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.

The Germ of an idea: microhealth

At a meeting today with Dr Rita and Dr Annie, the first germs of an entirely new, community centred, asset based approach to mental care have been cast into fertile soil. I am repressing any premature excitement, but perhaps you can tell by the way I am typing how enthusiastic I am.

The problem: debilitating mental illness and mental impairment is a huge burden in rural India. Let's face it, it's no picnic in the UK, but in India it is catastrophic. According to the WHO only 1% of India's health budget is spent on mental health. There are a puny 3500 psychiatrists in India. By that I am not passing judgement on their stature or relative musculature. Considering there is a lifetime prevalence of 22% of mental illness in a country of 1 billion, 3500 psychiatrists does not go very far. Of course most of those doctors will be in the cities and as already mentioned earlier in the blog, 70% of the country’s population is rural. Mental health in the villages is in a dismal situation: there is quite simply no help.

So starting any mental health program is a gargantuan task. The need is enormous and the resources microscopic. When Dr Rita, Dr Annie and I first spoke about this last year, fresh from the introduction to asset mapping as opposed to needs assessment, we explored the new concept of figuring out how, given that they have absolutely nothing, these people are managing; because somehow, however crappily, they are; like the elderly at Keelalathur before we came along to offer food, who were also somehow managing. They had a life. It probably was not great, but we did not account for any of it and as a result we simply increased dependence.

Dependence in mental health is ruinous for two reasons, firstly it impedes recovery and welfare, secondly, it unleashes the untameable beast of unmeetable need. No health care service can solve the problem of mental illness; it's not like removing footprints from a polished floor. Mental illness is messy, complicated, intrusive, pervasive and, most of all, endemic. In fact, most of all, it is embedded within the lives of individuals and their community. Solutions therefore must necessarily mostly be born from within those communities. Any health care professional who fails to acknowledge that from the start is starting a long journey across a hot desert in a thermal snowsuit with lead weights in his boots. Without water. Or a phone. In other words, it is madness. The astounding thing is that the madness of mental illness is indeed in those very professionals for the idea of actually asking people how they cope is not only incredibly new, but it is not done well: "Ask a mad person how to manage their mental illness? Are you mad? That would be like asking a heart translant patient if they had any hot, new suturing tips." It would appear then, that the idea of starting a project with this concept is new. I’ve researched it and I cannot find anything along these lines. If anyone knows of anything similar I would love to hear of it.

So, the plan: at RUHSA there is an occupational therapy clinic for children with mental impairment. There are some extremely keen mothers who come every week and have already noticed a difference. These mothers have to look after their children 24/7 so there is no time to do any income generating activities. The double whammy of illness and poverty. So the plan is to tap into this keenness and have a training session for these women. Firstly, learn how they manage – effective techniques can be disseminated to others. Secondly, equip them with generic skills for caring such as hygiene, nutrition etc. Add in specific skills for children with learning difficulties and adults with severe and enduring mental health needs. Then, and here is the genius bit, train them to look after more than person. Now send them back to the village with back up from the community staff already in place, such as RUHSA’s Rural Community Officers, family care volunteers, health aids who have been working for the medical care team for the last 30 years, who will now be additionally trained to recognise and destigmatise mental illness in order to identify other families in the village in need. Let the women in their own community persuade other families of the benefit of OT work and then encourage them come for training and then to form co-operatives so that the care burden can be shared. This will allow some women to be relieved of their 24/7 caregiving role to enable them to generate an income which can be shared. As more people benefit, the training programs can become more specialist and directive according to need. It seems to be a win win situation. Serious problems are more likely to be delflected with better care or recognised with increased experience and then can be directed as appropriate to the medical team.

This idea is so simple, I like to call it microhealth because, like microfinance, it draws on the big ideas, but brings them to a simple, manageable practical solution for the individual and leaves the medics to deal with cases which cannot be managed except by medication. The outlay of the mental health system then becomes training plus appropriate, hardcore management rather than getting bogged down by taking on problems indiscriminately; the momentum and power is generated by the community, for itself.

I think you’ll agree, it’s genius in its simplicity, but as I mentioned before, this is just the beginning and the road to make this idea a reality will be long and hard. It will need passion and dedication and effective leadership to make it work: Dr Rita & Dr Annie embody these values.

Waffle vs Ryvita

The most exciting piece of news, which I forgot to mention in the first posting is that after three years of coming and having to sleep on a twice baked ryvita mattress (the dimply side) I have been awarded the honour of being given a proper, no coir, foamy, spongy, bouncy, thick, cosy, deep, enveloping, DELICIOUS new mattress. It is impossible to describe the joy I felt when I sat down on the bed, expecting to go "crunch" and instead going "squish". My brain could barely compute the significance of the signals coming from my bum. No longer do I have to put the two mattresses together to give a semblance of substance beyond tungsten carbide to my sleep. Despite the addition of a slightly thicker coir mattress last time - which sandwiched between the other two wafers, created a marginally less horrific night's sleep, I still developed pressure sores albeit to a lesser depth than without the coir mattress, but now! NOW! Now, I sink into blissful slumber as soon as my head hits the brick. (A comfy pillow is a step too far). Anyway, thank you to the Gods of Nighttime Torture, that they have taken pity on me and facilitated this new look RUHSA room.

As if a new mattress were not enough, however, when I walked into the bathroom, I saw to my absolute delight a newly fitted electric hot water cylinder. Oh. My. GOD! I am going to be able to have an appropriately temperature-regulated shower. No more freezing ones in the morning (when it's cold) or tepid ones in the afternoon (when it's boiling). With shining eyes and clapping hands I turned excitedly towards one of the Henchmen. My smile dropped. An imperceptible head wobble did not bode well. Wafting his hand towards the gleaming new apparatus I heard the devastating words, "not working", crushing my new found hope. It's true, not only is it not plugged in (and the socket too far from the cylinder) but it is not attached to a water source. As such it is merely decorative and very beautiful it looks too. Still, one step at a time. How things have changed even since I first came here three years ago. I have high hopes that next visit I will have a sit-down loo, a comfy mattress AND hot water. Woohoo.

A New Year, a New Visit, a New Director and a New Start

Firstly, I must thank & congratulate Dr John, the erstwhile director of RUHSA, who has been made director of CHAD, which has long been his personal vision. Although we have had a stormy relationship, he has welcomed me and allowed me to visit RUHSA; working and learning here for the last 3 and a half years. It is impossible to quantify how much I have gained from my time here. Much of it has has formed the philosophical scaffolding of my MSc and continues to inform my practice in the UK. Therefore, I wish him the very best for his last few months at CMC before final retirement.

Our meeting in January 1989 over 20 years ago was inspirational for me then; there was a propitious sense then, but I was not to know how influential in many ways that first meeting would be. I remember so clearly our trip to the tribal village by jeep aged 18. As we crossed a dried river bed, bouncing against the hard springs, we passed a woman being carried in a makeshift sling by two men. She was still and cachectic. With her huge bulging stomach, a visible ovarian tumour beneath the paperleaf skin, she looked like a child's badly made doll. Dr John stopped to talk to the men. The woman was incapable of doing anything more exhausting than breathing. She was being brought home to die. The faintly glowing embers of interest in medicine in me were fanned. Many years, and several arguments later, despite our often fractious interactions, I am very grateful to him and all he has done for me.

Dr John's leaving, however, means that a good friend and excellent person is now director of RUHSA and I am delighted not only at her achievements, but also at her keenness to continue my association here, working on nothing less than my main interest - mental health. I wish Dr Rita Isaac best wishes for her and RUHSA's furture success. I have every confidence in her.

So far 2010 has had a great start and I can't wait to get stuck in. Early plans suggest that she is keen for me to start looking at community resources for mental health. Mental illness has a huge impact on poor families in rural India - family members are sacrificed to look after the ill person and therefore not only is there a loss of income to medical care but also because of loss of working capacity. This results in mental ill children growing up neglected, tied to cots, restrained, being mistreated and reaching very much less than their full capacity in the strive for families to manage. It is extremely tough. However, mental institutions can neither cope nor provide the answer necessarily. The starting point for sustainable mental care is to look at what communities already do and try to help them to do it better in conjunction with delivering appropriate medical care. A cluster of families with mentally ill relatives have been identified and we are going to explore the idea of developing co-operatives between them. Anything like this whichde velops within the community must evolve through community potential and not be imposed, so I expect the road to the right solution will be long and occasionally disheartening, but I have no doubts that it is the correct path to be taking.