Being Positive in the News!

Here's the NGO we helped set up.

RK and his colleague Ashoojit were on the radio on the 1st of December to talk about their work and about BPF!

The God of Small Things= Kalpavriksha

This concept of Kalpavriksha, or the tree that gives you what you desire, is an ancient one in Hindu mythology. Except there is no tree- it is a metaphor for the universe.
'Ask and you shall receive' has been described in the Bible, Quran and recurs in multiple texts in Hindu philosophy. I'm sure the same is present in the texts of other religions too.

It took me a long time to realize what this means. Some years ago, I had written a blog post (which I feel too lazy to ferret out) on my God of Small Things . I'd described how, if I would ever express a little wish out aloud or with some degree of ferventness, such as 'God, I wish I had a whole crate of alphonso mangoes all for myself' or 'Wouldn't it be great to be able to read this out of print book?', I would usually be granted this wish. It wouldn't be immediately, or even in the same form that I might have thought of, but ultimately, I would get whatever I had wished for.

I never thought then that it would work for bigger wishes too- mainly because I was never in the habit of making such wishes. I would never, for example, say 'I wish to become a doctor' or 'I wish to make a lot of money'. This wasn't out of a lack of desire for either of these things, but I felt uncomfortable saying these- did I really want to become a doctor? Did I really wish to make a huge amount of money? What was considered huge, anyway?

Over the years, and after multiple long conversations with a lot of people, including my friends, I realize that my original God of Small Things is the same Kalpavriksha which is the same universe that gives you what you most desire. Paulo Coehlo says this in his so-famous-that-it-is-a-cliche book 'The Alchemist'- And, when you want something, all the universe conspires in helping you to achieve it

So recently, I had a chance to test this out. A few months after I started MSCH, I decided I would no longer continue working as a lactation counselor at St.Philomena's. I felt it was too distracting, the benefit-to-cost ratio wasn't really leaning in the benefit angle any more, for multiple reasons. But about two weeks ago, I realized my personal connection with patients had drastically reduced. I wasn't there entering their data, I wasn't speaking to them about the need for some tests, I wasn't there when their blood was being drawn and I wasn't even there to give them their reports and explain what that meant. All the things that I'd enjoyed in the initial stages of my company, when it was just a 1-woman show, I was no longer doing because now I had people for that.

So I reflected on this and made a statement out aloud, 'I wish to meet real people again and do more counseling and hopefully help them'
Almost immediately afterwards, a young doctor I knew back in Philomena's phoned me to get an appointment for postpartum counseling. I loved the experience of holding a baby again, helping her figure out feeding issues.
And a few days after that, out of the blue, a guy from Pune called me up to ask me about testing. But because I was in this new primed plane now, I asked him, 'tell me more. What got you interested in this test?'And that led to a 45 minute conversation during which he shared his story of assault, his reluctance to be intimate with his wife and finally agreed to come to Bangalore for an extended workup, testing and counseling.

Yesterday RK referred another patient from Delhi for counseling.

So, my wish came true!

----------*------------------------------*------------------------------*-----------------------------*------------*----
Interestingly enough, yesterday night I heard Jim Carrey in an interview with Oprah mention that he had written a cheque to himself, when he was poor and still an aspiring actor, for $100,000 'for acting services rendered' and he gave himself five years to accomplish this. And he did.

So, looks like Kalpavriksha works for monetary success too.

Conversation between Durga and her grandfather

Durga: Thatha, small Ajji gave birth to you, right?
My dad: Yes
D: And Ajji to my mummy?
Yes
D: And my mummy to me?
Yes
D: And Ambika athai to baby Lakshmi?
Yes

After a few seconds of intense thought...
D: Thatha, what is birth?

What does success mean to me

While pondering about Jessica Pearson, I thought to myself, what does success mean to me?
So here's a list (so I don't forget):

a) Success means that I should have no money worries- I should be getting the salary I deserve. I shouldn't have to make do with less just because there is no money in the company or where ever.
b) Success means that I have a team of people I can rely on- senior and junior scientists, motivated, energetic people who can carry a project on by themselves. I'd be there for brain-storming or troubleshooting, but I shouldn't have to be in lab all the time.
c) Success means that people associate me with high quality and reliable work.
d) Success means that I work with everybody at every level, be it private firms, government or NGOs. It doesn't matter if it is 1 test or a 100,000. We should be able to do it.
e) Success means I have a vast network- people in different fields, people who trust me and whom I trust.
f) Success means that I contribute to my society in terms of service and scholarship.
g) Finally, success means that I get done with work related stuff by the evening so I have time to spend with the kids. Travels once in a while is okay. But there is no success if I don't get to hang out with my kids at the end of the day.

My life and "Suits"

This post was initially going to be about my disgust with some of the married men I see at our clinic who come for HIV check ups because they had an unsafe exposure. Their Whatsapp profile pics will be the picture perfect version of a happy marriage- unsuspecting wives kissing them on their cheeks, kids in the background and so on. Yet there they are, waving their d**ks around while on trips and then coming to me to get their blood tested for HIV. I am very nonjudgmental when they are in my lab. No reason why I can't be perfectly judgmental, full of self-righteous indignation and scorn over here.

It's all a question of commitment, isn't it? Commitment probably means different things to different people. And people probably argue about the degree of commitment needed as well. For instance, my ever-loving, ever exasperating husband yesterday accused me of not committing to my personal growth. What exactly he means by this, he refused to tell me. If you don't know it yourself, then there's no point in telling you, seems to be his credo (and they say WOMEN make statements like that. Ah hello, for every single time a woman says it, a man would have said it twice).

Anyway, in the off-chance that he might be right, I have been thinking about all the fields in which I might have to improve. I have also been hugely influenced by the show "Suits",so I'm actually thinking this is a good exercise to become more like say, Jessica Pearson.

Molecular Solutions right now is a bit like Pearson Hardman right before the merger with Darby- out of money, besieged by multiple external factors, including their own mistakes, and fighting to survive. PH survives by joining hands with Darby, getting a much-needed influx of money, fighting off the competition and then merging with Darby, albeit in a weaker position. Despite that, Pearson moves against the explicit wishes of Darby in a particular case, which actually ends up being the right move down the line.
Pearson does this by a) being very clear-eyed about their financial status (esp when they were with their backs against the wall) b) knowing the financials inside out c) doing what had to be done to keep the firm intact, even if that meant signing a merger deal from a weaker position d) refusing to make decisions under stress e) predicting next moves by Darby, Hardman and the rest of the sharks as well as by her own team's Specter f) She gets her team on board with her decisions, by persuasion or threats.g) Most importantly, she knows exactly what she wants and she does what she needs to to get there.
She makes a few mistakes, of course: doesn't recognize Louis Litt's value early enough, signs the confidentiality  clause with Hardman, for some unknown reason, which comes back to bite her in the ass later, but she sticks to her guns when moving against Darby (and Specter) despite not knowing that it would turn out ok.

Okay, I'm becoming clearer-eyed about our financial status (it's very easy- we have no money). I think I'm getting to understanding the financials inside out. I have some ideas about how to keep the company intact, even if means doing something that I wasn't particularly keen on earlier. The bit about refusing to make decisions under stress is a bit difficult, but let me try anyway. My weakness is predicting moves, but it comes down to knowing what I want vs what each connected person also might want. I'll work on this some more. I am no good with threats- unlike Pearson, I really care about being liked by my business partners and everyone else. But I think persuasion is a good tool to use.
Am I just as good at knowing what I want? I hope so. I want my company to grow, do good work. I want it to be reliable, with a broad range of tests, and accessible to everyone.

In the end, I'm going to do one more thing that Pearson does not do- ask for help. My dad, my cousin-in-law, my business partner's cousin, my uncle-in-law... these are all people who have been helpful before and whom I am specifically planning to ask specific questions.

And hopefully, we can also do what Pearson does: turn the company around.

Hitting a Century and Beyond

We crossed 100 samples at Molecular Solutions a few days ago! Hurray!

This is 100 HIV, HCV and HBV viral loads and drug resistance genotypes. About 75% of our samples have been from the NGO sector, with subsidized pricing.

Clearly, we need to get cracking on finding funding for these samples and at the same time amp up our full-price private sector patients.

But marketing aside, I spent the last weekend poring over this data. It is fascinating stuff. We are finding high levels of HIV drug resistance in our populations. While India has made amazing strides in its control of HIV, looks like the next face of the HIV epidemic is about to hit. Once drug resistance levels creep up, the whole world will have to grapple again with high drug costs, low availability and a need to triage out drugs only to the sickest. The debate on who gets to start what medicines will begin again.

This will be a short note, but worth considering. India made HIV generic drugs and saved the world. Now, for the HCV epidemic, Indian companies have signed a pact with Western pharma such that they will produce the branded drugs at a fraction of the cost seen in the US, but at a price that is still quite high. Pakistan and Egypt, which didn't sign this pact, have since developed drugs which are supposedly just as effective at about 1/10th the price that India manufactures it at.

When I am less pressed for time, I must sit down and reflect upon this milestone of 100 samples. It is a great thing, but with my technician gone, my mind is burdened with the stress of getting the remaining samples processed and sent out.

Cuts to Science Funding- An Impassioned Essay Against Them!

There have been multiple threats to science budgets in multiple countries in the recent past. The biggest threat looming is, of course, Trump. Trump's budget sought to cut funding to the NIH by billions of dollars. While this seems overall like a bad idea to a lot of people, it is hard for a layperson to understand how exactly this would affect the average Joe on a day to day basis. When I found myself wondering the same, a recent experience with an HIV database brought the situation to clarity.

Here is the Stanford HIV database. It is free- anyone in the world with an internet connection can access it and use it. It is the world's largest curated database on HIV sequences- all sequences ever published anywhere in the world make their way into the Stanford database, fitted neatly into the grand scheme, accompanied by neat little texts on how each sequence advances our knowledge of the virus.

So after you amplify your HIV genes (the genes that we like the most are Reverse Transcriptase or RT and Protease or PR. These are the genes against whose products many HIV drugs are targeted. So a drug that targets RT is called RTI, short for Reverse Transcriptase Inhibitor; one that targets PR is called PI, or Protease inhibitor). The virus, being the ultra mutable thing that it is, will try to mutate against either or both of these medications in a patient taking these medicines to escape their effects and proliferate. If it successfully mutates itself so that the drugs no longer act against it, it is said to have acquired drug resistance mutations.

The Stanford database is what helps a researcher or diagnostician figure out if the most prevalent type of virus in an infected patient has drug resistance mutations or not.

You can input your sequence (as I've shown below) and select whatever HIV drugs the patient is on.

And then the software gives you back something like this:

It tells you if there are any specific mutations that lead to drug resistance and how it might affect any of the medications that the patient is on. But this is the most basic utility. 

The database is something out of a fantasy novel- just like Hogwarts is so massive that nobody is ever supposed to know all its nooks and crannies, every turn brings up something new and marvelous, every day reveals new aspects.

For instance, you can also look at how prevalent certain mutations are according to the particular type of HIV that is found in a region, and what kind of medications the person is on.

This table above shows you the various amino acids that are possible at a particular site and how prevalent they are in different subtypes of HIV(A, B, C and so on. What does a subtype mean? Just like we all belong to the species Homo sapiens, but obviously look different based on whether we have Mongoloid, Caucusoid, Negroid etc features, subtypes A, B, C etc are the different faces of HIV in different parts of the world. There are clear genetic differences, and each subtype has multiple millions of members belonging to it. Subtype B is found in North America and Western Europe; Subtype C in most of Africa and Asia; Subtype A in Eastern Europe etc). 

It also tells me what is the proportion of finding this mutation in people who are RTI Naive and RTI-Treated (You know what RTI means. Naive means those who are not taking this medicine yet and have never been exposed to it, therefore providing no selection pressure for the virus to try to mutate against it). 

How is this information useful? 

For instance, look at picture 2 above. You see how it says 'Other Mutations' and lists out a bunch of things like V35T, T39E etc? 

How do we know if this V35T is important or not in our patient? We scroll down the page that is shown on picture 3 and come to this:

What this picture tells me is that in Subtype C, the proportion of people who are RTI-Naive and having V35T mutation is 92% (the little superscripted number above the T) and the proportion of people who are RTI-treated and having V35T is 91%. So V35T appears to be really common among those with Subtype C virus and therefore very unlikely to be something that actually causes drug resistance because it is found in high proportions among people who have never taken an RTI medicine. So I don't have to worry about my patient having V35T. Similarly, I look at the other mutations in my list and see which ones are unlikely to be appearing and therefore merit a second look.

For every single site on the RT protein the table lists out what amino acids are likely to be seen, and how prevalent they are, for every single subtype of HIV. You can also click on each underlined amino acid and get the primary sources of literature upon which this table is based. 

The amount of work that has gone into making this table is mind boggling. 

And we haven't even scratched the surface yet. The Stanford Database also has tools that tell you the fold decrease in the effectiveness of a drug in the presence of each drug resistance mutation, how the fold decrease changes if there are multiple resistance mutations in combination, how treatment should be changed based on what mutations there are and what you can expect to see in the patient over time.

The database also tracks resistance mutations across the world. One of the most important and challenging issues facing us right now is the problem of transmitted drug resistance- imagine there's a guy who is HIV positive and taking his medicines. Unknown to him, he has developed resistance against some of his medicines. He has unsafe sex and transmits HIV to his partner. Now the transmitted HIV will be the drug resistant version. When the partner starts the default first line medications, they will not work at all and the partner will start failing very soon. The Stanford Database tracks the levels of these transmitted resistant viruses across the world by linking up to the WHO surveillance system.  

Who made all this? How was this even done? Answer: much of it is through NIH funding. Someone in Stanford (Dr. Robert Shafer and his team) had this brilliant vision and the funding through NIH is what made it reality. 

This database is one of many that the NIH has developed and hosts free to the public. There are multiple such mammoth works that link clinical, systemic, organ-level, and molecular data. There are databases for various types of cancer, infectious diseases other than HIV, auto-immune diseases, databases linking environmental hazards to various health problems. These are more than just collections of raw data. They are magnificent works of art.  

Without funding, how will these function? A funding cut to NIH in the US affects the whole world. 

Crashing down to earth

There's always a new way to be dumb. You think, man, I'm in my mid-30s, I've seen a bit of life, I think I can handle most things that life throws at me now and sure enough, you find a new way to prove yourself so utterly stupid or naive that you wonder, what the heck have I learned in all these years?

Moronicus indicus

This is the name that I give every dumb ass person driving on the wrong side of the road. And Indians are probably the most populous in this class of humans.

It could be a super-fast highway with cars speeding at >100km/hr. But no matter. To the intrepid M.indicus, this is all the more reason why he has to drive in the exact opposite direction, preferably in the middle of the highway.

BBMP recently constituted a ban on all liquor sales within 500m of a highway supposedly to prevent accidents. Drunken driving is one thing, BBMP. But if you were truly serious about lowering the accident and death rates on highways, please exterminate that pestilent subclass, so uniquely found in India, the Moronicus indicus.

Screening

Our junior doctor Dr.SP was very much in favor of the clinic buying some HIV, HCV, HBV and syphilis screening tests. 'Madam', he told me, 'The number of people I know who don't get screening done because it is not private in the government hospitals, or who don't believe their test results because they feel their samples got mixed up with other people's....!'

Okay then.

I ordered the tests and as the scientist at hand, offered to perform the tests. They are fairly easy.
I told Dr.SP, Bring your friends over and we'll do these tests right in front of them. Privacy, reliability assured! It's a piece of cake!

A few days later, a tall young man, boy really, walks in. I am alone at the clinic, but for the nurse. He looks around and whispers, Dr.SP sent me. I'm here for the HIV screening test.

I quickly assume my counselor avatar (thank you, lactation counseling!). I talk to him about his life, about what he does, about why he wants to take the screening test. We discuss his sexual experience, his knowledge of safe sex and his practices of safe sex. Then I tell him how the test will be done, how long it will take and what the possible results might mean.  I also speak about future steps after the test. If it is a positive, then what. If it is negative, then what.

Then we discuss whether he wants to sit in the room and watch me perform the test or go to the reception area and wait. He decides he wants to watch the test being performed.

I open the kit and we go over the steps of the test together.

I ask the nurse to draw blood, I spin the blood to get the plasma (why, oh why, are screening tests with whole blood so difficult to come by?),  and we begin. I add the plasma drop to the little window,  wait for the plasma to get absorbed, then I add two drops of diluent and we watch the liquid disappear into the window and the line of the liquid climb slowly through the narrow strip.

The boy starts to shake. His legs are drumming a tattoo on the floor, his fingers are trembling, he hasn't exhaled since we added the diluent. He stares at the test kit without blinking. I watch him watch the strip. When I look down, the liquid has climbed through the entire strip and a light pink line is seen where the plastic rim says HIV-1 and a clear blue line is seen where the rim says "control".

He looks up at me, hope and devastation in his eyes. Hope that I will say something that negates the test, devastation because he knows what the test results mean.

I grip his hand and I say, As you can see, the blue control line is present. This means that the test has worked. The light pink line says that HIV-1 antibodies are present. However, we will need to do a confirmatory test to make sure.

His mouth twists. He starts to weep. Courage, courage, I whisper gently. We will only know for certain once the confirmatory test comes back.

We begin the 4th generation confirmatory ELISA test for HIV. This time the boy does not look at me or the test strip. He stares at the table, his knees knocking against each, his fingers tapping the table. I perform the steps. I look up and say, I am sorry.You are HIV+

He breaks down. I hold his hand while he sobs. After a few minutes, I whisper It's okay. It's okay. You'll be fine. We spoke about this, remember? It's not the end of the world. There are medicines that can control it. You'll be fine.

Just then, Dr. SP walks in. I brief him on what has gone on. Then I turn to the boy and tell him, Dr. SP will talk to you now.

In the reception, I sit. I realize my hands are covered in a thin sheen of sweat and I feel like I haven't taken a breath in a long time. I inhale and exhale slowly.

Not a piece of cake at all.

Memorable Patient Encounters-3

I met Manu and his wife when they came to the lab to ask me to do an HIV drug resistance genotyping test on them. They came with his mom, who did not know that either of them was HIV+. I spoke to each of them separately and together. His mom tended to blame the wife for Manu''s sudden illness; his wife ignored his mom for the most part.

When I spoke to Manu alone, he denied ever having sexual relations with anyone other than his wife; he pulled out pictures of his kids aged 4 and 7 to show me; he also claimed that he had had a blood transfusion at a small local hospital near his village some years ago. He thought that could have been the cause of his HIV infection. Nobody ever admits to having extra- or pre-marital sex, I thought cynically.

He had been diagnosed with HIV in Feb 2016, when he had gone to the government hospital after weeks of illness, inability to eat and a visible weight loss. His CD4 count was 25 at the time (normal is about 800-1200 cells/uL of blood). He was also diagnosed with TB at the same time. He had lost 20kgs of weight; from 65 a few months prior to 45kg in Feb 2016.

The doctors started all the medications, controlled the side effects as well an opportunistic infection of Herpes, but in Dec of the same year, his weight had reduced even further to 32 kgs; his CD4 count was 11. Clearly, something was not working.

 In Feb 2017, one of the doctors who works with us recommended that he check if the virus was resistant to the drugs. Hence, Manu, his wife and mother made the trip from Ramanagara, a town about 2 hours from Bangalore to our clinic. The taxi that they had ordered for the trip left them about a block away from the clinic, for some reason, and I watched him shuffle very slowly the one block to the clinic. His cheeks were sunken, his voice was weak. This was a very sick man.

I walked them through the steps of the test. I told them why his doctor had recommended it and what information they would receive. They were all so thankful.

Most HIV+ people, in my rather limited experience, love to talk to a clinician or even a diagnostician. They want to understand what is going on, they want information and they are hungry for reassurance. It did not matter to them that I was not a medical doctor. They were grateful for my time, my attention, just as I was grateful to them, for talking to me, for explaining their story. I was grateful for the chance to put a face and a story to the blood tube. And I was humbled by the reminder of how crucially relevant these tests are.


I should also mention here that Manu was the FIRST patient on whom we were doing the drug resistance genotype. We had established our lab in Jan 2017 and while I was confident that I could amplify and genotype his sequences, given my doctorate experience, I had never before done it yet in India. But Manu had been sent to me because I was offering this test at less than half the market price. In most standard labs, this test costs Rs. 15,000. I was offering it for Rs. 6000, just enough to make up the cost of the reagents and rental on the machines that I would be using.

I actually mentioned this to Manu and told him, keep the 6k. Let me get the results first and then you can pay me. He immediately said, "No Madam. Please. You will be doing the work. You should be paid for that work. And I may not have the 6000 rupees afterwards".

Thus, Manu's sample became the first of many successful drug resistance genotyping tests conducted by our lab. We found his virus to contain the M184V, K65R, L100I and K103N mutations; mutations that confer high level resistance to nearly all the anti HIV drugs that he was currently on (Tenofovir, Emtricitabine, Efavirenz)

The doctors changed his regimen (and how they did so is a whole different story. The Indian government does not accept drug resistance genotyping reports from private labs as evidence to switch medications for a patient. At the same time, there are no government labs that offer this test). Through multiple letters and phone calls, the doctors convinced the government ART office to switch his medications to ZLA/r (Zidovudine, Lamivudine, Atazanavir/ritonavir).

Later on, I heard from other doctors  about the uncontrolled number of blood transfusions that occur in many private hospitals. Many HIV doctors also mentioned that a lot of patients reported having blood transfusions before they were diagnosed to be HIV+. So I wonder, maybe Manu was right about how he was infected.

Manu never really recovered though. In May I learned that he had actually gained some weight (about a kg) and cheered. But he was in and out of hospitals and then, yesterday, I got the news that he died.

It pained me even more when the doctor said, some patients are too far gone by the time they start their medications. Nothing you can do can get them back from the brink.

I pray for his wife. She too is positive, but thankfully their kids are not. But how will she be treated if it comes out that he died of AIDS?

This is the unfortunate, stark reality of HIV in our country. We may have the world’s largest free ART distribution program, but the stigma of HIV still looms as large as it ever did. This same stigma is the reason why men do not get tested for HIV early enough and why most people fear coming to the hospital until it is too late. Interestingly enough, most women get diagnosed with HIV sooner, when they are healthy and before they reach the stage of AIDS. This is because of mandatory HIV testing during the antenatal period for all women, a clear vindication of universal screening.

The other problem is that of monitoring. CD4 cell count based monitoring is not an optimal measure of detecting treatment failure and drug resistance in HIV. The standard of care, as recommended by the WHO, is that all patients found to be HIV+ get a baseline viral load and drug resistance genotyping to check if they have been infected with a resistant form of the virus. Viral load tests are also recommended twice a year to monitor for adherence and early detection of resistance. In the current scenario, by the time a patient on ART is found to be drug resistant and his medications switched, the patient is so close to death that it is unlikely that he can survive without extensive ongoing medical help.

And finally, HIV in India suffers from a dearth of research. There are but a handful of studies describing the emergence of drug resistant virus in India; with only a few laboratories in the country working on Subtype C HIV, the type found in our country, that differs in virulence from Subtype B, found in Western Europe and Northern America and on which the most research has been done.

Stories like Manu’s are all too common. With the nature of HIV undergoing a slow change from an acute disease that kills  to a chronic disease that people have to learn to live with, a shift needs to occur from running centers that primarily rollout ART to delivering the full gamut of preventive and health promotional services in a non-judgemental and sensitive manner.

x

Overcoming my driving-phobia

It took me an eon to start driving in the US. Most people come from India, check out the empty, vast roads, their eyes light up and they quickly purchase a car and zip along here, there and everywhere. Me, because I have issues, decided I would be the stick in the mud who uses public transport everywhere.
I can assure you, nobody I know has used Grey Hound and Amtrak as much as I have... and memorable experiences they were too! How much of a story can you tell with the statement "I drove my car to Buffalo, NY?" But when you take a Grey Hound, there's a whole world to describe right there. "The driver lost his way, we ended up in Cleveland! And it was 2am, and the guy next to me was traveling to meet his incarcerated girlfriend who had just given birth to their daughter in jail!"
Come on- can there even be a comparison to the experiences? Grey Hound rules!

Anyway, after being bitten by the car-bug in my last year in the US (only because I was getting tired of lugging around two kids by bus to soccer and parks and all the things that "good"moms do), finally bought a little 3rd-hand Toyota, which I had to sell within a year because of our move back to India.

In India though, I decided I would drive. Got my license much before RK (hah!) and in fact, was a pretty good driver. The secret to driving in India (or Bangalore, at least. I cannot claim to have driven elsewhere) is to tell yourself a little mantra before you begin driving: I will not hit another person or a vehicle. I will remain unfazed no matter what.
You will be fine if you remind yourself of this every time you start driving.

Soon after we bought a car, RK's work load increased in multiple different places and of course he, being a car hog, started using it pretty exclusively. Compared to the US, India is like public transport- haven. Plenty of buses and auto rickshaws; and even the metro. You can even rent bikes, cycles- anything you want. Not that one would EVER want to rent a cycle and ride it on an Indian road, but still, it's nice that options exist.

More than a year after RK started exclusively using the car, I suddenly had a fear: what if all the work I put in to learn how to drive in India had completely rusted away and I wouldn't be able to drive at all? Isn't driving an essential skill that everyone should know and use?

So one day, when RK had taken the metro, I pulled the car out of its parking spot by the curb and went for a drive. Indian cars are stick-shifts; plus, on many roads, it's impossible to drive beyond the 2nd gear because of the traffic. Add a steep uphill; multiple traffic lights; pedestrians, cows and dogs crossing wherever they want and it can be a bit scary. I did stall a couple of times, mostly because I had forgotten that when one is in the first gear, one has to let the car roll a bit before gunning the accelerator.
At the end of my hour of driving, I felt:
a) Exhausted. My thighs and foot joint (is it called talus?) were screaming in pain and I had to hobble out of the car, much like people unused to horse riding might have done a century ago.Stick shifts are hard when you are constantly shifting or holding a car in place waiting for the traffic to clear a few inches.
b) Mildly happy that I could still drive without completely panicking.
c) Slightly panicky about the amount of time I had wasted just driving around a couple of blocks near my home.

So, sum total of the experience: mostly negative.

I can drive, hurray.  But heck, why would I want to?

Mindfulness

Mindfulness is something I heard more than a decade ago but only now am realizing how much I need.

What does mindful even mean? To me, it means being aware of what you are doing or saying and how you are doing or saying it, and why you are doing or saying it. You recall Polonius' words to his son? 

"...give thy thoughts no tongue

Nor any unproportioned thought, his act"

..

"Give every man thy ear, but few thy voice;

Take each man's censure, but reserve thy judgement"

(Hamlet)

This captures the essence of mindfulness, I think.

 Needless to say, I've found it incredibly difficult to be mindful... 

There are obviously good days and bad. I realize that I recall the bad days, but I don't really celebrate the good ones. 

But I also realize that I have no role model. The great saints or sages whose images instantly come to mind when one thinks about mindfulness are not working women with jobs and kids and other obligations. In fact, each of those great mindful souls rejected women, family life and well, work.

I don't claim to understand a fraction of the enlightenment that Buddha attained, but come on, he obviously had to leave behind everything and everyone he knew to attain it.

However, a recent story about the Buddha reassured me like nothing else: Buddha and his faithful devotee Ananda were walking along the side of a river. Buddha is deep in conversation with Ananda. A fly sits on his arm and he swats it. A moment later, Ananda notices Buddha repeating that same movement (of swatting the fly) again, although there is no fly. He asks Him, "Why do you do that?"
Buddha replies, "When I first swatted it, I did it unthinkingly. The second time I moved my hand, I did it to remind myself to do so mindfully"

So. I guess even the great saints and wise men who relinquish society and all its claims on them need to practice!

This story put me in a very optimistic frame of mind and honestly, I could start looking at Buddha as a decent role model for mindfulness.
However, for a more immediate, day-to-day role model, I signed up for the Art of Living's 3 day course on Sudarshan Kriya. I have been quite dismissive of AoL before. But I feel the need for frequent reminders to be mindful. Hence the signing up.

My objective is just one- let me learn how to be mindful.

By this I specifically mean:

 a) Let me not lose my temper with my kids and family; 

b) Let me not promise things without understanding the full implications of it; 

c) Let me recognize situations that can turn explosive and prevent them.

I am hoping to find role models- other working women and men who have similar stresses and obligations that I do and who still manage to juggle them really well, without getting stressed, without losing their control or their cool.

And writing this has also made me realize that I should celebrate my little successes. Maybe I need to keep a journal, though knowing me, I'll probably lose the journal within a couple of days; so maybe I need to type up stuff on my phone to keep tally on all the occasions I could have lost my temper, but did not.

Expertise

Am attending the HIV Update CME at St. Martha's.
For one of the first times in my life, I'm understanding the importance of sticking something out- of picking a field and continuing with it, growing in it for years and years.
I always prided myself on being a Jack of all trades; now I want to become a Master of something.

Maybe it is because I never before felt that I either had a future in a particular geographical place or a field of study. India has given me both. It's an unexpectedly inspiring and empowering feeling