"Stop! Sound Horn!"

Breakfast: Pongal, Vada, Iddli, Coconut Chutney, smothered in Sambar. 

Today I began my first full day in Chennai with a traditional south Indian breakfast. While the Iddli, small white steamed cakes made of rice and lentils, brought back memories of smothering them in sugar as a child, the other elements were a bit less familiar. Pongal is made of rice mashed together with spices and ghee to form a thick paste. It was very tasty but the consistency means you should go slowly as to avoid feeling overly full later. Even with such small portions, I still wasn't hungry by the evening. Along with the Iddli and Pongal, I tried a Vada, which is essentially a small savory donut. Finally, my love of condiments was rewarded with a light coconut chutney and the Sambar, a tomato lentil sauce, which I added to everything. After such a tasty start to the day, I was feeling confident about venturing out on my own. 

Chennai traffic with a background of ever present advertisements.

Upon arriving in Chennai, the first and most visible element of life in this southern Indian city is of course the traffic. Like most Indian cities, the sheer number of cars, buses, auto rickshaws, bicycles, motorcycles and pedestrians can be overwhelming to visitors. Leaving the airport and making your way onto the highway that leads into the center of the city, the roads appear to be complete chaos with an 'anything goes' attitude. However, when looking more closely, it is apparent that there exists a method to the madness, a shared knowledge among drivers that creates an intricate dance along the pavement. 

Pedestrian, Bicycle, and Auto Rickshaw

"Autos" tut-tut their way around the city while overcrowded buses with their windows removed (for air circulation) lumber from stop to stop. Motorcycles and bicycles weave in and out of the spaces created as traffic starts and stops, trying to get just that tiny bit further ahead. The sound of beeps and honks is almost constant with "Stop! Sound Horn" - the popular slogan hand painted onto the backs of trucks, buses and autos - being taken literally. Here in India, the horn is used rarely to signify anger or frustration at other drivers. Instead, it is primarily used to convey location to drivers ahead when overtaking. Short, rapid fire bursts of sound stating "I am here, please be attentive" are appreciated by all those involved as it helps to avoid accidents. 

Roadside coconut stand

This morning was my first real experience with Chennai traffic as my hired taxi wound its way through the city in search of the Taramani headquarters of the Y.R. Gaitonde Center for AIDS Research and Education. Located to the south of the city center, YRGCARE is housed in a large building where they provide doctors visits, counselling services, nutritional advice and pharmacy supplies to HIV-positive individuals along side their research pursuits. This one-stop-shopping approach has proved extremely successful here in Chennai as their studies found patients who had to see a doctor in one location and a counsellor in another before finally making their way to still a third location to collect medications were less likely to adhere to their prescriptions due to the high cost of travel and the loss of time needed for work or family commitments. By providing everything in one place, YRGCARE has helped to increase the adherence rates of individuals on anti-retroviral medications. In addition, this method allows for increased privacy as individuals are able to quickly complete their business and continue on rather than incurring suspicion from family, friends and neighbors as they race all over town. 

The recognition of these local concerns was part of the reason I applied to YRGCARE's internship program because my research focuses on exactly these issues which differentiate local epidemics from the greater global pandemic. While there is a general universal approach to HIV (increase awareness, decrease stigma, prevent further infections through safe sexual practices, etc), it is the local differences and unique cultural issues that will determine the success rate in one country verses another. 

When I arrived at the building, I was disappointed to find that my assigned mentor was actually not in today having been called up to New Delhi on business. However, the day was actually surprisingly successful as I was given a tour of the impressive facilities, finalized documents for my research with the representative of the Institutional Review Board (IRB), and finally, heard a presentation by Dr. Suniti Solomon about the history of the organization and how it has grown into its current form. The presentation, attended by one other young researcher, covered the period from 1986 when Dr. Solomon first discovered the presence of HIV in Chennai to the present, including the different programs they have started, their locations over the years, and the responses of government officials to her work. Peppered with personal observations and memories of conversations, presentations and meetings with celebrities, this was a presentation so rich in information it was hard to take in. Once I recovered from being slightly starstruck at meeting Dr. Solomon, I listened intently while trying to simultaneously scribble everything down, a habit that amused my companions. 

While it is impossible to share the entire presentation in this format, I'd like to point out several of the most interesting parts (in my opinion): 

- 1986: Dr. Solomon tells her research assistant that she would like to look for HIV in Chennai, and is greeted with the response: "We won't find AIDS because we have no homosexuals in India and we are all religious... I will fail my MD!" Uncertain of how to seek out the underground gay community, the ladies instead turned to commercial sex workers who had been rounded up by the police. After arrest, they are taken to a remand home to await their court appointment the next morning. Taking advantage of this system, the ladies were able to collect samples from 100 commercial sex workers, of which they found six to be positive for HIV. These results shocked India, to the point where government officials refused to believe them. Rather than being impressed by the dedication given to finding the virus' presence in India, the women received a "mouthful of scolding" for drawing attention to this less than desirable fact. 

- 1987: Started the first voluntary counselling and testing (VCT) center at the internationally recognized Madras Medical College. However, upon starting sexual education presentations at local schools, Dr. Solomon realized that she was actually learning a great deal about modern sexual practices from the students themselves. For example, when asked if HIV could be spread through French kissing, Dr. Solomon's first response was "I don't know, I've never kissed a Frenchman." After being informed of the meanings of this and other terms, she realized there was a whole sexual language known only to younger generations. By learning more about the terms and phrases, she was able to gain the students trust while also opening the eyes of the school administrators, who had previously declared that their students were 'angels' who would not be participating in sexual activities at such  young ages (15-18). 

- 1997 to 2012: The awareness of social issues specific to India has led to the creation of individual programs directed at combating the stigma and other cultural obstacles individuals face. The first example of this was the couple approach to married individuals. If a young married woman comes in for testing, they will not disclose her results until her husband also comes in and is tested. This is to spare the woman from being blamed unfairly for bringing HIV into the marriage (22% of individuals who tested positive at the center in 2007 were housewives with only one partner). By approaching the issue with both parties, the counsellors can attempt to limit the negative consequences of blame, which could result in the woman being thrown out of the marriage  home and therefore left to fend for herself unfairly. The second example that I found particularly interesting is related to this through the recognition of the importance of marriage within Indian society. Dr. Solomon and her associates found they were constantly hearing about how an individual's parents were pressuring them to get married and, since their status had not been disclosed to the family, the individual felt they had no choice but to enter a marriage without disclosing their status to the future partner. Seeking to prevent further infections, YRGCARE started a matrimonial service in 2002. When an individual was feeling pressured to marry, the NGO would circulate their CV and picture to other NGOs working with HIV-positive individuals. If the two parties were interested, they would meet and ultimately, if the match making proved successful, marry without having to disclose their status to either family. In addition, by allowing the partners to be honest with each other, it was possible for treatment to continue and the transmission of the virus to the couple's children to be prevented. (After marriage, family pressure turns immediately to having children and therefore this program allows YRGCARE to manage two of the biggest cultural focuses at once.) 

All in all, today proved to be a fantastic opportunity to hear about the local epidemic from arguably the most well known and knowledgeable source in Chennai. And, I was able to successfully make my way to and from the NGO's headquarters on my own! 

Although today was a bit exhausting, I'm really looking forward to meeting my mentor tomorrow and getting started on my research!