I think we've cracked it.

Ever since we started the Elderly Welfare projects at RUHSA we have struggled to find a way of making them sustainable. There has always been a sense that unless the centre itself can be self-sufficient or community are able to support it, then it is just another example of an paternalistic imposition, ultimately creating dependency not independency and as a model is not one which can be applied to beyond how it is being used now. Certainly, the initial centre in Keelalathur was a victim of this. Our attempts to get some income generation program or garden grown to generate some funds for the running of the project were not successful in the way in which we wanted it to be. Income generating programs did not generate income, Richard Smith's funding for goats given to the elderly gave some elderly some small income and passed on a goat to another person in the village, but it felt like a separate program as it generated no funds for the centre, however, it was the closest thing to sustainability we managed. The next group of elderly who were given goats ate them, so that did not work. Again the garden there, despite the participants being keen and asking to run it, was also not a success. The monkey nets to protect the fruit & veg were simply used as giant trampolines by the monkeys until the nets caved in and gave them access to snacking after their vigourous gymnastic routines.

A glimmer of possibility was seen shimmering when a self help group came to ask whether they could start an elderly centre. This was a new development. Raising the profile of the elderly in the area was giving them a hitherto unheard of status and local women's groups keen to provide a social service to their community wanted to run an elderly centre. In fact 2 groups wanted to and they share the work, providing meals for 40, which is almost twice as many as the RUHSA-run centres. So now there is a desire in the communities to run the centres and the money is being used to benefit two groups. The charity pays the self help group to run the centre and the more efficiently they do it the more profit they make. It is starting to feel as if this is a model which, whilst not sustainable, is at least supporting a community welfare system. The goat scheme, meanwhile had captured the imagination of donors in the UK and money has come in for 20 more goats. Reluctant to give goats to people who are too hungry, RUHSA decided to give the goats to a self-help group using a different model. Previously, the goat owners would give the first kid back to RUHSA to pass on and then every kid after that belonged to the new owner, but now their scheme is slightly different. RUHSA & the SHG are business partners. RUHSA retains ownership of the goat, but all profits from selling the goat are halved, RUHSA's half being used to contribute to the elderly fund. Now we have a potential income stream for the elderly program. but it was still having to be financially managed by RUHSA and therefore incurring  the added expense of RUHSA staff working on it, which does not cost the charity any more, but does use up resources and limits the amount of programs which can be started.

So. The final piece in the jigsaw evolved during the course of our first meeting. But first, a little background to set the scene. SHGs (self help groups) were set up in Bangladesh as part of the micro-finance model, which is a grass roots financial lending initiative, enabling women to form co-operatives and develop or start small businesses with small amounts of capital. It has been deemed successful and the guy who developed it in Bangladesh, Muhammed Yunus won the Nobel Peace prize in 2006. His micro-credit organisation, Grameen Bank, has 7 million of the poorest women in Bangladesh as it's customers. These women are in SHGs. India has adopted the concept of SHG development and nowhere is this more evident than in South India. All the four S Indian states - Tamil Nadu, Kerala, Andra Pradesh & Karnataka - are effectively committed to the empowerment of women & other of the poorest members within communities and there are many government schemes supporting these principles. In Tamil Nadu in particular, the government has gone a step further. The Bangladeshi model is only an economic model, but in TN, the government has incentivised social development as well. Each SHG is graded and on the basis of their grading, may be eligible for microfinancial assistance or micro-credit. They will get extra points if they contribute to the social welfare of their community, which helps to explain why the women have been interested in starting up elderly centres within their communities. Not only is there a social drive, but also there is financial benefit, because it improves their credit rating.

One more piece of background. Clearly the effectiveness of any micro-finance scheme depends on the loan repayments and of course one of the difficulties of keeping track of what's going on is the sheer number of borrowers. A system like this run from a bank is open to abuse, either by the borrowers who default because there is no incentive to pay back (there is no means of legally recouping small amounts of money from very poor people in India) and secondly from corrupt lenders or their minions who say a rupee for the bank and a rupee for me. In Tamil Nadu (and perhaps elsewhere) they have developed a system of local corporations  called a PLF - Panchayat level federation, I think (panchayat meaning district) - to which the SHGs must belong. The executive members are elected from the full membership of women in the SHGs. The PLF is then responsible for the financial interactions. They collect the money from the SHGs, they pay the loans out, they administer funds, they ensure financial probity within the groups and because everybody either benefits or loses out depending on how effective the PLF is at managing funds, there is is strong collective peer pressure to run things smoothly. It is a very clever system which uses big business principles at a local level where there are still direct relationships between social equals, which makes the peer pressure more meaningful.

So...the plan as it unfolds is this. The PLF are given goats to distribute to those members who wish to rear them for profit. It's quite a hard job, so not everyone is keen. Each goat costs, say 2000 rs (roughly 30 quid). The goat can be reared and then sold at peak, goat-eating season (often Islamic festivals) for 5000 rs. That means there is 2000rs available to invest in another goat (in the non-eating season) and 3000rs to share. The goat owner will get 1500rs and another goat and the PLF will get the remaining profit, which they will hold in a new bank account specifically for Social Development (elderly welfare). It can then be used to pay another SHG, of which there are several, who wish to start an elderly welfare centre in their village. RUHSA will calculate how many goats are needed to pay for each centre over the course of a year and can raise funds as a one off payment (seed funding). As we have already given goats to an SHG, in 6 months time we will know what  the actual earnings are and develop a business model for future goat schemes. So now, we have an model whereby the elderly get fed, women in the community earn money from goat rearing, another SHG can earn money by running an elderly welfare centre AND improve their credit ratings for future projects (and improve the PLFs rating too) and the very poor elderly in more villages are given an increased status and lunch 5 times a week. All RUHSA has to do is keep an eye on the overall equation: Number of goats = so many elderly meals. Call me old-fashioned, but I think it's brilliant and seems run along everyone's incentive lines smoothly. Everyone at RUHSA is very excited and thinks it will facilitate many more elderly centres being started. In addition, it is JUST the kind of thing people like to put their hands in their pockets for and has already proven extremely attractive. Genius.

What’s your secret?

I arrived back at RUHSA in the dead of night, without anyone much seeing me, because firstly it was dark and secondly, most people had gone home by the time I rocked up, so the next morning there was a big (or smaller) unveiling and I have to say, it has created quite a stir. I guess 12 months and 39 kilos is quite some time ago.  Vartsala, the lovely secretary with a predilection for peach saris, was cross. Her first words, after screwing up her nose in disapproval were “I loved that round face, now it is soooo long. I miss that face”, but then I caught her sneakily peeking at my less-existent belly. At one point she pinched my arm to see what less fat felt like. Then she confessed that she wanted to reduce too, but was secretly glad to discover that although I don’t have a chicken neck, there was evidence elsewhere of imperfect re-elastication of skin. 

Every conversation and greeting has started with, “Ooohh-hooo, so much reduced!” followed by furious head-wobbling and grinning. 

Rita was trying to explain to some nearby interns whom I had not met and who, incidentally, could not have been less interested, unsurprisingly, in the whole conversation, what a transformation there had been. “Before, you couldn’t believe how fat she was. Sooooo broad” (Coupled with actions to recreate general girth & enormity of body). The interns looked a little shocked at that, I have to say.

I had been due to meet Mathew at 8 o’clock sharp - my own arrangement on which I reneged owing, I think, to ongoing jet lag and a missed alarm clock - so he came down to find me at the entrance where he heard I was hanging around about 50 minutes late. I hadn’t been able to get very far owing to everyone wanting to know my secret. He guffawed when he saw me. “Oh my God, when I knew you were coming, I specially opened both doors to my office because I thought it is more comfortable for you to get through!” It just goes to show that however hidden we think we are and however private we feel how we look, nowhere more so than India reminds you what public property we are.

Stalin, the media guru at RUHSA, came up and said to me, “you must give me tips for my wife” Small and petite himself and less like his more famous namesake would be hard to find, except for the presence of a beard, his wife is certainly no taller, but has expanded horizontally according to him. He looked a bit wistful when he told me she was “now 82kg” I am sure his wife would be delighted to know how he’s bandying her weight around so freely. He asked the question that everyone has asked. It is clear that they believe there is some magic answer accessible to reduced rich white English doctors. “Any English medicine?”

I asked him how his wife ended up being 82kg, he said she eats too much, I replied well there you go.

So many people have sidled up to me asking to know my secret, hoping against hope that there is a magic answer and all I did, for example, was put a half ripe mango under my pillow one night and woke up transformed, or that taking a diet pill every day caused the fat to slip away. The disappointment is palpable when I tell them no magic bullets, only hard work and dedication. I missed a trick there. I could have had such fun thinking up weird and wonderful ways in which it could have happened.

Going to the tailors, those of Innerwear fame, was the final hurdle. At the tailors are two girls who have been working there for the whole time I have been coming to Vellore and who inexplicably find me HILARIOUS without any effort on my behalf. I have never needed to do anything more amusing than order a pair of trouser made of underpant material or buy a rickshaw horn for my bicycle and now even the very sight of me makes them fall about with laughter, continuously. And loudly. Today, the laughter stopped briefly in amazement, so that was a good thing and then it redoubled and they called everyone who might have been interested and quite a few who clearly weren't, to come and see the new freak show - The Magical Disappearing Woman. Any new customer who came in whilst I was there was forced to listen to the tale whilst trying to mind their own business and buy saris or innerwear material. I could tell from the few interspersed English words like Doctor, UK, exercise, eating, accompanied by the universally understood Indian gesture for fat, which approximates to clenched fists facing each other at chest height with elbows out with a pumping in & out action, culminating in not-so-subtle pointing at the "new me". Of course, its really touching how much interest people have taken, I think, despite the sometimes clumsily made comments, it indicates a genuine fondness for me which I both reciprocate and appreciate

The RUHSA effect

It is so lovely to be back. RUHSA is the equivalent of a little place in the country for me. Unfortunately, its a little place in another country so its not possible to nip here for the odd weekend, but whenever I imagine solitude and peace to achieve clear thinking away from the hustle & bustle of normality, I imagine sitting in this dear, bare room, with the throaty bird calls and constant chattering of insects embalming my ears. Ironically, it is less quiet than the equally gorgeous place I live normally, but of course there is only one room to manage, no washing up and no daily minutiae to interrupt continuity of thought.

Arriving late wednesday evening after a brief and monsoony visit to the swimming pool, Immanuel’s replacement, Vinodh, greeted me. Immanuel, sadly & unexpectedly died last September. Unexpectedly, because although he was almost moribund from obesity, he did not have any obvious, pressing health issues, but from all accounts, a minor illness became overwhelmingly difficult for his poor beleaguered body to deal with and his heart gave out. His death left a huge hole in RUHSA’s fabric, both literally and figuratively. He had been here since the very beginning and knew each contour of the warp & weft of RUHSA. He was the oil that greased the machinery. We had our problems, there’s no doubt. Having spent so much time here on my first visit, my deferential guest status transformed into something more meaningful and I think he found me intrusive and tricky & I found him to be controlling and sometimes obstructive. I had several run ins with his henchmen who could make my life quite difficult, but Immanuel was essentially a good and kind man, who’s entire life was RUHSA and he served RUHSA with his whole heart and he was loved my many. His passing was a sad, sad time for RUHSA.

His replacement was only appointed 3 weeks ago and has the look of someone who is not quite sure of the magnitude of the mouthful he has bitten off, but he is very pleasant and seems to have a quiet certainty about him, which will serve him well in his new role. His wife & daughter are an unusual accessory in this post, but charming non the less. He is very young and as Rita said, will grow in the job. Personally, I think it is an incredibly exciting position to have, RUHSA is in a new ascendancy and has the potential to become an extraordinary place once again after its years in the wilderness.

Yesterday, in between the frequent conversations about how I managed to reduce so so much (UK medicine? Special diet? - more of those conversations later, they deserve a chapter of their own) there was much to take in since my last visit. Already conversations about how to further develop the elderly welfare centres have been animated and voluble. At the moment there are 100 beneficiaries, in four different centres all of which have slightly different models, having evolved each time a new one was set up. I thought there were going to be two in one village but in fact they have merged and there is one centre with 40 participants instead of the more usual 25. Similarly, there is a joint centre with Bishopstown kindergarten to which 10 attend. By the way THE WELL HAS BEEN DUG (only last week, but borewell in place nonetheless. Water was reached at 265m) Last year the monsoon was a good one after 4 years of drought so no water had to be bought for the whole of last year, and hopefully, this year the monsoon will keep the water table topped up, easing up the pressures of increasing global food prices for the local villagers. 

It looks like we are in the process of developing a fully sustainable elderly care model, which, after 5 years, is thrilling. I learnt some fascinating local politics yesterday. It seems that there is no means of recouping money lost to the poor. Local law states that if a poor person owes money from a government or NGO loan, there is no legal method of getting the money back. Which is great for those with so little, but of course, makes creating a dialogue with trustworthy partners a little harder if there are only carrots & no sticks on the table. However, RUHSAs reputation & relationship with the local community is so highly valued that engagement with schemes is high and honesty - in some form - prevails. The clearest example being when the goats went missing presumed consumed at the second elderly centre, Rita felt strongly that they ought to have some responsibility for this “stealing” although one can see that if you are so deprived a free goat is manna from heaven, but of course it comes attached to a longer term benefit. Since she said that they ought to pay for the goats, money in small amounts to recoup that loss has come steadily trickling in from every single person. Not a huge flood, but a clear intent to redress the balance. One can argue that when people have so little, asking for repayment is unfair, however, I agree with Rita, that the most important commodity for both the present and the future, which is more than a single goat can offer, is a trusting relationship and this needs to be preciously guarded. It naturally fits right in with my fundamental philosophy which is that anything is possible, just don’t take the piss. This has implications for setting up any project, because it implies that the most important fundamental is the relationship, but how can you start with a relationship, something which takes the longest time to develop. It completely undermines any attempts to develop system introduction of projects, because the foundation of those projects, if not evolved from existing relationships, will be based on sand not rock. Of course, the one person I would love to discuss this with is dad. He’d find it so interesting.

Mobility India

On my second day in India a very exciting thing happened. I saw my name in print for a chapter on Primary Health Care I had written on the basis of a chance encounter in the Indian Embassy in Sri Lanka in January 2007.

Whilst waiting for my visa I went into a waiting room with one other person who happened to be a charming physiotherapist from England who was working on for an NGO dealing with prostheses (false limbs etc) and orthoses (walking aids, braces, supports etc) for people with physical disabilities, amputations, cerebral palsy and the like. We got chatting because her work sounded so interesting and of course being out here doing stuff too we realised quickly that we had a similar philosophy of enablement. Sadly she was not coming back to India for long so I never had a chance to meet her again in Bangalore, but we kept in email contact over the years and at some point she asked me if I could write a chapter on primary health care for the training manual designed for the rehabilitation therapy assistants at the Mobility India Centre, in Bangalore, who are less skilled than physios or occupational therapists, but who are very practical and needed a practical & philosophical overview of primary care. Absolutely not, I said, I was really sorry but I had so much on I couldn't possibly. Ok, we won't re-write it, but could you proof read and revise the existing chapter. I felt capable of that and agreed to do that. You might imagine what ended up happening. It was so paternalistic & impractical that I ended up re-writing the whole thing. The whole project was very interesting and made me think about primary care in a more cohesive way in order to try and convey the principles to non-medics, whilst giving them some simple skills to deal with potentially complex situations and on Tuesday, I got to see it published. Very, very exciting. There is now a textbook in which I am a credited contributor. The whole manual and indeed the whole centre in Bangalore was fascinating. Truthfully, I think my chapter is probably the driest and least interesting, because the rest of the textbook deals with the very practical issues of managing and coping with persons with disability. Or as they call them over here PWDs - not sure what I think of that.

Physical disabilities can for simplification broadly be divided into amputations and  cerebral palsy. As might be imagined, the pathology in India is profound, so children, or indeed adults with CP rarely have simple or exclusively motor disabilities, they more usually have profound learning needs as well, so the isolation of physical disability from mental disability is difficult in terms of management. Mobility India or other agencies dealing with physical enablement, must also train their rehab assistants to manage these physical disabilities within the context of learning difficulties. New to this book is also a chapter on mental health both the effects on the carers and the effects on the individuals with disabilities. It has been interesting working with them on that too, because although the idea that a carer has any needs at all is new, the "fixing" culture still very much prevails, ie we need to get them back to functioning as carers again otherwise the whole family suffers, rather than creating a supportive environment for the whole family to prevent mental health crises from happening in the first place. But these are easy philosophies to set into motion, because as soon as you explain it, it is obvious how important that approach is. Putting it in a text book to create a new learning culture encompassing this philosophy is very exciting.

As well as the problems with CP, there is also a lot of fieldwork and RTA injury leading to amputation, so there is a large demand for prosthetic limbs and one of the most interesting aspects of the visit to Mobility India was seeing the Jaipur Foot being made. It is a very cheap, lightweight, prosthetic foot, moulded for some realism, originally made of tyre rubber, but now it is  alsodeveloped in polyurethane, which does increase the cost slightly, but is longer wearing. . It was co-invented (in Jaipur) by and orthopaedic surgeon, PK Sethi and Ram Chandra Sharma (not related to Simon) who thought of the idea, allegedly, when his bicycle had a puncture. It was developed in 1969 and it's 2 USPs are that it is incredibly cheap to make (480 rs, about £7) and it is flexible, allowing walking without aids on a prosthetic limb. Although it has no articulation, being made of rubber it flexes with gait and even on uneven surfaces which fixed rigid limbs cannot do. It has enabled millions of people, including those with limbs blown off in Afghanistan to walk again. At MI, they have lots of different options, and they showed me another foot which looked similar but was made of a polyurethane shell which could be changed without the need for whole new leg, but the cost was 100 times more.

Mobility India as an organisation is one of many, many individual NGOs working with physical disability. It is fascinating to learn of how poorly such organisations collaborate and co-operate with each other. They are doing such amazing stuff individually, but on the face of it there is no network to share ideas or resources. Of course in the UK, there is a social welfare system that provides some kind of baseline collaborative and universal access. Of course the funding is largely centrally determined, whereas NGOs are essentially competing for the same pot, which means that they are more likely to need to be independent, but of course, the result is that the service provided to the people of India is very patchy. If we feel hard done by in the UK, by the postcode lottery, the problem is magnified a million times in India. Those who benefit work such as MI are lucky and few, relatively speaking, and it is not just the individuals who get to take home another leg who benefit, because almost 50% of their workforce have a physical disability, which is a claim few places in the UK can make. Thus, not only is MI enabling individuals to be physically more functional, but they are also offering employment opportunities and providing a visible, functional, integrated front to the rest of the community reducing exclusion and stigma.

Never shop when jet-lagged

Celine's eyes looked past the woman walking purposefully towards her, searching the airport crowd for a familiar face, but the unfamiliar one kept on going, fixing her with a beady stare and knowing grin until she locked eyes and recognised me. Very satisfactory moment filled with exclamations and standing back looking me up and down, saying "I can't believe it" and "what's your secret" etc etc. She was most gratifyingly impressed with my transformation. Funnily enough, I have been slightly nervous of how my friends here would react because change is always a little difficult to accept. When you get to know someone, their characteristics and character become enmeshed, so when one aspect changes almost beyond recognition, it might fundamentally shift the sands of the relationship. However, Celine is honest and direct, so it would be clear what her reaction would be from the outset and it was wholly positive. In fact, she was so positive, that we have spent the entire day redesigning my wardrobe and modelling the contents already. Bliss. I have been waiting for months to shop in Bangalore for beautiful Indian tops THAT FIT. I have held off buying too many new things in the UK, despite the fact that I have had to have all new clothes, not once, but twice, especially in anticipation of this moment. Even my interim wardrobe is now too big. So when we passed the road on which my favourite mall is, I asked whether we could stop off there. Big mistake. Being jet-lagged and excited about being able to fit into clothes for the first time ever in your favourite shop in the world is a staggeringly bad combination for the wallet. I fully expected a phone call from visa at some point asking "Are you SURE about this?" Of course, although these are not dirt cheap clothes because it is a proper shop, they are still beautifully made for significantly less than in the UK and also in ranges of colours, trims, decoration and styles that are not readily available in Barrow-in-Furness.

The adrenalin surge of excitement filled my almost empty jet-lagged body and shunted it rapidly into high gear. I became ultra-decisive but minimally restrained. Everything was so tempting. Turquioses, golds, reds, oranges, pinks, greens, blues, sequins, embroidery, beads. They were delicious. For some time, simply stroking the clothes was enough, and then the basket started to fill up. One of the many, many serving ladies employed by shops to look busy and help the customers part with their hard earned cash, kept following me, then sidling up to me as I rattled through the racks, stroking or picking items up apparently without discrimination.

She made the mistake of saying softly, "Too small madam, you need big size." Well.  Deceptively calmly, I asked what size she thought I needed. Of course, the Indian frame is much smaller than the European one and she was the height of my shoulder, so I expect I looked enormous to her, but, hey, she should have been around a year ago. 

"You need XL madam"

Quieter still, I asked "What size is XL?"

"44 madam"

"44 centimetres, I hope?"

"Yes madam." Puzzled look. "Um, no Madam, 44 inches"

Outraged, the volume escalated without intent. "THESE" I yelped, pointing to my boobs, "Are NOT 44 inches" To her teeny weeny, slight, petite, delicate eyes, which were basically on the level with them, they probably looked 54 inches, but I was completely indignant. These babies have been measured on a regular basis over the last year and I know EXACTLY how big they were and they were not 44 inches.

We had a stand-off.

The only way of resolving the issue was by scientific means. I made her get her tape measure out and measure them then and there on the shop floor. I was right. They weren't. Not even close. I celebrated my triumph by buying her beautiful clothes. It so much FUN when you can fit into things! Of course, once we left the shop, adrenalin surge over, clutching our many, many purchases, my poor jet-lagged body, depleted of any remaining energy, was a mere husk. Once home, I collapsed on the bed, hugging my new finery and fell into a deep and lengthy sleep.

Back at last

Aaaah. It's so familiar and lovely. Although, it has to be said that sitting in Chhatrapati (yes there really are two 'h's) Shivaji International Airport, Mumbai, waiting for the bus to the Domestic Terminal is admittedly not the most romantic start for what feels like a home coming after a year away. It ought to be a more dramatic return with vibrant colours and swirling activity, instead it's a bit grey and soulless, but a quick jingle on the anklets and a waft of coconut oil is enough to transport me to more spiritual imaginings. Having been spectacularly disorganised, I think I surpassed any previous PB for inefficiency, I only really started to get excited on Friday, just after I bought my ticket for Sunday. Since then, I have been in a steady state of joy at the thought of coming back, relaxing, seeing friends, seeing India (who feels like an illicit lover) smelling India, feeling India. I have no idea what I am going to do, clearly everyone can get on very well without me, so my presence is superfluous, but I am going to barge my nose in and make my presence felt anyway. And who knows, they may forget how unnecessary I am and include me all over again. I shan't take no for an answer.

I am excited about seeing how things have developed at RUHSA since my last visit, most particularly, the mental health project which was just incipient a year ago, but is a whole year down the line. My only sadness is that my year out co-incided with a year of Dr Rita's directorship. Out of five years, one year is a big proportion and I am sorry not to have spent time working more closely with her. Hey ho, what to do?

The flight over was brilliant. So much blooming bum space now. I guess previously, it was like sharing a seat with a whole other person. No wonder it was squished. I flew Air India,  which was very comfortable and quiet. I have been on previous Air India flights, where it was so full and noisy that it seemed as if everyone was sharing a seat with another person. This time, however, it was lovely. At the beginning, there was the usual perfunctory health & safety announcement telling us briefly about what to do if we crashed, how to get out of the plane, what kind of equipment our lifejackets would be adorned with - whistle, light (all of which look rather like they might have come out of a cheap cracker) etc etc. Then there was an extremely detailed announcement about how to use the lavatories aboard. Seriously, she went on and on about flushing, not putting anything down the loo - listing exhaustively all the kinds of things one might have on board which could end up down the loo and then went on sternly to tell us in a school marmy kind of way how "deeply inconvenienced" fellow passengers would be were some foolish traveller inconsiderately to use the toilet in an inaccurate and frankly irresponsible way. I guess the amount of time she spent talking about the relative dangers of flying on Air India reflected the likelihood of them actually happening and I am glad it was that way round. In the event, when I did nervously make my way to the loo, expecting it to be chock-a-block with diapers, napkins, tampons, combs, razors or small children, it was cleaner than a budget whistle on a life jacket and surprisingly fragrant. The Bad Cop routine obviously works.