Holy Cow - Jeff's Leaving India

My strengths lie in speeches, acting and drama. But these are not skills I have known my whole life. These skills have been derived from her taking the time to get to know me and understand what I would be good at. She helped me to learn appropriate facial expressions and gestures. She always strived to make me and others as perfect and whole as possible, never leaving things half-finished or incomplete. She made sure that the same person finishes the task whom she assigned it to, correctly. She was fearless.

Even though she is physically not around us anymore, she still guides all of us, so much so that every single morning I cannot start my work until I pay a visit to her memorial site. I have done this every morning for nine years, and my experience is that work goes much smoother with the leadership she still plays in my life.

- Ganpatrao Waibhat (CRHP Worker since 1971)

I remember a story that has since changed my life: Once, we were a little late to Mandli village and there was a leprosy patient sitting under a tree. His fingers were fully deformed and he was not able to break the bread he was trying to eat. She noticed it and went close to him, took his bread, and broke it for him. The patient said “madam, please don’t do this, what if you get leprosy?” She replied “I cannot get leprosy by touching you or your bread. The disease does not spread like that, so you don’t worry about me getting it.” Her love shown for leprosy patients, displayed to the village by cleaning their feet sores, made me very upset that I avoided touching leprosy patients. Yet such a big doctor breaks the bread for him! Slowly, her examples helped me to start to adapt this way. Today, if any leprosy patients come for x-ray, I feel very comfortable to touch them. For the last forty years, I have been working and chatting with them.

People always said good things about those who have passed away, but I genuinely, from the bottom of heart, thank her for what she has taught me professionally and personally.

- Moses Gurram (CRHP Worker since 1972)

As I leave Jamkhed and begin to head home back to the states, I am given the opportunity to look back on my own personal growth and what I have learned. Perhaps more interesting, though, are those I have learned from. One of the most impressive people I have met since I arrived in Jamkhed has been Mabelle Arole. However, Mabelle died in 1999. Over the past five to six months, I have worked with a social worker to interview and collect the stories and memories of Mabelle from those who knew her best - thirty seven village health workers, villagers and staff members.

One of the challenges that CRHP seems to face in the future is to continue to push the organization forward, be innovative and exemplify a sustainable, equitable and integrated mission. This is still done well but it will become more difficult when the original staff, those who knew the initial struggle s faced by CRHP and the dependence on a vision and values, begin to retire. To help keep Mabelle’s stories alive and her spirit active in new staff, the video hopes to capture the original struggle and soul behind CRHP.

But it is not difficult to still feel Mabelle on campus. Every village health worker continues to speak of her. Her memorial site on campus is visited daily by staff. People live their lives based on the teachings she gave them. Through the interviews, I was amazed at how many little things about Mabelle people remember. It is those small things that really seem to touch people, that people remember the most. Mabelle never wore jewelry, her sarees rarely matched, she at times wore her shoes on the wrong feet, she laughed loudly and openly, she would rush out of bed if a patient came or VHW called, and she lived a simple life. She brought life to villages upon arrival and every visit used to be a community event. People would sit and listen to her speak, believing not only in her intellect but in the fact that she was one of them. And that seems to be one of her biggest contributions – she made each person not only feel empowered, but made them believe that others are equally good. She truly believed in the power, goodness and strength in each person and people feel alive by having known and spoken with her.

A common theme to the interviews was the feeling of one large family. “She cared for her family just as she cared for us. The world community seemed to be her family,” Yamunabai said, a VHW in Ghodegaon for 30 years. And she worked to spread primary health care and women’s rights around the world, working with the local, state, and national government. She was regional director to UNICEF for Southeast Asia, working in Kathmandu, Nepal, and she was a member of the Christian Medical Commission and World Council of Churches. Her greatest legacy, however, lives in those she continues to touch and the leadership she continues to play at CRHP, nine years after her death. “She taught us how to care for the problems of others. How to love others. How to participate in the sorrows of others. She guided us throughout our path. She taught us how to struggle in order to achieve something bigger. She gave us the gift of a lifetime-courage. This will help us as long as we live.” - Sofia Bee Shaikh, VHW in Patoda for 32 years. I feel so proud to have completed a fellowship in her name.

My eleven months in Jamkhed have ended and I almost ready to go. I am excited but very sad and I would certainly be able to stay here for one more year if need be. The people I have met, the things I have done and learned, the projects I have worked on, the food that I have eaten have all been much better than I could have asked for.

Before arriving in Jamkhed, I did not know what primary health care was, but now I hope to dedicate my life to its principles. I had no understanding of community development, yet now I hope to be a doctor to serve the needs of the community. There are a couple key lessons that CRHP has taught me that I will quickly point out:

One – It doesn’t matter how smart you are, or how much money you have, or how well connected you seem to be. What matters when it comes to success is a die-hard commitment to the community, especially those who are most vulnerable and needy. In fact, I have come to find that money and intellect can serve as barriers to really being able to work with the community.

Two – The work done with the community needs to be based not on finances, not on theory or formulas that have been shown to work, not on great ideas, but on values. Values like love, equity, trust, humility and confidence are the pillars of a successful organization and project. Without them, struggles and uphill battles cannot be overcome. And these values need to be reflected in every staff member.

Three – The true caretakers of the community and the family are women, and that very often they get little of the respect they deserve. The women are the ones who are constantly there for their family, who work their butts off to make their family safe and healthy, and yet who rarely share many of the luxuries that us men share. Even in America, I have come to realize that women are often mistreated and not allotted the full status they deserve.

In Jamkhed, I leave behind cows in the middle of the street, tea stalls at every corner, the extremes of rain and heat, and people defecating on the side of the road. And I have little idea how I will be able to readjust back to life in America. Tea is 100 rupees in America (2 rupees here), haircuts are 750 rupees (25 rupees here), and I can’t be stuffed with delicious Indian food for under 1000 rupees (250 rupees here). I leave Jamkhed happy not because I am leaving, but because of all I have gained.

I encourage you to help Jamkhed in the future, visit if you can, or read the Jamkhed book if you have the time. I also ask that you help CRHP financially, with however much money you can give. Every little bit counts and your money will be well spent at CRHP, as their overhead and staff costs are kept at 20%. If you have read this blog, or if you have spoken with me over the past year, you see the incredible work CRHP has done and continues to do. If you are interested in donating anything from $5 to $500, you can visit www.jamkhed.org.

Finally, I want to say thanks to those who have followed my blog and kept up with me over the past year. The blog has given me an opportunity to write down my thoughts and experiences, as well as keep in touch with friends and family back home. These conversations and posts have played a big part in my hope to fully grasp what I am experiencing here.

So now that we’re in rural India, where’s the poverty?

As you drive from urban Mumbai or Pune into rural Maharashtra, on your way to Jamkhed, the scene changes quite dramatically. Big buildings are traded in for tea stalls and hair cutteries, computer stores for paan and tobacco shops, cars for cows, and traffic five lanes wide for traffic in the game of ‘chicken’ with the opposing driver. Concurrently, the poverty also changes and many might ask where it went. In the city, poverty is in your face – men, women and children sleeping on the streets, claiming a piece of sidewalk as their own, wearing torn clothing and covered in dirt asking you for money. Many have disabilities – no legs, one eye, leprosy, or scars on their face. The concentration of poverty in cities is greater, with slum houses stacked on top of each other and men sleeping in their rickshaws if they can get off the street. For many visitors, urban poverty is overwhelming and leaves you questioning yourself and a system that permits such overt struggle and inequity.

And then you travel to rural areas and that poverty seems to disappear. Sidewalks no longer exist and people do not sleep on the streets. You say that it’s better in rural areas because at least the poorest sleep under a tent made of hay or tarp rather than uncovered on the sidewalk. It is much rarer that someone comes to you asking for money. Twenty years ago, Dr. Arole tells how it was rare to see a village woman without patches in her only saree. Yet today, you’d be hard struck to find a woman who does not own at least two to three sarees, none with patches. Where as twenty years ago people barely had any food, families now have bags of sorghum grain stored for difficult times. Twenty years ago only the rich had goats yet now the majority of families seem to own buffaloes, cows, goats or chickens. Even the poorest of villages can seem better off than the conditions faced by the homeless and poor in the cities. So where is the rural poverty if you cannot see it? How do you explain the statistics of high rural poverty when it is so much more transparent in urban areas?

To understand where poverty exists in rural areas, one must look a little deeper than appearances. One major cause of rural poverty is access – to government services, health facilities, higher education, and transportation. In rural areas, 36.5% of children are immunized and 36.9% of pregnant women receive at least three antenatal care visits, compared to 56.6% and 70.1% in urban areas, respectively. In the public sector there are 1.5 physicians per 10,000 inhabitants. Even when facilities exist in remote or underserved areas, posts often remain unfilled due to the financial draw of private practice, exemplifying why not one caesarean delivery has been done in the Jamkhed government hospital in the past ten years. Doctors, teachers and government officials prefer to live in cities, dragging appropriate health facilities, good educational opportunities and access to government resources away from rural India. The anti-poverty programs that have targeted rural India are ineffective and inadequate, often ending in corruption or mismanagement so that the funds and services meant to assist rarely make it to the needy. No program exemplifies this better than the Anganwadi worker program (established by Integrated Child Development Services) or the National Rural Health Mission and their Accredited Social Health Activist, both of which are meant to combat rural poverty yet are stuck in beaurocracy and inefficiency.

Poverty can also be understood in the dependence on agriculture for income and how unforeseen occurrences in weather and crops can disable a family for years. If there is a famine, or if there is too much rain, or if the cost for machinery is too high, then the crop is disabled or ruined and there is little to sell in the market and thereby no daily wage. For farmers without land, drought or insect infestation can mean no work for two to three weeks. For a typical family with little savings, a bad year or crop can mean taking out money from a bank or money lender and paying it back over one, five, ten or even more years. At times this dependence on the farm for income leads to women or children working on the land. For rural women, this is particularly hard due to their requirements also inside the house and raising children, or if they are pregnant. For children, working often replaces education.

When I asked Dr. Arole why the poverty numbers are so high in rural areas when it seems to have changed so much from twenty years back, he explains that it has much to do with the inequality between rich and poor. In the past twenty years, rural women wear more sarees and eat more consistent grains, yet their growth out of poverty has been much slower than urban growth into wealth. And compared with 20 years ago, the gap between the rich and the poor, even in rural areas, is growing. 21.1% of the rural population lives on less than 356 rupees ($7.5 – rural poverty line) per month, and 15% of the urban population lives on less than 538 rupees ($11 – urban poverty line) per month. And with poor health facilities in rural areas, 77% of outpatient cases in rural areas are seen by private doctors who have bills in the range that only the rich can pay. When a family earns 50 to 60 rupees per day, a medical bill from a private doctor can put you in debt for months to years, considering the average expenditure per hospitalization in rural government hospitals is 3238 rupees ($67) compared to 7408 rupees ($154) in rural private hospitals. Given the low level of services in remote areas, it is little surprise that the infant mortality rate for rural areas is 79.7 per 1000 compared with 49.2 in urban areas.

In addition to debt from unanticipated occurrences such as a medical bill or drought, financial strain also arises from rural families spending for marriages, feasts, or other social ceremonies. If the daughter is due for marriage, her family not only pays for the wedding ceremony but also for the dowry which can range from 10,000 to 500,000 rupees. And considering the fertility in rural areas is 3.07 compared with 2.27 in urban areas, the chance of having to arrange the marriage of two daughters is higher in rural India.

Finally, it is essential to recognize that statistics are just that – numbers. Poverty can be just as debilitating when it is taken as a mindset. For example, I lived with a family in a village for two days and during conversation they said they were poor and wondered how I could live with them. I was surprised to hear this as they ate three meals a day, all the men were employed and their babies looked healthy. They have plenty of space in their concrete house and even had many goats. Over time, I came to find that their lifestyle met basic needs and they had little to no luxuries. One of these luxuries very much includes freedom, something that they see as effervescent in cities.

For women, this freedom and escape is even more evident. While housing and meals are consistent, their life is still very much subservient to that of the husband. Her life outside the house is limited and there was little to take her away from the duties of daily life (the daughter-in-law I observed left the house twice the whole day – once to clean the clothes and the other to fetch water). She never eats outside the house nor travels to cities because of the money associated with a vacation, where as for a man it could be work-related. Yet men very much view their freedoms as limited in villages as well. So while the appearance of poverty may have been reduced, there is still very much the feeling of mental impoverishment. And this mental poverty becomes even more entrenched with debt, unexpected occurrences, and the Hindu philosophy of karma and accepting the circumstances of your life.

Where the average daily laborer makes 50-100 rupees per day working on a farm, the idea that in the cities they can make over 500 rupees per day is always in their mind. If given the opportunity, many men migrate to cities, at times alone and at other times with their families. These migrants tend to make up the urban poverty, as they eventually find their home in slums or on the sidewalk. However, if they get a job as a rickshaw driver or helping to construct a hotel, that brings in more money in three months than would one year of village work. The ambition and dream of many rural boys and girls is to work and live in the cities.

The message I hope to come across is twofold. First, I hope to give a better understanding of the causes of rural poverty and why you may wonder where it is when you come to visit villages. Second, I hope to explain the differences between what poverty is like in rural areas versus in urban settings, and why so many prefer to live in an urban setting, where to us it may seem dramatically worse.

Alcoholism as a symptom of addiction

Hi. My name is Jeff, and I am an addict. When I was in college, I studied for the MCATs consistently, non-stop for four months. The more I studied, the more I kept on thinking about studying and the more I ended up studying. When I wasn’t studying, I felt that I should be studying to the point of being self-destructive. I was surrendering friendships and fun, losing touch with old friends and not making new ones, besides my MCAT books. My downstairs neighbor commented that she was often in our apartment hanging out but never saw me since I was never there. Instead, I was studying. I stopped exercising, started getting anxious, and I thought it was all normal and that it would only make the test go better. When I took the actual exam, I had actually studied too hard and could not physically put my brain through the verbal section. My brain was fried, burnt out, and said ‘no more’ at the time I needed it the most. I ended up doing poorly on the verbal section, forcing me to retake the MCATs.

My behavior was compulsive, progressive and self-destructive, all signs of an addiction. Was I addicted to studying for the MCATs? No, but my dependence on it does point to an underlying addiction. So how could I be dependant on MCAT studying without being addicted to it? This is an important distinction to make and one that is essential in my alcoholism and deaddiction project in Jamkhed.

What happens when our brain receives information? And how does that information then turn into action? Studies have come to find that our limbic system, or more specifically our amygdale, plays a large role in the actions we make. Previously it was understood that our feelings were simply derived from our actions, yet brain imaging studies have shown that the amygdale actually responds to information collected before the action takes place. Thereby, our actions are in large part a reflection of our feelings. This has had a great deal of importance in addiction medicine, showing that to truly treat an addiction you must go to the root of the cause, which involves feelings rather than simply thought and action.

In our life, we have both good feelings and bad ones. Both are strong, but it is usually the negative ones that burden us. These negative feelings derive from unhealthy relationships with friends, family, money, work, society and ourselves. These negative emotions exist in all of us and drive us to need good feelings, largely determining our behavior in life. With alcoholism, the good feeling is found in a bottle, with the drive to alcohol propagated by our underlying negative feelings. Alcoholism is thereby a dependency on alcohol to achieve that good feeling, similar to dependencies on gambling, drugs, eating, sex, exercising and many other behaviors. The dependency increases as tolerance increases and chemical imbalances create a need for it beyond emotion. Yet originally behind that dependency is a different addiction – a disease of our emotions in which we are reliant upon negative emotions. The dependency can change while the addiction remains, as often we find alcoholics who stop drinking but turn to workaholics, or who stop tobacco yet take on gambling, or quit eating and switch to exercise. The addiction has little to do with the alcoholism but rather the alcoholism serves as a symptom of addiction.

Further, studies have shown that similar chemical imbalances are achieved in the brain by alcohol, working, gambling, shopping, sex and drugs (1). This research has shown that the same pleasures can be achieved regardless of the dependence. The significance is that what is important is not the dependence which creates the pleasure but rather the addiction that drives the need for a pleasure. Therefore, removing the alcohol from an addict may remove that specific dependency but the addiction will drive the man to find a new dependant behavior. This is regardless of the fact that it may be much more difficult for a man to quit his dependence on alcohol or drugs than exercise or eating due to higher tolerance and cravings.

Addiction counseling and rehabilitation must focus on the understanding that the removal of alcohol from the addict will not solve the whole problem but that the underlying negative emotions must be addressed. Deeper examination is necessary of the addict’s relationship with the world around him and with himself. For this reason, the Twelve Step Program (used by Alcoholics Anonymous and other groups) is such a success. The twelve steps focus on the concept that that we are powerless over alcohol. To make amends, we must deeply examine ourselves and repair those relationships that have been harmed and harmful. It is a focus on examining the emotions and the struggle within ourselves, not with the bottle or with the actual dependency.

In Jamkhed, Friday and Saturday were spent with an addiction doctor and counselor from Pune Adventist Hospital. To update from a previous post Beginning part two of the alcohol and hypertension study: a 2^nd and more successful meeting was held with the village where hypertension was discussed, results from the study shared, and the issue of alcohol only touched upon. Connections were kept with the Indiranagar village as we identified men in the village who were open to discussing alcohol. A partnership was made with Pune Adventist Hospital’s deaddiction program and they just recently came to Jamkhed for a two-day session with our three counselors focusing on both theory and logistics.

At this point, the plan is for the counselors to meet throughout the week and continue to discuss the theory behind addiction, using AA’s The Big Book as a guide. Simultaneously, one of the counselors (a recovered alcoholic) will begin to meet with men from Indiranagar who want to quit three times per week, eventually taking them through the twelve steps. Once a solid group has formed, an awareness program will be launched and the Pune Adventist group will return to run a five-day detox center. Most importantly, at this point the outlook looks promising and achievable. If the steps as planned are taken, the project has a bright (although difficult) future for CRHP and the men who deserve the opportunity to quit drinking and treat their addiction if they so desire.

When we tell alcoholics that they are wrong and bad people, we are not only wrong about the alcoholics but we are lying to ourselves. We are all addicts. We all face feelings very similar to those of alcoholics, including fear, sadness, resentment, guilt, insecurity, egoism, irresponsibility and shame. The difference comes in our coping mechanisms, as we are able to deal with and hide these feelings from others and ourselves better than is someone who deals with alcoholism. Because of their impaired coping skills, these universal feelings are expressed more openly, allowing us to label and diagnose an alcoholic as some different than ourselves rather than examining our own relation with those feelings. Alcoholics are not mad or bad people but rather are sick with a disease of the emotions. A great first step in helping recovering alcoholics is to recognize that we are not so different after all, and we all face our own addictions.

These peanuts are making me thirsty

We walked into the farm beside the new hospital, bent down and grabbed out a couple bushels of plants with roots of peanuts. We sat on the dirt, removing the peanuts from the plant, rubbing the dirt with our hands, opening them and popping them into our mouths. Eating with friends was nothing new, but eating raw food straight from the source was something rarely experienced. At Jamkhed, it has been nice knowing where my food comes from and I have come to appreciate that relationship in health, both by respecting the food and understanding the conditions it came from. The relationship is important at CRHP and is imbedded into us while at Karkut Farm, CRHP’s local farm 20 minutes from the hospital.

All the food made at CRHP comes from Karkut, which I have visited around ten times. At Karkut, we often pick corn from the field and roast it in coal, watch farmers milk cows and place the milk into jars then brought to CRHP, see chickens lay eggs that are put into bags and then into omelets at breakfast, speak with farmers who till the land where eggplant is grown, or walk through fields of sorghum wheat. Karkut serves many purposes, one of which is to provide organic food for the Arole’s, guests and some staff at the CRHP campus.

The farm’s larger contribution comes from harmonizing our relationship with the environment and land. Karkut teaches villagers and farmers about farming techniques, focusing on those which foster a beneficial and sustainable relationship with the environment. Upon initial arrival to Jamkhed, the Arole’s found that men had a rather destructive relationship with their land, unsure of how to best utilize their space and have it provide for them, especially during drought. There was no leveling of land, no water harvesting and farmland was rocky. With the understanding that it was essential to have productive agriculture to reduce child mortality, for families to be happy and mentally at ease, and for nutrition to be discussed, CRHP started the watershed development program and farmer’s clubs. Farmer’s clubs were men who would come together and discuss new techniques and solutions to common problems plaguing their land and crops, as well as displaying good farming techniques. Techniques such as irrigation, farm ponds, proper spacing of land, co-placement of trees and crops and crop rotation are all exemplified and discussed at Karkut.

Karkut also provides the space to be inventive and experimental with farming methods that are affordable and natural. The earth provides for our own needs and when properly utilized can save the trouble, cost and danger of using products usually paid for. The Neem plant, for example, serves many purposes. When planted along the side of the road, it prevents animals from grazing and plant infections from entering. When converted into a liquid, Neem becomes a natural insecticide. When the branches are torn off, many Indians use it as a toothbrush. Or the Moringa tree, which originated from India and is commonly found throughout Africa. The seed pods have been proven to purify contaminated water. The leaves can be prepared similarly to spinach and are low in fats and carbohydrates but contain a high content of protein, calcium, iron, potassium and vitamins A, B and C. Additionally, soil fertilization at Karkut farm is done by worms that eat up old vegetables, soil and cow dung and poop out rejuvenated soil. Thousands of worms squirm away next to the farmhouse producing fertilizer within weeks and at only marginal cost. These methods are all experimented with on the farm and those that are successful then transferred to other farmers.

Karkut also works to reduce stigma associated with HIV/AIDS, as every female farm-worker is HIV positive. Karkut provides them with housing, stability, work and acceptance. This trend started in the mid-nineties when HIV positive women began to present at the hospital sick, stigmatized, alone and depressed. With food, support and love, these women serve an indispensable role in running and maintaining the farm. All receive antiretrovirals from the government and CRHP is not shy to tell their story and raise awareness about their success.

In urban areas, it is all too easy to become disconnected with our food and forget its origins. Living in Atlanta, Boston and New York, I would rarely think about where my food came from, how it got there, who was responsible for growing it, or how my own actions effect its growth. All that was important was my food getting to me when I needed it. Living in a rural area changes this view, not only by eating peanuts straight from the ground or walking on farmland, but from seeing how the rain (and lack of it) affects the mood of villagers, or how suddenly we will not be eating onions because the crop became infected and prices raised. The connection is especially strong from seeing how the health of children and families is dramatically affected by the weather. It is important both as a person and as a doctor to think about the behind-the-scenes view of the food we eat because it is usually grown right next door and plays a large component in our own health as well as that of our community.

It’s more than just a name

Before the money makes its hands into the pockets of local and national politicians, the ideas behind the money make its way into headlines and speeches that dominate the news before elections. Each Indian has the right to vote and the dalits (untouchable caste) comprise over 16% of Indians. This population is thus targeted during the election, showing that while the caste system has been banished upon independence from Britain, the entrenchment of it in every way of life is still very ripe. Programs dedicated to raising the status of India’s poor, providing them better education, housing and food security all appear. This year the message focused on infrastructure, namely roads and electricity, defined as the hot topics for this election.

Election Day is a madhouse, with a good rate of turnout from all castes and both genders, upwards of 55% in Jamkhed. Advertisements to vote dominate the radio and speeches are made in many villages and towns pre-election. On Election Day, party representatives line the streets handing out money and attracting swing voters. This year’s election is dominated by three parties: United Progressive Alliance, National Democratic Alliance, and the Communist Party. The UPA is largely formed by the Congress Party, started by Nehru (India’s first PM) and Gandhi and synonymous with Indian politics for the last 60 years. NDA is largely formed by the BJP, a more fundamentalist Hindu party attempting, among many other things, to restore power to the Hindu population. The Communist Party is formed by three to four smaller parties on the basis of secularism, including no casteism, in addition to opposing globalization and U.S. relations.

The party that has been most helpful to the dalits is the Congress Party, although many programs instituted to help the neediest of Indians have failed to make their mark, as only 1% of India’s GDP is spent on health while malnutrition is suffered by 55% of children living in rural areas and 45% in urban areas. The caste system is supposed to be banned yet still exists, according to Dr. Arole, in the mind of every Indian in every village. Although land is supposed to be distributed equitably, much of the good farmland in Maharashtra continues to be controlled by Brahmins and Marathas (upper-caste Hindus) and worked on by dalits and Muslims. Although inter-caste and love marriages occur, every parent I have met seems to be faced with the incredible difficulty of pairing their son/daughter with someone on the same caste. For one lower-caste family at CRHP, their daughter is enrolled higher education and they are having difficulty finding a son-in-law in their same caste but of reputable education and standing.

The caste system is set so that it is nearly impossible to escape a line of work simply based on your last name. In Jamkhed, ‘Dadar’ typically cleans roads and works for the municipality, ‘Shindi’ are businessmen, ‘Madari’ are snake-charmers, and ‘Dukre’ are stone workers. It is possible to escape and create your own name, but on the contrary it is sometimes said that this delegation of responsibilities according to last name is good and useful for India, ensuring that every task is accounted for. However, when a system institutes a profession from birth with little chance for individual thinking and felt opportunity, human development becomes static. Much has been written about the social structure of India with its caste hierarchy but a system that enforces a subcaste to clean bathrooms and carry a bucket of human feces on their head keep the spirit stagnant and ignored.

Saying the situation today is as bad as it was when CRHP first entered villages in 1970 is incorrect. When Drs. Mabelle and Raj Arole first went into villages, caste was one of the greatest barriers to overcome and enable health. Low castes usually lived in the outskirts of the village, on area owned by landlords who lived within the village. Dalits were often not allowed to enter the homes of the high caste, or if so, could not touch anything. In some villages, dalits were prohibited from drawing water from the common pump, waiting for a high caste member to come and pump for them. They would not drink from the same cup of water, afraid of contamination. In school, the children would play among their own caste and sit in sections according to caste, at times only taught by teachers from their own caste. Malnutrition and disease was much higher in the dalit section outside the village. Further, the system was reinforced by a belief that this discrepancy in life was deserved from a past life and justified by a belief of moral superiority of the high caste.

To overcome these caste barriers, CRHP used unique techniques. One was use of a water diviner, who was encouraged to place a water well only in the dalit section of the village, forcing the high caste to walk into this section and confront the realities of other villagers. Children were used to break false beliefs about contamination as different castes would bring water from their homes to pour into a cooking pot, sharing the common food together. The village health worker, commonly a dalit, would display her value by entering high caste homes, delivering high caste babies, and proving necessary to rid villages of disease. Over time and with the help of villagers and awareness campaigns, caste discrimination has been lessened while caste distinction still remains. In non-CRHP project villages, caste discrimination continues to remain and CRHP has had to drop projects in some villages because the issue of caste could not be overcome. Government programs plentifully exist that attempt to raise the status of the untouchables, many initiated by Dr. Ambedkar (a hero among Maharashtran’s – his portrait can be seen on the wall of every village house) but it is fascinating to see how villages and events utilize caste to their advantage.

Swimming in sweat and sunscreen, attempting to deal with heat delirium

Today it reached 115 degrees Fahrenheit. Yesterday it was cool at around 98 degrees. For the past week it has consistently been over 105 degrees. It is a different kind of heat then I am used to, as it is not humid but simply direct from the cloudless sky and constant all day and night. It is debilitating heat, where you have to work to get through it. Resting makes it worse so you must work to try and ignore it but it always seems to be a losing battle. It is quite amazing how much less productive the heat can make you. There are no air conditioners except in some rooms, where at times we huddle together to keep cool and find ourselves getting five times more work done.

If you walk around at one o’clock in the afternoon, you typically find one of two sights: either men lying down under a tree taking a nap or women working in the middle of a farm working. Both acts at 1pm are amazing. The farmer is amazing for being able to work in the heat in the middle of the day, wearing pants or a cotton saree. The napper is laudable for being able to simply sleep more than fifteen minutes. Some days I try to make it through a whole day without taking a nap but rarely last past three o’clock before being drained. However, taking a nap leaves me swimming in my own sweat after fifteen minutes, searching on my bed or chair for a dry spot, trying to ignore how I am more delirious now than before I slept.

A byproduct of the heat are snakes, which have been appearing in high numbers for the past couple weeks. They usually appear in the early morning, around 6am to 7am, when they search for food or a cooler area to spend the day. One morning I was sitting outside my room reading when I heard a rustling behind me. Looking back, I saw nothing. Ten seconds later I heard the rustling again with a hissing sound. Coming around the corner towards my bench was a five foot rat snake, squirming its way quickly. I jumped up and followed it as it made its way right in front of my room, bumping its head against my door. After yelling out “sapa” [snake], a staff member came out of his room with two sticks, handing one to me. On the concrete the snake had great difficulty moving and we were able to handle the snake with little problem. The next day there was another snake outside the staff housing, and three days later a king cobra was found in the evening. I only saw it after it had been badly wounded by the guard who fancies himself a snake-charmer, but the sight of it fully upright was awesome.

The hospital has thus seen an increase in snakebites, complications ranging from two little marks on the ankle from a non-poisenous snake (like a rat snake) to a hemotoxic bite (most due to vipers) causing necrosis and kidney damage to paralysis from a neurotoxic bite (most due to cobras). One patient in the hospital now has swollen hands, paralysis and kidney problems caused by the crate, the most dangerous snake in the area. In addition to snakebites, more patients with severe diarrhea have been presenting in the hospital. It is unclear exactly what has caused the increase but logic seems to say that people are drinking dirtier water since there is less of it. Finally, the heat gives a lot of trouble to pregnant women, especially if they are actively working. They lose water at a rapid pace yet need it more. The doctors are working hard to educate the pregnant women as to the risk factors of working in this heat.

Every year from April to early June, everything seems to just stop around one o’clock in the afternoon. Patients increase in the mornings and afternoons, but mid-day there is a lull, and even the doctors try to catch little naps to reenergize. Farmers have much less work in the fields and are at home more, and kids are off from school and usually running around CRHP throwing stones to knock down almonds from the tree or riding adult bikes too big for them. The women still work very hard, getting water and taking care of the house and kids, cooking and sometimes even tending to the farms. While it has been difficult to get through, understanding how Jamkhed and CRHP make it through these months each year is also an educating experience.

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.