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 I think it’s possible that they feared aid being rescinded if they happened to make more income than they were supposed to.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!

Only one more week with Pratham!

I have just finished a 17 hour train journey back from Delhi... and im exhausted. 

This past week has been a challenging, and frustrating one, but also one where I have learned some good lessons. On Monday I got to office a little early like I usually do to read online articles for my research and couldn't find the word document where I had been keeping all of my notes. It just wasn't there and all the carefully saved weblinks, and bullet pointed facts in addition to the phone numbers and contacts I had carefully saved were all gone. I did everything to try and recover the file, but my computer just said it couldn't open the encrypted document. Like everyone does in this situation, I beat myself over the head for not saving my work in an online google doc or backing it up through email. But also like everyone knows, this never helps the situation. Instead, I took a deep breath dove into office work and decided to start again tomorrow. Thankfully the day got much better when my colleague, Pratyush, called my name and handed me a large stack of completed surveys that I had given him the week before.  I had been struggling to get enough people to take my survey, not to mention a diverse crowd of people, and had asked my NGO if they could send my survey to members of their field staff including teachers, tutors, administrators etc. Many of them are not very highly educated and thus with the help of my friends in the office, I had translated the survey into Marathi, the local language in Maharashtra, and handed over 80 copies. I got back 75 copies that I will be able to add to the 20 or so that I will get from my online survey, the 30 or so that I will get from the office and the 25 or so that I got while harassing people in the mall. This news greatly improved my day and I tried to stay positive and remind myself that all the work I lost can be recovered.

I didn't have much time to start on the research again the following day because my team and I prepared to leave for Delhi. We were getting on the train that night and would arrive in Delhi the next day in the afternoon. My NGO graciously paid for my train ticket because it was a work trip, and I quickly prepared the Delhi surveys that I hoped to get filled out while I was visiting the Pratham, Delhi office. The 3 day trip was a success and I returned home with about 30 Delhi surveys filled out and a lot more knowledge about interoffice politics. Throughout this entire month working with Pratham I have learned some valuable skills when it comes to working with other colleagues, especially ones who are older and more experienced. I have also observed how toxic a disliked member can be for the rest of the team. I have loved getting to know the colleagues in my office in Mumbai, and their passion for what they do inspires me everyday.  Even though I haven't been able to get out into the field as much as I would have liked, I have made the most of my time in the office. Below is a picture of me with my colleagues after we all went out for lunch.

 4 down, two 2 go.

Spending a month in India has not been akin to spending a month anywhere else. It goes by…really fast. I have come to the realization  that I came to India at an impeccable time in relation to the progresses the rickshaw pulling sector in Bihar has been taking. About a week ago, the Chief minister of Bihar announced that the state government is going to launch a Rickshaw Puller cooperative sheme that is going to affect at least 7.5 million people statewide. The considerable success of organizations such as Sammaan and others working with the rickshaw pulling sector have proved that there are viable solutions to be applied to the current condition that Bihar’s 1.5 million rickshaw pullers and 6 million dependents persist in.

Not only has the government adopted this innovative shceme but they plan to get it up and running in time for an official launch on Muhatma Ghandi’s birthday on October 2nd. With this being said,  Sammaan has gotten straight to work having been given the duty of helping develop a comprehensive draft proposal for the cooperative scheme and an additional presentation for a meeting soon with the Chief minister of Bihar this coming week. This week has been quite hectic as I’ve been given the privilege to help out with the proposal and more especially with the powerpoint presentation that will have to look attractive and engaging for the Chief minister. It has been an awesome learning experience participating in such a potenitally massive step for the state. This current project has allowed me to see how dedicated  the Sammaan staff are to their work for the sake of the rickshaw pullers. In spite of this,  I would’ve preferred to have had more time spent to continue with data collection from the rickshaw pullers. Accessing the rickshaw pullers has been quite a difficult since they are also hard at work during the day as they are all around town making a living. As much as I would hate to interrupt their schedule, this week will be spent trying to get into contact with as many of them as possible to get direct testimonials and information regarding the strides they have been making with the new resources, opportunities and services they have access to through the Sammaan program. So this next week should fly by quickly once again with lots to do. I plan to complete my data collection and spend the next 2 weeks moulding my investigation to suit the resources that I will have the most access to with the short time I have left. 

Today, a member from the church I've been attending here in Patna invited me for his son's birthday get-together. Here is a photo with some of the kids present at the party. The hospitality was sheer brilliance, a really heart-warming (and stomach-filling) experience.

A week on the ground

This week was very stimulating having conducted my first proper field visit to witness some of the ground work Sammaan Foundation has been doing and to get a chance to interact with the beneficiaries i.e. the rickshaw pullers under the program. Most of the field visit however, was spent observing. In order to truly understand the existing need for intervention and change of the condition of Patna’s rickshaws pullers, I had to first realize the initial condition in which many rickshaw pullers persist. Being migrants from the rural districts, these pullers do not have the right circumstances to gain suitable housing while they work in Patna. As a result, we found multiple pullers, some with families, camping by the roadside, having pitched temporary tents and made for themselves an operational livelihood. This is where they reside when they are not working and they are often forced to relocate by the police, as there camps are not fit for the site of some politicians who may drive by these same roads.

Rickshaw puller camps by the side of one of Patna's main roads

The state government had however, intervened a decade ago and managed to build night shelters for the rickshaw pullers. These shelters meet the bare minimum need of protecting them from the rain and much less. With the increasing number of rickshaws in town, these shelters can only hold so many rickshaws so more and more are forced to vacate to the roadside camps. With little financial liberty due to fleet owners having control over their finances, they struggle to gain a means to change their situations and persist unpleasantly in the city until they return to their rural homes for the harvest and sowing season.

 Night shelters built by the government a decade ago

The interior of the night shelters built for the rickshaw pullers

Luckily, that same day we visited, I had the privilege of witnessing five rickshaw pullers, who had signed up to the Sammaan program a month ago, receive their new rickshaws and saving bank accounts at the local state bank. I was able to witness this fascinating process as the beginning of their entrepreneurial journey as they were congratulated by bank managers for having taken special loans to purchase their rickshaws forming a direct financial relationship with the banks keen on assisting them to gain financial liberty. Every fifteen days, rickshaw pullers are signing up under the Samman program and go through the same process of being connected to banks and members of society that will allow them to develop their own personal relationships and give them the independence and confidence to strive to uplift themselves soci-economically.

A rickshaw puller receiving his passbook and Sammaan rickshaw puller ID from a local UCO bank manager

Photo with rickshaw pullers, Sammaan staff and UCO bank staff

Rickshaw pullers about to start their entrepreneurial journey with their new rickshaws and resources

I had also had the privilege of hearing that after five long years, the state government has finally agreed to adopt the Sammaan model and implement it on a larger and state-wide scale, which could potentially affect all rickshaw pullers in the state of Bihar. Government support and funding is key to bringing people such as the rickshaw pullers to trust that enrolling in this program will be a worthwile and positive investment.

As far as my research goes, I am due to visit the field again and perform case studies on individual rickshaw pullers who have been under the  Samman program for some time now, to learn the personal impact they have had since they embarked on this journey. It is difficult to get a hold of them as they are very busy out and about at work and this may make data collection a bit more difficult but I am sure to work a feasible method out with the Samman staff and their beneficiaries.