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.

---

[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.

Gandhi and Hiring

As I mentioned in a prior post, we've gotten our data entry problem pretty well licked. So well, in fact, that we've finally completed the "primary survey" phase of REACH -- the one where huge phonebook-sized ledgers of every family in a village need to be laboriously keyed into a computer. We did this by hiring up our data entry workforce to 20 (it was somewhere between 12 and 15 when I started here) and working them all at 12-hour shifts (for 1.5 times their regular per-shift pay, but time-and-a-half overtime doesn't happen here).

But now, we have a problem. Steady-state need for data entry techs on this project is about 10. If we get some of the software fixes in place that I want to see, it might drop as low as 6 because entry can be made more efficient. What do we do with the remaining 10 to 14 people? On one hand, we're a public health project, not a jobs program. On the other, these are all young men from local villages who REALLY can use the rather paltry Rs 100/day they're being paid. Furthermore, if we just drop half of them from the pay roster right now, there's apparently some political risk -- they could in theory go and complain to village authorities (the panchayat council). Is there a legal right to their jobs? Probably not, but given the speed of the court system here and the NGO's desire to keep goodwill with the people, it's not a good thing to try to figure out.

It's interesting because the whole situation can, in some ways, be traced back to Gandhi. The Mahatma was a big believer in avoiding automation whenever there were humans available to do the work. This was one of the reasons he often carried around and used a spinning wheel -- to demonstrate to Indians his idea of a "village republic" where every village was an almost-self-sufficient unit of people doing work for themselves by hand. Much has since been said about this idea, and deconstruction of whether it contains the discredited "noble savage" concept at its roots is left to my readers with backgrounds in the humanities. Regardless, the application of Gandhian thinking to my problem seems clear -- there are people to do the work, so simply split the available work among all of them, and deal with the inefficiency that results. I can hardly blame India' vast reliance on slow/unreliable human labor entirely on Gandhi, but I can't help but think that these same ideals are the ones that have left most Indians unable to enjoy the quality brought by mass standardization.

Sadly for Gandhi-ji (but luckily for the organization's bank statements), our particular NGO does not quite believe in full employment at any cost. In time, these data entry operators will be leaving us; it's just a question of when. For now, they've been converted into field workers, assigned to go out to the anganwadi and collect the data that we know are missing. (They are proving remarkably bad at this task, mainly because they fail to collect data.) It has also allowed me the opportunity to institute something I've been wanting for weeks now, namely a system where every operator's entries are eventually double-checked by the supervisor, and a record is kept of errors discovered. That tracking is going to be used to justify letting someone go, and I'm not thrilled that I've fulfilled the classic stereotype of a consultant -- coming in and getting people fired. Still, even the people who leave will have more money than they otherwise might, and that ought to help their health a little.

Food Is Not Respect

Following up on the previous entry, Jennifer and I are fond of commenting that the defining characteristic of both Indian and Italian families (and, we think, also Eastern European and Jewish) is that Food Equals Love. If you love someone, you feed them. If someone tries to feed you and you don't eat enough of the food, you don't love them enough. It turns out that food can also equal respect, or at least acknowledgement of relative positions on the social-work ladder. If you respect someone, you feed them. In some ways, this is good. It means that there's almost always a cup of tea available when you want one, and it does mean that I never go hungry. When I'm with my family, it means a cornucopia of calories that might put Mr. Creosote to shame.

The problem with use of food as a status symbol is that it can get regressive. For instance, when we go to a meeting with our community health workers, they want to show that we're to be respected. So, they sit on the floor, and we sit up front in chairs, and nobody sits down until I sit down (despite my protests otherwise). We are then given tea, and sometimes a decent snack. (Fried things plus some biscuits and a sweet is the typical.) Meanwhile, the much less nutritionally-endowed women of our audience get fed after we do, if they get fed at all. Same thing happens when any dignitary visits here. He sits up on a dais and munches pakoras (battered fried things, usually potatoes). The audience, none of whom make a tenth what he does, may not even get water. I find it hard to deal with chowing down in front of people who might not quite have food security each day[1]. But, it'd be rejecting hospitality not to eat (and in fairness, these days I'm usually hungry, since my GI tract has recovered), so I eat. A close variant happens when we're doing fieldwork. About every fourth house, we get detained for fifteen minutes because someone insists that we take a cup of tea with them.

Now, that part alone isn't too bad. Yes, it's discomforting to be lording it over people like that, but more often than not they do eventually get fed, so I could deal. The truly bad part is that as noted in a prior post, when food = respect, you can lose some of the other things that might show up on the left side of that equation. For instance, in the US, work = respect also. If you respect me, and I'm a boss or co-worker, you'll do a good job on projects that I ask you to help with. Standard work culture here is more that as long as you've given me food, offered me a chair, and otherwise scraped/bowed a bit, you're not obligated to actually do work. This has gotten a few people shouted at when they've ignored important project-related duties in favor of trying to locate foods they think I'll want (the most recent being someone arranging a lassi instead of arranging a meeting I'd asked him to take care of). And, as usual, the language barrier makes it hard to explain in advance that no, I don't care about whether lunch happens on time or is especially gourmet, I care about whether we visit our houses and collect our data and get the job done.

I think there's a lot of people around here who'll be glad when this pesky doctor sahib finally goes away and lets them get back to doing things they way they've always been done.

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[1] It's even more heartbreaking when the guy who works for you tries to give you his only pen as a gift, because he feels he NEEDS to give Doctor Sir a gift to prove friendship. I can't do it. I know it's courteous to accept, but I can't take things from a guy trying to manage on Rs 100 a day.

Servants and "Leadership"

One of the things that remains difficult for me, even after two months here, is the very hierarchical nature of Indian society, and how it affects both my work relations and my general life.

To summarize, for those who haven't been here: overpopulation means labor is cheap. This, in turn, means that there are a LOT of servants and functionaries around, and have been for a long time. Secondarily, India was a colony for a loooong time, and the ways of doing business evolved in that colonial atmosphere. That, combined with the prior existence of a caste system, means that rank matters a lot here. "Doctor" is high up on the pyramid. So is "Westerner". So is "friend of the boss". "Visiting American doctor sent here by the guy whose money runs the entire organization" basically means that I can give orders, or at least very strong requests, to anyone in the organization who isn't Dr. Ashok himself.

On the work side, this gave me at the start a certain amount of management unease. My project staff are all masters-level educated. In the US, it'd be a collaborative process -- I'd suggest ideas, they'd suggest back, we'd try to flatten the hierarchy. If I were a pure Indian boss, I'd give them orders, they'd say "Yes, sir", and then go do them. Sort of. The Indian work mentality often includes a tendency to do as little as possible unless a boss is directly watching. Certain things are done assiduously -- always offering the boss the first/best chair, always offering tea/coffee, always offering food[1]. The problem is, these are done well in order to cover up the lack of actual progress on, e.g., data entry or annoying tedious analysis. (We can argue about lazy Indians vs lazy Americans until the sun comes back up, and in fact, this is a common topic of discussion among NRIs[2].) So, I am caught in between. I want to try to teach a style other than "managing by yelling at people". At the same time, I know there are cultural frames that I should try to fit into, because in some ways the staff are more comfortable if I behave like everyone else. I have actually made some attempt at "What do you think?" with the staff who speak good English, but the result tends to be blank stares.

The personal life side is where things can really get complicated. The fact is, life out here has not been comfortable for a Westerner -- beds are hard, water is cold (unless you want cold water, in which case it tends to be hot), you're living life on someone else's schedule, and sometimes the food and your biology just don't agree. However, I could have any or all of those mitigated if I so choose. I could have had an extra mattress[3] brought in, I can summon buckets of hot water if the geyser doesn't work, and I could get daily delivery of morning tea and potentially all of my meals. The problem is doing so defeats the point of trying to come out and experience "real India", to say nothing of creating unnecessary work for others. Moreover, the more things I request, the fewer are going to actually get done in any reasonable time. On the flip side, if I request absolutely nothing and accept whatever's given as a default, when I do finally need something (e.g., some clean drinking water, which was a big problem the first few weeks), the responsible parties may not quite understand that this needs to happen NOW. My Hindi is not up to the task of conveying the spectrum of need between "Not a big deal, I don't care if it never happens" and "Seriously, I will be back in an hour and if this is not done, heads will roll." (It does help that the higher up someone is in the social structure here, the better their English, so the nearest person who can understand me also tends to have plenty of power to get things done for me.)

Interactions of this sort pervade everything in India, and it's a constant struggle between my innate instinct to be nice to lower-wage people and a fear that this is sending the wrong message. Furthermore, I've found that if I don't behave at least somewhat like an Indian boss, the social cues don't quite kick in, and thus the work won't get done. The resulting requirement to occasionally be emotionally explosive and constantly be complaining about something is definitely taking causing some mental fatigue. The main thing I'm looking forward to about going home is knowing that when I ask for something, it's going to get done without my having to follow it like a hawk[4].

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[1] There is a whole 'nother entry pending on the use of food as a status symbol and the ways it drives me mildly berserk.

[2] Non Resident Indian, AKA "screw you guys, I want plumbing". Technically, I count as an NRI under the current set of rules, as India really would like her overseas children to come home and share the wealth.

[3] A "mattress" is an object one inch thick that keeps the wood of your bed from getting dirty. The exchange rate between rural Indian mattresses and the Sealy PosturePedic is approximately twelve to one.

[4] Well, right up until I start residency, at which point the administration of meds, planning for discharge, and everything else will of course get carried out with inefficiency that might make an Indian proud. But you can't shout at nurses.

[n] If you are wondering: yes to morning tea, no to delivery of meals, no to delivery of hot water, no to extra mattress, and special requests placed for a stock of fruit in the cafeteria and a personal copy of the daily newspaper. Net cost of requests, about Rs 10 per day, or $12 over the course of my stay.

Easter Egg

This is what my sister created for me last Sunday for Easter:



Even I have to admit that's pretty neat. (If you don't recognize it, that's the Indian tricolor flag.)

I Can't Help You

I don't think I've commented yet on the surprising number of people I just can't help. I don't mean the public health project -- I've gotten over the fact that I'm trying to add a small amount of momentum to a rather large mountain of poverty/malnutrition/maladaptive thinking. I mean the individuals I can't help. Pretty much every other day, somebody here comes to me with a request that they think I've got special powers to solve.

The most common is a visa. All the staff want to go study or work in the US, and have asked me at some point to tell them how to come over. Of course, right now, it's basically impossible to get a visa to come work in the US, and student visas aren't much easier post 9/11. At any major university, they're reserved for people who've gone to "name brand" Indian universities. I definitely don't know how to get an entry visa or a green card for the guy who makes the tea, no matter how good his English is (it's not bad -- better than my Hindi).

Next most common is telling them what field of IT to study. I am not sure if there's just something different about Indian PhDs than American PhDs in terms of what's taught, or if there's really not an understanding that the PhD is a research degree, not a commercial degree. At any rate, when I explain that no, I can't teach a class on Oracle databases, and no, I don't know what field someone should specialize in to make the most money, or what are the key things to help prepare for IIT, I get this look that says "Why aren't you sharing your knowledge? Why are you holding out on us?" (Thankfully, the most recent was someone asking me about programs at the University of Pittsburgh. I can answer that one.)

The most heartbreaking, though, are the ones I just can't understand, of which there's one every two weeks or so. These come from the guys who sweep the floor or empty the water buckets or do something else menial. They'll come up, start walking beside me or just standing there, and they'll ask if I understand Hindi. To which they get told (in Hindi), "Only a little, and you have to speak slowly." Of course, I invariably get a torrent of words I don't understand, and after about six repetitions of "samja nahi" (I don't understand), they walk away like hurt little puppies. I think they're asking for some kind of favor for their kids, or at least, I hear the word for "child" in these conversations a lot. I've tried, with the latest one, getting someone else to see what he wanted, but have not had any luck.

I do exploit this illusion of Infinite Knowledge to get work done on my project -- since nobody has any clue about any of the things we're doing, my marginal level of expertise plus the lofty degrees is enough to convince them to go ahead. So, I can't complain when people come seeking wisdom. I just wish they didn't all seem to believe that I'm deliberately being unhelpful. I don't know how to convey that America is a big place, the world of science and medicine is MUCH bigger than they're taught, and no one person can know all the things they're hoping for (no matter how much Dr. Ashok and others may proclaim my virtues).

Strategic Programming

My time here is rapidly winding down, and by the time you're reading this entry, there'll be only one week of work time before I head to Jaipur, Mumbai, and the mysterious land called America. (I've found myself actually wandering through Pittsburgh streets on Google Maps just to remind myself what home looks like.) The nature of my work in these past few weeks (basically, since about 1st April) has really changed. As you might remember, when I first came here, a lot of what I was doing was data analysis and just trying to get a handle on where the project was overall. Once I realized the level of corruption/error in the data, it turned into an extended effort to just get the fundamentals ironed out. Over the final week or two of March, that's started to sort itself out. The female health workers are almost getting the hang of the surveying, we've gotten data entry up to a reasonable speed[1], and they've hired a new statistician who's helped a lot from an analysis perspective. They're also expecting him to take over as boss, so I'm deliberately turning over to him much of the work I'd otherwise do.

So, if some of my problems are solved and the rest are now in someone else's job description, what does that leave me? Conveniently, our friends at the Harvard Business Review decided to publish an article that advised CEOs to focus on the work only they can do. Having reflected on that, the work that only I can do is something vaguely resembling strategic planning. PS Reddy is now in America, and even though he knows the Hyderabad project well, he's not intimately familiar with the organization or the technology. Dr. Ashok knows the organization, but not the technology or what it's capable of. The staff here know the technology, but visionary thinking is not a common product of Indian higher education.

Thus, I've spent the past 1.5 weeks and will spend the next 1.5 weeks working primarily on laying out a vision for REACH: where is it going to go in the next year or so? I'll share some of those ideas in another post, as they're still being run up the chain of command for feedback. It turns out, though, that what I'm doing is not so much strategic planning as it is "strategic programming". This organization has turnover. A LOT of turnover. As in, my project alone has lost three and gained three staff in my two months, and it's a three-person project. (Thankfully, one of the three positions turned over twice, so I still have one original.) This means that I can't depend on whoever's reading my plan to know anything at all about the project. That, in turn, means that I don't get to just paint with broad brush strokes; I fill in all the little details.

I've said to some of you that this project like using human beings to do computation -- that wasn't entirely a joke. It really does feel a lot like programming, albeit with a serious latency. I have to build detailed lists of everything I want to see happen in the next year, think of all the ways in which someone might do it incorrectly, and then write down instructions to prevent that. The planning document for starting REACH in the next district over is eighteen pages long, and there'll be another document (not quite so long) for continued operations in this district. Reading it would cure any insomniac. It's a semi-futile exercise, since there'll still be mistakes made, but at least they won't be the same mistakes we made here.

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[1] By hiring double the number of operators we need at steady-state, which has now left us with an unfortunate quandary. More on that in another post.

Mount Abu

The recent hiatus from blogging was due to me being on a bit of holiday. Since I knew the excellent Dr. Ashok would be coming up on the 9th from Jaipur, I made a plan to get away for a few days, then hit Jaipur on morning of the 9th and ride back in his car. Saves fuel, saves the organization some cash, and lets me spend some proper time getting to know better the man I've been working for. The chosen destination for R&R was Mount Abu, Rajasthan's only "hill station". (Hill stations are where anyone with money would retreat to in summer to avoid the heat.) Set off on the 7th from here in the village, spent two days in the mountains, and am thoroughly refreshed from it.

Day 1 was purely travel. We started from Bhorugram by jeep around 7 AM. Originally just me, but no car leaves Bhorugram with empty seats. We picked up two visiting MSW students who wanted to see Jaipur, one staff member trying to get to the Churu bus station, one guy who I never did figure out who/what he was, and one villager just going two towns over. Not much to say about that trip -- same old one-lane roads, scrub, and Hindi-Punjabi mix tapes. (He did finally get a new tape, at least.)

I got dropped at the railway station in Jaipur and had an hour to explore a bit, finding mainly a so-so $6 lunch buffet and a major decrease in my traffic-dodging skills since Hyderabad. The train this time was 3-tier AC, as I was traveling on the cheap. It remains an excellent way to travel, especially with only a small suitcase. The compartment is more crowded than 2AC, but still spacious by Indian standards. You stretch out on your berth, read and nap as you like, and take tea, samosa, omelette, chips, and other such delectables from passing caterers. The only disappointment is the tea, which is bag-based and not worthy of the name "chai". Energy and a little entertainment come from the many little kids running up and down. A lot more energy was added by a discussion that arose between my compartment-mates and stretched to entertain the whole coach for over an hour. The topic, as best I could tell, was the merits/lack thereof of holy men collecting large sums of money for their blessings, although it ranged pretty wide (there was something about hypnotism in there at some point).

As usual, getting off the train is where things went a bit rough, as the train station is down at the base of a 30km mountain road that leads to Mt Abu. Like all train stations, it is surrounded by a mob of taxi/rickshaw predators. Either no buses were running at 9:30 PM (possible) or I got bad directions, but I ended up having to go by (comfy) taxi for Rs 200. Not bad, except when I tell you that my room was Rs 200 per night. (Shri Ganesh hotel, recommended by Lonely Planet and Rough Guide. OK, not as good as the guides make it out to be, great place to meet fellow foreigners.)

Day 2 was for seeing the town, trekking (expensive at Rs 300, but amazing views), and a trip to the much-acclaimed Dilwara temples. No photos of the latter due to their rules, but they are indeed as amazing as the guidebooks say. I cannot begin to imagine the number of man-hours required to carve marble in that level of sophistication/detail. In the meantime, here's a view of what we climbed:





and what we found at the top:





The rest of the town is nice, although not quite something to write home about. It's sort of an Indian version of Gatlinburg, TN: lots of religious stuff, also lots of amusement for kids and random people trying to sell you crap. Among other things, they have an Eiffel Tower in the middle of the market:





Nevertheless, in town it's best to stick to the lake, which is beautiful.






Day 3 ended up with me hitching a ride on the back of a motorcycle, accompanying a Brit (Adam) and a Frenchman (Matthieu) to various temples. They drove, I acted as navigator and guide to various aspects of Indian religion/food. (They now know who Shiva is, why they get given sugar at every temple, what a dosa is, and to order the thali instead of bothering with a menu.) It definitely strengthened my desire to get a bike and learn to ride properly when I get home -- I have my "M" license, but need practice before I'm road-safe. Renting a scooter/bike seems to be *the* efficient way to tour rural South Asia. It was a fast way to handle the very steep 17km up to Guru Shikar, highest point in all Rajasthan. One photo cannot do the views justice, and I'm working on a panorama, but here's me being a tourist with much of the valley behind me:






Highlight of the day, though, was our last stop at Gaumukh, a temple reachable only via about 750 steps along a staircase hidden in the forest. (I counted.) The Gaumukh spring is, by legend, from the same source as the Ganges, and thus bathing in it is equivalent. Gaumukh water being much cleaner than Varanasi gangajal, I got myself fully purified.






From there, it was back to Jaipur by my next adventure: the sleeper bus (Rs 280 one way). Basically, remove the overhead luggage racks on a Greyhound and put in some padded berths. Not uncomfortable, although not as nice as train. I still don't understand how the system works -- the bus stands and stops aren't marked, there seems to be no fixed number of tickets per bus, and no way to know what your bus is like before you board. Still, you get curtains for privacy, and I slept well. Yet again, the only problem was arrival, where my driver was unable to find me. Private buses aren't allowed to pick up or drop off at or near to the main government bus stands, so they tend to go to nearby streets/gullies, and of course there's no road signs to help you direct someone. The wait isn't bad, it's once again the [bleeping] rickshaws. If that system ever gets a little less predatory, budget travel in India will become an extremely enjoyable experience.

On balance though, a thoroughly worthwhile little excursion, highly recommended. Great views (do look at the full photoset), nice cool climate, decent food, and plenty of new friends to meet.

Teaching the Children

Occasionally, in between work (there will be another work-related entry soon, honest), I do get to have a bit of fun and do something emotionally/mentally stimulating. Safe Water was one of those. Even better was one that happened just before that -- I got to teach some of the local schoolkids.

As I've mentioned before, my project office is actually embedded in a school. It's a K-12 campus, both boarders and day students (mostly day students transported by private bus network), with affiliated vocational campus. This means that I spend my day surrounded by students and teachers, and of course the teachers are aware that there's an American doctor who also happens to have an IT degree. I've mentioned before that "foreigner" carries a pretty high social standing around here, so it was only a matter of time before someone realized that they should have me teach a class or two in order to bump up the prestige.
(The school is English-language, so by 10th grade, the kids are pretty decent.)

In this case, it was the principal's wife, and I was asked to talk for an hour on how to become a doctor and why the kids should consider this as a career. (Apparently, just as in the US, they have a problem with potential docs opting to do IT or business because it's more money for less work. Of course, the US doesn't have a problem with its doctors fleeing to India.) My skill at this was limited by the fact that I had no clue about the Indian medical education system, but since nobody at the school does either, half an hour with Wikipedia and a good poker face was pretty much enough. We got some good shots of Dr. Alik expounding on the virtues of medicine, including this one:





I focused mainly on the theme that in order to be a successful doc, you have to have three things: love of other people, love of science, and love of learning. It's an arguable doctrine, but I do think it characterizes the physicians who I look up to as good role models. Plus, if you've got those three, the need to memorize piles of useless crap does tend to take care of itself. I definitely painted a rosier picture of medicine than is really justified, but the developing world does need more doctors, and especially more doctors who'll care about the villages.

Of course, I also got to talk about my project, and the process of doing that was remarkably therapeutic. You'll recall my prior post where I wondered if I was doing any good here. Over the course of prepping for this talk, I pulled up the example of one infant death in a neighboring village. I was able to trace back the cause of death (stillbirth/low birth weight) and the mother's status (no tetanus shot or supplemental nutrition), which gives me a pretty decent picture of what might have happened here. More importantly, I do know that if a mom like this happens in the coming year, there'll be someone watching who can at least try to get her that antenatal care. That's a pretty concrete example of a kid who could have been saved. Thinking about that and telling the story really renewed my faith in the meaning of the work I'm doing. Now, I'm mainly hoping it inspired some of those kids to do the same. They seemed more focused on my descriptions of mental illness (how do you explain schizophrenia to a fifteen-year-old from another culture?) than on my big-picture point. But, you never know what might stick in the back of someone's brain.

There's not much time left for me in Bhorugram, but at least now I can leave here with the feeling that my work made a difference. That's about the best anyone can hope for on a problem of this size.

Everything Comes Down to Poo

(The title of this post is a 2-point reference. Search engines are cheating.)

I also spend a lot of time thinking about poop. Some of this is because I often end up eating/drinking something a bit dodgy and wondering if it's going to come back and bite me the next day. The other reason is that it pervades my life, and I'm not talking about the fact that (I am not making this up) every street in Bhorugram has an open sewer running right down the middle. See also, previous post about water supplies.

Poop pervades my life because of two factors. First, as the book has taught us, Everybody Poops. And, as I've mentioned in a previous entry, toilet paper is not common here, in the same way that diamonds are not common. So, you wipe with your left hand. Another thing that is not common is soap. Or, since we are in a desert, copious amounts of water. The net result is that most people are wandering around with a left hand covered in a microscopic (hopefully) film of poop and no way to wash off said poop. Some of them are involved in food preparation, and I pretend to myself that they wash their hands and the school provides them soap. Others are involved in the constant fetch-and-carry that keep India going, which means that eventually, they WILL touch something that I'm going to touch.

The second factor is that, in a resource-poor society, you waste nothing that could be used. You are thinking "fertilizer", but that only applies during the rainy season (when poop can be kept moist long enough to compost). The correct answer is "fuel". In villages throughout India, but especially here, a major source of fire for cooking/heating/etc. is the burning of dried dung, sometimes mixed with straw/sticks. There are piles of the stuff everywhere, looking like this:



If you look closely, you will notice that every one of those is covered in handprints. That's how they're made; pick up a lump of droppings and get to work. See above about handwashing.

So, basically every surface, and every standing body of water, has a nice batch of friendly fecal coliform bacteria on it. In a very real sense, every bite of food, every piece of furniture, every drop of water, contains a small bit of someone/something's poop. This, in turn, is why it's almost impossible to avoid getting sick -- the contamination is everywhere. As the saying goes, poop happens. Sometimes, it happens a lot.

The fact that I am now able to drink village water and eat pretty much anything in Rajgarh town without incident tells you exactly how much poop I've eaten in these three months. Pretty much world's best probiotic regimen. I'm sure I've been well-colonized with C. difficile after two years working in a hospital, but the bugs here are going to give those spores a run for their money.

How Pepsi Might Save the World

It's really been seriously non-stop excitement since I returned to Bhorugram from Mumbai. Some of that I've detailed in previous entries. The latest bit was a visit of various high-ups from the Safe Water Network. I'm still working on fully understanding what SWN does, but it involves having a lot of cash. No, more than that. A large (not totality, but large) chunk of their funding comes from Pepsi and the Pepsi Foundation. They also have a board of various well-connected business and political figures, which means they've got a lot of opportunities for global reach. The website doesn't tell much about what they do, but I can say that at least in the Churu District, it's about building water structures. Specifically, a kind of rainwater-harvesting setup called a khund. I've taken some photos that I'll try to composite together to show you, but it's essentially a covered tank with a few inlets to let in rainwater. The fancy ones have gravel to filter the water a bit and maybe some pipes that let them collect runoff from nearby rooftops. SWN is giving BCT money to build them, both large-scale community ones and smaller household ones, and this is apparently the beginning of a project that's expected to scale up a lot.

Anyway, aside from meaning that I got to enjoy upgraded food for a day, the SWN visit also turned into my chance to play tour guide. I'd met one of their India-side execs at breakfast on my very first day in Jaipur, so when we ran into each other at breakfast again, it was inevitable that I'd be invited to join their fieldwork. So, after giving them a bit of a tour of my own REACH project (which potentially could measure the health outcomes of their water activities), I got packed into one of their SUVs and ended up serving as tour guide to the local landscape and the experience of being an expat in India. Can't say as I was sorry to go -- it really is nice to be able to just talk to someone in English without having to worry about the complexity of sentences or reducing my accent. Plus, trips like this are always educational.

Sadly, the village experience waiting for them was more song-and-dance than actual experience of village life. Once the cameras came out (they were trying to get some shots for the brochures), it mostly became everyone showing off their camels/children/whatever for the foreigners. There was what purported to be a meeting with village leaders to assess needs, but even my poor Hindi skills told me they were being taken for a ride. (Thankfully, so did the much better Hindi skills of their board member who's a former Pepsi India executive.) When they tried to ask the village spokesperson about things like average income levels, it was always "Oh, everyone here is very poor, we need your money," but somehow he could never tell exactly how much he or anyone else made for a day's work, or how they all afforded recharges for their mobiles, or how it was that they were still alive if it cost Rs 5000 per month to have water trucked in. The worst was when he got asked about illness in the village. He flatly denied that any children had died in the village that past year, and as far as ailments, the biggest concerns were sore backs and heart trouble[1].

So, for once, yours truly got to be a bit of a hero by steering our visitors in a new direction. Namely, offering them a chance to come five minutes down the road with me to the anganwadi. (Not that they couldn't have done it on their own, but it wouldn't have been on the normal itinerary, and I'm legitimately a semi-expert on the dang things now.) There was more song and dance here (literally -- the anganwadi worker basically made the kids dance for photos like circus animals[2]), but after that, I was able to show them something real -- the registers full of data that our project requires the workers to keep. The ones that show that yes, there were both infant deaths and stillbirths the prior year. Along with the health worker who can tell that yes, diarrhea is a very frequent problem here, and is sometimes fatal. They had video rolling the whole time for their PR work, so who knows? Maybe I'll be in a future Pepsi-sponsored video.

Even with the village numbskull, I'm still very glad they visited. They learned something, and I found out a few ideas along the way. I certainly got another example of how the REACH public health database model could be put to good use. Beyond that, it was interesting to hear about how Pepsi's starting to rebrand/rethink itself for the developing world. They've still got their traditional recreational beverage line, but they're also starting to realize that pre-packaged foods could have a very positive effect here. For one, anything Pepsi makes is an order of magnitude cleaner than any other available food. Second, most people here are undernourished. Supplying large numbers of calories (and maybe even some micronutrients) in a compact, well-distributed package is basically a core competency of soda companies. So, they might actually be able to help these villagers (in the short run) with just a slight twist on the formula that's rapidly putting Americans into an early grave. It's quite innovative and also mildly ironic.

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[1] And this is why, despite the fact that women already do too damn much work in this part of the world, we run our project on the backs of female health workers. In anything having to do with children, village men have zero concern. Some of them can't even name all the children in their own family.

[2] You may be detecting a bit of an aggrieved tone here. I don't know why I was so bothered by the amount of photography that day. It's good that the level of poverty was being documented. I think it's that a lot of the human beings were being trotted around like showpieces. It's the same reason you might find it offensive that people around were snapping pictures of you just for being a white person in India. It's not the visitors' fault exactly, it's just that the whole thing got a bit distasteful despite their efforts towards cultural sensitivity.

Light Amusement: Out of the Mouth of Babes

As a bit of light-hearted fun, two pictures done by the school students that are hanging on a bulletin board downstairs:




 




Above, proof that drinking cheap Indian whiskey caused the extinction of dinosaurs. I don't know if the kid ever saw the classic Far Side cartoon that says the same about smoking or if it's a case of convergent evolution.

Below, a young child's understanding of global warming. The ozone hole gives light so that Mr. Pollution (aka Mr. Satan) can see to put the Earth on a fire, with the logs made of greenhouse gases. The result is that skin cancer and cataracts reduce us all to skeletons. In truth, it's a pretty effective message.

These two would not be out of place in any school hallway in America, so someone's doing a fine job.

Stranger in a Strange Land

I've been trying for some time to write something insightful that captures what it's like to be a foreigner living and working in India, especially village India. It's still not where I want it to be, but there's less than a month left in Bhorugram, so it's time to start posting. Some of you have parallel experiences, most notably Justin & Marjorie, but this is different from the India you'll experience as a tourist. It's also very different from India as I've known her, because most of my experience is in Mumbai with my relatives. Generalizing to India from Mumbai is like generalizing to America from New York City.

Let's take the good first. Number one on that list is improved patience. My ability to handle delay, particularly long car trips or half-hour periods just spent sitting and waiting, has grown dramatically. As you know, in the US five minutes of no activity is sufficient excuse for me to pull out the phone and check my email. Here, there being neither email nor books on tape nor any other distraction, you sit and you watch the shrubbery. It does leave a lot of time for thinking and planning, which is very nice.

A close second is an appreciation for the basics of life -- eating when you want to, sleeping when you want to, not having wildlife right outside your door, and not having effluent everywhere. I'm going to try to do another panorama of main street in Bhorugram, just so you can see the level of shack-itude that exists in the most-cared-for village in this district. You'll see this level of poverty even in the big cities, and you can't help but realize how much we've all won the lottery to have been born in the USA.

On the major downsides of being an expat, the #1 is isolation. I'm learning a little Hindi, but not enough to understand a rapid conversation conducted with use of slang/imperfect grammar. I still can't read Devangari script, either. Combine this with the need to keep at least some distance between me and the staff (see future entry about hierarchies), and it can get really lonely. The availability of Internet and at least the occasional cheap phone call home (neither of which would have been available here five years ago) have helped with this a lot. Nevertheless, if I seem more talkative than usual by blog and/or email, it's because this is a lifeline for me. This is my only chance to communicate about something beyond basic physical needs or my work.

The other big kicker is Indian social mores, which differ in two major ways from what we're used to back home. One, EVERYONE asks you how much your possessions cost and how much you make. It's supposed to be a way of placing you in society. However, the problem is that they translate any dollar figure into rupees, and then assume you can buy as much in the US as you could here with those same rupees. As such, my laptop could probably buy a house. Dodging those is hard without being at least a little rude to your conversant, and people are already nervous about talking with the Doctor sahib as it is.

Interestingly, this contrasts with social weirdness the second: laughing/staring at people is somehow not considered as rude as we would think it. Every time I walk into the mess or into the colony where I stay, I face a wave of giggling. If I dare to actually say something in Hindi, it gets repeated back and forth for ten minutes or more. When there's not giggling, it's goggle-eyed stares from a room full of kids and adults. (Mind you, it's worse for women -- Maggie had people actually following her around and taking pictures.) Could I shout at people? Sure. But I spend my entire day shouting at people as it is, just to get the basic work done. There's only so much angry you can do in a single day.

Finally, privacy. Yes, it's a communal culture and there isn't much of it. This, I know. I did not expect that it extends to someone constantly looking over my shoulder when I'm trying to write emails/blogs/whatever. I have had to dish out some major scoldings to our data entry operators for what were (I think) innocently curious attempts to read personal emails. They look like hurt little puppies afterwards, and I have no way to explain to them the concept of differing cultures.

It's been a good learning experience overall, and with this week's increase in the rate of work, I'm not having as many doubts about my value to the project. I'll still be glad to leave it behind and come back to Jennifer, the comforts of "civilization", and just being ordinary again.

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Postscript: In between writing this and posting it, a friend sent me a link to her niece's blog from Botswana. Odd how many things are not unique to India...

Pano-rama

Experimenting with trying to do some better pictures of the area, with help form panorama software. Here's sample 1:



Warning: links to 7 MB image. Do not try to download to your phone.

Holi

Don't think I ever posted these, so have some entertainment. Back around March 11th, we celebrated Holi, the festival of colors. This being a school, it's a rather safe place with a minimum of mischief, but it's still something worth wearing old clothes for. (or, in my case, clothes bought in bazaars for net of Rs 150). When you're the foreign guest, you're also pretty much a magnet for people wanting to play Holi, so I got colored but good. The full set, including photos of the schoolkids, is here, but here's a taste:

Omphaloskepsis

As a bit of follow-on from that last post, some internal introspection about a question that's been affecting me a lot: "Am I doing anything useful here?" Sure, I'm busy all day. I write emails, I debug computers, I go to these meetings in the field, I tell people to bring this or that here or there, and I occasionally run some queries in the database. But am I doing anything useful? Put another way, is all of this actually increasing the speed at which some kid is going to get the vaccine that'll save her life? Is the work I'm doing worth the extra hassle caused by having this guy around who can't speak the local language and thus is constantly tying up others with his requests?

I know it's being helpful for me. I'm definitely gaining an appreciation for the comforts of civilization and a bit more tolerance for discomfort/boredom. There's also some minor fringe learnings about vaccines, Hindi, SQL, database configuration, and other technical topics. Plus, there's the broader experience of seeing just what it means to be in a village and how the vast majority of the world makes their daily life. It's pretty sobering. You hear the statistic about people living on $2 per day, and in fact, that is what we pay my data entry techs. It's another thing to see what $2 per day and true subsistence farming mean. I take a lot of comfort in the fact that I'm now more in touch with "real India" than my relatives who have spent their whole lives in city luxury.

The trouble is, I'm working on a huge problem, and I'm working on it for two months. The ability to make an impact on something as big as Indian rural poverty is epsilon at best. Moreover, there's that language barrier, which means that anytime I want to meet with someone, I have to haul along an interpreter. I can handle Hindi for "I want some tea", "Has the newspaper come yet?", "Turn left there", and "You're doing a good job." Understanding a complete description of how someone collects data in her village is a bit outside my capacity. (We won't get into the fact that some of the people here don't even use Hindi, but instead use the vaguely related dialect of Marwari.)

On the plus side, I bring a couple things. First is experience with planning, project management, and higher-order thinking. I'm used to having to grasp the big picture quickly, and so my daily actions are informed by something beyond the task at hand. Second, I can cause things to happen. If one of my staff asks for something that costs Rs 3000, he gets hassle/resistance, and it'll take one or more weeks. If I ask for it, it happens ASAP. If it does not happen ASAP, the person concerned is reminded that I have the source of his salary on speed-dial, which generally produces rapid compliance. Furthermore, the Indian culture of semi-slavish respect for "superiors" in class (more on that in a future entry) means that my simple presence in any gathering causes more attention. Basically, I am the local agent of PS Reddy and Ashok Agarwal and have defined my role as doing the same shouting-at-people that they would do.

Net result? Project probably gets up and running a bit faster than otherwise, maybe a month or two earlier. Data will have slightly better quality, although I don't know how well I can put in place measures to prevent them from degrading once I'm gone. How many lives is that really going to change? One? Ten? A hundred? I have no clue, and have to take it on faith that I'm doing something other than low-budget tourism.

A Day in the Life

Thinking further on blog topics after a bit of a breather, one thing I recall being asked is "So what do you do all day?". I have two types, field days and not-field days.

Not-Field Days

• 7:00 AM (ish): Wake up. Caused by combination of light, noise (usually from daily morning power failure and resultant generator start-up), and (usually) someone bringing me a cup of tea, one of precisely three special privileges I've claimed.
  
• 7:30 AM: Shower, shave, etc. Since returning to Bhorugram, I do actually have a genuine shower. With hot water. Didn't request it, but not complaining.
  
• 8:00 AM: Walk 1km to school (not uphill both ways, but fraught with the peril of rogue sheep). Take breakfast in school cafeteria. Generally, I will ignore the breakfast entree of the day in favor of a plate of fruit and a cup of tea. (Second special privilege: daily delivery of breakfast fruit.)
  
• 8:30 AM: Get to office, start day of work. "Work" is variable. There's at least one phone call to someone regarding whatever is going wrong this day, usually some time spent doing queries in the database, debugging of some non-working program, teaching the staff how to do some particular task with the programs, tracking down source of a data entry error one of our techs is having, and meeting with other Bhoruka Charitable Trust staff about whatever it is I need that day.
  
  
  The list of things that are not working on any given day has included, but is not limited to:
  
  • Lack of electricity to computers or lights
    
  • Wasps building nest on main ventilation duct
    
  • Computer teacher stealing our OS installation CDs and our Oracle CDs in mistaken belief that we are hiding a new version of Oracle
    
  • Tech unplugging the server to charge his mobile phones
    
  • Dustbin in room overflowing with trash due to not being emptied past three/four days
    
  
  
• 10:30 AM (ish): Tea break. Cup #3, for those keeping count. Obtain copy of The Hindu, my preferred English-language daily. (Special privilege #3.)
  
• 10:45 AM onwards: See work above.
  
• 1:30 PM: Lunch. Meals other than breakfast are a fixed menu of roti (bread), chavval (rice), sabzi (vegetable; the potato is considered a vegetable), and dal (lentils, chickpeas on a good day). Pure vegetarian, although they do use ghee.
  
• 2:00 PM onwards: See work above. Follow up on whatever's gone wrong in the morning. Yell at people as needed, feel bad about constantly yelling at people.
  
• 4:00 PM: Optional cup of tea #4.
  
• 6:00 PM (ish): Attempt to finish work and switch over to typing blog entries, reading email, writing Scope & Scalpel, other personal work for day.
  
• 7:30 PM: Dinner, see also lunch. 8 PM is student dinner time; either take dinner early and get hot food, or wait until 9 and get great personal service, but cold food and not much veggie left.
  
• 9:00 to 10:00 PM: Finish up residual work and personal Internet use, head back to quarters (1 km walk back, lovely view of night sky, stray dogs not aggressive).
  
• 10:15 to 11:00 PM: Read book, relax, maybe eat a biscuit or chocolate from the secret stash. Suppress mild craving for glass of Scotch and some ice.
  
• 11:00 to 11:30 PM: Bedtime. Turn on geyser so that hot water will be produced overnight and thus will not be prevented by morning power failure.
  

Field Day

• 7:00 to 9:00 AM: Same.
  
• 9:00 AM: Jeep arrives, with Hanuman the driver. Fill up water bottles, grab lunch from cafeteria (if ordered the night before), start interminable process of getting crap together.
  
• 10:00 AM: Depart Bhorugram. Spend rest of day bumping over sand dunes to sound of various Punjabi, Rajasthani, or Haryani music tapes. (See also, prior post re: roads and lack thereof in most of district.)
  
• 11:00 AM(ish): Arrive first of usually three sites. Spend about an hour sitting with village women looking through their registers, cross-checking their data with our data, and trying to explain to them why exactly it's important that they fill out all these damn forms (in between herding children, cooking all the meals, fetching water, keeping fire going, obtaining clothes/food, and doing every bloody other thing that keeps their families alive).
  
• 1:00 PM(ish): Lunch break. Lunch is eaten by spreading newspaper under the shade of a random tree in the middle of a desert, placing whatever food we've brought on the paper, and sharing as best we can.
  
• 1:15 PM(ish): Back on road, see above.
  
• 4:30 PM(ish): End of final meeting. Pick up one or more health supervisors who need a ride home, shuttle them home, and head for Sardarpur or Rajgarh.
  
• 5:00 PM(ish): Start running what occasionally seem like interminable errands in Rajgarh. Errands can include, but are not limited to:
  
  
  
  • Pick up generator or water pump parts for school
    
  • Collect school/BCT's mail from our Rajgarh mail drop in a little copy center
    
  • Tea, sweets, sugar cane juice, or fried snacks
    
  • Recharge one or more mobile phones
    
  • Collect more REACH data sheets
    
  • Process photos for school/BCT publicity (a nightmarish hour-long task of computer incompetence)
    
  • Pick up random people from various bus drop-off points
    
  • Any other shopping the organization may need done.
    
  
  
• 6:00 PM(ish): Head for home, reach Bhorugram around 6:30. Remainder of program as per non-field day.
  

Sundays are a bit lighter; I generally only work a half/quarter day, and there's usually something special for breakfast. Other than that, this is the pace of life here in Bhorugram. I've gotten pretty used to it, but I'll still be glad to come home.

More about work

Time for status update #2. Basically, since I got back, we've been working double-time, and this is the first night I've even had enough break to write something. My trip back to Bhorugram from Delhi was in the company of our computer guru from Hyderabad, with whom I spent three days trying to install and configure our new server and four new client computers to match it. You'd think this would be easy, but when you're six hours from any serious tech support, nothing is easy. Everything in India is done with pirated OS and pirated software, and hardware is patched together as custom jobs. Net result: we had a hard drive that was wired wrongly into the machine and multiple machines riddled with viruses. With heroic efforts (and not celebrating Holi in the traditional fashion of getting seriously high/drunk), we got it marginally working. Getting it production-level working is still in progress.

That left me with two days before the big bosses themselves, Drs. Reddy and Agarwal, came to down. So, I decided to implement some of that quality checking, using two time-honored statistical techniques: the convenience sample and the n-of-1 study. Namely, we printed out our data concerning the anganwadi centre located in Bhorugram village, traipsed down there, and started hassling the workers with our questions. Once we'd gone through everything she had written down in her register, we spent two half-days marching around the village (with plenty of people staring at the mini-parade), wandering into houses and investigating vaccination cards, numbers of children, pregnancy dates, and so on. This was clearly quite an event, even for a town that sees plenty of strangers -- we had at least two local children following us at all times, and any entry into a house meant a small crowd of neighbors outside.

Unfortunately, the fieldwork revealed about what I was afraid of -- even with records on over 250,000 people in the database, we are missing a pile of information. We had records on 20 births in 2008. In a pile of papers not a kilometer from our computers, we found records of another 20. We knew of 6 pregnant women; the workers knew of 5 more. Mind you, these are the same workers who fill out the paperwork on which the database is built, and on whom we depend for our monthly updates.

So, what do you do when you've spent a whole lot of time doing a cross-sectional survey of 233 villages, only to find out that it looks like you might be missing a lot of data? That was the topic of discussion with the "attendings". Thankfully, the answer will not be "start the whole dang thing over". It will, however, be "Make some village women do more work." Basically, since we know they've got much of what we need hiding in their registers, we hand them a form and tell them "fill this out, we'll want it back in a week". Not necessarily what I'd have chosen to do (I don't trust their reports, as the forms are printed in English, which most of them don't read), but I'm only the local manager around here. It'll do for a short-term fix, which is all we have time for before I pack up and go in another 1.3 months.


The big question for me right now is how to maximize that 1.3 months. I have a lot of potential focus areas, which I'll try to describe in a future post.
Meanwhile, while I was gone, one of my staff flat-out quit and another accepted a position to begin in two weeks. On the bright side, I got added a really smart statistician. So, I need to figure out how to use these new resources, and how to design something that'll survive this highly unstable environment. "Challenge" is putting this mildly.

Luckily, at least as far as blog entries go, I've got enough pictures and pre-written general posts to keep you entertained for a few weeks. :-)

Tourism photos

As promised, a brief summary of my two weeks' semi-vacation. There are a lot of photos associated with this, and I've provided links to the main photosets and a few excerpts of note.

The whole thing is made possible by the fact that years ago, my father's company decided they wanted to do international joint ventures in steelmaking. One of the places they looked at (because it's got cheap labor and a big demand for materials) is India. They realized that there was exactly one Indian guy in their upper management, and thus began a process that would lead to my dad needing to take yearly trips to India for board meetings. The American Express corporation lent a kindly hand by setting a policy that, whenever a sufficiently high-value cardholder buys a business class international ticket, he gets a free companion ticket. Net result: my dad gets a free trip home every year and can take one person with him.

This year, that one person was Jennifer, my fiancee. So, our goal was to introduce her to the core of the family here in India and give her a taste of the major sights. We thus ended up with a whirlwind tour of India -- 3 days in Mumbai, 2 in Varanasi, 2.5 in Delhi, 2.5 in Jaipur, and another 2 in Mumbai before they headed home and I hopped the train up to Delhi (and a car from there to Bhorugram).

First off, Mumbai, the New York City of India. Big, crowded, insane traffic. Also home to my grandmother, chacha/chachi (grandfather's brother and his wife), and the highly Westernized family of my older aunt. Mostly, we ate, we hugged, we shopped, and we argued over where to eat and shop next. We did get in some tourism, mostly the British-era buildings that have unique architecture. Photos of those here, and here's a sample of us at the Gateway to India:



Next to Varanasi, one of the most important holy cities for Hindus, as it's situated on the banks of the Ganges river. Varanasi also happens to be a central pilgrimage site for Buddhists, particularly the outlying town of Sarnath. Sarnath is where the Buddha preached his first sermon setting out the precepts of what became Buddhism. It is also the site of some very impressive ruins:




The centre-piece of Varanasi, though, is the ghats. These are sets of steps leading down into the Ganges, and most Varanasi tourism involves them. We did tour some other major temples, but photography being not allowed, you mostly get shots of the ghats. Here's one of the nightly worship ceremony at the biggest ghat:





Overall, Varanasi was seriously dirty, but a lot better than my uncle (who can be somewhat fastidious) led us to believe it would be. The Ganges remains badly polluted, but isn't quite the sewer one might fear. Nevertheless, from the gullies, we next headed to Delhi, where my younger aunt lives. It turns out I haven't seen her in about 15 years, so we packed a lot of catching up into a few short days. Delhi is also only a few short hours from Agra, home to some of India's most famous monuments. So, we did Agra, including (of course) the Taj Mahal:





We also hit the Agra fort and Sikandra, burial place of the Mughal emperor Akbar. Those did produce a few nice photos too:






Nevertheless, for beauty, you just can't beat the Taj. Unfortunately, you also can't beat it for sheer hassle factor. The number of touts, pushy souvenir vendors, drink sellers, and people trying to use every conveyance available to take you the 0.5km between parking lot and main gate is beyond belief. It's also got one of the worst "jack up admission price for foreigners" systems I've ever seen. Glad we went, won't be doing it again until the kids are old enough to appreciate it.

The next day was meant to be more touring around Delhi, but got cut short by (A) souvenir shopping and (B) some general exhaustion due to packing too much in the day before. We did see the Red Fort, but that's about it. The rest will happen next visit.

From Delhi, it was on to Jaipur. Not truly my home base, but since my NGO is Rajasthan-based, we had the benefit of some local hospitality (including the use of one of the boss' cars with driver). Aside from the Taj, I'd have to call this the high point of the trip, if only for the forts. I love exploring them, and Rajasthan is full of incredible citadels built during the era of warring princely states. Of those, we only got to do Amber and Jaigarh, but even those were impressive. Amber in particular was a good place for tourists:





Other notable features of Jaipur included wandering around the old Pink City and Jennifer getting a chance to experience local means of transportation:




There's also an amazing astronomical observatory (mainly a collection of very large, very precise, and strangely targeted sundials) called the Jantar Mantar. Almost the Indian version of Stonehenge. Noteable mainly for being one of the few places where you can climb on the art:




And from there, it was a brief tea and snacks with Dr. Ashok Agarwal and his wife, back to Mumbai, packing of the bags, and semi-tearful goodbyes. An entirely enjoyable vacation, and it appears that the Bhorugram folks even got a fair amount of work done while I was gone.

And next up -- something resembling work of my own!

Riding on trains

I've just returned to Bhorugram after taking about two weeks to bop all over the subcontinent visiting family and giving Jennifer a bit of a taste of India. (Sort of a tourism thali, if you will.) Photos of that will be forthcoming shortly, as will some further progress reports. In the meantime, since I made the return journey by train, I thought I'd give a review of the state of Indian rail travel.

There are two disclaimers here. First, I traveled by 2AC, which is "first class light" -- air conditioning, bedding provided, fair amount of space, decent security. (The class system is convoluted, and if you're interested, look here.) Second, I was on a Rajdhani express, one of the fast trains that radiate out from Delhi. Rajdhanis include food as part of the ticket price and thus may have better catering than other trains.

That said, I would do it again, and in fact intend to book a train ticket back to Mumbai as soon as I've got internet access. I found it to be a much more pleasant experience than airplane travel. Major comparison points include:

• Luggage allowance. If you can carry it, you can bring it aboard, no extra fees.
  
• Legroom. The berths have enough room to stretch out even for a six-footer like me.
  
• View. There's a great view of villages, mountains, sunrises, sunsets, and the general Indian countryside.
  
• Peace and quiet. In the AC levels, passengers barely talk, and there's outlets in every compartment. Very easy to relax and even do some work (or at least write some blogs).
  
• Better sleep. It's genuinely dark, you have a full lie-flat berth that's big enough even for a six-footer like me, and the back-forth motion of the train is an excellent hypnotic.
  

Now, with that recommendation that anyone with time to spare give train travel a whirl, I will say that there are a few mild disadvantages:

• The toilets are fragrant, even the Western ones. By American standards, they reek, as does the station itself. By Indian standards and my now-numbed olfactory bulb, I've smelled worse.
  
• Security notwithstanding, you do need to watch your valuables closely. I chained everything down and locked my suitcase. I lost nothing.
  
• That high amount of luggage space does come with a need to make sure your luggage fits under the seat or is otherwise keepable near to you. American suitcases have problems with this.
  
• If you go by AC class, your windows don't open. (Duh.) So, you can get less of a good view of the outside. The remedy is to lock up your stuff, go to the end of the compartment, and hang out the door.
  
• "Time to spare" is key. Mumbai->Delhi flight time is under 2 hours. Mumbai->Delhi train time is 17 hours. Not a disadvantage if, like me, you've time to spare. Might be a problem for tourists on a time crunch.
  

And now, some work.

So, then, a status update on the project itself. I've been out here 1.5 weeks now, but actual working time is only a week, due to the initial few days being taken up with various Agarwal-related social activities. I also lose about 30 to 60 minutes daily in pursuit of various quality of life initiatives (e.g., the continual pursuit of safe drinking water). That said, I'm starting to get a handle on the issues involved in scaling this project up from 40 villages in an area with decent health statistics to 230 villages in an area with not-so-good statistics (or infrastructure).

First, the good news. I have good staff -- they're pretty smart, and 2 of the 3 speak English well enough that between their English and my Hindi, we can communicate well. Both of them are constantly searching for new jobs, as being posted to the desert is not fun for anyone, but they're mine for the next two months. I also have good resources -- an Internet connection that's working whenever the power is, a new server coming to handle the database load, and soon, a nice room of 10 data entry terminals to feed that survey. Reliable techs to do the data entry remain a work in progress.

Now, the troubles. They really come down to one thing: the Rajgarh Block is BIG. Blocks are set up by population, and so in a sparsely populated environment, you get a big geographic area to cover. This then gets exacerbated by the fact that roads are somewhat lacking out here, case in point:



So, to get from any one point to another is a minimum 30 minute trip, and usually more like an hour, even by car. This affects the three main parts of a database project, namely data collection, data entry, and data checking. As far as collection, we're dependent on women in the villages. Sometimes they fill out the phonebook-size registers we hand them. Sometimes they don't. Sometimes they fill them out incorrectly, in which case we have to send them back as a do-over.

Entry goes OK when the power is on, but is dependent on the hiring of computer-wallahs. When the transport infrastructure fails them, they don't come. When they do come, they're rather tempted to spend their time surfing the Internet for music. They do less of that (and make fewer mistakes) when supervised, but we only have three professional staff, and if they're out in the field, there's not much they can be doing.

It's quality control that I see as my real task while I'm out here, and that's the one that seems like a particular bear. The only way you know if the data are trustworthy is to check them against reality. Reality is a bunch of women and their families in various structures throughout a village. Checking it means going house-to-house. The first REACH project serves 40 villages, and they're small. You can just do exhaustive surveying. This new REACH project covers 230, and about 270 total community centers within them. I'm going to have to figure out a successful technique for sampling villages and households within those villages, and ideally I need to oversample the places where the problems are so that I can start rooting them out. How I think I'm going to do that is the topic of the next work-related entry.

Only In India

I really don't think there's anything more I can add. These were playing cards, originally.

The Way of the Bucket

This is my bucket.
There are many others like it, but this one is mine.
My bucket is my best friend. It is my life.
Without me, my bucket is nothing.
Without my bucket, I am nothing.

In all seriousness, one thing that always interests people about foreign lands is plumbing. Eating and excreting are the fundamental activities of life, and thus it's no surprise that everyone does them a little differently. (The popularity of ethnic restaurants makes me wonder if there'd be any value in opening up a "Toilets of the World" complex where you could experience bathing and toileting in a bathroom from another country. I bet the kids would like it.) Today, we will discuss the Indian bathroom, and its most important feature, the bucket.

All bathrooms come with at least one bucket. You use it more or less depending on your level of wealth, but even in rich peoples' apartments in Mumbai, it's there. If you don't have running water, you use it to get the water to bathe. If you have running water but no shower, you fill it to get the temperature right. If you have a shower, you still need it to rinse the floor afterwards. Your clothes are washed in a bucket, even if it's by servants and not your own hands. (The packet of Tide I bought in Hyderabad actually includes directions on the back for bucket washing, but NOT machine washing.) After using the toilet, your bucket might be your only source of water for cleaning your nether regions. If you're really hard up, the bucket might BE the toilet. Ultimately, every Indian, rich or poor, probably begins and ends his/her day in salutation to a bucket.

A few things in the preceding paragraph might have surprised you, so let's discuss the rest of the bathroom. First, the toilet. They do come in the "squatting" version, but there are also plenty of "European style"; most of them look like the ones you know from home, with a slightly different flush mechanism. What'll get you is when you finish and realize there's no toilet paper. In the bad old days, you'd dip a cup (or your hand) into your trusty bucket, fill it with water, and use your left hand to assist you with some washing. (Hence why the left hand is not polite to touch/pass food with.) Nowadays, most people have a little hand-held showerhead that effectively acts as a mini-bidet. I had one in Hyderabad. I don't have one here. It's taken some getting used to, especially because there is often not soap by the sink. Hand sanitizer has been my friend.

Next, your water supply. Running water is pretty common these days (don't try to drink it). The central hot water heater, on the other hand, is almost unheard of. Hot water comes from a little just-in-time gizmo called a "geyser". Flip the switch, wait five minutes, and your hot tap is suddenly working. Try to remember to flip it back off when you're done.

Then, the shower. The shower itself is pretty much the same, albeit minus the various modes and gizmos we have. If you're lucky, the hot water line from the geyser connects to the showerhead as well as to the hot water tap. If not... well, say hello to Mr. Bucket again, as I do each morning. What we haven't mentioned is where all that water goes. There usually is neither tub nor shower stall. The entire floor is slightly tilted, and water from showering or clothes-washing simply runs downhill to a drain in the floor. Said drain is usually near the toilet, and is inevitably unable to completely dry the floor. Thus, answering nature's call almost always means wet feet, one of many reasons why most Indians go barefoot in their own homes. Given the almost-ubiquitous fine dust, it also means that it's impossible to enter the bathroom without producing muddy footprints on the floor. Hence, the usefulness of a bucket of water to re-rinse the floor every so often.

Power outages are frequent, the rains come and go, but the bucket endures forever.

Dramatis Personae

I thought that it might be helpful in decoding the prior entry if you had a list of some of the major players here:

• Dr. PS Reddy: Cardiologist from Pittsburgh, runs the SHARE NGO in the rural area around Hyderabad. This whole thing is sort of his fault, since he's the one who arranged the trip for me.
  
  
• Agarwals: Broadly, a clan of Indians hailing from an ancient city called Agara (distinct from current-day Agra, I think). In my case, a particular family of wealthy brothers descended from a single entrepreneur, all of whom fund various charitable projects.
  
  
• Bhoruka Charitable Trust (BCT): The primary vehicle through which the Agarwals do most of their philanthropy, which is heavily biased towards trying to help a single village of particular importance.
  
  
• Dr. Ashok Agarwal: On behalf of the Agarwal family, runs the Bhoruka Charitable Trust and the Indian Institute of Health Management Research. Sort of my "boss", since everything I'm provided comes out of his money.
  
  
• Amitava Banerjee: The guy Dr. Ashok employs to take care of anything related to BCT. Amitava himself has the usual staff of various functionaries, drivers, and other "The doctor sahib's problem is now your problem, go fix it" sort of people.
  
  
• Bhorugram: The village where the original ancestor, PD Agarwal, was born and grew up. (Originally called "Nangal Badi", but renamed in honor of Bhoru Ram, PD's father.) Isolated in the middle of nowhere, poor water supply, and mostly subsistence-level agriculture. Thanks to BCT, it now has a school, an adequate (if narrow) road, and a small "hospital" (mostly a birthing centre).