I just finished up my final report for SEWA with a detailed analysis of case studies and an evaluation of their telemedicine system. I’m surprised it took so long to process all of that information into a readable document, but admittedly I have been a bit distracted with life back at Harvard.
I guess here is where I reflect on how great this experience has been and how much I have learned. I’ll try not to be too cliché…
As I would hope you can tell from my past entries, I have learned tremendously about the surroundings I was in this past summer. I navigated my way through the NGO world as I explored and engrossed myself in SEWA’s interactions with the rural population, large private corporations, all levels of government bureaucracy, and even its own internal administration. I also got to visit remote villages and have unprecedented access to investigate the lives of the rural poor.
This experience has gotten me thinking about involvement in economic development from a new perspective. Many people (or organizations, governments, and even corporations) in developed countries may have ideas to solve the problems that often plague developing countries, and maybe even the resources to back it up. However, in reality, very few succeed (or else we would have solved most of the world’s problems already). Through my experiences talking to everyone from villagers to corporate executives this summer, I now believe that a lot of this friction between idealistic intention and successful implementation is enveloped in an area’s culture. While the West may develop sustainable models to provide a formulaic supply of institutions for developing countries, the demand for these institutions is entirely dependent on an area’s culture. If one truly wants to make a change in the world, one has to understand an area’s culture thoroughly. One has to live it, breathe it, feel it, and then consider its impact on the proposed solution or institution, as well as the proposed solution’s impact upon the area’s culture.
On a more tangible note, I feel like I also helped SEWA a lot during this experience. Before leaving, I finished up several projects and left with SEWA a VRC database for easy record keeping and analysis; a detailed brochure detailing SEWA’s VRC system and its impact for distribution to government officials, donors, etc.; and a telemedicine training module to orient district VRC leaders and para-health workers on the telemedicine system.
I feel like I have invested a lot of myself into this experience, and I feel motivated to see my projects and recommendations through to successful implementation. I will keep in touch with SEWA and do whatever else I can to help. I guess that includes helping some more people do internships there. And maybe even helping them get a Ghungroo Grant.
October 19th, 2007
Our jeep veered off the highway and began to rattle along the broken road. The thunderstorms had come back to help the sun set and drench us once again. As our headlights cut into the stormy smear of black and blue outside, I took in our journey four meters at a time, occasionally stealing glances of the foreign terrain in the flashes of lightening. Five kilometers away from the rest of India we found Varsol.
It was 8:30, and the village was nearing its bedtime. Once the downpour outside had calmed, we ventured outside our vehicle and explored the dimly lit surroundings. The nearly parched lanterns dangling from each household guided us down a muddy path towards a row of small, earthen dwellings. We were careful to avoid the resting livestock, rural rubble, and newly created puddles of filth along the way. Curious stares from each doorstep followed us as we neared the last house in the row, our final destination for the day.
We were documenting telemedicine case studies. The woman who lived here had come to one of the VRC tele-consultation sessions with a dermatologist at Apollo Hospital, and we had come to hear her story. She welcomed us onto her porch, and began to light some firewood so she could make tea. We, of course, could not refuse her offering, so I swore on my immune system and prepared to gulp it down. This being the last of the 12 cases documented that day, it would be my fifth cup of tea.
This particular woman had been suffering from severe psoriasis all over her face and body for the last 10 years of her life. She sought treatment at a variety of doctors and hospitals, spending over Rs. 15,000 (roughly $375), but to no avail. Any medicine she was prescribed was only a temporary solution to her problem, and eventually doctors said her condition was untreatable. As an agricultural laborer by day, and a housewife for her family of agricultural laborers by night, this condition severely affected her family’s livelihood. However, through treatment via telemedicine, her condition has mostly gotten better. The specialist dermatologist at Apollo diagnosed her psoriasis and prescribed her the appropriate medications. She came to a follow-up consultation two months later, and she continues to take the medications today.
Perhaps it was the moving success story I had just heard, or the rural air, freshly cleansed by the passing storm, or merely the caffeine-induced semi-conscious stupor that I was in after 15 hours of documenting case studies, but I felt different coming back. I felt as if I were in a dream, exploring the rural Indian countryside, seeking out those in need and those who have been helped. The locals (albeit mistakenly) called me doctor and freely let me into their homes and hearts. I couldn’t help but think what would happen if our car were to stop working, if we could stay there a little longer and live amongst them. The roosters would alert us to prepare our eyes for the daybreak sunbeams every morning and a canyon of croaking toads would lull us to sleep every night. I felt detached from the trivialities of my modern world and connected to the hardships and joys of the simple rural life.
I had been in the field a lot in the past couple of weeks, documenting cases. The goal is to analyze all of this to evaluate the impact of this telemedicine system. This fieldwork has helped me develop my grassroots research skills. Because all of my interviews took place in these people’s homes, and in their mother tongue, I eventually learned how to adapt to foreign settings and carefully extract useful information through conversation. I also got to hear some really crazy Gujarati accents.
September 16th, 2007
You can find just about anything you want in Ahmedabad now, except an sd card reader. I finally found a cord from another Nikon that would get pics off my camera. Here are some of the better ones. Enjoy.
This is from when I visited the first female agricultural collective. This field is for eggplant.
A dog escaping the midday sun.
The people with whom we met. These women helped start the co-operative.
Last week, I visited villages in the Anand District.
In this particular village, SEWA helped rejuvenate the handloom workers’ craft by giving them trainings and purchasing their products at a fair market price.
SEWA then processes and markets whatever is made at the SEWA Trade Facilitation Center (STFC) located in Ahmedabad.
More to come soon.
August 30th, 2007
Most of what I have done thus far seems like it would have promising results, but I can’t too sure. While my meetings usually end with gratifying promises, contact info exchange, and sometimes even a firm follow-up date, I’m not sure how much we discuss will actually translate into implementation. Nevertheless, I feel like there is much potential for the work I am doing, both in ‘evaluating this telemedicine system’ and in ‘optimizing it to maximize benefit to the rural poor’-my two major tasks.
Meetings with SEWA Gram Haat (the rural marketing/distribution organization), the Research office in SEWA Academy (where they conduct action-oriented studies of SEWA activities), and SEWA Health (a part of SEWA’s Social Security) have resulted in identifying datasets that might be useful for evaluation/research purposes. However, I haven’t actually received much of this information yet, as I plan on meeting with SEWA Academy tomorrow, the Gram Haat data is at their processing facility in the Sabarkantha District, and SEWA Health has yet to get back to me.
My meetings outside SEWA have been more interesting. Last Thursday, I went down to Apollo Hospital for a VRC session on tele-consultation for skin diseases to see the expert end of the VRC telemedicine network in action. By the end of the 3-hour-long session, the dermatologist seemed spent. While technical difficulties and poor camera-handling slowed down the session significantly, the biggest problem appeared to be in the Electronic Medical Record (EMR) forms filled out by each district for each patient in advance. For whatever reason, patient description and medical history often did not correlate with what was on paper. This became apparent when a rather large woman was reported to weigh 42 kilos (~92 lbs) when she was clearly at least double that weight, if not moreso. This was corroborated by the male/female mix-up which followed. It was clear that the current telemedicine system was ‘suboptimal,’ and we started discussing ideas for things to change.
At Apollo, I also had the chance to sit down and talk with their director of telemedicine in Gujarat (as Apollo has its own telemedicine network in addition to the VRC system). As we went through their different business models for telemedicine, I found that none were particularly sustainable just yet. A lot of the telemedicine that is currently being used is based on CSR (corporate social responsibility) or the intrinsic motivation of particular doctors. While this may have dented my faith in the concept of telemedicine a little, it made me admire the efforts put forth by Apollo and the specialist doctors a little more.
On Tuesday, I went down to Vadodara (Baroda) to met with the District Health Officer (DHO). We told him about our VRC system, and he seemed incredibly supportive. He lent us the use of his PHC (Public Health Center) in Bodeli, one of the our VRC sites. This opened the door for telemedicine applications from a wide range of specialties. Currently, SEWA’s VRCs don’t have any diagnostic equipment, and thus are confined to teleconsultation for skin diseases alone (as the video camera is enough for diagnosis). With use of blood pressure monitors, ECGs, and blood testing at the PHC, not to mention the doctors and medicine dispensary, much more detailed information can be sent to Apollo for specialty consultation. The DHO asked SEWA to compose a Memorandum of Understanding (MoU) of what it wanted to do exactly.
In the next week or so, we plan to meet with the PHC doctors, a block level health officer, and Apollo Hospital once again to put together some sort of framework for expansion of telemedicine. Hopefully the ideas we are getting from talking to all of these people will not die with just that, all talk.
August 23rd, 2007
A lot has happened at work in the past week and a half. Initially, my direct liaison to SEWA, the VRC Coordinator, had not given me much attention. This led to the ‘excelling’ and the creation of a draft of a pamphlet on the VRC program (for ISRO and potential donors). My attempts to make progress on the other ideas I had were met with seemingly inane roadblocks, such as records in hand-written Gujarati or failure to set up a meeting with someone downstairs. All of this changed last Wednesday.
I met with the Director of Rural Development to discuss what I had thus far completed and what I planned to do for the remainder of my time here. In preparation for this meeting, I had organized my work into separate projects, each with a clearly defined purpose and progress report detailing work completed, steps remaining, and roadblocks. The Director was either impressed or caught off guard and told my liaison to free her schedule completely and give me her full attention.
I was surprised by this commitment, as my liaison had a full plate. The others assigned to the VRC Program were either absent or split their time with other projects. Nevertheless, this eventually translated to less time wastage (hence, me taking so long to make this post). All of the roadblocks I identified were addressed, and I now have a schedule full of meetings with officials and field visits to last me for the next week and a half.
On a side note, last Thursday I had the opportunity to visit the first registered women’s cooperative in Gujarat. Someone from another NGO (Going to School) was doing research for a documentary, and I was allowed to come along.
About twenty years ago, SEWA started one of its agricultural campaigns by leasing unused land from a local government (panchayat) in a village in the Mehesana District. The women in this village then developed this ‘waste’ land into fertile farmland and started an agricultural collective. I got to interact with the women who helped start this collective and hear their stories.
I was amazed at the impact of this project on these women. Cooperative members went from being seasonal workers in large plantations to having the opportunity to generate their own income from their small plot of land. Women who used to be frequent victims of domestic abuse were now managing their family’s finances. They had even started their own savings collectives. Stories of this pilot project’s success reached other villages and SEWA helped create something similar in many other districts in Gujarat.
I took a lot of pictures, which I will upload as soon as I find a way to get them off of my camera. Until then, happy Indian Independence Day!
August 14th, 2007
I pretty much spent this week Excelling, or at least attempting to. I created a database of all of their teleconsultation records with macros that automatically generated useful summaries whenever it was updated with session attendance logs.
After the first day, I was impressed with how I picked up VBA so easily (I had learned some VB 6 back in high school). I had written code to separate parts of a single name, search the total attendance for duplicates, delete the repeats, and display unique names alongside counts and the dates attended. I later learned this was called a filter, and excel had this feature built in.
Two days later, the same thing happened again. Except this time, I had programmed a pivot table. Or actually like 6 different pivot tables. Oh well, at least I know how to program in VB again.
August 4th, 2007
…doesn’t really exist here. But I’m kind of glad. I got to experience the two extremes of India firsthand (hence this really long post)…
I had my first field visit on Saturday. We went to the VRC at Bodeli. It’s about a 4 hour drive from Ahmedabad, so we left at 8 in the morning and came back at around 9. PM. Honestly though, by the end of the day, I had had such a good time I almost didn’t want to leave.
Six of us went-4 from SEWA, and 2 from another NGO (the All India Disaster Mitigation Institute) looking to become a new expert center. When we arrived at the VRC, located in a town of perhaps a couple thousand (but enveloped in ‘tribal area’), we sat down with some of the women in charge and heard their stories. I was amazed at how SEWA has helped transform their lives. I was even more amazed at their spirit – at how, even at the age of 35, having never picked up a pen (much less having learned to read), they were still motivated to educate themselves and attempt to come out of poverty.
The representatives from the other NGO and I asked these people, who had all arrived early for a teleconference session later in the day, questions in order to characterize this system in more detail. In a way, I was already ‘evaluating their teleconference system’ (my assigned task), and I was already getting ideas for things we could possibly change.
My biggest accomplishment for the day (or rather the first actual thing that had something to do with what I have some experience in) came afterwards, when I sat down to talk with the woman in charge of the VRC. She, herself, wasn’t very educated, but she was very eager to help. We began to talk about SEWA at the district level. What started with a conversation about the layout of villages in the district led to a potential goldmine of data. She had detailed records of pretty much every activity that any aspect of SEWA did in all of their villages. The econ major in me was already getting ideas about indicators and difference-in-difference equations in order to quantify the impact of these telemedicine sessions on these villages. I managed to get some electronic copies of monthly summaries in Gujarati (which I read at about, um, 20 minutes a page) for analysis in the future. In short, I finally had some way to possibly go about ‘evaluating their teleconference system.’
We pretty much brought a monsoon storm as we were coming back to Ahmedabad, as the streets in the eastern par of the city were flooding as we entered. However, I was told that always happens when it rains an inch or more.
I saw the other extreme of India on Sunday, when I was out with some of my cousins. We spent half of the day in Gandhinagar at Science City (think the Indian government’s attempt at Epcot). It really turned out to be a rundown museum, where most of the exhibits where either broken or empty, with a large 3D Imax screen, where people lined up half an hour early to enter despite seat numbers written on all their tickets. Nevertheless, it was a valiant attempt at science literacy in India, and I am sure that place can be cleaned up in no time when a high ranking government official or a corporate sponsor visits.
The other half of the day was spent in the rapidly developing Western side of Ahmedabad. Here, I finally saw firsthand the effects of India’s 10% growth rate. My cousins’ new flat was very Western. Looking out of their 4th floor balcony over their complex and more broadly at the multitude of cookie-cutter bungalows taking shape over the landscape, I could almost imagine myself being in Europe. There were evenly spaced streets (many under construction), and (a couple) grassy lawns. It almost seemed like what we would call suburbia. The only giveaway would have been the crazy traffic. And the peacocks chilling on rooftops. And the monkeys, cows,…
Then we went to a mall. Not THE mall, because that’s two streets over (and even bigger one is under construction like ten minutes away). It was the Himalaya Mall, with 4.5 floors, a food court, an arcade, and the enormous Big Bazaar (think Wal-Mart) stacked on top of a three story parking garage. It had attractions, such as a giant climbing rope, and big tubes all around which blew crisp AC air, revitalizing those entering from the torturous heat outside. It even had several stores common to malls in the States, with prices that (although cheap to us) would be pretty expensive for an Indian salary. And it was packed.
India’s culture has changed so much from what I had last remembered it to be. For this rapidly growing (middle?) class, everything is driven by consuming as much (preferably American or Western) as possible, almost mindlessly. Perhaps I get this impression because I usually live with my grandparents in their albeit large, but old-fashioned bungalow in an older part of town, or because I had visited some of the poorest of the poor in this country only the day before. While I want to embrace this dramatic increase in standard of living, I don’t know how I feel about its impact on those on the other side of the spectrum. The existence of stores like Big Bazaar in India takes the Wal-Mart effect to a whole new level. I’m sure I’ll see more in the next seven weeks and eventually get around to making up my mind, which was sufficiently blown by this weekend.
August 2nd, 2007
My first week at SEWA was a lot of things – fun, educational, influential, long. Boring, however, it was not. Whenever I had downtime at work, I would find something cool to read or talk to some of my co-workers, many of whom had interesting back-stories. I spent much of my time going through material and orienting myself to the Village Resource Center (VRC) program, of which telemedicine is a part.
[Some background (very skippable)…
The VRC program is part of the Indian government’s “Mission 2007” to “bridge the technology divide” between urban and rural India. A VRC is a center accessible to those in rural areas linked up via satellite to expert centers in urban areas such as hospitals or agricultural universities. These expert centers hold teleconference sessions on a wide variety of topics practically relevant to rural life in India. These sessions, broadcast simultaneously to all VRC’s in a region, last roughly 2 hours (at least in Gujarat). During this time, one hour is usually spent on prepared material, while the other is for questions answered live via this link. In Gujarat, SEWA has set up 5 VRC’s and another NGO has set up 5 more in the desert-like Kachh region where India meets Pakistan. According to the latest report, the VRC’s in Gujarat are the only ones deemed ‘functioning’ by the Indian government, and SEWA’s VRC’s are the only ones in this state which regularly attract a fair amount of people.]
Our office in Ahmedabad is one of SEWA’s 5 VRC’s, so, on Thursday, I had the opportunity to sit in on a tele-agriculture session by Anand Agricultural University. Overall, I found the setup and the system easily operable and surprisingly interactive. Even uneducated rural women felt comfortable asking any questions they had to these experts. This system facilitated such interaction extremely well, as these women felt like they were face to face with these experts without any sense of intimidation that they would normally feel in their villages. I also witnessed a tele-consultation session for skin diseases with the other NGO in Kachh. This is the essence of telemedicine, where the entire session consisted of a doctor treating patients, writing prescriptions, etc. During this particular session, which happened to be a follow-up from a previous consultation, I could see many cases of successful treatment which would not have been otherwise possible.
Through all of this, I have learned a lot about how NGO’s really function. This being my first experience actually working with one, I am probably over-generalizing. Nevertheless, I do find some truth to many of the things I have heard about in the past, namely much bureaucracy and high staff turnover, ultimately leading to inefficient use of time and resources. Despite all of this, I am surprised by how much SEWA has actually accomplished. I am still trying to gauge whether the people who work here do so because of some intrinsic motivation to impact change (as the money isn’t really that good), or simply because they couldn’t find anything better to do. Right now, I am leaning towards the former, or at least hoping.
August 1st, 2007
Rickshaws, goats, people, scooters, camels, cows, bikes, people, peacocks, lizards, buses, people. The sights and sounds of the utter chaos that is Ashram Road (and pretty much all other roads in Ahmedabad) met me as I was riding back from the airport at six in the morning on Monday. I left Boston Saturday evening, met up with my mom during the layover in Amsterdam, and reached Mumbai Sunday night. We had to spend the night in the Mumbai airport for our early morning flight to Ahmedabad on Monday. Needless to say, I was severely jetlagged when I reached my grandparents house.
The first day consisted of eating, napping, and visits from a wide assortment of my parents’ friends and relatives. My grandparents have a flat in Ahmedabad near Paldi (“Anjli chaar rastaa” is what I tell rickshaw drivers), and one of my cousins currently lives with them. My mother was planning on visiting them, and flew over with me. Any arrival of people who live in America is met with either a phone call or a visit from all of my mother’s extended family within the following two days.
I had increasingly been in contact with SEWA in the preceding couple of weeks, and I called them upon my arrival in Ahmedabad. I decided to come in the next day to meet with Reemaben Nanavaty, the Director of Rural and Economic Development, for my orientation. I learned that my direct supervisor would be Veenaben Sharma, the person in charge of the telemedicine program, as Ms. Nanavaty kind of seemed like a big deal. I would meet with Ms. Nanavaty weekly, however, to discuss weekly plans, etc.
Overall, I haven’t really gotten many details about my daily activities other than that I should ‘evaluate their telemedicine program.’ I am the only person charged with doing this, leaving me with the impression that this is going to be very open-ended. I’ve been briefed on the program in a little more detail, and I will probably sit down with Ms. Sharma tomorrow (Wednesday) to make my plans more concrete. They seem very willing to let me dig deep into their system and explore the situation in more detail. Sounds fun.
July 27th, 2007
So… I’ll use this blog to talk about my experience working with the Self Employed Women’s Association (SEWA) in India this summer. Currently an undergraduate economics concentrator at Harvard, I have received funding from the Harvard SAI and SAA through the Ghungroo Grant to complete a project dealing with SEWA’s new telemedicine program in Gujarat, India.
A little bit about telemedicine (this might be a bit dry)…
Telemedicine consists of linking up superspeciality urban hospitals with poor, understaffed, rural hospitals in India, in order to provide otherwise inaccessible specialty consultation and training of health workers. With its potential to bridge the urban/rural gap in health care access and quality, telemedicine represents a promising solution to the persistence of poverty in a country plagued with health care inequities such as India. The Indian government and NGO’s have been experimenting with telemedicine over the past several years, and only recently has this technology developed to prove an efficient solution to meeting health care needs. Now, even the private sector in India has begun to embrace telemedicine as a profitable means to serving the poor. In short, telemedicine is kind of hot in India right now.
A little bit about SEWA and my project…
As a very large and influential NGO in India, SEWA has recently started its own telemedicine program linking up 2 private hospitals (the Apollo Hospital and the Vaghad Trust Hospital) with 9 rural district hospitals. My project is to help optimize their newly created system. I will analyze the cases attended so far and help design a system and process of telemedicine to maximize benefit to the rural poor. I will talk to hospital doctors and rural health workers and eventually help implement the proposed changes and orient them to the new system.
Although I’ll be based in Ahmedabad, I will travel to rural district hospitals in Gujarat for most of the week so I might not have regular internet access. That means that I’ll try to update this blog as frequently as I can, and aim for something regular at least weekly, if not bi-weekly.
Hopefully this blog will help me document my first encounter with healthcare in India and translate my experience as the rural Indian reality colors my perception of developing world… or something like that.
July 6th, 2007
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