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).
  

Bhorugram Arrival

I've been out at Bhorugram for three or four days now, but it's taken a while to write this entry due to an absolute whirlwind of stuff happening (and one or two days of dysentery that was pretty much inevitable). I arrived on a Thursday evening in the company of Amitava, and had basically an evening and a morning to try to understand what was in place as far as the existing REACH project and try to gather some data. At about 2 PM Friday, Dr. Reddy showed up, and I had perhaps five minutes to tell what I'd found before he'd seized on something, made his own plans about the next step in analysis, and corralled the staff into gathering that data.

Saturday, we had again until just after lunch to try to make some useful sense out of very preliminary data, at which point Dr. Ashok and the other Agarwals also showed up. As it turns out, my timing of arrival was either very fortuitous or very much not. Once a year, the entire Agarwal clan, with kids and grandkids, converges on Bhorugram for a family reunion/review of BCT's work. Since that point, it's basically all been a blur of Agarwals. (Dr. Reddy is here by virtue of having been semi-adopted by the Agarwals along the way. I get to sponge off the fruits of his labor.) They seem like very nice people, albeit from a much higher social stratum than I usually get to talk with. It's also really nice to get to know the people for whom I'm technically working.

Bhorugram itself is what you'd expect for a place out in the Indian desert, six hours by car from any major city. Life for most of the villagers does not include electricity or running water, and is spent on the traditional activities: grow crops, dry camel/cow dung for fuel, cook food, wash and clean, and if you get some relaxation time (i.e., if you're a man), smoke hukka and play some cards. All around the village itself, all you see is empty -- a few scrub trees, the fields of chickpeas and mustards, and maybe someone in the fields. The rest is sand.

That's the downside. The bright side is that as a temporary retreat, it's beautiful. Like all Indian villages, wildlife wanders freely anywhere it wants, which means that there are peacocks and peahens strutting and calling right outside my door each morning. At night, the lack of electricity means one of the most incredible views of the stars that I've ever seen. It is definitely lonely, especially if you don't really speak Hindi well, but there are plenty of worse places to be spending two months.

Jaipur Arrival

Made it to Jaipur and am spending Wednesday and part of Thursday at IIHMR, the Indian Institute for Health Management Research, just outside the Jaipur airport. This is the home base of Dr. Ashok Agarwal, who's technically the patron of my work here in Rajasthan. It is LARGE, the size of a small college campus in the US. It's also clearly a high-powered place; over the breakfast table, my companions were discussing one of Obama's administration picks (NASA head, I think) because he was also a recent co-worker of theirs. They're part of a group called Safe Water Network, over here to work on a new rainwater collection scheme. I'd trust their capacity to do it, too -- one of the guys with them is an engineer who was telling me some of his war stories, which include making a Pepsi bottling plant work with the highly-suspect Indian water and designing a sewage treatment plant that produces zero sludge. (If you don't understand why zero sludge is impressive, go to my Flickr and leaf through the public health photoset.)

I mostly spent the day soaking in the place, chilling in the computer lab, and meeting a few faculty. Mainly, I managed to define better in my head what's going on with the relationships here -- the initial project info talked about working for the Bhoruka Charitable Trust, but most of my contact has been with people from the Indian Institute for Health Management Research. The basic story is that both derive from the late Shri PD Agarwal, who is as much a rags-to-riches as you'll ever hear. See the websites for the full story, but the basic deal is that the dude came to a small town from an even smaller village, busted his butt alongside his brothers, and eventually bought a truck. From that, he became the magnate of the Transport Company of India, and the resulting wealth established the BCT to attempt to de-suckify the area of Rajasthan where he grew up. His sons run various parts of the ensuing megacorp, which handles transportation, power, mail, and other infrastructure needs.

One son, however, went to the US to do an MD (and an MPH? I'm not sure) at Johns Hopkins. That's Dr. Ashok Agarwal. Dr. Ashok returned to India and realized that the concept of "health systems management" didn't exist here, and promptly decided to start what is basically the equivalent of a healthcare MBA program. That same Institute also does a lot of training for NGOs, hospitals, and anyone else who wants to make their staff manage better. Practically, as the son who's least involved in running corporations (although he does manage a few), Dr. Ashok is also the one most directly involved in keeping BCT going. So, the two organizations share a building, though the lion's share by far is IIHMR. They divide up the work such that IIHMR does planning/research and BCT does actual work involving slogging through deserts.

Have not seen much of Jaipur the city as yet (and probably won't before I ship out for Bhorugram tomorrow), but the weather is lovely here -- feels about like Pittsburgh in mid-March. We even had a brief thunderstorm the night I arrived. Summer will show up in April, and then we'll be baking, but for now it's nice. Dr. Ashok's house in particular is very nice. It's not large; in fact, it's smaller than most doctors' houses I know in the US. It is, however, extremely well-decorated. Not lavishly, but everything is of genuinely well-executed craftsmanship, from the perfectly arranged vases of flowers to the inlaid marble all throughout to the hand-painted paisleys on the ceiling. In a country where labor is cheap but quality work is a constant struggle to find, that might be the ultimate statement of wealth. It's making me feel a little bad that all I'm able to give the guy in thanks for 2.5 months of taking care of me is a measly bottle of blended Scotch.

Made it to Jaipur and am spending Wednesday and part of Thursday at IIHMR, the Indian Institute for Health Management Research, just outside the Jaipur airport. This is the home base of Dr. Ashok Agarwal, who's technically the patron of my work here in Rajasthan (even if I've yet to meet him as of this writing). It is LARGE, the size of a small college campus in the US. It's also clearly a high-powered place; over the breakfast table, my companions were discussing one of Obama's administration picks (NASA head, I think) because he was also a recent co-worker of theirs. They're part of a group called Safe Water Network, over here to work on a new rainwater collection scheme. I'd trust their capacity to do it, too -- one of the guys with them is an engineer who was telling me some of his war stories, which include making a Pepsi bottling plant work with the highly-suspect Indian water and designing a sewage treatment plant that produces zero sludge. (If you don't understand why zero sludge is impressive, go to my Flickr and leaf through the public health photoset.)

I mostly spent the day soaking in the place, chilling in the computer lab, and meeting a few faculty. Mainly, I managed to define better in my head what's going on with the relationships here -- the initial project info talked about working for the Bhoruka Charitable Trust, but most of my contact has been with people from the Indian Institute for Health Management Research. The basic story is that both derive from the late Shri PD Agarwal, who is as much a rags-to-riches as you'll ever hear. See the websites for the full story, but the basic deal is that the dude came to a small town from an even smaller village, busted his butt alongside his brothers, and eventually bought a truck. From that, he became the magnate of the Transport Company of India, and the resulting wealth established the BCT to attempt to de-suckify the area of Rajasthan where he grew up. His sons run various parts of the ensuing megacorp, which handles transportation, power, mail, and other infrastructure needs.

One son, however, went to the US to do an MPH at Johns Hopkins. That's Dr. Ashok Agarwal. Dr. Ashok returned to India and realized that the concept of "health systems management" didn't exist here, and promptly decided to start what is basically the equivalent of a healthcare MBA program. That same Institute also does a lot of training for NGOs, hospitals, and anyone else who wants to make their staff manage better. Practically, as the son who's least involved in running corporations (although he does manage a few), Dr. Ashok is also the one most directly involved in keeping BCT going. So, the two organizations share a building, though the lion's share by far is IIHMR. They divide up the work such that IIHMR does planning/research and BCT does actual work involving slogging through deserts.

Have not seen much of Jaipur the city as yet (and probably won't before I ship out for Bhorugram tomorrow), but the weather is lovely here -- feels about like Pittsburgh in mid-March. We even had a brief thunderstorm the night I arrived. Summer will show up in April, and then we'll be baking, but for now it's nice. Dr. Ashok's house in particular is very nice. It's not large; in fact, it's smaller than most doctors' houses I know in the US. It is, however, extremely well-decorated. Not lavishly, but everything is of genuinely well-executed craftsmanship, from the perfectly arranged vases of flowers to the inlaid marble all throughout to the hand-painted paisleys on the ceiling. In a country where labor is cheap but quality work is a constant struggle to find, that might be the ultimate statement of wealth. It's making me feel a little bad that all I'm able to give the guy in thanks for 2.5 months of taking care of me is a measly bottle of blended Scotch.

Air Travel in India

As part of the Hyderabad->Jaipur transfer, I had my first experience with Indian domestic air travel in over 4 years. Here, the class distinction really shows itself. Once you get through the airport doors, the ubiquitous dust is gone. All the signs are in English, most of the business is conducted in English, and personal technology is everywhere. There's a McDonalds, a Subway, and more coffee shops than you could shake a stick at. There's even a wi-fi network (free for 45 minutes if you have a mobile phone to which they can send an SMS). It feels pretty obvious that you've left the street behind and entered a separate world.

The flight itself is pretty much identical to US domestic air travel, right down to the "Oh, you have more baggage than we expected, pay us Rs 1400." (That's about $30 for those playing the home game, actually slightly *more* than the US rate.) They've even replaced the previous years' complimentary food/beverage with pay-as-you-go. The announcements are in English (and the local language), and all the in-flight rules are identical.

Only big difference is in the boarding process. Jetways seem to be reserved for long-haul or international flights. For anything of only a few hours, you get on a bus, the bus drives you to the plane, and you walk up the stairs. (The space for carry-on baggage is much smaller.) Getting on and off said bus displays the traditional approach to queueing, namely, throw some elbows and get your butt in gear. Oddly, there's still a courtesy norm of giving up seats for women.

It was, overall, a perfectly reasonable experience. It also costs exactly the same as in the US -- my ticket (which I thankfully did not pay for) was Rs 8400, which works out to about $175. (Actual ticket price, Rs 2000; the rest is taxes and fees. I hope that little innovation does NOT make its way west.) Two weeks from now, I've got to get back down to Mumbai to rendezvous with Jennifer and my father. There's plenty of flight room available (thankfully, 21-day advance booking has also not caught on yet), but at comparable prices. The train, if I go absolute highest-class, would be Rs 4000 round trip, about half the price. Assuming I can get a ticket off the tourist quota, here's hoping the next traveling entry is telling you about the joys of Indian train travel.

Tourism Weekend #2

This weekend, I actually did have work to do, but didn't get much of it done. It's my last chance to see some Hyderabad, as Tuesday I ship out to Jaipur, and Thursday I head out to Bhorugram (that middle-of-nowhere spot in the desert where I'll spend most of my remaining time). So, I saw some Hyderabad.

Saturday I paid a visit to one of the REACH project coordinators at his home in Kokatpally, a bit north-northwest of Hyderabad proper. In his spare time, he helps run and fundraise for a school for hearing-impaired and cognition-impaired/special-needs kids. The main point of having people like me visit is that they can have us give them a quote that goes on the website to say "See, an American doctor says we're doing good work." He was also trying to twist my arm for money, because everyone here is convinced that all American doctors are made of it. I don't think they quite grasp that medical students and residents don't automatically have attending income. Nevertheless, once I get some photos, I'll post them and maybe ask the ENTs out there about some equipment donations.

Aside from being an interesting peek into how special-needs kids get educated in India (decently well -- they understand mainstreaming and setting high expectations, even if the facilities aren't as shiny as ours), it was also an opportunity to experience public transit. To me, paying Rs 100 for an autorickshaw is not a big deal -- that's about $2.50 for a half-hour cab ride. For him, it's of course expensive. So, I got sent back home by public bus. If you're not a native, it's pretty hard to figure out bus routes -- this is the entirety of the available route map, and I can tell you they do NOT go in a straight line. However, once you know your route, it's not a bad experience -- a bit more close quarters than US buses, but at fares between Rs 4 and Rs 10, an incredible bargain. You basically just tell the conductor where you're going and hand him a 10, and he hands you back some change and a little paper ticket. If you're lucky, he gets your attention when it's your stop. Getting on and off is a bit more interesting -- "bus stop" is kind of a euphemism here. They don't stop, they just slow to a crawl. It's your job to get a bit of a running start, grab the stairwell, and jump on (or hop off and absorb the sudden deceleration). There's a bit more kindness shown if some old lady is getting on/off, but men and boys are expected to fight for it.

Sunday morning was an expedition to the Salar Jung Museum, with further bus routing thanks to a bit of a tip from my host's driver. Salar Jung is, in brief, the knick-knacks (ranging from dolls to model trains to incredible works of art to utter extravagances like a coach made of ivory) accumulated by one of the last royal rulers of Hyderabad. Sadly, it is also photography strictly prohibited, with guards in every room to enforce that. (On the bright side, it is also orderly and trash-free.) It took a couple hours just to glance at everything -- anything resembling an in-depth look would take days. It gives you a sense for the level of insane wealth the ruling class had back then. (Maybe still does -- don't ask me what's in the house of a Tata or a Mittal.)

The plan for Sunday afternoon was to try to find a sample of haleem, a local Muslim dish that's largely a porridge of lamb and wheat (with a lot of butter). It's commonly eaten during Ramadan, since it's a good way to get a day's calories in a single serving. I spent a whole lot of time in two different areas of the city trying to find the places that are allegedly good at it, but had zero luck and ended up going home empty-handed (although not empty-bellied, thanks to the ready availability of biscuits and tea).

Sunday evening, we'd originally planned to get the research group together and go see a Hindi movie. That changed Saturday afternoon, when Dr. Reddy informed us that we'd all been invited to a sangeet. Basically, it's a pre-wedding party, and it happened to be held on some land belong to Dr. Reddy's wife, hence the invite. It turned out to be the second wedding ceremony of a pair of Indian expats living in London, and furthermore, the groom's a doctor. Net result meant that the place was crawling with docs and folks who spoke English as a native language, as well as with waiters serving highly tasty kebabs and other appetizers. We didn't stay long enough for the whole-crowd dancing to kick off, sadly, but we did get a good meal and a good show out of it. I do have pictures of this, which I'll post as part of a future general-pictures update.

As a cap-off to the night, the buffet at this sangeet happened to include (surprisingly) haleem! So, I actually did end up trying it, or at least the version produced by the Hyderabad House chain of restaurants. The verdict is "meh". It's sort of a very rich oatmeal. I'm more familiar with the version my mom has made before, called harees, and IMHO that's much tastier. Still glad I got to try it, though.

Next stop, Rajasthan!

Photography -- Golconda and Qutb Shahi

These are shots from Sunday the 1st of February, when I took a brief excursion by auto-rickshaw to the Golconda Fort (home of the Qutb kings) and the nearby Qutb Shahi tombs (what they built for themselves when not building forts). I should preface these by explaining that "fort" really does not do justice to what we're talking about here. "Fort" to me means something like Fort Duquesne in Pittsburgh, something the size of one or two city blocks with a decent wall around it. "Fort" to these guys means "take a big hill that has big rocks on it, build walls on top of those rocks, put a palace and down around the walls, put another wall around those, and then put a third really big wall even further out". (Apparently, the medieval Deccan Plateau was not a very sociable place.) In its time, Golconda was a full-fledged city. (Still is -- the outermost wall is actually right in the middle of a thriving town.) You would NOT want to be the guy charged with trying to break your way in, especially not after the invention of cannons and other devices for dropping large heavy objects on invaders.

The photoset for the fort and tombs is even bigger than the main Hyderabad set, and is here if you're into wasting some time. These are, in my opinion, the higher points.


First, a view of Golconda from the bottom, before you start climbing:



Your humble narrator, with the fort in the background:


A view from the top of the fort towards the tombs:




A view of the walls, with a woman whose dress I thought really matched the scene nicely:




Back down at the bottom, the upper fort at sunset:


One of many photos of the Qutb Shahi tombs, about a kilometer north of the fort:


There are many other tomb pictures in the photoset, but they all look about the same, so you get one.

As a closing point, there's something you may notice if you looked at the close-ups, and that's trash, in quantities that would make Oscar the Grouch crack a smile. For all their history and beauty, these places are NOT well kept-up. There's garbage, stray dogs, and weeds growing everywhere. Once you get inside, the guards will be very certain you have a ticket, and there's plenty of touts offering to be your guide, but you could scratch your name into something, toss bottles off walls (yes, Golconda has bottle kids), or even set up a cricket pitch right outside some king's tomb (not making this up). It's kind of sad, because it means they're going to decay further. On the bright side, unlike visiting a ruin in the Western world, it means that you have free reign. You can explore anywhere you'd like, violate the "photos only if you paid Rs 20 for a camera permit" rule, and generally roll your own guided tour. It just makes me wonder what these places could be like if someone spent the money and effort to really set up a proper visiting experience.

Goin' Crazy

I'd give you a project update, but there's not much to say yet. I've basically spent this work week learning what's in the REACH database and how to get it out when I need it. This has meant trying to re-learn what little SQL I used to know, complicated by the fact that sometimes it's in an Oracle format and sometimes in a Microsoft Access format. After that, it was just making figures and tables for the 2008 REACH Annual Report, which looks like it's going to be the first time anyone's tried to sit down and give a truly comprehensive history of what the program is, how it works, where it's been, and where it's going. I might put a copy online once it's approved in the next few weeks.

One thing I did do this week is get myself a tour of the psychiatric ward at the Mediciti hospital. I was honestly a bit surprised to find that there was one, but it shows that things are getting more advanced than we'd think. They've got inpatient facilities for about ten patients at a time. Now, this is not quite what we'd think of in the West as inpatient psychiatry. The wards are not locked, as one needs a special license to maintain that kind of semi-voluntary treatment. Furthermore, like most Indian hospitals, it's a single group ward room (well, two, one for each sex), not individual patient rooms. Third, family members usually stay by the bedside most of the time, in part because that's how the patient gets fed and gets their medicines. In the US, if you took six or so psych inpatients and made them share a room 24/7, you'd be calling security and administering extra doses of meds before lunchtime. At least when I visited, it was mostly just a bunch of people lying on beds, some looking at me, many sleeping/resting. Much less of the active disturbance I've come to expect.

Part of this may also be the cultural presentation of mental illness here. As you might imagine, in rural India the depression/anxiety part of the spectrum doesn't quite look the same. Since there's no clear way to express severe emotional distress, you get a lot of somatization (physical symptoms that express the patient's mental pain). Now, that alone isn't odd, because any primary care doc in the US will tell you he sees two of those a day. What's interesting is that it takes a different form. In Pittsburgh, I'm used to seeing it present as headaches, GI pain, or sometimes joint/back pain. Here, it apparently tends to present as convulsions (pseudo-seizures). There are, unsurprisingly, also some very complicated issues involving the gain of being able to take on the "sick role" (I never can remember whether that's primary or secondary gain.)

One of the things I was very curious about was what happened after the acute inpatient hospitalization. Since we can't really cure mental illness in any real sense, follow-up and continuity of care are critical. In the US, this is accomplished (sort of) by a network of social workers, government agencies, NGOs, and community treatment teams. In India, all of the above are lacking and/or minimally functional. However, what is available and strong, especially in rural areas, is family. I've spoken to some of you before about the central place of family in Indian culture (although in truth, I've only ever experienced a mild version, being from the Westernized branch of the Widges). In the US, a semi-controlled chronic schizophrenic is often not living with his family, because they can no longer deal. Instead, he'll be drawing a Social Security disability check to live in a supervised group home or his own modest apartment. He may have a part-time, low-skill job. His meds, if he's often noncompliant, may be managed by intensive community follow-up. At least according to the chief psychiatrist here (n=1 without direct verification, salt recommended), what happens in India is that he goes back to his village and lives in his family's house. (We're talking at least three generations under same roof, assuming they have room. Maybe four if it's a family with good life expectancy.) They make sure he takes his meds. He stays at home and is given small manageable jobs to do around the house. They handle necessary personal care tasks. They bring him for medical appointments if needed. If true, it'd be surprisingly effective. I really hope it's true.

Hardly a deep analysis of the mental health system, I know, but it was still a highlight of the week.

Photography -- Mediciti

I did promise photographs, so here are some. This first part is all about the Mediciti Institute of Medical Sciences, where I spend my weeks. The next one will be Golconda Fort and the nearby tombs.

First, Mediciti/Ghanpur. This is a very lovely place, with some odd contrasts in geography. Down by the hospital, there's a lake and some rice paddies. Just behind the hospital, there's a huge outcropping of what I think is basalt (something igneous) that marks the start of a large stretch of rock-and-thorn-scrub badlands. So, it's beautiful, but also a very desolate sort of beauty.

On to the photos. The hospital close-up, in profile:



And, a view from further away, atop what I call "Shiva Hill" for the temple at the top.



The main entrance to the hospital:



The boys' hostel (yes, that's the official name), my living quarters during the week:



Steve the Gecko, my semi-roommate:



An example of those "badlands" I was mentioning, just behind the hospital:



And, a sunset shot of the Shiva temple that's on the big rock outcropping, from which most of the other panoramas are shot. I'm very fond of this one.



There's a lot more than these, and if I showed all my favorites we'd be here all night. The rest can be viewed in a photoset here.

Over the weekend, in between trying to resolve some logistical problems with database access (the burden of being on a Mac and working for an NGO without many computers), I got some tourism in. Practically speaking, since very few Indian white-collar folks do work on weekends, there's not much point in us being out at the hospital, and so we come back into Hyderabad itself. And, since I'm only here until I get that report written, there's only this weekend and maybe next. I bounced to several different neighborhoods, but since much of that was shopping to take care of some basic needs (e.g., the fact that the hospital canteen serves very good food, but no fresh fruit), I'll hit the highlights.

First, Charminar. Central landmark of the old city, surrounded by a lot of jewelry and clothing bazaar. Here's the photo from street level:



The function of Charminar is still not totally clear to me, although it does contain a mosque on the top floor (which tourists are not permitted to enter). These days, it seems to serve mostly as an observation platform for the bazaar; more photos of that start here.

Courtesy of a fellow tourist, I did also get a photo of me next to the central fountain:



After that, Saturday's wanderings included some much less picturesque museums and a stroll through some department stores just to get a sense for prices and what was on offer. Sunday's morning was similar, but in the afternoon I took a trip out to Golconda Fort, once the bastion of the local kings. Photos of that will follow soon
once they're processed. I did take pride in my ability to convince them (with a lot of bluffery) that I was an India resident and thus entitled to pay Rs 5 as opposed to Rs 100 to get in.

The logistics of all this travel are always interesting, because the primary mode of transport for a medium-income solo tourist is the auto-rickshaw. Ride-wise, these are less terrifying than they initially appear, despite traffic laws being significantly more flexible. It's the price where things get interesting,
because even knowing a few words of Hindi, it's impossible to hide the fact that you're a foreigner. You have the choice of either using the meter (which often requires some forcefulness) or negotiating a fixed price. The former requires you to
know what a direct route to your destination should look like. The latter requires a good sense of what it should cost, often acquired by one or more metered rides (or guesswork off a map, once you know what a given distance should mean in rupees).

I ended up in very spirited discussion with the other grad student on Saturday night about this. She's been here eight weeks, and thus has gotten very good at the art of rickshaw haggling (and thankfully is willing to share her knowledge), but also clearly feels upset about the fact that she's forced to continually wage a one-women crusade against the cheating of white people. I still bargain, but take much more of a "As long as I pay less than X, I don't care if it's still double the local rate" perspective; for me, it's more of a sport. It's also the fact that when the price differential gets down to that last ten rupees (about a quarter), my willingness to spend more than thirty seconds on it is pretty small. I think this will change once the novelty of being in India wears off and it's back to ordinary conserve-money living; at two tourist days a week and four cab rides each, 10 rupees over the course of my visit is $50, and the overcharge isn't always 10. Travel broadens the mind, but usually not the pocketbook.

Figuring out the project

The details of my actual project are starting to nail themselves down. As I mentioned before, I've been brought in to help expand the REACH project (which mainly means the REACH database system) to a new geographic location in Rajasthan, thus proving that it can scale and be replicated throughout India. However, I've never been entirely sure what that meant, since I'm not a database programmer, and I don't have the language or cultural skills needed to go out to the villages and collect the raw health data.

The task becomes clearer once you understand how REACH works. The theory is simple: we build a giant database tracking all the women and children in our covered district, we track who's getting their shots and prenatal visits and everything else, and then we either provide the care directly (the model used here in Medchal) or we show the "failure list" to the governmental ICDS worker and try to guilt them into doing their job (the model to be used in Rajasthan, with a slight twist I'll get to in another entry). The practicality is a bit harder. How do you maintain a database covering all the births, deaths, and medical interactions of nearly 45,000 people in an area that's still working on developing what we in the West would consider basic infrastructure?

The answer, not uncommonly, is to look to the patient population. For REACH, that specifically means a corps of Community Health Volunteers (CHVs) -- women who live in our target villages and are willing to serve as our eyes and ears. (The name says "volunteer", but they're paid a small honorarium. I need to find out just how much.) However, they don't exactly have laptops handy. So, they have to write their data in a big ledger. Once a week, they come with their ledgers and present them to our supervisors, who copy down the data into their own ledgers. They also copy it onto special data entry forms. These forms are then given to a room full of data entry techs, who type them into an app that loads the data into the Oracle backend. Now, consider that in most of the steps along that chain, it's being done by someone who cares, but also has only an eighth grade education. Stuff gets lost or corrupted, and the data entry techs are neither paid nor educated enough to think about the numbers they're keying in.

That, then, is where I come in. I'm basically a rented brain being shipped out to Rajasthan to look at the work that's being done on a daily basis. Most especially, I'm to look at the data coming in and be the lone guy who actually THINKS about whether we can trust them. Likely, I'll find that we can't, which means we'll have to try to figure out what's going wrong and how to fix it. This sounds a lot like some of those consulting jobs I applied for earlier in the year.

Of course, in the meantime, I first have to become an expert in how this system is supposed to work, both logistically and technologically. In order to achieve this within the space of about a week, I've been assigned to write the 2008 REACH Annual Report. The theory goes that in order to write about it, I have to understand it and locate the holes in my understanding. I think this is a pretty solid theory, and that's what I'll be pounding on this week.