CASI Student Blog
Over the past week or so we have been having a surprising amount of fun in ol’ Yamuna Nagar. We had settled into an after-work routine of doing something active (running around the college track or kicking a soccer ball around the field), finding a new place to eat “downtown,” and then watching a movie or writing our blogs in the evenings. But, this healthy and productive routine did not last long because, it seems, we have developed busy social lives.
One reason our social lives have bloomed is because LEAP has had many occasions to celebrate. LEAP’s beloved employees celebrated many “LEAP anniversaries,” birthdays and family milestones in the month of June. After celebrating several of these events with food, cake and dancing in the office, we decided to celebrate Saloni’s last day at LEAP by going to a Bollywood movie in the theatre after work. The movie Dil Dhadakne Do, is a hilarious, light comedy that traces the melodramatic lives of a wealthy businessman and his grown children. Narrated by the family dog, Dil Dhadakne Do was surprisingly easy to understand even though it is three hours long and it did not have English subtitles. The storyline was predictable and characters’ reactions were exaggerated, which made the humour understandable (most of the time). Bonus: every character in Dil Dhadakne Do is extremely easy to look at.
But, enough about our new obsession with Ranveer Singh. This week we were also invited to a co-workers house for dinner. Niharika is one of LEAP’s dedicated trainers. Her kindness and willingness to help us find the things we need around town is overwhelming. Her family is extremely generous as well. They fed us a five-course meal (including two special desserts: one from her mum and one from her dad). It was by far the best food in town. Her father also gave us a thorough tour of the city and took us to the temple where we each had a chance to ring the bell.
Aside from the company of co-workers, we have started to get to know the people we see daily as well. For instance, the man who sells samosas down the road recognizes us and reluctantly smiles occasionally; auntie in the canteen cooks our favorite dishes for lunch; and Isha at Beauty Palace has found Bill all of the hair and cosmetic products he needs.
(Shopping with Isha at Beauty Palace)
Although we have been busy developing thriving social lives we have also managed to maintain focus at work. This month Leora and I are working on some very exciting projects. We are helping to develop a fixed induction training program for new employees and we are planning workshops for a two-day training program for LEAP’s current trainers, which will be conducted next week. The program will feature workshops on experiential learning, classroom presence, discussion leading, incorporating technology in the classroom and effective feedback, among other topics.
Finally (for now), we are doing further research the skills development ecology in India. It is so fascinating to note the rate at which the field is developing and diversifying. Last semester I read a significant amount of research and wrote a few papers concerning the viability of skills development as a solution for India’s growing unemployed youth population. Since writing those papers potentially significant steps have been made by the new Ministry of Skills Development and Entrepreneurship including a tentative draft of their long anticipated National Policy for Skill Development and Entrepreneurship 2015. Staying updated on developments in Skills Development in India is complicated and exhausting because there are many different types of public and private stakeholders and programs already in place. Learning about various approaches to Skills Development is increasing my understanding of the urgency for more research in this field.
PS. Happy Canada Day from your two favourite Canadians in Yamuna Nagar!!!
I said Poka-yoke, not Pokemon: Where Checklist Manifestos and Japanese Manufacturing Meet Cataract Surgery
Have you ever taken a test and then gotten back the graded paper and discovered some incredibly careless mistake that you never thought you could possibly have made? It is amazing that even when we double check our answers, we still sometimes make those stupid, little errors: we add two key numbers instead of multiplying or we forget a word that renders our thesis statement incoherent to the outside world. My test-taking career has certainly been riddled by these kinds of errors, and what I have come to accept is that they are beyond prevention, unavoidable, a price of being a member of the species homo sapiens.
Medicine is not immune to human error. In fact, the procedures and practice of medicine are so complicated that the likelihood of making an error may be much higher than a stupid mistake on a three-page written exam. And, worse still, the price that is paid for those errors is exponentially higher. A doctor forgetting to wash his hands can be the difference between sending an inpatient home safely the day after a procedure and an extended stay in the inpatient ward with a potentially life-threatening hospital-acquired infection. It’s hard to really appreciate the chance of a medical error or the costs that medical errors exact without some context. 403 people across the world died in plane crashes in 2012, just over 30,000 people died in the US in car accidents in the same year, and it is estimated that over 200,000 in the US died from preventable medical errors in 2012 (Journal of Patient Safety: http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx). Why do so many medical errors occur? The explanation probably has to do with systemic problems and challenges in medical care; it’s not about a few bad doctors/nurses. Medical care is really hard to do properly, and there are just failings in the system that put patients at risk.
At Aravind Eye Care Systems, there have been extensive measures taken to refine the system to prevent medical errors. As a result, the rates of complications in procedures and hospital-acquired infections are extremely low and well below national and international averages; Aravind surgical complication rates are less than half those seen in the UK.
A figure from the consulting giant, Mckinsey & Company:
However, the problem that Aravind runs into is a sort of law of large numbers. There are huge patient volumes at Aravind, and the way that patient flow is designed, patients are interacting with many, many people in a single visit. In one out-patient visit, there may be as many as 15 patient interactions with Aravind staff, and there are even more during an inpatient admission. This means that in a typical, single day, when Aravind is seeing well over 2000 patients, there can be as many as 50,000 interactions with patients. So even if the chance of an error is 0.0001% per interaction, with this many patient interactions, there are still bound to be a non-trivial number of medical errors. And this is something that the Chairman of the Hospital, Dr. R.D. Ravindran (aka Dr. RDR), is dogmatic about. To him, having a low rate of errors is not enough; one medical error that harms a patient is too many. A 0% rate of medical errors is the only acceptable value.
One of my projects for the summer is to work on the issue of patient safety to try to prevent medical errors. In part, this involves putting together a patient safety manual for staff along with posters and presentations that include comprehensive protocols for all procedures in the hospital. At another level, though, I am trying to find little ideas for small process changes that can be done to make procedures a little safer. To that end, I have been reading a lot about checklists.
The checklist is not a novel concept, and yet a checklist was probably one of the most significant, life-saving medical innovations in the last fifteen years. In the early 2000’s, Peter Pronovost, an ICU doctor at Johns Hopkins, started to find that steps in the official, standard procedural protocols were often being skipped (inadvertently) by nurses and doctors. So he pushed people in his ICU to use a short checklist when inserting central venous catheters. The result he found was that just the simple checklist could greatly reduce the number of hospital-acquired infections. In a large study of Michigan hospitals that was published in 2003 in the New England Journal of Medicine, it was discovered that installation of Pronovost’s checklist approach reduced infection rates in ICUs by 66% and saved as many as 1500 lives (http://www.nejm.org/doi/full/10.1056/NEJMoa061115). The success of the initiative partially inspired the famous public health researcher and New Yorker staff-writer, Atul Gawande, to write a book called the Checklist Manifesto: How to Get Things Right, in which he promoted the use of checklists in surgery and beyond (here’s a link to an article Gawande wrote in 2007 about the Pronovost checklist: http://www.newyorker.com/magazine/2007/12/10/the-checklist).
Aravind has a very simple checklist for eye procedures; it involves the surgeon and operating theatre team signing off on the fact that they have confirmed the patient identity, the site of surgery, the procedure to be done, and the type of intraocular lens to be inserted in the case of a cataract procedure. The checklist seems to work quite well, but I am obsessed (probably to the annoyance of Olivia and Busra, at whom I throw my wacky ideas all the time) with trying to see if there are some ways to supercharge it because even in spite of the checklist, mistakes are still being made. One idea is to have more people (in particular, those who interact with the patient prior to the operation theatre) fill out a checklist. Even though, these individuals are supposed to already be doing checks, filling out a checklist may reduce the likelihood of a nurse or a physician forgetting to ask about something or forgetting to check something. It would in essence be like running a check on the check that is already being done by the operating team, or in other words, like doing a triple- or quadruple-check of your answer on an exam.
Yesterday, though, I was sitting in the patient care office of the outpatient hospital, and I got to talking to an engineer, who worked at Coca Cola as a manager of operations, but who was in the process of resigning from Coke to start a robotics start-up targeted at the health care industry. He had come to Aravind to see how robotics technology could be used in the hospital. After telling him a little bit about the patient safety project and my ideas with beefing up the checklist, he suggested that I shouldn’t be looking for more checks. He said I should be thinking about a Japanese technique called “poka-yoke,” which in English means “mistake-proofing.” It is a strategy that Coke and other manufacturers use on the manufacturing line to prevent human error from even coming into the equation, and it involves using automation to eliminate unnecessary human discretion or make it incredibly obvious when an error is being made. The analogy here would be that if you were worried about people making small, stupid mistakes in an answer to a test question, don’t just force them to check the answer, turn the question from free response into multiple choice. Eliminate the possibility of little mistakes.
In the few minutes of talking to him alone, I think that I came up with one idea where mistake-proofing can be used in the hospital. One of the medical errors that Aravind is desperately trying to completely eliminate involves operating or doing something at the wrong site (i.e. the wrong eye). There are a couple of checks and tricks that are used to prevent a mistake like this. There’s the checklist, but there are also others: a patient identification wrist-band is placed on the hand corresponding to the eye of the operation, a bright sticker designating the target eye is placed on the patient’s case folder, and a small mark is made above the temple of the target eye to basically give the surgeon and anesthesiologist a bull’s-eye target (most surgeries here use local anesthesia, so the anesthesiologist anesthetizes the eye to be operated upon and is very much implicated in targeting the correct eye). Even in spite of these little checks, there are a number of cases each year where the wrong eye was anesthetized or even operated upon, and in more than half of these cases, everything, including the wristband, the sticker, and the marking, was done correctly. These so-called “acute” cases are very mysterious, but they can happen because a doctor didn’t realize which side of the bed he or she was standing on, or had already done so many in a day that he/she momentarily lost focus. I think that these acute cases can be totally eliminated with a little poka-yoke. What if at the time that the temple is marked in the inpatient ward, a patch is put over the eye not being operated upon. Then, not only is the target for the surgery marked on the correct eye, but the possibility of doing something inadvertently to the other eye has been literally blocked with a piece of cloth. Not only is the test question multiple choice, the wrong answer has already been scratched out.
Maybe mistake-proofing like this is so simple that it can’t solve larger cultural weaknesses in the Aravind system for patient safety. Maybe even beefing up the checklist isn’t particularly relevant to reducing medical errors. But maybe, just maybe, we can prevent a mistake.
Every day here presents new challenges and adventures. We’re generally greeted with at least one surprise or new experience each day.
This past week we headed out with our high school Propeller students for an Outbound Session – essentially a field trip. Because the program is very focused on orientating the students towards their careers, the trip consisted of an industrial site visit to the factory of a heavy engineering firm. To be honest I’m not sure how much the students got out of the visit, I think even the trainers were a bit disappointed, but we did get to see some very big machines (this one is so big that it is machine used to make machines that cut metal for cars):
And do some fun dress up: (we learned that safety is key in an industrial setting!)
After a jam-packed two weeks of work, we finally took some time off and headed back to Delhi!
The last time we were in Delhi, we spent six days there and did hardly any sightseeing. When we tried to sight-see, we almost collapsed in the heat.
This time around, we were determined to do things right. We managed to book the hostel that last summer’s interns had recommended, called The Moustache. It was a great place, with a friendly man named Raj at the front desk to greet us and this incredible sign on the kitchen door:
While hanging out in the hostel we made a new friend, named Lissa. Originally from Ohio, she did the Peace Corps in Benin, West Africa and is headed for a Master’s in Global Studies at Yale in the fall. (the people you meet in India often sound like they should be writing memoirs). Now we’re certainly no experts on India, but Lissa had just landed 8 hours before we met her, so it was exciting to take her with us around the city, spewing all of our ‘expert’ advice about everything ranging from food, to travel, to the proper way to haggle with an auto rickshaw driver.
We got up early (relatively speaking), and got out of the hostel by 9 a.m., hoping to beat the midday heat, and headed out (in an expertly bargained-down auto) to Old Delhi in the north of the city.
We got dropped off at Chandni Chowk, one of the oldest markets in Delhi, originally built in the 17th century! We may have thought Delhi was narrow, loud, and full of people before, but we had no idea what was in store for us. At first we walked along the wide, busy main street and then, unsure how to find the “market” itself, we dove into a crammed alleyway. We then found ourselves winding through endless narrow streets crammed with bicycle rickshaws, shoppers, and stores selling books, saris, and wide varieties of food:
After asking lots of directions, we magically didn’t get lost in the maze of alleys and made our way to Jama Masjid, the most famous mosque in Delhi and (according to Wikipedia) the largest mosque in India. Built in the 17th century, it has three giant domes made of red sandstone and white marble and a wide pavilion for worshippers. Clothed in some robes helpfully (read: forcefully) offered to us by the mosque’s gatekeepers, we ventured inside, doing our best to move across the red sandstone without burning the soles of our feet in the scorching sun. Despite the numerous tourists taking pictures, when we reached the front portion of the mosque, it felt peaceful A few men sat crouched over praying quietly, and a few others simply lay on their backs in the shade, enjoying a welcome respite from the heat.
After lots of walking and seeing, we made sure to finish the day’s adventures (at around 1 p.m. considering the heat) with some eating.
Chandni Chowk is known for having a lane called Parantha Wali Gali, where they sell an enormous variety of paranthas, basically fried dough stuffed with different fillings. Usually they’re just filled with potato or cauliflower, but these restaurants offer dozens of flavors, from mint to banana to radish to cashew. Suffice to say, they were delicious!
(cashew was my favorite)
No we’re back in Yamuna Nagar, gearing up for another jam packed week of work!
Although I was planning on posting tomorrow, I was thinking so much about our hike yesterday that we did on our day off, that I decided to post today. Yesterday, we hiked to the Old Chamunda Temple, about 17 km each way. There is the new Chamunda Temple that was built years ago, which is on the main road in Chamunda, but, as people we met told us, last year, a fire burned much of the temple. The statue of Chamunda Devi survived however, so it was consequently moved back up to the mountaintop temple.
The temple that we went to is very old, and is very high up, near the snowline, and only accessible by trail. We were so fortunate with all of the people who we met and got to talk to. We did most of our hike with a woman from Palampur and her daughter, who was in her early twenties. At first, I wrongly assumed that we would be going faster than them, but after going the wrong way on a very steep part a few times, it became clear to me, as Ravi had suggested, that we should all go together. I am so glad we did, as they were so incredibly nice, and the mother was so helpful, in terms of picking out shortcuts, and in many more ways.
It was great to talk to other people along the way, and so interesting to imagine what it must be like to live so high up in the mountains, and have to hike for hours to reach the town. There were some small shops where people could sit and rest along the way. At one of these, I asked how many hours were left. The man responded, "No, this isn’t about asking how many this, how many that. Don’t be looking toward the top of the mountain. You look down, where your feet are stepping, and all along the way, you just keep saying, Jai Mata Di, Jai Mata Di.:
He was so right, as it took us around 7 hours to reach the top. Every time we looked, there was a higher mountain to reach, and if someone told us we had some amount of kilometers left, we would ask an hour later and sometimes we would be told there were more kilometers left than last time! The hike was challenging, as most of my hikes have been up and down, rather than straight up for that long, and I am so thankful of Soumya (another awesome intern who lives at the center) and Ravi for coming, even though they weren’t as much into hiking as I am. We all still can’t believe we made it.
We were very lucky with the day we picked, not just because of the good weather, but because it was a special day. It was the first day that there was water at the top of the temple. Before, they used to bring up about 50 L each day by horse, and have to ration it out. However, at another of the small stores, one of the men told us that the locals themselves decided to built an 8 kilometer pipeline from a different mountain, where there is always snow and thus always water, to the temple. Thus, we got there not only to find plenty of water, but a celebration, and dham (a multi-course meal usually given at celebratory occasions).
It was amazing to see so many people of all ages making the trek, with ease. We met an old man who said he had heart problems, and children about 6 years old, running up and down from their father, who was higher up, to their mother, who hiked with us for a time. We also encountered an elderly religious man, who told us more about the temple, and talked about his love for India, and the concept of a family that can encompass a whole village or a whole nation. On the way down, we were passed by about a dozen young women, who were singing lively songs in Pahardi (the local language).
One evening, us four interns staying at the center decided to do some bonding, and took turns answering questions about ourselves. One was to describe a perfect day, which I described as a day where I woke up, and hiked the whole day, with friends. At the end, Soumya commented that it had been my perfect day. It is definitely the steepest hike I have done, and at every turn, the view was absolutely amazing. When we got to the top, we were in the middle of a cloud, so just seeing nothing but white on all sides was an amazing feeling of its own. I’d like to learn more about the history behind this temple, and am so thankful to have had this experience and to all the people I shared it with.
I slipped off my sandals and stepped inside of the room. As I walked towards the woven rug in front of me, I could feel the coolness of the tiled floor against the soles of my feet. The fan whirled overhead, blowing strands of thick chocolate-brown hair across my face. Sitting cross-legged on the rug were three women wearing brightly colored fabrics – gold, blue, and fuchsia hues were draped across their bodies. As I approached, their smiles filled the room. “Namaste,” the women said warmly, greeting Andrew, Sasha (an intern hailing from England) and me. “Namaste, Didi,” we chanted back. We moved towards the ground and propped ourselves against the white wall behind us. Unlike the women before us, we constantly shifted our bodies until we found comfort, which typically lasted only ten minutes before we changed positions once more. I turned to my right and pulled out my camera, placing it strategically atop my folded knee. Andrew and Sasha pulled out their notebooks and pens.
We traveled two hours down winding dirt roads to Barwaha the Friday before last to interview the three women who work for SPS as mitaans or “friends.” Mitaans are members of the community that serve as mediators between self-help groups (SHGs) and SPS. The duties of mitaans are numerous, as they serve as liaisons between local banks and SHGs, help SHG members with bank transactions and records, conduct calculations during meetings, promote SPS’s livelihood programs, and provide SHG members with valuable personal and financial advice. As part of our internship work, Andrew and I are collecting the stories of female and male mitaans throughout the region.
Speaking with the women was inspiring. One woman lived in an abusive household with her husband and in-laws, and fled a year before joining SPS to her parent’s home with her one-year-old son. During that year, she faced social pressure from her neighbors and distant relatives who called upon her to return to her husband. She also lived in isolation at her parent’s home. Over and over again, she told us that working for SPS set her “free.” She was not only able to move about outside her home, but the woman – who only had a fifth grade education – was financially liberated. With the money she received she was able to pay for her son to attend a private school, as well as provide financial support to her family.
Another woman that we spoke with, who had also been working for the organization for ten years, was able to fulfill her lifelong career aspirations through SPS. Prior to working at SPS, she worked as a teacher, as well as at an institute that served mothers and their children. Although she enjoyed her work, she thought that working for SPS would better enable her to improve her community. Since working at SPS, the women in her SHGs now have bank accounts and have even learned how to use checkbooks. These women have also gained the confidence to leave the home on their own and speak with government and bank officials about their concerns. Working for SPS has also helped her, as it gave her a family. While she was going through a divorce, her colleagues supported and cared for her.
The last woman that we spoke with also found a family through her work as a mitaan. She joined SPS nine years ago, because her father – a government official – wanted her to give back to her community. Prior to working for the organization, she worked for an adult literacy NGO in Indore and operated a small grocery store. Several years ago, her father passed away and the entire community came out to support her while she grieved. His passing was especially difficult for her, as he played a pivotal role in encouraging her to join SPS – he even helped her with accounting calculations late into the night while she was training. She had told us that she knows that when she passes, the community will be there for her family, too.
I was so moved by the stories of these women. They had been so open with us about their struggles and the ways in which SPS altered their lives. Additionally, it was great to see firsthand SPS’s “ripple effect.” Not only did SPS help these women become independent and pursue their dreams, but these female mitaans in turn are helping the SHG members become self-sufficient. After the interview, we hopped back into the car and drove home.
I gave one final look at Barwaha through the open window of the FWD, my hair and dupatta thrashing violently in the wind. Barwaha was immense and had many features of a city: auto-rickshaws pushing past buses, cars, and motorcycles; bustling shops selling gadgets, clothes, medicine, and a number of other items; hole-in-the-wall restaurants smelling of freshly fried samosas, rotis, and potatoes; and multi-story homes and businesses. After spending three weeks in villages and small towns, Barwaha – one of three towns SPS works at in the Khargone District – was an overwhelming site. We drove fifteen-minutes through the town – stopping to buy treats along the way – before we entered familiar territory: scattered villages, lively rivers, and the rural countryside.
An hour into our drive home, Ayush (one of our many drivers) turned off the main road into an otherwise ordinary village. The homes we drove past were painted with pastel blues, pinks, and oranges, topped with tin or straw roofs. Men were speaking with one another on the streets, while women returned home with metallic jugs of water either planted atop their heads or tucked underneath their armpits. Young children were playing with one another by rolling car tires, while older ones herded cattle and goats to their stables.
Suddenly, the car came to a halt. To our left sat one of the most beautiful Hindu temples I have seen since arriving in India. According to Ayush, it is one of the most sacred and oldest temples in the country revering Hanuman, the eleventh incarnation of Lord Shiva.
The temple with its open layout was quite expansive. Its orange walls wore signs of time, as segments of paint were peeled away and the color faded. As we stepped through the gate into the temple, we heard the rhythmic chanting of one of its many swamis (Hindu monks). The swami, whose small body was hunched over the enormous pages of the holy text, had circular glasses and thick white hair, which clung to his back. I was amazed by his piousness, as he never glanced up from his text to look at the three outsiders nor did he break for water or air.
We entered another section of the temple, which was under renovation due to its age, and met three other swamis. The swamis – two of which had orange-colored hair from henna dye – entertained conversations with us. They then proceeded to show us Hanuman’s shrine, which had exotic flowers strewn across it and a container with water. The shrine was lit up by a number of candles, which glowed brightly against the black curtain of night. The smell of burning wax, as well as that of incense, also swam through the air. I was overwhelmed by the sanctity of the temple and shrine, which was over 5,000 years old.
Before we left, we thanked the swamis and accepted the Prasad they gave us with our right hands. As we collected our shoes, I stopped to look once more at the swami reciting the Vedas (“Book of Knowledge”). Next to him was a statue of another swami who died many years beforehand and in front of that was a statue of Hanuman. The swami at the shrine had told us that when the swami died, Hanuman’s statue cried; therefore, the swamis decided to construct the statue of the devoted monk and place the two in front of each other. I imagined that the statue would shed a tear once more when the graying monk before me passes away too. With that, I made my exit out from the gates of the temple and into the car.
Towards the end of dinner that night, the sky began to weep. We could hear the clap of thunder, as well as the howling of wind and water beating against the pavement outside. We had experienced torrential downpour one week earlier while out on the field.
During orientation, Andrew, Eden (one of two PhD research fellows), and I were en route to look at a chick rearing station for SPS’s livestock program. The station, which was forty-five minutes away from campus, required that we drive down an unpaved road filled with ditches and boulders. With 2km left into our drive, we decided to turn around and return home, because of the road’s poor condition. As soon as we began driving home, however, the rains began. The soil muddied and trapped the wheels of the FWD. We exited the car and took cover under a roof belonging to one of the local villagers (who, despite not knowing us, took us to her chicken coop to look at her birds and two-week old goats), as the driver attempted to reverse from the mud. After the engine revved for ten minutes without any results, we helped push the car from its muddy grave. The three of us, as well as two SPS employees, successfully pushed the car onto the road much to the amusement of the local children. In addition to this struggle, we were faced with yet another later that day. Rain poured into Andrew’s room, as his window did not properly shut. While attempting to close it, the window frame popped off. We had a similar introduction to the monsoon rains the night we visited Barwaha and the temple.
While the storm raged, the lights to the mess hall shut off momentarily. During the power outage, employees began to sing vintage Hindu songs that their parents used to sing to them. It was memorizing to hear their singing against the bursts of thunder and the flashes of lightning. Once electricity was restored, the singing continued. Sasha and I sat for an hour listening to the Hindu songs. At times, men and women tossed lyrics at one another; while at others all ten voices came together as one. I listened as my friend, Sohini, sang a particularly captivating song on her own. Had fatigue not consumed me, I could have stayed listening to the music for hours.
On our way out from the mess, Sasha and I were surprised to see that the storm persisted in its severity. I put on my soggy sandals (which had been left out in the rain) and ran towards home; my headlamp capturing the shadow of frogs, as they hopped away from us into the dark. Although our apartment was only three minutes away, the moments we spent in the rain without an umbrella or raincoat left us drenched. Unsurprisingly, the symphony of thunder, wind, and rain continued to play throughout the night.
Hindi Phrases and Words:
Ālū = Potato
Āma = Mango
Aṇḍā = Egg
Āpa kaisē haiṁ = How are you doing?
Āpakā svāgata hai = Your welcome
Aura āpa = And you?
Bakara = Goat
Bāriśa = Rain
Bhiṇḍī = Okra
Bijalī = Lightning
Cāvala = Rice
Copy = Notebook
Imalī-Chutney = Tamarind chutney
Kēlā = Banana
Macchara = Mosquito
Madada = Help
Maiṁ amērikā sē hūm̐ = I am from America
Mērā nāma (NAME) hai = My name is….
Nag = Cobra
Pānī = Water
Sām̐pa = Snake
Ṭhīka hai = Okay
Dil Dhadakne Do (“Let the Heart Beat”) – enough “Hinglish” is used that subtitles are not necessary.
In the past two weeks, I have spent my time here in the new state of Telangana observing and honing my research questions at the Mulukanoor Women’s Dairy Cooperative Union. Mulukanoor is a rural village in the Karimnagar district of Telangana and their dairy cooperative is made up of 20,000 women farmers in a 30km radius from the central milk collecting and processing center. Each farmer has approximately 2-3 cattle and water buffalo that produce an average of 6 liters of milk per day. The Cooperative is successfully growing and is a model that has been studied and repeated because of its progress in helping and supporting small holder farmers. Although country-wide milk production has increased dramatically over the last 10 years, the projected population growth requires that India produce 200-210 million tons of milk per year for domestic consumption by 2020. The current output of about 122 million tons of milk per year has called for improvements in dairy nutrition and husbandry through the work of many organizations including the National Dairy Development Board (NDDB) of India and the International Livestock Research Institute (ILRI). In my next few weeks at Mulukanoor, I will be studying the current Ration Balancing Program implemented by the NDDB last year at the dairy cooperative. This program helps each woman farmer to record and adjust the diet of their animals to increase efficiency and improve milk production and profits. I am also planning farmer and veterinary personnel surveys to better understand the challenges faced by this particular district as I study the ration balancing program.
As I searched out these opportunities in the past week, I had some exciting adventures with a visiting Animal Nutrition PhD from Cornell, Maureen Valentine. Being in a rural village was a fun change of pace from the packed traffic of Hyderabad. Although Mulukanoor was bustling as well, walking along the streets and attending some of the meetings of the co-op members was welcoming and personal. After one particular afternoon of walking in the village, we attended a local meeting with visiting Ethiopian farmers (originally, we misheard that they were from Utopia which we found amusing). The day after the this meeting, we were surprised to find out that our picture was in the local newspaper with a short article in Telugu. (Please enjoy the proof of that below)
Many of the farmers that I have met so far have been welcoming and ready to help with the research project and seem to enjoy telling us about their livestock. I am certainly looking forward to getting to know some of them more in the following weeks. I am also hoping to master the art of eating spicy village food by hand with a straight face and doing physical exams of cattle and buffalo in a kurta.
The next phase of my project at work is fully underway. As I wrote in an earlier blog post, our goal had changed to a comparison between our own enterprise survey and that of the economic census, with the idea that small to mid-size businesses, especially those without a set structure, might be underrepresented by the government. This has evolved into a much larger project than originally expected, as the new final goal is a policy paper, and for our comparison to be conclusive and worthy of action, our methods need to be very exact. For this reason, we’ve reframed our past survey and will resurvey an area surrounding Bazaar Street, a very popular strip of shops and stores in a lower class area, and then compare our results to the results from the equivalent area of the economic census. This resurveying involves going house to house in order to ensure we cover every enterprise, including those done within the household, and creates quite the challenge as the full area is pretty large.
Being present from the start of a new survey, however, means I’ve been able to make it out of the office and into the field. As this phase of the project is looking at the same area of Bangalore as the last phase, which involved me analyzing the already collected survey data, I finally got to see how the reality matched up with the image I got from the data on the computer. Having spent so much time with the data I thought I had an idea of what the area might be like, but seeing it in person was much more revealing. The sheer number of enterprises was quite impressive, and it was quickly clear why this area was one that was a prime target, and home to many customers, of microfinance loans and other services.
Getting to wander the streets and map out survey boundaries with the other members of my team and our field workers, I was able to get a small taste of what everyday life might be like there. I was also able to see why the planning stages of these surveys was so long and included so many steps. You never know what obstacles you might run into when it comes to surveying every household in such a densely packed Indian city, from having to match up hand drawn census maps to small blocks of buildings to training the field workers how to best get accurate and reliable responses and data. I was reminded again how much I might stand out as a local approached my coworker in the local language and asked what our group was doing. After explaining the general idea, he then asked curiously, “So why is he here?” pointing at me.
With just under four weeks remaining in my CORD internship, I have reached the peak intensity of my work in the field. But if I’m being really honest, it doesn’t feel much like work. When I think of the word “work,” it seems to me to have an almost negative connotation, as if to imply that something is laborious to the point of being undesirable or objectionable. “Work” makes me think of something I wouldn’t want to do. That certainly isn’t the case here. If I feel passionate about it, as is the case with spending time with farmers in the villages here, defining it as work doesn’t quite do justice to that exhilarating sense of adventure I experience.
Let me take a step back for a moment and provide some context. For my Nutrition and Food Security project, my goal is to interview 30 women farmers, who are direct beneficiaries of CORD, about their nutritional and health practices, particularly those for their young children. The women I interview all have one or more children under the age of 5, as the age range of 0-59 months is a critical growth period for children; hence, the emphasis on food intake.
While the interviews themselves are certainly a joy to undertake, they are not the source of adventure out there in the field. The adventure lies in finding the people I want to interview. Each day I travel to a different Panchayat, or village district. The Panchayats are pretty large, and the 4 or 5 people I seek to interview in each Panchayat are not clustered in one area, but spread throughout. Furthermore, nobody really has an “address” as they would in the U.S. or elsewhere. Let’s say I want to interview a woman farmer who lives in the Panchayat Jassour. All I know is that she lives in some Ward within Jassour. Not a lot of information to go on, right?
So my translator, Uday, and I are tasked with locating the farmers whom I want to speak to, which becomes a quest in itself. Sometimes we go house to house asking where someone lives; sometimes we’ll ask the worker at the Anganwadi Center (a place providing basic health care in the villages, especially for mothers and children); and sometimes we just get lost. Lost in the midst of crops, trees, lush vegetation, towering mountains and a heck of a lot of cows and chickens. It is nothing short of a quest. We brave steep slopes, leap over small streams, and hover on the edge of cliffs. We ask, we point, we move on. We sweat and we search. Inquire and investigate.
I love every second of it. The field quest is a liberating one. It fuses adventure with application of the intellectual tools I have learned at Penn, and merges knowledge with passion.
Oh, and the kids are adorable. Yesterday I was in the Panchayat Bhuned, and got to hold a baby. Her mother said she was always mistrustful of strangers, and that it was a wonder I could pick her up without conjuring cries of protest. I’m pretty sure my face turned slightly red at that point; needless to say, I was pleased. During my last interview of the day in Bhuned, a bunch of kids from neighboring households came crowding to see what was going on, poking curious glances. I finished by taking a picture with the whole group! (see below)
(Can’t stop won’t stop with the punny titles)
Since my CASI internship is approximately halfway over, I suppose I should at least talk about the reason I came to India in the first place: to pet elephants my project! I’ve been spending excessive amounts of time with Hepsiba, Nithya, and Sakthipriya in the Aurosiksha office. Aurosiksha is Aravind’s online resource that offers courses for eye care professionals of varying education levels. In particular, it contains the streams of course materials for the MLOPs, or Aravind’s equivalent of specially trained ophthalmic nurses. I have been focusing on the basic training modules-the courses that all incoming MLOPs are required to take.
Aravind is attempting to rework this curriculum by converting the lessons into a “Learning Module Framework.” This is a standardized set of criteria for each lesson that includes teachers’ guides, assessments, activities, relevant resources, etc. The MLOP training division hopes that this coursework development will set clear expectations for learning while creating a more interactive classroom experience. The ultimate goal is to optimize the academic and technical preparation of the MLOPs, aiming to give them confidence when they interact with and treat the thousands of patients that visit Aravind everyday. If the preparation work is comprehensive and solid, they will make fewer errors and be able to correctly make critical decisions in the clinical setting.
My current task list involves the following items:
- Clearly define each set (and correlating subset) of modules within the stream
- Identify the materials that are missing from each module
- Modify the current modules to fit within the Learning Module Framework by correcting presentations, locating additional resources, creating activities or handouts, writing teachers’ guides, etc.
- Create new modules to cover topics that are currently not included in Aurosiksha
- Receive verification from experts in the field on each module (for example, the module that I created about Strabismus was verified by a senior sister in the pediatric department)
- Force either Sakthipriya or Nithya to get married before I leave so I can help plan/attend a wedding (this one has proved to be the most challenging)
Recently, I’ve also discovered an area for improvement in the training for MLOP surgical assistants. As I described in a previous blog post, the MLOPs originate from rural areas in Tamil Nadu, generally with little exposure to the medical field. Going into the operating theatre for the first time can be daunting for anyone, and given the expedited pace of work at Aravind, it could be quite intimidating for the new trainees. I am proposing a small, introductory course (similar to an orientation pre-requisite) to the operating theatre at Aravind that would occur before formal training. This would at least provide exposure to the field and serve as a glimpse into the environment that they will be training and working in for the next few years.
Yesterday I went to meet with one of the senior sisters from the surgical department in order to discuss this idea. As usual, I was not disappointed with Aravind’s execution of high capacity care, as the OTs are meticulously organized despite running four operating beds simultaneously. I arrived as a retinal injury surgery was occurring, allowing me to watch a specialty procedure. I watched cataract surgeries this morning, by far Aravind’s most common procedure, and I will be focusing on cataract operations in the lessons that I create.
While investigating Aravind’s practices of confirming that the sisters are prepared for clinical work, I learned that the MLOP stream lacks a formal certification process. Though there are exams and skill assessments that occur along the timeline of the training process, the division lacks consistent criteria in some areas. One proposal would be to “certify” the girls as a first phase MLOP before they advance to specialty training in each department. This would be accomplished by an exam that reflects nursing licensure testing in the United States. This provides more structure in the form of benchmarks through the first year and could additionally serve as a diagnostic tool for specialty placement if it is completed after the initial four months of training. We are meeting with professors and training supervisors next week to discuss the feasibility of this idea.
We are currently trying to introduce the “new and improved” lessons for the incoming group of trainees. The first module that I created was entitled “Introduction to Basic Microbiology” accompanied by a course in “Advanced Microbiology Techniques”. The introduction will be presented to all incoming MLOPs, as it focuses on fundamental biological principles (with an emphasis on pathogens), and it reinforces the practical knowledge of practicing proper hygiene around patients. We’re hoping to present the lesson as a “pilot course” at another branch hospital (likely Pondicherry) in order to evaluate the success of our lesson planning and classroom strategies.
Over the past few weeks, we met elephants, were attacked by hundreds of leeches in the rainforest, raced through gorgeous Western Ghats, found ourselves in a field of butterflies, ate parottas, explored a tea plantation, played in the Indian Ocean and the Bay of Bengal, received Ayurveda massages (@Busra), witnessed the amazing night sky of Thekkady, wandered around a palace from the 1600s, celebrated Vivek’s 22nd birthday (cue T-Swift), and, most importantly, consumed multiple pizzas from Dominos. About 5 seconds ago I looked out of our window to see a temple elephant strolling down the street. India continues to surprise me everyday, yet it has become my new standard of normal. I still can’t wrap my head around the fact that we’ve been here for over 5 weeks, but luckily we still have plenty of time to sightsee, eat weird foods, and (maybe, just maybe) make progress with our projects.
I. The Global Development Network Conference
During the first few weeks I created a slide presentation that CORD used at the Global Development Network Annual Conference in Morocco in early June. CORD was in the running for a $30,000 prize for its government-sponsored rural development project, MKSP (“Mahila Kisan Sashktikaran Pariyojana”, translated to “Women Farmer Empowerment Project”). The goal of the three-year project is to introduce a number of sustainable changes to women farmers’ agricultural practices that will improve their livelihood in the long-term, and to reduce their dependence on government aids such as subsidized tools and inputs as well as welfare, considering that most of them fall below the poverty line.
I am pleased to report that CORD placed first at the competition, which not only won the grant but also makes it eligible for a $200,000 grant from the Japanese government through the Japan Social Development Fund. While the assignment of making the slide presentation was an suspension from my actual project, I was very glad to have been selected for it because it was an important learning experience in terms of helping me understand the broad overview of all of CORD’s farming-related activities, and also see where my project fits in.
WFG and PLWFG stand for “Women Farmer Group” and “Panchayat Level Women Farmer Group.” The PLWFG consists of representatives from each WFG. My project this summer fits into the “Development of Market Linkage” component, where as I mentioned in my last blog post I develop an organized system for the farmers to sell their surplus produce and also acquire inputs such as seeds, fodder, and fertilizer for less.
The government chose to focus on female farmers because in rural Indian agriculture, women are responsible for most of the labor yet do not have the decision-making power in the household that comes with the money they earn as a result. Gender inequality is perceived as a significant issue and one of the ways proposed to resolve it is through livelihood improvements in agriculture. As my supervisor Narender views the issues, empowering women will help “unveil the veil” that while before was considered an aspect of femininity, might now be a symbol of oppression.
II. Overview of Collective Marketing
*note: Since I’ve never taken business classes, I’m not familiar with the jargon that would simplify my explanations, so I’m using the vocabulary I have.
The purpose of the sales outlet is to collectivize the farmers’ outputs and demands so that they can have a higher negotiating power. Most farmers CORD works with have small-scale production levels so in order to sell they need to bring their produce to big markets. Additionally, they require inputs such as seeds, fodder, and tools and machinery. Rather than attempt both processes individually, the collective effort of farmers in groups can allow them to set up a business of their own, hence the need for a marketing outlet operated by the farmers.
The idea of the marketing outlet is especially important and common in India, where a majority of the farmers are small. However, there is significant regional diversity in how the outlets are structured since each region has different needs influenced by local infrastructure and agricultural patterns, and hence an outlet in, say, Odissa would be very different than outlets in Himachal Pradesh. Even within Himachal Pradesh there are differences in agriculture.
III. My Project
I am tasked with improving the marketing outlet business model. CORD has established three collective marketing outlets in the area that have been running for about a month and a half, and I spend a week visiting the three, observing the kinds of daily issues they face, and reviewing their accounting and records.
I found that the main issues are culturally or geographically based:
Most of the saleswomen are farmers themselves, and have limited schooling. While it is completely possible and normal to operate a business without formal education, an understanding of certain business principles like accounting, management, marketing, and communication, is essential.
An example of the importance of accounting knowledge is evident in the practice of selling on credit. Often times customers will come without exact change, and if the shopkeeper is unable to make change, she will allow the customer to return at a later time when he or she is prepared. This practice is common throughout India; however, without accurate records, it makes it difficult for outside observers such as myself, or even a CORD volunteer, to make projections for future revenue if we don’t know how much the shop takes in as receivables. This in turn was the basis for my first suggestion for improvement – a system of record-keeping for loans.
Additionally, a significant issue the shopkeepers face is produce wastage, since in the hot and humid summers watery vegetables like tomatoes and cucumber don’t last long. Add in the lack of reliable electricity for dairy refrigeration, and there is potential for serious losses. A recommendation I made to resolve this issue is to establish linkages with markets in nearby cities, where the demand for produce is much higher since usually people don’t farm their own vegetables. In general, the purpose of having a marketing outlet in a rural area would be to provide goods that farmers can’t produce on their own, since they will only sell their goods to the outlet anyway if they have a surplus. For example, if they only cultivate pulses (beans, lentils) in their backyard, then they would have plenty for themselves but would need to purchase fruit, vegetables and dairy. Many farmers cultivate a decent enough variety of crops but depending on the season and other factors, they may end up with the same vegetables every day, and so to have a variety they then turn to buying.
Another cultural issue I’ve encountered is that many farmers don’t feel comfortable selling their produce, and would much rather give their surplus to a friend in need or use it for some other purpose. It is difficult to entice them to change their giving, selfless nature into a “business” mindset, but that’s where revenue projections come in – to explain exactly how much money they forego, and outline all the possible ways they could the extra cash: education for their children, more comprehensive health care, among other lifestyle factors that people prioritize.
Currently I’m putting together a sort of training manual for the saleswomen, so they have a checklist of their responsibilities and can learn best practices for communicating with the farmers to compile their various demands and supply of goods. While the structure for how the information, cash, and goods will flow has been established, one of the crucial missing elements is understanding and implementation. The outlet is powered by farmers’ active participation, and the more the better, so their skepticism truly inhibits their earning the benefits it provides them.
It’s 4:30 am. I scramble to find the small plastic bowl containing my hard boiled egg, a corn on the cob, and 2 pieces of toast. After swiftly preparing an egg sandwich, I finish all the contents of the bowl and and top off the meal with a small date. Making a quick dash to the water tank outside our room, I fill my bottle and gulp down the water right before the sound of the adhan fills the corridors of the hostel.
As most of you may know, Muslims in India (and around the world) began fasting last week for the holy month of Ramadan. Ramadan is essentially a time for Muslims to re-examine their lives and re-charge spiritually for the rest of the year. While fasting involves refraining from water and food during the daylight hours, it stands for much more than the physical restraints. Besides increasing self-control, fasting has always allowed me to develop a greater appreciation for the things we take for granted: food and water (especially now), a place to sleep at night, and love from our family and friends. It’s a 30 day reminder—sunrise to sundown— of those who are less fortunate and less privileged than we are.
One of my favorite aspects of Ramadan is the overall sense of community. From waking up to the smell of Turkish sujuk and chai for suhoor (predawn meal) to breaking fast (iftar) at different friends’ homes each night to eating an abundance of dates, Ramadan has always brought a time of excitement and much anticipation in my family. To be completely honest, I feared that I would not find the sense of community or feel that excitement in India—9,000 miles away from home.
But thankfully, I was mistaken.
Inspiration—the hostel we’re currently staying at—has truly leaved up to its name this past week. Needless to say, eating at 4am isn’t the most convenient time to ask for a meal. However, the women working in the kitchen have been very kind and generous; each night, they prepare a small to-go container after dinner and hand it to me with big smiles. I am (and will continue to be) truly grateful for their extra efforts and their hospitality.
Aravind—a hospital with a diverse mixture of doctors, sisters, fellows, staff members, and interns from all over the world, be it from Nigeria, Cambodia, UAE, Pune, Bangalore, or Philadelphia. I have recently started working with the medical records department in new patient registration, medical records processing, and record retrieval about 2-3 times a week. Since coffee/chai breaks are common and much anticipated throughout the workday, the sisters were at first intrigued by the fact that I was fasting. Within a few days, it seemed like most of the hospital had heard. Doctors and staff members personally came and greeted me with “Ramadan Mubarak.” The support and encouragement of the workers, not only for me but also for each other, profoundly effects the atmosphere in the workplace. The sense of community I was hoping for was here.
Over the past few weeks, Olivia, Vivek, and I have been quite adventurous. We took a weekend trip (about a 4 hour car ride) to see the beauty of Thekkady through elephant rides, a nature walk, and a boat ride. This was our first trip to another part of India and it definitely will be a memorable one. The first half of our nature walk was hands-down the scariest thing I’ve gone through. As someone with a severe phobia of spiders and most small critters, the sight of leeches attacking our brightly colored shoes and legs was horrifying. (Special shout-out to our guide and Vivek for helping Olivia and I pull off leeches every 2 minutes).
Last Sunday we decided to take a day trip to the sacred town of Rameswaram (~3 hrs from Madurai) with some people from Inspiration. Rameswaram, located on Pamban Island, is at the end point of the Indian isthmus. Before crossing over to the island, we stopped on the bridge to admire how the Bay of Bengal and the Indian Ocean came together. It was a remarkable sight and, unfortunately, no picture could capture the drastic change in the color where the 2 bodies of water merged. By the end of the day, we saw/held photoshoots/jumped into 3 beaches, each one more beautiful and different than the last. After a long exhausting day, I broke my fast at none other than Dominos with pizza and chocolate molten cake. Although traveling while fasting is not as difficult as I thought it would be, the smell of street food and heat was overwhelming at times. I’m thankful for Olivia and Vivek’s support as they are constantly faced with my food cravings and need to find shade. Our trips and adventures are making this Ramadan all the more special.
With each passing day, the meaning of Ramadan is taking on new forms and interpretations for me in India. The people, my surroundings, and the culture all provide a large canvas for self-reflection. But in the meantime…it’s time for another date…
This week was the first time that walking back from the field, I got absolutely drenched in the rain. I’ve been in heavy rain before, but for some reason, maybe because it had been a while, or because I was in such a beautiful place, I found it especially amazing to be in the rain, that was pouring in from all directions, making it impossible to see very far, and making such a loud noise. Though the monsoons haven’t yet started, I’m so excited for more rain to come. The patty fields are already starting to flood, and I can’t wait to see what it will look like when all of the valleys are covered in hundreds of shining rice patty pools.
Ravi and I were talking about how you can learn a lot about a culture through the language, which has been the case here. For example, there are 3 levels of politeness (ap, tum, tu), which, as compared to English’s one way (you) or Spanish’s two ways (usted, tu), means there are more nuances in terms of ways of showing respect. Another thing is that you can address anyone with a family member type of name appropriate to their age, such as brother or sister, or aunt or uncle. To me, I feel like there is more closeness when using these family terms. Also, there is not a word for cousin specifically, since the words “brother” and “sister” are also used. Also, there are so many different words for God. On the topic of family, when people either introduce themselves or ask questions to someone they are meeting, there are usually an equal amount of questions about their family than about themselves.
Also on the topic of family, something that I have found funny is that talking to people in the field, many times I will say something, and, unexpectedly to me, their response is, “You should find someone to marry here!” For example, there is this rose-water drink here that is soooo good, and that I’ve never had before. We often get it offered to us at people’s houses. One time I was commenting on how good it was, and the lady responds, “You should find someone to marry here!” And I was like, “Why??” and she was like, “Because then you can drink rose-water every day!” I often get asked whether I like it here or not, which is always an absolute yes. I’ve found that anything else I say, which I usually do, either about the mountains, or the food, or anything else, is all fair game for the “why don’t you get married” response as well.
I’ve been doing more interviewing in the field this week, and I can’t explain how happy I feel when I’m in a conversation and I am somehow able to understand the vast majority of what is being said. Since that wasn’t the case at all just a week ago, it seems like magic! Also seems like magic because one given conversation, I’ll understand practically everything, whereas in the next, I will be lost beyond the general subject. So, when the comprehension happens, it feels like such a gift, and I feel helpless to understand why or how it is happening, which I do not mind in the least!
India is busy.
I mentioned this before right? Well, naïve was I to think that what I had seen before encompasses the scope of busy-ness. The scale of which is completely incomprehensible for those who have not tried to cross a bridge designed for walking pedestrians. This is what they call Lakshman Jhula or Luxman Jhula, both pronounced the same I believe, but I’m no expert. However this much I know: the name literally means the “Lukshman swing” and even for people on both sides waiting to get on, it might be confusing why a bridge might be called a swing. But I can assure you, for the enormous number of determined people (and the dozens of motorcycles) sharing the breeze and the sun in this creatively organized chaos, this is no mystery. Despite looking like a feat of engineering, a very sturdy steel structure supported by lots of concrete, the bridge swings. Up and down and up and down. Resonating with the wind and resonating with the people’s busy footsteps.
3 LEAP interns getting ready to cross…
The beautiful Luxman swing on top of the beautiful Ganges
Cow + Laura + Monkey + %&*$% = Profit
Over a weekend, the other LEAP interns and I had a chance to experience it ourselves, and needless to say, it was busier than we expected. It was such a popular bridge that we ended up sharing it with monkeys and cows. The water was fun to look at from the top of the bridge, but even more fun was sharing a raft with a bunch of others down the Ganges.
So many rafts, so many people
The weekend before, LEAP had a change to sit down with CORD in a small shop in Dharamshala. Well, what I mean by sit down was more like squeezing ourselves on the benches and tightly as we could and still some of us would be hanging off the side. But, look around, how else are the people sitting? We were physically squished into 2 rows.
We are still missing people
Now, it becomes more evident: we were also emotionally squished together, and it was more like a family sitting rather than an unfamiliar setting. Furthermore, having amazing paratas shared between the all of us re-inforced this notion of sharing and enjoy each other’s company. The friends were great, the food was great, this country is busy, but fascinatingly comfortable.
What is even more impressive is the extensiveness of the familiar comforts one finds in food and family. As we wandered around as a confused flock of foreigners, sharing the heat of the “Sun”day, we wandered into a post wedding celebration of food after food after food. Wander is a bad word. We were all invited and they even wanted to invite more. It was a wonderful sight of waves of people sitting and eating, talking and laughing, singing and sharing. It was the first time that I got the opportunity to stuff my face with my hands with amazing food on wonderful banana leaves.
Do these colors not seem soooo enticing?
And then there’s one more place which has completely shattered the naïve notion onto which I held of crowdedness. After a fruitful relaxation is Rishikesh, LEAP interns made one last stop before heading back to Home Sweet Yamuna Nagar: the holy city of Haridwar.
Beautiful water, beautiful colors, beautiful lights
Considered one of the seven holy cities, Haridwar is where the Ganges enters the Indo-Gangetic Plains of North India for the first time. According to the Samudra Manthan, one of the more famous stories in Hinduism, this location is one of four sites where drops of Amrit, the elixir of immortality, accidentally spilled over from the pitcher while being carried by the celestial bird Garuda. If that doesn’t sound holy moly amazing to you guys, I don’t know what will.
People sharing songs, chants, and more lights
I mean, there were literally thousands of people, crowded around the rushing tides, all of whom wanting a little of the elixir for themselves. There were even venders for containers so the visitors can bring a bit of the immortality back to where they are from to share with family and friends.
Sharing the goodness of the land with the waters
We arrived just in time for the Evening Aarti, and the bright colors, flowers, lights and plants were plentiful. One mighty river cutting through the heart of India; it is so amazing to see so many people sharing the pleasures and reaping its benefits.
Flies fly up, up, and away
I guess these thousands of flies also were interested in immortality. Don’t worry there’s more than enough immortality to go around…… or they were interested in the bright lights, I don’t know. Their priorities might be a little different than ours.
By far my favourite picture of the whole trip.
They may be big, they may be dirty and they may be smelly, but they get thirsty too. There more than enough to share.
Food & Health
I really miss really good Korean food. Indian cuisine is great, don’t get me wrong. But growing up in a Korean household, my taste buds are used to the subtle spices and intricacies that make up Korean food. This is great though, because when I go back home, I know I am definitely going to appreciate and love all of the food I left behind. This week we found some new places to eat, including Phobidden Fruit, Chinita, and 3Oh3. Jacob and I also found a cool cafe in Koramangala (one of the districts of Bangalore) called Dyu Art Cafe. Here are some pics:
It’s not as great as the cafe near my apartment (mostly because it’s farther and has no WiFi), but it’s pretty cozy and definitely a great place to read. Their French toast was pretty good and they have awesome coffee that they serve black. I have never been so happy to see black coffee.
Things have been picking up at Janalakshmi. Currently I am married to three different projects:
- The one that I am almost finished with is a cross-analysis between the operational and financial characteristics of Janalakshmi and SKS, the second largest microfinance institution in India and one of my organization’s main competitors. I spent a good amount of time reading the P&L (profit & loss) reports, balance sheets, and quarterly reports of both firms, trying my best to figure out which information is the most precise and reorganizing the data to evaluate the metrics as percentages of the average loan portfolios over quarters and fiscal years (fiscal years in India start in April and end in May, unlike American companies). It was interesting to see the financial records of microfinance institutions and what they deem important. I spent a little bit of time looking at LBO (leveraged buy-out) models last summer and the metrics that they prioritize are pretty different from MFIs. It makes sense though since private equity firms value companies and their performance metrics as percentages of their revenues and cash flows. I’m supposed to present my data and observations of trends and patterns to the CEO on Monday. Should be fun.
- The Chief Innovation and Strategy Officer has instructed me to create dashboards for the company’s payment-related projects. In other words, I need to build presentations that show how the different components of the payment program have been doing weekly, monthly, and yearly. Therefore, I’ve been running around to different departments asking for their data and just my luck, none of the projects are evaluated the same way. In addition, I was told to figure out more effective, efficient methods to show how well they’re doing (of course, after parsing though all of the spreadsheets), so I feel slightly overwhelmed. This is probably how I’m going to be spending most of my week (and probably next week too).
- I spent a day going through a database full M&A valuations, private companies’ financials, and other investor-related information. It was basically for me to see if that specific website was useful. We are currently trying to figure out methods of valuing companies in the e-commerce and payment industries. It’s not really appropriate to see how much these kinds of firms are worth by just doing DCF (discounted cash flow) or revenue/EBITDA (earnings before interest, taxes, depreciation, amortization)/PAT (profit after tax) multiple valuations since there are many other metrics that go into their operations, such as footfalls and CLV (customer lifetime value). I’ve been told to start thinking about ways to effectively evaluate these kinds of firms and some plausible assumptions we can use. I foresee many financial models coming my way this week (yay?).
This weekend, your favorite Bangalore CASI interns have decided to spend time away from bars and pubs and go into the wilderness #rugged. One of my coworkers was kind enough to plan a trip to Nandi Hills, which is approximately an hour and a half drive away from where I am staying. Nandi is the name of the bull that the god Shiva rides and serves as the gatekeeper of Shiva and Parvati. On our way to the hills, there were a few statues of Nandi (to be honest I thought it was a dog before I did my research — not to offend anyone, I just couldn’t tell by looking at the statues). The hills were not as detached from the city as I would have liked and there were too many cars and motorcycles (and a result, honking) than I would have preferred, but it was still an amazing trip. We woke up at 3AM and saw the sun rise as we climbed up the hill (the original plan was to see the sun rise from the top but that didn’t work out since the hills open at 6AM). It was incredible to see rural parts of the country from so high up! And you know me, I hesitated at nothing to take some selfies. While going up the hill, there were some overhanging boulders that you can climb to get a better view of the landscape, which I was super excited to climb. I wanted to go to the edge but was advised not to do so by my coworker’s friend, who happens to be a zoologist who knows the area well. I trusted his judgement. To the picture on the right is Valentine, Amy, Chan, and Lakshmi (from left to right). Eventually we got to the top and saw a lot of amazing historic monuments, ranging from old summer houses of the local ruler to temples and plant nurseries.
That pit you see on the left with the steps is where people collected water. That dark section is actually around 15 feet deep. I can’t help but wonder if people from back then played water sports in that area. I can totally see some water polo going down. Follow me on the yellow-brick road! (Disregard the red bricks — there wasn’t a red-brick road in the book anyways.) All the mysteries in the world and what do we find?A rock. Just imagine the dilemma the people who were making this path had. Should we remove the rock? Break it apart? Maybe build around it? Or paint the rock yellow and road and try to have it blend in? Or maybe they just didn’t care and I’m just crazy… But you know what’s definitely pretty crazy. Apparently this plant has the potential cure for cancer. I totally forgot what it’s called and I can’t seem to find it on Google, so I guess that’s where this paragraph ends. I don’t know any other fun facts about this plant besides that the middle part of it looks like it’s made out of mini bananas. And speaking of bananas… MONKEYS! They appeared to be cute as first but they’re vicious as hell. They travel in groups #squad and they are not afraid to steal your eatables, bottles, and even bags. One monkey jumped on Chan to try to take away her drawstring bag. Evil creatures. And that pretty much sums up our seven hour trip to Nandi Hills. Next on our list of travels is Mysore and then hopefully Goa!
Observations of India’s Fashion
After passing by a lot of shopping malls, looking at billboards with clothing advertisements, and people-watching, I can’t help but notice that people don’t really put a lot of time into “fashion.” No one really talks about it and a lot of the department stores here carry basic items that all look very similar (button-ups, polos, and pants). I’m no fashionista and I’m not saying that the people here don’t dress well or look nice, but you could tell there’s a lesser amount of effort to stand out and bear “fashionable” garments and accessories (although a lot of traditional clothes that some people wear here are swaggerific). Maybe “fashion” is a first-world construct? It makes sense why people might not care too much about looking like someone in Vogue though. The weather in India is pretty warm year around and it rains a lot. Fashionable clothing may not be as accessible or affordable. Standing out might not be something people want to do. Showing a lot of skin isn’t socially appropriate, especially for females. The reasons are probably plentiful. But what I noticed is that men here love button-ups, especially with stripes, and they wear them with the top one or two buttons loose (that tropical beach look though). The majority of women here wear saris, mostly in purple and yellow colors. I did see one that was in black and gold and thought it was fresh to death. I’ve seen a few ladies wear skinny jeans/pants and “western-style” dresses, but even that’s pretty rare. Definitely no short-shorts. I wonder if those kinds of outfits will ever be acceptable. Maybe one day, but not out of compliance and instead because there are a bunch of expats that don’t care about what people think. [Plot twist: Maybe everyone in India is incredibly fashionable and they look at me and they wonder why expats look so weird and if foreigners care about fashion at all. Oof, that’d be rough.]
More Thoughts on Childhood in India
In my first blog post, I wrote a little bit about the wealth disparity in India and how it especially affects children. I haven’t thought about the issue that much but recently it’s been popping up in my head. There aren’t a lot of kids in the area that I’m staying in. I’m guessing it’s because most of them are indoors or at school or something. But a thought that struck me was how completely different the kids who come from healthy, stable families look like from those who live on the streets who may or may not have parents. Besides the obvious features, such as their clothes, there is a different atmosphere that surrounds them. While I was waiting for my Mexican food, there was a family that walked in and the kids looked so incredibly happy and carefree, as children should be. Completely different from the children that go around the roads, knocking on car windows trying to sell pens and roses and begging for money. Their faces are aged with stress and fear and their eyes look tired. This has been something I took attention to because of the discussions and readings I did for one of my social impact courses. In the class, we talked about how poverty just completely warps how a child develops. I also can’t help but wonder if these children are being exploited. I remember reading about how babies are sometimes kidnapped in American cities to be used as props held by homeless people to foster more pity and as a result, more donations. I think it would be naive to assume that similar things aren’t happening here. But who is to blame? I don’t know. Dark stuff.
Completely Random Thoughts
- One of my coworkers told me that songs in India become popular as a result of being in Bollywood movies. Kind of the reverse of what happens in the States. Movies usually use songs that are well-known to begin with. Apparently songs from Bollywood films catch on because people are better able to visualize the songs in their heads because of the associated scenes. But I argued that the beauty of music comes from the fact that you can take a song and attach your own interpretations and feelings behind it. My coworker agreed. And then we talked about Harry Potter.
- [Before you read this bullet point, please keep in my mind that I do not consider any of the relationships I have with people as a way of means to get something or take advantage of someone. I make strong, deliberate efforts to create bonds with others strictly out of peace and love. This train of thought spawned from the business-y, analytical side of my brain, coupled with all of the text about psychology I’ve been reading.] I would be interested to see if there are any studies that talk about the threshold at which relationships stop growing. I’m not restricting my definition of relationships to just romantic ones, but all personable human one-to-one interactions. Also, the relationships I’m talking about are a bit further developed than the ones with acquaintances and the majority of your Facebook friends. I’m more curious about relationships that were marked as “best friends” or “bffs” but slowly trickled away. I think it’s definitely plausible to say that there is a limit to how much a relationship grows (in my thought-chain, I’m considering a relationship as an entity separate from the individuals that make it, which I guess is weird to say since a relationship grows as a result of the growth of the individuals involved — I digress). I’m not old nor do I consider myself experienced in forming relationships, but looking at the ones that I have made and lost, I can’t wonder if there was a pre-destined (for a lack of a better word) stopping point for them. I wonder if there’s some sort of correlation or trend that show how long a person’s relationship with another lasts and how “deep” it is depending on the different characteristics of the people involved and what their innate motive for that relationship was. I believe that strong, healthy relationships form when both parties’ intents match. It’s not surprising to see relationships in which one person wants love but the other wants money fall apart. But that’s of course not the only factors that help relationships grow. You need complementary personalities, geographic proximity, socioeconomic, educational, and cultural similarities (sadly, to some degree), moral and ethical consistencies, and varying types of goals and interests but with somewhat identical levels of ambition, among other qualities. I can’t help but wonder if these characteristics can be mapped to see how long and “deep” a relationship is or will become. But of course, doing so will completely take away from the beauty of the relationship itself, seeing how some of the intrinsic value of a relationship derives from the mystery and awesomeness of not knowing how it will develop and what it will become through the efforts and contributions of both parties.
6 days a week, I wake up at 8:30. For breakfast: muesli, pomegranate/mango/banana, walnuts, curd. I am the third one to stir in the house, after a pair of kittens. (They love to try to jump up on the table to steal curd when they think I’m not looking, but I’ve caught onto their game!) I am out of the house by 9:45, when I don a medical mask to cope with the pollution (see NYT, “Holding Your Breath in India”) and open an umbrella to avoid sunburn. I hit the metro, arriving to work by 10:15. I punch in by fingerprint.
At the garment factory, my time is split among three divisions that correspond to production. I am spending the first two weeks in in product development. The next two will be in merchandising, where the process turns to after a bulk order has been placed. This will be the first month. The second month I will spend in bulk production. I think I would probably prefer to stay in product development, as I’m enjoying my time among a friendly team and a wonderful director, but as an intern I’m not going to push back against a schedule that an owner has established for me! And I can’t deny that it will be important to deeply understand how the entire process works, even though my principle interest is in pre-production.
Each day I sit with two divisions: In the morning I go to the fabric department, for example, and receive lessons about more types of fabric than I ever knew existed. Everyone in product development interacts with the fabric department – designers, merchandisers, and pattern cutters all speak the same language of weave and texture. My strategy is to learn the technical basics while asking the questions I’m actually interested in: “How do you coordinate with other departments? Where do you source the fabric? How much of the fabric is produced by the factory and how much purchased from other suppliers?” In the afternoon I am run through another department and learn another part of the process. The amount of inter-division coordination is impeccably complex.
The day ends around 5:30, when I again take up mask and umbrella and trek back to the metro. I inevitably arrive home exhausted, but perk up with a mango/coconut/watermelon refresher. Shower, maybe an hour or two for notes, dinner at 9, bed. Repeat. Including Saturdays.
It is a very intense schedule. I am beginning to wonder if I will be able to keep up with it through the entire two months… at the same time, the entire design team comes to work earlier and leaves later than I do every day, 6 days a week. The director of my current division works 9 hours/day in the off-season, 11 at peak times – again, 6 days a week, averaging out to 60-hour weeks. I am currently feeling very grateful that I am allowed to arrive 45 minutes to work in the mornings.
Despite the schedule, I am trying to figure out ways to come back to India for dissertation research. One site will not be enough to make any generalizations about the pre-production process, nor will one month. There are 5 or 6 other Delhi manufacturers, though, as well as at least one site in Bengaluru. In the end I am hoping for three months in three different places.
Pre-dissertation research is important. As the owner here told me in my first meeting with him, “You know nothing about fabrics, you know nothing about production…” This is true. I also knew nothing about the organizational structure of the manufacturer, which indeed I am still learning. Without understanding how the parts link to one another, it would be far more difficult to write a decent dissertation proposal. It would be tremendously more difficult to write the needed grant proposals that I am working on in my (little) spare time. It would be very hard to figure out even the first step of where I want to concentrate my time and attention, and even to know what can possibly be arranged in the first place.
I am very grateful to CASI for their help in getting this project off the ground. It will be a fairly massive project (as a dissertation should be?), but even little steps can be hard – like getting a follow-up response to an e-mail from a manager. Still working on this one…
Probably time for another mango.
It’s been almost two weeks since my last post, and I wanted to share a few updates.
I am currently working on implementing a “buddy” system: each incoming migrant female worker (aka “fresher”) will be paired up with a more experienced worker living in the same hostel. The “senior buddy” will be in charge of helping the fresher solve her problems and feel more at home. The buddy system will mainly target migrants from Orissa (poor rural region in the North East of India), as they are the ones that suffer the greatest lifestyle change. Orissa migrants often come from very poor families, have been brought up on a very different food, and are usually overwhelmed from the sudden exposure to the fast paced city life. But, most importantly, many of them do not speak Kannada or Hindi, making it very difficult for them to communicate with the outside world as well as with their work supervisor.
Part of my research involves finding out about existing related resources/schemes and assessing their effectiveness. For example, I have sought to assess a different buddy system that is still in its beginning phases, which already exists in unit 12. My first step was therefore to visit unit 12 and to collect useful information. Sounds easy right? So I thought myself… In fact it appeared that collecting such data was in fact really challenging.
At this point, I thought it would be interesting to reflect on one of the practical difficulties all of us have been confronted with at least once during this internship: receiving precise and accurate data from various departments, groups, and individuals within the factory. The veiling of information is certainly frustrating, but if we think about it, this behavior is also relatively understandable.
The garment industry is extremely regulated and is subject to constant pressures by various external parties. Such pressures, on the whole, yield positive effects: they ensure that workers’ rights and safety are respected. In some cases, however, these pressures are exerted in a manner that reflects the regulators’ lack of understanding of factory life. These regulations can disrupt internal order and slow things down. One consequence is that people at Shahi have learned to be cautious and to not entrust any visitor.
Because people from other units do not know us, their natural inclination is to view us as outsiders trying to sneak out information that could some day be used against them. Thus, to avoid receiving unnecessarily adorned information, our job is to effectively communicate our true “unharming” intentions to them. Chitra (our supervisor and mentor) has made us practice a little introduction spiel “we are not from the brands, we are merely students from the USA doing research… the research we conduct will be used to directly benefit you…etc.”, and has somewhat briefed us on the behavior to adopt in order to initially gain people’s trust and obtain useful information. I think we are slowly getting better at it, but work still needs to be done (as you can see from my questionable success at obtaining correct information relative to buddy scheme in unit 12). Anyway, once I master this communication and persuasion skill (if I ever manage to), I think it will be one of the most important professional take aways from this internship. As the internship progresses, I also hope to get a better understanding of the power dynamics of the company at every level. Indeed, I believe it would enable us to behave more tactfully, as well as to gain a better understanding of the origin and intricacy of many problems.
Last Sunday, Amy, Kendra and I decided to do something touristy (for a change!) in Bangalore and visited the Bangalore palace. I say it was touristy because once we arrived there, we realized that a significant number of visitors were non-Indians. We even got nice Dutch man to take a great photo of us!
Equipped with audio guides, we toured the palace. The experience was slightly unsettling at first: I think I was initially expecting to be confronted to authentic “Indian” style (Although I’m not sure exactly what Indian style would mean since the country is so diverse). In my ignorance, I had probably been picturing the palace to be some kind of miniature modern version of the Taj Mahal). Instead, the architecture we witnessed was a mix of different influences. The palace was built in the late 19th century, while the country was still under British rule, so it is not so surprising that it predominantly followed an English-derived style, “Tudor architecture”. According to our guide, the palace was inspired by Windsor castle in England. (If you look at the following pictures you can probably spot some similarities)
However, there was definitely- if I may say- a unique “Indian” twist to the interior design and furniture of the palace.
Stuffed elephant head, hunting trophy brought back by one of the princes who used to inhabit the palace.
SPS is a radical organization. I write this in the sense that its work has been revolutionary in empowering the villages of the Dewas district. Working with state schemes and local institutions, the SPS programs have shifted many of the imbalanced power dynamics that occur in the daily lives of villagers, particularly the families of farmers and landless laborers. During this past week of orientation, we have been able to learn first-hand about the operations and impacts of these programs through field visits guided by some of the SPS professionals. One project in particular, the sanitation program, highlighted the potential of the NGO’s work.
Also referred to as “toilets”, the sanitation program aims to promote construction of in-home bathrooms through work with the women’s Self-Help Groups (SHGs). Until speaking with some of the SHG members, I did not realize the impact of an in-home toilet on a woman’s security and health. We were able to hear about the experiences of the some of the women in the village of Hatpipaliya from one of the SHG members in the process of installing a toilet for her own home.
Without a toilet, women in the village typically take a wash bucket to a near-by forested area for privacy when going to the bathroom. The walk to the trees with a bucket incurs public shame, so to avoid the ridicule, the women make a once daily trip to the bathroom in the early morning before many of the villagers are awake. However, having a regular bathroom schedule in the open woods has resulted in instances of harassment and assault from men who have learned the routine, which forces the women to go in groups once a day. Aside from the social consequences, the once daily bathroom trip has had some health impacts, including increased cases of urinary tract infections for these women without in-home toilets.
The sanitation program makes installing the toilets, or rather in-ground pits connected to a septic tank, more affordable for the women through loans given out by the SHG. The SHG acts as an alternative to local money-lenders and loan sharks whose high interest rates result in debilitating indebtedness, particularly for the population of illiterate and laborer women. By pooling together the small savings of a group of ten to twenty women of a village, the women have access to greater loan capacities from the bank. The sanitation loan is a new loan offered through the SHG, which covers the construction cost of a two-pit toilet with a low interest for repayment to the group.
Despite the access to funds for and the benefits of in-home toilets, many women have been reluctant to take the loan. Installation of a two-pit toilet requires a substantial amount of space that is not usually available in the village homes. The ground above the pit must be cleared so that the pit can be uncovered for cleaning every ten years. Unfortunately, many families do not have the space or require what free space they do have for extra sleeping rooms. One-pit toilets do not require as much space, but they are significantly more costly for initial construction and long-term maintenance costs, which exceed the amount of the sanitation loan.
The woman with whom we spoke is a 55 year old widow and is entering her last year of participation in her local SHG. She has received the sanitation loan, but is looking for other funds, as she has opted to construct the more expensive one-pit toilet to conserve space in her home. She hopes to serve as an example for use of the sanitation loan in her village. In addition, the SPS media team is currently making a documentary film focusing on sanitation and toilets in Hatpipaliya that will be used to educate women throughout the region about the process of acquiring and benefits of an in-home toilet. While the initial adoption of the sanitation loan has been slow, SPS will see future impacts on the near-by communities through outreach and education efforts in the SHGs.
Throughout this past week, we have been able to hear similar stories about how the multitude of SPS projects have changed the daily lives of farmers, women, laborers, and the community as a whole. Orientation week has been an informative introduction to SPS and the region, and it has given us an understating of the scope of our project. We will be documenting stories of recent SPS projects and initiatives through field visits, interviews, and case studies. These stories will evaluate the factors contributing to the successes or shortcomings of the projects. Areas of focus will include the promotion of crop diversity for farmers, the Participatory Groundwater Managment (PGWM) program, and other SHG and alternative livelihood initiatives. With a new understanding of our location and the people SPS serves, I am inspired to dive deeper into the projects.
Side note: The rains have begun, and they are intimidating. The monsoon storms seem to hurricanes compacted into the length of an hour. But, water storage is rising and the green landscape is spreading. A transformation of seasons is underway.
Let it rain,
I think one of the most challenging aspects of the work we’re doing at LEAP is that we don’t always see the impact of our work. For those who don’t remember, the four of us in Yamuna Nagar are interning at LEAP Skills Academy, an education start up that focuses on skill development: basically giving students the practical and soft skills they need to build successful careers.
But LEAP’s flagship program, called Education for Employment (E4E), happens alongside college students’ usual classes during the school year and not during the summer.
So much of our work has more behind the scenes.
For example, Laura and I have been working on helping the trainers (LEAP’s name for the teachers) revise their curriculum. Indian college students have jam-packed schedules (trust me when I say we Penn students would never survive here), so they have to dramatically cut down the number of hours included in E4E. Though we tried to help the trainers in finding ways to shorten classes, it was a very painful process: we could see how passionate they were about their work and how frustrating it was to have to reduce the numbers of hours they had to transmit material.
Another aspect of our work centers on revising individual lessons. LEAP’s pedagogical philosophy centers on experiential learning – which is not necessarily even so common in American schools, but certainly non-existent in the Indian education system. Here learning is done from books and lectures (that’s what we’ve been told). Laura and I have been going through individual lesson plans and trying to brainstorm more activity-based teaching methods. We’ve been drawing on activities from summer camp, improv workshops, and from Laura’s experience studying and teaching in the education field.
We’re also working on designing a program for training new trainers that start at LEAP, to make sure they’re adequately prepared for the classroom.
Some of the dedicated trainers at LEAP
Laura with some of the LEAP trainers. Can you spot her?
All of this work – it’s very interesting, don’t get me wrong. It’s exactly the kind of experience that I was looking for this summer – thinking about the practical methods of implementing pedagogy and developing curriculum.
But I think none of us are used spending so much time in an office. And we won’t necessarily see the results of all the work we put into redeveloping lessons or designing training programs. (We have done some work with high school students, which the other LEAP interns have written about already).
So it was very powerful for me to have the opportunity this past week to help write up testimonials for LEAP’s website. I was given the transcripts of various interviews with LEAP alumni in which they detailed their personal stories and how LEAP has impacted them.
They told stories of incredible challenges and really awe-inspiring perseverance. One female student’s father fell extremely ill and the family’s finances collapsed. She managed to acquire a scholarship from LEAP, finish her degree and the E4E program, and get hired for a well-paying job that allows her to now support her family. One student lost her parents at a young age and the relatives who raised her tried to prevent her from pursuing higher education. But she was determined to get a job and become independent, so she tutored students and scrupulously saved her money to enroll in E4E, which helped her get a good, secure job. She said that now her relatives are proud of her. A third student came from a family that was too poor to provide him with a strong education. After finishing high school, he found a job, but was unsatisfied with it. He quit and searched for better opportunities and ultimately found the LEAP program that helped him build the skills to find a new career path.
Reading these stories had a pretty emotional effect on me. I’ve never had to struggle to get an education. My parents worked hard to send me to a prestigious private school. There was never a question that I would go to a good college and get a degree. In fact, like many Penn students, I spend a solid chunk of my days in college complaining about it, wishing I didn’t have so many classes or assignments.
But these college students, all just around my age, had to fight tooth and nail to get an education. Even this simple fact: they had to make a conscious decision that they wanted an education. Have I ever had to do that?
I haven’t even seen pictures of these students. In many ways they’re just names on a page, and yet I’ve learned so much from them.
Just one of the many lessons that India has taught me.
I absolutely cannot believe it has been a year since I was interning with the Central Himalayan Rural Action Group in Uttarakhand, India as part of my CASI experience. And a year later, instead of being in the beautiful, peaceful foothills of the Himalayas, I am now living in the bustling, cosmopolitan city of Shanghai, China. In lieu of daal and chapatis, I am feasting on xiaolongbao (Shanghai dumplings), zongzi (sticky rice and filling, usually pork or red bean, wrapped with reed leaves – eaten in time for the Dragon Boat Festival which is June 20th) and other Chinese food that I have grown up with. Rather than hopelessly trying to figure out what people are saying in Hindi or Kumaoni, I can actually communicate with locals in Mandarin (yay!). Instead of living with other interns at the NGO and hiking up mountain paths, I am living alone and dodging unforgiving cars and motor-scooters when I walk to Jiading Central Hospital, where I am conducting my thesis research.
While it’s a completely different, yet exciting, experience, I am doing the same exact thing I did last year in a far different context: interviewing pregnant women, as well as mothers, family members and doctors. However, instead of asking about neonatal care practices to rural women who often lack access to prenatal check-ups and well-resourced hospitals, I am asking about how urban women give birth in a place where 100% of women deliver in hospitals. In particular, my thesis research is looking at the sociocultural reasons behind cesarean sections on maternal request, in a country where cesarean rates are hitting 50%, and even higher in urban areas like Shanghai. Through ethnographic research: observing the hospital environment and interviewing various actors in the hospital, I have tried to integrate myself into the Chinese context and understand this phenomenon: why are cesarean rates so high in China, and what is even more fascinating to me: why are mothers requesting surgery without medical indication?
The “answer” to this, well, could be written into a 60-70 page thesis that clearly would not fit onto this blog. However, there’s a number of reasons: women fear pain and childbirth (and it does not help that the usage of epidurals, or anesthesia for childbirth, is uncommon, nor that women labor without family members in an open ward with other laboring women); doctors are often overworked and underpaid, and perhaps see cesareans as a faster (and more profitable) way to achieving the same outcome; and China’s One Child Policy, which meant that the risk of a cesarean stopped at one birth (although now this is changing as the policy has been relaxed and parents can now have two children). The reasons are numerous and meld together into this environment ripe for cesareans. All of this, however, has been changing in recent years as there has been pressure on the Chinese government from the international community to reduce cesarean births –after 2011, the government began implementing new financial incentives in regards to how the hospital is paid for birth as well as how it is rewarded (i.e. if it’s cesarean section rate is below a certain number), which has so far seemed to have reduced the cesarean rate. I could go on and on, but this would, again, extend into a thesis-long post.
What I have learned from both my experience in India and China, as a Health and Societies major and Anthropology minor, is that while childbirth is the same across all cultures, the childbirth experience is one that differs by country, by region, by class. It depends on the structural environment, financial incentives, and lifestyles. And I feel incredibly lucky to have investigated the experiences of both sides of the childbirth spectrum: from a place where perhaps medical intervention was not enough, risking the life of the baby and mother, to a place where medical intervention has become the norm, which has its own maternal-child health consequences…
The CASI experience definitely helped grow my interest in maternal-child health and global health, and I feel grateful to be able to continue this type of research for my thesis. Not only that, I also feel bolder about traveling about and wanderlusting (India is definitely a harder country to travel in than China is…perhaps because of my language and cultural upbringing?).
Anyway, here’s to happy mothers and babies, and the spirit of wanderlust and intellectual inquiry!
Week 4 at Aravind is drawing to a close (cue the perfunctory cliché about how fast time is flying), and there is much to report on from Madurai. This past weekend we devoted our Sunday off from work to travel. Busra, Olivia, and I went to the neighboring state of Kerala for the weekend to visit the beautiful town of Thekkady, which is next to the Periyar National Park and Tiger Reserve. The trip was full of many adventures, not the least of which included us being attacked by literally hundreds (the number is not hyperbole) of leeches on a nature walk into the Tiger Reserve. But I am going to leave the grim details of that story and some of the more uplifting parts of the trip to Olivia and Busra to share in future blog posts. Here are a couple photos as a teaser trailer:
I realized that I have neglected over my first few posts to describe my project for the summer at Aravind. The project that I am working on is tied to patient satisfaction. Before describing my project, though, let me give some context.
Aravind is an extremely data-driven place. I think that when I tell people from the US and even other parts of India that I am working at a hospital in south India, they have a vision of a small, noble clinic that is caring for needy patients through an admirable combination of determination and good intentions. As I briefly alluded to in one of my earlier blog posts, this is not exactly the case. Aravind has the most noble of intentions, but it is gigantic in terms of numbers. It serves more patients per annum than any eye care institution in the world, and it has all of the bells and whistles and capabilities of America’s best hospitals for eye care. What is more, the hospital is not just built on the heroic dedication of a super-doctor like Paul Farmer; instead as the founder of the hospital, Dr. Venkataswamy (Dr. V), intended, it is built fundamentally on process. In Dr. V’s eyes, the hospital was meant to be the McDonald’s of eye care, where you could deliver a product at a really cheap price, and not only that, you can do it by having a standardized process, in which you can train anyone and stick them into the system.
This morning, I shadowed Dr. Aravind, one of the directors of the hospital, in the Operating Theatre (not spelt wrong, just staying true to the British spellings in India!) as he conducted nearly 20 cataract surgeries in the span of about an hour and a half. The feel in the Operating Theatre is like an assembly line in Henry Ford’s Model T factory because there are four beds in a single spotlessly clean, state of the art room. As one patient is being operated on nurses are already readying the next for the procedure, so that the doctor can simply pivot his chair and begin the next surgery moments after finishing with inserting the new intra-ocular lens in the previous patient. Part of the reason that Aravind has been able to set up this kind of cataract factory is that they collect data on everything. They know how long patients are waiting in the waiting room; they know what the utilization rates are across the hospital; they are tracking outcomes so that they know how each department is performing along various measures of quality. Data is key to Aravind’s ability to continuously evaluate and improve the process to maximize efficiency. That’s how you get a process like Henry Ford’s factory, and that’s how you deliver cataracts at prices that (in the health care world) are tantamount to something off of the dollar menu.
A new realm of data analysis and assessment for Aravind is patient satisfaction. For the past three years, Aravind has been conducting surveys of patients through its newly developed patient feedback team: a determined group of six women from Madurai, who have to this point conducted thousands of patient satisfaction surveys. The goal is to get surveys from a random sample of roughly 1% of all Aravind patients, and as the team has grown over the past year, they have begun to systematically hit that mark. The upshot of all of this is that to date, Aravind has survey data on patient satisfaction for more than 15,000 patients.
Insert me. And my project is to take those 15,000 survey responses and explain what they tell us. There are around 20 questions in most of the surveys (there are a 6 different surveys for the different forms of care delivered at the hospital: out patient, in-patient, etc), covering patient experiences with reception staff, doctors, nurses, and facilities. So that’s well over 300,000 data points, and I have to admit that at first, I wasn’t sure where to begin. I have a little experience with using the statistical program R, though, so I started coding. From this work, I think that I have been able to come by some pretty interesting results.
It turns out that “free” (or highly subsidized) and (fully) “paying” patients have some pretty different levels of satisfaction. Free patients are consistently giving lower overall ratings for virtually all forms of care (out patient, in-patient, and day care; Day care describes when a procedure is done and patients can go home the same day without being admitted). Why is this? It is not that free and paying patients are getting different quality in terms of outcomes; parameters measuring readmission rates and health after procedures all suggest that outcomes are the same across both free and paying.
Some more analysis eventually revealed that free patients consistently rate their doctors and their facilities lower. The facilities part makes sense at some level (though my supervisor said it was still not excusable) because the free hospital is separate from the paying hospital and does have worse amenities (that’s generally why patients opt to go to the paying hospital). But why are the doctors rated lower? Not entirely sure why that is, but we are trying to figure that one out now so that it can be dealt with…
Other interesting insights to explain the paying/free differential: it turns out that it looks like paying and free patients in out-patient settings differ in terms of what variables drive overall perceptions of Aravind. Free patients are really affected by how they perceive doctors’ treatment, while it turns out that paying patients don’t really seem to be affected much by how they perceive the doctors. Ratings for paying patients tend to come down to how clean they think the hospital is and how good the nursing care is (nursing care doesn’t look that significant for free patients).
The survey data has also been useful for pinpointing how specific clinics can improve in delivering care for patients. For example, from the data, I can tell you that Glaucoma patients feel as though they are receiving less direction than any other patient from reception staff. Reports on these sorts of things will hopefully prove useful to each individual clinic.
The next step in my project is to integrate this dataset with the existing medical records database, which has more information on the demographics of individual patients. This is going to be helpful in trying to figure out whether certain patients tend to have worse experiences at Aravind. We will be addressing questions like: do patients coming from farther distances tend to struggle more? Or, is it possible that women don’t feel as comfortable as men?.
Additionally, one of the big goals is to be able to analyze patient satisfaction along patient volumes. At Aravind, the prevailing notion is that high patient volumes are actually helping in a lot of ways because they bring down unit costs, and interestingly enough, they may help surgeons like Dr. Aravind become really good at their craft because they get so much practice. But it may in fact be that patient satisfaction dips off when volumes get too high; it may be that having long waiting times and having too many people around eventually begins to cause patients to feel worse about the care. I am hoping to be able to use the data to find some thresholds for patient volume where satisfaction dips off. Hopefully, Aravind can then use that information to adjust their capacity to deal with when patient volumes are really high.
One final element of the project will be to design a new IT architecture so that patient satisfaction can be reported on a consistent basis to departments and staff. But don’t worry, I am going to close the post here because this post has probably once again been way too long, and I don’t even want to know where my reader satisfaction is.