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.
[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.
Thursday, April 30, 2009
Friday, April 24, 2009
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.
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.
Wednesday, April 22, 2009
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.
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.
Tuesday, April 21, 2009
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.
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.
Sunday, April 19, 2009
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.
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.
Saturday, April 18, 2009
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.
[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.
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.
[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.
Friday, April 17, 2009
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].
[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.
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].
[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.
Thursday, April 16, 2009
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.)
Even I have to admit that's pretty neat. (If you don't recognize it, that's the Indian tricolor flag.)
Wednesday, April 15, 2009
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).
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).
Tuesday, April 14, 2009
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.
[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.
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.
[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.
Saturday, April 11, 2009
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.
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.
Friday, April 10, 2009
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.
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.
Friday, April 3, 2009
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.
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.
Wednesday, April 1, 2009
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.
[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.
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.
[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.
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