Leadership - The Mother Lode

It is already a couple of weeks since I returned from India and if I weren't wearing my sparkly bangles I would barely remember I had been abroad. Time moves on so quickly and covers its tracks so well. My English life has re-established itself effortlessly; I no longer expect to be entertained by posting a parcel or have to fight to get information about how things are working. No hang on, I work in the NHS, of course I still have to do that.

The main lesson I learnt on this trip is that leadership is the key. How one person can make so much difference; not because they do everything themselves, but because they empower others to be the best they can. Effective leaders are resonators - they emit an emotional frequency which resonates with people and increases each individuals ability, capacity and, most importantly, willingness to work together in unison. They coalesce activity so the noise in the system is reduced and the energy expended becomes so much more productive. Often the amount of net energy can be reduced which has the knock-on effect of keeping people healthier. Also, there is the more subtle effect of creating a unified ideology, the buzz word I think is ownership - by generating the feeling that the doorstep belongs to people reduces their tendency to crap on it.

RUHSA, New Best Life Shelter and Karuna Niwas are prime examples of this and, not coincidentally I feel, each one is lead by a fabulous, strong, determined, clear-headed and passionate woman - Rita, Catherine and Celine. Going back to the beginning and we find the story also begins with another impressive woman - Ida Scudder. The women are extraordinary role models and I feel blessed to have found myself a part of these women's lives.

Karuna Niwas photos

Here are some photos I am hoping to put on the website. They are taken with my new camera to which I am still adjusting, so the colour is a little funny, but they give a flavour and people can do amazing things with photoshop nowadays.

Binsy, Celine's lovely second in command. With flower.

Celine, Binsy and Karuna Niwas

The Manayani Complex and classroom inside where the woman and local villagers are currently taught English and computer skills and where classes in Ayurvedic Massage are going to start.

A website, two saucepans and a cockroach

After I left RUHSA on Thurs I came to stay at Celine's partly to see her and partly to finish the bl*&%*y website which has been hanging over my head like a sword of Damacles. We started it at least a year ago. In January, fed up with the delay, I put a firecracker underneath it, so it took a leap forward. A few weeks later, it then came grinding to a spectacular halt and nothing, but nothing has moved since, despite a few plaintive emails trying to ascertain why no headway was being being made. Although, I am the person who is raising funds for it, it is not my website and I do not live in India, so it should not depend on my having to bully everyone like a starched nanny to bring things together. So, truthfully, I was a little narked with the situation, even with dear Celine. She does want the website, but she wants it to be a fait accompli; she is not at all interested in the hows and whys of it, which I can understand, but it won't happen by itself. Anyway, now there is an ultimatum on the table, and I hope that will be the end of procrastination.

Once the weight of sorting out the website was finished, I felt much lighter, so Celine and I could really enjoy ourselves. Today, she gave me a cooking lesson; I now know how to make dosa - a half crispy half soft rice pancake - brinjal curry, a coconut and cabbage dish, Indian fried rice, sambar - the lentil dish eaten with all meals in South India - and garlic pickle. We ate really well today! I even took some of the coconut and cabbage dish before it was cooked and fusioned it with lime, mango and roasted peanuts to make a sweet and hot salad. They don't know it yet, but I shall be experimenting with the medical students when they come for the end of term barbeque.

In anticipation of all the cooking I would be doing, I had already decided to buy a dosa pan to take home. My suitcase when I came out was light as a feather, weighing a mere 12kg of which at least 6-7kg was the case. So I thought to myself that I could afford to do some shopping. Giving myself licence to shop is a like an alcoholic saying "Well, I'll just have a small one." I can now barely lift the suitcase off the ground. As if the dosa pan were not enough Celine, after our gastronomique triumph this afternoon, went out and bought me a pressure cooker. It is nestling between underpants, incense sticks and packets of biryani mix, tamarind rice mix, fish fry masala, two pots of honey and a bottle of mango squash. I haven't even mentioned the shirts, earrings, bangles and delicious tooled leather laptop bag. Or the Indian board game. I am going to have to put more than my wallet and my phone down my bra.

Revoltingly, when I emptied my hand luggage case completely to repack it, I noticed a shimmering in the corner. I looked a little closer and realised I had brought a friend from RUHSA with me. There was a cockroach in my bag. I don't know why they are so particularly unsavoury, but they are absolutely disgusting. I really had to steel myself to catch it and throw it out. It's partly their incredibly long feelers which somehow look so knowing, as if nothing escapes them; they sense exactly where you are, what you are doing, they can taste your fear and they revel in it. I have to say though, once the chase was on, the fear equilibrium tipped in my favour, which sent the roach scurrying onto the deepest crevices of the case in a very unhandy way. At once point I was worried it had got between the lining and the frame never to be removed, resulting in me having to take it as hand luggage and it emerging sometime during the inflight meal causing a commotion on the plane. I did not relish the thought. Luckily, however it hadn't and, with a plastic bag over my hand as if I were picking up dog poo, I managed after several attempts to catch it and chuck it outside where, bemused, it scuttled off leaving me shivering in revulsion. I have to say, as I was sitting here writing about how I managed to outwit and outscare the roach, a huge mayfly type thing landed on my bare shoulder causing me to leap off my chair shrieking (which I am not usually wont to do) flapping my shirt ineffectually to get the thing off me. Revenge of the insects. Me 1, bugs 2.

Parcel for United England

One of the joys of RUHSA is a post office just opposite my room and although I failed to take full advantage of it my first trip, every time I go now, I take a long list of people to whom I should have written but have been too busy and, between crazy village visits or knitting, I catch up on my letter writing. This time, I also decided to send some parcels. Last visit I also sent a couple and although I remember it exercising the sub post master general somewhat, I did not remember it being quite as spectacularly Indianish as this time. The time taken to undertake the whole thing was gargantuan. I should have brought my knitting.

The sub post master general is a distinguished looking man with a toothy sidekick, who is less distinguished, but sees more jokes. The sidekick roared with laughter when, after telling me to write my return address "Madam, small, small" in the corner, I started writing in letters barely bigger than the width of the pen nib. He laughed and laughed (I was doing a bit of smug chortling myself) and with several "Saar, saar"s encouraged the SPMG to join in the gaiety. He was not impressed. Chastened, I wrote it in normal writing.

The SPMG, despite having an enormously broad, smooth upper lip with barely a crease for the philtrum between nose and mouth, has one of those moustaches that was almost as fine as my writing. In fact it is so thin, that I didn't notice it at first, but when you are sitting looking expectantly at the same face for over an hour, these things start to filter in. It is the mark of a pedant, I would suggest, who can be bothered to meticulously shave every hair from his face apart from the bottom line of single hairs along his upper lip. But not to let them grow. Oh no, that would be frivolous. They too must be kept in check and not allowed to stray beyond 2mm. Scintillating. I spent much of the time wondering how long it took him, what happened if his hand slipped, how long was too long, was 3mm outragously hippy-ish, did he every ring the changes and do the penultimate row above his upper lip? Sadly, I'll never know the answers as the subtleties of shaving are beyond the scope of his English comprehension and far beyond the bounds of my 6 words in Tamil.

Two of the parcels were to the UK and one was to the US. Well, that caused confusion number one and we had at least a 10 minute conversation about which parcel was for the US or UK, despite being clearly addressed as such. And once it was cleared up, the round of clarifications started again. Everyone joined in enthusiastically, including the sidekick and wandering locals coming in for a bit of entertainment. Gesticulating to parcel number one. US? Yes. America? Mmm-hmm. USA? Yup. United States of America? Yes, yes, head wobble, pointing, pointing at address, the works. Ah, OK. Ding, ding, round 2. Parcel 2. US? No. UK. Ok. United States? No, United Kingdom. Not America? No. Ah Ok. UK? Yes. Ah Ok. You get the general picture. Carefully, the SPMG puts the two for the UK on one side and the one for the US on the other. Then, they are weighed and the weights written on the back. During this process they are shuffled. My heart sinks. The round of discussions re the parcels eventual destinations starts again. I'm getting better at it now so it is resolved quicker.

In order for the SPMG to give me the correct stamps he has to telephone the higher eschelons of Postmastergeneraldom to find out the postage for the weight of the parcel. This is when the fun really starts. It becomes clear that the entire conversation about whether the parcel was for the US or the UK was merely a theoretical discussion because no-one actually knew what UK meant. This subtlety eluded me til about 20 minutes into the phone call, during which all I can hear is a stream of Tamil, with occasional familiar tamil numbers, then either US or UK repeated, repeatedly. Sometimes he turns to me, points to a random parcel and says US? or UK? depending on his whim. Reading the address I confirm or deny the answer. I hear him saying "Serie, saar" (OK, sir) or "No, saar" (No, sir) throughout the conversation. But there is no real sense of progress until he turns to me and says ""UK, is United States?" Er no. United Kingdom. Realising perhaps a little more clarification is required I say "Great Britain? England?" "Aaaah, Uk, United Eng-eland, saar" A few more serie saars, a couple more United Engelands for good measure then unexpectedly he hangs up. I sit waiting, wondering what to do whilst he gets on with some general SPMG stuff and pays no attention to me. After the furious and prolonged interchange of moments before, the quiet is disconcerting.

The phone rings. Phew. The God of PMGdom has spoken and the prices are duly written down. Expensive compared to seamail, but worth it for the pleasure given to small godchildren and nieces at receiving a parcel from India. 542rs for the heaviest and 397rs for the lightest. You have guessed it. The largest stamp available is 20rs which means that each parcel has to be literally covered in at least 20 stamps, especially as I buy him out of his stock of 20rs stamps and the next largest denomination is 10rs. Luckily, at least two of the parcels are quite sizeable and there is space, but the heaviest is also the smallest and there is only just room to fit all the stamps on. In times of old, the stamps used to have no glue on them, so you had to stick them on with cheap-gloy like paper glue which usually just made every surface soggy and semi-tacky, but did not really confer proper adhesive properties onto the stamps. Nowadays, the stamps do have glue, but the prospect of licking the backs of over 60 stamps with glue made from god-knows-what was daunting and made my mouth pucker, so when they offered me the glue pot (clearly they did not believe in new fangled technology like stamps with glue on them) I gratefully used it covering myself, the parcels, the sidekick and luckily also the stamps with glue. The whole process took a mere 65 minutes and we all had a jolly good time doing it. I am going to bring an even longer list of people to send presents to whilst I'm out there, I can't wait to do it all over again.

Mrs Catherine

A couple of days ago, as I alluded to, I revisited Mrs Catherine, the extraordinary woman who started not one but two schools for children with learning difficulties. Both schools were set up with private funds - she and her husband took out substantial loans and borrowed from the families and when the first school was taken away from her, she set up another one. Her whole life is immersed in the school. She was driven, as I mentioned before by the fact that her son caught meningitis and developed profound learning difficulties. Since then her whole life has been caring for children with learning difficulties, but that is not all. She does not just provide a place of saftey for them, not indeed is her school simply a place of learning, the whole philosophy is about equality despite disability. Three of her teachers, including a progressive special educator, who works with the children increasing and improving their capacities, have physical disabilities.

Interestingly, although her school is primarily for children with learning difficulties, the system in INdia for some of the rural children is inadequate to say the least and therefore children with physcial disabilities, for example cerebral palsy, especially if there are speech difficulties, are assumed to have learning difficulties. One of the children who was brought to her was so oppresssed by his treatment as a result of his physical disability, that he was presumed ot have MR and sent to her. He did not speak and was very withdrawn. The special educators worked with him and gaining his confidence brought him out. Eventually the psychology assessment showed that he had no learning difficulties at all and now he is integrated into a normal school. All these stories are so extraordinary, that it beggars belief. This is not being done as a result of a government program, this is being done despite government apathy. She forges ahead making a difference to so many children and families simply because she believes so strongly that they deserve better. And she is right.

There are 47 children on her register at present of which 36-8 attend regularly. Her school costs 60,000rs a month to run. She receives 13,000rs from local sources, including a paltry government grant and notional fees from the children (if they can pay, they give her £1.30 per month) leaving 47,000rs (~£650) to find through other sources and they are difficult to come by. I would like to help her and if anyone is interested in learning more or becoming a donor, please email me.

Some photos

Driving through a political rally at night with fireworks, cracker and mayhem all around.

Playing a game in Keelalathur which involves flicking a ball into a basket. Much hilarity and scattering of little tiny balls.

The car kept needing a push, but there were loads of willing, photogenic young lads wanting to push, until one fell over and put a hole in his trousers, which he then tried to make me pay for. Cheeky bugger.

Not quite used to the new camera, but another brilliant road safety awareness message that saves millions of lives.

Glossary

I've had a sensible request about explaining some of the abbreviations and terms used here. Of course, I have been jotting things down for (amazingly) 4 years now and so forget that terms familiar to me may be completely obscure to others. If there is anything else needing explanation, comment on this post and I will add to it as I shall refer to this post whenever there are loads more terms. I expect there is a neater way of doing it, but the dust is in my wiring and I can't work it out.

RUHSA: Rural Unit for Health & Social Affairs. This is where I have been staying all this time whenever I come out. It is a campus 30km outside Vellore a city in S India. It is a department of the CMC and provides health care through outpatient clinics, hospital care, community clinics and nursing services. It also provides training in development for local people to learn skills such as air conditioning servicing, 2/3/4 wheeler mechanics and other vocational courses to improve employment prospects. It is also a training centre for student nurses and intern doctors.

CMC: Christian Medical College. An enormous tertiary hospital and medical college in Vellore, originally started in 1901 by an American woman called Ida Scudder. See link opposite and also http://belons.blogspot.com/2006/09/project.html for the whole story. It's quite amazing.

SHG: A self help group. These are government recognised groups of women who work together in a micro-business model. They must have a bank account and keep clear accounts and then they are eligible for funding from the government to start a micro-business. SHGs are designed to empower women and only allow women members. Sometimes, you hear the men moaning that there is nothing similar for them, which is true, but there is still sufficient inequality that they are still, in general, better off. In KVKuppam block, which is the catchment area of RUHSA the SHGs are highly valued, both by the community and RUHSA. There are over 350 active groups known to RUHSA alone in the region, which has a population of 120,000 and each group can have around 15-30 members, so there are many, many women who belong to an SHG. The canteen and the waste management scheme at RUHSA are two prominent micro-businesses run extrememly efficiently by SHGs. Of course at least 4 EWCs are also run/to be run by SHGs.

EWC: Elderly welfare centre.

CHEW building: Community health education and welfare centres. These are buildings built by RUHSA over 30y ago in the villages in order to hold health or development clinics or provide health education in the villages, enabling them to disseminate health messages or health care deep to rural parts of KVKuppam block. We have renovated 3 buildings, as many of them had not been maintained sufficiently over the years, and are using them for the EWCs.

Anything else you need to know, let me know.

Inventive solutions

After I wrote yesterday, we spent the afternoon going to another village where there is to be an EWC and after that we re-visited the lady in Ranipet who set up her own school for children with learning difficulties . Over here, it is difficult to listen to, but they still call it mental retardation, or MR. It is a strange thing, because ultimately they are just words, but they sound very hard and unyielding to me; however, a more progressive, aware and experienced woman would be hard to find than Mrs Catherine, who, as you may remember from my visit in January http://belons.blogspot.com/2010/01/plump-delicious-models.html set the school up as a result of there being no help available at all for her son who developed developmental arrest after meningitis. She knows more about MR/LD than most people and has an exemplary attitude towards it and as such it softens the blow, but it still takes some getting used to. I will fill you in about that trip in a later post, but first news of the other EWCs.

At the beginning of the afternoon at Rajapuram, we held a village meeting to discuss the finer points of the 4th EWC. It is a very poor village and the local community requested that an EWC be started. During an earlier meeting, some interns performed social mapping with the villagers and identified 40 extremely disadvantaged elderly people. Unfortunately, this is not a village with a RUHSA building, but interestingly, there is a building that the locals are offering free to enable the centre to run. It's capacity is only 20 so the group of possible participants had to be further divided into poor and very poor. No-one in the village wanted to exclude anyone whom they identified, but as the constraints dictated, eventually they whittled the group down to 20. Another complication is that there are two SHGs in the village and they both want to run the centre. In addition, where were the women going to cook the food as the volunteered room was just that, a room, with nothing else. Today was simply supposed to be a meeting to finalise the details and decide which of the groups should be the ones to run it.

As we are in India and therefore used to expecting the unepected, the meeting took an interesting turn. Neither SHG wanted to give up the chance to run the centre and no-one wanted to prevent 20 people from attending. Is there a place big enough for 40 in the village? I asked. No. The undulating chat rolled backwards and forwards between the RUHSA staff and the villagers. Where will they cook? I wondered. It transpired that an unusual solution was evolving through the discussion. There was no single room big enough, but the villagers offered not one, not two, not three but four rooms for the project. 2 rooms for the participants and 2 kitchens to do the cooking, enabling 2 parallel centres to start, meaning that no-one need be left out and both SHGs are able to provide the service. The most gripping part of the whole meeting was when Mathew told me that the reason the SHGs were so keen to start an EWC was that their community had been asking them what they were contributing to the community. Self help groups, which are a well-established, government recognised scheme to empower women and enable them to form small businesses are perceived by the community as an asset. Perhaps, they are considered to be "lucky" and therefore expected to give something back. I don't know whether this village is unusual in this; interestingly, it is a predominantly Christian village and therefore there may be different cultural expectations, but none-the-less, in all the areas we have worked in, the SHGs have all been keen to come forward to run the centres, but I attributed that to the financial benefits, but it would appear that there may be something more subtle at play. What an amazing mobilisation of resources and what a way to deliver community welfare.

Starfish Day

Yesterday I had a starfish day. I realised that over the last few months I have been so busy that my brain has been buzzing like a bee on acid. Add into the mix that I have been doing more physical exercise in the last 6m than I had done in the previous 6y and as a result I was exhausted. Jetlag, heat and humidity has rendered my body unable to function, so with a double whammy of no functioning brain or body, when I tried to make any decisions or do anything, I couldn't muster the energy. So the only decision I made was to be a starfish for the day. Firstly, I went to the pool and lay like a starfish in it or by it. Reading. Then I went out for lunch with Dr Rita and her daughter. I managed to resist the urge to lie like a startfish on the floor of the restaurant, but it did require some effort. Then I came home and lay like a starfish on my bed reading. Or knitting. Or, believe it or not doing tapestry. Or, lets not beat around the bush, sleeping.

Today however, the starfish awakes. This morning I had a stellar conversation with Dr Rita and we have nailed several issues and started to develop several more threads. The Elderly Porject formula is coming along nicely and we are beginning to develop an exportable model. RUHSA is the overseer and, with charitable funds, sponsors a local self help group to run an elderly centre, providing a couple of meals per week and snacks for the other days. In addition, they make a small porift and provide some recreational activities. Other charitable funds may enable RUHSA to buy a goat for each of the beneficiaries after they have been attending the centre for 6m at least. The beneficiary must give RUHSA their first female kid - if they fail to do this or the goat mysteriously disappears, they must refund the money. If the elderly wish to partake in other activities, like develping a garden or something, funds can usually be found to help start the work up, but it must be sustainable. There are now 4 centres running and the model is working well. There is considerable interest in running them from the SHGs because it gives them an income from a reliable source, in addition, in enables RUHSA to start these centres at a very low cost using local resources. It is interesting how the model has evolved over the last 4 years. I think it is about right now and the proof of the pudding is in the fact that 2 centres have been initiated by people other than me or RUHSA.

Today I went to lovely Keelalathur, although we almost didn't make it as the car had a flat battery and needed pushing. Mathew & I were sitting in the car chatting when there was a flurry of Tamil. A hoard of nursing students poured out of a lecture room and surrounded the car, but instead of going past it, we felt the car rocking as they pushed it. It jumped into action and off we spluttered waving merrily to the obliging students. We arrived at Keelalathur - my how bustling it was. There are 6 new participants owing to recent deaths (poor Sukkupattu) and the centre was full even though we arrived at 11.30. Previously when I have been, there have been only a few there. We spoke to some of the newcomers. One woman, who is blind has no-one at home to look after her. Her husband and son borrowed a large amount of money from a money lender and then, unable to pay it back, snuck away in the middle of the night leaving her alone. Being blind she finds it difficult to care for herself and is grateful to have a meal and company at the centre every day. Another new woman, has a son and daughter who live in the same village as her but they do not acknowledge her because she is simply a burden to them. The blind woman has another problem. Without a family, she has been unable to get to the eye clinic for much needed treatment. Now she is finally able to go as one of the other women at the centre also needs to go to the eye clinic and therefore they can go together. If all the centre does is reduce peoples isolation, then it is a good thing.

A shiny new bicycle

Rita looked very well when I saw her this morning. She was very pleased to see me, we hugged and kissed enthusiastically. It is so nice not to have to work out what my reception is going to be like and to negotiate my response accordingly. It’s very simple now. She is delighted to see me just as if she were a genuine friend, which she is. We had a half hour catch before the engineers arrived to discuss the details of the new outpatient block which has finally been approved by CMC who are also funding it. At one point, RUHSA applied to us to support this, but we felt that this was not the best use of our funds, because it should be core business for the organisation and would cost an enormous amount, meaning the small, small grass roots stuff would not get done. RUHSA has, due to personal politics, been quite isolated and forgotten for about 25 years and so the campus has been neglected, despite receiving about £25,000 annually from us for maintenance in the past. There has been no evidence really of this money being spent well in the previous, previous administration. One of the reasons I went out in the first place, was because VRCT (the English charitable trust I am now a trustee of) had stopped sending any money because no-one could or would say how it was being used and the new director, Dr John, my old contact from many, many years ago as a 19y old on my year off, had made a request with his proposal for a project to work with the vulnerable and they wanted me to see whether it was a sensible thing to fund. In the last 4y since I have been involved now, VRCT has been much more rigorous about what they send money for and overall campus maintenance is no longer considered to be our responsibility. It was important for RUHSA to start shouting about the work it does and get the recognition it deserves and the exciting thing is that this seems to be happening. Credit to Dr J, I think it started with him, but Rita has cranked things up by several gears. So Rita has not only obtained both approval and money from CMC, but the work is starting and scheduled to finish in 2012. The little hospital at RUHSA is going to be a proper DGH and be able to do much more without having to send people up to CMC by bus.

When I went in first to see her, there was another doctor in with her. She introduced him. He is a newly appointed Family Medicine doctor. This is the first time there has been such an appointment at RUHSA. His wife is also an FMD and they are bringing their whole family to live on the campus as soon as his wife’s current post finishes. Half was through the conversation, after he had gone, there was a knock on the door and another man was standing out side. She introduced me again. He was the newly appointed chaplain who, with his family, is coming to live at RUHSA. Two new young families with children is a turn around compared to the previous long standing depletion of RUHSA through retirement. Even since I have been here, at least 3 people have retired and not being replaced, but there are new physicians here and at least 2 permanent families, not to mention the now guaranteed flow of interns, nurses and students from TUFTS in Boston. RUHSA seems to be slowly but surely coming back to life again. Of course, the fact that two of the new appointments are primary care physicians, makes my little heart skip with joy.

A completely unrelated but very exciting thing to happen the very day of my arrival was an email I received from a Dr in Delhi, with whom I had been intermittently communicating when I had been doing my MSc. I can’t quite remember why I contacted him to start with, I think it was something to do with trying to find out more about primary health care in India and discuss the principles of the 2002 health policy document which was so interesting and did theoretically put primary health care at the forefront of the health service in India, but of course the reality is that is is considered very much a second best option, not a vocation so much as a cop out if you can’t make any of the specialty grades. Of course, that is complete rubbish. Primary care is an extraordinary discipline in its own right but this fact needs to be actively promoted in order to attract young medics to consider it as a career option. I can’t remember where I found his email address, on a paper or something I think, but anyway, we have been intermittent corresponding all that time and we both have the same views on the importance and value of primary care and when I arrived in India, there was an email he had sent in a timely fashion telling me that as the president of the newly set up Association of Family Practitioners in India he would like to ask me to join as an honorary member. My God. How thrilling is that? Whole new vistas are opening; new contacts, new ideas and new futures.

As far as the projects which VRCT has been involved in there has been progress. There are now three EWC (eldery welfare centres) with another one due to open soon. I think the model is working well now and seems to be easily transferrable to other regions. They all depend on willing slf help groups who run the centres, feeding and providing exercises and company for very disadvantaged elderly. This not only provides a meal for people who would otherwise not get one, but also creates some employment for village women. It is an attractive model too, for overseas donators, because 2 of the EWCs are funded by people other than VRCT so there is growth beyond our involvement. Apparently, there has been some stasis on the development of the vegetable garden, which may be because it is easier to take than contribute and being passive is quite easy. However, this was a request made by some of the women at the centre and some of the stalling is due to an inefficient RUHSA community officer. Mathew says that they have finally started digging and Rita told me before I asked that since they asked for it, they will do it. Typically, there are often obstacles in starting something but once it gets going it is easier to maintain. The monkey net is up, but the pipes, although they are there, are not connected, neither to each other nor to the mains supply, but that too is in hand. Usually, there is a fury of activity whilst I’m here, so that may all take place in the next few days.

On Monday I am gong to see a couple of the centres and I look forward to seeing how things have moved on. There are new people at Keelalathur, although of course I shall miss not seeing Sukkupattu’s smile any more. The goat fund is generating money now with the sale of first kids which is great. In Kovasampet, there was a little controversy as some of the goats went “missing presumed consumed”, but they have repaid the money as they could not give RUHSA a kid. On Tuesday, I am going to see the expanded mental health clinic which now has started seeing children with intellectual difficulties in addition to adults with mental health conditions in anticipation of the newly appointed OT who will start in 2w or so. Wednesday I may try to see the kindergarten set up by Sally, for they have also started an elderly welfare centre and on Thursday I will go to Kovasmapet, so I will be busy. I am also going t try and see the woman who started her own school for children with intellectual disability after her son developed global developmental impairment following meningitis.

Meanwhile, I have a shiny new bicycle. It is too thrilling. Last time I was here I gave some money to buy three bicycles or so for any international visitors or interns, because it is so far from anywhere it is difficult to get around only on foot. Truthfully, I had totally forgotten I had done this until I arrived and asked for a bike and there was this glorious apparition in silver and green with a basket and a bell. They told me they have kept it specially for me and my bum is the first one to be on it. It is an exgtraordinary thing in India, that despite the overage height of the population, especially in Tamil Nadu being orders of magnitude smaller than me, the bicycles are enormous, I can barely touch the floor when I am sitting on the seat, but apparently this is standard size. I am wobbling all over the shop when I first start so although the bike looks glorious, its rider does not. God knows how the locals manage to do it and not look as idiotic as me, but I went for a ride today and like most bikes here, the only way you can cycle is incredibly upright like the queen. It’s a very regal experience and I’m glad to say that my new bike lives up to the image, so hopefully that will detract from the less than regal rider.

Let the itching begin

I love India as might be obvious but one thing I do not love is the bloody deliciousness of my blood to the local 6-legged population. I swear they don’t eat between my visits. They save themselves, so they are starving by the time I come back again. Word goes round pretty quickly, I think they must have a very sophisticated communication network . I don’t even see them as they sneak up on me for their All-You-Can-Eat extravaganza. They are somewhat discerning in their tastes though, it has to be said. Location and ambience is clearly important, dicated by the effort required to get to their food. They are not interested in having to work for their food by digging through layers of adipose, which means that the small selection of bony areas (which are a premium on me as might be imagined) are the most desirable spots to lunch on. Net result is that I have agonisingly itchy ankles already and I’ve not even been here 24 hours.

Anyway, enough moaning about the mozzies, let me fill in the details of what has happened so far. Fiirrstly, I had a totally mammoth taxi ride from the airport. Of course, not having access to my own personal chauuffeur any more, which has it's own downsides, I had to figure out how I was going to get to RUHSA from Bangalore which is about 160km away and usually takes around 4 hours. I could have woven my way into the city, a mere 40km away in the wrong direction, waited for a train, on which I probably would not get a seat, and get another taxi or rickshaw to travel the last 30km from the station to RUHSA, or I could spend the princely sum of £50 getting a taxi directly there. I agonised for about a picosecond before asking Dr Rita to arrange a cab. The driver arrived late, meanwhile, I had been wandering disconsolately along the line of enthusiastic drivers furiously waving papers bearing an extraordinary array of names. Even if the name said Mr Krishnan Gupta, they still shook extra vigourously at me in case it might have been me. Sadly, there was no sign of a Dr Arabella. After walking along the line as many times as I could bear their pitying eyes, I decided to try and get some money out and then wafted around aimlessly, wondering how I was going to phone RIta when my English phone had no power and my Indian phone had no inclination to work. Eventually, a sweet man, who I think I have seen before came up and shoved a sheet with my name on it under my nose. I was v happy. I guess he had been told to look out for a large sweaty English woman.

We walked to the car, he pushing my suitcase containing all my knitting and I got in. I was absolutely shattered having slept very little on the two flights out. The car was probably a Tamil people carrier, but it was barely big enough for me in the back. If I sat up straight, my head touched the ceiling and I was desperate for some sleep so I tried to lie down. It reminded me of my first trip on the bus all those years ago when I felt like I was simply on a different scale to everyone else. Similarly, the entire back seat was filled by me. In order to get comfortable I had to put my legs across the back of the front seat and lean them against the window. Meanwhile the driver was so tiny, that in order to reach the pedals, he sat so close to the wheel that his seat back came halfway across the window. Whenever we stopped at traffic lights or a toll station people looked in in amazement at the cargo he was carrying. Still, I managed to drop off pretty quickly and slept solidly for 2 hours. When I woke up, we were still in Bangalore. He had got comprehensively lost and remained lost for quite some time whilst I dozed. In total, it took 6 1/2 hours to get to RUHSA, everyone was very concerned wondering what on earth had happened. Although it took longer than if I had done the schlepping through Bangalore thing, it was worth everything to be dropped off at my room, which was lovely to see again. The resident insect population has increased somewhat since my last visit and the water heater is still purely for decorative purposes, but truthfully, I didn't care as I crashed out completely until this morning.

On my way out

In case you are thinking this post title suggests that I am feeling peaky, nothing could be further from the truth. Although it took me a little longer than 2 months, I am, once again, sitting excitedly on the train to Manchester Airport on my way out to India. Although this time will be a little different for reasons I shall not be going into (send an sae for further information as required) in essence I am very much looking forward to seeing what has been going on down at good ol' RUHSA in the 6m since I last visited and I will be trying to bloody well get the website for Celine finished. The latter job is proving extremely tricky owing to the fact that it is turning out to be as arduous a conversion to electronic infonology as it would be if someone had tried to get Winston Churchill to tweet the content of his speeches to the troops instead of orating them. If it does not work this time, then I will threaten her with retirement.

This trip, I have to confess, I surpassed even my previous PB for disorganisation. I bought my ticket on tuesday and started packing thursday morning at 6.30, ready to leave on an 8.10 train. I feel I pack rather like you might expect a Border Collie would, were they to go on holiday with accessories. I sort of round up my belongings into an ever decreasing area until I have a wobbly pile, then I pop everything in the suitcase. Usually this rounding up process starts several days, even weeks, before I am due to go asI come upon things I might want to have out with me. They then swirl around my house as they get nearer to, but not actually into, the final receptacle. In between these Herding Manoeuvres occur Random Thoughts, which need to be written down immediately or they are lost forever, referring to things I've remembered I would like to do or take, but have not yet come across. These RTs are written on equally random bits of paper which join the moving flock of debris circling the suitcase. This time however, I outdid myself. The herding process itself only actually started on Thursday morning, I have no idea what was going on except perhaps there was something at a subconscious level ...... As a result, I have plenty of knitting and underwear, but no actual clothes. I hope to God I remembered correctly and I did in fact leave a suitcase full of salwars with Dr Rita, otherwise I am going to have to knit an outfit pretty quickly and that's not a good look in 35 degrees heat and 150% humidity.

Anyway, I'm on my way and I'll keep you posted

Photos

Traditional teastall with traditional youths texting their mates

Dinner with my favourite people

The elderly group at Keelalathur - without Sukkupattu :-(

the women who run the elderly welfare centre



the newly menstruating girl in front of the blood red throne. Vimala of Rendu Dinner fame is on her right.

detail of Kolam - the coloured chalk patterns drawn on the ground outside houses to celebrate New Year

on the Ooty train. The door kept flying open on the dangerous curves and steep embankments (you can tell by my white knuckles)

helpful driving tips

Tidying up

Eventually Celine and I managed to get the bones of a website written. Her story is so interesting that it was not hard to get some amazing things to write on it. I feel that there will be something on the internet in a month or so which is very exciting. As soon as something occurs I will post the link on the blog and facebook in case anyone is still reading by then.

On my last day at RUHSA, we were also talking about trying to set up a RUHSA website in order for them to raise funds or their elderly projects. It would be impossible for the elderly projects to be fully sustainable; in the UK, welfare centres are rarely fully sustainable, they usually get a grant of some variety, so I think it is unreasonable to expect the extremely poor elderly people in India to be able to fully fund a centre - if they were able to generate enough income to do that, they wouldn't need the centre in the first place. Anyway, it will be an exciting departure for RUHSA to be more proactve about it's future. Interestingly I heard that the German charity supporting the main hospital has become disillusioned with raising money for the highly technological and advanced CMC with it's renal transplants because money doesn't go very far towards funding such high tech stuff and it is not reaching the poorest anymore, so with luck RUHSA with it's grass roots projects will generate much appeal because not only will the money go further - a full annual wage for an OT to develop the whole mental health project for KV Kuppam block, with a population of 120,000, costs a fraction of a renal transplant procedure. I am thinking of doing a display for the surgery for our "Market Street Overseas" noticeboard to compete with Ann (our practice nurses) fund raising for Sudan vaccination programs. Let the fight begin!

The conclusion of my trip was absolutely lovely. One of the highlights of the last week was a dinner party held at Kudla - a Manglorean fish restaurant. It's so easy to be generous in India, taking 8 people out for a fancy pancy meal costs about the same as a Valentine evening for a couple. All my favourite people in India came - Arun, his son and mother, Celine, Victoria, Sudhir and Richard Smith, the Director of Friends of Vellore, without whom none of this would have even happened. Everyone had a great time, the food was delicious and messy - not something for a first date. Most people hadn't met each other before, but there were many connections made. I had a lovely time.

After that, I went to Ooty which I had never visited before. Although many people are disillusioned by its commercialisation, it still retains some colonial charm. I took the "toy" train through the tea estates, which is almost as famous as the Darjeeling toy train. We stayed in a log cabin in the middle of a wildlife park in the core area and then coming back from dinner one evening, there was a distinct trumpeting sound which nearly caused Arun to drive off the road in shock. As we swept round the corner, we saw the unmistakable outline of a pachyderm and her baby having a midnight snack. Arun drove to a friends camp where there is a watchtower and by the light of a full moon we gradually accommodated to see a herd of elephants with a couple of accompanying bison grazing in front of us. It was so funny to think that the munching sound, which could have been made by an enthusiastic cow was actually made by wild elephants. They were adorable. Then we went back to our camp and whilst we were sitting outside having a chat on the veranda, there was vigourous rustling sounding about 10m away in the forest. There, the main tree is teak and now is the season for shedding leaves. Teak are beautiful and broad leafed with slender, silky trunks. The leaves are huge and heavy and when one falls to the ground, it sounds like a paperback book falling off a shelf in the library. The dry leaves on the ground, if disturbed, sound like autumn leaves amplified unbearably. So the rustling was disturbingly loud. I thought it must be a huge creature like another elephant or perhaps a bear, but in the end I startled 2 wild pigs who ran off in terror, unaware that their heart rate and mine might have been uncannily similar.

Spending time in the forest was a lovely end to a fabulous trip. So much has been accomplished and relationships have been further forged. I think I will return in a couple of months, but don't tell anyone yet.

Making Celine sit on the naughty step

In between seeing plump delicious models at RUHSA and getting rendu tyres bursti on the road back to Bangalore, I spent a few days with Celine at Karuna Niwas which is the Home of Compassion for women who have been disadvantaged by life, their family or society at large. The main aim, apart from seeing Celine, was to try and get a website organised for her so that she can start raising money for her Women’s Settlement and Children’s Education Trust fund. Her plan is to set up a fixed, high interest account of about 1 crore rupees, which will generate sufficient interest each year to pay for the occasional wedding – at least one per year at a cost of 1 lakh rupees, and to ensure that those children still under the auspices of Celine at Karuna Niwas, get a decent education. There is free education in Karnataka until about 14, however, it is in local language medium – Kannada. The sad truth of the world is that being educated in their own language does not give the children the best chance in life. Studies have apparently shown that the single best link to future success is the ability to speak English. So, a mixed English and Kannada school has better prospects, but is more costly.

Just to explain, a crore and a lakh are uniquely Indian numbers, which take me several moments of staring blankly at my fingers in order to figure out how many noughts are involved for each. At RUHSA, lots of projects cost portions or numbers of lakh rupees. A lakh is 100000. For a little bit of recent cultural context, Slumdog Millionaire revolves around the Indian version of Who Wants to be a Millionaire, which in India is called "Kaun Banega Crorepati?", which means "Who Wants to be a Crorepati?". The film is called Slumdog Crorepati. No-one is called a millionaire over here, which, in view of the exchange rate of 75 rupees to the pound, would only give you £13,000 in your account and although India is cheap, that is not that much money for the rich over there. Instead, they use their own number of a crore which is 10,000,000: you become a Crorepati, and you have 10 million rupees. A crore is 100 lakh. It’s all very confusing and as mentioned, coupled with the exchange rate makes for very difficult calculation of costs. As if it weren’t hard enough, they put the commas in different places so a lakh is 1,00,000 and a crore is 100,00,000.

Anyhow, Celine wants to raise a quarter of a million dollars – approximately a crore rupees, which would give her about 70 lakh per year in interest. Each wedding as mentioned costs 1 lakh, each child costs 16,000 rupees per year to educate - of which she has responsibility for about 7 children - also she wants to be able to send them to college if necessary which is extremely expensive at nearly 2 lakh per year. In addition, anyone who comes to Celine with a need without the ability to manage, she helps. Women have come back to her after many years and she has helped them unthinkingly. She feels it is very important to be able to support her family, which is grows continuously, whenever they need help.

She has therefore wanted to develop a website for several years, but never got around to it. Last year I made some slight inroads into it, but for some reason nothing much happened in the intervening months, despite sending occasional emails to enquire as to progress. Everyone seemed to be waiting for someone else to do something. I had vaguely assumed that Celine, who can arrange for the most extraordinary things to happen in the most serendipitous way, would have picked up the website baton and run with it. However, in fact what I found when I asked what had been done in the last 12m was a mischievous smile and a distinct tendency to slope off to avoid having to do any “homework”. In short, Celine, not unsurprisingly for a techno-agnostic 65 year old, basically does not want to be involved in the nuts and bolts of the website setup, she just wants it to be up and running without being bothered by how, when or why.

The problem was, I was not really wanting to be involved either, I was doing the donor thing of munificently offering to pay for it, but definitely hoping not actually to have to do anything. Net result, nothing done for 12m. Poor Sudhir, who has been trying his best, has, over the course of the year, sent emails to both of us, which we denied vociferously ever having seen, or if seen, swore blind we had replied fulsomely, only to discover each of the emails languishing in the dusty corners of our inboxes unloved, unread and unreplied to. So I bit the bullet and tried to rein in Celine’s reluctance to do her homework. It was hilarious, every opportunity I thought we might have for her to go through the text I had tidied up from her original leaflet, she found some pretext not to do it. Showing me a new project, being introduced to some of the women who were hovering about (not in the least interested in meeting me) visiting her sister, having lunch with her nephew, shopping, cooking breakfast for the next day, admiring a new plaque. Anything would do.

Eventually, I started getting even bossier than usual, telling her that we weren't doing anything else until she had done her homework. No fun things until the work is done. I started marching her towards the papers, to sit her down every time there was a spare moment between admiring vital brass plates and grating crucial coconut for chutney, but by god she is slippery. I have to confess, I was tempted to get her to sit on the naughty step until she had done it, but I felt that was a step (pardon another pun) too far. I even managed to persuade her to let me cook lunch whilst she sat on the table writing her story ideas and expectations on paper for the website. I had to ensure there was not the whiff of a distraction or she would leap up like a child with ADHD whose just had a tubful of brightly coloured smarties and devote her fickle attention (a luxury the homework did not have) to the alternative topic. Of course when Sudhir came for a meeting about the website to finalise the details I had no chance. I did not have enough energy to keep Celine in the meeting and listen to what Sudhir said. She could be heard giggling faintly in the kitchen, delighted at having escaped. Naughty child.

Rendu tyres busti

Yesterday was a day of adventure. In the morning, there were 5 hours of meetings consolidating all the work on the projects at RUHSA with representatives from various funding agencies. There is a palpable burgeoning of focused enthusiasm for RUHSA, which I attribute entirely to the defined leadership of Dr Rita. In 3 short months she has transformed not only the campus, but the spirit and drive at RUHSA. Projects are bounded and manageable instead of infinite and amorphous, creating a sense of journey which enables people to feel their achievements once more.

There was a serendipitous arrival of the representative for FoV Germany, whose members have become slightly disillusioned about sending charitable donations to a hospital as advanced as CMC. RUHSA, with its work at the very grass roots of need and it's philosophy of empowerment may well be able to picked this dropped stitch of apathy and knit it into the fabric of their work. Next year the focus is on sustainability which may well raising funds from other agencies. A fund raising officer, for the first time in RUHSA's history, is planned, with the possibility of creating a website - something I have been boringly banging on about ever since I went there.

Of course, the lengthy meetings meant that I did not have a chance to pack. Especially as I misread the time of the start of the meetings and was starting to pack (in the nude as it happens) when I realised I was supposed to be in the Mental Health Project meeting. Cold showers in this instance become a bonus and I barely (no pun intended) felt the icy needles, only their invigourating effects. As a result I had to spend an hour or so packing after lunch, resulting in our leaving much later than intended. It was for this reason that we were driving on the patchy old Madras Highway at night and therefore did not see the pothole. I was dozing at the time, so I definitely did not see it, but by God I felt it. It was as if the car had been dropped from a great height without the cushioning effect of the wheels. There was lots of swearing and clutching of dashboards whilst Arun realised that the car was not driving properly and pulled over to the side.

His fear was confirmed, the left front tyre was busti. Comprehensiveli busti. Of course there is no AA or RAC in India, but then there is such an air of general helpfulness that I'm not sure it would catch on if introduced. Having said that we were in the middle of Idlisquat, Nowhere. Mercifully there was a space between the busy, bumpy road and a drop to the fields below and Arun started to work on changing the tyre. There was a spare and there was a jack, but there was no handle for the jack which meant we spent a lot of time trying to raise it in a cack-handed manner using the wheel spanner. Luckily I remembered I had a very small torch. Unfortunately I forgot I had a much bigger and more effective one in my handbag. After 45 grueling minutes with lorries passing us rattling our teeth and dust beginning to cake each hair shaft, the tyre was changed.

We drove off. For about 30 seconds it was fine, then there was a suspicious noise, then a suspicious tapping, then a deeply suspicious bumping, noise and tapping all together.

"If that's another burst tyre, we're buggered"

It was. The phone came out and there was much excited jabbering on it. The phrase "rendu tyres busti" being notable for the frequency of its utterance. A plan unfolded. He would, carrying the wheel with the original tyre busti, hitch a lift on the back of a two wheeler from a chivalrous man who stopped for no reason except for boredom, curiosity and kindness, and get the tyre mended. Dubiously I looked at the large uncompromising rent in the rubber. Mended? I chose to say nothing, knowing from experience that extraordinary outcomes happen in India and who was I to question the inscrutable ways of providence?

We pulled the car over as far as possible and, vaguely aware that this was in direct opposition af advice from British Transport Police, I stayed in the car on the side of the road with the luggage (ie every single thing I owned in India - and I had done some heavy duty shopping). Off he went with his new friend. Three phone calls and 90 minutes later I heard the unmistakeable phutting of a rickshaw coming nearer. Sure enough he was back with a bulging patched tyre and three teeny, tiny mechanics. I didn't ask or look closely, I did not want to know.

The three teeny, tiny mechanics squatted around the lame, rendu tyre busti looking at it by the light of their mobile phones. I offered the services of my small torch again (I did not find the bigger one in my bag until after the work was all finished - grr). It improved visibility marginally and they set to work - having the same nightmare with the jack as we had. As they were working, between the subsonic rumbling of lorries, I heard a strange sound.

"Has that man got hiccups?" I asked Arun. He did. In the glow of the torch I could see the slight jolting of his body in time with each unmistakeable sound . The entire job was completed to the beat of his spasming diaphragm with no-one saying a word or mentioning it. Each time I heard one I got the giggles, creating a complimentary syncopated rhythm. Only in India. As I have said many a time, anything is possible in India, you just never know how it's going to be accomplished and rendu tryes bursti, mended accompanied by hiccups was not the outcome I was expecting on leaving RUHSA.

Psychiatry outpatients

I also spent a day in the psychiatry outpatient clinic at RUHSA. There was an interesting mix of problems which presented, from anxiety to psychosis, as well as clearly organic problems. These, because they present with psychiatric symtpoms, for example depression in low thyroid disease and epilepsy with post ictal states, are managed by psychiatry. Apparently, the endocrinologists will not treat low thyroid until physical symptoms appear, despite the blood tests for hypothyroidism being positive. So their threshold for treatment is much higher than the UK. If someone needs treatment for hypothyroidism with only psychological symptoms, like lethargy, depression etc, they need to come to the psychi docs.

Another interesting difference was the presnce of "proxy" patients. People came to the clinic not for themselves, but arrived to talk about their family members who had psychiatric symptoms. This is acceptable practice here and in some cases, although it clearly compromises patient confidentiality, you can see the point of it. The doctor in charge of the clinic was Dr Ruby, a lovely colleague of Dr Annie's, who comes from the tertiary hospital for one day a week. She was much more patient-centred than I have ever seen in India, including actually shooing people away from the clinic area so she could talk to the patients without people, including family, earwigging.

Patients themselves rarely came alone, they always had someone with them, a family member who usually looked after them in some way at home. A youth with learning difficulties and psychosis was brought in by his father, a woman with schizophrenia was brought in by her husband and another man with schizophrenia, who is resistant to taking treatment, was brought in by his two sisters. He is still working as a rickshaw driver and does not want to take medication but has some quite disabling psychotic episodes. Dr Ruby made some plans with the sisters to covertly give him his medication in food. Of course there is no sectioning here, but then it is not really needed because the ethics of informed consent is not well practiced.

The clinic was fascinating and being held in a room once a week in a general hosptial is easier for people to come without feeling the stigma than going to a known mental hospital. So now the establishment of the medical side of the mental healthcare project has been established, there is medical backup for follow up and the good news is that VRCT has agreed funding for an OT for one year to start the mental health care community project, which means that the community part will also be able to start now. I will be keeping close tabs on what is happening and even if I am not in India, as I think commmunication is going to be better from now on, I will be able to write about what's happening between trips.

Plump delicious models

It might be clear from the title that this blog post is not going to be describing the latest exploits of Agness Deyn or even that of the so called plus-sized ladies being touted in recent newspapers whose curves are as slightly undulating as the terrain in Norfolk; no, this post as all about the wonderful examples of mental health and development models I have been sampling over the last few days at RUHSA. I have fitted so much in that I am not able to keep up and note everything down. I am therefore leading a schizophrenic life – staying at Celine’s (more later) but still catching up with the last couple of days in Vellore which as mentioned have passed in a whirling fury. Keelalathur is as mentioned, but there is also another elderly welfare project under way which is a slightly different model. Latest developments at Kavasampet are that there is netting being organised to put over the yard area to protect it from monkeys. One woman wants to have a vegetable shop, so she is going to use the area to grow vegetables, some of which will be used to make lunch for the elderly, the rest she can sell. This makes the Kovasampet model more proactive and sustainable than the Keelalathur model because they are generating some of their own food from the assets of the centre. We will see how that evolves. Also, a woman from the UK charity Friends of Vellore, having heard all about the elderly projects and having visited one of the centres in December, came back in order to gather some stories about the participants. I look forward to hearing about those and hope that they generate some charitable donations, so the centres can start raising money to keep them going.

However, moving on from the elderly models I also spent a lot of time looking at several mental health models and discussing our plans for community mental health asset mapping and resource development. Firstly, we went to the Worth Trust which is a school, Technical college and Factory all on one campus which schools, trains and employs children and adults with learning difficulties or visual or hearing impairments. It has been set up since 1963. The aspect we wanted to see the most was the children’s day centre where children with mixed abilities came for daily schooling and activities with their parents. This centre has only been running for 3 years. They make less of a distinction about adults and children as the oldest participant is 28. But the key aspect is that their main carers, usually their mothers are co-therapists and are there to be trained as well, with the aim that they can become more independent. There is no time limit for attending and so far few have actually left the classes and progressed, but the idea of co-training the carers and the child is the model we wish to partly use.

After that, we went to see an extraordinary woman, Mrs Catherine, who as the mother of a young man with severe learning difficulties, was so depressed by the lack of options for her son, that she started a school for children with learning difficulties not once, but twice. When her son was not much older than a year, he developed brain fever - probably encephalitis. Despite taking him to the best hospitals, he was undiagnosed for 3 weeks. When he was eventually diagnosed, he had substantial brain damage. She did not understand, probably because she was not clearly told, that he would have severe developmental delay and would have permenant mental disability. As he grew older in body without growing older in skill, she took him around the country trying to find out what was wrong with him. The brain fever was over, why was he like this? Doctors wherever she went failed to explain to her the significance and meaning of his condition. After several years, at last someone explained to her so she understood. She became deeply depressed and, despite having a strong faith, berated God for allowing this to happen to her. For a long time she wept, unable to think or believe in anything. Then she realised. If no-one else was going to do anything for her son, she would, so she enrolled in college, acquired a BA in social work, went back to work to earn money, learnt about the needs of the mentally disabled and, raising an extraordinary amount of money, built and started her own school, for which she won a civic award. Unfortunately, getting this award made the governers of the school jealous, so they squeezed her out. She fell back into an intractable depression. After some time of no imporovement in his wife's mental state, her husband realised that her welfare depended on her running a school for mentally challenged children. He lobbied politicians and spent all his savings and bought a plot of land on which to build another school. This was opened 4 years ago.

Her son is now 21 and is still completely dependent, but he lies, happily, on a rush mat in the corner smiling indiscriminately at the activity around him and the attention he gets. Catharine told me how much she loves these children. Her every waking thought is about these children with their special needs and sometimes she even dreams about them.

“They love me too, and call me Amma. I am so happy, if my own son cannot call me Amma then let these children call me.”

Catharine is clearly extraordinary, but the model of mental health which Rita and Annie are trying to set up aims to find other women like this and Catharine is a fabulous role model to show what can be done. Not only that but she has a wealth of experience in grass roots community activity and management of mental disability. She too uses parents as co-therapists. She even uses some mothers as other workers, for example in the kitchen. And, best of all, she gets mothers carrying out therapy on other children too. She is not only an inspiration to other women, but will also be a useful ally to RUHSA in developing the model for sustainable community mental care.

The Sweetness of Keelalathur

Over the last couple of days, I have had a glorious time, so busy that my feet have barely touched the ground. I have either been cycling to a village or bouncing along, my hair generating static electricity from rubbing against the velveteen roof of a hard-sprung Ambassador, or I have been revolving from office to office talking to different, different people in a heady combination of opportunistic interactions and tightly scheduled meetings. What a difference to my early days at RUHSA when I had to pretend not to be interested too much and setting up meetings gave me a sense of what it must have been like to organise Charlotte Grey’s schedule with informers in Occupied France.

As I mentioned, yesterday, was bittersweet, but I only described the sadness of Sukkupattu’s death, however, there were also many wonderful things to emerge from the visit. Most importantly, the elderly people still attend the centre. Every day for the last three years they have been turning up: coming to sit and chat, to read the newspaper, put together jigsaw puzzles, do some, admittedly, pretty pointless exercises (the kind someone does if they want to feel good about exercising without in any way exerting themselves – the kind my Dad would enjoy), to watch television or simply to get away from the worries at home. I must admit that last year I was disappointed that the function of the centre did not seem to have evolved; there was no sense of trying to generate sustainability and that made me feel that it had not been a success as a model. However, there have been a steady stream of people from the UK who having heard about it, have visited and their fresh-eyed impressions have been much different to mine. They have seen a gathering of chatty, happy-looking elderly people who gladly tell them how much they enjoy coming for all or some of the reasons above, who tell them how life is different now, how they feel valued, both by the attention from people such as them and also, by reflection, by their family. I have been told that it has the kind of atmosphere they would have liked to have been able to offer their aging parents, instead of some of the more sterile, soulless Day centres at home. That is an accolade indeed. For all its simplicity, the feel of the place is right. That is not to say that the model is perfect, it is not. I still feel that we have increased dependency and we did not take sufficient account fo their assets before we started. This means we are left in a dilemma - either we continue as is or stop funding, in which case the centre ceases to be. I would prefer to see a model that has some capacity to draw from local resources, not necessarily from the elderly themselves, but the wider community at least and this is what we are working on - taking the excellent components of Keelalthur but imbuing them with a greater sense of agency.

But there was a moment yesterday which corroborated the idea that success cannot necessarily be measured in financial output. Just as I am not supposed to have favourites, I am also not supposed to have anti-favourites, but I’m afraid I do. I can’t help it, she’s just really, really annoying. Always moaning and whining, not in a charming, chance-it kind of a way, but in a petulant, irritating, unrelenting kind of a way. Anyhow, it would appear that she doesn’t only evoke this reaction in me. Everyone metaphorically rolls their eyes when she starts talking. She sits a little apart from the others and scowls. Poor thing, I’m sure she’s a natural charmer to her family but I can’t see it. When Kalaimanai asked everyone at large what they thought of the centre, whether they felt they had benefitted or not, she started talking. Obviously I couldn’t understand more than a few words of the torrent of Tamil (ie sapad –food, kashtum- difficulty) but the tone was whiny and wheedling. The effect was instantaneous, everyone started up in fury, waving their hands at her, talking to Kalai and tutting in disapproval. It turned out she had said the centre was pointless except for food, she derived no other benefit from it and it was this which unleashed a flood of indignation. They were furious with her; they stridently contradicted her assertion that this was merely a place of feeding. It was lovely to see them so protective - she wasn't voicing the unvoiced, she was being unjust.

We also talked about whether the vacancies from participants’ deaths should be filled. Good old Minnie* moaned that we would not have enough food for her if we took on more people. Everyone else felt that more people should be invited, but they were concerned about finances from our point of view. They felt any incomers should have the same opportunities they have had in which case, they would be happy to have fewer meals per week if that helped. In fact, they said that if the project had to stop in order to benefit others, they have had a lovely time and would happily relinquish their turn for someone else. It emerged during the course of the conversation, that although the centre itself is not more sustainable, the individuals themselves have become so. Another adorable, deaf, bewhiskered old man called Duraisamy, who walks on swollen feet a mile each way in order to come to the centre, and who has a beaming smile as big as Sukkupattu’s, told us his story. 3 years ago, he tottered aimlessly around his village, sewing sacks together to swap for food. Some days he managed to get a small, small meal or snack and some days he got nothing. Now he gets a good meal every day, he feels better, he makes more sacks which, not having to swap for food, he able to make a little income from. I passed him whilst cycling home after lunch, he was walking briskly back to his village and gave me an Indianormous grin in response to my cheery wave. His life is definitely better. I am seriously having to re-evaluate my expectations about what outcome measures to use for the project. It would be wrong to expect him to use this little money he is gaining to pay for his food, it effectively puts him back in square one. Besides, he has already given us his goat’s kid back, how much more should we expect them to contribute? These are interesting philosophical problems between opposing positions between which I vacillate constantly.

The last thing to mention is the most personally moving. Rathinam is a small, neat man with a few words of English he polishes and shows me each visit. He is married to a woman with untreated schizophrenia with whom he had some children. Soon after marriage, it became apparent that she could not cope with caring for them or him, or sometimes, even herself. The solution was to also marry her sister, with whom he has some other children and who is the main carer for them and the household. He brings his schizophrenic wife to the centre every day where she sits softly blank, but in blessed calm. He told us how she enjoys coming, it has brought peace to her and she is has many fewer distressing episodes now. Every day she plays Pallankuzhi and he assembles the world map, pointing out India to his friends and Australia and UK to me, if I am there and then, being one of the few literate members, he reads the newspaper aloud to others. He told Kalaimanai how thankful he is for the centre and how his life has changed since coming here, a fact he attributes to me. I noticed him pointing to me a lot whilst he was talking and when Kalai translated, he told me that every day, when Rathinam says his prayers, he prays for me. It makes me ashamed to be so free and easy with life when I hear something like that.


* She's not really called Minnie, that would be ridiculous

Sukkupattu

Today was bittersweet. I went to Keelalathur today to say an enormous thank you to Kalaimanai, who has been instrumental in the development and continuation of the elderly welfare project, and who has retired after 30 years working at RUHSA. His meticulous and fair approach has ensured that any initiative started has been carried out in the best of ways. Unlike at Kovasambet, all the elderly people who wanted goats have not only received them, kept them and looked after them, but they have produced baby goats and, as per agreement with RUHSA, have handed the first kid back to donate to someone else and now have gone on to produce more kids. At Kovasambet, there have been several goats which have mysteriously “disappeared” (kid-napped?) and ended up garnishing someone else’s plate. But under Kalai’s stewardship, all of the Keelalathur goats have been a prolific success, giving increased freedom to the elderly, and in some cases, renewed respect for them within their family.

Happily, he looks like he is going to embrace and enjoy his retirement, but obviously, I am sad to say goodbye to him. He is a huge personality with a smile to match. He speaks a rolling, flamboyant English like a crowd of over-excited children running downhill; sometimes falling, sometimes running so fast it seems their feet will never catch up, laughing and jostling each other to get to the bottom first. In every word containing an R, he adds several more for good measure. In words without them, he adds them in for extra embellishment. His tongue moves rapidly and nimbly around his mouth, his accent so thick, that sometimes it is difficult to tell the point at which he swaps from Tamil to English or vice versa. He is a lovely man and I shall thoroughly miss him next time I go to the village and he is not there. He has been a ubiquitous presence, greeting me so warmly “Ahh, Drrrr Arrrrabella!”

We held a small celebration of thanks in the centre, with an exchange of presents and short speeches; the participants and self help group women smiling as broadly as only the Indians can. However, during the celebration I asked where my favourite was – Sukkupattu - as he had not turned up. I was told he had died on Monday.

I know you are not supposed to have favourites, but I couldn’t help it, he was adorable; a hugely tall, thin man with an elegant, lived-in face. His height gave him a slight stoop, the effect of which was enhanced by the presence of a lipoma the size of a melon nestling on his right shoulder like a shy, squat, monochrome parrot. His soft smile and warm, crinkly eyes always made a point of finding mine in order to express a greeting, knowing that words could not be exchanged. We wobbled at each other furiously every time I went to the centre, both of our faces lighting up with pleasure to see each other. It’s difficult to explain why one person moves us more than another. I think it is to do with the intensity of light in their eyes, the presence of an undeniable twinkle, a hint of gentle mischief. He never looked humble or ingratiating, he simply looked delighted to see me and who could resist that? He was very old for a rural villager, more than 80, and had a terrible cough. I have been dreading the time when I would go and learn of his death and finally, after three years, it came. I was devastated to have missed him by such a short time, but I am so glad that in the last few years of his life, he spent some time feeling less alone or abandoned by his family, being given some of his deserved dignity back and enjoying twinkling at a crazy English woman who turned up unexpectedly, usually sweaty and red-faced but who tried to return his heartfelt greetings with matched enthusiasm. I shall miss the wordless, graceful friendship.

Rendu Dinner

Ruhsa canteen used to be run by a lovely woman called Vimala. She was always pleased to see me when I came back and we used to spend hours cahtting after eating. When my sister and her boyfriend came to stay at RUHSA, she showed them how to make vadai. When my mum and dad came to stay, she showed them how to make a chicken biryani. Last March, however, she lost the contract for the canteen, so when I came back this year she was gone.

Yesterday, a beaming boy on a moped whizzed past me, vanishing into the dust before I registered that it was Sammy, her son. A couple of judicious questions to Immanuel as part of my daily routine revealed that she was living in Vellore, yes, her husband still worked here and yes, it had been her son on the back of the moped as he came back often to see his friends. In reply to my questions about whether he still spoke to her he said he did, adding darkly that calling her was dangerous as she talked 23 hours a day. Always, always on the mobile phone: when cooking, eating, on the bus, in every situation. He phoned her then and there on the spot. She was busy. After a couple more tries we got through and had an ecstatic verbal reunion, rapidly arranging an actual reunion that night – arranging to go to her house for dinner.

Since being here in India, I have been attempting in my half-hearted way to continue my quest for effortless weight loss with nematode assistance. To no avail. I have been cycling furiously, sweating and panting my way through all the nearby villages, assisted by the breezes contained in their gales of hysterical laughter. Not much difference. In desperation, I added a new regime the other day, I would only have one cooked meal a day. For the other two, I would have home made muesli, which I love here. The dried fruit has barely less water than when it was plucked from the tree or vine and the fresh fruits, such as pomegranates, are plumptious, so home made muesli is a pleasure not a chore. I started in earnest the day before yesterday. Unfortunately, I was so pleased with myself after a massive hour long cycle ride, I ate 3 vadai, a coconut cup cake and 2 wicked sugary things, that I don’t even want to discuss. I had the muesli as well to pretend everything was above board. So yesterday was going to be a new day and all was going well until Vimala asked me to dinner. The invitation came after lunch so the opportunity for having 2 muesli meals today was already lost. Little did I realise that the opportunity was more than lost, it was murdered, dismembered and then buried in an unmarked grave in a remote part of the Gobi Desert which only scorpions and sidewinders visit.

I arrived at Vimala’s and the physical reunion was as joyous and noisy as the telephonic one. We chatted and chatted, in miniature breathes between sentences she rattled off orders to Sammy to buy, this and that and the other and more things for dinner.

“You want snacks? Biscuits, tea, coffee”
“No, no,” I replied, "I’m fine."
“Sure?”
“Sure, sure. I’m not really a fan of biscuits.”
“Ok, ok, me neither”

Of course she ignored me, but I managed to escape by eating only one of the egg puffs she brought, despite her looks of sadness that I refused the second one. My problem is that I have limited will power. Well, none actually.

As she started preparing the dinner, her teenaged son and daughter wafted languidly in and out of the kitchen either being helpful or disruptive depending on the presence of a Y chromosome.
In the miniscule hairs breadths between the miniature pauses, her mobile rang, which resulted in tens of minutes of one-handed cooking accompanied by yelled conversations at her various friends, family or acquaintance in that fabulously ululating language, interspersed with faintly recognisable English words, like “farinner” (foreigner – me presumably) and “dacktar” (me again, I would guess.)

I watched attentively to the cooking process which as you might imagine, without direct instruction, was somewhat obscure – pinch of this, dash of that, oops, what went in then, missed it. She was preparing ‘mashroom and baby corn soop’, capsicum fry, chicken fry, chicken with gravy, raitha and chapatti. Recipes on request.

In between the miniscule etc etc jingly feet padded in and out of the house from upstairs. Longing looks were cast at me, with much head wobbling and intimations to follow. Apparently, India, never short of events to celebrate or poojas to make had found another brilliant excuse for a party. Her neighbours' daughter had come of age and the whole building was celebrating. Struck by a sudden thought, I wondered how they measured this coming of age. Is it literally, an age, eg 13 or ……? Yup, you got it, once she starts her period the fact is announced to the world. Remembering the humiliation of mine which started unexpectedly in the school gym aged 12 ¾ this was one ceremony I’m glad we didn’t celebrate in West Clandon. The idea of bouffant women from the stockbroker belt all coming to ogle me knowing the shame of my transformation turned my blood cold. Then again, it’s all hideous anyway as a teenager, so perhaps one last bash as a child is not a bad idea.

Vimala promised that we would go upstairs and help celebrate. For reasons I still can’t fathom and which cause me cultural embarrassment, having a farriner at such events is highly desirable. I’ve said before and I’ll say it again, the honour is not reciprocated by White English in middle England to their Asian brothers and sisters. However, on this occasion my presence would be mutually satisfactory for everyone. I was dying to know what they did to the poor kid.

Meanwhile, Vimala continued cooking and cooking and cooking and cooking. When making chapattis I looked at the small pile of dough balls ready to be rolled out and thought it a bit strange that she was only cooking one each. Then she said,

“Four chapattis enough for you?”
Pardon? Was all this food for me?
“Yes, yes, special meal for a special friend”.
“But what are you going to eat?” I said, astonished and horrified.
“They will give us something something upstairs”.

Oh my God, not only did I have a gargantuan 5 dish meal being prepared for me downstainrs, but I was also going to have to eat dinner upstairs as well. It is impossible to refuse food in India, it is as bad as sleeping with a member of their family in public.

It didn’t matter how I tried to work it out, I was stuffed, figuratively and soon to be literally.
We went upstairs to celebrate the menstruation. A delightful and articulate young girl/ stood up from an appropriately blood red velvet covered throne with silver embellishment, dressed in a heavy brocade sari which rippled below her feet by several inches. Her hair was plaited and extended to her knees decorated with diamante buckles and jasmine flowers. Across her forehead lay a diamante chain coming from her parting and ending is a perfect drop. Henna decorated her hands and feet in elaborate patterns and rather charmingly she had her specs on.


“I am so very happy you could come to my celebration” she said to me and I responded in kind; she was adorable. Many photos, laughing and talking before the dreaded battle with dinner Number One started. A banana leaf with piles of rice, rasam, sambar, vegetable and lentils with a fried sweet snack thing and banana lay in front of me. I do not exude the impression of a picky eater so they looked at me expectantly. Knowing there were a further 5 dishes waiting for me downstairs put some brakes on my hunger. I looked at Vimala.

“Eat, eat” she said.

Traitor I thought. I managed the first wave of food, they had not been over generous which was lucky, but it did take an enormous surge of energy to stem the flow of further helpings.

“Rendu dinner" I said, pathetically -two dinners- looking at Vimala to back me up. She stepped in with a flood of Tamil and the efforts to fatten me up abated mildly until I got downstairs.
Vimala behaved as if she hadn’t just seen me eat. I did cope with a substantial serving of each dish, stuffing it down my increasingly rising gorge with sheer determination not to offend my friend whom I had watched slaving over a hot stove for an hour and a half. All three sat and watched.

“Please have some”, I pleaded.
“No, no”, they said as one. “We are too full.”

It was impossible, Vimala looked as if I had singled out her favourite relative to dance naked in front of when I refused to eat any more. I still had food in my mouth I couldn’t swallow, so talking was becoming increasingly difficult. It was torture. Torture to eat and torture to watch her face and torture to see all her efforts sitting sadly uneaten on the side.

I told her next time I was bringing my own dinner so I could have three meals with her. She did laugh. Today I am not eating a thing. Except I have been asked out for lunch and dinner. Oh God.

Evolution

The plan is evolving. Today the adult psychiatrist, Dr Anna Tharyan, who is an adult psychiatrist working in community rehabilitation, came to RUHSA to discuss the germ with us and the plan is unfolding, forming definite shapes and vistas. As expected there is no capacity in the Psychiatry department to spare an OT who can come and train the village carers on a regular basis, which means that VRCT is in an ideal position to consider funding an OT post for RUHSA. Of course being an OT of children with learning difficulties and an OT of adults with severe and enduring mental illness are two distant branches of a great tree connected only via the trunk of undergraduate learning. Once beyond university training, decisions as to which branch to follow come immediately and decisively. This means one of three possibilities: either the OT who is appointed must have little ambition of personal academic development down the specialist route – which in India, where continued professional achievement is paramount, is going to be difficult to find; or RUHSA needs 2 OTs, which would be prohibitively expensive and also misses the point that these branches are arbitrarily determined by medics not communities and in practical terms the needs of the carers of these two groups of patients are remarkably similar and it is the carers we are wanting to train not the patients; thirdly, RUHSA uses this as an opportunity to look at developing this concept as a subspecialty in it’s own right. In other words, becoming an OT in the subtleties of training community members in management of dependent family members of all types is a validly different and separate skill set than being an OT for children with learning difficulties or an OT of adults with mental health problems. Needless to say, I favour the latter option. It validates this entire approach rather than making it seem a makeshift alternative to proper services, which indeed it is not, it just happens to be a cheaper option.

So, how to start the project running? How to establish trust in the community that meaningful services are going to be provided before we appoint a full time OT, which may take 2m or, more likely, 6m? Selvakumar, in a blinding flash of brilliance, volunteered his son, who is just about to finish his exams, but then has 2m to wait before finding out the results to volunteer during the waiting period. Eyes gleamed at this. He is known to be local, dedicated, bright, enthusiastic, innovative and most of all, currently working in the community rehabilitation department.

Dr Tharyan mentioned that training for women in caring for special needs children already takes place. It is a 3m course and takes place the other side of Vellore 35km aware, so in principle this would be difficult for the mothers in the local villages here. Another role for VRCT? Perhaps, sponsorship of these mothers with regard to travel and living expenses. It is a daily interactive course which the children attend too. Interestingly, an unexpected side effect (from the perspective of the psychiatry department) is that 2 mothers have started day centres in their own homes for 5-6 children. Hallelujah. This is not to be an unintended consequence for this project, but the overarching aim. Dr Annie and I will try and visit these mothers next week to hear their stories and hopefully, ask them to come deliver some of the early introductory training sessions at RUHSA to inspire mothers here.

So, now we have an interim OT, with the promise of cover for a couple of months if there is a hiatus between the end of the appropriately named Trinity Selvakumar’s voluntary period and the full time appointment. We have training opportunities for keen mothers in both intensive out of campus established training programs and introductory training sessions at RUHSA for staff, mothers other carers and SHGs. I suggested to Dr Tharyan that her department and RUHSA could start to develop and formalise training sessions for caring for adults with mental illness. It takes place but ad hoc. She made an interesting point which is that in adult psychiatry, the single most important intervention is affordable and effective medication regimes. The only problem is that often villagers have no sense of conventional time. Next Tuesday means nothing at all to them. Again, an effective community lead co-ordinating timetabling of medication regimes would be incredibly empowering for the community. It begins to unfold some of the unmanageability of sever and enduring mental illness. Formalising the caring role is another future potential of this project in terms of academic validation and transferrable usefullness for other health centres; not to mention the benefit to the community. People can start being untied from their beds.