Karigiri

This morning Moriah and I hopped into a rickshaw (yes, on our own volition) and took a one hour ride to the other side of vellore to visit the karigiri leprosy clinic, rumored to be one of the most worthwhile medical experiences here, and it did not disappoint. And while this was a very moving experience for both of us, I have to warn that some of my descriptions detailing leprosy and the are somewhat gruesome. No disgusting pictures though, so please feel free to skip to the bottom if that stuff really bothers you.

With the help of Christian Medical College and it's founder Dr. Ida Scudder, karigiri was founded by Dr. Paul Brand, a British orthopedic surgeon who had spent his life in India treating and studying leprosy, or Hansen's disease. He wanted to establish a free standing hospital where patients could receive comprehensive care for leprosy and other skin diseases, and escape the stigma they faced every day. He not only led the way in the field of surgical treatment of the disease and it's devastating impact on limbs, but was also the first person to discover that contrary to widely held beliefs (which are still widely held by much of the world, contributing to the painful stigma associated with the disease, but more on that later) the bacteria itself did not cause loss of limbs, rather this was caused by accumulating injury due to the loss of sensation. In a rather painful yet very revealing anecdote, it is said that he made this initial discovery after seeing a rat gnaw at a persons hand without them feeling a thing.

This clinic was his dream, and grew from 17 inpatient beds when it was initially opened in 1955 to nearly 200 today, and has become the premier institute in Asia for the treatment and research of leprosy. Most of the treatment occurs in the outpatient clinics, where they see hundreds of patients a day.

Though they specialize in leprosy, they emphasized that many skin diseases that mimic leprosy are relatively prevalent in India, and they maintain a staff of internists, dermatologists, and pathologists with wide expertise in this mimics. They can also treat chronic medical conditions which are very prevalent in India in general.

Though they were cognizant of the psychosocial impact of the disease and the high prevalence of depression in their population, they do not have a psychiatrist on staff at the moment. They did have an impressive team of social workers that they felt helped in this respect. They also emphasized that their nursing program had a heavy emphasis on providing very compassionate care.

See? Proof. Moriah did "work".

We were taken on a tour of the entire facility, starting with the laboratory. Each patient diagnosed with leprosy has a skin biopsy performed, both to diagnose leprosy as well as to gather their bacteria for resistance testing. In the USA, we use a test called PCR (polymerase chain reaction) to isolate the bacterial DNA and predict what medications it will be resistant to. This is somewhat expensive, and at karigiri they have an interesting though time consuming way around this. Each patients bacteria is isolated and injected into the foot pads of nine immune compromised mice, which are divided into three groups and given food with different antibiotics used to treat leprosy. In six months (necessary because of the extremely slow growth rate of the bacteria, the longest known in nature) the mice are sacrificed and their feet are analyzed for bacteria. Depending on what antibiotics work, the patients treatment, already underway, will be modified if necessary. Many patients require an entire year of treatment, in many cases this can be longer.

After the lab they took us to the physical therapy and occupational therapy departments. Sensory loss from the damaged nerves can lead to severe functional loss of limbs, contractures, and limb loss. In physical therapy the patients go through exercises to maximize functional use of the limbs, as well as stretching techniques to prevent contractures. The occupational therapy was especially interesting for the devices the patients were given to improve the function of their limbs. Specially made tools for lifting hot lids or cups of tea, gloves for manual labor, all to prevent the patients sensory loss to causing more damage.

The complex was also equipped with a factory where they manufactured a special rubber shoe that contoured better with the patients feet, preventing further damage. They could also manufacture limb prostheses for patients, specifically tailored to their needs.

Most of the patients are not admitted to the hospital, requiring only outpatient treatment with antibiotics and occasional visits with physical or occupational therapy. Patients in need of further care due to complicated wounds or contractures were admitted to the hospital, most of them to undergo surgery. We saw a very large, nasty looking ulcer on one patients leg which was being cleaned by one of the technicians. The patient calmly watched the man work on his leg without pain medication or topical anesthetic, as he could not feel the majority of his leg.

We saw the very busy outpatient clinic, and one to the doctors was kind enough to allow five students to pile into her tiny office and see patients with her. We saw the characteristic smooth, well defined hypo pigmented patches, over which the patients were entirely insensate. She gave a very impressive impromptu lecture on the treatment of leprosy. I was most impressed by the fact that she refused to start until all of us found a seat and sat down. This isn't the first time that has happened here, and I don't think I've ever had it happen in the US, where med students mostly just observe standing in the corner. This doctor insisted that we be comfortable, a quality I hope I retain.

After the clinic, we were taken to the "gift shop." The stigma of the disease is especially powerful in India, and a large number of patients who are severely affected by the disease are not welcome to return to their homes, despite the vast resources this clinic as well as the government spend in order to provide public education on leprosy. Because they are banished and left without a place to live or a way to earn a living, the hospital established a program where former patients are taught to make linen products like tablecloths and aprons, and the hospital sells them, with all profits going to the former patients.

At the end of this we were taken to a place called shanthigramam (village of peace) a hospice for patients with leprosy too disabled to care for themselves and without family willing to care for them. They live on a small farm, and those still able help with gathering some of their food. We talked to a few of them through a translator, they were very happy we'd come though most wondered why we were stupid enough to come to India in April. The thought of families abandoning these people horrific, and not only in life but in death as well, and the tiny village also has a small cemetery for those patients who are rejected by their family even after death. In a way it is very beautiful for them to have a welcoming place both in life and death.

A patient outside of his hut in Shanthigramam

We rode back to CMC in the rickshaw, very glad that we visited this special place.