7 pills to swallow

On Tuesday morning our group arrived in Delhi eager to check out a new city in India. While Delhi is still a major metropolitan area that is similar to Bombay in many ways, it is much more geographically spread out (think LA) and less congested, though it feels like everything is at least an hour away from wherever you are. Hello, quality time on the bus!  

Our first stop in Delhi was at the U.S. Embassy where we met with Nandita Chopra, the NIH representative based in India. The security checkpoint to enter the embassy compound was thorough – there’s no place like home. When we entered, we immediately noticed a building that looked identical to the Kennedy Center in DC. We quickly learned that the architectural inspiration for the Kennedy Center came from the U.S. Embassy in India. Sorry, no cameras were allowed inside, so you’ll have to trust me that they were identical. Pictures of Obama, Biden and Clinton lined the walls. Nandita took us to a conference room and discussed the portfolio of NIH in India, which is quite comprehensive. One of the initiatives she works on is a bilateral collaborative between researchers and scientists in the U.S. and India that fosters project and idea sharing to assess and improve various health indicators. Much of the NIH work is research-based and they serve as a leader in field of development and in testing new technologies and pilot studies. Additionally, the NIH supports centers of excellence addressing various diseases throughout the country. Since the process of applying for funding is so complex both in the U.S. and in India, one of Nandita’s many roles is to support researchers in pursuit of funding. She has fully utilized her network of contacts and has become a master at navigating the complex systems in both countries. Without her, much of these partnerships would likely not materialize or would take much longer to naturally filtrate through the system. After our meeting, we took a brief tour of the embassy grounds, including housing for diplomats, restaurants, a bowling alley and a pool. Pretty cool stuff!

The following morning, we met with Operation ASHA (Op ASHA) in Delhi. Many of the NGOs that we’ve met with have multi-pronged strategies that address different populations and health issues. In this respect, Op ASHA is completely different from the majority in that they focus on one thing: treating tuberculosis (TB). To provide a touch of background information for those who are unfamiliar with TB, it is a communicable disease that is spread through the air by someone coughing or sneezing. With 2 million new cases each year, India has the highest burden of TB in the world. TB thrives is crowded spaces where the disease can more easily spread, so slum areas are an ideal setting for the disease to permeate. Just because you come in contact with TB does not mean that you will necessarily contract the disease; many people (I believe one in four), in fact, have latent TB that will never manifest. However, when your immune system is weakened, then TB thrives. The great thing about TB is that it is treatable. However, it is difficult for people to understand the need to take medication when they have no visible symptoms. As one of the Op ASHA staff members said, “People value their health in India, but there is no concept of prevention.” As a result, people start taking their medications and don’t finish them and, as a result, develop a drug-resistant strand of TB, which can then be passed on to someone else. Multiple drug resistant strands require longer-term and more intensive regimens.

One dose of TB medication

Op ASHA aims to enable people to have easy access to their medications and uses the DOTS intervention (directly observed treatment short-course) to ensure that people are taking their meds every other day. Since there’s significant stigma associated with TB (people are fired from their jobs, kids are kicked out of school, etc…), Op ASHA has found a way to discretely provide and track patients with TB. They partner with local shops or small businesses in slums and villages. The owners of these shops are paid a stipend to house the small operation and are trained in medication distribution. They use a biomedical tracking device that scans a patient’s fingerprint, which pulls up their medical record through a system. Then they are given their medication while the business owner watches them take their medication. Usually, there is also an Op ASHA nurse present as well. If a person misses a dose, the Op ASHA nurse is notified and follows up with a house visit to see what’s going on. Our group visited one such site nested in a store in a village and it was excellent to see the process first-hand. While Op ASHA is hugely successful in ensuring that people adhere to their TB medication, our group of public health students could help but wonder if there was some sort of missed opportunity in the process. Couldn’t they also provide family planning services since they already have such a high rate of daily traffic? Or perhaps they could screen people for HIV or provide vitamins to address malnutrition? I completely understand that a large part of the success of Op ASHA is due to its simplicity and directness and without that, people would likely not be as adherent, but could they be doing more? Couldn’t we all, though?

Biomedical tracking computer used by Op ASHA

The afternoon brought with it an unexpected surge of infectious energy from our guest speaker, Kiran Bedi. Dr. Bedi is a well-known social activist in India. She was the first woman officer in the Indian Police Service, which inspired her quest to seek justice for many of the underserved. She is the founder of two NGOs: the Indian Vision Foundation, which supports the children of women prisoners who often grow up with their mothers in jail, and the Navjyoti India Foundation, which aims to serve vulnerable populations throughout India. She believes that there is a huge amount of corruption within the Indian government, which contributes heavily to the myriad of basic problems facing India’s poor. Dr. Bedi wants to rid this corruption so that the next generation can grow up in a safe and healthy environment, fully supported by their government. She speaks about her work using metaphors and conveys her points with such conviction that many of us found ourselves lingering on the edge of our seats so as not to miss a word. It’s rare to be in the presence of someone with so much charisma and chutzpah and it was quite refreshing. Only time will tell what will happen with India’s next round of political elections, but there is no doubt that regardless of the outcome, Dr. Bedi will rest assured that she did all that she could as an activist to rid much of the corruption that she perceives exists with the current regime. While she is passionate about her cause, she has no interest in dabbling in politics (yet). “I want to be accepted by all; I don’t want to compete, I just want reform.”

Dr. Bedi and I in her office

We ended our day with a trip to the India Gate and Rashtrapati Bhavan, the president’s house. We ate at a fabulous Indian restaurant called Punjabi by Nature where I had the best dahl of my life!

The group at the India Gate

YOLO

            #YOLO.  It is a popular phrase these days, an acronym for “You only live once.”  It is a somewhat daunting yet exhilarating notion, and although catchy, you cannot help but recognize its underlying truth.  As another tag line from the title of an old soap opera on television in U.S. popular culture notes, we have one life to live, and the very real question of how we want to spend our lives rests on all of us individually.  I am not running around screaming YOLO in a literal sense.  In most regards, I love saying it ironically, as a hit to its wide usage by online status-updaters and chronic hash-taggers.  On the other hand, a tiny part of me cannot stray from the idea that this moment is fleeting and I better take advantage of it.

            Maybe it seems as though I am going off on some philosophical rant about how short life is, and the need to take advantage of it.  Go ahead and laugh, but as we have been visiting the various NGO sites this week in New Delhi, the starkness of the idea that life is in fact fleeting resonates on a personal level.  As I sit, listen and watch numerous individuals discussing their work and giving way to personal memoires, I am ignited by the passion and commitment to social development and assistance of so many of these individuals.  Whether more grassroots or from a more top-down approach, many of these people are spending every day working to improve the lives of members of the community through their careers.  So as I walk away from the past two weeks, one question I am left with is whether or not I will do the same. 

            To some extent, I believe this commitment and passion to improve the world on some level has been the drive for many to become involved in public health.  At some point in our lives, we saw a need for change, and it sparked an interest in this social movement to advance health outcomes and work to prevent disease on a population basis.  This brings up another observation about the work of NGOs and general trends throughout society.  It is really interesting to see how many of the organizations and individuals are making use of social media to spread their messages and stay connected.  Whether on Twitter, MySpace or Facebook, it was noted numerous times that this was one way people are striving to enhance their work and ideas.  Innovation through technology.  These Internet resources are free outlets for exposure and social networking, so why not take advantage of them?

            As I move into the day-by-day accounts of this trip, it is noteworthy to make some of these overall reflections about the work and progress at hand.  Many group discussions have brought up the point that helping to improve the world does not have to occur on a mass scale.  As many of the organizations prove, helping a relatively small number of people can still have a major impact with the potential to “go viral,” if you will, at a population level.  My use of the phrase “relatively small” is intentional, as impacting several thousand individuals is a relatively small number within a community of hundreds of thousands, if not millions.  But as we see on the Internet, several hits on a Youtube video can turn into millions within a matter of hours.  Maybe it is the same with community-based work, and the tipping point is upon us.  All of these organizations began with an idea and the need for action.  Individuals stepped up to the plate, and are working to create change.  Although many of these phrases and ideas may sound cliché, it does not matter.  I have to push these thoughts out of my head.  At the end of the day, I do want to help on some level, and witnessing the work of the individuals we have met in India proves it is possible. 

So all jokes aside, YOLO.

Tuesday, August 7, 2012

            My good friend Halli on the trip often jokes about the need to “tuck and roll” out of bed when you are in a hurry.  She could not have been more spot-on with this idea than today, as today was the day we traveled from Mumbai to New Delhi. 

Wakeup.   

Pack.

Shower.

Email.

Breakfast.

            We are in India, but all of the tasks of everyday life in the U.S. have not disappeared.  As a group, we keep joking about the fact that many of our friends and family members back at home continually tell us to have a great vacation.  As I struggle to keep my eyes open on bus rides between meetings, I cannot help but silently curse those who think I am relaxing on a beach somewhere or riding an elephant down the street.  A bit harsh?  Maybe.  But with more than a dozen site visits in less than 10 days, a bout of Delhi Belly (our group stomach virus episode), visits to the slums, numerous stops at cultural tourist sites, daily group discussions and periods of reflections, I am not sure if I would call this trip your average vacation.  This is not to complain, I feel like we are all taking in loads of information and being exposed to a side of India we would otherwise never have access to, if not for the work and connections of our professors and university.  But tired, yes.

            Anyways, back to today.  We check out of the hotel and get into cars to be driven to the airport.  Right after we are dropped off, we realized we are at the wrong gate.  With limited time before our flight, panic sets in.  Just what we need, a group of chatty Americans running through the Mumbai airport like baby ducks chasing Dr. Vyas and Dr. Parrish.  I mean, it’s not like we stuck-out before here in India.  Regardless, we made it to the right counter and the professors got us on the plane.  Several people outside of our group even thanked Dr. Vyas afterwards for our group holding up the flight because they were late as well. 

Take-off.

Read.

Land.

            New city, same smells.  We arrive in New Delhi, which turns out to be just as chaotic as Mumbai, although a seemingly bit cleaner.  We have a few hours to check-in at the hotel, and then it is off to the U.S. Embassy to meet with Nandita Chopra, the representative of the National Institutes of Health (NIH) here in India.  Let’s go.

            As we walk through the gate to the Embassy, we are all struck by how similar one of the buildings looks to the Kennedy Center back in D.C.  As it turns out, Nandita informed us that Jacqueline Kennedy was actually inspired by this building and commissioned the same architect to design the Kennedy Center in the States.  It is always interesting to pick up historical facts here and there, especially when you are halfway around the world from your home.  As we walk along the grounds, I cannot help but feel as though I am on the set of an old U.S. sitcom, such as “I Dream of Jeannie,” as some of the building appear as though they were built during the 1960s or 70s.

            Our meeting with Nandita takes place in a conference room inside of the USAID building.  As we learned through several other site visits, USAID’s presence in India has declined in recent years, but at one point, it was fairly strong.  Nandita does not keep us waiting, and immediately walks into the room to greet us.  As our meeting begins, Nandita describes her role as the NIH representative in India, a relatively new position, and how she landed the position a little over a year ago.  She encourages all of us to voice our interests, demonstrating the role this behavior played in helping her to get this job.  As most of her career had been spent doing domestic work in the U.S. other than a global fellowship in Mozambique prior to this position, Nandita says it was voicing her desire to work abroad that led to her being considered to work in India.

            In learning about the NIH portfolio in this country, it is incredible to realize that Nandita handles most of this work alone.  Only until recently did she have a staff member assigned to assist her, and the realities of these types of positions set in.  Nandita mentions some of her time is spent helping researchers calm down who are waiting on governmental approval before they receive their grants.  In India, government relations are different than they are in the U.S.  The process of building trust and getting your message across to government officials in this country is time consuming, requiring a fine balance between coaxing individuals into the validity of your project and ideas and not coming across as being overly pushy.  Beyond that, the time difference between India and the U.S. can really take its toll.  As the workday is ending in India, people at NIH are just beginning their days, so the emails and conference calls flood in.  These are all things to consider in terms of the logistics of global work.  

            As the representative of NIH in India, it is really interesting to hear about all of the coordination and communication this job entails.  Not only does Nandita have to represent NIH as a single entity, she also has to act on behalf the various institutions within the agency.  It is important to remember that all of these separate research facilities are working with their own goals in mind to some extent, with the need for funding and support, and to each one, they are a priority group at NIH.  It can be difficult to find a balance and to represent each one individually, but again, it is all part of the job.  Another aspect of coordination this job entails is communicating work and information between U.S. researchers and Indian researchers.  Luckily, Nandita says that Indian researchers are cooperative and willing to share disease and health-related information with U.S. representatives. 

            After meeting with multiple social enterprises and NGOs, it was very informative to listen to an individual who is working for a government agency, especially one representing the U.S. abroad.  Many of us in the group are interested in becoming involved in global health, and working for the government or for an NGO are two options with a wide number of similarities and differences.  In general, it seems as though the NGOs we have met with are more grassroots in their work, but this does not exempt them from the bureaucracies of government.  Again and again, it has struck me how large of a role government relations play in the abilities and functions of many NGOs.  Even if an organization is not receiving direct funds from the government, it is still important to for staff to be able to navigate the political system in order to facilitation their own needs and priorities.  Policies will affect an organization on some level from a top-down affect, and this must be acknowledged on a broader scope.  Politics can often be dirty and frustrating, but this is the scheme in which we live, and it is vital to learn to navigate this system efficiently and effectively, especially on a global scale.

           

Wednesday, August 8, 2012

            This morning we met with Operation ASHA, an organization aiming to reduce the incidence of tuberculosis (TB) in the slums of New Delhi.  Two young American women introduced the organization and their work to us, one of whom is a completing a fellowship through iCATS at OpASHA.  Their drive and compassion in their work was immediately evident as they stood before us, asking questions about our own interests and tying these back into international nonprofit work.  These two women spoke about their education and work experience in the States, and how they eventually became involved in international health work in India, encouraging us to do the same.  As one of them put it, “Work experience abroad is worth its weight in gold.”

            The great thing about this conversation was how candid the women were in their discussion about nonprofit development work.  International work tends to be idealized, but you do not understand the hardships and frustrations of grassroots level work in global health until you step into the field and listen to those who are actually doing it.  Beyond language barriers, there are countless other cultural factors to consider when entering a foreign community to engage in social development.  Gender roles, age distinctions and other factors may influence behavior, acceptance and participation of community members in a particular program.  Sometimes translating appropriate health behaviors is not as simple as saying, “A, B, C.”  In this regard, forming an effective community health intervention can be a complicated process, but as the dedicated staff at OpASHA demonstrate, reducing stigma, effective use of technology and engaging with members of the community are essential to effectual nonprofit work and stimulating social change.  

            After meeting with the two women, we were accompanied into the field.  This means that we were able to go to one of the sites where TB is distributed on a daily basis.  We got to observe the storage of the medication, and speak with the woman running the site about her involvement with the organization.  Learning about the long-term task of adhering to daily TB medication requirements from the perspective of those who hand out the medicine was really interesting.  Beyond the stigma associated with the disease, ensuring individuals show up to the site and take their medications every other day seems like a demanding endeavor, requiring commitment from both organizational staff and the patient.  It can be difficult to imagine this type of work being conducted on a mass scale, but as OpASHA shows, working to do so with any portion of the community will help to reduce stigma and encourage individuals to seek treatment.

            The next stop we made was to an organization titled India Vision Foundation.  This nonprofit is working to improve conditions within female prison facilities in the country.  As we learned, the prison system in India is somewhat different to the idea of prison life that exists in the U.S.  In India, there is apparently less violence within the prison facilities, and children live with their mothers who are imprisoned.  These children receive formal education through schools on site, and they sleep with their mothers in the cells.  The women in the prisons learn how to weave and are taught other vocational skills to help provide support for rehabilitation and eventually a smooth transition back into society. 

            At this point, we were able to meet with Dr. Karin Bedi, a founder of India Vision Foundation.  Dr. Bedi was the first female police officer in India, and since retiring from this job, she has become one of the leaders in the anti-corruption and female empowerment movements in the country.  It was really inspiring to meet with an individual who has been inspired by her own experiences to create social change through nonviolent political activism.  She spoke of the drive within herself to work out of her somewhat privileged position in life in terms of education and opportunity, in order to impact others who have not been as fortunate as her.  It will be interesting to see where Dr. Bedi ends up in a couple of years, as she struggles with the decision to become more politically involved or remain more oriented in advocacy work as a social activist.

Thursday, August 9, 2012

            This morning we made our last NGO visit to Care India.  This was the first larger organization we met with, and this meeting provided yet another perspective on the nonprofit sector.  Some of the main concern expressed by members of my class were in regards to the large size of Care, and how different sectors of the organization are able to cooperate, as well as cooperate.  Is it possible for some of the more genuine aspects and commitment in regards to community development to dissipate through the hierarchy of such a large organization?

            The members of the Care staff who we met with described the technical assistance provided by the organization, and how this compares with some of the grassroots work being done by smaller nonprofits and social enterprises.  As one member noted, social enterprises have their own niche, but there is still a need for technical programs.  In order to provide adequate and effective technical assistance, the need exists to enquire throughout the community and learn about people’s perspectives on their specific needs.  These ideas must be incorporated into the planning and design of projects in a practical manner.  The technical assistance being provided must exist in the context of the social system that has been in place for years.  The underlying question is how do we build upon the infrastructure that is already in place based on what members of the community believe? 

           

            These were all ideas thrown around the meeting, and one member finally noted that development work should not be thought of in the context of technical versus social.  Both types of work are interconnected, and the best practices will develop in respect to both sides of the puzzle.  Technical assistance should be planned and implemented through a social lens.  Once an organization reaches the level and size of one such as Care, it is important to maintain a focus on the actual needs of smaller communities.  What the best model should be for this approach is where focus should lie.

            The final NGO we met with on our trip was called Saalam Baalak Trust.  This organization aims to improve the lives of street children who have runaway from home and arrive at the train station in New Delhi.  Most of the children rescued by Saalam Baalak are restored to their families if possible.  Emphasize if possible.  Thousands of children arrive in New Delhi each year from all over the countries, and it can be difficult to trace their parents or other members of their families.  If children cannot be returned to their families, or do not want to be returned due to histories of abuse, etc., then they are placed in one of the 5 shelters or children hopes to help educate and raise the children into maturity.  One of the greatest things about this organization is that some of the staff are former runaways themselves who have grown up through this system and are now contributing back to the community through this program.  These individuals know the needs and mindsets of runaway children firsthand, so their assistance is extremely beneficial.

            After visiting the site at the train station where children receive their health evaluations, we were able to visit the new drop-in center a few blocks away.  This site appeared to be somewhat of a community center, where young children were working on computers, doing artwork and socializing with others their age.  There were also several volunteers at the center when we visited.  We got the chance to actually speak with some of the older teens, many of them having runaway from home at very young ages.  They were friendly, open to sharing their stories, and seemingly appreciative of Saalam Baalak Trust.

Friday, August 10, 2012

            Well, that’s it.  We wrapped up this morning with a final group session at breakfast, during which we all introduced ideas for our business plans.  There were a lot of ideas to throw around the table, considering all that we had seen and done over the past 2 weeks.  It seems that many of us are revising our original plans based on our broader knowledge of the work of social enterprises and NGOs.  I think many of us now have a deeper appreciation for the work these organizations do, as well as hope for community development and social change through public health.  Now to actually write our plans… YOLO.