India and Thailand 2013 – Breezing Through Nandi Hills

Saturday was a quiet day as I intended initially to go to Nandi Hills or at least visit some famous temples around town, but was stymied by TATA Docomo’s 3G network being off the whole morning. Fearful of wandering without Google maps directions to the bus system, I instead went to the library to study and work in the morning, and by chance at lunch ran into Dr. Bhullar. He told me of a place nearby to buy quality dress shirts for men, which I sorely needed to replenish my stash here (I hadn’t brought enough of those things for work, it seems), as well as to buy high quality fabric on the cheap.

I followed his directions to a shopping complex right beside the Forum Mall, which was called Shopper’s Stop. Apparently it’s a high-end fashion retailer (eek, what have I become). And for the first time in my life I busied myself trying on various shirts, as choosy as any woman. Ironically enough, I felt an odd kinship to Mat Cauthon, whose chapters I had been covering in my audiobook, emphatically claiming to still be the same farmboy despite dressing in fancy robes. “There’s nothing wrong with a good coat for a man.” In the end, I picked out a dark red one and a white one with blue stripes. I would have preferred a different pattern in the end, but the fit of the shirts (size 39 from Austin Reed) was great and the material felt solid. I hadn’t heard of the brand before, but my contacts and wikipedia assure me that it’s solidly upper mid tier.

On the way back, I stopped to get some miscellaneous shopping done, picking up snacks for the next day, batteries for my shaver, and soap.

The next day I awoke early to catch the first bus at 8:30 to Nandi Hills. It was quite an ordeal asking around and trying to find the mysterious platform 13 where all the websites assured me the bus would depart from. Most Indians are useless with these inquiries, but eventually I found that I would have to leave the city bus stand and go across the road to the KSRTC, or long-distance inter-city transport stand. Bummer. Even there, I couldn’t find a sign for platform 13, instead standing between signs 5 and 14, asking around for the bus. Unfortunately all the signs were in Kannada (not even Hindi!) which I couldn’t read. It was only by $deity’s grace that I caught sight of a sign saying that certain platforms were in a new area a bit of a walk away. Great. It’s good that I arrived early anticipating this kind of problem.

And what do you know. As I walked through the tunnel, my eye caught a glimmer of a folded 100 rupee bill on the ground. I quickly, and hopefully surreptitiously, bent down to pick it up. It reminds me of the time in Dublin Airport when Wayne and I (well, mostly me) picked up 40 euros in bills right off the ground. This haul wasn’t nearly as lucrative, though the purchasing power is probably comparable. The find would end up paying for the round trip bus ticket to and from the Hills.

I bought a samosa for 8 rupees to augment my brunch and hopped on the bus. Again, it was labeled only in Kannada, but I was able to confirm with the conductor that it was heading to the Nandi Hills. What happened en route was a very irksome 2 hours of me trying to shut the window (to prevent dust from blowing into my face) and the person beside me on the aisle seat opening it for the breeze.

Luckily he got off a stop or two before the hills, and I was free to enjoy the marvelous open plains leading up to the hills. Then, from the wide expanse opened up a spire into the sky, with a narrow ledge of a road leading up to the top. The bus carefully honked its way around the corners up the slope and we eventually arrived at the top. Somehow I was let in without paying the 5 rupee entrance fee; the ticket seller just waved me on by when I said I was alone without a vehicle. *shrug* Can’t complain about it I guess, though that 5 rupee did go immediate to use paying for the privilege of using a bathroom.

Instead of noticing a map of the layout, I followed the sides of the fort, seeing the many arrow slits along the walls. Tipu Sultan also built a summer residence up here that was stark but opened down to a flight of stairs leading to the bottom. I went down about a quarter of the way before turning back. It’s apparently a path of entry for some visitors to this place.

From there, it was a matter of walking through gardens, old cottages (including former residences of Gandhi and Nehru), restaurants, scenic views of the surrounding countryside, a jungle gym where children roamed, and Tipu’s drop, where he executed prisoners. There’s not much specific to say until I have the pictures uploaded; the sites themselves were enjoyable but not strikingly unique. I guess the unique mix of everything offered on the hill makes it an enjoyable destination. With that said, by early afternoon I had seen everything on the hill, so I had ate a quick noodle dish before heading back to the main gate, viewing the gardens, and catching the 2:30 bus back to Bangalore. The half day excursion, make that full day due to transportation, is definitely worth it for the chance to see the impressive views and take in the relaxing vibe of the hill fort.

India and Thailand 2013 – Second Week Blues

Cough cough. That’s the sound I heard all throughout the second week of chest medicine. The pathology here is less diverse than that seen in dermatology, though almost as interesting. Note that when I say less diverse it still means loads more strange and exotic stuff compared to the US. Thankfully, I trained at HCMC for most of my 4th year, and consider myself relatively proficient on all things TB, much thanks to Dr. Tsukayama.

The work is mostly ward rounds, with the occasional OPD day if you desire it. The day starts with a morning lecture or case presentation (in an odd format with the patient brought sitting in front of a panel of doctors) followed by rounds, then a quick break for lunch if there’s time. The afternoon lecture for the medicine department runs from 2:30 to 4 PM, at which time students are free to leave. Residents have to unfortunately stay to finish notes and handle admissions, including rotating overnight duties.

I’ve taken to spending time in the library reading textbooks (something I didn’t do much of in medical school, thus the joke that I graduated from the Kaplan School of Medicine, though Dr. Fisher’s lectures were bloody effective in Step 2) and ebooks, as well as blogging and working on my books. Speaking of those by the way, the first will be entitled “Life: Your Missing Guide” and will be an evidence based approach to life, work, and love. It’s very much in progress (estimated 1/5 done?). The next, and still very much in the planning phase (meaning don’t expect it for at least 7 years as I plan to write it when I’m well into partial retirement) will be a fictional story (working title The One Thousand and One Threads) of a dwindling tribal family living in the rural mountains of China. It will be a coming of age story of a child growing up in rapidly changing times, in a village that’s being hit with the full force of modernity, while each night the mother weaves thread and tells him stories of the myths and legends of her dying culture.

Anyways, here’s the customary list of pathology seen in the week during chest medicine:

  • Tons of asthma and COPD
  • MRSA pneumonia with chest tube for parapneumonic effusion
  • Strep pneumo pneumonia
  • Post viral respiratory failure and prolonged convalescence requiring tracheostomy
  • Palliative patient post-pneumonia
  • COPD with Parkinson’s
  • Mediastinal lymphadenopathy with bronchoscopic biopsy
  • Adenocarcinoma of lung with systemic mets
  • Bilateral pleural effusion, initially transudative, then exudative
  • Squaemous cell ca of lung with right main bronchus obstruction, also spinocerebellar ataxia
  • HIV patient with TB and MRSA pyopneumothorax (ouch!)
  • Fulminant TB with multiple cold abscesses and laryngeal compression
  • Chronic intermittent cough with wheeze, considering ILD

India and Thailand 2013 – Maharajas and Mysore

Each weekend brings along a new trip, right? You bet! I had originally planned to do a sedate trip to the nearby Nandi Hills to get myself oriented and to continue adjusting to India. But I met up with a few Germans (they’re everywhere it seems) on my first week living in the same wing of the hostel (all the elective students are clustered there). They were the same ones I commented upon earlier with whom I went to eat dinner and watch a movie. On the way back, we discussed going on some weekend excursions together. We decided on going to Mysore on the upcoming weekend, and bought train tickets for Hampi 3 weekends away.

Instead of going to Nandi Hills my first week, I worked overtime on Saturday, which was worthwhile as I saw more interesting pathology in dermatology clinic. Early Sunday, we all got up at 5:45, later than I’d have liked, to try to catch the 171 bus going to the train station. We got on the bus at around 6:15 AM and were a bit pressed for time because the bus stopped in Koramangala for quite a while. I tried to reassure the other two that we’d still likely make our 7:00 AM train, but they insisted on getting a rickshaw for about 200 INR the rest of the way to the station. Even then we arrived barely in time, which turned out to not have mattered as the train didn’t head out until 7:30 (you can always count on an Indian train to be delayed).

This was the first time any of us had traveled in sleeper. It was totally appropriate for a short journey, though I wouldn’t recommend it for actually sleeping overnight. Due to RAC tickets, the moment one vacates one’s seat or berth, someone else can come charging in to claim it. I also wouldn’t be surprised if more than a few second class passengers made their way to sleeper for the better seats. There were way too many people and during the ride we didn’t see the conductor come by once to check tickets. The other two girls slept on their upper berths while I sat and tried to get comfortable on my side upper (the best berth in my opinion) seat, which had someone else sitting on the other end. I listened to my audiobook and read Lonely Planet while waiting out the 3 hour train ride.

Mysore is considered the jewel of south India because of its opulent palace. It’s also one of the cleaner cities in all of India. We headed south east from the train station, relying on Lonely Planet maps as my Google maps didn’t have the city saved for offline use, and my 3G sim card which I had just bought wasn’t activated yet. We passed nice hotels, fenced off mansions, before eventually reaching the market district. It was near noon, and we were all a bit hungry, so we hunkered down at the only restaurant we could find. It was too early for anything major to be served, so I had a dosa and the two girls had multiple cups of coffee and juice.

We decided to go to the palace first, and then head up to the Chamundi Hills in the high afternoon, before coming back to see the palace be lighted up at night, then get dinner, and take the bus back home. On the way, we passed quite a number of touts, rickshaws, and vendors eager for a piece of our business. This was quite shocking as I had previously not seen any of that attitude in the Deccan or in Bangalore. Maybe it was because we were an attractive target, three obvious foreigners traveling in a group, or maybe it is because Mysore is a tourist hotspot. We saw so many other visitors, especially Germans, that the two girls took to a game of guessing their nationalities before sneaking up and eavesdropping to confirm by listening to the language used.

The palace itself is indeed impressive from the outside. The whole city and local area somehow remained nominally self-governing throughout the British Raj period, ruled by the beloved Wodeyar family until independence. The palace is testament to the degree of wealth they possessed. We entered for an inflated 200 INR tourist fee, though that does include audioguides. Nearby is a Hindu temple where we could pay to have our shoes kept and again pay to snap pictures within (argh, I detest the commercialization of temples). There were many tourists and surprisingly locals wandering the palace grounds, which was clear of trash and featured carefully manicured gardens and lawns. We entered the main entrance and walked through a carefully cordoned off sequence of rooms, listening to the audioguide on select stops.

The palace contained polished ivory staircases, pillars made of bronze but made to look like wood (to avoid the fate of  the old palace, which burnt down), cavernous ballrooms, and detailed spanning paintings. The Wodeyars sure knew how to keep a palace! Near the end we circled to a hall of mirrors, designed to reflect infinity. All throughout were reminders of the Hindu religion in paintings, wall carvings, and gates, as well as the twin headed bird that is the sigil of the ruling family. Finally we came to the grand entrance, where many candelabras and chandeliers would light up the night whenever the royal family held a ball. It was also the location from where the Maharaja would address his people, who would be massed in the grounds below. Very ceremonial indeed! Unfortunately, cameras were prohibited inside the palace, but the guard asked for a bribe instead of requiring us to go back to the main gate to check them in! Even still, enough guards were watching inside that we didn’t dare try to snap pictures. As I was wandering through the exhibit, I even saw a man who was surreptitiously snapping shots on his cellphone get busted by a guard. You’ll just have to take my word for it on how amazing the palace is and how it’s definitely worth a visit to Mysore just to see this gem (actually, there’s precious little reason otherwise to visit).

With the sightseeing done, we reapplied sunscreen and rounded the palace to get back to the bus stop. From there it was a short hop to the Chamundi Hills, which were not all that impressive. The top was covered by a flea market selling random local goods (not all that impressive) as well as stuff like kids’ clothing (why?). Beyond the market there was a golden temple with a massive throng of humanity queued up to enter, and undoubtedly experience being herded and shuffled through like cattle with nary a moment to snap a photo. Not unexpectedly, we passed on joining them. Instead, we picked up some cold drinks from some brick and mortar shops nearby and wandered the top of the hill, admiring the mudbrick houses of the locals, and looking down on the plains from the top. We spent most of the time telling “black stories” to each other (read up on it). I didn’t get it at first but it did become surprisingly fun, to a point. It must be a German thing.

With not much to do on the hills, we hailed the same bus heading the other way and got back to the palace. We wandered the markets for a while, not finding anything of interest, and then sat around for a while in a plaza waiting for the sun to go down. Miri was desperately trying to find a spot to recharge a Tata SIM, but there was none to be found, surprisingly. About 3 hours before our bus was scheduled to depart, we went to a restaurant that unfortunately only had south Indian snack food (where *are* all the decent restaurants in Mysore?), which was thankfully still tasty and cheap.

From there it was just a matter of going back to the palace to round out our day. The palace at night is drastically different from the day. Yes, there are tourists swarming the grounds, but no one is allowed into the exhibits, and instead the outside of the building and gate are lit up with incandescent lightbulbs (how wasteful!) light starlight in a dark sky. I stood there marveling at the display but also wondering how much nicer it would be if those things moved about or flashed like Christmas lights.

Our ride back was courtesy of a private bus from SRS Travels. It was comfortable enough, with long curtained beds that were more comfy than the train. However, the bus let in all the honks of Indian roads, as well as jiggled with the occasional pothole, so much that despite how tired we all were, we didn’t get a wink of sleep. To add insult to injury, back in Bangalore, we had to take a rickshaw back to our rooms because the bus ceases to run after 10 PM or so. The one who approached us (red flag!) offered to use a meter, and we were all tired enough to agree without searching too hard for another driver. This one was crafty though. Nora figured out quickly that his meter was tampered with, and ran faster than normal. I also had the suspicion that we were going around in a circuitous route to add cost, though I was slow to confirm this via GPS. In the end, it took 24 km for a ride that should have been half of that, according to Google Maps. The end price came out to be 600 INR for all three of us, after doubling due to the night-time fare increase. Nora was quite indignant and only paid 300 before stomping off across the road. Luckily he shouted at us for a bit but didn’t come chasing after.

From there, we sneaked back into our dorm rooms, bypassing the loosely enforced curfew (they are more lenient for foreigners, perhaps?) to a sound sleep despite the ever so stiff mattress.

On My Own

It certainly feels that way. Recently, I found out that a girl I had a crush on (and went out with a few times) back in undergrad is getting married. While a tiny part of me wishes her joy, the biggest portion is withstanding a torrent of conflicted emotions. There’s a mixture of regret, rekindled passion, fond memories, and longing. In my head I know it’s not just because she ticks off so many items on my checklist, but a trick of the mind in making certain past experiences seem more wonderful than they actually were. Call this the “grass is greener” syndrome or “your ex is always better in your mind than she was in real life”.

Still, it’s not impossible to imagine a wonderful life together with her, were we getting married this instant (hm, I’d do it in the Caribbean). We were compatible in so many ways, but perhaps that one nagging thorn (religion, what else) would have been our downfall in the end. But regardless, the biggest regret will be that nothing was ever explored. Our happy moments together (save for a few that actually happened) will remain the stuff of daydreams for lazy times.

Yes, I can follow my own advice of “hay mejores”, to move on and find more fish in the sea, but the slog can get tiring at times. Oh how easy life would be if I could arrange a marriage for myself Indian style and just be done with this mess.

The Most Inspirational Figures

Throughout medical school, there were a few inspirational characters that have made a mark on my life and way of thinking.

  1. Elizabeth Pisani: I was first exposed when I picked up her book Wisdom of Whores off of Tyler Cowen’s recommendation (he’s surprisingly good for many things, including food advice, book recs, and general econ stuff). She’s got an amazing life story that involves trekking around the globe doing good and having fun at the same time. She was born in the US to British parents, then grew up in Asia learning Indonesian, Mandarin, French, and Spanish. Then she got a job as a journalist for major papers and covered the Tiananmen incident live (which is quite a story). Surprising, in her mid-life, she switched careers and got degrees in public health and epidemiology. This was at the height of the AIDS epidemic, and as such she worked in Indonesia among sex workers coming up with a coherent and effective plan to fight the spread of AIDS, as an advisor to the Indonesian government. This formed the material for her first book. Now she’s running her own consulting agency (Ternyata) and occasionally serves as a keynote speaker. Most recently, she took a sabbatical from work to write another book, this time on the joys and headaches of life in Indonesia. Just by any one of the things mentioned she would have been a hero to me, but by combining travel, public health, adventure, mastery of languages, and work in Asia, all as a single woman is nothing short of astounding.
  2. Dan Ariely: This was another book reference, from Tyler Cowen I believe. I often tell people that it was in med school that I discovered my true passion (in terms of career) – behavioural economics. It came about as a series of books, of which Dan’s is the most entertaining and useful. His main influence is in getting me interested in the field as well as thinking critically about what matters in life in terms of happiness.
  3. Rebecca Zadroga: Similar to Pisani, Becky’s experiences are remarkable. She grew up in Costa Rica, born of American expat parents, and thus is bilingual. Then she went into medicine, graduating from UMN and HCMC, before embarking on a locums career caring for Navajo Indians and Maori in New Zealand, interspersed with backpacking trips around the world. Incidentally, that’s exactly the kind of lifestyle I intend to have, with a dash of public health work thrown in.
  4. Mani Mokalla: The best at the end, no? In this case I’m talking about doing my pediatrics rotation at the end of my 4th year and running into the best staff ever. If I had done my peds rotation with him earlier, it might have fundamentally altered my career trajectory. I don’t see how any student working under him can fail to be inspired by his passion and concern for children. He also again has a moving personal story which may be too personal for me to share here. Unlike many other great clinicians, he pays great attention to teaching in the Socratic style by asking students to read and do research. But at the same time he’s eminently approachable and down to earth. Truly he is a hero of the age!

India and Thailand 2013 – First Week at St. John’s

So I’ve now gotten settled in Bangalore and can kick back to relax a little. The Annexe is a nice accommodation overall, and definitely very reasonably priced considering how high-end a district it’s located in. St. John’s is walled campus that, though surrounded by 4 busy streets, has hardly any noise pollution. It’s truly a retreat to study and contemplate in the best of Catholic traditions.

Annexe III where all the students stay at is a good deal. It costs 10000 INR per month and offers a series of budget-style hotel rooms designed for short-stay guests. Occasionally you may see bigwigs attending various conference here. The elective students are clustered in a hallway on the end of the 3rd floor. Rooms are basic, but with western-style toilets, shower with variable hot water
availability, fan without AC, and hard beds. I eventually stacked the two  mattresses together to provide enough give so as not to develop back pain. There is a loosely enforced no-food, no-alcohol, no-guests, and curfew policy, as this is a Catholic institution.

My first posting is in Dermatology, which I chose due to previous recommendations and the amount of infectious pathology unique to India that can affect the skin. I was not disappointed. Here’s the list of what I saw each day:

  • Erythema nodosum
  • Nodulocystic acne w/ hyperpigmentation
  • Vitiligo
  • Halo nevus
  • Venereal ulcer
  • Post steroid rosacea
  • Tinea cruris
  • Alopecia areata
  • Hair loss from stress
  • Chronic urticaria
  • LSEA vs erythroplasia penile lesion
  • Palmar psoriasis with fissures
  • New HIV with zoster
  • Hansons dz
  • Cutaneous vasculitis
  • Really bad diffuse molluscum contagiosum in a kid with concurrent hyper IgE syndrome (wow!)
  • Psoriatic arthritis
  • Erythema multiforme
  • HSV oral ulcers
  • Seborrheic dermatis
  • Keratosis pilaris
  • Favre racouchot
  • Scabies
  • Forefoot eczema
  • Wart and subsequent cryotherapy
  • Nevus sebaceous
  • Nail psoriasis
  • Post surgical keloid scarring
  • Scleroderma
  • Polymorphous light eruption
  • Mycosis fungoides
  • Macular dermatosis xerosis
  • Lymphangioma circumscripta
  • Icthyosis vulgaris
  • Lichen planus
  • Seborrheic keratosis
  • Photodermatitis
  • Pityriasis alba
  • Pemphigus vegitans
  • Corn excision
  • Monaereal infection
  • Pretibial myxedema
  • Methotrexate toxicity
  • Lymphedema
  • Erythro keratodrma
  • Dermatosis papillosis nigrans
  • Acne keloidalis nuchae
  • Pityriasis rubra pilares
  • Pyoderma gangrenosum

That’s essentially all the possible derm diagnoses in the textbook in just one week! The amount of variety and volume in Indian hospitals is nothing short of amazing. While clinics and inpatient censuses per team in the US average round 10-12 for resident teams, Indian residents routinely handle 30-40 clinic patients and almost as many inpatients. Granted this is not all due to differences in expectations or workload, but made possible by the system. The key reason that Indian doctors are able to see so much more is that they don’t have to chart as much. Close to half the day in the US can be spent just hammering out documentation. Indian clinic appointments on the other hand, last 1-2 minutes at most, and involve a description of symptoms, focal examination, and prescription of medication. While the senior staff is talking, the intern or resident is dutifully scribing the succinct note and filling out the hand prescription form. Inpatient is similarly handled. Presentations are super brief and problem focused. Teaching is minimal. This makes for lightning fast rounds.

The general flow of the day is to begin inpatient rounds at 9:00 AM with staff. Residents barely pre-round, needing just 30 minutes beforehand to gather overnight labs and assess symptomatic changes. Rounds usually finish at 11 AM, leaving some time for notes and orders. Then whenever the residents are ready, they head down to outpatient clinic and sit/scribe with a senior staff member. One of them is usually assigned to a procedure room as well with a dermatosurgery fellow. That segment usually concludes by 1:30 PM, at which time there is a 1 hour lunch break. At 2:30 PM on most days there is a resident or guest lecture. Following that, everyone heads back to the ward to take care of admissions that have built up. Unlike in the US (perhaps because there are so few emergencies in dermatology), patients can hang out for hours on the floor without nursing screaming for admission orders to be written.

I do have a few general observations about how medicine is different in India compared to the US. First of all, the training. In India, the MBBS degree starts after a competitive entrance examination (no interview, mind you) after 12th grade. What follows is 2 years of pre-clinical lectures and 2.5 years of clinical observership. Then there is  1 year internship where the student is in charge of managing patients across medicine, surgery, pediatrics, obg, etc. The student thus graduates after 5.5 years and tries for post-graduate examinations into residency positions. Spots are very competitive, with one Indian resident telling me that there is 1 seat for every 10 MBBS graduates. Therefore, most people have to sit the exam multiple years or otherwise give up and work as a general practitioner.

In terms of how this education process works, I have to say that it is quite effective in drilling in all the theory behind medicine. Indian students are head and shoulders stronger than even the best US students at reciting all the salient features of a disease, and even obscure facts, signs, and methodology. They actually have to read the textbook during medical school! In contrast, because the US has to train adequate clinicians in a shorter period of time, there is greater importance placed on knowing enough about a disease to diagnose and treat. That means eschewing the possibly interesting but clinically negligible things like lab medicine techniques and history of medicine. Heck, some students graduate in the US without even taking courses in certain subjects such as surgical sub-specialties, dermatology, or radiology (due to interest, time, and space limitations). Indian students by contrast have to do clerkships in every single department, often for multiple weeks. At St. John’s, 6 weeks (divided into separate postings cross the years) of dermatology is required. The US student though is better at management at an equivalent level of training. For example, I was quite comfortable suggesting antibiotic therapy, pain management strategies, and palliative measures for things like itching and constipation. For this I was given praise which I felt was somewhat undeserved. I am not better or worse than an Indian 4th year student, just different in the focus of our medical education.

Another interesting difference is patients’ expectations regarding care. Most patients in India are self-payers. Morning clinic costs 40 rupees for a new visit and 30 for follow-up. In the afternoon are private patients paying more for I don’t know what difference in care. The interesting thing is that all the morning self-payers don’t have appointments. They just walk up to the desk, pay, and sit in line for what could be hours. The doctor has to eventually finish seeing everyone (who shows up before a certain time), regardless of how long it takes him (thus the incentive to make visits quick?). Thinking about this, I realized that it would never work in the US. Patients are far too VIP, demanding on-time appointments but also asking questions that consume valuable time, and also grumbling about paying even a small co-pay.

It’s similar on the inpatient side. Patients are mostly cost-conscious self-payers, so they are offered a variety of rooming options. There is the common ward where stacks of beds are lined up in rows. There is no entertainment except for a TV. Women are thankfully in a separate common ward. Then for more well-off patients there is the option of paying more (starting at 250 rupees per day) for private rooms with 3, 2, or just 1 bed, all with dividers between each other of course. Interestingly enough, as we move up with wealth ladder, patients are more likely to have family members by their side, speak English, and have private insurance. There’s not increased VIP tendency though.

The food here is great and really exotic to American taste buds. Most of the restaurants serve local south Indian food, which is delicious enough but possibly slightly foreign to Americans used to an image of Mughlai cuisine of the north. Southern food is eaten more with the hands, is more likely to be veggie, and have a lot of cereal/grain content. Dosas, idly, vada, chapati, chana masala, chole batura, etc are all examples of dishes here that typically involve some kind of fried flour dipped into sauce. Surprisingly, Chinese food is quite popular and considered expensive high-end cuisine. Many shops offer their own knock off interpretations of Chinese food, and I have to say that most of the fried rice I’ve tried has been distinctly subpar.

During the off hours, which were plentiful because most working days last from 9-3, give or take the occasional late afternoon lecture. This leaves plenty of time for reading, eating, and outings into the city. There are many other elective students here, mostly from Germany surprisingly enough. Though there isn’t a direct connection between German schools and St. John’s like there is with my school, students there can choose to do their medicine or surgery rotations abroad, which many decide to arrange for themselves. It’s not surprising given how Germans love to travel. In my corner of the suite I was introduced to three other Germans (though one is technically a Finn). We went out to eat at a restaurant called Empire (which was decent enough, not too expensive but whose food wasn’t all that tasty either). Another evening, we went to a local theatre at Forum Mall, which cost close to western prices, to watch Zero Dark Thirty. I had been eager to see this ever since I saw trailers with Wayne last December. The actual result was quite disappointing however. It felt disjointed, almost as if the director wanted to follow some of what happened in reality but also to build in enough suspense to make for a good movie. The plot was full of unfired guns, loopholes, and loose plot direction. The action sequence at the end was also quite overdone. I can’t explain why the movie is so critically acclaimed, other than chalking it up to differing tastes.

India and Thailand 2013 – Mangos in Mangalore?

Blast it! I miscalculated on distances. The train hop between Goa and Mangalore was only about 4 hours, which meant that I could easily have gone on a sleeper class train (which paradoxically is the one you get when you don’t expect to get much sleep) and saved money. This is because I was dropped off at 2:30 AM in Mangalore station. There I decided to wait for a few hours before trying to walk into town. While I sat in the waiting room, trying to sit still and let the fans work over my tired body, a sudden downpour started outside. Now, this was quite unexpected, mind you, given that the monsoon season is not due for a few more months yet.

With the rain more people came inside into the sheltered waiting room. It was hot and stifling, with fans that spun at low enough speeds not to be of much use. Many people lay on the floor on blankets or clothing. In particular, a Muslim family came in with two children and the wife in a burqa. The man was lying on the floor clutching his abdomen, obviously in pain. Every so often, the wife would come over and rub his abdomen for comfort. Eventually, I felt I had to do something, so I talked with the wife, explaining that I would like to examine him. He had a bit of vitiligo and an acute abdomen in the upper quadrants. He didn’t appear to be too dehydrated, wasn’t febrile, but hadn’t eaten for a few days due to pain. Unfortunately, there wasn’t much I could do. The pills I had on me (ibuprofen, tylenol, and cipro) weren’t too appropriate for him without knowing what was specifically was causing his abdominal pain; don’t want to exacerbate acetaminophen toxicity or worsen a peptic ulcer. Fortunately though, he was on his way to the hospital (via train???) and hopefully would be taken care of there.

When the time got to 5:30 AM, I decided to brave the night and try to walk to some hotels I had decided upon earlier. However, to my consternation, the GPS did not show any hotels nearby and I was having trouble getting my bearings. Then I realized something. I was at a different railway station! Yes, it was still Mangalore, but not Mangalore Central, which was close to downtown and was where I expected to end up. No, I was at Mangalore Junction on the far east side of town, which served as a stop for ongoing trains heading south along the Deccan peninsula. After seeing the distance I had to walk and the darkness outside, I decided to give up and take a rickshaw into town. It was 150 rupees (double because of night-time I imagine) and about 15-20 minutes. The driver was at least honest and didn’t try to charge an exorbitant price or lead me to a dark alley to be murdered.

I had him take me to a potential hotel on my list, but after inquiring there found it all full. The hotel next door had an expensive 2000 rupee room available that I equivocated on, preferring to see my options further down the road. While walking along, an annoying rickshaw driver kept trying to take me to hotels around. He was quite persistent and repeatedly ignored my pleas to leave. Instead I had to stand in the middle of a coil of rope warded off from the street by some barriers for him to eventually give up and drive away. 4 hotels later, I turned left into a narrow alley and found a 800 rupee AC room at Hotel Laxmi Mahal. It was also wifi-equipped, allowing me to check email and update contacts stateside through Talkatone and Google chat.

The hotel itself looked just like any other, with a large bed this time but an annoyingly thin mattress just like every budget hotel in India. The AC worked as advertised, and the shower was basic but tolerable. I took a shower, went down for a basic breakfast, and collapsed on the bed for a few hours.

I eventually woke in the mid-afternoon and decided to take a stroll around town. Mangalore is a remarkably diverse city. It is about 10-15% Catholic (Mangalorean Catholics are distant offshoots of Goans who moved down during Portuguese times, and still have similar converted names), 20% Muslim, and the rest Hindu by my guess. The amazing thing is that the city is dotted by majestic churches, hidden temples, and mosques that denied me admission (like everywhere else in the world so far). Religious harmony is evident, and everyone seems to get along without problems.

I had a delicious but expensive fish curry dish before trying to make my way down to the docks. On the way, I passed Rosario College, a Catholic finishing school (combined high school and college) which was incidentally celebrating graduation (called College day locally). A few enthusiastic students invited me inside to sit in on the ceremony, which I did. I left near the end and chatted with the students outside. The young people here, as in most parts of the world, spoke reasonably good English. We discussed graduation, future plans, and life in Mangalore. The one in particular who took most interest in me told me of his dream of getting a business degree.

I continued down the road, kindly turning down their invitation to stay for the end of festivities, relying on my GPS to roughly get me down to the docks. By luck, I found my way to the end of a small jetty where several men were relaxing by fishing. The view of the coastline was superb, the wind relaxing and gentle. The late afternoon setting sun added a finishing relaxing touch to the whole affair. I felt the urge to lie down and let the rhythm of the place take me in. I chatted with the fishermen for a bit, learning that they were friends who worked in the town and came to this jetty nearly every evening to relax and fish. They don’t catch nearly as much as commercial fishing boats and thus can’t make this into a job, but they do get to eat their catch. :)

The next day I checked out of the hotel early at 5 AM, due to the 24 hour check out policy to avoid being billed for an extra day. I spent the extra time doing some work with the free wifi. I headed out for the day early to catch the 7 AM bus to Ullal beach across the river to the south. It was an hour long drive with some beautiful scenery on the outside as the sun rose. The beach itself was disappointing, however. There was garbage strewn about, the waves were cold, and the mosquitos still hadn’t retreated from the evening. I did lie down and listen to my audiobooks and soaking in as much sunlight as I could manage. Once when I waded into the seashore a particularly strong wave came in and washed one of my sandals out to sea. Curses! I swam out a bit into the water and rescued it before coming back drenched down to my smallclothes. The few others on the beach stared at me, probably because as I would later find out, most Indian people can’t swim.

After a morning at the beach, I hopped on the train back to Mangalore proper, arriving in the early afternoon. Ah, it’s always so refreshing to have the wind blowing through the window on a hot day, even if it does bring along pollution and dust. The afternoon was devoted to going to the Sultan Battery, a local attraction in the northwest of the city. I spent a heck of a time standing outside in the sun trying to find the #16 bus that is said to go there. I think the problem is that the bus came only very intermittently, and stopped in a large street (rather than a proper parking lot or bus stand) with all the other buses making for a very chaotic time trying to see the bus number. I did take the chance to stockpile on bottled mango juice. Man, I’ve become addicted to the “Slice” stuff they package. Imagine 50 US cents for a 600 mL bottle of tasty cold squeezed juice!

With that in my hand, as my rucksack was again heavy after checking out for the day, I arrived at the Sultan Battery. From the outside it wasn’t very impressive. Overlooking the water’s edge, there rose up a small circular tower with musket slits. On top of a flight of gated stairs are benches, likely newly added, for visitors to sit on. It seemed to be a popular place to celebrate birthdays. As I was looking over the ramparts, a group of kids appeared on there and started chatting with me. They seemed enthusiastic and I decided to accompany them in their daily outing. It turned out that these kids were from Canara High School, and had just graduated. They were out today for celebration as a group. Many wore the uniform and colours of their school (shirts for men, saris for women).

We chatted for a while on the battery and then headed down to take a cheap 4 rupee boat ride across the river to a clean and scantly occupied Tannir Bavi beach on the other side. It was remarkable what a gem was so close to the city, so much better when compared to the more famous Ullal beach to the south. We waded into the water for a while before taking some photos and heading back. Again, reflecting the diversity of the group, there were Muslims, Hindus, and Christians as part of the school, and they were all present in the outing. It was a rare look at the daily lives of kids in India, and indeed I got a good look at some western-style dating that has infiltrated their lives. As for technology, all had mobile phones with some degree of data coverage (feature phones from Nokia are most popular, but Android phones mostly from Samsung are making inroads).

We headed back and got some drinks and ice cream before parting. The kids were heading to a mall in the city, and I had a few more hours before my train to Bangalore that I decided to spend watching the sunset from the top of Sultan Battery.

India and Thailand 2013 – Legacy of Da Gama

Woke up at some insane time 3:30am or so. I suppose I managed to sleep that much only because I had been on the road and not sleeping very well there.

So I stayed up, finished my cashews, and popped a tab each of Malarone and Cipro  for malaria prophylaxis and the traveler’s diarrhea I was developing.

The plan for the day was to visit the sights of north Goa before returning to the south for the onward train. I did the usual shower and quick pack. Conveniently my clothes were dry from the hand washing the day prior. Packing cubes are also a lifesaver when trying to organize and compress clothes.

I decided to walk between downtown and the long distance regional bus station 2 km to the north. Along the way, I got a good snapshot of western restaurant chains, churches, and colonial era quaint villas. Interestingly ads on billboards show off new developed property with pools and other luxuries. The old houses are marked with Portuguese last names, a legacy of the 400 years of Portuguese rule where the locals converted to Christianity and adopted the names of their rulers.

I was already a bit hot and sweaty by the time I got to the bus terminal. Curses for the heavy backpack, reluctance to take autorickshaws, and jacket kept wrapped around my waist that I couldn’t stuff into an already full backpack.

After inquiring at the station, I bought a 30 rupee express ticket to Panaji, the regional capital in central Goa. The nearly 1 hour journey had a breathtaking view over the river between the two halves of Goa.

Panaji is quite a walkable town after getting ones bearings. It was near midday by the time I made my way down to the city center from the coastal road. I was sorely in need of some ac and drink so I stopped at Fishland for some Goan specialty – chanok curry rice with lime soda. It was a delicious meal with just a bit of tangy spice.

I continued my way south along a main street to a procession of a giant church, Hindu temple, and closed off mosque. The road made a sloping wind through hills and passing by the Indian high court.

I still had some time left in the afternoon, this time intending to catch the bus to Old Goa. At the station I met mt first tout who was overeager to show me buses to random places. Luckily I shook him off by finding my own bus to Old Goa for 10 rupees, standard fare for medium distances in India.

Old Goa is really a marvel. What was at its height a larger city than Rome or London is now but a hollow shell of monuments and museums. I couldn’t see too many houses for locals in the area. It seemed more like a commuter town where locals come in from the surrounding towns for work in the tourism industry.

Nevertheless there are some quite finely preserved museums of the region’s history, including a giant statue of a Portuguese poet. There was also an impressive collection of portraits of colonial governors and viceroys, as well as the highlights of their reign, done in imitation of the Italian style by native artists. As photos were forbidden, I can only tell you of the curious change in attire over the centuries as petticoats morphed into jackets and then military uniforms before ending in suits.

I also visited the other cathedrals clustered nearby, including one where the remains of Francis Xavier are interred. With that done, I took the bus back to Panaji and then to Margao, lugging my heavy backpack on the 4 km walk to the train station. It was brutal, but I managed the hour+ long walk because I still had all evening to go and I had already checked out of my hotel. Undoubtedly rickshaw drivers passed me by in frustration and locals stared at me in confusion. I didn’t notice any of it.

When I finally hauled my stuff into the station, I was sweaty, tired, and hungry. To my annoyance, the evening train was also delayed by 1.5 hours. Oh well. I passed my time listening to my WOT audiobook and getting dinner from a veg cafe in the station.

India and Thailand 2013 – The Beaches of Goa

The train rumbled into Madgaon station early in the morning and I confirmed my stop with the cabin boy. It’s surprising that they don’t announce or show the station. That would be very helpful especially at night when station names are not visible. The train ended up delayed by an hour overall, which I later learned is common to this area of India due to single track rails. Double track ones are apparently not possible due to difficult terrain.

In terms of compartment, I don’t have much comparison as I only booked AC3. This for me is the best balance of cost-effectiveness, comfort, and berth availability. The fellow passengers are also more likely to be middle class professionals who speak English. Another nice thing about ac trains is that the berths are covered by curtains allowing actually decent sleep.

Anyway, one look at my GPS app showed that I was at the train station in the far south of Goa. I thus slowly made my way to the city proper along small narrow main roads with no sidewalk. At the main city, I stopped for some food before trying to find hotel Tanish, which came highly recommended by lonely planet. Here’s a word of caution regarding relying on LP absolutely. Most authors only try a few hotels and thus can’t make an informed comparison of all available choices. The cycle then propagates as subsequent travelers stick to the tried and adequate. In my experience, the non LP hotels and restaurants are on average neither better nor worse than listed ones. Actually, wikitravels has a more up to date and comprehensive listing, if it does lack for detail and pizzazz sometimes. Go crowdsourcing!

Hotel Tanish is located at the top of a mini shopping mall and acquits itself well. For about 750 rupees, I got an air conditioned double room.
Actually, the hotels in India come standard with double rooms and two people renting would actually only add an incremental 50-150 rupees to the room cost.

In the hotel, I quickly threw down my luggage, showered (would prove to be a recurring theme to make up for overnight sleeper trains without shower facilities. I actually appreciate the freedom that travel with just one backpack gives. A suitcase would be a nightmare to bring along, necessitating cab rides wherever I go, and making day of departure exploration impossible (though in retrospect dragging around a heavy backpack is not much fun either).

But enough of that distraction. I went out in a t-shirt and shorts under my jeans. I picked up a bag of cashews, a Goan specialty, for 350 rupees. That price is actually the closest I’ve felt to state side prices (using Costco as a reference).

In terms of safety, India is one of the best in my short time so far. There’s a refreshing complete lack of touts that plague Morocco. Also regular people, outside of Mumbai and popular tourist hotspots, are genuinely curious about visitors, and are infinitely patient in their attempts to communicate. Petty theft has not been a concern so far. Although I am on heightened precautions, there are no thugs at night or on deserted streets and no expert pickpockets that plague Latin America. Combine that with the cheapest cost of living I’ve seen so far and you get a great backpacking locale.

Now armed with my cashews and drink, I made my way to the local bus stop across from the municipal gardens. From there I got on the bus to Colva beach for 10 rupees. There were a surprising number of young European vacationers there (as predicted by LP in Goa) probably because of their more worldly mentality and availability of vacation time.

Colva beach turned out to be pretty typical for a beach (once you’ve seen one…). It was reasonably clean, of medium occupancy (meaning not nearly as crowded as American ones). The usual assortment of ice cream sellers dotted the periphery. The sand was crisp golden, water mildly warm, and sun blazing. There were plenty of water activities to engage in, including paragliding. No surfing though.

After I returned from a relaxing time mostly spent soaking in the sun and listening to audiobooks, I decided to turn in early at around 5 PM to slowly readjust my body to the time zone shift.

India and Thailand 2013 – From Mumbai On

The flight to Mumbai was uneventful, even though the wait was long. That’s the problem with hacker flights- it can be hard to coordinate layover times. After the 18 hour wait, and many trips to the mart for cheap sandwiches, I got on the plane. I immediately noticed a difference in the behavior of the other passengers. They were not very friendly or talkative at all. Plus they had a tendency of edging ahead or pushing in queues. It makes sense to a certain extent as there are so many people in India, and Mumbai in particular, that they can’t afford to care too much about other individuals. The same thing extends to things like the price of labour, making India one of the lowest cost countries in the world.

Clearing customs was easy. Though of note to future students looking to follow this route, it’s important to get the visa as late as possible to maximize the amount of time to spend in leisure travel. The problem is that you can’t apply for the medical council approval (almost always granted) without a confirmed visa. And it’s not ideal to buy the plane ticket before the other two items are obtained.

Anyways, Mumbai is a mess. The best way of describing it is organized chaos. People churn through crowded streets on scooters. Everyone honks without a good reason to do so. There are no traffic lights. The public transportation system is overcrowded. Still thanks to my GPS phone, I managed to take the 306 bus to the metro station and from there to Churchgate by a 20 rupee 2nd class ticket. Here’s a moment to reflect on prices in India. The time I traveled can be considered the most favourable in a long time for USD:INR value. In short, public transportation costs a few cents. Food varies. Sit down restaurants run $4-5 for a full filling meal. Buying snacks and munching/grazing on those can come out much cheaper, on the range of 1-2 dollars. Hotels start at 700 rupees for a serviceable basic room with hard mattresses and private showers. The choice of ac vs non ac room is up to the individual. I generally consider the upgrade to be worth it on rooms and long overnight trains but not for short hop buses. Indeed city buses don’t even have ac due to open windows and the created wind. Again, your mileage will vary depending on preference and season.

Another thing about Mumbai is that it’s both hot and humid. In early Feb, supposedly the best time to go, the temperature is already comparable to the Florida summer, even if the overall degree of humidity is not *quite* up there yet. And there’s me trudging around in the standard dress of Indian males – a polo shirt and jeans. This is to be polite and respectful and would have worked fine if not for carrying around a 10 kilo backpack while walking everywhere.

The metro was super crowded, with multiple people squished on benches and more standing. I already had my guard up but surprisingly no one made any attempt at petty theft, quite a departure from Ecuador. But I did see the man beside me pour some powder and crushed plant material before snorting it all. Hm, I thought discretion ideal and pretended not to see.

It was already late by the time I got to Churchgate, and it was surprisingly dark as well for 6pm. So I stopped at a veg restaurant outside the metro station and had my first Indian meal. I chose the Hyderabadi biryani, not knowing any better. It was okay, filling like most Indian food but not having the rich flavour of curry. I also had a glass of watermelon juice which was half the price of the whole entree!

During my meal, I sat across 4 children. I took the name of one of them and made her an origami crane. Dang my skill with folds has regressed for lack of practice. Still she seemed fascinated by it and the other kids constantly yelled at me to make them some. The mothers seemed to be chatting away obliviously. My waiter stepped in to help relieve the children, giving them napkins to play with and also delivered my meal. I struck up a conversation with him and learned that he is from the provincial Bihar province and had lived in Mumbai for several years now for employment purposes. This is a quite common occurrence in India as Mumbai is the financial and moviemaking capital, comparable to NY and LA combined.

I initially tried to catch a taxi to the station, intending to arrive early having never dealt with the indian railway system before. Plus I had a waitlist ticket for the ever popular mumbai to goa route. However none of the cabbies parked outside the metro spoke english and I didn’t trust them to know my intentions just by the name cst.

Let me be sidetracked for a moment and discuss waitlisted tickets. Because train tickets are so cheap in comparison to international prices, many people or tourist agencies snap up all available tickets as soon as they go on sale 60 days in advance. They can then cancel prior to departure for quite cheap. This leaves legitimate voyagers in quite a pickle not knowing if they will make the journey or not. In general, 10-20% of positions get canceled starting 48 hours before departure, corresponding with rising cancellation fees. I had waitlist #17 which had creeped up to 8 when I last checked in Narita airport. Indiarailinfo.com was quite useful in predicting the chances of a ticket becoming confirmed. 14/15 users there predicted confirmation, and there were 128 AC3 seats on the train, so I didn’t cancel to book a bus ticket beforehand. That would still be a possibility if I found out at the station that I didn’t get confirmed.

Back to the story. That’s when I took off by foot braving the darkness and the lack of sidewalks and traffic lights. I was aided by my GPS which I consulted at least 5 times en route. Nevertheless I managed to reach CST, formerly known as Victoria terminus. Even in the darkness it looked splendid and grand, combining the best of British and local architectural styles.

In the station I had a fiend of a time locating the waitlist sheets, which per indiamike should have been posted on some board 4 hours before departure. Everyone I asked, including some uniformed officers stared at my ticket printout for a long time and then shook their heads or asked me to enquire somewhere else.

Eventually I found a small booth by the ticket seller which looked to be addressing waitlist concerns. Here there was another Indian custom i had to get used to. Instead of orderly lines, everyone clustered en masse around the speakerhole, jostling each other and shouting out questions. I had to fight against my trained instinct to wait to be acknowledged before asking my question. The staff took my PNR number and wrote down B1 42. Joy! I had been confirmed on seat 42 of carriage B1.

The train eventually arrived and I found myself at my seat but seeing an entire family having occupied it. I showed them my ticket and assigned position but surprise surprise the old lady on my spot also had a ticket for the same seat. I went to the conductor who verified my name on his computer as being in possession of that seat. I went back to the family and found out that she had canceled her spot (but somehow was still on the train?), thus opening up the seat for me.

Initially it was a bit awkward nestled among a clearly large Indian extended family, but we all soon got to chatting. All of them spoke great English, and the patriarch told me that the family is Gujarati, but based in Mumbai due to business (makes sense as they were all traveling on AC3). There was an in-law living in Houston but who comes back to India every so often to visit relatives. This particular journey is to go to the wedding of a nephew getting married to a girl from Mangalore. They shared some packaged snacks with me before we all turned in for the night.