Tanning and Skin cancer on the Rise

Among white women of college age, one in three visited indoor tanning salons in 2010 according to the CDC.

Oh my pale skinned ladies! What is becoming of us? I thought that the one upside of that whole “Twilight” thing would be a resurgence of appreciation for porcelain skin. Alas, it looks like indoor tanning continues to be a scourge that will take more than hormonally crazed vampire fans to overcome.

This is a really important message and one that seems to fall on deaf ears. I think that it can be very hard for young adults to delay gratification for an abstract gain later in life. We are, after all, the YOLO (you only live once) generation (shudder). Even aesthetic reasons aren’t compelling: “I don’t care if I look like a prune late in life” is a response I get when informing adolescent patients about the consequences of sun exposure. And cancer risk? It hardly seems relevant and gets filtered out with the rest of the fear-based assault by the media and heath professionals.

Despite efforts from many dermatologic organizations and dedicated sunscreen wielding parents (we call my mom sergeant sunscreen), the incidence of melanoma (skin cancer) has increased fourfold since the 1970s for women under 40. Egads!

I don’t know what the answer is. Before I left, I was trying to start a program at my med school where med students and resident physicians would visit sorority houses and answer their questions about skin care etc with an emphasis on sun/UV safety, specifically indoor tanning. For example: many people feel that a base tan is actually protective- what they don’t realize that any suntanned skin is de facto sun damaged skin. In this way, we could treat these college students like the adults that they are and simply answer their questions without shoving information down their throats. Plus, I think that having people close in age might make the message feel a bit more palatable and relevant. But in truth, I don’t know what the best methods are for this intervention.

And I won’t pretend that it’s limited to women in adolescence or very early adulthood. In fact, I am hardly a role model of great sun protection. Even with all education and dedication to dermatology- I too have fallen prey to forgetfulness when it comes to sunscreen: witness my freckles on the right hand side. But I continue to try to be vigilant in my crusade against the sun’s harmful rays even while enjoying my time in India and Thailand. And I’ve learned to accept my paleness- it’s what makes me who I am. Meanwhile, I will try not to sigh every time I see someone’s comment on a friend’s facebook photo: “you look so tan and healthy!”

Baroda by Bike

Perhaps my favorite part of my Gujarati weekend was an hours long bike ride I took with Dr. Verma. An avid cyclist, he arranged for me to borrow a friend’s bike and we headed off around 6:30 am. The ride took us through the outskirts of town, weaving through cars, people, cows, rickshaws, stray dogs and motorcycles. After about 30 min, however, we ended up on a stunning road through several tiny rural villages. It was a perfect way to see the countryside. There is something fascinating about seeing these small, tarp covered homes. I was pondering why they drew my eye more than, say, an impressive concretehouse in the city and I theorized that it’s because the domesticity of these dwellings was much more in your face. We drove by people cooking, giving a bath to (an adorable) baby, brushing their teeth in a drainpipe, drinking tea at one of the innumerable chai stalls, praying, eating etc. Even moving at a decent clip on our bikes- it still felt like a strangely intimate experience.

And when we did stop, everyone was incredibly friendly. First we took a break to see some buffalo being milked because duh. The family who owned them immediately started speaking in Gujarti to Dr. Verma and insisted that we try some fresh milk. I watched the woman of the house clean the tin cup with her sari and did some quick gastrointestinal risk calculations (which, if you’ll excuse some foreshadowing, may have been sorely misguided) and decided that of course I need to at least try a sip. It was rich, creamy and more like a milkshake than anything that we call milk.

Along the way there was lots of flora and fauna to be seen above and beyond the usual multitude of cows and dogs: monkeys, wild peacocks (!) and colorful parakeets were the highlight but we also saw lots of other big birds (my father, a bird enthusiast, will be appalled but not at all surprised to see me reveal my avian ignorance. Dad, some looked like egrets or ibises or cranes or something? Best I can do). Let’s also not forget the veritable zoo of insects that wedged themselves into my eyes/mouth as we pedaled (it’s just like home!) or the two dead snakes we saw. 

But the real treasure of this ride was simply the lush, green countryside- dotted with farms, banyon trees and incredible foliage. Throughout our journey Dr. Verma (who is almost 30 years my senior) was, of course, riding circles around me- that man has some serious stamina! He was fresh as a daisy after almost 4 hours of riding. Luckily I am used to people double my age smoking me on the running path at home so my ego wasn’t even dented. I am so grateful that he let me tag along and see his beautiful state in this unique way. 

 

Donate Your Caller Tune for Public Health

As many of you know, I love telemedicine and have done some research in this area. I am always interested, therefore, in novel applications of telemedicine- especially to public health.

So I was excited when I learned that I would be attending the launch of the “Donate your caller tune” initiative. This program, created by the WHO Indian country office, allows users to transform their caller tune into a public health message of their choosing. Caller tunes are less popular in the US but they are essentially “ringbacks”- a song (typically a Bollywood song here in India) that someone hears instead of a ringtone when they are calling you. Participants in this program sign up through the internet or by scanning a QR code (made out of a celebrity’s face) with their smart phone. They choose a cause (cervical cancer, diabetes, fitness, high blood pressure, breast cancer etc) and anyone who calls them will hear a message from a celeb related to that cause. For example, the caller tune for obesity is recorded by John Abraham, a popular Bollywood actor/model: 

“Hi this is John Abraham and I think that obesity can be beat. Say no to smoking, drinking, junk food. Say yes to walking, running, dancing. And remember, this won’t happen overnight- so be patient, don’t give up. For more information visit donateyourcallertune.in”

Nata Menabde, WHO’s ambassador to India explained the rationale behind the initiative: 

“The idea is to reach out with creative messages for adopting healthy lifestyles. India has one of the largest mobile users in this world and on an average, a person receives around 15 calls a day, making the space of caller tune an untapped area for promoting health causes.”

Always a cynic, I wondered if simply listening to a pre-recorded celebrity message could effect change in thorny public health issues such as obesity or smoking cessation. But the more I thought about it, the more I liked it. As far as I am concerned, this program could serve several functions beyond just broadcasting of the messages:

The use of popular Indian celebrities, mobile phones and current technology such as QR codes gives this public health initiative a youthful, slick feel and reinforces the idea that these issues are relevant.

Most importantly, it creates stakeholders. A young person who changes their caller tune will not hear it themselves, but the very act of doing something related to public health is important. To feeling like an agent of change as opposed to a passive recipient of public health messages. Hopefully it keeps them active in promoting and normalizing these messages and becoming stewards of the health of themselves and their peers.

 

Weekend in Gujarat

I spent the weekend in Vadodara- which is in a state called Gujarat (southwest of New Delhi). I came to stay with Dr. Verma- an esteemed Indian dermatologist who has many connections to Penn. He and his amazing family were so welcoming, kind and  accommodating. From street food to fine cuisine- they fed me so much Gujarati food that a) I’m still full and b) I should get checked for pre-diabetes (Guarati food is known for being sweet). They also showed me around, allowed me to attend dermatology clinic and even clothed me in my first sari!

While at dermatology clinic, Dr. Verma told me that there is a severe shortage of dermatology coverage in India, especially for rural areas. One reason for this coverage gap is that most dermatologists (and other speciality docs) are in cash only private practice. Villagers simply cannot afford it. I also learned that a common practice model is having purely walk-in clinics- which means that patients don’t have set appointments. When I asked him why he did this, he replied that his patients rarely show up on time for appointments- a phenomenon he deemed “Indian Standard Time”

Below are some pictures from my visit to this beautiful city.
 

Grooming tips, courtesy of airtel

I have a love/hate relationship with my international cell phone- a classic black and white Nokia that has lasted me through many stints abroad. I love, for example, that it comes with a flashlight (perfect for developing countries), it’s virtually indestructible and its battery life is so good that that I think need to charge it once a year on the summer solstice. I hate, however, that it takes 45 minutes to compose a text message and that everyone I talk to sounds like they are speaking from a well in middle earth.

Yesterday I added a tick mark into the “hate” column. Thanks to my impatience and clumsy fingers I managed to accidentally subscribe myself to SMS (text message) “tips for good grooming.” I kid you not.

I got the first of these lovely, essential tips at 3:42 am. Now recall- this is an Indian cell phone company. There is no time difference. They chose to wake me up at an ungodly hour.

After a weekend away, I had gotten to my apartment at 2am (thanks to a delayed flight and a 35 minute taxi queue). I was subsequently woken up by a power outage a 3am which caused some unidentifiable device to beep loudly every 4 minutes to alert me that it was running on battery. And I needed to get up at 6:30am to get to work. So when I was woken again by this text I was ready to lose it. But instead, I read it and literally started cackling to myself alone in the dark. I mean, c’mon- you can’t make this stuff up:

So what was this urgent missive?

“The beard gives man (sic) a more masculine look. So, it’s imperative that you shape your beard correctly. For those with a double chin, opt for a full beard. It helps conceal the double chin. For round faces, the best is a short goatee, you can play with the straight lines connecting the beard to the sideburns for a smart look.”

I got my second message this afternoon and it concerns the use and overuse of cologne. I would like to submit it for consideration to several fellows passengers on the metro this morning who clearly are not subscribers to this delightful service. Can’t wait to discover the rest of my grooming tips…

Seeing and being seen at the Taj Mahal

So it wouldn’t be a blog about India if I didn’t write about visiting the Taj Mahal, right? Pretty sure it’s a requirement before they allow you to leave thecountry. I don’t know what to say that hasn’t already been said more eloquently by far more esteemed writers. What I will say is that the Taj is not overrated- it’s truly stunning. Can’t say I want a tomb like this myself but the white marble is eerie and beautiful and elegant. You take off your shoes to walk around and there is something incredible about feeling that 17th century marble under your toes. Or was that some weird exotic fungus I was feeling? Hard to tell. But what’s a little tinea pedis (athlete’s foot) among friends? 

I went with a few other colleagues from the WHO.

We encountered many Indian tourists who felt that we were an attraction unto ourselves. Most would simply take our picture. The more bold ones would rush up and herd us toward their families, saying “you take snaps with us, madam. Snaps please.”

The paparazzi. Love how their backs are to the Taj in order to take a picture of a tourist in a wrinkled scarf.

At one point a couple thrust their (hugely fat and adorable) baby into my arms and asked for “snaps.” I like to imagine the caption in that album: “baby’s first white girl photo.” 

My other favorite story had to be from a kid outside the Taj who was hawking his wares. Most of the kids were selling kitschy Taj-related trinkets. This lil’ entrepreneur, however, was selling what appeared to be a rat. I had so many questions for him that I couldn’t communicate in my limited Hindi: was there a demand for this product- had any tourist actually bought a rat before? Why would I purchase a rat when even an inexperienced rat gatherer could  easily pluck one off the streets for free? In the end I had to agree that, yes, the little vermin was a bargain at 30 rupees (~50 cents) but, no, I would have to defer a purchase at the present time.

We also went to a few other historical sites in Agra: Agra fort and the Tomb of I’timād-ud-Daulah. The latter was probably my favorite stop of the day- calmer and home to some gorgeous mosaics. But without further ado- more pictures: 

Leprosy Mission Hospital

Yesterday I had the opportunity to spend the day at the Leprosy Mission Hospital. It was my favorite day thus far in Delhi. I spent time talking with the patients, hearing their opinions on some educational materials as well as learning about their stories. 

One man told me that he was depressed. He worked as a rickshaw puller and he was beginning to feel numbness in his hands (since leprosy affects the nerves of the hands, it can lead to lack of sensation and inability to use the hands) so was worried about the future of his family. He hoped to become a vegetable seller but wasn’t sure how to accomplish this. He only offered this information when I asked him specifically. He wasn’t asking for money, or assistance- just giving voice to the 

anxieties that clearly haunted him. As for me, I felt that horrible impuissance of feeling like nothing more than an observer of his pain- able only to listen. 

Helping me set up a tripod

Although it was hard to hear stories like that, I left feeling uplifted and humbled by the visit. To say that the patients were amazing is a huge understatement. At one point I was trying to construct an improvised tripod to shoot some video and all the patients were

 helping me- even  one who had no use of his legs. Truly incredible. 

I took care to explain the reason for myphotographs (educational materials) and I asked the patients through a Hindi translator if they had any questions for me. They wanted to know my job, my age and where my family was from but, the translator explained, “they also want to let you know that they are thankful to you for taking the time to come here and take photos and listen to them.” Yes, they were thanking me- a random, probably intrusive visitor. It took me back to the feeling I have many times during medical school (I think I did the best job of voicing it here)– floored and honored by how incredibly generous people can be even when they are suffering.

A few thoughts about leprosy

Although some may think of leprosy as an antiquated or even medieval disease, it is still a huge problem in several countries and leads to significant morbidity and mortality. Although “global eradication” was achieved in 2000 which means that across the world there is less than 1 case per 10,000 people but that figure may be misleading as it takes into account countries where there are zero cases of leprosy. In 2011, for example,  219,075 cases were reported- most in areas of high endemicity- especially in Africa and South Eastern Asia. 

Plaster of paris prosthetic legs for leprosy patients

For those who don’t know- leprosy is a chronic disease caused by Mycobacterium leprae (a mycobacteria is a kind of bacteria). The disease affects the skin, nerves (especially the peripheral nerves- nerves that go to places like hands and feet) as well as the lining of the upper respiratory tract and the eyes. It is spread through respiratory droplets (from the nose and mouth) via prolonged and frequent contact–it is NOT highly contagious.

What most people don’t know about leprosy is that is it completely curable with multidrug therapy (MDT). This treatment is completely free to all patients across the world. However, without treatment or even despite treatment, many patients suffer irreversible damage to their skin, nerves and eyes– leading to disfigurement, muscle wasting, paralysis and blindness. Additionally, there is still significant stigma for patients which leads to psychological distress, marginalization and discrimination.

India

All ready for work in my new Indian clothes

I’ve arrived in India! As some of you know, my preparations for this leg of my journey were somewhat…err…complicated. Getting a visa and trying to find housing in New Delhi felt overwhelming at times but things worked out splendidly as they always tend to. So I’m not homeless! And I didn’t get deported yet!

Jet lagged view from my apartment

Women selling dahl at my local market

One of my great sorrows is that I am not allowed to blog about my work at the World Health Organization (WHO). Because it’s already been incredibly fascinating and I feel very lucky to be here. Seriously lucky. And I have a supervisor who is committed to making this a great learning experiences. By my second day she has started to arrange a meeting with a major newspaper and TV station here and we have arranged a field visit to a rural hospital with a large population of patients with leprosy. But that is all that I will say.

Given that I am unable to talk about my job I will have to work hard to ensure that this doesn’t turn into a chronicle of my inevitable gastrointestinal misadventures. But even if I manage to avoid the salacious tales of digestion, I know it will be hard to refrain from talking about how hot it is here. Spoiler alert: it’s really, really hot. I was walking with the woman I’m staying with (an incredibly nice American who works at the world bank and offered me shelter just as I almost hit a panic mode) and she remarked that it was “pretty nice out and not actually that hot.” Not wanting to appear a pathetic, weak newbie I agreed that it was “very temperate.” Meanwhile I could have filled a swimming pool with the sweat of my pinkie finger alone and I was strategizing how many more steps I could take before I could invent an excuse to stop under a shady tree to “admire something.” Which I did and felt very successful until I realized that I was standing near a dead cat. Signing off now so I can chug some water.