Paint-covered snake-bite patients make great hosts

I wanted to share three findings:

Interesting Hospital Observations: Working in a hospital brings patients, diseases and complications not ordinarily viewed in daily life. Working in a hospital in a rural village of India breaks the door even further, bringing in patients and infections rarely seen even in the U.S. Over the past eight months, patients with rather interesting histories have walked through the hospital door. Many leprosy patients have come at different stages of complication. One man stands out in particular, as the tissue in his arm had died so that maggots had been living inside and needed to be pulled out. Maggots can be beneficial when eating dead skin but in this case served no good purpose.

Also coming into the hospital was a case of mumps (MMR is not given in India), many patients with typhoid, diabetic feet, lip cancer (due to tobacco), snake bites from cobras to vipers, women and children with second & third degree burns, and large goiters. The most striking case was a child who was delivered and died within three minutes. The baby would not have lived long, though. It was born with a huge abdomen but a chest the width of a baseball, it had no penis but enlarged testicles, and at the end of shriveled arms and legs, each foot and hand had six fingers and toes. The complications were congenital, although the exact cause we did not know.

Would you like extra sugar with your tea? The humility and graciousness of Indian families has humbled me since arriving in India and continues to quiet me to this day. Never have I consistently seen such caring hosts. Families who work on the farm to feed three children and send them to school immediately stop what they are doing when I enter their house to offer me tea and biscuits. Further, they insist we put extra sugar in our tea, a sign of respect and good status for the family. Also customary is on the anniversary of the death of a family member, their memory is honored by inviting guests from the village for dinner and eating to their hearts content. Additionally, the first time I visited a friend’s house for lunch, I was seated and we were both served until we could eat no more. Then I was presented with a coconut, a scarf, a bindi and a farmer’s cap as a sign of welcome. There was no hesitation at all from my friend or from any of the houses I visit, as there seems to be true appreciation in their actions.

It does feel uncomfortable as the family is far from rich and offering you lunch and tea with extra sugar. However, it is only more complicated and ungracious to not accept. It is equally uncomfortable to eat dinner and end up simply being served, mostly by women. Often I sit and eat with the men as the women prepare the food and then serve it. When we are finished, the plates are taken, a water bowl is brought for our hands to wash, and then the wife cleans the dishes before sitting and eating her own meal. This routine is so consistent that it seems to be a sign of a good host. Their actions seem filled with graciousness and placing values over material things. It constantly challenges me to think about my own hospitality and possessiveness, often at the expense of relationships and my own values.

Just don’t let them cover you in the silver paint: In mid-March, the festival of Holi was celebrated. It is a holiday commemorating the burning of Holika, who was burned to death to protect Prahlada, the son of Hiranyakashipu (King of Demons), who was a devotee of Lord Vishnu. The day is richly celebrated by covering others from head to toe in paint. The morning is spent buying the paint powder and mixing it in water bottles with a hole in the cap for spraying. The next eight hours are then spent roaming and searching for friends to spray and color. It was not a choice of whether you wanted to have paint on you or not; rather, it was a choice of how much paint. Even then, those who protested the most were usually sprayed the most.

The fantastic thing about Holi was the universal playful attitude. Those who do not want to be sprayed may protest but eventually they will be sprayed, and when they did they simply smiled. Even today when you walk around Jamkhed, women will wear sarees and men will wear shirts and pants with paint marks covering the back and sides. But I did not see one person who was truly upset about being covered in paint even after protesting for minutes about being colored. That ease made the day very friendly and familial. By the end of the day, after hours of playing, I was unrecognizable – walking through Jamkhed afterwards, I was covered in paint to the extent that people could not tell who I was.

The goal is not an increase in patient numbers but patient care

Since 1970, CRHP has been a leader in primary health care (PHC) and village level empowerment, especially of women. It has trained over 20,000 people from across the world on its model of equity, integration and empowerment in the hopes of spreading the message of locally-based PHC. By starting at the level of the neediest villager, CRHP has been able to collectively raise the status of the whole village while simultaneously breaking down caste barriers, long-held destructive traditions and the low status of women.

The key player in this primary health program at Jamkhed is the village health worker. She is a woman selected by her villagers to raise not only the health of the village but also its capacity to handle its own problems. At the outset, many of these women were dalits (untouchable caste) and illiterate. She was not accepted, trusted or supported in her village and the knowledge she was had was often overlooked by higher caste villagers. It was not until problems arose that the VHW was given her chance to break through the barriers.

Many of these problems were referred to the hospital, including complicated deliveries, snakebites, and pneumonia. The hospital served not only to care for the referred patients but also to support the village health worker in her decision. Questions asked by the patient’s family would be referred to the VHW, who would give the correct answer and then be supported by the doctor. When a patient was referred, the VHW would be recognized for her work. When complications arose, villagers saw that the doctor taught the VHW and trusted her. The hospital provided an invaluable service in supporting and encouraging the VHW, assisting her to be accepted and recognized in the village. Soon enough, the VHW was allowed into houses, was performing deliveries in high caste homes, and was listened to when speaking on leprosy, snakebites and other health issues.

The secondary care component of CRHP is essential to the success of its primary health program. When a flow chart is constructed of the CRHP model, two adjacent circles are connected by a horizontal line. In one circle is the village & VHW, in the other is the hospital, and in between is the mobile health team. CRHP is known for its PHC program and village work, but its ability to provide low-cost, honest hospital care is invaluable. How effective would the VHW be if she referred cesareans to a government hospital where it cost 10-15,000 rupees ($200-$300) and placed the family in lifetime debt, rather than to CRHP’s hospital for 5000 rupees ($100)? Or to a private clinician who charged extra for leprosy medications rather than to CRHP where the meds were covered by a leprosy fund? Or to a hospital where the staff treated you like an animal, versus CRHP where you were not only respected but you and the village health worker were taught?

The secondary care component, in addition to supporting the VHW and her efforts, provides low-cost hospital care, supports a non-intimidating environment, and allows the villager to learn about medicine, thus breaking down unfounded beliefs. Each year about 26,000 outpatients receive treatment, 350 deliveries take place (usually for high-risk patients), and 500 surgical procedures are performed. Family members are allowed into the operating theater during the procedure and family is expected to care for the patient as a nurse would.

On Sunday, a new 50-bed hospital was opened with a bang at CRHP. Plans have been three years in the making and construction has taken the past year. The hospital is not only bigger but better built. While the old hospital was built thirty years past with tin roofing and one floor, the new hospital is reinforced with plaster and bricks and has two floors with plenty of space, also permitting a much cooler atmosphere in the hot summer months. The larger wards and consulting rooms will allow for better care of patients and the updated surgery rooms (including one for laparoscopy) will make it easier for doctors to operate. Private rooms will provide safety and comfort to patients with burns and smelly wounds. And the building will provide a long-term hospital solution, as the last hospital (while full of character) was not built to last as long as it did.

While CRHP has in many ways set the mould for an effective primary health program, a major focus now is to become a leader in creating low-cost secondary care. Protocols for patient care, drug therapy and operations will accompany the change in space to streamline and improve access and cost. Villagers with little hospital experience but tons of real life experience will be trained to provide patient care. Doctors will hopefully be attracted to the rural setting to provide services to the neediest of Indians – in eye care, dentistry, surgery and pediatrics. The goal for the new hospital is not an increase in patient numbers but rather an improvement and standardization in patient care, something reiterated throughout Sunday’s opening. The opening of the new hospital represents the hope that CRHP will continue to be at the forefront of change in the health sector throughout India and other developing countries.

Spirituality and/in Medicine

Sultan passed away three days ago today. His condition had been rapidly deteriorating for six to eight weeks since the blood transfusions stopped. When he passed, the 27 year old Jamkhed resident was skinny as a stick, with bad bed sores on his back and arms (despite being moved into a waterbed), barely able to speak, with eyes as mellow but alive as ever. His nails were all raised, his tongue and eyelids pale, and his mother was reliably by his side. It is not the first time someone has died in the hospital since I arrived in Jamkhed, but Sultan was a particularly unusual case, considering he was active, happy and jumping around when I arrived in August.

Around eight years ago, Sultan went to a Jamkhed hospital presenting with kidney problems. He was treated for kidney failure but a side product of the toxic meds soon left him with aplastic anemia, rendering his bone marrow disabled in producing new red (and white) blood cells. Aplastic anemia is a very difficult disease to treat, requiring a bone marrow transplant available for a good amount of money, especially considering the risk after operation. Sultan, nor CRHP, could afford the transplant. Instead, he received blood transfusions every two weeks to reoxyginate his body. Oddly, even with the transfusions he would present with fever, chills, pain and vomiting. He was tested for malaria, typhoid, tuberculosis but none could explain the ongoing sickness, especially with the limited diagnostic equipment available in the hospital. Eventually, Dr. Shobha, Dr. Wout, Sultan and his mother sat down to discuss the options. They decided to take Sultan off blood transfusions and rest until death.

The healthy-looking Sultan soon became bed ridden, quiet and contemplative. He never seemed angry for the decision or for the chances and changes life had given him. There were few palliative medications to ensure he would live out pain-free besides the common pain meds. What seemed to do the most for Sultan, however, were the daily prayer sessions at his bed. During morning and afternoon rounds, the nurses, doctors and patients would stop, some holding Sultan’s hand or rubbing his leg while a nurse or doctor said a prayer. He would close his eyes, seeming to listen deeply, and then open them again to look at us afterwards. The prayer was not an excuse for lack of treatment but was in fact a constructive form of supplemental palliative care.

With Sultan I began to think deeply about the role of spirituality in medicine. It often seems like a taboo subject, a mixture of contradictions and worlds that should not collide. However, it also seems that spirituality should exist in health and the hospital as much as, if not more than, most anywhere else. The hospital is a place of life and death, healing and suffering, crying and laughing, of miracles and catastrophes, family and friends, love and closure, and of searching and retrospection. Something so important, so innate in a patient as their own health deserves to be accompanied by faith, by a belief in truth and security. Health is much greater than the pain and treatment that accompany disease or injury but involves equally mental and social well-being. For most, spirituality (in whatever form it may be) is a determining factor in this well-being which can greatly affect the patient’s compliance, motivation and success in overcoming the pain and disease.

Spirituality is different than religion, and it should not be used as a substitute for rational medicine or in the place of treatment, but it does deserve recognition and a place in healing. Sultan was dying – he knew it, his mother knew it, we knew it and, for him, God knew it. Is it wrong for the doctor to pray with Sultan, asking for his well-being after he leaves this earth? Was it not more comforting for Sultan to know that he was in the hearts and minds of those who were caring for him?

Spirituality, and especially religion, could be dismissed as counter-science and anti-medicine, but rather it is neither – it just happens to be most controversial when difficult decisions need to be made. Normally, though, spirituality helps treatment and medicine by supplementing it with a valuable service in a place where meds cannot reach. Sultan and his mother seemed to be at peace when he died, and I can’t believe it was the doctors, the medications or the hospital that did that for him. Rather, it seemed to be a faith in something larger than just himself and that he was far from dead even after his body left the hospital.

Beginning part two of the alcohol and hypertension study

The hypertension survey is complete. From mid-December to early-March, three hundred and four men have been visited in their homes, had their blood pressure (BP) checked, and were asked questions relating to exercise, diet, tobacco use, and alcohol use. Initially, the goal was to simply collect data on alcohol use, but the strong alcohol-associated stigma prevented the sharing of honest and reliable answers. Rather, the survey was paired with a hypertension study. Using the local village health worker to gain trust and acceptance, the study focused on blood pressure to reduce the fear of stigma and create an environment where men could be honest. While many men continued to understate the amount they drink or chew, a safer environment was created and reliable data collected. Besides that, the study allowed me to explore the fascinating village and create relationships that otherwise would not have been made.

Of the 304 men, 46% had normal blood pressure, 37% were pre-hypertensive, 12% were stage 1 hypertensive, and 5% were stage 2 hypertensive (BP greater than 160/100 mm Hg). 31% of the men were found to drink at least once per week – 42% of whom drank up to seven glasses per week, 13% up to fourteen glasses per week, and 45% fifteen glasses or more. And this isn’t beer and whiskey but rather country liquor, as 82% drank an odd mix of distilled brown sugar with battery acid, trash, and other things I don’t know about. The more alcohol a man drank, the higher his blood pressure was found to be – of non-drinkers, 52% had normal BP and 10% were hypertensive, whereas of those who drank heavily, 28% had a normal BP and 37% were hypertensive.

77% of the men use a tobacco product, with 85% of these men chewing tobacco (grinded up in their hand) and others using bidi (cheap cigarettes), goa gutka, cigarettes, paan, or marijuana. Of those who drink or use tobacco, 12,045 rupees ($251) were spent on alcohol and 9991 rupees ($208) on tobacco per week. Thereby, 22,036 rupees ($459) are spent in total on both alcohol and tobacco, averaging to 92 rupees per week per drinking and/or chewing man, an astonishing amount considering the average female laborer makes 40-50 rupees per day and male laborer 60-90 rupees per day, five to six days per week. We also found that 90.5% eat mutton at least once per week (counter-intuitive to the western idea that India is a vegetarian country) and 93.5% eat green vegetables at least once per week (mostly palak – a form of spinach).

With the understanding that the data would be used to uplift the health of the village and direct community-inspired interventions, a meeting was held on Thursday for all the men and their families to learn about blood pressure, hear the results from the study and discuss solutions. The week previous was spent up and down the village informing people about the meeting and getting them prepared for it. By 6:45pm on Thursday, two men had shown for the 6pm meeting. Back into the village we went, a pack of six guys encouraging every man we saw to make their way to the hall. That helped to get fifteen men to the meeting. Then the rickshaw (three-wheeled taxi) with a giant speaker strapped to the top rumbled through the village, announcing the meeting that was now taking place at 7pm. The rickshaw, combined with the Hindi music blaring from the meeting site, attracted the other forty people by the 7pm start, many of them drinkers.

The meeting was intended to be led by Dr. Shobha (director of CRHP) and Asha (local VHW) but the meeting soon became dry and information-filled without proper context. So Dr. Arole (co-founder of CRHP) took over and began to place the data in the context of the larger problem, explaining the risk factors and ill effects of hypertension. Unfortunately, once the data regarding alcohol was shared, five men immediately felt targeted and left. The skit by four village health workers on the effects of hypertension and stroke made the situation even worse, as it merged into a skit on alcohol abuse by men, causing ten more men to leave, some taking friends with them. By the end of the skit and song, the safe feeling of the meeting had largely dissipated. The twenty or so men who remained were very interested and some discussion was held but with little lasting effect.

The most discouraging thing from the meeting is not the failure to create a safe environment for those using alcohol but rather the failure to even create a comfortable environment for them. While there were no direct attacks to the men who drank and they have certainly heard that drinking is a problem before, the values that supported and drove the survey to completion were lacking at the meeting. It was a meeting led by data rather than by honesty, trust, support, love and unity, all values that make the information understandable and introspective. Since this was the first meeting with the community, chances of getting full participation is low, so another meeting will be held in the following week to shoot for a different result. This time we hope to build on what was successful, including the informative survey results, and correct the downsides of the last meeting to create an engaging and comfortable meeting.

A matriarchal society outside of Kerala

Those who live in urban areas, rural settings, and tribal villages – India is largely made up of these three communities. Jamkhed is squarely in the rural setting but across Maharashtra state exist pockets of tribals who have congregated in hills and mountainous regions. While in Gadchiroli in early December, I had the opportunity to visit a tribal village with SEARCH India, learning about the very unique community and their traditions, in addition to the difficult work done by partnering NGOs.

The tribals in India are comprised of the groups declared as tribals by order of the president. The essential characteristics to be identified as a scheduled tribe are: primitive traits, distinctive culture, shyness of public interaction, geographical isolation, and backwardness, both social and economic. In 1991, the tribal population was estimated at 68 million, 8% of total population.

“Do not tell them you are American,” I was warned before exiting the bus into the village. “What should I tell them?” I asked. “Just tell them you are from Jamkhed.” From the beginning, the tribal area looked and felt differently from all the other rural villages I had visited, most prominently by the use of bamboo everywhere – building houses, serving as storage facilities, and as a fence around sheds and the village – anything to protect from tigers and panthers entering from the jungle. The tribal village was a part of the Madiya tribe, a tribe connected with the Naxalite community, a militant group of civilians in central India fighting the police and government for their rights and an independent state.

Tribals are matriarchal where the woman is respected above the man, a rare trait in Indian society. The praise for women seen throughout their beliefs (husband to wife dowry, female politicians, praising of goddesses) was most prominently showcased in two unique traditions. The kurma house is an external hut located in the village where women live for 4-6 days during menstruation. I have seen similar huts where women are kicked out of the house or forced to stay in only one room during menstruation because of its associated dirtiness and contamination. However, the intention of the kurma house was much different. Here, five to six women at a time stayed together to talk, rest, eat, sleep and abstain from work in order to regain energy and strength during this emotional time. In the home, the man would cook the food and bring it to her, take care of the kids, clean the house, and feed the animals.

The second tradition is that of the gotul, a community center located in the village center. Once or twice a year, usually once the harvest is finished, the gotul is set as a social event to bring together boys and girls to dance, sing, drink and socialize. During the event, a courting process initiated over the previous couple months is now cemented, as the interested couple will spend the night together, either going into the jungle or in a neighboring hut to be with each other. After the gotul, the female goes to live with the boy and his family in his house for six to twelve months, evaluating whether the boy and his family are a good fit for her. If so, then the marriage will take place. If not, then she will thank them and give a gift, and the courting process will begin again. As different as it may be, problems rarely arise. If the couple sleeps together post-gotul, it is always consensual (entrusted in the matriarchal society) and there has been little to no history of rape or abuse. If it creates a pregnancy, then the couple is highly encouraged to marry. If on the rare occasion that they do not, then the village will come together to decide who will care for the baby.

The gotul also serves as the center for teaching and tradition, where the history and culture of the tribe is passed down from generation to generation. Every father will take their son into the gotul and share with him the tribal traditions and beliefs. Yet it is all done by word of mouth, as there are no writings and all history is passed down through stories, songs and dance.

During my limited stay, I became very impressed with the ability of the tribals to maintain their unique tradition in a country that is very opposite in many ways. Tribals seem to get a bad rap in India because they are mountainous, segregated from urban life and shy in nature, yet my experience was very positive. The strong sense of belief and tradition has drawbacks, especially since a major part of their resources are used for ritual purposes rather than economic activities, such as in health. The literacy rate of scheduled tribes is around 29.6% against the national average of 52%. More than three quarters of scheduled tribes women are illiterate. In the Madiya community I visited, the three major health concerns were malaria, diarrhea and back ache – malaria due to the large amount of standing water in the open drains, paddy fields and jungle; diarrhea due to the unclean wells and poor sanitation; and back ache due to the constant bending required in farming.

Both SEARCH and CRHP have been working with tribals for years in health and social development. Their work with tribals has been understated by a recognition that education of the villagers needs to take place without stepping on long- and deeply-held traditions. In addition to dealing with disease, social barriers have been addressed, including access to government programs, increasing the rate of (higher) education, and in many cases working with government forest policy and conservation efforts that have divested tribals off almost all their rights in the forest.

On the wrong side of the railroad tracks

The storage space on the tin roof was tiny, the boxes were warped due to rain from months back, and the tin roof shook as the fifth train went by since I had arrived. I looked down the row of clay and tin houses that bordered the train tracks, as children ran along adjacent tracks chasing tires hit with sticks, mothers beat wet clothes against stone platforms or bathed their children, and some men still passed out, now melting in the sun from the heavy night of drinking. We had stopped to speak with a mother in the women’s group who had no legs, cut off from an accident with a passing train as a child. The slum of Mayapuri in Delhi was not one of the bigger slums, and certainly nothing compared with Dharavi slum of Mumbai (and Slum Dog Millionaire), yet was nonetheless eye-opening. Houses were piled on top of each other and squeezed in between, so that each wall separated two houses. Roofs of tin were covered with bricks, sticks, cartons for storage, trash, or anything else that would weigh the roof down. The inside of the one room house was cozy to say the least, made for five to six people and their clothes, food and other needs, with parents sleeping on the bed and children on the floor or on mattresses.

Mayapuri’s roads had recently been upgraded, thanks in part to Asha - the NGO my supervisor had come to evaluate - so that the main road was concrete and side roads had ditches for water. The ditches were meant to be covered to prevent mosquito breeding but in many plays stood uncovered and unflowing, filled to the brim with dirty, soapy water. Some of the roads had yet to be converted to concrete and it was a jumping maze from one clean area to the next, splashing through mud or dust, walking through dirty water puddles and trash-filled passageways. The kids running around us had no problem as they fought for attention, running through and often falling into the mud, getting right back up and pushing the other kid down, squeezing into the photos we were taking. Clothes filthy, cuts and bruises covering faces and arms yet these kids were nothing but smiles.

The maze was equal for my nose, as different smells competed for recognition by my brain. At times the scent of animals dominated, where as at others metal dust (since the slum was situated next to a metal plant), or sweets and tea, or just of trash that accumulated in muddy piles along the street. In addition to smells, Mayapuri was pocketed with settlements, as most slum residents came from different parts of India in search of work and money. In one section were the Gujurati’s, in another from Uttar Pradesh, in another from Orissa or Bihar – all with different languages, trades, cultures, and work skills. Some helped to build the new upper-class mall, others rickshaw driving, or some in the local metal factory. It is exactly that need for work that drives people to the cities, yet without money they are forced to live in transitory and overcrowded areas, creating a slum. Slums are illegal, yet in places like Mumbai 55% of the population lives in them because other options cost so much money.

The traditional definition of a slum is a run-down area of a city characterized by substandard housing and squalor and lacking in tenure security. Mayapuri is an area of land also owned by the government yet inhabited by squatters, who settle in the very condensed area. As it is so condensed, slums are often subjected to abnormally high rates of disease, most commonly diarrhea (rotavirus), malnutrition, hepatitis, worms (round, hook), tuberculosis, HIV, pneumonia, or at times mosquito-born diseases like malaria, dengue and chickun gunya. As it is illegal, the slum is subject to destruction at the government’s will. Some of Asha’s other slums had been leveled in a matter of hours with a day’s notice because the land was needed, with no assistance in relocation. More than just a slum, the leveling destroys an industrious city-within-a-city, where businesses flourish and essential services provided.

As I looked down the row of shacks strung along the railroad tracks, I recognized the difference in the effect that Asha could make in a slum versus CRHP in a rural village. A slum faces a less united community as it is inhabited by pockets of people and most families are first-generation to the slum. In villages, though, residents know each other and relationships have been built through generations. It is more difficult to map out a slum, coordinate slum dwellers to identify their highest areas of need, and mobilize action when the population is so large, the problems so varied and the community so diverse. And as goals can be longer-term in a village, slums need more immediate impacts and are threatened to be destroyed the next day.

Asha has done great work, using CRHP’s model translated to a slum setting. Each area has a local dispensary, composed of a health clinic and classrooms. On the ground, community health volunteers are elected to monitor the health of 250 houses, performing pregnancies, prenatal care and necessary referrals. Female lane volunteers are further responsible for the health of their local lane of 40-50 houses, reporting to the CHV. Groups of women are organized into Mahila Mandels (for empowerment, decisions, and representation) and adolescents into Bal Mandels (for education on sexual health, diseases and nutrition through street performances). In the dispensary, computer and English classes are set up for the kids, encouraging higher education and career paths. On computers, young kids who cannot read English have learned to input data and write formulas in Excel, create logos on Microsoft Word, create powerpoint presentations with photos and graphics, and use google and check their gmail account – further signs that Indians are just way too smart. Success is on a smaller scale but nevertheless great, as 34 kids from the slum have free rides through college, roads have improved and water cleaned, tuberculosis and malnutrition has reduced, and a strong sense of empowerment, especially among the women who have demonstrated they are not afraid to hold their political representation accountable for problems in their city-within-a-city.

How does the Kinsey scale apply in India?

A rumble came over the crowd as we entered the outdoor auditorium, packed with students since it was a school dance competition dedicated to the daughter of a CRHP nurse who had passed away in an auto accident a couple years back. We made our way to the front to our usual designated seats with the rest of the CRHP staff as the crowd got more excited after noticing the 6’4” white doctor Wout, from Holland. Among dance contestants in all costumes, including many boys who dressed in saris and danced as girls, the winner was a boy dressed as the PM Manmohan Singh, dancing with a cane and making fantastic facial expressions. During the following winners dance, a roar erupted as Wout, David (American student), and I were pulled up on stage to dance with the boy, stunned as we attempted to move our bodies in front of over two thousand people.

Common to most events, all boys were seated to the left and girls to the right, with a small wooden fence separating them. No fence was needed, though, as the divide between male and female was bigger than just the auditorium. By the fifth dance, all the boys were on the feet, crowding the front and dancing in place and with each other. All were screaming, singing, jumping on each others shoulders, and yelling to get our attention. The girls, however, were all seated in rows, some with their mothers, calmly watching the show and making little reaction, only at times mouthing the words to a song they knew. Sometimes they would peer to the boy’s side and vice-versa, almost curious what it was like on the other side.

Interaction between male and female is minimal and only rarely do I see boys and girls talking or playing with each other, outside of being married or related. Sexuality is rarely discussed and fear exists not only between sexes but even in what happens to your own body, a trend the adolescent girls program at CRHP is changing. Nonetheless, having a boy or girlfriend before marriage does occur, yet it is kept very secretive and both parents and friends rarely know. A friend of mine had a girlfriend for two years when he was twenty one that neither his nor her parents knew about. Despite knowing that she would soon be married off, he loved her even though they rarely saw each other. He told me that often they would look at the other’s school picture while talking on the phone or eating dinner at their homes. They had kissed but sexual relations ended at that, a theme common even in their private intimacy since sexuality is so taboo. Public display of affection rarely is shown and not one couple, married or unmarried, have I seen kiss at all since arriving in Jamkhed, except for my three day trip to Mumbai (where eight hours from Jamkhed can take you into a different world).

The difference in sexuality and intergender relations is fascinating, as most boys are not married until age 22-26. These boys go through the peak years of puberty and adolescence in a state of confusion and sexual fear, bottling up that energy and seeming at times to translate it into their relationships with male friends. Often male friendships are very physical, very touchy, grabbing and loving, past the holding hands and hugging that is also seen in other countries. I find my own level of comfort challenged as friends rub my arm or hand, whisper in my ear very close, or rest their head on my chest while I sit, massaging my neck. Stories are also often told of male friends entering physical relationships with each other in the sheer curiosity of what sexuality is. Nevertheless, when relations between partners and what happens to your own body is not discussed, sexuality gets pushed to the foreground and stigmatized.

As you watch these boys at the competition dance and sing with each other, it is only natural to wonder how much is attributable to a different culture and how much a drastic difference in the relationship between boys confused about sexuality. It is as if the boys are strained to release the sexual tension built up during the most sexual years of their lives, taking it out in odd ways in their relationships with men and perhaps equally affecting their future relationship with their wife, confused about the intimacy that often accompanies marriage.

There does seem to be a shift occurring in this generation, as exposure to western influence increases and Bollywood movies made easily accessible. In addition, attention is being paid to sexual education by NGOs and schools as the issue has additionally become about personal sanitation and health. One NGO I recently visited has worked with local schools to create sexual education classes not only for boys and girls, but another technique which received a very positive response - for students and their parents.