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.
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