to say that the patients in India were quite a bit cheerier than those at the VA in San Antonio. At any rate, I wish I could come back and work here but there does not seem to be much demand for OBs. They are in need of dermatologist, ophthalmologists, orthopedeists, general surgeons and ancillary staff. Ms Koshi said we were welcome back any time and that there was lodging there if students wished to do a week long rotation in the future.

We head to Goa, Bangalore and Bombay this weekend to complete our whirlwind tour of India before flying to Istanbul. Hope everyone at home is doing well!! (as usual, pictures to come when I get to a computer that has all parts working properly!)