The broad reach of RUHSA

One of my main ambitions this time was to gain a better understanding of the areas I have been less aware of at RUHSA. I am very well acquainted with their social welfare programs which VRCT are involved in, but there is so much more going one here including other international collaborations. It is mind-boggling what a microcosm of a benign welfare state RUHSA is to the people and community of KV Kuppam block. They are a vocational college, Healthcare System, Social Services, Citizens Advice, University, Research Centre, Agricultural College, Community Support and much, much more all rolled into one. Just to illustrate the diversity of approach, the class I took today contained a wide variety of students: there were nurses, doctors, social workers, medical sociologists and health administrators all learning together. This fundamentally integrated approach to welfare delivery means that each person who comes into contact with RUHSA has a much broader perspective of what constitutes wellbeing. It would be amazing if universities in the UK had such a mixed syllabus approach for students instead of isolating everyone into their ivory tower subjects. 

I was especially interested in learning of the other international collaborations for research projects. With the Bill & Melinda Gates foundation, RUHSA is a centre researching the aetiology of neonatal sepsis. They have recruited 1100 or so women, of which 750 have delivered and so far one baby instead of the expected 10% has developed sepsis.

In a long standing collaboration with University of Sydney, there has been a 7 year project looking at cervical screening of the local population. In rural India they are way away from the acceptance of having a 5 yearly smear and education about the need for women to be screened is slow work. You can just imagine the multitude of barriers in a country where no-one even kisses on screen in films, so to expect them to come freely and have an intrusive internal examination when they have no symptoms is a big ask, but even though the pilot project finished after 2y RUHSA has maintained the impetus, making it one of their core pieces of work to try & improve the health of the women in this block. The education about the causes of cervical screening is also fraught with problems because most of these village women have only slept with their husbands, but infidelity is a common occurrence and the women have little or no influence on the number & frequency of their husbands other partners. Husbands are welcome to attend the screening with their wives, but little or nothing is said to them about their role in the whole process. Cultural taboos make this difficult.

Aberdeen and RUHSA have started a new collaborative around nutrition in children for which they have opened a new nutrition centre, where they give cooking lessons to families in which there has been a child identified as being underweight. I did not have a chance to see the cooking lessons, but it would be lovely to see next time.

I also spent some time in the clinics. My god they are busy and apparently this is a lean time due to Pongal. It is like a noisy, bustling, exceptionally colourful conveyor belt. Forget about 10 minute appointments, no chance. People are even scattered all around the grounds as there are insufficient benches for everyone to sit on whilst waiting for the few moments with a harried Doctor squished into a short walled, open plan cubicle with an equally harried colleague an elbow poke away in the same space. There was not enough space for me to sit and observe, I had to lean over the partition from the entrance, whilst being bumped and squeezed past by the constant flow of patients, relatives, staff and children moving through the clinic like grains of rice sloshing around on a plate with too much rasam. The luxury of a spacious room to myself with a comfy lean-back chair - absolutely no possibility of leaning at all unless it is into the next cubicle to borrow a pencil - a large desk with computerised notes (yup the remaining spaces between people awash with thin Indian sheets of paper for various & all purposes) are but a few of the things I will be heartily thankful for on my return.

Keelalathur continues

One of the great privileges of being fairly independent is that I can arrive unannounced at the project sites and see for myself how they are really doing without anyone being warned in advance scrub up and look busy. Last Saturday I cycled to Keelalathur, the first and dearest project to me. It is where it all started and I always make a point to go there. To a certain extent it is a survival mechanism to have shameless favouritism in India. With over 1.2 billion people, some means of selection is essential or you would drown. There are now 5 elderly welfare centres and only 3 of there are funded by VRCT. Of course, I was deeply involved in the development of the principle of an elderly welfare centre and the rest evolved from then onwards, but this occured once I was back in the UK, consequently, I had much less personal input and connection with the members of the group. At Keelalathur, they actually feel like old friends. Pushpampal, who grudgingly attended at the beginning, always looking dissatisfied and complaining that whatever we were giving was not enough, is now one of the staunchest members. She is always gratifyingly pleased to see me and is very cheeky with her greetings. Last time she told me I looked like a boy since I had lost weight, this time, she pointed to her hair, to me & then to the greying paint on the wall. Nothing escapes peoples' notice over here and my increasingly greying hair was no exception to the beady eyes of Pushpamal.

In the back, the garden is a little more productive than before. Proudly, they presented me with some lemons from their tree. Beans hide between twisted vines and curry leaf plants glisten from their recent watering. Apparently they have a harvest for approximately 6m per year. Its not a huge amount, but the Elders enjoy tending the plants and they can reduce by a small amount their food costs. A few years ago, everyone was enthusiastic about the idea of a working garden, but when the monkeys used the net as a trampoline before snaffling the produce at Kovasampet, everyone became downhearted and I assumed the idea was dead in the water. Somehow, despite this, those little seeds of enthusiasm flourished despite an apparent lack of encouragementNow each centres with land attached. It is a metaphor we would do well to heed. In the UK we start projects and when they do not produce results exactly as expected in the proposal, they are often binned, but we rarely give them enough bedding in time. These projects have shown me that the pace of change is slow but steady instead of rapid and transformational. Perhaps we need to aim for smaller, tidier ambitions and apply them with greater patience, so after a few years, we do not have several failed initiatives to show, but a subtle shift in perspective and outcome. 

Today, I promised them to come back so they could give me lunch. It is important not to always be the donor and create a permanent sense of gratitude, it is an ultimately destructive and disempowering dynamic, consequently, going to have lunch is an easy way of allowing them to give back. I look forward to it even though I will not really be able to understand the dinner table conversation! 

First RUHSA visit 2014

Owing to the beauty & brevity of twitter I have been able to annotate this year's progress at RUHSA without resorting to lengthy blog posts, for which I seem no longer to have the time. The seductive pleasures of intermittently tweeting have overtaken the homework-like feel of blogging. But there is so much going on that several times 140 characters cannot possibly be sufficient so I have forced myself to be a good girl and sit down to my long overdue prep on "What I did in my holidays at RUHSA".

The most momentous news is that Rita is a grandmother. She was delighted to welcome her newborn grandson to her family on 7th January 2014 - the second time in 2y I have been lucky enough to see a friend's unexpectedly early arrival. Last year, Victoria & Sudhir were delighted at Aadya's eager entry into the world which, had she been, on time, I would have missed. Rita's as yet unnamed grandson is very beautiful and clearly seems to have all his faculties intact as he blinks angrily at the bright lights when the blanket is lifted so admiring glances can be made and startles tremulously at the toxic air-horns on the passing trains. He too was early and is no doubt wondering why he bothered to rush as he is subject to the sensory overload India provides.

Of course, this week is Pongal, which has turned out to be a mixed blessing. As the organisation is Christian, the staff do not celebrate the Tamil Hindu Harvest Festival/New Year celebrations which exuberantly stretch across several days. However, the local community does, which means that the staff have an unexpectedly lean time, with fewer activities and therefore more time to sit down & talk to me about how things have been in the last 11 months. Of course it also means that a few staff are taking advantage & are on leave and also the projects might not be running exactly as usual, but being here fore 10d has helped ensure that I have seen pretty much everything I wanted to, which is great.

Everyone is well and happy to see me, as I am them. Most of us a little greyer, some faces new, some faces missing from the annual retirement cull but new faces also on the scene: despite her age and previous mid-life crisis, RUHSA is burgeoning new life and forging into the future with great purpose and intent. 

Rather irritatingly, several people have correctly noticed that I am not as lean as I was when I first returned after my great loss. Although to a man (and woman) they are all saying they prefer me like this, still it is galling and has forced me to take stock. I am trying to think lean whilst here, but it is almost impossible. The Indian diet is a gigantic challenge for your average dieter. It is heavy in oil, the food is cooked till pulpy and the body needs expend no energy to digest it thereby increasing its glycaemic index & the quantities served, are ridiculous. The plates are the size of small tea trays. Not even small tea trays, come to think of it. Couple this with a natural desire for people here to force a constant stream of tidbits, heavily sugared tea and coffee, snacks, extra portions, large portions and other consumables, refusing all the while to allow "No" to mean anything other than a coy segue to a resounding "Yes", spells disaster for someone who is naturally greedy. On more than one occasion, an extra portion has been slipped underneath my outstretched hands vainly attempting to cover my plate, amidst lentil-showering, increasingly desperate protestations of impending food-induced explosion. I don't even want to think about how hard I am going to have to work on my return. I think the quest is on once more for a non-anorexic tape-worm.

However, the simplistic luxuries of my room have allowed me to have a couple of lean meals on my lovely induction ring which is so aesthetic it is a pleasure to use. In addition, a kettle provides me with the ability not only to have tea without sugar (my natural preference) but also a stirring glass of Booths Earl Grey, which I have successfully, if a little pointlessly, introduced to a couple of people here. They all agree it is delicious.

Final thoughts on our 2013 visit

In February, 3 members of FOV spent a wonderful week in Vellore
looking at all the amazing work that takes place there done by some
incredible, inspirational, dedicated people and teams. One of those
days was spent at RUHSA which is the extraordinary multi-disciplinary
rural health & social welfare department about 30km outside CMC in KV
Kuppam. Covering an area of 200,000 people, RUHSA works on a multitude
of different projects to improve the local community from providing a
small local hospital, outreach clinics, preventative medicine and
educational programs, training local boys in auto maintenance, setting
up & supporting self-help groups; and those are just the ones that FOV
is not directly involved in!

We in FOV are delighted to provide support for a range of diverse
projects at RUHSA. We worked with them to set up their flagship
elderly welfare centres which provide welcome havens of friendship &
support, as well as a delicious meal made by local women who are keen
to become involved & raise the issue of elderly care within their
community. The FOV-supported occupational therapist has started income
generation projects in all centres so the participants can raise small
amounts of money for themselves by making paper bags which are then
used in the college shop on Bagayam campus.

The first centre opened in January 2007 and the fifth centre, funded
by FOV Sweden has just opened in January 2013. RUHSA hope to
proliferate these simple, but effective models throughout the area.
This year we were told of one of the participants, a lady who has
no-one and nothing in her life except a small bag she hangs from a
tree under which she sleeps each night. Her time spent surrounded by
other members of her community, chatting and being included gives her
such pleasure, that every morning she is waiting at the door of the
centre hours before it opens.

Raising the profile of the elderly centres is always a priority for
FOV as we are so aware of the increasing burden of ill health this
sector of society bears and other work we support helps to improve
family finances in the poorest groups so that they can afford to look
after all their family members, but also some of the money generated
can be recycled back in into the elderly welfare projects. This year
we are supporting a pilot stall fed goat scheme. We are funding the
building of a goat stall which can more intensively rear goats for
better profit margins. We visited an organisation in the Javardi Hills
who have a similar project & we were impressed with the set up. The
stalls are airy & light, the goats are allowed to roam free for a
couple of hours a day and they are fed well. RUHSA hopes that this
will generate personal & project incomes as well as becoming an
exportable model for other SHGs.

This year, RUHSA made a further proposal looking at another difficult
group, the local village youth, who often become rootless & aimless,
reducing their future prospects. This year, they are looking to
develop sports clubs in the local villages to encourage youngsters to
take part, have fun & feel part of a community. With FOV support they
will provide simple sports equipment for several villages and every
year, there will be a sports tournament organised at RUHSA in order to
give the lads something to work towards & achieve. Next year perhaps,
some FOV members can present the first RUHSA trophy to the winners!

It is always such a privilege to see first hand the work done out in
India, the level of expertise & experience is extraordinary; their
vision about their local community’s better future is inspirational
and I hope this newsletter gives at least a flavour of what takes
place. I would urge anyone to visit and see for themselves.

Reflections

After writing about all the things I have seen and done here since my arrival, I wondered what being here really meant to me. Its easy to write about hard luck stories, they are the literary equivalent of shooting fish in a barrel. But, in reality, what is the point in all of this?

This thought occupied me greatly whilst padding around my room, for the first time in my 8 years of coming, able to enjoy the luxuries a single ringed induction cooker offered - the ability to boil vegetables and, with the wonderful sachets of spices here, cook a half decent curry. I had just finished watching Africa by David Attenborough the last episode of which I had downloaded before the trip out and which had moved me to tears. The sight of this brilliant, empassioned, octogenarian naturalist, who has spent his life bringing the wonders of the natural world right inside our homes, mewling softly on his hands and knees to engage with a blind baby rhinoceros, forcefully illustrated both how amazingly powerful and yet futile humans are. We are agents of devastation and awesome change, but at the same time, to think that this is so feels like an enormous arrogance. The horrors of climate change seem both inevitably and impossibly to be caused by humans. Humans whizz around doing 'stuff' - both good & bad and the world spins on - rocks shifting, waters rising and falling - our eventual destiny surely completely unknowable. Sometimes it seems we influence everything and other times, nothing.

Given that rhinos do not reach their full maturity until they are about 10 years old, David Attenborough will be long gone by the time that baby has lived a full life & reached the potential hoped for by the wildlife team; he will never know whether he was a successful adult siring a whole new generation of black rhinos helping bring his species away from the edge of extinction. Watching someone towards the end of his life see, brutally, how much there is, will always be to do - no less than when he was hacking his way through the tropical forests with a black & white film crew makes me wonder whether there any point in doing anything at all, since the work is never done.

Being here reinforces that sense of powerful futility. I spend half my time here feeling pleased at the effects the work is having on the local community, then I take a step back and see the drop-in-the-ocean-perspective which makes everything feel pointless. Finding a middle ground especially here, in India, a place of such extremes, is difficult; the human brain can find it hard to bridge these two spectrum-ending perspectives; we are binary by nature with our paired limbs and symmetrical bodies - on the one hand this, on the other that. We must either be useful or useless. Yet, reassuringly, a single grain of rice feeds no-one and no-one expects it to. It is not big institutions which make the differences, it is the accumulation of relationships. No-one has the "answer" there is no "answer", we are all simply part of an iterative process, some things we will do better and others we will do worse: influencing what we can, learning from mistakes, striving to improve and, crucially, enjoying ourselves. Meantime, the world turns until it stops. Then and only then do we need to search for progress no further. I guess at that point we simply say "Bugger" and accept our fate. Until then: Anything possible, Madam.

The Palliative care team

Yesterday morning we went out with the palliative care outreach team which was a window into a world of extraordinary suffering and reminds me anew how goddam lucky we are to live in a country which, whilst perhaps being less inventive, is better at looking after its most vulnerable. Yet, even amongst the ashes of despair and hopelessness there are extraordinary sparks of vitality. India is a country in which one never stops learning inventive and ingenious ways of doing things. The familiar is turned upside down to reveals its bloomers, probably made from recycled umbrellas.

In this country chewing betel & paan is very common. For years men & women hold masticated toxic leaves in their mouth, with their delicate cheek tissues soaking up the carcinogenic chemicals. As a result of this, disfiguring, fungating, destructive tumours of the mouth are common. One of the patients the palliative care team visited had this type of cancer. She was 67 & the whole right side of her face resembled a mine field after someone has driven a tank through it. She was unable to drink because any liquid dribbled out of the hole in her face; that which made it to the back of her throat was misdirected by the tumourous growth into her windpipe causing her to hack and cough. The malodorous flesh passed close to her now exposed olfactory system. Her daughters tended to her as if she were a delicate flower, it was clear they did not want to lose their mother, yet they wanted her to pass peacefully with dignity and without suffering. They were quiet, calming and efficient, yet never forgot their instinct for hospitality, plying us with cold drinks, tea & biscuits as they intently watched the nurse showing them how to dress their mother's wound.

The nurse used a sterile pack with cotton dressings, but these are expensive for the average indian family. So the nurse explained how to make a home made dressing pack. Firstly, place the cleaned steel equipment in a pressure cooker and cook for 10 minutes. The put 2 tsp of salt into a pan of boiling water & bring to the boil for 10 and allow to cool. For the dressings, cut a clean cotton sari into pieces and sterilised them in the idli maker. An idli maker is a steamer in which makes the breakfast rice patties are cooked.

During this process, the lady was barely able to register our presence, she had her eyes downcast. The only sign of acknowledgement was as we arrived and saw her horrific plight, she raised her hands to the sky and looked at us - despairing, begging. It was our turn to have our eyes downcast. Who could deny the justification of her unspoken request? At the end of the visit, the christian chaplain, part of the multi-skilled palliative care team, stood with her, a muslim, embracing her faith and desire to be reunited with God by praying with her. Even I, a non believer, silently prayed that God might hear her.

From Idea to Movement

Today was the day I came out for. Three members of Friends of Vellore UK coming to RUHSA to hear about their projects and decide which could be supported. In past years, we have had to be fairly directive, often instrumental in the inception and development of the projects, but this year was different. Under the stewardship of Dr Rita, RUHSA has grown up. It is finally starting to realise its potential, which is very great. It is one of the most holistic organisations I know of, with its approach to community health and development. It pre-empts problems, finds problems, educates, trains, supports, heals, provides, empowers and all with generosity of spirit and kindness. Whether you are a woman who needs her blood pressure checking during her pregnancy, or you are a young man with learning difficulties who needs to learn simple activities of daily living, or you are an older person whose family has decided no longer to support you or you are a farmer who needs an interest free loan to buy a cow, RUHSA is able to facilitate you to a better state of being, whilst constantly on the search for new & innovative ways of improving the local wellbeing.

We learnt of their recent successes, heard their new project proposals and listened to their ideas for the future. As so often in India, a circle of opportunity is starting to form, linking different spheres together. The newest proposal laid on the table, astonishingly & co-incidentally, was that of starting up a recreational youth club. The idea was born out of concern for the younger generation of lads who, not wishing to become agriculturalists, like their fathers, but with no additional skills to do anything different except yearn for easy money as apparently available to those on the public media, but lie just out of reach of their sparsely-educated, rural hands. There is a disenfranchised generation of young men who are ripe for the plucking for addiction, domestic violence, poverty & crime. RUHSA seeing this potential on the horizon wants to start a socially inclusive movement which nurtures skills, relationships and enthusiasms for these youths. They may not be a psychologically damaged as Celines lad, although undoubtedly there will be some who are, but the principle of need is the same.

This starting point feels similar to where we were 6 years and 6 elderly centres ago, when we had no idea how we were going to do it, but we wanted to give the elderly people of poor communities a better and more dignified existence in their latter years. Now not only are villages coming to ask RUHSA to help them set up elderly welfare centres, but different countries are starting to sponsor the programs. Three were started by VRCT, the fourth was set up by the Bishopston link, the fifth by FOV Sweden and a sixth is earmarked by FOV Germany (we hope). Wherever we go to these centres, the story is the same, the elderly participants feel more highly valued & content than they have for years. They are enjoying the company, the attention the food and the small income generating programs. I wrote last year of a woman who has saved enough money to ensure she can have a proper funeral instead of the paupers funeral she had been destined for.

These elderly project models are well established now and can be set up very easily. They include 10-40 members depending on the capacity of the villagers who provide the food and cost £126 a year per person for a daily meal 5 days a week. This money not only feeds an older person, but provides an income for women of the village. Today we went to the newest centre set up by FOV Sweden after seeing our flagship centre a couple of years ago. It was an unexpected visit because we had been due to see another one, so they were not awaiting our arrival. A wonderful sight greeted us: children playing in one of the rooms, wriggling around, running in and out of where the older persons were more sedately sitting playing games chalked out on the floor, batting the kids away as they knocked counters over whilst in the corner, the smell of spicy beetroot wafted across the newly cooked steaming rice. So much energy, laughing and chatting emanated from all and wrapped us in their pleasure at being there. The women of Panamadangi village wanted to start this centre; they were instrumental in helping identify the most needy villagers and donated their own building and money to ensure the centre had appropriate facilities (loo). I felt humbled & not some little pride at how our early efforts have become a movement of its own. I hope that, in 6 years time, we are experiencing the same sense of pride and awe looking back at the inception of the youth project.

RUHSA and the radical public health solution

There's a new state in central India which has more consonants in its name than most people might expect except perhaps a Welshman. Chhattisgarh. Their health outcomes are very poor and doctors trained in their medical schools do not work where they are most needed - the remote rural villages. The shortfall is high throughout the state and dire in the most needy places. There are plenty of health sub-centres, but almost 1/3 do not have even a nurse practitioner, let alone a doctor. This is a problem all over India, but especially acute in this new state, which has the added disadvantage of having acquired none of the medical schools subsequent to its bifurcation from Madyar Pradesh from whence it was carved. There was another problem to be countered as well. In the health professional void of rural Chhattisgarh “jhola chaap” doctors, a derisive term for unqualified practitioners, were mushrooming in the villages, making matters worse with their nefarious practices.

The obviously passionately enthused state government therefore came up with a radical & contentious public health solution. They tinkered with the medical school degree, shortening it & targeting more local, less affluent students to train them to deliver community health care. These 3-year diplomas of medicine were government endorsed & privately funded with 50% free places and the remaining at least partly subsidised. The trade off for the graduates attaining a level of skill and employment opportunity they might not have been otherwise able to afford was that they were encouraged to practice in the less attractive rural areas normal graduates would shun, thereby generating expertise and a willing workforce right where it is needed.

One of the proponents of this model was an erstwhile RUHSA graduate and, knowing how broad RUHSA's expertise is in rural healthcare and economic development, he suggested part of the training took place at here, so every one of the 1000 trainees will pass through RUHSA's wise portals. As a result, RUHSA has developed and is delivering part of the syllabus for these Rural Medical Assistants - a cadre of trainees specially designed to improve the welfare of very disadvantaged populations right at the core of where it is needed, the local community.

Unfortunately, as one might imagine the Medical Council of India was dubious and rejected the proposals out of hand before the course started but it had been designed so their approval was not in principal needed. However, the Indian Medical Association, equally threatened by this erosion of their "standards" jumped on the bandwagon and mounted a legal challenge almost immediately after the program started, causing a war of attrition with the state government whose energies became subsumed by the need to find ways and means of fighting the challenge, so withdrew their endorsement. After quite some in-fighting, this training program ceased recruiting after 3 years so there are no new trainees coming through at the moment. One can understand the arguments against embedding a two tiered system instead of increasing the value of working at a local level. It is a well recognised problem with no easy solution; Indian Health Policy (2002) describes it well. Becoming a doctor is a highly desirable career path, the opportunities to make significant amounts of money & maintain a certain lifestyle are legion. You have to be rich to be a doctor, unless you are exceptional, and coming from a certain sector of society is not going to make it likely you want to hide yourself away earning a pittance delivering basic healthcare needs to a highly disadvantaged community. However, there is also an argument that filling that need from an alternative path and gradually increasing its value over time, might have enabled the two perspectives to meet in the middle.

It is sad that this innovative program seems to have ground to a halt, but a recent review http://cghealth.nic.in/ehealth/studyreports/chhattisgarh%20experience%20with%203-year.pdf suggests that there is still an impetus behind the program. There has been an iterative approach to finding a solution and there is life in this model yet.

A constant reminder of how lucky we are.

Celine was waiting for me, sitting calmly in her still-crisp sari stiff to the floor like the flights of a shuttlecock. She had been there for four hours having arrived from Mumbai earlier in the evening and in her typical generous way had offered to wait for me to drive back to her house for the day. The precise timings of what was needed to effect this transaction had been overlooked in our mutual enthusiasm at our impending re-union. It was only as the plane taxied to its stop that I realised how truly saintly her offer was. I hadn't even told her which flight I was coming in on, so she had been searching for flights from Heathrow arriving at 2.55. There were none, they were all coming in well after 4am. Still she waited, not knowing to check the arrival of flights from Doha. Her usual telephonic response to my slightly guilty call, as the plane wheels skidded to a halt, of "Where are you?" was never more appropriate.

In contrast to her crispness, I was crumpled, tousled, ruffled & dusty, but no less delighted to see her. We spent the day driving around and chatting. Firstly we visited my friend Victoria, who, with perfect timing, had delivered a delicious little girl two days previously, then, in a extension of her saintliness, she accompanied me to RUHSA (four hours there and four hours back). In between my brief but deep trips to unconsciousness whenever the hum of background India lured my grateful brain to sleep we caught up on all the news of the year since we had last seen each other.

Karuna Niwas continues its work. Recently a new lady has come to stay. She was a victim of domestic violence whose husband beat her because she produced only girls. Clearly, he was not up to date with biological fact. She ran away on many occasions, but he would drag her back for more beatings. Eventually he left her, destitute and degraded, with her three daughters to find a younger woman to give him boys. She has a lovely face, sweet and earnest, with soft brown eyes and a kind smile. She looks happier now. Celine has ensured the oldest two children are in an English Medium school, which she could never have afforded before. Hopefully it will give her girls a better future than they had looked forwards to before. The youngest will benefit from the gift of a teddy bear that one of my lovely patients gave me to bring out for someone. Celine is now helping the mother to find a job. Her prospects are good but even if she cannot find any work, then she could do one of the several training courses available at Karuna Niwas - beautician training, spoken english, tailoring, computing to name a few.

However, the story that troubled me the most this time was that of the newly teenaged young lad & his sister who have been under Celine's care for over 7 years. Their mother too was a victim of domestic violence which they witnessed in brutal detail. When the girl was 4 & the boy, 6, the father beat the mother to death & set fire to her. She had been holding her daughter who suffered extensive, disfiguring burns over her limbs & torso. Her scars are visible. Tangible and easy to identify. A constant reminder of her need for empathy & love. Luckily, she does not consciously remember the incident, although she does get nightmares. The boy, however, witnessed the entire incident and remembers clearly & consciously. His scars are more penetrating and eviscerating. Celine is the only family they have, but she is not a family. She is alone and a loner - part of the reason for her success in the work she does, but this makes it difficult for her to provide the unquestioning presence & constancy children who have suffered such as they need. They love her and she them, but the young boy is reaching difficult teenage years which is a different country at the best of times, without starting from such a desperately traumatised position. He does not understand anything except loss and anger. Celine is despairing because he has become so destructive. He makes no friends, he trusts no-one, he cherishes nothing. He has no idea how to invest in his future, he simply perpetuates the familiar cycle of loss, bereavement & rejection.

We talked at length about him. Two spinsters without children exchanging theories on what to do. In some ways, however, the cultural context of the UK, which attempts to be children-centric would be a kinder place than India, where expectations of good behaviour are high and deviations from the norm are treated as wilful intent to upset. This results in the poor boy constantly being told off, giving perpetual momentum to his dysfunctional behavioural cycle.
Celine is trying to teach him to be independent and look after himself, but thinking about it, that is exactly what he has had to do all his life. No-one has looked after or even nurtured him so the only person he trusts is himself and even that is fragile.

This middle group of children - not privileged and not destitute - are a forgotten segment of India's future. There are so many people to rescue in India, that those who appear not to be wanting in the most basic of Maslow's hierarchy of need are left to work it out for themselves. I have no idea what the state of child psychology is here, but judging how less than perfect it is in the UK, cannot imagine that is going to be more sophisticated. There are so many things he needs, but no-one has any idea how he might access them. I mean, that I can also say about some who come to see me at home. If the means of getting help for troubled children is obscure in Dalton, imagine how much more challenging it is here. Apparently, he did go to see a child psychiatrist once, who, on seeing his easy completion of age-appropriate motor tasks, concluded that he had no need for input because his development was normal.

In the absence of good child & adolescent mental health services, he might benefit from activity clubs where he could go to do things he enjoyed. For example, he loves cycling. Perhaps joining a club where he could meet people doing activities along side each other, learning gradually to get to know and like them through shared interests, would give him some confidence. However there are no such places like that in Bangalore, Celine says. I confirmed this on google.

In a pathetic attempt to show him that there are some people who, even if they don't know him, might care about him, I will ask my two to become pen-pals to him & his sister. I am sure they will consider it an arduous task, but it would be good to encourage them to do something for someone else's benefit entirely. Perhaps a small kindness from strangers prolonged over time may in a tiny way challenge some of his self-destructive beliefs. Of course it fixes nothing really; no doubt this is a response to being overwhelmed by the obvious contrasts between my easy life & theirs. Nonetheless, one day, I hope to bring the kids to India. If they have shared correspondence for a while perhaps it would also give them an interest to meet up.

Outline of all Projects 2: The Goat & Cow Schemes

The thorny issue of the Goat Scheme has always been tricky. It was first introduced as a passing on the gift scheme which benefited some individuals, but as has been mentioned several times, the second time we tried to introduce it in another village, the goats went missing presumed consumed. In the original village, Keelalathur, we are now on the 3rd or 4th generation and there are 11 kids to be redistributed. I think we should see whether the smaller group at Seeterampet look after the goat better than at Kovasampet.

After the passing on the gift scheme faltered, we introduced the idea of SHGs raising goats, but as mentioned in a previous posting, this produced only modest returns. Mathew and colleagues went to an NGO convention and saw a co-operative model which we are keen to introduce here at RUHSA run by an SHG as a coperative, so we have the benefits of a group deriving an income, but also being able to generate an income for the EWCs. The capital could be put up by VRCT, 50% returns come to RUHSA for the EWCs and 50% go to the group. The newly redesigned VRCT committee will await a full proposal from RUHSA about this project and hope to be able to approve it for the coming year.

The Farmers Club Milking Program is another co-operative model initiated by one of the RCOs to benefit poor village farmers. FOV raised funds for 15 cows, giving 5 to each of 3 co-operatives. This acts as an interest free loan. The farmers pay 2000rs (£28) back per month from the milk and dung income they receive. It is early days, but we went to see the projects on weds (see previous pictures) and it is looking promising. RUHSA have trained the farmers in cow management and dung collection and as milk prices are good, the returns are also good. Each cow can produce 10l per day of milk which can fetch 17rs per litre. After feed costs etc they can earn about 100rs per day from milk alone. RUHSA feels that the farmers’ wellbeing has increased and there may be a chance to explore the impact of schemes such as this on other dimensions of health such as domestic violence, alcoholism etc. We will await the evauation after a year is up to see what the impact has been.

Next to be continued: diabetic shoes made by disability SHG, community college revamping & fund raising officer