Belated update

I feel chastened. I was too busy having a great time in India to keep the blog updated and although I did go out there for a holiday (driving from Vellore, Tamil Nadu to Chamba, Himachal Pradesh) I also did some work so I stand corrected about my neglect.


Ostensibly, I went out as part of my cunning plan to "encourage" RUHSA to finish the building works on the CHEW (Community health education and welfare) buildings in which we were planning to start two other elderly welfare centres. Ie, the cunning plan was to announce a Grand Opening (with photo opportunities) in order to create a deadline to be met, rather than an open-ended timeframe. Oringially the Grand Opening was planned for August, then it was moved forwards to July and finally, much to the distress of those whose responisbility it was to actually deliver the goods before the deadline (ie not the person who was swayed by the thought of the photo opportunities) it was brought forwards to June. So the date was set that two trustees, Dr William Cutting and myself, would come out to open the CHEW buildings at Kovasambet and Sholamur respectively on Monday 22nd June. William would then go on to other meeting whilst I went on to other fun.


Prior to going to RUHSA, I met Celine, who has the women's refuge centre/Home of Compassion in Bangalore. We are trying to set up a website for her so people can donate money to her work. Her aim is to establish a core capital fund, from which there would be interest and income generated to enable her pay for any children's schooling, so no-one remains disadvantaged by circumstances. So far she is already paying (with some sponsorship) for about 7 children's schooling. And she is fussy, the cheapest school will not do, she wants the best. This still only costs about £300 a year, but that is a substantial amount to find if there is no income. She also thinks it is important for women to have some possessions of their own to take into a future marriage with them, even if this happens many years after they leave her care. As these women usually arrive with nothing, the only person who can provide these - usually it comes from the brides family - is Celine, who becomes their new family, often. As soon as the website is up and running I will post it. It is looking good so far.


RUHSA had planned a full and interesting day for William and myself. In the morning, there were the ceremonial openings, Willam opened the building at Kovasambet and I opened the Sholamur building. I even have a plaque which was revealed by pulling on a little curtain! After I opened the curtain I had to cut the ribbon into the building.

Unfortunately, someone had forgotten to arrange for a pair of scissors, so for a while, I thought I would have to improvise and gnaw through the ribbon with my teeth. Eventually, with much puffing and panting, a local teenager ran back from the village carrying a huge, blunt pair of comedy scissors. It took a while to get through the ribbon. I think my teeth would have been better and it wouldn't have given me RSI on my wrist.

We also visited the original health centre where the elderly are enjoying the fruits of the goat scheme. Several goats have had two kids, enabling the owners to give one back to RUHSA as part of the pass it on scheme but also sell one to make money. I was a bit concerned that we might simply have generated a means of causing several fractured neck of femurs, as the goats yanked their frail owners towards something tasty looking (see left), but apparently they all know when to let go of the rope. The picture on the right shows a couple of generations of goat owners.

After the Grand Openings, William and I had a series of very interesting meetings with Dr John, Dr Rita and the RUHSA team. There are several very exciting new projects on the horizon, the two most gripping for me are the mental health developments and the microfinance project. Mental health has been a significantly under-resources aspect of health (sound familiar) and of course there is some serious pathology out there. I heard about two twin sons who have developmental delay and mental health problems and who are now physcially grown men. the only way thei family can manage them is by tying them up every day to prevent injury to themselves and to others. The first phase of the mental health project is to identify the most serious, behavioural pathology and treat what is possible. This is already starting, but there is a great need to harness community support, because medical treatment is not the complete answer. So Annie, who is one of the Community Health Physicians, is trying to develop programs to utilise community resources to increase the management options for people with mental health issues. I look forward to getting involved with that in January.

The microfinance project is also very exciting. It capitalises on the uniquely uncorrupt reputation of RUHSA and the relationship of trust between RUHSA and the local community. The plan is to create a Federation from a few of the most successful self help groups and using funds from the VRCT Trust, enable them to loan small amounts of money to local groups who want to set up their own SHG. RUHSA would not be in charge of the money, nor indeed be giving the money, but passing the donation on according to the small business proposals. The Federation would then be responsible for collecting the repayments. Part of the agreement would be that they would have to contribute some of the money recouped for local charity projects, thereby reinvesting the moeny into the community - eg keeping the elderly welfare centres running, but would then be able to keep the profits, whilst not losing the capital. It is a brilliant idea and only one which can work because of RUHSA's long history in working for the local area. By january, I think there may be some real development on this.

As for my holiday. I won't bore you, but I had a great time. The middle of India was very hot (52 degrees C) and the top of India was very beautiful. It was too short, but not long before I go back again. I think I'm addicted.

A treat....

From balmy PK Puram to Snowy London*

Am back in the UK now, after a blissful week travelling around the western ghats and Indian Ocean coastline relaxing and trying to get a tan. I have managed to get a good hand tan, but my face just looks dirty. I am slightly concerned that it will in fact all wash off in the bath, which makes me reluctant to have one. Think it's getting to the point I need both metaphorically and literally to take the plunge. All in all this trip was much more of a success than I ever expected. I was quite pessimistic about what I would find, how I would be greeted and what I would do, but in fact it has surpassed expectation. Of course, there was the minor hiccup of no-one knowing I was coming, but I was half expecting that, given previous form. However, unlike last year, they did seem more pleased to see me! Once the initial hurdle of getting my room ready, everything was fine. In fact there were some advantages to coming unexpectedly because no-one polished things up to present to me, I saw it all in it's unprepared state and the elderly centres really have a life of their own now and look like being an easily replicatable model. The group from Bishopston in Bristol, who are setting up a play and teaching resource centre want to use one of the spare rooms for a similar elderly welfare . The exciting potential consequence for this is that there will be a juxtaposition of the elderly and very young. One of the ideas about the sustainability of the first centre was to use the physical presence of the elderly as a kind of baby sitting/creche service. This did not seem very culturally acceptable at the time, but the propinquity in the Bishopston centre may result in a natural evolution of this, making it much more acceptable and therefore, potentially be used in other areas. So another really exciting avenue is opened and we will see how it develops. In addition to this, building works have actually started in the new centres, there will be a "Grand Opening" in August (ploy to accelerate the building works), which will give me an exucse to come out again (hurrah), although for a shorter time (boo). Here are some pictures to show works in progress.

Of course the other interesting development is the mental health project proposal. During my last couple of days there I attended a couple of lectures on mental health in the community which were fascinating. Suicide is a huge problem in India, although studies suggest that unlike in the UK, the proportion which are due to mental illness is only about 1/3, meaning 2/3 probably commit suicide for socioeconomical reasons. In addition, unlike the developing world, more women than men commit suicide and of those there are 2 peaks, the first, horrifyingly, is in the 15-25 age range and the second in the >65y olds. This is such a waste of life. Most people who commit suicide do so through quite definitive and likely to be successful means - poisoning, eg organophosphate poisoning, drowning, hanging. The implications of all this are that there need to be significant population based approaches to prevention, for example more sociostructural support, outlawing of poisonous substances etc, rather than simply measures targeting mental health, because these measures would only capture a small proportion of people who commit suicide.

Interestingly, the lecturer mentioned, as an important strategy, the need to map community assets. Very excited I went up to him afterwards and asked what research had been done in this area. None, he said. Ah, well, that is both disappointing and thrilling. I look forward to cutting a wave (or falling flat on my face!)

*attr. Lot Onslow in sms circa 2007

Signs of the Times

Just a couple of photos to entertain everyone.

I saw this when going to buy the tickets to the jungle. I thought it most appropriate.

This is the sign for school children crossing the road. The fear of imminent death is plainly conveyed even in this monochrome silhouette as the child pegs it across the road to dodge the lethal traffic.

Concentration at Kovasambet

Today I went to Kovasambet, which is the village in which a second elderly welfare centre has started. I went once before in March, but only briefly, and I have not been directly involved in the setting up of this centre, so the participants have no idea who I am. This model is different to the Keelalathur model. Trying to minimise the dependency we created in Keelalathur, there is no midday meal only mid-morning snack. The caretaker is more proactive than Jamuna and leads them in a program every day of prayers (Hindu), exercises and reading of news. They sit and chat, sharing their troubles. When asked, they said that they enjoy the company, and indeed this must be true because that is the only real benefit, otherwise they would be sitting in their houses alone. It was very good to see a much purer reflection of what we were trying to achieve in Keelalathur. There are several reasons for this I think: being less munificent as donors, having a more proactive caretaker and being in a more disadvantaged village. Kovasambet is more rural than Keelalathur with increased isolation, so this meeting place has relatively more benefits for the participants.

It was noticeable that they were a cheekier bunch, asking me directly what I was doing there, which I thought was great. They seemed less “grateful”, which seemed to translate into feeling less disempowered. We had a great discussion where they told me about themselves and then asked me about myself. One lady, who was particularly funny and vocal, made the universal sign – clenched fists and flexed pumping biceps conveying astonishment at enormity (fat not muscular) and asked me why I had come all the way from England to look at her. Good question. Telling her about the plan to start welfare centres elsewhere, I answered that they were helping me understand how these places could work well. She replied – you ask us if we are happy, but what about you, are you happy? Jebaraj, who was translating this, was astonished at her frankness, but it was perfect because it helped normalise our relative statuses and made us interesting to one another, rather than relating to one another as provider and recipient. Several other women, well aware of this lady’s frankness, were shaking their heads and smiling in mock despair, but the whole exchange provided much amusement and was a great ice-breaker. By the end of the morning we were all sitting in a circle with me trying to teach them “Concentration” which is a rhythmic game of clapping and pointing to others whilst trying to keep up the rhythm.

Up a tree hiding from elephants Part II

Ok, so Maddy and I are in Garuda and on our way to the Jungle retreat. It is night time and the jungle sounds are loud, but the jeep sounds are louder. Ravi is a charming, peaceful-faced young man with a goatee and eye crinkles, who drives through the potholes with a familiar disregard for the lack of suspension in Garuda, resulting in Maddy & I, sitting in the open backed jeep clinging onto the metal frame and bracing ourselves from head butting the roof. On the way the headlights catch and hold a majestic blue-grey male sambar deer with a full heavy set of antlers. A family of sleeping white spotted deer are woken and look up through the long grasses at the commotion.

Forest Hills is a resort is owned by a family who came here from Himachel Pradesh to farm, but found the local vermin a little difficult to manage. Crop growing here needs to be resistant not just to various insects, but also deer, boar, bison and of course elephants. Rahul, the youngest son told me that the deer jump the cattle grids and the elephants just barge through whatever fencing is put up. In other words, there is no stopping an elephant who wants to snack on some papaya or indeed whatever takes their fancy. Even an elephant with an itch is a menace, because most structures, the spindly legs of tree houses included, will not stand up to being used as a scratching post by a 10 tonne elephant. The family therefore decided to abandon farming and start a jungle safari lodge.

Arun had organised us to stay in one of their tree-houses, which was a house on stilts wrapped around a tree. I refer you to Maddy’s blog (http://www.madelainescragg.blogspot.com/) for some excellent pictures of Maddy climbing the internal tree. Sadly, there is no photo of the expression on Maddy’s face when she woke up after a mammoth sleep catch up (11½ hours) and first encountered the unexpected tree in her bedroom.

We had a fabulous time at the resort. On the first night we went for a safari, which basically consisted of bumping around the roads in Garuda, with Ravi stopping and exchanging tracking tips with other guides to get to see the best animals. The place was teeming with excited tourists all keen to see wild elephants, which I guess is the equivalent to trucks of Biharis driving excitedly around the Lake District trying to get to spot a rabbit or too. We did see some, and they were totally adorable - big, lumbering, brown, dusty beasts with faraway looks in their tiny eyes, guarding a titchy-trunked baby. Compared to the domesticated elephants they seemed plumper and less concerned with life. I guess being unstoppable and persistently photographed will give you that air.

I interrupt this entry with an exciting news flash. Dr Rita has given me a new mattress!!!!!!!! On it’s own, being coir (coconut matting) it is quite hard, but I can tell you, sandwiched between the two ryvita gave me the best night sleep, perched as I was, precariously, on 3 mattresses high above my bed like a pea on a drum, that I have ever had at RUHSA. Hallelujah. I even snuck in an extra kip at lunch time.

On the second day of the safari, we went to a Nilgiri Tea Estate in search of Tea Nirvana – ie the perfect cuppa. Since I visited tea estates in Assam all those years ago I have loved them. They are like beautiful sculpted slopes, plucked to an even undulating height, interspersed with peppercorn wrapped shade trees. The factories still contain machines brought over by Europeans over 100 years ago – in this case Irish – which roll, sort and dry the tea. It’s astonishing, to think that the process of making a cuppa has not changed at all in over a century. Certainly, it looked exactly the same as it did in Assam in 1995. Radically, the manager said that within 6m it’s all going to be computerised. I can’t imagine they will last into the next century.

That night, as Maddy and I lay in our little eyrie, she worm-like in a sleeping bag, me blissfully happily wrapped in several blankets, we heard the unmistakable sound of a nearby bull elephant, trumpeting loudly. He sounded quite cross. We fervently hoped he didn’t have an uncontrollable itch.

Up a tree hiding from elephants Part I

Having seen Pongal for a couple of years now and knowing that little happens in the villages apart from cow painting and bull racing, I felt that it was not very useful to be hanging around RUHSA, so I thought it would be fun to go on a trip with Maddy.

Maddy is the daughter of a friend of mine who has been teaching spoken English in classes run by Celine. Last year, Celine asked me if I knew anyone who wanted to spend 6m in India teaching as a volunteer. Maddy was the first and only person suggested, but she and a friend turned up trumps and have been here since September, although her friend, Sarah, has since gone home. Celine specified that she wanted someone English to help perfect their accent which is the hardest thing for them to master out here apparently. Entertainingly, although Maddy has quite a posh voice, Sarah is full frontal Barrovian, so somewhere in deepest Bangalore, there is a little group of Indians walking around speaking English with a thick northern accent, saying things like, “Where’s the rickshaw at?” no doubt thinking they speak like the queen because they were taught by a genuine Englishwoman.

Sadly, Celine was not free this weekend as she had booked herself in for her annual and much deserved retreat. Consequently, it was just Maddy and myself who set off for a Nadventure. After some indecision, we plumped for a safari trip, staying in a tree house. Arun arranged it all so, not really knowing what we were in for, we set off on a night bus to somewhere near Ooty, to which I had never been before. Arun had given us comprehensive, if a little complicated instructions, like get off half way up the mountain at some unpronounceable place at 4 in the morning and there will be a jeep waiting for you to take you to the resort. Feeling the weight of responsibility for a young girl 20 years my junior (aaaaaaggghhh – how weird is that? I guess if I had my own children, not weird at all, but as I don’t and barely feel older than 18 myself sometimes, I found it most peculiar), I made every precaution of making sure the conductor knew what we wanted to do. I spoke to him, I phoned the manager of the resort and he spoke to him – in three languages – and smiled encouragingly every time he wafted past me to check tickets. He was a handsome man with the usual look of Tom Selleck but the additional feature of sparkly violent pink nail varnish on his left hand (maybe to give his bum something exciting to look at). Finally, confident I had done everything to ensure all went to plan and there was no crisis with which to traumatise Maddy and introduce her too early to the Arabella way of travel, I dozed on the bumpy, slidy seats.

Pink-taloned Tom told me that the bus would arrive Somewhere Unpronounceable at 5 in the morning. Waking as someone got off at 4.15, I took advantage of the brief moment of bus calm and went to the front to remind him to tell us when to get off. He was sleeping, his cheek resting on his magenta nailed hand. He flapped me away irritatedly with his undecorated hand. The bus moved on. Suddenly he woke up and went to talk to the driver. The bus stopped. All the lights went on. He gestured towards me. I went up to the front to talk to him. The conversation did not flow easily, but the gist of it was that we had passed our unpronounceable destination a while back. Leaning casually against the drivers counter, he airly said that it was not a problem we could catch a bus back in the other direction. Just a small, small trip. At 4 in the morning. With no idea how to pronounce the bloody place name and an expectant 18 year old, assuming I was in charge.

Acquiring some of his airiness, I breezily updated Maddy, acting as if this was all part of the plan. Luckily, I had the phone number of the resort manager so Ravi and Garuda, his trusty jeep (about which more in the next chapter), wove their way further up into the jungle and found us huddled together in the cold mountain air, drinking chai with a couple of bemused local men who couldn’t believe their early morning luck at having two gorgeous beauties chance upon their normally dull, pre-dawn routine. Ok so, one beauty and a fearsome-looking, if ineffective, chaperone.

Strangling a rickshaw driver

I'm not sure what it is about me that attracts them, perhaps it is the mirth in my eyes or even the girth of my thighs, but whatever it is, I have acquired another rickshaw admirer today. He looked just like Oliver Reed so there was a little admiration going in the other direction too. We started chatting (maybe that's it) and he learnt quite quickly I was from England (no, that must be the attraction) and he asked, as usual, which is better, Madam, England or India. I said for some things India, for others, England. Good answer, he replied, laughing. So he won me over and the conversation started in earnest.

Once the conversation came around to the fact I was a doctor he became even more interested and, interspersed with questions about how much it would cost to come to India and how he wanted to have an English bride, he asked me what pills he should take for his strange tremor. Ever interested in wierd and wonderful symptoms, I leant forward eagerly. Firing questions at him, I tried to work out the diagnosis. A benign essential tremor, anxiety, thyroid disease? When I asked him about a goitre, he (obviously mishearing me and not wanting to be rude) answered with the ubiquitous "Yes".

"Oooh," I said excitedly, "do you mind if I examine you?"

"No" he said. But I think my hands were round his neck before he managed to get the word out fully and with the bumpy ride, and my hands round his throat, it was a bit hard for him to get any words out after. Comletely oblivious to what it must have looked like from the outside, I tried to do a full thyroid exam from the back of a rickshaw, on a complete strangeer, for whom being touched by a stranger, let alone a foreign stranger, is highly suggestive. All this while negotiating heavy, fumey, noisy Banglore traffic. Of course, from an idle spectators viewpoint, of course, it simply looked like I was strangling him, which would have made perfect sense given the erratic nature of his driving.

This year's projects

I have yet to see the elderly welfare centres as it is Pongal - Tamil New Year - when people are too busy celebrating and painting cows to come to the centre, so I plan to go next week. In actual fact there are only 2 centres open at present. Keelalathur, the pilot centre and a second centre opened in Kovasambet. The second centre is a slightly different model, they get only snacks - tea and biscuits - which tends to discourage all but the poorest of the poor. They still come every day, but the on dit is that it is a more dynamic centre than the original. This is partly due I beleive to the caretaker who is more proactive and ensures that they do exercises and other activities every day. This highlights an interesting point that, above all, projects need good leadership; with the best will in the world, nothing will happen if there is no good, strong, clera co-ordinating force.

The other exciting development is the embryonic mental health project. In line with the global trend there is an increased focus on mental health in India and the director of mentla health services has commissined RUHSA to carry out a project to tackle this issue in rural areas. only remit is to develop a service which relies less on secondary and tertiaty care. Currently there is little input for all but the most florid and there is no active programs seeking out and assessing the mental health status of the local population, porbably because they know that it is a potential pandora's box with a tardis-like interior.

Rita and I discussed what strategies could be used. We talked about needs assessment and categorising the mental health issues in the region, but with the white elephant in the room of finite diminishing resources. We have therefore come up with a strategy which starts with asset mapping in a single village. At present, as physicians we know there is unmet mental health need in the community, however, there must also be met mental health need - essentially there is some way of coping, even if it is not perfect. It is therefore important to establish the resources available in the community. Once this has been done, there can then be a further assessment of where there is need shortfall. The first aspect of improving mental health care will therefore concentrate on bolstering and enhancing the existing resources. This process will culminate in building a resource pyramid, starting as locally as possible with self & family and only when all the resources fail will medical care be needed.

One conundrum is how to access the information about existing resources, it is difficult to enumerate or categorise as nothing like this has been done before. We are therefore toying with the idea of using narratives and traditonal story telling to elicit coping stories wich with hopefully reveal indirectly the resources people draw on to manage mental health problems.

Astonishingly, once again, India has managed to mirror and crystallise my work - both MSc and professional -into a single nugget, helping me clarify my thoughts and refocus. Amazing.

RUHSA joins the broadband wagon

I can scarcely believe my ears. Apparently, providing I’m not too far from the server, which essentially means sitting under the huge tamarind tree in the yard just outside the computer room, I can actually use wireless internet on my lap top AT RUHSA. What is the world coming to? Next they’ll be telling me I can have piped hot water into my bathroom every morning to shower in.

But it is true. RUHSA has gone all modern and joined the internet revolution. No longer is there a need for a wire to dangle from the concrete ledge above my window. A wire, which, in the few short weeks I was able to have the luxury of internet in my room, wove it’s way through a hole under the mosquito netting - providing a shortcut for canny insects of all varieties into my private space - where it plugged into my laptop looking efficient and internet highway-like. However, it was not in India for nothing and much like the highways of the vehicular type in this wonderful country, the means by which data transmitted itself down the line was unpredictable, jam-packed and moving at a chaotic, but barely perceptible forward pace with enormous quantities of noise.

Now however, although the luxury of internet is still not realisable from my bijou boudoir, I did fire off a furious email sitting in the warmth of the Indian sun, with dusty dogs fighting over a scrap of vadai at my feet and a man in the Vellore Winter Wardrobe combo of balaclava and lunghi watching interestedly, dividing his attention fairly between his peeing child and my flying fingers. All this without having to lug my computer into dusty Vellore on a hours cramped bus ride, to sit in the sweaty library at CMC, full of students, half of whom usually were looking at facebook or playing solitaire, whilst the other half were researching obscure means of treating hypertension in people with leprosy or some such. No, now I can sit in a rural idyll, googling away, the peace broken only by the frequent and slowly moving trains driven by men with the unusual affliction of having their hands welded to the horn, the numerous crows who all seem to have hearing difficulties judging by the volume at which they communicate with one another and the tidal stream of chattering women and children surging through the overflowing hospital. It’s bliss.

However, despite this communications revolution, there is a minor counter-rebellion going on at a more personal level, whereby certain people who have received emails about my arrival have failed to pass them on to certain other individuals who might like to know I was coming AT ALL, let alone the boring specifics like date, time etc, in order to prepare the room, rent the bike, get enough towels in, not have to mask astonishment at my unexpected arrival, yada, yada. Hence the furious emails. But it’s only a minor blip and it’s all smoothed over now, but it would be nice to arrive one day and actually have people a) know I was coming and also b) pleased I was coming. I only ever seem to get one out of two at each visit. Next time I plan on a full house.

Nonetheless, it is lovely to be here. I am back in my little room which has been spruced up somewhat. As well as the new curtains, there is now a plush desk that can fit my whole laptop and a piece of paper on at the same time; there are a couple more “comfy” chairs and a new side table which is now my “dressing table”. Sadly, the thickness of the mattresses is unchanged and I am once again going to be a large dollop of Philadelphia to their crispy crackerness.

Owing to the “unexpectedness” of my arrival, I haven’t seen much yet, but the advantage of not being a trumpeted bigwig is that I can slip in under the radar (a little bit too effectively sometimes) and that gives me a chance to talk to people on the ground more and find out what is really going on. In short, the answer is quite a lot. I have yet to speak to Mathew to find out about the welfare projects specifically, but I have had some interesting discussions aready and there is lots to be hopeful about. Today I will find out more about the elderly welfare projects as well as make some plans for the future. I would like there to be a clear agenda for 2009 with regard to VRCT funds and relationship, but I’m not sure that will be a possible outcome, so we might have to make a longer plan.

There are several other ongoing projects which might be suitable for us to get involved in, especially if the welfare projects become self-sustainable, which is ultimately the aim. One discussion which has taken place is about micro-finance, where RUHSA provides a legitimate, reliable and non-corrupt lending scheme for small projects which local self-help groups want to set up. At present it costs a lot extra to get a loan due to interest rates, palm-greasing and cream-skimming. RUHSA has an unimpeachable reputation for honesty and rightly deserved, which would make it a popular place for people to come and borrow money. This sounds like a wonderfully empowering idea but does need extremely careful planning and infrastructure development. VRCT is not keen to dish out the dough until that undertaking can be guaranteed, but it will be interesting to become involved in. I heard whisper also of a mental health project which got my ears pricking up, I am going today to find out a little more about it. In addition, there are plans for a much needed revamp for the outpatients’ department, which is totally unable to cope with demand at present and refers almost everything to CMC, increasing rather than reducing the tertiary care burden. I personally would like to see evolution of a primary health care set up, but this may be the start of it which is very exciting.