Shit Luck & Slum Health: Dropping Your Phone into Sewage Slush

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What would you do if you dropped your cell phone in raw human sewage in the middle of a slum?

This was my dilemma last week in Bhopal. I was rushing to the airport, navigating my way on foot through a slum in Old Town, dodging potholes with my roll-a-luggage, when I bumped my cell phone off my hip clip and it flew into the gulley of raw human sewage, right where I had seen boys pooing the day before. The image of one lad was fresh in my mind. He must have been 3 years old. While maintaining his squat nicely throughout the download, he waved at me with one hand and screamed "Hello, Hello, Vat Yer Name, Vat Yer Name, Hello, Hello?" The image vanished as I realized the task before me.

Option A: Don't even think about going for it. Head to airport.
Option B: Look dejected and deeply troubled until a good Samaritan comes and gets it out for you. Offer them a cash reward.
Option C: Start screaming "Oh No, Hurry Hurry - Aye-oooooo, Julthee, Julthee" As people gather, wave a 100 rupee note and see who goes for it.
Option D: Delve in with your hands and pick it out.

I pondered for ten long seconds.
Mind you this wasn't your average plastic Nokia Indian cell phone, it was my Palm Treo PDA-Personal Digital Assistant. Basically, my secretary was drowning before my eyes and I had to take action. Given my rush to catch a plane and the thought of all the necessary information I had stored in that phone (all my Indian contacts, my calendar, my medical drug encyclopedia and clinical software programs), I chose Option D and fished out the phone. It was submerged in brown tarry goop. A lady in a nearby shack brought me a bucket of water to wash my hands and gently rinse off the phone. I dropped the phone into a spare plastic bag and rushed off to find an auto rickshaw. After airport security clearance, I dashed to the bathroom and used Dettol soap to scrub my hands and my phone. The smell wouldn't go away. While trying to use the phone, I discerned that clots of gunk had gotten stuck in the ports on the bottom of the phone. The phone was optically sensing the micro-poo-pieces lodged in the ports and thought it was the cable connecting to my laptop so the phone was stuck in "Synchronizing with Computer, Please Wait....." mode.

On the plane, I asked the air hostess for a plastic tea stirrer that, to my luck, looked more like an olive spear. I broke it into pieces and used it as a tool to dissect out the poo pieces. After 15 minutes of using my cadaveric trained surgical precision, with full sterile procedure taking care not to fling pieces on my neighbor or get my hands dirty, I had managed to dislodge all the major pieces. "Synchronizing with Computer" had disappeared. Victory! Unfortunately, I had more hurdles ahead. I quickly learned that none of the buttons on the phone worked. I reached home and scrubbed the phone more. The following day, I took it to a phone repair center for a thorough inside clean-job. 250 rupees and 24 hours later, I had my phone back in order with 80% of the buttons working and only 10% of the stench still present.

In a perfect world all kids would poo like this boy from the classic Japanese children's book Everybody Poops.

"washes his hands" "with soap and water" the cartoon forgot to add

Unfortunately, the situation in slums is quite different. Due to the rush to catch my flight and my acute traumatic reaction, I was unable to photodocument my experience. But with a little imagination, you can put the following 3 pictures together (obtained from Google Images) and recreate the exact scene.

I gained great compassion for those who don't have toilets and especially for those slum-dwellers who may occasionally drop something into the sewage gully. This is more than a few little boys. 32% of humans currently live in slums. The UN predicts that before 2030, two billion more people will be crammed into urban spaces. Slum health is a serious issue that I will write more about in future postings. If you'd like a nice overview you can read this article titled Slum Health: From Understanding to Action, co-authored by one of my professors Dr. Lee Riley.

But for now, in honor of going into sewage to get what you really want in life, I present my favorite movie vignette of all time, from the award-winning Slumdog Millionaire. Although I got my cell phone back and was able to rehabilitate it, I didn't get an Amitabh Bachan autograph like this brave soul.

For Emergency Dial Auspicious 1-0-8, not 9-1-1

Get your cell phones out and put 1-0-8 on Speed Dial in case you find yourself in India with an emergency. Although certain Indian states tried using 911 as the code to dial (based on  Western movies and TV shows), some locales faced excessive prank calls and the number 911 was discontinued. Furthermore, the average Indian can remember 108 much easier than 911 based on its cultural significance (read on!).

Surprisingly, India has never had a coordinated Emergency Response service until a public-private partnership sprung up in 2005. The Emergency Management and Research Institute (EMRI) has handled emergencies in an increasing number of Indian cities and is now present in 10 of India's 28 states. It is a toll-free 24-7 service for health, fire, and police related emergencies.  Testimonies vary from hour long waits to prompt service. Some people still prefer to take their loved ones directly to an Emergency Room, or they have the number for an ambulance based at the closest hospital to where they live. However, most people panic and don’t have such prepared plans, thus 108 is providing a niche service to many in unanticipated need.

In Tamil Nadu, the Southeastern Indian state where I’m based, Mrs. G. Saraswathi got up close and personal with this new service when she delivered twins in the ambulance at the hands of paramedics. So far 15 deliveries have taken place inside the ambulances in Tamil Nadu. Since the service was introduced, 1,709 calls have been attended to reports a Special Correspondent from The Hindu on November 5th.

Why 108? 

It's a favorite astrological number in Hinduism, Buddhism, Jainism, and Sikhism that has many meanings.

*The prayer beads that Indians use (japamalas) have 108 beads.

*Ancient Vedic scholars correctly predicted that:

-The distance between the Earth and Moon is 108 times the diameter of the Moon

-The distance between the Earth and Sun is 108 times the diameter of the Sun

-The diameter of the Sun is 108 times the diameter of the Earth

*Ayurveda, Indian traditional healing system, believes there are 108 pressure points.

*Lord Shiva's cosmic dance, Nataraja, is done in 108 poses

*Lord Krishna flirted with 108 gopis: cow-herd-girls

*Most Hindu deities have 108 names that are ceremoniously recited

*Many Buddhist temples have 108 steps

*In mathematics 108 is a semiperfect number and a tetranacci number

*Hundreds of other 108 significances can be viewed here:

108 for 1.1 Billion

1.1 billion people become a challenge for scalability of such emergency services. In addition, crowds and Indian traffic create extra hurdles for 108. This photo I took shows a 108 ambulance trying to penetrate a huge crowd of pilgrims taking up the road.

At this pilgrimage I attended ~500,000 people came to walk a holy circuit and the one lane road was packed like sardines for over 24 hours straight. The pilgrimage was a challenging 14km around a mountain, which must be undertaken barefoot, in a sea of people, which I equate to a 5-hour moving mosh pit. Children, the elderly, and the disabled do the circuit as well for many believe that completing the pradakshina (circumambulation) will bestow you with good health and success. I saw one man with a shortened leg hobbling along in makeshift crutches and suddenly my toes (which I stubbed 3 times amongst the crowd) didn't hurt as much. Throughout the night I saw several 108 ambulances battling the crowds trying to get through and I wondered how 108 is faring in other parts of India.

"100 million limbs are at risk of amputation!"

Diabetes in India: A Sandal Scandal

"India will have 50 million diabetics by 2010. Close to 20% of all diabetics have some form of amputation and surveys indicate that 60% of these amputations are because of wrong or no footwear" said Mr. Vijay Viswanathan, Managing Director of the MV Hospital for Diabetes. Although he was referring to unpublished data which was likely somewhat exaggerated, India is becoming the diabetes capital of the world.

During the first week of November when Diastep was launched, a new Indian sandal for low-risk diabetics to prevent foot ulcers and ultimately amputations, I happened to spend a morning at a rural diabetic foot clinic with a physical therapist.

In 150 minutes, we examined 47 patients with diabetes for cracks, callouses, corns, bunions, ulcers, tingling, burning, loss of sensation, and other risk factors for nerve damage, infection, and amputation. The only thing that slowed us down was when the electricity went off and we had to use the light from our cell phones to examine people's feet. That morning I saw the rigor of village life emblazoned on the feet of dozens of farmers, coolies, animal herders, and other rural folk. All the patients had their pre-breakfast glucose checked and they were surprisingly high across the board. My colleague commented on the "post-Diwali glucose surge" (Diwali is the Indian festival of lights where people eat copious sweets with friends and family).

That same afternoon while making a home visit to a patient with HIV/AIDS, we passed a man on the street who the hospital had distributed a tricycle to after he lost his leg from diabetes.  I asked him if I could take his picture and use it to educate others about what can happen in late stages of poorly managed diabetes and he obliged. Mr Subramaniam of NK Pallayam village, featured in the photo below, stated "It started out as a blister on my foot, before I knew it I had to get a below the knee amputation. I didn't take my medicines so things got worse and I had to have an above the knee amputation." His message to other diabetics is "I suffer so you better take care of your diabetes so you don't suffer too. This happened to me because I was careless."

In an attempt to meet the needs of (and profit from) the millions of diabetics in India, Diastep was launched through a collaboration between the MV Hospital for Diabetes, its research wing the Diabetes Research Center, the Novo Nordisk Education Foundation, and the Central Leather Research Institute.

Its special design features address issues such as pressure distribution on the foot, grip, traction, comfort and durability to prevent foot ulcers and infection. “We have the best medical technology in the world but very poor access. Affordability and access are the primary concerns which have to be addressed,” said T. Ramasami, Secretary, Department of Science and Technology, IIT-Chennai. Although such important issues were discussed at the launch, they have yet to be addressed.

At a starting price of 1,350 rupees a pair ($35 USD) who can afford Diastep? None of the 57 villagers I saw that morning at the diabetic foot clinic, most of whom earn less than $2 dollars a day, could afford Diastep.  Mr. Subramaniam, featured above, couldn't even afford a Diastep for his remaining left leg. He lamented to me, his inability to pay for his insulin injections which totaled less than 500 rupees per month.

Diastep should have hired a cultural anthropologist to assist in marketing and distribution because amputations and special sandals have a long history in India.  I learned that earlier models of the MCR Chappals marketed for diabetics faced resistance from some local people since they were worn by people with leprosy in the past who had peripheral nerve damage and amputations. Perhaps more important than the stigma of special footwear, is the need for gradated pricing and social marketing to the lower socioeconomic classes. My colleagues who work with diabetics told me the on-the-ground reality: many elderly aren't used to wearing shoes, farmers don't like to wear them when they're wading through their fields, and most models are too costly.

Although the multidisciplinary research collaboration to create Diastep was exciting and impressive, is it simply another example of an Indian innovation that will never reach the average Indian? Time will tell if it is really a technological "feet" or a sandal scandal.

Watch a video of the launch of Diastep below set to classical music:

PM safe but CM dead

     A common man died on November 3rd due to the traffic restrictions in place for the visit of Indian Prime Minister Manmohan Singh to the Post Graduate Institute of Medical Education and Research in Chandigarh. Security restrictions during the movement of VVIP’s are notorious for causing inconveniences to the public, but unfortunately this time the delay was fatal.

     The 32-year-old now widow of the patient received a letter from Singh stating “I am writing to you to express my profound sense of sadness at the death of your husband Shri Sumit Verma yesterday. I understand that he could not get access to the Post Graduate Institute of Medical Education and Research, Chandigarh, in time because of the restrictions in place for my visit there. This is something I regret deeply. I have issued instructions, so that in future the authorities are more sensitive to the concerns of the common man, while imposing such restrictions for reasons of security.”

     What changes will actually take place? In a country of 1.1 billion people is this a “collateral damage” or “necessary loss” that is to be expected? My cousin said, “This is India. If 1 person dies like this nobody pays attention. People die every day from tragic accidents. That’s life.” Being a public health practitioner, I’m befuddled by how many of these deaths can be prevented by structural changes.