Earning your Rupees

(Tuesday Night)

Tonight was a good night. It was a night that serves as a perfect example for the importance of education, and the perfect conclusion to my internship with Pratham. During my time interning at Pratham, I have seen what can be done to ensure quality education for all children, I have seen how it can be done, but I did not have the opportunity to spend enough time in the field to understand why it must be done. Tonight, I have finally realized what education can offer these young children.

I was on the train at 8pm going to visit some friends, and two little beggar children had jumped on right behind, nagging me for money. The train was relatively empty since it was after rush hour, and I was sitting in the less crowded women’s compartment. I have gotten quite used to being pegged as the compassionate tourist who quickly doles out money with one pleading look, but I have also learned that if you give money to one child, many others start crowding you, asking you for money. Besides the discomfort of 10 little children surrounding you telling you they’re hungry, I have also been told that many of the children work for an underground system, and that the money you give them doesn’t actually go to them at all. For these reasons I have become quite wary of handing out a few rupees here and there, even while my conscious is screaming to help them.

Sitting on the train, trying to ignore the little boy tapping my knee, my conscious was again longing to give the children what they wanted to pacify their pleading eyes.  Finally, once the boys realized I wasn’t going to budge, they began talking among themselves and exchanging pieces of the crackers they were holding in their hands. Every once in awhile they would catch me looking at them and give me a big warm smile. I smiled back and asked one of the boys if he knew any English. He began to count to 10 in English and the other younger boy quickly joined in. I had learned to count to 10 in Hindi, and after they finished I stumbled through the Hindi numbers with their help. They absolutely loved showing me what they knew, and they loved teaching me even more. Soon I was using the telephone numbers in the advertisements on the walls of the train to test the boys on their recall time, and we soon had made a game of it. I was almost at my stop and I told the boys that I would give each of them 2 rupees if they could correctly recall all the numbers I pointed to in the advertisement. They eagerly agreed and worked hard to get the numbers right. We were all so absorbed in the game that I almost missed my stop, and had to jump out after the train had already begun moving again. The children followed me out and as I had promised I gave them each 2 rupees. It may have been my imagination, but the boys looked proud of the money they had earned, and they didn’t ask me for more. They understood that at least with this American tourist, they had to work for the money I gave them.  Smiling and telling them good job, I was suddenly reminded of my grandfather who always rewarded us with a few dollars or a gold coin if we memorized a poem, or earned all “As” at school. He never believed in just “inheriting” money or simply giving it away. I always thought he was a little cold for doing so, but now I understand it goes both ways. Money takes on a whole new meaning when you have earned it yourself, and your self-image and self-confidence change drastically in the process. On a very minute scale, I caught a glimpse of what Pratham does through its focus on quality education for hundreds of thousands of children in India. I realized that educating them isn’t only to provide them the basic skills needed to secure a job, but also the personal and interpersonal skills necessary to develop their confidence in their own capabilities. The education that these children receive through Pratham develops discipline, commitment, and self-worth, keeping them off the streets and bothering sympathetic travelers like me. 

Visiting the wards

This week, I drafted a questionnaire and current inpatients who were insured by a scheme were interviewed at the Narayana Cardiac Center. I was up on the 6^th floor in the general ward. There, patient’s beds lie next to each other, much like an emergency room. Patients have the option of upgrading their rooms to shared double rooms, private rooms, and even executive and deluxe style rooms. However, this comes at a cost that many scheme-paying patients simply cannot afford. The questionnaire I drafted had information regarding age, gender, occupation, role in family, patient income and expenditures, family income and expenditures, level of completed education, community support, duration of illness, and existing burdens.

One of my biggest roadblocks included the questionnaires themselves. My research head decided that the best place to pull participants was from within the hospital itself. I interviewed current inpatient using a translator as my aide. This proved to be difficult as some of the participants became unwilling to provide information about their financial status partway through an interview. I think it’s possible that they feared aid being rescinded if they happened to make more income than they were supposed to. Another roadblock was finding eligible candidates for my study. Many cardiac patients were typically older, nominal heads. The nominal head was typically a retired grandparent who garnered respect from the rest of the family, but was not oftentimes involved in big decision-making discussions. They didn’t often have a comprehensive view of what the family finances looked like. Many patients had adult children (who were likely functional heads) accompanying them during their inpatient visit. My translator avoided all contact with any patients who had accompanying adult children nearby because he told me that they would cause trouble for me and ask too many questions. He insisted that they would be more trouble than they were worth. I worked with what I could and conducted my interviews with what was available to me.

 I preferred to conduct my interviews with the functional head of household over the nominal head because they tended to have the most information about the welfare of the family. Nine cardiac patients were sampled and the families had and average of 4.6 children each. I was surprised to see that the completed level of education for participants was so broad. They ranged from 3^rd standard to a B.S. C. Family monthly income was also very broad with a range of 2000 rupees to 50,000 rupees a month.

                                                                                              

Every participant claimed to have expenditure costs that were greater than their level of income. Despite the fact that private money lenders and self-help groups exist, patients insisted that these were not options that were available to them or options that they would consider. When money became a problem, they sold the land and jewelry they had and depended on their joint family members and adult children to aid them in their times of need. Family cohesiveness truly appears to be one of the most important values that upheld in the subcontinent.

I found that all patients reported that had they lacked an insurance scheme to ease at least some of the financial burden, they would either not be seeking treatment at a renowned institution such as Narayana Healthcare Hospital or pursue alternative methods of treatment such a managing their healthcare problems with medicines instead of more permanent and ideal treatments such as surgery.

The Mazumdar-Shaw Cancer Center where my research takes form.

Also, I had the honor of attending a traditional Indian wedding! Indian wedding festivities take place over the period of multiple days and are often large-scale affair. I am told that it is not uncommon to have 1000+ guests. In the past, wedding invitations were often addressed to the invitee’s “family and friends” but today, many people are scaling down and limiting the events to guests and their family members. It seemed that many of the attendees were unknown to the bride and groom themselves. The bride and groom sat on a decorated sofa on an adorned stage for most of the event. The bride wore a traditional red sari with lots of bangles and henna that went above her elbow. The bride and groom wore garlands made of jasmine and roses. Throughout the night, there were a variety of dance performances put on by close friends and family members of the wedding party. The bride and the groom put on the final performance to end the night.  While I didn’t recognize many of the songs, it was an amusing surprise to recognize Gangnam Style blaring over the speakers. Overall, the experience was quite pleasant. I was able to sample an array of spicy, yet delicious Indian foods such as gobi (cauliflower) and chat.

I’m wearing a traditional Indian Anarkali dress and some glittery bangles here. 

Settling in the Garden City: Bangalore

Last summer, I spent many Thursday evenings eagerly waiting for my father to arrive from work. We would have dinner and then promptly plop down in front of the iPad. Our Thursday ritual was watching the Al-Jazeerah Network’s Indian Hospital, a documentary about Narayana Hrudayalaya (now renamed Narayana Healthcare this month), one of India's biggest multi-specialty hospital chains that uses large economies of scale to bargain down the cost to supplies and care. The institution, situated in Bengaluru, India, is able to offer holistic healthcare at a fraction of what it costs across the globe, while remaining a world-renowned institution for care that is both profitable and growing business. Typically, most healthcare institutions are geared towards making money. This one is geared towards serving the socioeconomically disadvantaged. I was touched by the story of an almost paralyzed man who received a cornea transplant despite his deteriorating condition. While he was almost paralyzed, creating music was his passion, so his ability to read music was essential. It wasn’t long before I was enamored. I told my family that I would one day visit the place, and today, here I am!

I would like to thank our generous sponsor and everyone at the Center of South Asian Studies that made this opportunity possible. My objective is to research how the practices of this hospital have changed the lives of socioeconomically disadvantaged patients. Dr. Paul C. Salins, director of the Mazumdar-Shaw Cancer Center and Dr. Biju Jacob, Head of Research have been mentoring me throughout my journey. My journey to the hospital begins early in the day. While the hospital is on the outskirts of the city, I am staying closer to the center, which means a grueling one and a half hour journey each way. In the beginning, my work was predominantly to gain an understanding of poverty. Dr. Salins quickly decided that the best way to do that is to experience it firsthand. I arranged a visit to the Biocon Foundation, an organization that has health clinics all across rural India. The foundation offers an insurance scheme to patients that make a certain amount of income. The scheme covers outpatient visits in the clinics available and treatment at tertiary centers like Narayana Hospital. My site observation was at the Biocon Foundation at Houskur, Karnataka. To truly understand poverty, Dr. Salins asked me to understand the structure that an Indian family typically takes, the family dynamic, the kind of support that a community offers to a family, and the costs that are associated with an illness when a patient does or does not have a microinsurance scheme to support them. I met Ms. Gracy Thomas at the Biocon Foundation and we took a company bus to the site. The clinic was situated in front of a temple, and I quickly got to know how important religion and rituals were to the community.

 

Hindu temple in front of the clinic

The Arogya Raksha Yojana  clinic in Huskur that has a comprehensive health insurance plan and subsidized medicines that offer the people of rural India affordable access to high quality healthcare.

Unknown to me naïve me, the pool of red on the floor that everyone was trying to avoid stepping in was not some sort of festive colorful dye, but blood from the 24 goats that were sacrificed the day before for a festival. My first day there, I did not get to have very much interaction with patients because many were either involved with the festivities going on or tending to their crops because it had rained the day before.  My subsequent visits provided me with more insight about the residents of Houskur and poverty in general. I found out that agriculturists made up 70% of India’s work force. In Karnataka, India, the state where Nayarayana Healthcare Hospital is, this statement holds true despite the fact that the land is not very fertile.  To aid these agriculturists, the government and companies such as Biocon have created different microinsurance schemes that allow farmers and patients below the poverty line to have insurance that costs from about 10 US cents a month to nothing. Despite this, there are many who have not enrolled for such schemes and cannot reap the benefits. When an illness hits families without coverage, the result is debilitating—families are left in poverty with no chance of escape.

During my site visit, I also learned that joint families are a commonplace in India. Homes are multigenerational so that children can more easily take care of their parents physically and financially. However, this is not always the case. Like any family, tensions can arise, which makes support hard to come by. When this happens, families have to resort to borrowing from sources such as private money lenders that sometimes charge 100% interest. For a family that is already poor and desperate to keep their loved ones alive, the choice is difficult. I learned that while the cost to treat a child or an adult may be the same, the effect on the family can be very different. When a child is sick, the net income may not take a hit as bad as if the breadwinner is the patient. I also found out more about the microinsurance schemes that exist. When a patient does not have a microinsurance scheme but seeks treatment, hospitals such as Narayana may have philanthropic care to offer them. However, there is still a fee (approximately 40,000 rupees or so). If the patient cannot pay this subsidized fee, does not have a microcinsurance scheme, or the hospital simply cannot handle the volume of patients that need philanthropic care, the patient has no choice but to go home. Even with a scheme to pay for treatment, families still experience burden both financially and emotionally. Many of the schemes do not cover all aspects of healthcare. Oxygen, ventilators, stents, and chemotherapy are just a short list of necessities that are not included in schemes. Additionally, patient’s families must arrange for lodging, food and transportation when their family member is sick and that oftentimes also means that they cannot be earning while looking after their loved ones. My next plan of action is to draft a questionnaire and speak with researchers to understand how to ask sensitive questions and get the information I need.

Final week in Patna

My final week in Patna has been a memorable one. It was spent collecting quanititaive data on the rickshaw pullers under Sammaan, regarding their health, income, education and socio-cultural aspects of their lives. From the knowledge of the staff and the Sammaan database I was able to observe trends regarding the situation with rickshaw pullers over the 5 years since their inception. Additionally, I had formed a survey, along with an intern at Sammaan from Mumbai who is doing similar work here, asking a range of questions pertining to these issues and reached out to as many rickshaws as possible. It was definitely a challenge to get to interview rickshaw pullers as they were not easily available. My greatest privilege however, was conducting a much more detailed interview with one of the on-the-ground managers. His name is Santos and was previously a rickshaw puller who signed on to the Samman program on 10th June, 2007( he recalled the exact date). Using the new resources and opportunities available to him; a savings account, an enhanced rickshaw preferred by passengers, skill training, free healthcare services etc, he eventually worked his way to becoming a manager now in charge of grassroots outreach to new rickshaw pullers and organizing the activities of new entrepreneurs. Who better than a living testimony to reach outh to conventional rickshaw pullers strugling to make a means to live! His story is a perfect example of the lasting impact that signing on to the Sammaan program had on various parts of not only his life but that of his family.

Santos and I

Regardless of the busy schedule, I managed to do a bit of last minute shopping for family back home in Kenya. The weekend was spent saying fairwell to new friends made at church, the guesthouse and of course the Sammaan office. It was emotional and I may have promised some that I'd return so looks like I have some future planning to do! I am very thankful for the hospitality shown by the church members of Patna Seventh-Day Adventist Church and the staff of the Club 10 guesthouse. When I've not been at work, they have kept me entertained and exposed to and interacting with everyday life in Patna. Listening to their own stories were probably where I gained the most, learning from their life experiences in this immensely different and unique nation. Yet I could still take lessons from them and apply them to my own life. We're all human after all.

I am particularly grateful however, for the lessons learnt from working with the Sammaan staff. They are a super busy lot, working sometimes 7 days of the week. I leave them as they currently work with the state government on an innovative ambulance service project in the state of Bihar. They have taken up a number of other development projects and it has been truly inspiring learning how easily change can be manifested through choosing the right partners to work with, being determined and working hard, keeping to set periodic goals. As much as my eyes have been opened to the urging problems that exist in the poorest state of India, the abject poverty seen in various parts of Patna, I've also seen the changemakers; social entrepreneurs, parts of the state government, rickshaw pullers and regular citizens, who are tirelessly fighting to implement solutions to reverse the effects of the issues countless Indians face. They are definitely moving forward. I wish them the best as I now travel to Delhi for a few days of touring, elaborately organized by Azad ( a fimlmaker, scripwriter and brother to the Sammaan founder) who does part-time on and off work with Sammaan. I plan to visit Agra, and Ranthabore National Park in hope of spotting the famous royal tigress of India: Machali.

Forced to be in the pic with these 3 new entrepreneurs earlier last week

Photo with friends from church

Some of the Sammaan staff, most looking at the other camera!