Final thoughts

It’s impossible trying to capture in one sentence the impact of the 5 weeks in India. “How was it?” is the normal question I have received, however I have yet to construct an adequate response. Such quandaries are part of life changing experiences, for which I am grateful to have witnessed.

The India of today will be but a memory in 20 years – especially in urban areas. For the rural communities it will take at least one or two generations for such change to be witnessed. It is this enormity of extremes that touches every nerve of your body, creating a heightened sense of your surroundings. It’s exciting, fascinating, and yes, overwhelming all at the same time. You can experience the 19th and 21st century in the same instant, and with it, the disparities of health care, education and living conditions. There are no borders, no lines that separate these contrasting lives; they greet your senses together and your emotions reflect what the mind is trying to comprehend. Sleep was not abundant in the beginning when my rational side was trying to deal with my emotional responses.

And that’s the way it should be, wakening to the realities of others should stir the soul and soften one’s heart. It should open one’s mind to new ideas and create an interest that goes beyond the curious to a respect for the culture and all it has to share. It is easy to criticize when the history of a land or its people is not understood. Solutions come only when one understands the complex layers of a society and it can not be accomplished half a world away. I have in 5 short weeks, only begun to understand some of the social fabric that makes this country so rich.

Yes, it is good to be home, but I do miss India. I had the privilege of learning from the frontline – from those who are trying to change lives one at a time. A chance to experience their reality for a brief moment and learn how they creatively address barriers to health care with limited resources, but with great passion. It’s the story of public health professionals all over the world, and learning requires more than a classroom lecture for the conditions they work in is the key to understanding their true success.

Coming home has been like being Alice in her wonderland – returning to cool spring breezes and daffodil’s, being able to drink the tap water – or better yet, being able to brush your teeth with it, are simple luxuries we take for granted. Warm showers, washing machines and dishwashers all require an infrastructure that others can only dream of. And yet we think we are deprived if we are expected to live without. But being deprived of such luxuries is part of the daily lives of millions in India. And yet there is richness that money can not buy – the closeness of community, the strength of faith and the bond of family. Yes it is a hard life, nothing comes easy. It’s the web of community that keeps this country strong and growing stronger every day.

It is this India that I miss and hope to see again soon. A land of contrast and passion, a people of great history and rich culture, and a hope for a future that we can all celebrate – an India of the 21st century where opportunity is available for all.

Leaving India

It rained last night, a hard rain that washed the dust from the air and off the leaves. It’s the first day that I can remember smelling the sweet earth free of the heat which bakes away such fragrances long before noon. Today my bags will be packed for the long trip home, back to loved ones and a world that will seem so far from the one I have known for these past 4 weeks. A home filled with new friends and fond memories.

I have fallen in love with this country, its people and all its wonderful texture. My favorite form of transportation is the very 3 wheel rickshaw that had originally thrown my adrenaline system into overdrive. I not only can negotiate with the drivers, but I actually relax and enjoy the ride. And yes, the vote is in… although Delhi traffic is nuts, they are amazingly agile drivers. In my 4 weeks I have not witnessed any major accidents, only near misses. In a city of 14 million, this is truly remarkable.

And let’s not forget the cows, parked anywhere they want to be… in the middle of traffic, shopping centers, or roaming the streets. Throw in a few donkeys, green parrots and monkeys and you get the overall picture of this wonderful place. Yes the temperature is rising, and it will only continue. The weather is not for the faint hearted, and it’s only March. But it won’t stop me from returning to this land of centuryies old tradition combined with the new excitement and energy of a young generation.

I will leave the soil of India behind for now, but my new friends and my memories will be part of my life long after I return home.

Bollywood

In our apartment, the TV is positioned next to the computer screen. As I have typed my journal this past month, Bollywood has been right by my side. Love stories, fight scenes old and new have accompanied me in the evenings. Although it’s all in Hindi, I have enjoyed watching the years of film unfold in front of me.

Today I was a real member of society and went to the movies. My country host raved about the new movie just released last month – Jodhaa Akbar. It’s the true story set in the 16th century about a Muslim ruler who married a Hindu girl to build unity between to areas in India. Apparently this story is still controversial with some groups. I showed-up to the cinema and got some chuckles from the ticket counter when they learned that I did not speak Hindi…. I had to agree it seemed silly. Unlike US theaters, seats are reserved, you actually are assigned a row and seat just as if you were going to a play (I love this). But the food is the same, popcorn, hotdogs (chicken) and Coke. There is a Baskin & Robbins stall and one for steamed corn – I could not resist. The corn cereals are full size, not cut as short as we get in the states. You pick from the flavors to add, Masala, Chinese, Mexican or pepper. I went with the Masala but skipped the chili pepper – what a great snack food for the movies.

Speaking of the movie, oh man, what a movie. Think epic – like Gone With The Wind. They spared no expense, the sets and costumes were extravagant, showcasing the astonishing fabrics of India. The two leading actors are gorgeous… and the leading man has spent serious time at the gym –six packs have arrived in India. Match it with amazing cinematography and acting and well, after 3.5 hours (including intermission)… it leaves you dazzled.

Great care went into the research for this film, historians and universities were given special recognition at the beginning of the film. The story is one of tolerance and peace – which is hard to believe with the amount of sword fighting involved. But from what I could take away – the union of the two individuals was also the start towards unification between the two religious groups. The story is but one of many adaptations to a legend that has changed with time. I know one thing; this is Bollywood at its best, even if you don’t know Hindi, it’s impossible not to be carried away by this film.

Polio Day

March 30th was National Polio Day in India. Unicef, the Rotary International and the Indian Government have teamed-up to eradicate this disease. It’s a united effort, with public and private health care workers joined together to protect the children. It was also a great day to gain further understanding of their national immunization program.

The central government has identified 5 mandatory immunizations that children must receive. They are provided for free at government clinics, but if you go to a private clinic you must pay a small fee. The Indian Academy of Pediatrics has a Committee on Immunization (IAPCOI) which creates the list of recommended childhood vaccines. Unlike the US, TB and Typhoid are on the list. Combination vaccines are available; the cost is significantly more so it’s up to the parent to decide. A list of all recommend vaccines and their prices are provided to parents, along with the timing of the vaccines and alternatives such as injected polio.

There was a news clipping in the pediatricians office: it focused on a recent case of polio in Delhi that was caused by the P1 strain – considered to be the most dangerous. It occurred in a slum, populated by villagers who came to Delhi for work. In 2007 there were two cases of P3 polio, in 2006 seven cases caused by P1. Many physicians are recommending their patients give injectable polio to their children, in addition to the oral. IAPCOI and government officials believe that switching to IPV from oral polio could jeopardize their entire polio program. So doctors recommend both if the parents can afford it.

Although India’s Polio program is ten years old, there were 676 cases in 2006 and 864 in 2007. On polio day, government schools and hospitals administer the vaccine and marked the child’s finger to show they were immunized. The following week, government employees go door-to-door to see if all the eligible children were immunized. They only record the number of doses given, not which children have been immunized. Keeping such detailed information is harder than it appears. Medical records in private offices are the responsibility of the parent, not the physician. If the child received services at a government center, a record will be kept. But migrant workers keep moving, making it hard to keep accurate and complete records on patients.

The goal is the same all over the world, protecting children by preventing disease. Many western countries have access to vaccines and government funding or health insurance helps cover the cost. With most of healthcare in India still out of pocket, most families must absorb the cost. But they do, they know these diseases are still in their community and could claim their child’s life. Westerners have forgotten what these diseases look like, but it’s just a plane ride away. SARS should have been a reminder that with the age of travel, disease can move faster than ever before. Every day I’m grateful for the health I have enjoyed because of the vaccines that have protected me.

Moti and friends

I really do believe camels smile; I have now seen enough of them to be sure of it (one day in Jaipur and I’ve crowned myself an expert). I had the chance to meet Moti on the way out of the city. Moti is a 52 year old camel who has the pleasure of dealing with tourists. A gentle and curious creature, Moti feels like a wool rug and smells a lot better than a horse. His countenance (assuming he is a boy, did not check) is peaceful and is happy to show you a few teeth.

Moti’s buddies are all over Jaipur, and on the highway leading into the city. Camels are workers, pulling everything from wood to bricks. They are dressed-up with necklaces, special paintings, and are amazingly calm as they walk between trucks, tractors and automobiles. It appears that they need little coercion to keep moving forward at a clip faster then oxen or water buffalo. It’s hard not to be totally enamored by these beautiful animals. Yes you can go for camel rides, but it’s going to have to wait – for now I’m just happy to have had a few minutes with Moti.

FXB Jaipur

FXB is a NGO operating in all states of India. I briefly met with them during our visit to Jaipur. As with other NGOs trying to impact public health, they have a wide variety of prevention programs aimed at education and behavioral change.

For HIV, they have 3 main projects: barbershop education, railway station outreach and nutrition for HIV positive women. The barbershop program is very creative. It started in 2005, and to date they have enlisted 350 barbers in the program… not an easy task. At first they were met with great resistance, finally one-by-one, they built up a group. The barbers are educated on HIV and how to prevent it. The goal is to get clients into FXB for counseling and testing. The NGO took the standard apron barbers wear and put a reversed image of their message on it – which you can read when viewing it in a mirror – perfect for someone getting a hair cut. To date, 48 men have come to FXB for more counseling, but most turn to their barber for more information. Condoms are available for free at barber shops – 80,000 have been distributed to date.

The railway station has also been a successful venue for outreach since many individuals commute between cities. The program started in July 2007; already 600 travelers have received education from their booth. FXB also has banners at fuel stations along the major highways leading into and out of Jaipur. Free condoms are also available – to date 125,000 have been distributed at these fuel stations alone.

But women who are already positive and widowed are also cared for by FXB. Nutrition is their key concern, food supplies are provided to these women once a month. They all come to FXB on the same day, for support, counseling, education and their monthly ration of food. This is what FXB and other NGOs are trying to prevent – men bringing HIV home to their wives, only to die leaving their families infected and destitute. It’s not glamorous work, but it’s so critical in the on-going efforts to stop HIV from destroying more lives.

Institute of Health Management Research

Located close to the Jaipur airport, in the newer part of Jaipur, you will find the Institute of Health Management Research. The campus is large, housing full time students along with facilities for internationally renowned seminars. Our trip to Jaipur was solely designed to visit the Institute and visit with the Dean, Dr. Goyal.

This private institution has been operating since the 1980’s and has witnessed not only the growth of Jaipur, but the Indian health system as well. Their focus is on improving the management side of health care delivery. Partners include the Government of India, the World Bank, WHO and UN organizations. Part think tank, part consultancy, this organization helps provide support for government programs that require a fresh business approach.

One government program is the National Rural Health Plan. The national plan encourages working with NGOs and creating Private/Public partnerships in the rural areas. 85% of the budget for the national program is given to the state level for manpower and other funding needs. The Institute helps by holding conferences to assist training partners: for instance they conduct seminars on capacity building for NGOs. The Institute will also be part of the dialogue concerning private/public partnerships that both the government and the World Bank are supporting.

Meeting Dr Goyal was inspiring in itself; he is a dynamic leader who will continue to move the Institute forward. In this time of transition, the Institute will be an important voice towards best management practices in the new Indian healthcare system.

Jaipur, the pink city

Jaipur, the capital city of Rajasthan, is divided into the old and new section. It’s in the old section that past centuries come to life. As you drive south from Delhi, the first thing you see is the fort in the distance. The wall seems to go on forever, and the fort looks down upon you with all the glory its original owner intended it to have. Elephants begin to appear as you navigate the narrow streets that lead into the old city.

The architecture of Rajasthan is influenced by the Muslims who ruled this land. They now share it with others, but evening prayers still bring the central street to a halt as men spill out of the mosque onto the pavement. Traffic resumes once prayers are over, it’s an accepted daily event that no one has changed and gives this city the texture you have to love. Although they call this the pink city, I have to admit, it’s more a shade of terracotta… but then again, I’m color blind. Whatever the color is, it’s wonderful and is the official color of old city.

Craftsmen line the streets with traditional colors and textures of the region. Rajasthan may be a dessert, but the colors women wear are bright, small mirrors are sown onto the fabric, making the clothing dance in the sunlight. Blue pottery (a name not it’s color), hand carved elephants and camels are just a few of the various crafts that line the street in the main market. It's a hub of energy that requires great skill and steady nerves when crossing the intersection. Tourists and locals fill the market seeking bargains as vendors call out for your business. I just follow my hosts as they lead me to a stall they frequent on every visit. The owners begin the process of showing their vast array of goods. As you sit and watch the show, chai is served…. oh how I love this custom.

It’s impossible to not be impressed by their selling skills and business savvy. These men speak several languages, enough of each for business transactions with potential customers from all over the world. Like so much of this country, one is both fascinated and enchanted by this city where the past centuries mixed with new technology, greet you against the vast Indian sky.

The $500 Stiletto

The newspaper ad that said “The $500 stiletto and other must haves: the latest for the high maintenance girl” caught my attention. Who is buying $500 shoes, not why (that's an entirely different question), but who in this new India is able to spend such amounts? Shashi Tharoor's book gives the first glimpse of this new economy. In his book The Elephant, the Tiger & the Cellphone, he describes the changes he has witnessed over the past 6 years.

The data he uses is from the National Council of Applied Economic Research (NCAER). The survey was between 1986 and 1994. They separate India into five economic classes: the very rich (6 million people), the consuming class (150M), the climbers or lower middle class (275M), the aspirants who in America would be classified as the poor (275M) and finally the destitute (210M). These figures are old, but it gives you the framework to build upon.

From the 2005 NCAER report, the following data show the number of households in each class. This is the % increase from 1995 to 2005:
Destitute + 1%
Aspirants + 84%
Climbers + 240%
Consumers + 393%
Very rich + 546%

In the 10 year period, the number of households increased by 23.5% while more families moved up into the higher economic levels. It’s an amazing transformation that helps explain the ads for luxury items and why American Express has a yellow Lamborghini in the middle of Delhi’s largest mall. The economy is booming and with it the desire for everything modern. The projections are as robust, showing continuous economic growth by 2009-10, again % change from 2005 to 2009:
Destitute - 14% (decrease)
Aspirants + 41%
Low Middle + 69%
Consuming + 92%
Very rich + 120%

So India can afford $500 stilettos among other things. But they will face important challenges – the strain on their natural resources, increasing wages that will make them less competitive for outsourcing and the need to bring the rural areas into the 21st century.

Shashi Tharoor begins his book with a story about an old elephant, slow in thought and action, that one day is transformed into a tiger. It's a perfect metaphor for India as it transforms into a powerful new economy. His story ends with the other animals believing that the elephant would always be old at heart, while others said it couldn’t last. I believe that once the transformation starts, the new generation will ensure it never stops.

2005 NCAER report: http://www.ncaer.org/downloads/PPT/TheGreatIndianMarket.pdf

Government Programs

Job posting: person responsible for scientific communication to 1.13 billion people with multiple languages and extreme cultural variation. Interested? We had the rare opportunity to meet the person who has this job - the head of the Science Communication Division, Department of Science & Technology. To make things more challenging, 70% of the population is located outside of the urban setting, with varying levels of education. In smaller villages, where even transportation is limited, they must find ways of accessing as many citizens as possible.

We learned of 2 creative projects to address this. Public radio stations are in all areas and cover 200 sq km. A pilot project was created to create educational programs for these stations. Students from universities conducted research to determine the health practices and beliefs of 1000 villagers in the radius of one radio station. They took the information and worked with the local community to create a 15 min educational program. Radio’s were provided to households (about $2/ea) and programmed for the local station. The educational program was aired during two different time periods per day. From this one test program, they were able to witness a 70% change in the health behaviors they measured. The program is now being expanded to a larger area.

The second program takes advantage of the vast railway network. The “Science Express” train will visit 57 locations for 3 days each, educating the local community. The goal is to change thinking at the fundamental level, to create new insights that can lead to new schools of thought. Using the latest technology, the program is in both English and Hindi (both written and audio) that introduces not only new concepts but the Indian centers of research in that field.

The department is vast in scope, looking at various issues that face the community. They even consider such challenges as how to eliminate stereotyping associated with HIV infection. It’s a think tank in many ways, testing new ideas and then moving forward to duplicate programs around the country with State leadership. Like public health leaders world over, their job requires creative ideas and simplistic approaches for maximum impact. It’s a job that requires an enormous amount of patience, persistence and the belief that their efforts can break through so many obstacles to improve the public's health.

LRS Institute of TB and Respiratory Diseases

1/3 of the world's population is infected with tuberculosis - 2 million die from the disease every year. In India, one person gets TB every 4 minutes, and one dies every minute. It’s a serious disease that has begun to develop resistant strains in many parts of the world. When combined with HIV, TB is extremely difficult to treat.

The LRS Institute is the largest hospital focused on the disease in Delhi. With 500 beds, the hospital can handle a large volume of patients, especially those who need constant care. We arrived early in the morning as their out patient clinic was already a sea of activity. Patients arrive with their mouths and noses covered with scarves, their family members do the same to protect themselves from possible exposure. Adults and children of all backgrounds are there, businessmen, police officers and street vendors all come to this government institute. Educational materials are in English, Hindi and for those who can’t read, pictures are used to educate.

In 2004, the Government had established the National ART program for 1st line HIV therapy. Centers were established all over India to provide the drugs under the care of trained physicians. LSR became one of these centers in 2005, treating patients referred to them by NGO’s like SAHARA. The location is strategic, the office is located in the TB ward where physicians can directly refer any TB patient they suspect may be HIV positive. India has an ambitious goal to get every TB patient tested for HIV. 2005 data showed .3% co-infection rate - at the hospital every 3rd patient is co-infected.

NACO has outlined the policy of drug treatment for TB and HIV, that can be adapted by the physician as needed. It’s a difficult process that requires close supervision of the patient where changes in their immune system can mean life and death. The Indian government has given the authority to NACO which creates the national action plan, monitors and evaluates the progress of both treatment and disease surveillance. 70% of the HIV budget goes to prevention programs, ART is not sustainable and their goal is to prevent cases.

The HIV director at the hospital introduced us to her favorite patient, a young widow with 2 children. The affection they had for each other was powerful; two women, one uneducated and the other a trained medical specialist, joined in a bond of trust and hope. They had known each other when the women’s husband was being treated for HIV. She contracted HIV and now alone, cares for their children. The physician has watched the transformation, from the white sari of a widow to a women moving forward to a new future. There is no medicine, no medical text book or government plan that can make this happen. It’s the humanity of the physician and her staff that brings such miracles to life.

Venu Eye Institute and Educational Center

75 to 80% of the patients Venu helps are subsidized, this includes those in the villages and in Delhi. Patient needs are very similar, but educational levels vary from educated to illiterate. Education for those who have low vision or who are blind normally begins at the local level with mobility clinics that teach patients how to use a cane and navigate the roads. Many schools for the blind can help children through the basic educational levels using books that are written in brail. But Venu has taken it to the next level.

We had the chance to meet their current class, 13 students who are part of Venu’s educational program. Although the hospital has been in operation for 25 years, the school has only been open since 2005. The current group of students is their 3rd class, it’s a one year program focused on job skills. Students commute from their home (which can be quite far and require many bus transfers) every day to attend school.

Computer software acts as their eyes; a US based NGO has worked with Microsoft to create software that reads the computer screen for them. It only works with English, not Hindi, their main language. So they have to learn to not only understand the spoken language, they must learn to spell it as well. It’s truly amazing, this group did not speak English when they arrived, now they can carry on a conversation with us. Since the school is affiliated with a university, they are considered college students. I asked them what their career plans were and the responses were inspiring: medical transcriptionist, software designer, call center worker, radio DJ and even a singer. They have the determination and intellect to make their dreams happen - I have no doubt of it.

Venu Eye Institute & Research Center

The Venu Eye Institute covers a 77 sq mile radius around Delhi. The main campus is within the city limits, and satellite hospitals provide services to villages up to 2.5 hours away. With 35 ophthalmologists on staff, the hospital can handle up to 75 surgeries a day while still conducting screening and routine care in their out patient department (OPD).

The most frequent eye problem they treat is cataracts: 72 out of every 100 patients suffer from the condition. Not only UV exposure, but poor nutrition and the relentless dust of the city and surrounding area irritate the eyes on a daily basis. I personally have needed to irrigate my eyes every day to eliminate the dust and reduce the irritation from the particulates in the air. Satellite hospitals also conduct cataract surgeries; all other intervention is conducted at the Delhi campus.

The grounds and hospital are a celebration of sight. Large colorful flowers greet you in a well maintained garden, while the corridors are decorated with a wide variety of paintings. Even the patient ward has paintings to enjoy, including one the ceiling that patients can see as they lay in their beds.

It’s a well organized NGO which has both a ward for private patients who can afford to pay for treatment, and an OPD that treats patients for free or reduced costs. The money raised from private paying patients is used to subsidize the services for the poor. Multilateral NGO’s and international corporations are the main source of funding. Domestic philanthropy also supports their efforts. A list posted outside the private clinic contains children who need sponsorship for their eye surgery. Their name, type of surgery and the amount needed is there for everyone to see. Half of the children on the list had already received sponsorship the day we were there. Patients grateful for the care they have received, often provide donations of whatever they can afford.

Eye donation is also part of their education, they are one of 6 eye banks in Delhi who collect and process donated eyes for corneal transplantation. They provide educational literature and consent forms so that when a loved one dies, their eyes can help others. Corneas, once extracted and processed, can last up to 72 hours before transplantation. For patients in the villages, this provides ample time to travel to Delhi. The clinic has stories of both the family who donated and the patient who received the gift. It’s a moving testament to the generosity of those suffering great loss, and the patient who has been hoping to one day see again.

HOLI

Holi, also known as the festival of colors, is the ultimate street party. It’s the celebration of spring that has religious origins and is a holiday focused on community and family.

Holi is a day when colored powder is thrown, sprayed, and rubbed onto each other. The party starts early; children are the first ones on the street with their water guns. Venders are out as well, selling all the supplies one needs. It’s a holiday where businesses are closed and families and communities spend the morning “playing holi”.

We were invited by our country coordinators to join their extended family on a rooftop just outside of Delhi. Special sweets were prepared just for the day, and clothes you never want to wear again are chosen for the occasion. It goes something like this: color, water fight, more color, more water fight, dancing, food, more color, another water fight…. you get the picture. Everyone’s a kid again, and by noon the energy has begun to fade. We take turns attempting to clean-up, eat lunch and then lounging the afternoon away. Evenings are spent with the family elders and sleep comes early to the party crowd.

The next few days you still enjoy the aftermath by witnessing the color slowly fading from your skin and hair. 2 days later my toes are still purple, my fingers bright pink, and my scalp shades of blue, green and red. The other student, who is blond, has a head of hair that resembles a faint fluorescent rainbow. It’s our first Holi celebration and will be remembered as one of the highlights of our trip. It was the perfect experience, sharing the day with our new friends and their family, watching a Bollywood movie with the kids in the afternoon, and sharing our stories together in days following. My skin will have faded to a normal color by the time I get home, but I guarantee my memories won’t.

YouTube film of Holi: http://www.youtube.com/watch?v=DPDR0ZMwSag&feature=related

Ranthambhore National Park

It’s wonderful to be the animal in the cage for a change, locked into a moving vehicle and told to be quiet for the 2 hour journey. We are the animals in the zoo; the difference is we chose to be there. It’s a cool morning, cooler still in the backseat of a 20 passenger jeep. The time is 6:45am and we are the last to be picked-up. We are greeted by tourists half asleep, but awake enough to wonder what type of hotel we are staying at. They have no idea it is a hospital, and our attempt to fit in with the locals make us look like 2 hippies from the 70’s. I couldn’t help but laugh.

The park is kept rugged; the dirt road resembles the bottom of a dried creek bed in many areas. Since we are in the very back, it’s like being in the ejector seat – every bump launches us up and into each other. I soon learned why the seats in front of us have rails to hang onto… it keeps us from landing in each others lap. Our guide stands in the front of the vehicle, scanning for a glimpse of the endangered Indian tiger. Occasionally we slow down and stop, providing a chance to take pictures, and to rest our wakened muscles.

The forest is dry, spring has not fully arrived and most trees are still barren. At times you feel like you are in the dessert, other times in the dry mountains of the Sierra foothills. Banyan trees of the southern states reach new roots to the earth, but there is no swamp to drink from. It’s beautiful and wild. Monkeys chase from tree to tree, spotted dear are perfectly camouflaged in the environment. And peacocks provide a radiant contract of color against the dry brown earth. Where water has been stored by a small retaining wall, crocodiles sunbath and ignore the crazy tourists snapping photos with glee.

To our dismay, the tiger decides to sleep. We know it’s there, footprints in the mud and dust is evident. But they are the smart ones, while we try to beat the heat they enjoy the mild temperatures in solitude. We later learn the cats start moving in the afternoon; around 4 pm your chances to see one of these amazing creatures improves. Your chance of getting heat stroke also increases, but only the brave are rewarded (I was obviously not brave). So we missed our chance to see the great tigers of India, but we did see the raw beauty of this wonderful land. Perhaps we will return again, to witness a tiger population large enough to help repopulate other areas of India.

Women and children

In rural areas all over India, literary rates have been low and birth rates high. Maternal mortality rates in this area were 700 deaths per 100,000 births per year, compared to 8-12/100,000 in western countries. Villagers would stay at home and give birth, with no medical staff available if needed. To address this, the government began a program to pay women to give birth in the government hospital. The 1400 rupees help pay for transportation and other costs. The Sevika Hospital and Out Patient Department are not allowed to pay the fee, so instead they focus on maternal and child health.

We take for granted the ability to read and write, to have information available through multiple sources. Imagine that the oral history of your village or tribe is all you know. Elders are your source of health care for you and your children. Local untrained healers are your other option, but you have no way of knowing that they do more harm than good. Imagine western medicine is available from a hospital and clinic, unfamiliar places that instruct you to do things that differ from what your elders tell you. If you are to visit one of these sites, you will first walk for miles and then have to hail a wagon passing by to take you the rest of the way. If you are lucky, a family member will take you on the back of their bike or motorcycle. Your husband, if he accompanies you, will loose an entire day of work. If a child is sick, the elders and your husband will be more willing to pay for medical treatment for the boy, but not for the girl.

It’s a world we can not comprehend, and a reality that physicians face every day. Prenatal counseling is focused on proper nutrition – traditions prevent the consumption of yogurt and butter milk, in its place clarified butter is consumed. For the women already malnourished, it only increases the problem. Physicians and nurses begin the long and continual education of birth control and sterilization. As the population of India continues to expand over 1.13 billion, family size needs to be reduced. Boys are preferred, and girls are often seen as a family burden. The NGO will not use technology to identify the sex of the fetus, and spends a great deal of time reinforcing the importance of the girl child. But since the boys inherit the family property and also perform last burial rights, the arguments for boys outnumber girls in their minds. Sterilization is therefore difficult for many to accept. If you only have girls or if your only son dies, this option offers no alternative.

But the tide is turning, one family at a time. We visited a village where one woman proudly showed us her 2 educated daughters, strong in both mind and body. They will marry well, or even leave the area for good paying jobs. The staff also provides an example; many have only one child - a girl, which they share with pride.
In urban areas, girls go on to college and excel in technology and medicine (traditional male roles). They know the value of an education and will make sure their daughters receive the best schooling possible. It’s just a matter of time for the same expectations to reach the rural areas. The young girls in school today will be the generation that opens the door to a future their mothers only dreamed of.

A holistic approach to being green…

Dr Rathore has looked for creative ways to save the tiger’s environment, knowing that you must provide alternatives that are attractive to the local community. As previously mentioned, the forest where the tigers live was being harvested for firewood and building materials. It was also used for grazing farm animals that would strip the leaves off of low branches and young trees. The tiger’s habitat was being destroyed, forcing them to leave the forest and seek food on the farmers land.

The Prakratik Society created a 3 prong approach; the first addressed the use of wood for cooking. Let’s talk cow dung for a while. With cows roaming free in India, there is plenty of it (yes you need to watch your step). The creative way to get rid of it is to use it as a fuel. The waste from cows, oxen and water buffalo (pictured above) is collected and formed, by hand, into patties (about the size of a salad plate). It’s left in the sun to dry, and then leaned on its side against another patty for further drying. They are stored in huts, also made from dung, and decorated with a design which is an art form unto itself. When they are burned, the smell is not bad, it’s almost pleasant (it fragranced our bathroom every morning as our neighbors prepared their breakfast).

Obviously the flavor wood imparts into the food is unique, and difficult to completely give-up. But to limit its use is good not only for the tigers, but the family. Since burning wood or dung creates poor indoor air quality, they took it one step further…the use of bio-gas. A bio-gas digester uses dung and water to create methane gas, which is piped directly to the stove. 2 cows and 2 buckets of water can create enough gas to prepare 2 meals a day for a family of 6. Once the methane is no longer generated, the bio-gas digester is emptied and the contents are used as fertilizer. They cost 18,000 rupees to build, the farmer pays 3,000 and the rest is subsidized by Climate Care, a UK based NGO.

This was only a start to saving the forest. The agro-forest program encourages the planting of trees on the farmers property, which can be used as food for the animals and building materials. The species selected will thrive in this dry climate, so long as they survive the 1st three years. Farmers pay 1 rupee/tree, but receive financial incentives to keep the trees alive during these critical years. To help reduce the burden of feeding large herds, they started a dairy development program to improve milk production in cows. This reduces the need for larger herds since the same amount of milk is generated from fewer cows. Fewer cows mean less feed, less money needed for a large herds and a better overall impact to the environment.

So far the progress has been positive, 1,213 families have benefited from the dairy program; 491 bio-gas digesters have been build in 76 villages and 32% of the trees planted have survived: a total of 155,980 trees. It may seem simple at first, but the effort to transform century old traditions is no easy task. It’s also a great reminder that part of any transformation is finding practical answers that take a holistic approach. The last and most important ingredient is the willingness to change: an example that these farmers have set the rest of us to follow.

Bio-gas digester and kitchen photos: Martin Wright

Ranthambhore Sevika Hospital

In 1994 Dr Rathore founded the Prakratik Society, an NGO that is the umbrella organization for the multitude of projects under his direction. Located in Sherpur Village, the Ranthambhore Sevika Hospital provides services to local villages. In the first 10 years of operation, the hospital has treated over 108,600 patients. As the trust in the hospital increases, so do the number of patients. They experienced a 34.3% increase in patients just this past year.

To our amazement, we learned that Sevika hospital has better equipment than the government hospital 10 miles away. Donations have led to state of the art medical equipment that helps attract young physicians to this rural area. Turnover is high do to the location and a need for young practitioners to advance their career. But those who do come are impressed with the services and enjoy escaping the fast pace of larger cities.

The rate of cataracts in this area is very high and strikes at a younger age. Lack of protection from UV light and long term use of steroids has led to this problem. We witnessed a 40 year old woman, blind from grade 4 cataracts in both eyes, being escorted through the eye clinic by her son. She will receive a new lens in one eye, followed by surgery on the other eye one month later. Technicians conduct screening and take measurements required for the cataract surgery, the ophthalmologists then take over. During eye clinics, a bus load of villagers is transported to the hospital; surgeries are performed that day. Patients stay over night, the incisions will heal within 48 hours and the gift of vision will slowly unfold.

The hospital has enlisted volunteers from local villages to identify women and men who need medical help but are too frightened to come to the hospital alone. They act as the bridge between the community and the medical staff, encouraging, educating and often accompanying the patients to receive services. Unfortunately, the hospital is used as a last option, after the local untrained healers. We witnessed a 10 year old undergoing surgery for a sinus polyp that had grown large enough to obstruct his breathing. Others come to the hospital with ruptured ear drums that could have been prevented with earlier intervention. The resulting hearing loss is anywhere between 30-50% and hearing aids are not economically feasible.

It’s not perfect, prevention messages are limited in this context, but the dedicated staff does not let it stop them. Days for the physicians are long, with a combination of clinic and OR time that can begin at 8am and end at 10pm. And yet they continue, on a NGO salary, knowing that they are using their skills to heal and educate a population just beyond their front door.