First impressions of Mumbai

So it's my first full day in Mumbai, and after driving around the city, I've had some time to form a few (public health-related) impressions.

The monsoon season hits Mumbai hard, which brings a host of issues in itself. The air is so humid and thick you can take a shower three times a day and still feel sticky. The weather is a breeding ground for water-borne diseases like malaria and yellow fever. Already, there have been reports of an unusually high number of malaria cases in the area...and that was before the monsoons even arrived this summer.

The rains bring more than infectious disease, although that in itself is disastrous to many people, particularly those living in the slums (Mumbai is home to the largest slum area in Asia, Dharavi). It also rips up the roads, creating huge craters that rickshaws and cars get stuck in, clogging the roads and endangering the lives of both drivers and pedestrians.

I've written about sanitation problems before, but multiply those at least twofold for a city like Mumbai, because of the rainy season. City planning is very poor, and the rains create terrible sanitation issues. Aside from the standing water everywhere, there is so much trash all over the streets. Scraps of food, rotting carcasses, plastic waste...these are all the types of things you'll encounter while walking (in your sandals!) on the road. It is deeply, deeply unsanitary.

Then there's the beaches. People visit the water in Mumbai for both religious and recreational purposes. There is the festival of Ganpati, where figures of the elephant god are made out of plaster of paris and then dunked into the water. There's Juhu Beach, which is famous for its beachside fun and its chaats (spicy snacks). Today, we had tea by the beach and until we walked closer to the waves, we didn't realize that the sand was chock full of all kinds of TRASH. How can beach goers bathe safely among so much trash? In Los Angeles, studies are done to estimate the social and economic costs of dirty beaches. It is SO much worse here in Mumbai.

Something must be done to improve the cities of India. Proper drainage must be installed; the rains will continue here from July until September. People are unable to go to work; many trains are not functioning and people are wary to step out of their houses after the flooding and loss of lives two years ago. The government has made no improvements to thwart another similar disaster. So much productivity is lost, meanwhile, in a country that cannot afford to lose productivity!

What can be done about the trash? What can be done to instill in Indian citizens a sense of civic duty? What can be done to inspire the government to make city planning a priority? To fix the roads so that huge craters don't punctuate the streets?

HAPPY BIRTHDAY NEENER!!!

Today is my sister Neener's birthday (you might know her as Reshma but inexplicably she's become Neener to me). Reshma means a thread of silk in Hindi. My sister is beautiful inside and out-if you know her you can vouch for that-but she's anything but soft and delicate, if you ask me. In my world, that's a high compliment.

Life is not about being soft and delicate...at least not most of the time (although it depends which path you take in life). I have no brothers, so my sister and I grew up not really knowing what it means to be a girl. We grew up thinking we were the same as boys. Of course, that's not exactly true. But my sister's fight and passion in life have always inspired me. Those qualities are especially useful here in India, where among one billion people, you have to be loud sometimes to get your voice heard (whether what you want is a cup of chai, or funding from an NGO for second-line ARVs).

My sister has lofty goals on the global business front, but the funny thing is that they are only lofty if you don't know her. If you do, you realize that her determination to harness market forces to solve global health problems is just about par for the course. She's already on her way there, with a prestigious internship at Gilead, a corporation known for its poverty-fighting activities in developing countries. She's also co-leading a team of fellow Stanford MBA students on an exchange program at the internationally renowned Indian Institute of Management in Bangalore.

With such an impressive resume building up, you'd think my sis would be getting a big head about it. That couldn't be further from the truth (she doesn't need fancy accolades for that! just kidding!!!) The truth is, she picked Stanford because of its commitment to fighting poverty with business acumen, and joined Gilead for similar reasons. God has blessed her with immense talent (plus, more importantly, she's the funniest person I know), so I really lucked out to get her for my big sis. Happy birthday Neener! You're good for the future of global public health.

One of my favorite Neener-inspired ideas: "The closest way to a public health solution is through business." Remember me when you're famous! And when you shop.

It's not easy being green

In California, it's hip to talk about clean fuel and recycling. Driving a Prius is "in". People who litter can expect dirty looks along with steep fines. We're all about the environment.

Given that I've lived my whole life in such a setting, I did not expect to come to India and feel like this country is a step ahead of the US in terms of converting to eco-friendly fuel. Almost all buses, and many other vehicles, sport the CNG logo, indicating that they run on certified natural gas. As I mentioned on my entry a couple weeks ago on Sawai Madhopur (tiger land), many village homes get their fule from biodigesters and similar methods-much more environmentally sound than what we have in the US. Remember how the Prakratik Society urges villagers to plant trees to offset wood-burning? Do we have that kind of accountability? What's the deal?

The deal is, environmentally, India might actually have an advantage over the US and countries like it. It's easier to go from having no buses at all (in some areas of India) to CNG buses. It's way more efficient to install biodigesters in villages that had not previous power source, rather than tear up old infrastructure and install new, incompatible systems.

So in the developed countries, or at least in most parts of them, our modern way of thinking-green is cool-still needs to be translated into action. Fewer SUVs. More public transportation. Cleaner burning fuel and more hybrid vehicles. More planting of trees and smaller carbon footprints for each transnational corporation, factory, family, and individual.

It's a tall order. Buses crammed with 100+ people may fly here in India, but people in the US don't want to deal with public transportation if they can afford not to (and most can). It's tough to go backwards, socioeconomically, once you've had the luxury of your own personal vehicle (and a sports utility one at that), your own power source, your own unlimited resources so long as you can foot the bill.

Not that India doesn't have its own hands full, environment wise. Pollution here is horrible. The rising middle class is suddenly able to afford cars, which is reflected in increased smog, toxic air (and rampant respiratory diseases), and unfailingly clogged, chaotic roads. But all I'm saying is that India is taking practical steps forward. Maybe it's not enough, maybe it's just a drop in the ocean, but it's a tangible effort.

Developed countries may be able to get away with doing nothing. They have lower population sizes, the ability to afford carbon credits, if they are ever implemented, and the ability to pay for skyrocketing fuel prices. It's even been said that global warming won't hit the richer countries so hard as the poor ones. Even if countries start to convert to biofuel, poor countries will face disadvantages because precious land (thousands and thousands of hectares in one state of India alone, as specified by Indian Oil) will be converted from food crop use to fuel crop use. Creative solutions, like using only crops that can be used for both food and fuel (ie corn, sugar cane) may need to be implemented. Even more complex is the fact that crop prices have already started to rise in response to the growing demand for biofuel raw materials. This will have negative consequences in countries dealing with suffering subsistence farmers and rising national food insecurity.

Sahastradhara and School-Based HIV/AIDS Education in Uttaranchal

From Ajay's travel blog...pretty similar to my own, except my pictures have about 3x more people!

Yesterday was another interesting day in Dehradun. Waking up for our last full day here, we thought we'd make a lazy day out of an internet cafe session, coffee shop relaxing, and other in-town pursuits.

Of course, that's not what happened. We did do all of the above, but we also made an impromptu trek to Sahastradhara, a cool sulfur spring embedded in the mountains. We had no idea what to expect, really, but in my mind I pictured a series of clear, deserted pools emitting a faint scent of boiled eggs.

Sahastradhara is neither clear nor deserted (come on, this is India), and the smells are of sweaty people, not sulfur. The pools themselves are undeniably beautiful (though probably not their natural color anymore), situated among mountain ranges and punctuated by big boulders. They ARE arranged in series, like a waterfall. But like Mussoorie, Sahastradhara has become a crazy tourist attraction full of food stalls and souvenir shops, trash, and PEOPLE.

The best part of our trip was the ride up the mountain. We took a bus, which, if you've never been in one, is quite an experience in Idnai. I got to know a LOT of people in that bus, if you know what I mean. You get stepped on, sat on, rubbed up against...ahhh, there's nothing like it. The views, as always, were gorgeous. Nature never disappoints; we humans are what deface things.

To treat ourselvse for finishing the last tourist attraction in Dehradun, Sej and I went to the haven that is McDonald's and got well-deserved junk food. It felt like imminent rain, so it was hot and humid as we walked the long walk back from the bus depot to our section of Rajpur Road (where we're staying). As soon as we got back, it started pouring. It's still coming down strong today. Monsoon season!

Now for the public health related part. Dehradun is located in Uttaranchal, and happens to be home to one of the two most prestigious prep schools in India. However, the fledgling state of Uttaranchal has just definitively banned school-based HIV/AIDS education because of traditionalist thinkers who fear talking about HIV in schools will encourage earlier sexual behavior among children.

Ironically, this is the same state that's pushing for IT and e-literacy for all in the next few years. What do you think children do on the internet? Not everyone looks up gossip and sports. I can tell you from my time spent in cyber cafes (where cookies are unfortunately not always cleared after use) that sex education is definitely taking place on the internet.

The UN has declared that school-based sex education actually deters early sexual behavior among youth; why, then, is India (and the world) having such a hard time with it?

As usual we are, foremost, victims of ourselves.

Historiography and Public Health

There are only a few voices in history, and they are the rich ones.

As a comparative literature major in college, I am most intrigued by the concept of history as works of literary fiction. I specialized in Latin American literature, and found that throughout various important literary time periods, colonial history-a history of occidental subjugation and exploitation-is deeply embedded in literary works (both colonial and postcolonial/postmodern). As a result, Latin American fiction is anything but. It’s a politically charged, militant vehicle to say what, in the real world, cannot be said. Meanwhile, history books written by conquerors sing their one-sided tune, painting a picture on the surface of things while destroying native culture and truth on the side. This is not history. This is historiography-the crafting of stories.

So what does this mean for India? There is a point. India is another country that not so long ago was under imperialist rule. After gaining its independence in 1952, the fledgling democracy suffered a lot of civil strife and poverty. Freedom has its costs, whether the emancipated party is Black slaves in America, Latin American countries under USSR/US occupation, or Indians ruled by the British. In Bharat’s case, Muslim-Hindu tension heightened, Pakistan was born, and population-and its partner in crime, poverty-exploded. Public health, as usual, suffered dearly.

Muslim-Hindu tensions are still high. The most ornate Hindu temples in Delhi (such as Akshardham) are high on the supposed Islamic terrorist list (according to Sej, my Hindu culture informant). It’s still considered controversial for Hindus and Muslims to marry-better a Hindu marry a Christian or a Sikh than a Muslim! I feel the tension myself when Hindus talk about the introduction of Islam to India-it is always portrayed as a shameless invasion by Moghuls who forcefully converted their subjects to the austere religion.

However, I just read an article in the Times of India that argues that the Moghul invasion theory is a myth, not a fact. The scholastically accepted version of history is now that Arab traders brought Islam into the country-not by force, but peacefully.

So, my faithful readers (hi Mom, Dad, Neener and Grandma) that I’m Muslim. But I’m not trying to defend my religion at all-it makes no difference to my identity or my faith how Islam came to influence my mother country. I AM, however, interested in this bit of history from a public health perspective. It’s not just Muslim-Hindu conflict that affects Indian public health, but tribalism and religious/ethnic clashes in general. Sometimes, individual pride, mistrust, and hatred of the Other run so deep that castes and tribes don’t even stop to think that their inability to unite under common causes (education, health, electricity, sanitation, city planning) results in much more damage to their communities than anything else.

Of course, from a social-ecological perspective, these individualists are not to blame; it’s not their fault. There are always deeply embedded root causes that explain surface tension. India’s immature democracy has the gargantuan task now of building political parties capable of appealing to hundreds of scheduled tribes (as well as the growing, modern middle class). I think the answer lies in human development-not just empty campaign promises during election months, but real follow through in areas of public health. That’s a cause no ethnic group should reject, if communication is effectively executed by the public sector (if only…).

Mussoorie Day Trip - A Hill Station in the Himalayas

Sej is featured in several of my photos. She has all of my pictures and I have all of hers. We've become very efficient at alternately running in front of a scene to have our pictures taken by each other!






Kempty Falls...ok, it's not Niagara, but it's a natural waterfall! I ain't complaining.



Today we went to Mussoorie, the main attraction of Dehradun. The Himalayas are breathtaking, although the little town was way too populated to take in the beauty of the mountains themselves. But still, it was amazing. When you stand in a mountain range like this one, you start to feel how small you are, and how you're just a part of something bigger and very, very amazing. Praise God.

Another interesting thing about Mussoorie is how much British influence is reflected in the architecture. As Sej pointed out, a lot of the buildings (and the windows, specifically) are not Indian. There are a lot of old structures, too--the library is dated to 1843. This was a British settlement. It makes me angry when I think about how imperialists claimed this beautiful mountain area as their own, making ugly pink buildings and bringing plastic and other types of garbage here. It's the Himalayas!!! It's a town among the clouds. And now it's way too touristy. In my opinion (and I probably am in the minority here), the ride up to and down from Mussoorie is much more calm and engaging than the town itself.

Bollywood and HIV/AIDS in India

The first photo is of Kareena Kapoor, who never disappoints by wearing too much clothing. The second is one of Shah Rukh Khan's scenes in the movie Sheesha. The first is from imageshack.com, second from timesofindia.com (click for source).

Having just watched my first blockbuster Bollywood film in India in a long time, I am shocked by just how much Indian pop culture has changed...for the worse. The cheapness of it is disheartening. Now, I'm definitely an old fashioned girl in this modern world, in some ways--in my world view there's no drunken partying, sleeping around, cleavage displays/miniskirts, and potty mouths (though I can be a brat sometimes, but that's different). But by any measure, Bollywood has definitely gotten more...modern in the past few years. Before, the scant clothing was there, but stars wouldn't openly kiss onscreen, and sex scenes (except the most subtle hint of them) were nonexistent. Suggestions of premarital sex were depicted as rare and negative (prostitutes, corrupt men, etc). This has changed. Films like Salaam, Namaste and Jhoom Barabar Jhoom reflect the changing values of this lumbering, developing country. Along with the high tech cell phones, latest fashions, and glossy scenes, tv and film depict India's anti-traditional cultural development (to be distinguished from what concerns public health--and me--that is, human development). India is inching further away from being that nation rich with history, culture and diversity; it's getting closer and closer to a modern democracy driven primarily by market forces. It's not as far along on that pathway as some other countries (eg, China), and its great diversity and population size will slow it down considerably, but I've noticed a definite shift in popular values.

What's the result? I just spent a day with my distant cousin Kirtina. She's 12 years old, lives in an upper middle class apartment complex in a very nice part of Delhi, and is fascinated by both US and Indian pop culture (these days, what's the difference--if anything, the Indian version is even more "pop" than its US counterpart). She loves The Disney Channel, Nickelodeon, and Hindi serials and films like Jhoom. She is seduced by the song, dance and drama of the media--the same media that allows superstars to smoke onscreen, depict premarital relationships as the new norm, and wear clothing that leaves nothing to the imagination.

If public health efforts in India don't keep up with the "westernization" of Indian pop, STDs (and particularly HIV) could become an even bigger issue in the country than it already is. Effective prevention campaigns, school based awareness and family involvement are all needed to catch up with the poorly regulated media circulating in India today. The anomaly is that despite the fact that pop culture has become so lax and open, society still clings to traditional beliefs that sex should not be openly discussed (particularly with kids). Parents and teachers, astonishingly, don't want school based sex education, nor do they take it upon themselves to educate their children at home. There's the rub.

The solution? That's a tough one. Perhaps it would help to recruit age appropriate superstars to speak up for the cause. Since parents need to get on board, an older film/tv star would help to convince them. Kids would likely respond to younger stars, obviously--and not just Hindi stars, but American ones too. Lizzie Maguire, That's So Raven, and the newest Nickelodeon shows are all really big here. HIV/AIDS awareness and prevention messages can be incorporated into story lines, too, the way they are in the US. Of course, ignoring the issue is a convenient and attractive option. But not dealing with it is one way to predict that it'll haunt Indian public health for decades to come.

Mewat in Pictures

The younger students. The one on the left was the Twinkle Twinkle Little Star fan. The one on the right was the littlest student, and kept unwittingly torturing this newborn kitten, which elicited some muted admonishing from me.



Group picture. We are in the way back...it was just me and Paulie, since Sej didn't feel well and Emma was tired from her trip to the Taj Mahal the day before.



The embroidery class. After looking at several designs I felt confident these girls' work can do well in the Delhi markets.



SPYM handprint mural outside the SPYM field office in Mewat. I hope to visit this village again soon! As Shalini said, there's something about working with these small, thin, raggedy, exuberant kids that makes it better than anything else. I felt this way at the St. Stephens' Outreach Center in Nandnargh (Delhi slum) too. Field work is where it's at.

Mewat Trip!

Our last day of the program, we finally went to the village of Mewat in Haryana. It's one of the most backwards areas of the north, with extremely poor "health indicators" (a term created by developed nations). High infant and maternal mortality rates, low female literacy rates and poor sanitation are all part of life in Mewat. Malnutrition. Multiple children. Tribalism.

The trip there was an experience in itself. The roads were terrible, with big potholes and lots of digressions and dead ends. We had a very difficult time finding our way. There was also a lot of construction going on. We saw big tractors moving dirt, and half-built temples along the way. We also saw a few rickshaws crammed with at least 12 people in each...Indians piled upon Indians. That would never happen in America...we're too big and tall to fit that many people (heck, half that many people) in a little rickshaw!

Once we finally arrived at the SPYM office in Mewat, we immediately left for our first site visit to the school that the NGO has built up. SPYM has taken government funding and formed a public-NGO partnership to establish 20 schools in the village. There are public and private schools nearby, but so many children (age 4-15) lack basic education and cannot enter those schools without first having basic reading and writing skills...which SPYM is trying to impart.

There ar etwo groups of children in the school we visited, which is conveniently located in a residential part of the village among simple adobe houses, dirt roads, and heaps of cow dung. The first group we met was younger children (age 4-11). They don't know their alphabets yet, but the hope is that they will learn here and then transfer to public school (government fees are nominal...5-6 rs).

The educator and SPYM officer told us how difficult starting this project was. Money is not the issue...SPYM services are free, and government fees are so low. Here in Mewat, families don't see the point of educating their kids. They should instead stay at home and look after the smaller children (even a 4 year old is usually an elder sibling in these baby factory families). They think school (even just a few hours of it) is a waste of time. What would they do if not in school, besides tending to their siblings? Play with friends in the dirt, do menial chores, etc. It took a lot of convincing to get parents to send their kids to school. There were about 30 little ones in the "classroom" (an outdoor hallway with all the rugged kids sitting in rows on tattered pieces of cloth). SPYM has ben doing outreach for 15 years in Mewat, and I got the sense that a lot of knocking on doors, rapport building, and gaining trust had to be done for these children to be sitting there ready to learn. Shalini (CFHI program coordinator and SPYM health worker) encouraged us to play a game with the little ones, so we sang Twinkle Twinkle Little Star (we even got an encore request) and also played a version of Simon Says that we dubbed "Didi Bolo" (Sister Says). It was fun...kinda like being in kindergarten again.

After saying goodbye to the younger batch, who went home (a 1-minute walk at most) for lunch, we moved on to the second classrom, which was basically the floor space behind the first class. Here, another 20 or so older girls were huddled together (age 11-15). All had their hair covered by their dupattas, indicating that they are Muslims (the younger kids were a mixed group). Mewat is primarily Hindu tribes; Muslims are in the minority (it's that way in the vast majority of India). We were told that it was even harder to convince these girls' families to let their kids come to school for a few hours each day, because they are Islamic. Girls from these families are expected to marry soon, so why waste an education on them? SPYM convinced families of the usefulness of schooling by setting classes up as "cutting and sewing" instruction. Muslim families in Mewat were much more responsive to their girls' learning a marketable skill than the alphabet. However, on the side of cutting and sewing, SPYM teachers ensure that literacy instruction is given to the girls. It was shocking for me to see (of course, intellectually, I already knew from MPH classes) the effects of Muslim traditionalism on women's and family health. How could these women progress if their only expectation in life is to bear (male) children, cook food, serve chai, do farm work and iron clothes? How can they educate their kids if, from the time they are young, they are not even allowed to leave the house?

After the customary intro session of singing (you won't believe it, but I sang "Lean on Me"...solo...upon request for an English song, and one of the Muslim students sang a Hindi song in response), we got to interact with these girls who were so eager and open.

The student who sang, a slim, fair girl wearing a simple salwar and a white eyelet dupatta over her head, broke the ice by asking us what we thought of them. I was taken aback by the question...how to answer? There are so many first impressions. Lovely. Dirty. Ignorant. Bright.

What we DID say was that what they were doing in school is very important, and that it's a very good thing. Just think what they could have done if they'd had proper education earlier on? This is a big step forward they've taken in life, and they should be congratulated. Acchi baat hai (It's a good thing). They seemed to like this reaction, and it was 100% true.

We asked them what THEY thought of US. They wanted to know why on earth we had troubled ourselves to come all the way there to see them. Where did we come from? What were our names? They were very surprised to learn I'm Hindustani (do I not look Indian????). We asked whether any of them would continue their education in official school after this course. Several wanted to, but expressed their desire, I thought, tentatively. They had to convince their parents to let them come this far (to cut and sew, not to read and write), and might not succeed in making it much further before their parents arranged their marriages and they moved into their in-laws' homes.

After a photo session with the whole group (minus the little ones, who had retired for the day), we left the girls and teachers, and moved on to the next part of our trip, to SPYM's income generation and microfinance projects. First, we met with some younger girls (about 10 years old on average) who were practicing their embroidering skills. Their designs were actually beautiful, and the future plan is to have companies deliver plain salwar suits and other items so that these kids can embroider them for rs 40-50 ($1 US) each day. The goal is to get more money into the hands of women and girls--female empowerment en route to community health and well-being. These girls were bright and friendly, less quiet and mor eopen than the Muslim girls at the school (these girls were mixed, mostly Hindi and a few Muslims). They asked our names (and remembered them!) and told us theirs. They even taught us how to embroider!

Next, after a spicy cup of chai, we met with the microfinance group members. All are daughter-in-laws living in the village of Mewat. There are 17 members. In order to join, they must be daughter-in-laws, must own land (for collateral) and must have about 50 rs. per month to contribute to their joint bank account (they scrape this money together from household money given to them by their husbands). With all this money in the bank, they're able to take out loans to run small businesses for income generation.

It was interesting to talk to these women and see how they struggle to empower themselves. They initially had 20 members, but 3 dropped out because they didn't have faith in the project (and 50 rs. per month is a tall order in these parts of India). When they get the loan money, they give priority to the women who need it most, in a true co-op fashion. They give loans not just for business reasons but for household needs, too, such as dowry.

The microfinance ladies also chatted to us about the government's education and health care efforts. They expressed a lot of distrust in the public sector. They complained about government hospitals and schools; the MBBS's (MD's) in government hospitals are not trustworthy because there's so much corruption these days you can pay for an MBBS certificate, they said. Government schools are so bad the kids just play cricket the whole day. The women prefer taking their health care from private doctors ,whether their credentials are rael or not. One woman told us that if the treatments given by private practitioners work, and those given by MBBS's from big hospitals do not, she will choose the private "professional" as her usual source of care.

I can't help thinking of all the times in India we hear about or meet HIV cases where "quack" doctors and private clinics were involved in transmitting the disease (unscreened blood transfusions, re-used needles).

Shalini also told us something quite interesting: people here (and in fact, everywhere) mistrust anything that's free, be it chocolate or education or health care. If the same thing is offered by one person free, and by another person for a fee, they will go to the seller to pay, because they are convinced that the seller's product must be of higher quality (simply because it's not free). How to get around that one?? But the mistrust of government services is not only because they are largely free. Shalini said that despite these villagers' illogical mistrust of free services, government schools and hospitals do indeed provide low-quality care in many cases. It is never simple.

So...that was our day, in a nutshell. It was one of my favorite, if not my most favorite, CFHI India experiences. Even the part where I publicly humiliated myself by singing (but it was so graciously received and fervently translated by the illustrious Shalini). Meeting the Muslim girls made me think a lot about myself and my own beliefs. I'm Muslim too, yet the culture and treatment of women these Mewat Muslims subsribe to is alien to me. The positive thing is that SPYM is working to change things and is finding willing, wanting students.

Saturday, Sej and I said goodbye to the rest of the CFHI crew (who we miss dearly!) and spent the day arranging our trip to Dehra Dun (where we are now, after taking the 12 AM train). We also hung out with my aunt, Chandrika Atta (my dad's cousin-sister), in her beautiful new flat in Delhi. She cooked us homemade dosas (crepes) with ginger chutney, aloo paranthas with dahi (potato pancakes w/ yogurt), and upma (ummm....cream of rice curry?)...we ate all day long. No more plain tortillas and lentil soup for these girls (not that that was bad at all).

Now we're enjoying Dehra Dun, aka the gateway to the Himalayas. There's a coffee shop across the street from where we're staying, we have all this free time, and we get to see the gorgeous Himalayas every day...thank God!

Oh, and I got off the waitlist and into UC Irvine for medical school. I found out a couple days ago and still can't believe it's true. I was all set to apply a 3rd time (now I have to say goodbye to $700 on a wasted AMCAS application, ugh) but God brought this news. Okay!

The Middle Man (and some digressions)

Click for source (I'm too lazy to put up my own, but this is pretty much what I see every day)

If you’ve spent quality time in a developing country, you know how ubiquitous the middle man is. Want to get something done without doing it yourself? Get a servant, he’ll be your middle man. He’ll go to the market for you, wash your clothes, call your rickshaw in the morning.

He’ll also be totally dependent on you, and so will his family.

There’s always someone here in India just waiting to be your middle man. I’m here studying public health and HIV issues in the country, through an organization called CFHI, and even then, there are a few middle men who are happy to throw their hats in the ring, do a little work, and make a cut of the money we paid for the program. Often, what looks at first to be hospitality and kindness (sure, we’ll arrange this for you…) may actually be someone trying to insert himself as your middle man. Like the tour guides at Indian monuments who promise to tell you all about the historical site you’re visiting (and take your picture with their Polaroid cameras for a nominal charge), the plots that middle men hatch are usually harmless to you and me. In fact, middle men are dependent on the lumbering economy of developing countries; if it wasn’t so poor, they’d be out of jobs (read on).

One of the things that concerns me about all of this is that with the presence of middle men, money is often going into the Wrong Hands. It’s harmless when an entirely unofficial, self-proclaimed tour guide charges you 50 rupees to tell you all about the Taj Mahal. He'll use that money to feed his wife and kids, and probably to buy some paan, tobacco or alcohol. But there are many cases where middle men are not simply people trying to make a living, but rather middle class or upper middle class trying to get something for nothing. They have more resources and can thus get away with more. It's most despicable in a country with so much need, but I suppose that way of looking at things is illogical. We are, after all, talking about the human being (a creature best suited to looking only after himself).

There’s the shady business that marks up prices or sells counterfeit goods (No really, it’s authentic Adidas, ma’am. Two year warranty.). Meanwhile, people running an honest business are not financially rewarded for their efforts, despite how valuable his or her good work is for the country’s economy as a whole. India is chock full of merchants—so many on every corner, selling the same thing (or close to it) as the guy next to him. No one is regulating these people. They’re free agents, ready to play the middle man to some unsuspecting customer (especially foreigners, national or international). Customers rely on these middle men for their goods…in India, there are very few supermarkets where you can get centralized pricing and dependable, brand-name goods. You still get your milk in a plastic bag from the merchant on the street. You still pick up mangoes from a bullock cart on the way home from work. You still drink lime juice from the man with the rusty machine by the subway. Unless, of course, you are upper middle class and know better.

So what’s the solution? Bring in the supermarkets with their fixed prices? That is indeed what’s happening; there are more food markets now, selling goods for lower prices (and all under one AC roof). Is this a good thing? Well, considering fixed prices (as opposed to bargaining over a pound of apples) and convenience, yes, it’s a good thing. But in light of the vast middle man market in India, many, many livelihoods are lost when a big corporation rolls out a new supermarket. All of a sudden, thousands of street merchants in one city alone see drastic reductions in their business. Now, the middle class housewife (yes, India has a tiny but growing middle class) can get her water, tea, juices, produce, ice cream and other sundries at a branded supermarket. And she will. Of course, she pays a price—the meats are no longer antibiotic-free, and the produce is no longer organic. Family farmers suffer too, because street merchants are no longer selling as much, so they’re not buying goods from the rural farmer. The whole mechanism is undercut, and more money goes into the wrong hands. The irony is that all this is happening in the name of development.

The real solution, I think, is to massively upgrade people’s skill sets. This is happening, but it needs to trickle down in a big way. Some people are able to afford the IT re-training sessions and English lessons that are advertised all over Delhi these days. So many are not. The rickshaw pullers, street vendors, servants…maybe it’s too late for them, maybe they don’t want to re-train, but certainly, their children should have a decent shot at it.

The government needs to realign its priorities. They aren’t pro-poor, from what I’ve gathered. Of course, in a country with a billion people…we all know that excuse. But there comes a time when you stop excusing and start doing. India is in dire need of creative solutions. They need a watershed system here, but it’s no use talking about an underground system of pipes like we have in the U.S. They need innovative thinkers. Even if an underground scheme is the only solution, how do we execute it? Certainly not in a planned way, before cities are sprung…urban squalor is everywhere. They need to educate their people, and provide health care for them. They need to invest in their poorest. I wrote this on my global health blog. Now I’m seeing it with my own eyes, and I’m saying, the government must educate its children who are eating, playing, showering, and defecating, living their lives out on the streets. Maybe then, what it means to be a middle man for the staggering poor in this country will improve.

Yoga's at 6:30!

This week we started our last rotation at Bapu Nature Cure Hospital and Yogashram. Sound familiar? That's because I've mentioned Bapu before; we stayed here our first week. But we didn't know what went on in all those consultation chambers. Now we do!

As the title tells you, the day starts with a 6:30 am yoga session, which is tough for those of us who can't seem to sleep before 1 am due to varied and loud distractions. But once we make the 10 minute trek to Bapu from Manu Apartments (where all 10 of us are staying in, ummm, three rooms and two bathrooms), it's worth it. The yoga's elementary, but it feels so good to stretch and we have been hearing from EVERYONE, from doctors, to HIV peer counselors to people on the street, how yoga heals everything. And there is something about it...the breathing, the meditation, the holding of poses, the "tourniquet effect" of blood being held in one place and then rushing to the limbs. There's gotta be something to it.

The official day starts at 9 am, Indian time. So around 11:30 we start doing outpatient department rounds (OPD), with the naturopath, physiologist, acupressurist and ayurvedic doctor. Today, we'll meet an acupuncturist too (although acupuncture is officially Chinese, so the Indian government doesn't recognize it as part of Ayush, the Indian medical system).

After OPD, we have lunch (ahhh, Bapu...it's always grams, rice, squash, and chapatis) and then a lecture by one of the doctors from the OPD. Yesterday Dr. Rukhamani Nair gave us a lecture on the basic tenets of naturopathy and ayurveda. It was pretty interesting. She seemed very aware she was speaking to (largely) allopathic people (although Emma is pretty alternative). She made sure to explain that the way ayurveda explains health and disease are simply explanations...they are not meant to overtake modern medicine. However, the naturopathic doctor we met, who chose to get a bachelors in naturopathy after getting low marks and failing to get a seat in medical school (sound familiar??), seemed to think that for chronic degenerative diseases, the natural approach is superior. And for the most part, I can't disagree.

I did rounds with Emma yesterday, and uor first noe was with a physiotherapy doctor, Shikha. She did her bachelors in physiotherapy (apparently, you don't have to have a masters degree to call yourself a doctor, and Shikha says the government now recognizes people like her as official doctors). Her patients mostly suffer from periarthritis. They are over 60 years old, for the most part. We watched her do some manipulations, and stretch a young girl's neck because it was bending over due to some kind of fibrosis. It was interesting to see that a lot of women had something they call "frozen shoulder" in their right arm, due to untreated tendonitis that eventually became periarthritis (a soft tissue disease). It appears that these women suffer from repetitive use of their arms...we've all seen women sweeping, scrubbing clothes, pots, pans, and floors. They also stoop with their backs instead of bending their legs, as Emma pointed out the other day. But Indian women don't complain.

Our next rotation was with Dr. Usha, an acupressurist with killer hands. She did some acupressure on Emma and me and it was awesome...very forceful. She taught us all about the soles of the feet and the palms of the hands...each part corresponds to some part of your body. Applying pressure to, say, the tip of the finger, is good for healing the sinuses. The back of yuor right toe also connects to the head...Dr. Usha got so specific as to say it affected the pituitary gland. In between the second and third toes is the eye point. And so on and so on. There's a point for every part of the body on your soles and palms, and by kneading these points, you can heal many complaints. The patient we observed had come in because his allopathic doctor told him he needed to have a tonsillectomy. He doesn't like modern medicine, and wants to avoid it at all costs. So he decided to come to Dr. Usha, who's been treating him for two or three months. Now, he says he's totally fit without any medicines or surgery. Hmmm.

The aforementioned naturopathic doctor was our next rotation. He describes his field as a drugless therapy, where water, mud, and diet are manipulated to treat ailments. Mud has a cold effect, so it helps with skin disorders, constipation, and abdominal organs. You don't just use any soil, but the black or yellow kind. Water therapy is, as we all know, hydrotherapy. He had a massive book the size of Gray's Anatomy, all on hydrotherapeutic techniques. One thing I respected a lot about this doctor's ideology is his belief that if you work on the patient's mind, you'll see positive results. Behavioral change is the biggest challenge, so patients need a lot of encouragement and hope. This doctor took that task upon himself, which I think is totally appropriate. And while the results from drugless therapy come much slower, you DO see results. And they are more lasting.

One of the things that bothered me about Bapu is that when I asked about the socioeconomic status of the patients that come to the OPD (and who come to stay at the hospital, for that matter), I was informed that they are mostly upper middle class. The poor can't invest the money for long-term therapy, which is what nature cure entails. It's an investment. I asked if they do charity cases too, and they do. Today I will ask about outreach efforts. There is so much filth around Bapu, in the Padpadganj area. There are children sloshing around in the foul water that has pooled due to yesterday's heavy rains. Who knows what microorganisms are in there?? Cholera? Typhoid? Giardia?

There's more to tell, but I have to go learn more stuff now!

HAPPY FATHER'S DAY, DAD!

Today is Father's Day here in India. I won't be home to celebrate it with my dad. He's the best dad I could have possibly gotten. I know everyone says that, and it's true for everyone if you look at things from a spiritual perspective. But still, that doesn't make it any less true: Dad, you're the best!

In fact, one of the reasons I'm motivated to approach life with a public health perspective is because that's exactly how my dad is. He always thinks of things in terms of the whole environment, instead of just one isolated fragment. Everything affects everything else, and there's no escaping that. My dad taught me that not just by telling me, but by example. He plants more trees than anyone else I know. He employs a LOT of people; if someone needs a job, he has a really really hard time saying no. He'll find something for them to do, whether it's in his office or in his garden. He doesn't like handouts, not because he doesn't want to give people free stuff, but because he knows that what they really need is a livelihood, not a gift.

My dad has been emphasizing things I learned in grad school for years. Even though he's a vascular surgeon (it doesn't get more clinical/technical than that!), he still stresses a public health view. He urges people to take preventive precautions rather than wait to treat a full-blown disease. He knows the importance of a balanced, varied diet. He planted crops in our backyard because he wants us to be self-sustaining and to eat organically-grown vegetables. As a result of his hard work and vision (and ultimately, of course, the thanks goes to God), we have lemons, tomatoes, avocadoes, and lots of other beautiful vegetables and even some fruits that give us more yield than we know what to do with. We also have chickens, cows, sheep and other animals that complete the farm. It's a truly blessed existence, and it was my dad's vision.

I could go on and on. I could write about how supportive my dad was of my grandma's learning how to use the computer and internet. Or about how kind my dad is to my grandpa, Babba, who has some dementia and needs patience and compassion mixed in with some good humor. My dad is there for that. He takes care of my mom, even though they have their moments. He makes her tea on the weekends, and fixes breakfast for her dad (the aforementioned Babba).

I think public health is a fundamental way of looking at life. And my dad has helped shape that outlook so much. If that wasn't enough, he's great fun to be around. Have a wonderful Father's Day, Dad. God willing, I can't wait to see you again!

Another One of those Paradigm Shifts We Need

Why is it OK that a person should feel uncomfortable having an HIV-positive person bagging their groceries, or sharing the common kitchen at work? Why is that socially acceptable? Why is it that the positive person is punished for putting the world at risk (sometimes at phantom risk) for HIV simply by breathing in the vicinity of so-called "clean" people? Is he or she somehow less deserving of that space? Do we not live in a world surrounded by risk? Do we not take proper precautions to protect ourselves every single day? Is it not worth it to spare a human being's livelihood by adopting general precautions in our daily lives, so that we protect ourselves from risk and then banish these discriminatory feelings from our minds, accepting that an HIV-positive person could very well be among us, but that it's alright because we're protecting ourselves against real risk, and learning how to differentiate that from perceived risk?

What we need is another one of those paradigm shifts, where we start to look at old problems with new eyes. Maybe we need to start putting education into people not just about how to protect themselves from getting HIV, but about how it's their own responsibility in this era of HIV/AIDS pandemicity (is that even a word?) to protect themselves in daily life. This is just one aspect of a very complex issue, but maybe if ordinary people were empowered to step forward and do that, PLWHA in India (and apparently Canada, and likely many other countries, too)wouldn't lose jobs and livelihood, live on the margins of society, and perpetuate the disease.

Last day in Rajasthan...

The title says it all. I'm sad we're leaving Rajasthan! With the nice showers, great mattresses, AC computer lab, and yummy food (not to mention some kind of non-veg EVERY NIGHT), it's going to be very hard re-acquainting ourselves with Bapu Nature Cure Hospital and Yogashram (see week 1 posts for details). Yes, Bapu has its charm, with its mice, lizards and gigantic cockroaches (we saw flying roaches here too, to be fair). But there's no protein connection, and the computers at the nearest internet cafes (non-AC, fly-infested according to Sej) are twenty years back in comparison.

Anyway, today we compiled a presentation for Dr. Goyal in our hours-long goodbye session. First, we showed him what we did every day this week (all the public health stuff I've blogged about recently). Then, each of us had picked a country to research its HIV/AIDS situation. Most of us picked the countries we live in, our the countries our parents came from. Sophia, Sej and I are all Indians living in the US, so the two of them picked India, and I chose Cuba (I love Spanish-speaking countries, and Cuba's HIV/AIDS history is intriguing). Other countries included Russia, Korea, Canada, Japan, Vietnam, Laos, and Cambodia. I don't know if Dr. Goyal appreciated our work, but it was interesting to do the research because it seems that now, we know more about the situation in India than in any other country (including our own!). So it was informative.

Cuba's history is interesting. There is a very low prevalence of HIV there...about 0.06% compared to 1.6% for the Caribbean in general. Why is it so much lower in Cuba? Cubans are known for their sexual promiscuity and high MSM population (70% of women were infected by bisexual men!). It's lower in Cuba in part because of its isolation during the Cold War. At that time, sexual tourism in countries like Guyana and Haiti was taking off, exposing those nations to the infection. Cuba did not experience that. Also, the country was extremely quick to respond. In 1986, the government mandated that all blood donors be screened. In 1987, that mandate spread to the entire population. This was years before other countries would follow suit, partly because Cuba was more efficiently able to mobilize its people. It then started the sanitoriums where positive people were ripped from their families and quarantined for years. Forced quarantining ended in 1999, but many people chose to stay at the sanitoriums. Too many years had passed, and too much had changed. They had created a new family.

Another country that was interesting to me was Canada. Jazmin did a great job with her presentation, and her analysis of social norms related to HIV among Canadians was excellent. She found a survey that showed that 25% of Canadians would feel uncomfortable sharing a workplace with a positive person. 25% would also feel uncomfortable if a positive child went to school with their own child. Job discrimination is such a huge issue when it comes to PLWHA. When educated people act this way, what can we expect from the uneducated? I realized relatively early in life that one of the biggest chasms for humans to face (and hopefully, cross) is that between theory and practice. In theory, we all know how HIV is spread, how to protect ourselves, and how to be just. But in practice, we let fear and bias rule. More on this tomorrow...this is an issue that must be tackled.

After our presentations, we wanted to watch a Hindi movie (more of that cultural immersion!) but it was sold out...apparently you can't just decide to go to a movie a couple hours before the showing here in India. There are just too many people! It rained and rained today, so we didn't want to go to another open market like Bapu Bazaar. So we ended up going shopping at an indoor mall, where we did some more bargaining and I walked away with more of those beautiful purses to give away as gifts.

It's the Network!

Today we visited RNP+, a non-governmental organization started in 2002 that links HIV-positive people with each other so that efforts against stigma and discrimination, and toward more rights and services for affected people, can be strengthened by the participation of HIV-positives themselves. Until now (and even now), one of the major problems has been mobilizing positive people to come out and let society know that they exist, and that their treatment by society and by the government has in many cases been extremely destructive. The presence of this network is absolutely vital to garnering public support, striking that emotional chord, and showing the government that HIV-positive voices can be political ones.

When we went today, we couldn't meet with the president of RNP+ because he had gone to the Rajasthani State Aids Control Society (RSACS) offices to go on hunger strike with several other staff members. They were wearing all black, with a covering over their mouths. Had they done this before? Yes, the director who answered our questions told us. It had been done before. Was it effective? Very, he said. Another tactic they've used is to create fake dead bodies and display them outside the RSACS offices. When questioned about the scene they were making, they produced a list of their demands. Today, too, they have a list of demands:



RNP+ does more than recruit new members to enlarge the network. It also has an Innovative Funding project, which records the skills, education level and work experience of PLWHA (people living with HIV/AIDS) to see whether they are candidates for retraining to do jobs. A lot of them are out of work, but are still able to function. Many of them are on life-prolonging ARVs. Work is what they need.

There are four types of training available: 1) professional peer counseling for other PLWHA (they would be placed in hospitals); 2) advocacy work at the district or block level; 3) computer work (they would be placed in any city with a positive persons network); and 4) receptionist work in an office (for women).

RNP+ has also built up a drop-in center. The director describes this as a real blessing for positive people. In Rajasthan there are only two ARV centers. People must travel frequently from far away to these two centers to get their monthly allotment of ARVs from the government. They often have to stay overnight, the trip is so long. Staying at the hospital is hard for positive people, because they often face stigma and discrimination. Sometimes they have high-risk behaviors. The drop-in center is more supportive than a hospital for them, and it's a relief that they can stay there while getting their monthly ARVs. It probably reduces the dropout rate for treatment, too.

Interestingly, the opposition that RNP+ faced when starting out was not from the public, but from the positive people themselves. Why would they be aginst an organization aimed at helping them mobilize? Because they were afraid of being identified. There was so much fear of stigma and discrimination that they did not want to join a network that explicitly singled them out as HIV-positive. That changed when peer counselors were put in hospitals (this was a government thing too; they initiated peer counseling on their own). A few peer counselors began telling their clients about the network, and that's how it began to grow. It now has over 5,000 people. It was great to hear about this. Mobilizing communities is one of the most difficult yet most important steps in creating public health changes. It takes not only persistence but creativity and craftiness!

The second part of our day was spent at Bapu Bazaar. We had a great time bargaining. I'm getting a LOT better, and starting to feel less bad about ripping merchants off. I've been reassured that they will ALWAYS be making a profit, and that no matter what, they're usually selling it to me for more than they would a local person. Hmmm.

Ranthambhore Trip in Pictures

Hopeful to see some tigers this morning after waking up before 5 AM (for those of us who were able to get to sleep in that hospital ward!).


A very very old banyan tree. This is one of the first things we saw. The hope was still alive that we'd see the promised tigers. The closest we got was fresh tracks and warnings from other species that (apparently) told us they were nearby. But the other group saw four tigers, so it's not a hoax!


Spotted deer. Judging by the striations in the rock and the roots in the banyan trees, I think generations of species have evolved to adapt really well to their surroundings. In wooded areas, it can be hard to spot the deer because they blend so well into the woods & understory.


Close-up of a monkey. I don't know what kind. He was just chillin'. There were so many monkeys there.


Emerald water at the park. There was also some beautiful striated rock.


The male peacock that wouldn't quit. He was trying to mate with four different ladies that just weren't feeling it.


During our tour of one of the villages. A typical house. One of the ladies was so hospitable, she garlanded us with jasmine as she welcomed us into her home.


The kids just line up in front of the camera! What they like is seeing the picture on the LCD, not just having their photo taken.


A biogas digester outside a village house. This is the smaller kind. This vessel is where you put the dung and where it gets mixed with water. Then the gas product travels through a pipe to stoves and other things that require energy.


Ranthambhore Sevika Hospital, from the outside. Also where we stayed while in town, in a vacant hospital ward, sweating out the night!


A victim of gender-based violence who received free treatment for her burn injuries at the hospital.

Save the Tiger: A Public Health Cause

The past two days, we've been traveling outside Jaipur in a rural area called Ranthambhore, home to some of India's last tigers. Ranthambhore is an internationally known destination in Rajasthan (a helipad was made for Bill Clinton there when he visited the tiger sanctuary), yet the villagers living in the area remain poor. They are subsistence farmers with cattle, crops, rationed water (it's the desert) and many children. We took a tour of their village and it was not as crowded as Delhi, but there were several people living in very humble quarters (pictures to follow).

So what were we doing there, as part of a trip to India to learn about HIV and Public Health Challenges? Well, our first stop was to the hospital, to meet with new executive director Rupinder. She gave us an overview of the NGO that started the Sevika Hospital 18 years ago. The NGO is called the Prakratik Society (Prakratik means environment), and has several subdivision. One of them is Tiger Watch, whose job it is to protect the tigers from encroaching villagers and "rehabilitate" poachers. However, Rupinder told us that while Prakratik's aim is to save the tigers, it realizes that the villagers, whose population has increased from 7,000 to 25,000 in just the past 40 years, are also in dire need of help.

How do the villagers disturb the tigers? These are poor people. They use wood for fuel, and have large families (because they are poor, they are farmers, and they have high infant mortality rates). Their cattle is not of great quality, so it does not produce so much milk. As a result, more cows are needed to produce what a family requires to survive (more animals is also a status symbol among poor farmers). More cows require more grazing area. Looking for wood and grazing area, farmers are increasingly entering Ranthambhore National Park (the park was established in 1955, but recognized as a tiger hunting area by the royal family much earlier). This endangers a natural habitat. There are also poachers coming from the Moriya tribes. Poachers are poor, and the profession is usually passed down from father to son. While all the parts of the tiger can be sold for up to $50,000 in places like China (particularly Tibet), the poacher makes a meager few hundred dollars. Still, in such a poor area of the country, the risk (and the fact that it's illegal) is very much worth it. 20-30 tigers have been poached since the 1950s, leaving an estimated 20-25 currently living in the sanctuary. We went on a tiger safari in two groups of four right after sunrise this morning, and my group ended up seeing only fresh paw prints. But the other group saw four tigers!!!

At first, when I heard Rupinder talking about all the projects aimed at helping villagers to stop encroaching on the tiger sanctuary (she stressed over and over that the ultimate goal was to save the tigers), I felt a little odd. What about the people? Shouldn't the #1 aim always be to help the people? But the founder of the hospital (and of various other projects to help enrich the 100 or so villages surrounding the national park), Dr. GS Rathore, has such an incredibly holistic vision of environmental welfare that nothing is excluded. The tiger AND the villager can and should both be happy. And it started to make sense to me that it is possible to save the tigers and the people. The answer is development. And a leader like Dr. Rathore.

Dr. Rathore grew up in the forest among tigers. His father was a wildlife enthusiast. We met him today; he's apparently very famous and regularly appears on television all over the world talking about the state of the tigers of Ranthambhore. Dr. Rathore went to medical school (which he describes as a bizarre twist of fate, since he'd rather call himself a maverick than a doctor). When he graduated and came back to Ranthambhore, he decided that he wanted to live in the forest again, and that was more important to him than anything else in the world. But to do that, he realized that he needed to get the villagers' support. In a few decades, their population had nearly quadrupled. They were, as I mentioned, using resources from the forest and endangering a reservoir of peacocks, monkeys, spotted deer, and other breathtaking wildlife (we saw it this morning, it really is that beautiful). When Dr. Rathore's father, Mr. Fateh Singh, was the director of the park, he simply built a fence around the park and banned the villagers from entering. Dr. Rathore realized that his father's way would no longer work; there were simply too many people now. They had needs, and he wanted to figure out how to supply them.

For the first eight years after his return, Dr. Rathore ran a mobile health clinic for the villagers, which helped to build rapport and, of course, bring health care to a previously unserved population. Then, he began to do some really creative stuff. To help them reduce their cattle size so that village families could have less cows grazing on park property, Dr. Rathore started an artificial insemination program. He helped villagers artificially inseminate their cows with high-yield varieties that still retained the disease-resistant qualities of local breeds. This increased the output of milk from each cow, while decreasing the amount of graze required to feed it. Perfect!

Another problem Dr. Rathore tackled was the cutting down of trees for fuel. While villagers still depend on firewood, they now have another option. 480 biofuel digesters have now been installed in village homes. All villagers need to do is have two cows (to produce a sufficient amount of dung for biofuel) and 3,000 rupees. The apparatus was formerly free, but it was found that when they were given freely, people didn't maintain them carefully. Now, they do. The process is simple: take the dung, put it in the digester, mix it with water, and the gas produced flows from a pipe into homes. We even got to see how it operates in a typical village home. As I said, they still use firewood, but another intervention gives farmers saplings that they are encouraged to keep alive each year to replace lost trees. If the farmer has kept his tree alive for a year, he gets a nominal reward of 3 rupees. If that same tree is still alive yet another year later, he gets another reward of 4 rupees. And so on.

The hospital is another marvel. We got to see a tour of the wards and the operating theaters (all three of them), and the equipment is impressive (all donated, mostly German). Dr. Rathore has some seriously good money-netting skills! Sophia, Linda, Paul and I even got to see an eye surgery. A little boy had gotten into an accident (according to his dad, who couldn't explain properly, something had blown up). His two eyes were in really bad shape...one was cut right through the middle, and in the other one, the whole iris had been displaced and there were small foreign bodies inside. The surgeon did a great job, and it was a microsurgery...high-tech equipment. Other special services offered at the hospital include sterilizations (they're big on encouraging family planning) and legal counseling for women experiencing gender-based violence (which seems to be a common problem in those villages). Services are offered at low-cost, and for women who've been burned by their husbands, or who are too poor to pay, they are free (poor patients who are able to are also offered the option of doing community service in exchange for health care).

To "rehabilitate" the Moriyas who poach tigers, Dr. Rathore realized he'd need to give them an alternative source of income. He has given them camels for livelihood and they are now protective of the tiger sanctuary. He has also offered them free schooling at Fateh Public School, a very prestigious school in the area (we got a tour, it's a good school by any standards, and simply amazing for village standards). Other groups who get free schooling are farmer's children (continuing with the theme of helping the farmers in order to help the tigers), and girl children.

That's all for now. I was really impressed with the whole scheme. It was a great public health trip. The only part I didn't like too much was sleeping in a non-AC hospital ward last night, and sitting on a bench in the back of the car for almost eight hours in two days. But it was worth it.

Tuesday Site Visits

Today we visited an ARV clinic (here they call them ART’s). The clinic was at SMS hospital, named after a royal Rajasthani family. It was a big hospital, so it was very crowded. The emergency department was overflowing. The ART clinic was also packed. We all felt bad (all eight of us!) because the doctor tending to the HIV patients stopped clinic right in the middle of seeing her patients (she sees about 100 per day!) just to give us an overview of her work and to add to our understanding of the situation in Rajasthan.

Since last year, the doctor (whose name we didn’t get…I know, bad manners) says that the number of patients jumped from 700 to 2,100! They currently treat men, women and children and counsel them so that they follow up. Patients must come every month for their ARVs, and must get CD4 counts done every 6 months. This is provided by the government. The HIV test is not free, but it’s only 10 rupees…affordable by any standards. The doctor said that counseling is one of the best ways to ensure patients stay on track and do not drop out. They are also counseled to bring in family members, which they do. This helps ensure effective treatment.

Our second site visit today was to a community care center called Jeevan Jyoti. It’s a government-run care home that resembles Sahara Michael’s. It is much smaller, with only ten beds. It does have a DOTS program for TB, which Sahara Michael’s didn’t. And of course the people running it are not HIV/AIDS peers. But it’s doing good work. Patients can stay at the home for 15 days, getting treated for OIs and recuperating. They seem to like their stay there very much. The care center also liaises with other centers to provide more comprehensive treatment. It also dispenses condoms…we saw an FXB-devised condom dispenser there! Awesome.

It was interesting to hear from the director of the care center why it was important to create such establishments. Despite all the government’s efforts to supply free ARVs and support HIV infected and affected persons, the director told us that the care at these smaller places is better because it’s free of the stigmatization that’s rampant (and so counter-productive for public health) at government hospitals. Treatment for OIs is also free at Jeevan Jyoti, which is not the case at government institutions. Another advantage of having these smaller care centers is that it reduces the burden of HIV/AIDS patients on government hospitals.

Both site visits made me realize that it is not only in rich countries that HIV/AIDS is a chronic disease. In India, too, it is a disease that is managed over time. At the SMS Hospital ART clinic, there is a high volume of patients, but few new patients. Many just come to get their medicines which are carefully dispensed by the government in measured quantities (and patients can get only a two-month advance on their medicines). At first, I was surprised when the doctor we spoke with said that she found working in the ART clinic monotonous. But it makes sense. There are several heartbreaking stories, like the stories of people who develop resistance, or cannot continue ARTs due to toxic side effects, or the children. But for the most part, many people are in the asymptomatic phase, and just need to get their ARTs dispensed and get educated on how to deal with common ailments like diarrhea.

Now, off to finish our lecture from yesterday with Dr. Goyal!

Day 1 in Jaipur, Pictures

A view of the beautiful courtyard at the Indian Institute of Health Management & Research.



A questionnaire devised by FXB to document the lives of street children.



Pictures created by FXB for illiterate street children living on the railways. They show the kids about proper hygiene and wellbeing.


A close up of the cutie pie.



Riding on a camel. Camels are my new favorite animal. This is a picture of Jazmin and Satoko. I mostly have pictures of other people doing these things, because when I was doing it, I couldn't take a picture!



Riding on an elephant.

Creative Solutions in Resource-Poor Settings

I have a post on creative solutions on my global health blog, from back when I was learning about these things in a classroom. But yesterday, on our first site visit in Jaipur to the NGOFXB, I was able to see it in action.

The creativity of FXB's interventions blew us out of the water. We've heard of using hair salons as points of disseminating health messages, because people go there habitually and spend at least 30 minutes waiting and being tended to. FXB designed a project to educate barbers (with male clientele) to teach their clients about HIV/AIDS and to distribute condoms to them. They have reached roughly 100 barbershops this way. They have distributed stickers with an FXB phone number and are receiving many calls about condoms. The condoms are advertised as free, which unfailingly attracts Indians, according Dr. Gupta, the director FXB.

Another project that the NGO has started grew out of the founder's love for children. The founder is Countess Alvina, a French woman who lost her son Francois (for whom the NGO is named) in an airplane accident. He was a rescue pilot and was flying over Mali on a mission when he died. Alvina is the primary funder for FXB now. Dr. Gupta says that one day, she asked him to take her to see street children. He took her to an orphanage. She was unsatisfied. So he took her to the railway station, where the street children really were. She befriended the kids and devised surveys to collect information on their lives. Most of the kids are runaways, and they come to the stations to find work. The most common work is collecting plastic waterbottles on the trains and in the station. Each one can be sold for 50-75 paise, which is less than one rupee. It's like dividing up one U.S. cent.

Countess Alvina wanted to teach these children about hygiene, and give them some informal education. She and Dr. Gupta set up health camps in the railway station, and one by one, children would come and receive care and instruction. They received nail trimmings and haircuts. They learned how to brush their teeth. They were given coloring books and crayons--Dr. Gupta says the railway kids loved to color. They also received regular checkups at these health camps. FXB worked with the childrens' schedule; after all, they were at the railway station to work.

At first, FXB met with some opposition. The railway police saw these homeless children as the cause of petty crime in the station. They also viewed the children as criminals, since they were squatting at the station and entered the trains without tickets. They would beat the children, too, blaming them for any crime that occurred. But with time and persistence, this obstacle was overcome.

To help the children with hygiene, Dr. Gupta contacted 5-star hotels in Jaipur to get used hand towels and soaps at no cost. 5-star hotels replace their soaps with each new guest, and a lot of soap is thus wasted. He showed us the towels and soaps and sure enough, they were from a top resort in the area. I marveled at this; what a great idea! In his own bathroom at the FXB office, I saw that Dr. Gupta himself uses these used soaps.

Other services for the children include field trips to the zoo, puppet shows, and screenings of fun, educational DVDs on HIV/AIDS.

Apart from the site visit to FXB, yesterday we got a comprehensive lecture on the Indian health care system from Dr. R. S. Goyal, professor and dean of IIHMR. He also gave us a tour of the campus, and an overview of the research and educational opportunities at the institute. It was interesting. IIHMR has a beautiful campus (pictures to follow), and the hospitality is astounding (upon arriving to the meeting hall yesterday morning, we were all presented with IIHMR computer bags, pens and notebooks). The campus also has a gym, a grass tennis court (I wanna play!), a swimming pool, and all the amenities you can think of. It also has an intriguing art collection. I have to admit to being slightly suspicious when I see such a high-maintenance public health institution--does this place really benefit everyone? It's possible...

At night, Dr. Goyal invited us to a Rajasthani theme park! The park is set up as a typical Rajasthani village. We rode an elephant and a camel (I got my wish!), and saw a lot of other performers dance and do amazing tricks. Emma rightly pointed out that some of these people should try out for Cirque du Soleil. Although as Sej said, there was a lot of child labor going on at the park. A lot of the performers were children, dancing or performing for hours. I don't know what their economic status is, but it just doesn't seem right. We all had an amazing time, though. By the time we reached home, it was about 11:30. Long day!

First day in Jaipur, and all I'm seeing is the four walls of this computer lab

...and many, many lizards.







So today the rest of the crew went out sightseeing, minus the fearsome threesome. Emma wanted to rest, and Sej and I had some deadlines encroaching on us (travel planning, practicum work, and a publication deadline).

But I don't like to disappoint, so the pictures above are postings of what we
would have seen had we gone out today.

There's Hawa Mahal, the five-story palace built in 1799 by the poet-King Sawai Pratap Singh. As the story goes, it was built so that the ladies of the royal household could watch the everyday life and processions of the city. The palace is part of the east wall of the City Palace complex (I'll know what that means later in the week, God willing!!!). Interesting stuff.

There's also the Bapu Bazaar, one of Jaipur's main attractions for us women who love shiny, pretty things. That was actually closed today, so I'll tell you about it when we actually go during the week. From the looks of what the rest of the group bought today, it seems like Jaipur is a great place to shop! Perhaps even better than Delhi (although I remain very fond of Dilli Haat, the birthplace of my first successful bargain).

The second photo above is Amber Fort, another major tourist attraction. Apparently, you can ride up the fort on an elephant, which is hopefully what I'll do, if we have enough time and I don't melt away/spontaneously combust (whichever comes first). The fort's architecture is a blend of Hindu and Muslim styles, and was built in the 16th century by Raja Man Singh.

Ok so it's a little weird that I'm posting about stuff I haven't seen yet. But I DID get a lot of work done on the book chapter I'm co-writing, so I feel a lot better entering the coming week with that under my belt. I still have some work to do, but with this A/C computer lab (open 24 hours!) I think it'll definitely work out.

Small Miracles Happen

Today we arrived at the Indian Institute for Health Management and Research, in Jaipur, the Pink City (in the state of Rajasthan). IIHMR is quite posh (a long way from Bapu Nature Cure!) and I can already tell it's going to be a great week staying here! It's going to be hot, because this is the desert (it's about 110 during the daytime), but I'm so excited. There's even been talk about a mini-safari! I want to ride an elephant. We'll see.

Anyway, since today's Saturday, we didn't do any public health-related work. But I want to blog about small miracles, like the title suggests. Because even in a country like India, where you'll see tribal riots, armed conflict, religious friction, and EXTREME poverty as inextraordinary things, there ARE small miracles happening here, and we've seen them during our trip.

Take all the staff we've seen who have beaten their drug addictions and come back to Sahara to help other sufferers rebuild their lives. Nicolla, for instance, was a drug user from Calcutta. She has slash marks up and down her left forearm, and what could be a healed abscess from former drug use on her right. She had some sort of an accident a few years back, and needed a hip replacement. Twice, she didn't have enough money for a permanent replacement, and had to go for the cement kind. Because of all her activity doing outreach for battered and marginalized women, the cement has been cracking. She needs a few thousand dollars to get a permanent hip replacement. She has found someone to help her pay what her savings cannot cover. Small miracles do happen.

Take Auntie Jennie, with her two daughters who fell into drug use. She still doesn't know why it happened. Her granddaughter was born going through withdrawal symptoms, because of her mother's drug use during the pregnancy. She showed us pictures of her granddaughter now, posing like a supermodel. Auntie Jennie is so humble and so happy in her new job as a counselor for HIV clients and drug users. She says she's also raising her granddaughter herself. A small miracle. I cannot imagine what she went through, with two daughters using drugs for over a decade. When she told us that addiction is hardest on the user's family, she knew what she was talking about.

I know this post sounds trite. But I've spent a little time here now, and from an American perspective, I'm learning a little bit what it's all about. What the differences are between my home country, and my parents' country. I still can't put my finger on it...there are so many things to love about the US, the land of hope and the American dream and all that. But small miracles do happen here, and amidst all the poverty, filth, corruption, and hobbling along that I see on the streets of Delhi, I see that there are people working quietly to make a difference.

Which makes me think that all those years ago, fighting for freedom in his own patented way in this very country, Gandhi struggled to find his way and came up with this:

Be the change you wish to see in the world.

In my life, this advice has yet to take on all the nuances and details I need to figure out my place in the world. But it's simple advice, and I think we have to believe that if we work hard and well, with our eyes and our minds wide open, we will find out how to do our part to make things better. I've seen small miracles happen, and they're really not so small at all.