Closing Thoughts

With the preceding questions about big-picture stuff raised, the last question is a bit smaller. What about me personally? What have I learned? And what might I do differently as a result?

I decided to do this trip for a couple reasons, in vague order of priority:

1. Getting some sense of what health care is like in the developing world.
   
2. Experiencing what it really means to try to deliver public health interventions in the field.
   
3. Getting back in touch with my cultural roots (sort of) and having a deeper understanding of what it's like to live in India (outside my family's bubble of AC and servants).
   
4. Doing the whole "travel broadens the mind" thing, i.e. absorbing experiences, having some discomfort, and building up stories to tell friends and family over the next few years.
   
5. Having some impact on an otherwise underserved population's health.
   

It may seem strange that the last item is, in fact, last, but I had realistic expectations going in. I don't speak the language, I don't truly understand the culture, and I was there for three months. Anyone who thinks he's going to make any major impact in that situation is delusional. Therefore, the goal was not to change the health care system here, but to change me, so that over the course of the rest of my life I take actions that will improve global health.

Of the metrics above, the only one where I don't think I met my aim was #1. With no medical license in the US, it wouldn't really be ethical for me to be delivering patient care, and I chose not to be in or near a major hospital where I could do much observation (because I wanted to see the village side of things). So, I have a good handle on how we try to keep people from getting sick, but my understanding of what happens to the average Indian when he/she falls ill remains a bit sketchy.

On the rest, I definitely feel more Indian than I have in a long time (look it, too, after all this sun exposure), and I have a deeper (not deep, but deeper) understanding of what "most people live on under $2 a day" really means. I have a much greater appreciation for all the things we take for granted in the West, and a much better tolerance for the boredoms and physical discomforts of travel. Now that I've seen what things are "really" like, I do feel much more motivated to help.

The question now is how, exactly, to help. Giving money (once I have some) would work, but that's kind of a cop-out. Doing another kind of immersive project like this probably isn't the best use of my time/skills, because one-offs don't produce enduring change. Long-term involvement does. I could come back as a clinical volunteer, but psychiatry isn't general surgery -- it requires long-term involvement of the physician, and I certainly would not be able to give psychiatric care in a rural setting without a LOT of intensive language training. My best guess would be that I might be of use as a consultant or project assistant to organizations working in addictions/alcoholism or something else on the "behavioral medicine" side. That's not even remotely close to my research or any of my clinical focus, so we'll see how it might come to fruition, but I know I can make something happen if I commit to finding the time. Plus, now I've got links to two different NGOs, and through them to a very wide network of NRI involvement/philanthropy. Somewhere in there, there's got to be a project that matches my skills -- for all my frustrations, it's turned out that I was probably about the best guy available for the job I've just finished doing.

I wouldn't call the experience "fun" exactly; at times, it was downright stressful, physically painful, and frustrating. But, that pretty describes every significant effort to improve the human condition. The word I'd use is "rewarding". I feel like a better person for having done this, and I hope I'll act like a better person as well.

And now, the next question: having gotten used to blogging about the interesting bits of my daily work, what should I title a blog about the experiences of a psychiatrist in training?

Photos Complete!

I have, after one week of being back in the US, finally finished uploading all the dang photos. They can be viewed, en masse, by going here.

One more post forthcoming, regarding overall learnings and future directions.

Paternalism?

"We had to destroy the village in order to save it."

-- Attributed to anonymous Vietnam War Major

It occurred to me, during my last week of fieldwork in Bhorugram (while I was daydreaming about the return to "civilization") that people like me are effectively plotting to destroy India[1]. That is to say, we are actively hammering away at the basic assumptions on which the entire Indian economic, political, and social system currently rests.

As mentioned in prior posts, the classic picture is that "India lives in her villages." It's not an exaggeration -- despite the hugeness of major cities like Mumbai, Delhi, or Bangalore, about 70% of the population still exists in the rural setting. That is to say, there are a hell of a lot of people still living with dirt roads, irregular electricity, erratic (if any) running water, questionable sewage, and poor infrastructure. More importantly, it means a lot of people still engaged in subsistence farming or activities that directly support subsistence farmers, and as noted before, it means an economy specifically geared around abundance (thus cheapness) of human labor.

Meanwhile, people like me are out there actively doing everything we can to build a health care system. Our stated goal is simple -- save lives, improve standard of living. BUT, one of the main metrics we use is the birth rate, and various numbers derived therefrom, and we cheer every time we get it nearer to the goal -- replacement level or below. And therein lies the problem. You can't run a subsistence agriculture economy with a developed-world birth rate. There's not enough people to do the work, because farm work depends on having a large number of young people around to gather the harvest by hand. Thus, we are effectively setting up the dominoes for forced mechanization of Indian agriculture over the next few decades.

But that's good, you say? Mechanization = more food to go around, and better standard of living (minus the air pollution from a few million tractors)? Sure. Except that we can see what the same thing has done to small-town America. We hear every day about the death of the family farm. The same thing is going to happen in India, except it'll be the death of the village. The path we're putting them on leads, as far as I can tell, to the rise of the same kind of large-scale "factory farming" we do (minus, hopefully, the meat factories).

Now, maybe that is good. I can't imagine myself wanting to be ruled in a political system where corruption is the order of the day and where most voters are barely educated[2]. But, being a good little geek (and given that there's a new Star Trek movie out this week) I can't help but think back to the Prime Directive, and how it's pretty much being shredded and used for toilet paper here[3]. We mean well, but we really are bringing along a whole pile of assumptions about what a society should look like. After you get past the surface, the whole thing starts to look a lot like Kipling's "White Man's Burden". As I said, I wouldn't want to live Indian village life. I just am not entirely sure that the villagers feel the same way.

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[1] Now there's a quote that'll come back to haunt me outside of its context someday.

[2] You think we have that in the USA too. Brother, you ain't seen nothing. They do vote buying the old school way here, and they play ethnic politics in ways that can be downright frightening. At least in the US, you aren't allowed to get re-elected from jail after getting thrown in there for murdering or otherwise harming political opponents.

[3] Probably softer than the regular stuff.

The Vision Thing

Having finished up my work, taken a few days R&R in Mumbai, and finally returned to the US of A, the question comes -- what next? I spent three months trying to help people build a database in a desert. What's going to happen to it? What can be done with this thing that might actually change the course of India?

To me, the key part of the vision (and the place where I might have added value by thinking of it) is getting away from the idea that REACH is "a database where we track what we're doing". Instead, I've been pitching the line that it's "networked MIS for public health" (MIS being Medical Information Systems, what we in the US call Health IT.) The second part isn't super-innovative; it's just raising the point that we should be starting to think of the possibility of a medical records system that tracks not only episodes of acute care, but the health of a community in which the individual patient is embedded. That said, the community is probably the largest determiner of health in both the developed and developing world, and in the West we don't pay enough attention to it. (Quite possibly we don't here in the East, either.)

The "networked" part, though, is where the really cool stuff might start to happen. Right now, this database sits on a server in a room, and if you want to know something, you go to the room and ask for a printout or maybe an Excel file. If you're not one of the twenty-odd people who work for this NGO in this specific village where the HQ is, you will never even know the damn thing exists. In my planning documents for the next phases (which will, if I have my way, include a major software redesign), I've repeatedly stressed that they should make the data directly available, in real-time, over the Web to any interested party[1]. When that happens, any interested government official can instantly see how much better our villages are doing than the surrounding blocks. Any deep-pocketed funder looking for proof of BCT's effectiveness can monitor directly what's happening as we spend their money.

Most importantly, as the Internet continues to rapidly pervade the Indian countryside (just as the mobile phone did in the previous decade), any person living in one of our villages can find out how his/her village is faring compared to the neighbors, and raise some hell with the old men down at the big house if the answer is "not well". There's some other interesting ramifications, such as the possibility that our field workers could update us directly via mobile phone/SMS rather than filling out paperwork, but to me, that potential for individuals to know about their own community is the biggest benefit. Social change comes about when a persnickety person finds out that something is wrong, sets out to fix it, and just won't go away until the problem does. The REACH I'm trying to design would give that person a target-rich environment, which is a worthy goal if I ever heard one.

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[1] Yes, there are privacy issues. Potentially hideous ones, since of course none of our data is de-identified. Heck, in the USA we wouldn't be able to even build the database in the first place, not without a lot of consent forms and community meetings. The lack of HIPAA is a blessing for India's health.

Fun fact

Am now in Mumbai enjoying a few days' R&R before I head back home. Air conditioning is a lovely and wonderful thing. As is my uncle's bar.

In lieu of a proper entry, here's today's fun fact: you will regularly hear the word "y'all" used in Mumbai, by native Indians. Hindi, like most languages, demonstrates respect by using the second person plural. So, lacking an internationally accepted translation for the Hindi "aap", they've chosen "y'all". It sounds strange to hear without any trace of a Southern US accent, but also kind of cool.

Survivor's Guilt

I am writing this from a comfortably-appointed room at the Indian Institute of Health Management Research[1]. That has an important significance -- I have left Bhorugram. Not for good, since I know I'm going to end up coming back to check on the project and on the village, but for the next few years. I am now in the process of going home. It is an extended process, with waypoints in Bombay and at my parents' farm, but those are basically just places to sit and get fed. The most stressful thing I am likely to endure between now and my return to Pittsburgh is trying to fit all my luggage into the train tomorrow. (Thankfully, Indian trains are commonly occupied by people trying to carry too damn much stuff, and if I can't handle it, the princely sum of Rs 50 will find me a porter who'll deal with things nicely.)

I find myself with a bit of a case of survivor's guilt. I am, without question, pining for the luxuries of the modern Western world, but I've been doing everything I can not to talk about the fact that I'm taking a first-class train back down to Mumbai, or exactly the comforts that await back home. I get to have them be part of my daily life, and to be making the equivalent of about Rs 20,00,000[2] next year. (On that amount here, one could live like at least a duke, if not quite a king.) The new REACH project manager, who came down in the car with me, gets to go back to the desert and stay there. The guy who brings my tea is, if he gets the luck he wants in the next few years (and I did put in a good word for him), going to still be making perhaps $5 per day. I find it hard to say "I'm going home" without feeling like I'm rubbing it in.

Those of you who know me know that both Jennifer and I are not particular consumption-heavy people. We like good food and good wine -- so we cook it at home and buy Two Buck Chuck. If it can be recycled, we recycle it, and if we can walk or take the bus, we do. We minimize our meat consumption, try to buy sustainable products (difficult at our level of income, especially with me unemployed), and generally attempt to be responsible global citizens. So, on one hand, it's not like I'm actively promoting exploitation of the developing world for my comfort, or that I've somehow acquired creature comforts by trampling on the necks of the proletariat. Nevertheless, I still have this sense of guilt, perhaps summed up as "I am very happy not to live in India, but I feel bad that I'm happy about it."

It's a passing thing, and on the whole, I'd rather have that over the opposite pole, a some smug self-satisfaction that "look at me, I spent a whole THREE MONTHS helping people who aren't white!" More importantly, if it keeps me committed to coming back to Bhorugram and/or doing further global work in future, then it's a good thing.

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[1] Where, instead of just kicking back and playing video games, I'm busy writing blogs and burning CDs and trying to be productive, instead of just enjoying a few hours to myself. One of my more annoying personality traits, I agree.

[2] Yes, that's how you punctuate it. Numbers above 10K are reckoned in "lakhs", each lakh being 100,000. So, you would say that as "twenty lakhs", not "two million". Thus endeth your math lesson for today.

Finding the Missing Pieces

I've mentioned a couple times now that I know the REACH data aren't very good (certainly not good enough to use for any public health planning), despite my two months of effort to make them otherwise. The question that should arise, as with any research project, is "How do you know?" It's a particularly thorny question in this case, because REACH is effectively a cross-sectional survey of an entire population (one block worth of villages). In theory, it's a complete census. So how could I tell if it's got holes in it? For instance, up to this point in the year 2009, REACH tells me that I've had 765 live births and 33 infant deaths, giving me a crude birth rate of 9.7 and an infant mortality rate of 43.1. (For reference, the infant mortality rate of the United States is 6 babies per 1000 live births.)

The answer, perhaps unsurprisingly, is to find similar entities and compare against them. In this regard, the Government of India has helped us out by constructing the National Family Health Survey and then releasing NFHS reports for the various states of India. Of course, the problem is that their "rural Rajasthan" figure is for all of Rajasthan, from the best to the worst. In theory, this district, where child development services are done by an NGO that cares a bit more about the average person's well-being, should be doing better than the average.

Thankfully, said NGO is also linked to a health research institute, and thus can commission their services to study its activities. From that, we have an estimate of the rates for my specific block of villages, as of January 2007 -- BUT, that estimate turns out to have less-than-ideal methodology and not to have tracked some rather important indicators, meaning it has to be treated with a fair-size pinch of salt.

At any rate, depending on which of those external indicators you trust, I should be seeing between 1400 and 2200 births thus far based on my population -- double what I've got. I should also have between 50 and 140 infant deaths. The mortality rate, on the other hand, should be about where we've pegged it, telling us that we've not got under-reporting of deaths or births in isolation, we've got a generalized problem of under-reporting in ALL our data. The potential causes of that include confusion (our forms can be complex, and not all are in Hindi), laziness (it's rather tedious work copying information into them), bad data entry (both of above apply to our data entry techs as well as to our female field workers), or a failure on our part to explain what it is we want. Probably, some combination of the above.

And that, in a nutshell, is what I've spent the past two months doing -- working out the evidence that problems exist, showing it to others, letting them shout at underlings, and trying to channel that shouting into something resembling progress. It's a little bit of a shaky thing to be doing, as all of this is reasoning based on low-grade math, and even the comparison data can't truly be trusted. Still, it's better than just plowing ahead assuming these REACH data are correct, which would have led us into serious deep camel dung.