Sunday, March 23, 2008

Monsoon Hungama

It’s been a rather insane week. I got back from Kerala last weekend, and just as I was getting back into the rhythm of things, my grandfather on my dad’s side took ill, rapidly declined, and passed away Tuesday morning. Although it caught the family somewhat by surprise, it was ultimately welcome, as the poor man was in extremely ill health. For those who would like to offer condolences, my dad (and in turn the family) can be reached at Alternatively, if you would like to call, his number in India (where he is for the next 10 days, having around a few days ago) is (country code: 91) 944 028 6893.
Two days after my grandfather passed, I had to prepare for an audit of my team’s work by our funding agency, Concern India, another stressful experience.

However, the week passed, and this weekend was actually quite nice, with a gathering of many members of my father’s far flung family. Yesterday, during the ziyarat (prayer meeting) for my deceased grandfather, Hyderabad surprised with one of its unexpected delights. A dry season rainstorm, which is still going, more than 24 hours later. In a curious inversion of definitions, rainstorms which would be considered the ruin of a good day, say in Minnesota, are here regarded as “lovely weather.” It was quite a scene, driving sheets of rain interspersed with urban images of holi, a traditional Hindu festival which essentially involves water fights in the streets with colored powder (I didn’t get a chance to take photos on holi itself, but you can see the traces in the pictures of our security guard below).

Dangerous Tendencies

(This post is actually for March 19th)

Fundamentalism has reared its ugly head once again. A few weeks ago, on a lazy Sunday, I thought I might revive a weekend tradition of my last household, 1759 Grand Avenue. My roommate(s) and I would cook scrambled eggs, with toast, and of course, bacon. Judge me if you so please, but pork looks good to even the most devout Muslims, and after 6 years at boarding school, I’d finally given into (literally) the pleasures of the flesh, the other white meat.
After sitting down a lovely breakfast, I must have succumbed to a mental haze brought on by post-meal stupor; when the maid asked me what the "ajib," or strange, meat was, I replied most casually, “suwar gosh,” pork. She immediately gasped, and began ranting about my wayward lifestyle. The beer, the women, the lack of prayers, that was all tolerable, but this, this consumption of pig, was unacceptable. She stared in disbelief at her own hands, which had just washed the pan used to cook the devil-meat. In a religious rage, she threatened to punch me next time I tried, and refused to more than grunt at my attempts at social interaction until a week later. The driver, overhearing only the maid’s threats of physical altercation, later questioned me in the car about why the maid was upset. A little rattled, I nonetheless replied casually with the same answer given to the maid, that I had eaten bacon. Initially thinking I was kidding, when I finally convinced of my transgression, he immediately recited an Arabic incantation, surely something to banish the demon which has taken grasp of this foolish young man. At the same time, he pulled the car to the side of the road, and lectured me on the vices of pork. I attempted to counter with a discussion of the roots of many Islamic practices, but my urdu was grossly insufficient to support this kind of interchange. Vainly attempting to maintain some shred of secular defiance, I more or less admitted defeat a week later, when I moved the bacon to the downstairs freezer, where it has remained ever since.
Apart from that, I was surprised again at my father’s household this week. My dad’s side of the family is rather bourgeoisie, quite the opposite of the jihadis on my mom’s side, so I normally don’t expect much harassment from that side. However, last week, my mom in a conversation with one of my aunts, always disapproving of my very existence, mentioned that I was developing, “dangerous tendencies.” My aunts later raised the issue. When they mentioned it, asking me about my dangerous tendencies, I assumed the usual: concern about a drug habit, the wrong sort of women, or criminal activities, and soothed these touching concerns by dismissing any such possibilities. Looking at me like I’m an idiot, they ignore these explanations, and say, “No, no, we mean.....are you having dangerous tendencies,” with eyebrows raised. Truly puzzled, I wait until one of my aunts finally comes out with it, “Are you dating know, boys.” They were worried that I was gay, which in Hyderabad, is right up there with eating bacon.

Sunday, March 16, 2008

Kerala Pictures

A week in God's Country

I haven't posted for a while, as I was in Kerala for a week long vacation. A good friend from high school, Esther, flew to Hyderabad, and we headed for a few days in Kerala.

It was a stunning trip, from the tea plantations of Munnar, to the wildlife sanctuary of Periyar, and finally, a trip through the backwaters of Allepey by kettu vallam (in plain english, a houseboat). Kerala is easily the prettiest place I've been in India, and is quite unique in many regards. A large Christian population, unique cuisine and the world's first democratically elected communist government set it apart culturally.

The first day was spent at a quiet beach, Cherai, nothing too eventful. The next day took us from coastal Cherai, and the sweltering humidity, into cool tranquility of the hills around Munnar, where we went boating on a local lake, and rode horses into out into the tea fields. The next day took us to Periyar, site of one of South India's foremost wildlife reserves. All the wildlife we spotted was from a boat which traverses a reservoir that extends through much of the park. The last day and night, in my opinion the highlight, were spent traveling through the famous Kerala backwaters by houseboat. Like a floating five star (There was an A/C bedroom, TV, dining room, get the picture), that somehow manages to feel only slightly contrived amid the rustic setting of the backwaters, it was an incredibly luxurious.

The photos more or less describe it all

Sunday, March 2, 2008

"Music, when soft voices die, vibrates in the memory"

I added some music to my blog (it's embedded on the right). A brilliant instrumental by the John Butler Trio out of Australia (props to Alia for introducing to a great band)

Deja-vu...all over again

The first time I ran into a Macalester student a few weeks ago here in Hyderabad, it wasn't a huge surprise. Mac students are always trying to save the world, so I only expected to find one in India. I didn't expect to find two in Hyderabad though. Last night, a girl approached me somewhat hysterically outside a night club, saying she recognized me from the States. Sure enough, she has seen me at Mac. In a city where you can eat street food wrapped in newspapers advertising jobs with Google, globalization is becoming very tangible.

Apart from that, work is good. Last week, we started dispatching mobile health teams to a large slum area, and needless to say, they were popular. Not surprising, as free quality healthcare can never fail in India. However, while the mobile team was doing its job, I went on a walking tour of the basti, Dewarconda. Home to about three thousand, the residents of the locality are tucked away behind the posh apartment blocks and villas of some of Hyderabad's wealthiest residents. My stated intention was to spread word about the mobile health team's timing and services, but the jaunt was more of a needs assessment/case finding trip. A community's needs, particularly when it comes to health, can be devastatingly obvious, but easily overlooked if you never bother to make first hand observation (the more I learn, the more it seems this happens in health development projects). On this trip, I found a diabetic who'd had both big toes amputated (and a rather gruesome abscess), as well as a hydroencephalic baby. I referred both of them on to the mobile team, but they evidenced a broader need: case finding. The residents of these slums are under a lot stress, and tend to work 10-14 hours a day, so it can be easy to overlook what appears to be a relatively innocuous symptom (e.g. the hydroencephalic child could suffer brain damage if the condition is not dealt with; to the eye, the kid only looks like he has a slightly swollen head and the mom didn’t think it was serious).
Case-finding also ties into other programmatic objectives. Since our goal is ultimately enable communities to achieve greater control over their own health (and in turn, health services), we provide training to community members in health. A significant avenue is through the training of community health workers, a paradigm pioneered in rural areas of the developing world (China having taken the lead several decades ago, with their "barefoot doctors"; you can read about it here: Essentially unpaid volunteers, and usually women, at a minimum these people end up serving as first contact points in rural community health systems, and can even act as "mini-doctors" who deliver many curative services. Essentially, this community health model is a response to chronic shortages of healthcare staff. In countries like India, where a very significant portion of the healthcare staff are recruited to developed nations (cruelly ironic, since many are trained in institutions supported by the Indian govt. It amounts to Indian-subsidization of Western health care), it can have a devastating impact.
The latest iteration of this migration involves a reverse migration: instead of our healthcare staff traveling abroad, patients are coming to India, as part of the much-lauded medical tourist industry. Although the odd source of pride for many in India, it's ultimately just a variation of the theme, as few of the medical staff serving foreign medical tourists would ever cater to the needs of destitute local communities.

So the innovate response of community health workers. If as a country, you’ve lost your doctors and nurses, you might as well train community members at the local level. Although it leads to some deskilling of the work force, community members offer immense benefits due to their local networks. Yet, the paradigm was initially, and still largely is, one of rural settings. The project I visited in Jamkhed was a spectacularly successful example based in such a setting. As the populations of developing countries increasingly urbanize, urban health development is becoming increasingly important. Porting the model is proving interesting. The urban poor enjoy much greater access to health services than their rural brethren, but I'm not sure if this is always a good thing. Indian healthcare has succumbed to rampant commercialism, and many hospitals' (and doctors') primary focus is not patients, but profits. Mix this with poor, relatively uneducated poor slum dwellers who often seek out care in emergency situations, and you have a prime recipe for exploitation. It also makes it tougher to operate low-cost, or no-cost health services, because we are in essence, competing with these institutions for patients, and because we don't charge a lot (or at all), we risk being perceived as inferior.
So where do community health workers fit in the urban paradigm? I'm not quite sure; I've searched the literature, and the body of work is minor compared to rural community health. However, I’m convinced that community health programs, and the community health workers that are integral to them, are needed as a counterpoint to the divergent nature of the Indian healthcare system, in which two systems are evolving. One to serve the needs of an elite, wealthy urban upper class, and another for everybody else (I’ll let you guess which one is far better resourced and staffed).
All this to say, case-finding, and accompanying referral protocols, could be a vital role for urban CHW’s. Although they might not directly deliver the vital curative services of their rural counterparts, by identifying impending illness, and in turn, referring such cases to institutions that provide quality, patient-centered care, such CHW’s might be able to help their communities make the best of a somewhat misdirected health system.
It’s a work in progress, which involves reasoning from first principles. Wish us luck ;).