Closing Thoughts

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

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

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

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

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

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

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

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

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

Photos Complete!

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

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

Paternalism?

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

-- Attributed to anonymous Vietnam War Major

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

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

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

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

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

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

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

[3] Probably softer than the regular stuff.