Locost: Low-Cost Standard Therapeutics

When I was an undergrad I was involved with a student group called UAEM (Universities Allied for Essential Medicines) that tried to pressure universities to cater their research policies to developing country needs. Part of our activities involved pressuring Columbia to play around with its patenting and licensing policies. Generally when a researcher at a university discovers a promising new chemical that might treat some disease, the university patents the chemical, giving itself ownership for 20 years. Since it usually doesnt have a large enough research budget to conduct all the safety and efficacy trials needed for FDA approval, it then licenses the chemical to a private pharmaceutical company, which does the rest of the work. In exchange, the company is usually the sole producer and distributor of the medicine for the remainder of the 20-year patent period, paying the university royalties from its sales.

This neat arrangement is usually sad for poor people, because the company's monopoly allows it to charge super high prices as a payoff for its research and development work. Part of UAEM's mission it to try to get universities to put more pressure on the pharma companies to relax their patent enforcement, especially in developing countries.

We had some success during my last year in school, as Columbia decided it would start trying a policy called mandatory sublicensing. The basic idea was this: if a government or ngo or someone complained that a company was not making a drug available at a reasonable price in their country, the university would reserve the right to issue another license to a producer who would only produce and sell for "humanitarian" uses.

This confused me at the time, as I had never heard of a pharmaceutical producer that wasn't a profit-making company, and wasn't sure who these humanitarian entities would be. At some point last year I was talking with another friend from UAEM, who realized that UAEM did a lot of clamoring for allowing more companies and producers to make and sell drugs in developing countries, but we didn't really have a clear idea of who these producers would be.

Which brings me to my point: When I was at Prayas, I was in touch via email with a man named Chinu, who helped me with the medicine pricing FAQ I was writing. He had written a book called "A Layperson's Guide to Medicines", which helped consumers understand issues like quality control, medicine pricing, branded vs. generic, research policies, etc. He ran an organization called Locost, which in addition to making helpful resources and engaging in pharmaceutical policy advocacy, actually produces essential medicines and sells them with little mark-up to NGOs working with the urban and rural poor in India. Eureka! This was just the type of producer referred to in the Columbia policy.

What was particularly cool was that at both Vivekananda Girijana Kelyana Kendra and Chinmaya Organization for Rural Development, the hospitals and OPD clinics stocked Locost drugs.

(OPD Clinic at CORD with Locost drugs)

Thus I encountered the organization at all three NGOs I visited, and thought that this kind of impact deserved its own post. Here is their website for anyone whose interested:

http://www.locostindia.com/

Kokilaben Dhirubhai Ambani Hospital

[May 17th, 2010]

After leaving VGKK, I went to Mumbai for a few days to stay with relatives. One of my relatives is a dietician at a very famous and high-tech Mumbai hospital called "Kokilaben Dhirubhai Ambani Hospital." This is what Indian's refer to as a "corporate" hospital, and is actually owned by Reliance Industries, a huge cell-phone and communications and pretty much everything else conglomerate.

http://www.kdah.in/index.html

My relative was nice enough to use her sway to arrange a tour for me. My tour guide usually gives tours to donors and famous people, so it was surprising he consented to giving a tour to lil' ol' me. However, it also meant that I had to be very polite and tactful in the questions I asked, so I probably didn't get all the information people might want.

For people moving from place to place, India is full of many of its own internal culture shocks. After a few lengthy trips in the country, I had pretty much gotten used to the drastic differences in wealth/culture/lifestyle from region to region, but my culture shock from VGKK Tribal Hospital to Kokilaben was unavoidable. The lobby was enormous with plush chairs, TV screens, air condition, information help desk, check-in counter, gift shop, etc. There were separate check-in counters for patients with insurance and those that paid out-of-pocket, and both counters had enormous computer screen registrations. The demographics of the patient population was wealthy, with many foreigners coming for medical tourism (I actually feel like this is the best term to describe my trip. Alas, its already taken, so I'll have to settle for "public health tourism").

I wasn't allowed to take pictures and unfortunately did not take notes, so the following details might be slightly off. From what I remember, the hospital had roughly 750 inpatient beds, and saw a large number of out-patients in various clinics. I was first brought to their emergency room, where they had about six beds and one room devoted to emergency trauma operations. Emergency patients were only brought in by the hospital's ambulances. They were not dispatched through emergency called to government lines, but only if the hospital's own emergency line was called. There was apparently constant communication between the ambulance crew and the emergency room staff while the patient was in transit. There were no patients in any of the beds while I was there, but I think one was on his way.

I then got tours of a bunch of radiology devices, such as MRIs, CAT scans, etc. They have cute additions like painting the ceiling with pretty murals so patients feel relaxed. I also got a tour of their massive radiation oncology machines, of which they have two. From the high-tech perspective, they seemed probably better equipped than a lot of American hospitals. As far as recruitment power, I think they basically tapped people from other famous hospitals in India, and many of them came, so their physicians were probably pretty excellent at their jobs. I briefly met a famous infectious disease doctor who does a lot of travel medicine work. It was funny to imagine Indians consulting travel medicine physicians, as most Americans make travel med appointments before coming to India.

The most interesting part of the whole tour had to do with room categories. It is obvious that there are going to be issues of access in expensive corporate hospitals in which patients need to either have a lot of money. But what was really interesting was that patients paid different rates for their rooms, creating an internal division of patient class. There were shared rooms, single patient rooms, deluxe rooms, super-deluxe rooms, and luxury suites. Patients in these different classes also paid different rates for some of the services, although the tour guide said all medicine prices were the same, because there was some law against elevating prices past the Maximum Retail Price. The shared rooms were already in much better shape than any of the previous hospitals or clinics I'd been in, but the luxury suite was insane. It had an ultra-comfortable patient bed and room on the top floor with a window view, as well as a personal waiting room for visitors, which had its own couches, TV, fridge, and other amenities. I asked as politely as I could about differences in quality of care for these classes, and the tour guide assured me that everyone received the same care, with differences only in comfort. But it was pretty clear that the luxury patients (who were often famous people) received much more attention from nurses and staff than patients in lower categories, and constant attention itself likely leads to different quality outcomes.

The government District Hospital in Chittorgarh, Rajasthan (see previous post) was also in the midst of constructing a luxury ward of a few beds. This ward had air-conditioning, as well as amenities like storage closets and nice bathrooms. Dr. Narendra at Prayas was against this in principle, likely for the same concerns about quality of care discrepancies. The number of different classes at Kokilaben took this to a whole new level. It kind of made me finally realize that the "corporate hospital" label is really not synonymous with US "private hospitals".

Nonetheless, it was heartening to see patients receiving high quality care in India. In a sense, it is nice that some Indians have enough money to keep such hospitals running, keeping health professionals in the country and decreasing the brain drain. Then at least doctor availability becomes a national distribution problem rather than a international one. Also, larger public health perspective and moral principles aside, if my family member was in an emergency and I had the money, I would bring them to Kokilaben.

Late Posts

I haven't written a substantial post for about a month, but I've seen a lot since then. I'm going to break stuff up topic-wise in different posts, adding the date of when they should have been written.

Anemia and Starvation

The sheer amount of malnutrition-related anemia I saw while at VGKK was frightening, so I'm getting more interested in nutrition and food security issues. This BBC article was pretty interesting, and completely depressing. It's called "Diet of mud and despair in Indian village."

http://news.bbc.co.uk/2/hi/south_asia/8682558.stm

Besides all the rest of the heartbreaking stuff, note the mention of the changing poverty line. Recently the Indian government decided to use better standards to define the poverty line, and percentage jumped from the mid-20s to a little less than 40%. Apparently even these standards aren't as stringent as international poverty line standards, which would make the number even higher.

Embrace

Yesterday I visited the Bangalore office of Embrace, a non-profit out of the design school at Stanford that makes low-cost neonatal incubators. I heard about them when I interviewed at Stanford, and got in touch with them through a friend. They were totally impressive. You can check this link for more info:

http://embraceglobal.org/

VGKK, Karuna Trust, BR Hills

I am now in Bangalore, Karnataka. I just spent a few weeks at a place called the B.R. Hills, which is about 5 hours away from here. The hills were absolutely beautiful:
http://en.wikipedia.org/wiki/Biligirirangan_Hills

The hills are home to the Soliga tribe, who used to practice shifting cultivation back in the day. A Forest Conservation Act in the early 1970s set up the B.R. Hills as a wildlife sanctuary, and prevented a lot of the activities the tribe had been doing for a long time. They were in a pretty sad situation with little exposure to other economic activities and pretty much no education with which to integrate into non-tribal ways of life. This was pretty much the state they were in when a man named Dr. Sudarshan first saw them. He began to wander around the jungle with a medicine bag looking for tribal people, who ran away from him at first. Eventually he was trusted enough to stay in their villages, and roamed from village to village treating people. He eventually set up a hut as a home and makeshift clinic, which is actually still standing:
He also started holding informal night classes for 6 tribal children in his hut. (One of these students now has a PhD, and another has a master's degree). Since then, the hut has evolved into an enormous, beautiful campus with a hospital and school, run by the NGO Dr. Sudarshan founded: Vivekananda Girijana Kalyana Kendra. Here is a picture of the school and hospital:


The school teaches 540 tribal children at a time, through 10th grade. Above 95 percent of the tribal children attend the school, and 99% of them pass the national 10th grade standardized exams. Many of the students are now working in some capacity for VGKK, and others have gone on to further education. Unfortunately it is vacation season, so I didn't get to see 500 kids running around campus.

This internship was very different than Prayas. It was much more of a clinical shadowing experience, in an incredible variety of clinical settings. As I was not helping draft documents for policy advocacy and such, I was perhaps less useful to the NGO than at Prayas, but I did help in minor ways such as taking blood pressures and keeping patient records. One of the tribal people working for VGKK said something like "We are showing you everything now, so come back one day and help us." Here are some of the clinical settings I volunteered in:

VGKK Hospital
The hospital has a daily outpatient clinic from 9 to 5, where I spent many of my days. It has a doctor, nurse, lab technician, pharmacist, and two medical students from Mysore Medical College. It sees about 40-50 outpatients a day, and has a handful of inpatients at any given time. There were two inpatient wards, male and female, each of which had about 10 beds. All consultations are free, as are the medicines given. A lot of the medicines are purchased from an organization called LOCOST, which produces low-cost generic medicines for use by NGOs and health organizations. (Incidentally, the head of LOCOST gave me a lot of input and advice on the FAQ I wrote at Prayas!). They have an operation theatre, but the surgeon they had on staff left a couple of years ago, and they have done few operations since.

While at the hospital, I saw quite a few exotic injuries. We redressed a surgical wound for this one guy who broke his foot while running away from an attacking elephant. Another 0ld woman was charged by a bull, and was kept as an inpatient for observation. I also saw a non-venomous snake bite on a guys foot, which had evolved into a large and nasty infected wound, as he didn't seek treatment for a few weeks. Another woman with a similar wound was now on crutches.

There was a few sad trauma cases: a car crash occurred at a temple up the road, and a woman came in with a concussion and deep gash on the top of her head. The driver of the vehicle's lower lip was split completely in two. They stitched the woman's wound while a free Karnataka state ambulance arrived, which took both patients to a bigger hospital in a nearby down.

For the most part though, the patients have had normal complaints of fever, diahrrea, vomiting, cough, etc. As expected, there were more infections than one would see in the US. One interesting note is that they check under the lower eyelids of almost all the patients for signs of anemia. Also, the prevalence of tobacco smoking was remarkably high among men in the area, and there was an inpatient with COPD. For very complicated things, VGKK generally refers to the nearest tertiary care hospital at Mysore Medical College. This is a public hospital, but still has some fees, which makes some of these patients unwilling to go.

Mobile Medical Clinic

Every Friday and Saturday, VGKK sends out a mobile medical clinic to surrounding villages, which is basically a jeep loaded with medicines for minor ailments. I went out with the medical students to various villages, where they held informal consultations with sick people, and gave them appropriate medicines. Some villages had only 2 or 3 patients, others had more than 20. If necessary, there were also home visits.

In one village, we visited the hut of a couple who had been attacked by a bear. The woman had broken her hand, and the man had a badly hurt lower back, and was lying on the floor. He had to use a rope which was dangling from the ceiling, to pull himself into a half-way sitting position. They had already gotten some treatment and x-rays somewhere, but I got conflicting reports about where. The medical student tried to convince the man that he needed further observation at Mysore Medical College, but the man was very relucant to go.

In my last two days with VGKK, we went on the mobile clinic to another region called the M.M. Hills, staying overnight. The villagers in this area seemed to be in generally worse shape than what I saw in the B.R. Hills. There was an incredible amount of anemia, so much that we ran out of ferrous sulphate about 2/3 of the way through the first day, and had to restock at a local Sub-center. One woman's anemia was so bad it was beginning to lead to heart complications. It was pretty sad to realize that the iron supplements would only help these people for a little while, but they would soon degenerate back into anemia without drastic changes in food availability. I also witnessed my very first leprosy diagnosis: a boy had been told he had a skin allergy, but the med student noticed a few signs that pointed to leprosy infection, and then the mother mentioned that he didn't feel pain when he touched burning hot surfaces. He was directed to a PHC to test for leprosy. The medical students were particularly awesome on this outing, as they walked us through almost every diagnosis. Some of the villages had more than 50 patients. I took a few blood pressures, gave an injection, and got to participate in patient examinations. I heard rhonchi lung sounds, heart murmurs, and plenty of other things that excited my geeky medical obsession. But generally, I was pretty sad about malnutrition and anemia.

Karuna Trust and Gumballi PHC
Dr. Sudarshan and colleagues also began a sister NGO in the mid 1980s called Karuna Trust, which is focused on rural development (whereas VGKK is focused on tribal development). It began as a health project in response to the high prevalence of leprosy in the rural areas at the bottom of the B.R. Hills, but has since spread into trying to provide comprehensive primary health care and development. Probably the coolest thing about Karuna Trust is that they were able to convince the Karnataka state government to allow them to take over operations of the Primary Health Center in Gumballi, at the foot of the B.R. Hills. They turned this into a model PHC, and are now operating PHCs in every district in Karnataka, as well as in five other states of India.

I visited the PHC at Gumballi, and saw what a government clinic could look like when operating at its theoretical best. The PHC has a doctor, several staff nurses, a pharmacist, lab technician, optician, opthamologist-in-training, three dental surgeons, as well as a general surgeon who visits every once in a while to do tubectomies (female sterilization). They have programs for mental health, epilepsy, TB, leprosy, and more.
Since the mid-1990s, they have been combatting mental health. They are currently treating around 350 epilepsy patients, as well as 150 general mental health patients. Every Sunday, they hold an epilepsy camp, where one-fourth of their patients come for an update and to receive new medicines. I got to see this epilepsy camp in action, and read through a lot of the case records. Some of the patients had spouses who thought they were possessed, which made their lives really sad until their medicines brought their convulsions under control. Most of the patients were no longer experiencing seizures. I also kept records during a mental health camp on a Saturday, which is held once a month. These were incredibly fascinating patients, with interesting case histories. One interesting sidenote: on the forms there was a question for the average monthly income for the patient's family: some of these were as low as 500 to 1000 rupees, which is between 10 and 20 US dollars for a month for a family. It is incredibly fortunate for these patients that they have free quality medical attention through the PHC.

The clinic is also following two leprosy patients, and 17 TB patients. (The leprosy rate has gone down dramatically since their control efforts). An optician does eyesight consultations, and they make glasses at the PHC. An opthamologist-in-training does eye consultations and cataract surgeries, and a new one rotates in every 3 months. Two volunteer opthamologists come from a private hospital in Bangalore every Saturday to do cataract surgeries and train the intern. All consultations and surgeries are free for patients. They invited me to watch last Saturday, and I got to scrub in.

(Thats me on the left in the picture)

Three dental surgeons also rotate in every 15 days, and operate a mobile dental clinic, where they are able to do consultations and minor operations. They consult out of the mobile clinic in the PHC parking lot, and drive it out to villages every few days.
The pharmacy was well stocked at Gumballi, which is more than many government clinics can say. They are provided to patients as a fixed nominal cost of 15 rupees for all medicines, whatever the quantity or relative expensiveness. They also have a well-equipped laboratory for tuberculosis sputums, blood sugar measures, urine analysis, and more. They have a trained staff nurse who performs many of the deliveries, people cultivating a medicinal herb garden, and a rangee of other activities that have gotten too numerous to keep listing. In summary, the PHC is incredible.

There was also a group that did health education teachings in villages in the block. They go to villages for 2 days at a time. On the first day, they parade around and get a lot of attention. Then they put on street plays and sing songs about water quality, infectious diseases, nutrition, and more. They did a demonstration for me and another volunteer at the PHC, singing songs and dancing. We were supposed to go out to a village, but they were asked not to by the government because Gram Panchayat (Village-level) elections were taking place.
B.R. Hills Sub-Center
This was a government clinic sub-center about a 2 km walk from VGKK. It is one of five subcenters attached to the PHC at Gumballi. It serves 8 tribal settlements and 2 non-tribal settlements in the B.R. Hills, for a total population of 2,383. There is one ANM on staff, who was actually trained at VGKK's nursing school. There are an average of 20 patients per day, mostly for minor ailments. There used to be about 2-3 birth deliveries per month, but the Karnataka state government is trying to get all deliveries to happen at the hospital level now. They favor squat delivery of babies rather than lying down, as it is believed to be less dangerous for the mother.

Karnataka has a pretty remarkable compensation system in place to try to reduce maternal mortality. (I think this is Karnataka-specific, but its possible the NRHM is trying to implement this in other places. I at least didn't hear anything about it when I was at Prayas in Rajasthan). A family will get 500 rupees if their home delivery is supervised by a healthcare provider, 700 rupees if the delivery happens at a hospital, and 1500 rupees if she gets a C-section. If the mother comes regularly for Ante-Natal Care check-ups, she will get 100 rupees before delivery, and 1000 rupees after. This benefit system is only in place up to 2 babies, as they do not want to encourage overpopulation. For a female baby, 100,000 rupees will be given to the mother when the daughter reaches 18 years. This is to discourage female infanticide, which has led to some pretty gross boy/girl ratios in a lot of states of India. (Girls are seen to be less economically useful, as the family will have to marry them off and pay a dowry). The ASHA system from Rajasthan is in place here, with 1 ASHA for every 2 or 3 villages.

The ANM at the SC did immunizations, which VGKK helped out with. We followed one of the VGKK health workers to some of the villages, where he visited the houses of people who were due for vaccination and reminded them to go. There was also a mentally ill patient who had TB, who had been coming irregularly for his TB medications. The health worker and the guy's father scolded him, and he promised to come the next day.

VGKK was also up to a bunch of other cool projects, such as training tribal people in honey processing and the sustainable harvesting of non-timber forest products. They are partnered with a biodiversity conservation organization called ATREE (Ashoka Trust for Research in Ecology and the Environment), whose B.R. Hills field office is actually run by one of the first 6 students in Dr. Sudarshan's hut in the 1970s. He is now working on his PhD.
http://www.atree.org/
Part of their mission is to do research on the ecological sustainability of the Soliga tribe's way of life, so that the tribals will be given more flexibility by the forest conservation act.

I'm now back in Bangalore. I'm going to visit relatives in Mumbai for a few days, then off to my last NGO in Dharamsala. This trip has been incredible so far.

More indians with access to mobile phones than toilets!

So a recent UN report on sanitation says that India has more mobile phones users (45%) than people with access to toilets or sanitation facilities (31%):
http://www.hindustantimes.com/News-Feed/india/India-has-more-cell-phones-than-toilets-UN/Article1-531449.aspx
I'm curious to know the amount of overlap, or people with mobile phones and no toilets. From my experiences over the last few weeks, I think it might actually be a decently high number. I downloaded the pdf of the report, but havien't finished reading it yet. If I find the overlap number, I'll edit this post.

End of my stay at Prayas

I leave Chittorgarh tonight on an overnight train to Delhi, and so ends my internship at Prayas. Its been great, I learned a lot, and met a bunch of cool people I hope to meet again.

Some interesting things I've seen since last post:

District Hospital, Chittorgarh
Saturday night I visited the District Hospital in Chittorgarh. This is basically the highest level of service that a public clinic/hospital can provide. Kiran and I went to the generic medicines shop outside the hospital to pick up some stuff (this is an initiative Prayas helped to start: pharmaceutical vendors that actually sell at reasonable prices. It has brought down the prices in a lot of the private chemist shops in the area too!) Afterwards, Kiran brought me in to show me around a little bit, and we were lucky enough to run into a GNM (General Nursing Midwife)-in-training, who just got off his shift. He showed me the entire hospital: surgical operation room, post-operation recovery room, women's ward, men's ward, etc. Some interesting features:
- There were a lot of minor user fees for services like diagnostics, ICU stays, etc. Kiran said these were way lower than at corporate hospitals, though.
- The hospital has a "BPL" counter, where poor people below the poverty line can get access to reduced or free services.
- There was a separate room for BPL patients in the in-patient wards, so as to prevent confusion on cheap/free services to the right patients. I would be concerned though about different treatment standards.
- There was a stray dog hanging out near the patient wards. Kiran said he's seen district hospitals with a lot more dogs, and that this one was relatively clean.
- The ICU had oxygen and heart rate monitors for almost every bed. This is apparently is really rare for government hospitals, which usually have just 1 or 2 for the whole ward.
- No doctors stayed overnight in the wards, but there were some on call at their homes. Kiran said that at corporate hospitals, there would be overnight shift doctors.
- There was a separate ward being built for people who wanted to pay a high price (I think around 500 rupees a night), which had 1 to 2 beds per room, air conditioning, private bathrooms, and generally luxurious accomadations. These were sort of similar to some of the US hospitals I've been in. Dr. Narendra is not so happy about this kind of unequal accomadations initiative.
The GNM was going to look for a job in Canada when he graduated. Woohoo brain drain! He was a really nice guy, though.

Immunization Day, Rajpura Village
On Monday I went back to Chotisadri, where one of the field workers, Manganlalji, picked me up on his motorcycle. I knew I should have been concerned when he wore a helmet and bandana covering his mouth. He is the only person I've seen wear a helmet. As I soon figured out, this is because his motorcycle is like twice as fast as everyone else's I've been on. Also, he doesn't particualrly like to slow down, even when the road turns into dirt/gravel, or kind of generally vanishes and becomes more of a foot path. I'm really happy I held on, but my fingers were kind of cramping by the end of the short 15 km ride.

Anyway, he brought me to one of the Prayas field offices, near the village of Rajpura. Every month each village has 1 immunization day, where they immunize children and pregnant ladies for things like measles, TB (BCG), diptheria, tetanus, and more. They also give iron folic acid to pregnant ladies, and test for malaria by dropping blood on slides and delivering to the local CHC lab for processing. The ANM/GNM, ASHA, Anganwari worker, and local NGO worker all take part. Every Monday and Thursday an ANM/GNM from the local Sub-Center arrives at a new village with the vaccines, and they rotate until the month is complete, then going back to the first. I went to the Anganwari center at Rajpura village, where all these folks were hanging out waiting for people to come by. Rajpura is a tribal village with about 680 people. Apparently the immunizers dont go house to house, they just wait for people to come. They only do about 3-4 immunizations a day. I talked to the GNM for a while, who showed me all the vaccines and explained their use. Here's a picture of him with his vaccine cooler:He apparently used to work for a couple of corporate hospitals, but then applied for a government job because his parents thought it was more prestigious. He said he was really bored though because he didn't really have an interest in village health, and found the work much more interesting at the corporate hospital. Sigh.

There is usually a Village Health and Sanitation Council meeting after the immunization day, but this one was going to take place late at night because most of the people were away on a NREGA (National Rural Employment Guarantee Act) project. Manganlalji did take me, however, to meet the president of the VHSC, who was a pretty goofy guy. Here's a picture of him and another woman who run's the village's women's self-help group:Manganlalji is on the right, and they are holding a Prayas banner. Manganlalji has been working with Prayas in the area since 1999. Before Prayas worked there, the health problems were much worse, but apparently now they currently weren't that bad. (Disclaimer: Manganlalji spoke almost no English, so once again some communication difficulties on details) There's no HIV/AIDS in the village, and Manganlalji said you only really find it outside of the "Tribal Belt" that Rajpura belonged to. About 10% of people got malaria in September/October every year, but the treatment was good and accessible now, so nobody died. I think 4 people had tuberculosis in the village. Apparently diahrreal diseases were not a problem (although maybe this was a communication difficulty, because I find that hard to believe). The main health problems seemed to be viral stomach illnesses.

As far as education, about 15% of boys and 10% of girls could read and write to some degree. There was a primary school in the village, but it had only 1 teacher to teach 8 grades. About 15% of kids went through 6th grade, 8-9% through 8th grade, 2% through 10th, and pretty much nobody further than that. The people who go through 10th have to go to a secondary school in another village. I think Manganlalji said nobody over the age of 20 there could read or write.

In between these visits, I have been finalizing some of the documents and office work I did at Prayas. I am now going stay with my cousin Maneesha in Delhi until Friday, when I will fly to Bangalore and stay the weekend with my cousin Aman. I then begin volunteering at Karuna Trust/VGKK next Monday. Apparently the head of the project, Dr. Sudarshan, is really awesome: http://en.wikipedia.org/wiki/Hanumappa_Sudarshan

I am really excited to eat a brownie sundae in Delhi, which I have been craving for about 2 weeks. Maneesha has promised me one.

Ambedkar's Birthday and Khemraj's Place

Wednesday: Ambedkar’s Birthday!

Prayas celebrated Ambedkar’s birthday, which is a national holiday in India. As mentioned before, Ambedkar was an untouchable who got educated and became the champion of untouchable and lower-caste rights in India. He also wrote the Indian constitution, converted to Buddhism, and hated Gandhi. You can read his Wikipedia page for more info: http://en.wikipedia.org/wiki/B._R._Ambedkar

We went to the Chittorgarh’s Ambedkar statute to put garlands over its head. There were already a lot on the statue when we arrived. Here is a picture of everyone in front of the statue:

And here is a picture of some people putting garlands over the statue.

I spent the rest of the day helping Dr. Narendra put together invites for a May 4^th panel on Patterns of Health Spending, Access to Medicines, and Free Treatment in India. This event will take place in Delhi, and will involve members of India’s parliament. Unfortunately, I will be in Karnataka by then.

At night, Dr. Narendra invited a bunch of old professor-types and otherwise important people over to talk about Ambedkar’s significance. As usual, I missed the details, but generally they taked about Ambedkar being awesome, and a little bit about the current Maoist Naxalite movement in India, which has been a subject of intense debate over the past week. Dr. Narendra also brought up Subaltern Studies and Ranajit Guha, which made me happy. Subaltern Studies is an Indian history movement that focuses on lower class/caste groups that generally have had no voice in colonial, nationalist, or Marxist histories of India. I took a class with one of the founders of the movement at Columbia, and it was one of my favorite classes ever. Apparently Dr. Narendra has read all the compiled volumes of Subaltern Studies, which is intense. Also, one of the historians of the movement, David Hardiman, actually stayed at Prayas for a couple of months with his girlfriend at some point. I think we actually read one of his articles in Gandhi’s India or Subaltern Studies.

Thursday: Khemraj’s Community Organizing

One of the older members of Prayas, Khemraj, was in the office on Tuesday, and invited me to his place on Thursday for a community meeting. He lives near a village called Amarpura, nexted to a small town called Badesar, which is about 30 km from Chittorgarh. I took a series of cramped strange vehicles to his place, and managed to only pay 15 rupees (~35 cents) total.

Khemraj now runs a sister NGO called Pratirodh. I’m not entirely clear on the goals of his organization, but I know it’s not primarily public health based. I think it’s more of a rights-based approach to helping poor people. Khemraj is basically an Obama-style community organizer, who spends his mornings and evenings walking around in villages and chatting with people. People discuss their problems with him, and he either connects them with law or health services that can address their problems, or organizes an agitation if multiple people are facing the same issue. He and his wife also run a school for poor girls from villages in the area. The girls are adorable, and apparently study really hard late into the night. Here are some pictures of the outside and the inside of the school:

(The portraits are of Bhagat Singh and Ambedkar, two nationalist rivals of Gandhi. Bhagat Singh was a young nationalist who supported using violence against the British. He was caught and schedule to be hanged. A lot of people think Gandhi had the power to prevent his death, but chose not to. Bhagat Singh is Khemraj’s nationalist hero of choice.)

Khemraj has 9 employees, and I’m not fully sure what they do, other than generally help him with these tasks. For the past few weeks he has been asking people to come to this community meeting. He was hoping for about 100 people or so, because he wanted to march in Badesar to protest some issues surrounding BPL (Below-Poverty-Line) status benefits. Unfortunately only about 30-40 showed up, so we stayed at his place and had a meeting there.

At the beginning, everyone went around the room and said why they had come. Here are some of the issues people were facing:

-Several women were below the poverty line, and even had a card that certified their BPL status, but still were not getting benefits that the government specifies for BPL people, such as subsidized wheat, kerosene, and other things. They were all from the same area, and it seemed to relate to one center of the PDS, or Public Distribution System, where the guy was generally being a jerk. Khemraj ended up writing a petition, which one of the literate people there helped everyone sign, and the women brought it to the jerk’s superior in Badesar.

-Another woman worked on a NREGA (National Rural Empoyment Guarantee Act) project, but was receiving below minimum wages. Her husband is ill and too weak to work, and she has children.

-Another woman had three children, and a mentally ill husband who vanished 11 years ago.

-One man had a small plot of land to his name, but for some reason I couldn’t understand, he could not grow anything on it. He is currently an agricultural laborer.

-One 10^th grade boy was a brilliant student, and was interested in science and wanted to become a doctor. His father was a bonded laborer, however, and he didn’t have much food at home and the boy generally was finding it difficult to focus on school. Khemraj asked me and Scott (another American who came to the meeting), if we could organize some sort of donation campaign in America for him and a few other students like him.

- A huge Maoist attack happened last week in the state of Chattisgarh. One man wanted to know more about it. Surprisingly, he was the only person in the entire room, outside of Khemraj and Pratirodh people, who had even heard that it had happened, even though it has been headline news every day.

Another part of the meeting consisted of Khemraj’s wife talking to parents of the girls in their school about the importance of studying and nutrition. Scott and I were used as examples of what good nutrition can do. I became sheepish about my belly. At some point we were asked about the literacy rate in America, and about children in school. One of the parents asked “Don’t they work?” They were shocked when we told them child labor was illegal.

After the meeting, I chatted with Khemraj. He is a self-proclaimed Marxist, and every once in a while slips “the revolution” into his sentences. I tried to ask about Marxism in the context of caste instead of class, and about whether Marxism can apply when the lower class consists mostly of super-poor, largely unproductive rural villagers instead of an industrialized productive labor force. The language barrier finally kicked in though. He speaks decent English, but I think not enough for this kind of a conversation. Which was sad, because I was pretty curious.

In the evening we went on Khemraj’s electric scooter to a village called Bhil Khera, one of the villages of the Bhil tribe. The journey there was comical, because his scooter was low on power, and we drove at a moderate jogging pace. Bhil Khera is pretty much what you would imagine an Indian village to be, with barefoot people, huts, chickens, and other livestock. It has a population of about 175. I didn't take pictures because it felt too weird. But here are some of the interactions we had at the village:

- One man, who was bicycling by, stopped to say hi (Everyone in the area knows and loves Khemraj, which made it easy for me to find his place in the morning). He had a pretty cool headdress on. When he learned I was from America, he said something like “Your country is very good. Our country has lots of problems. Right now our worst problem is water.” Apparently the rains have been very low for the past two years, but they are getting some water through government distribution.

-We sat outside the hut of another man, who lamented the general behavior and manners of the community. He wants to change them, but doesn’t know how. He said all other communities are improving, while he feels like his is only getting worse. He himself was decently well off, as he had sixteen sheep and one goat. He had steel and brass dishware, which Khemraj pointed out as a sign of his relative wealth. Through Khemraj’s translation, I asked about the literacy rate. Apparently in the entire village, there are three boys who can read and write. Outside of the two girls that attend Khemraj’s school, the female literacy rate is 0%. The guy said that his daughter is pregnant and due for delivery any day now, and Khemraj gave him the number of a free ambulance service run out of Chittorgarh. He also called a guy from the ambulance service to tell him about the upcoming delivery. The man gave me chai made with his sheep’s milk, which according to Khemraj has about 8-9% fat, whereas cow’s milk has 3.6%. I have no idea how he knows that.

-We sat with another family, whose somewhat distant relative passed away 15 days ago. They decided to throw a massive feast in his honor, which cost them 7000 to 8000 rupees. They had to borrow the money, and the money lender has now mortgaged their land. The three young men in the family are now bonded laborers as a result. Khemraj told them how stupid an action that was, and said something along the lines of “if you do things like this, you will drag your entire community down.” But he also will try to help. Apparently there is a law that says a moneylender cannot mortgage the law of Scheduled Castes or Scheduled Tribes (categories for certain groups of poor people in India). But the owner of the land has to know about the law and make the complaint to the court themselves. There’s also apparently a law that says no one can mortgage someone else’s land for more than 5 years, but apparently this is never enforced.

-We stopped at the hut of a girl, who used to attend Khemraj's. She got into a lot of quarrels, was eventually socially boycotted by the other girls, and left.

- We stopped at the head-of-village's hut, and Khemraj asked him why had the family thrown the death feast. The village-head said he didn’t support the decision, but I guess he did let it happen. So Khemraj was still pretty unhappy.

One thing I was kind of surprised about was the government either was addressing or could address some of their problems. For instance, the government was distributing water due to the drought, a free ambulance could come to take the pregnant woman to the hospital, and there was a law protecting against moneylenders mortgaging land. These maybe pale in comparison to what a lot of people think the government could be doing, but it was more than I expected.

On the slow scooter ride back home, Khemraj told me he and his family have been beaten several times by landlords/moneylenders/other people who unhappy with his activities. Two years ago they were beaten pretty bad.

I slept Thursday night at Khemraj’s place, and ate his papayas (he has 16 papaya trees!). I returned to Chittorgarh in the morning. Here is a picture with Khemraj and his wife:

Busy Week!

Its been an active few days, so this is going to be a longish post. I’ll break it down by day:

Thursday: Chotisadri; Age-determination for Pregnancy

I went back to Chotisadri (the small town where Prayas bases its community health activities) with Dr. Narendra for a meeting with all the health workers. One of the interesting debates at the meeting was about age of pregnancy. Prayas workers had been surveying women in the villages in Chotisadri block to assess at what age they first got pregnant. There’s a 2.5 times higher risk of maternity complications below age 18 than after age 18. The legal age of marriage in India is currently 18 for women, 21 for men (I’m not sure what the age of “consent” is, or if they even have such a concept). Unfortunately, many villagers have no idea how old they are (If you took Gandhi’s India with me, you’ll remember Prof. Bakhle talking about this in relation to the census). Dr. Narendra pointed out that Prayas had been using no standard set of questions to try to determine age. They called a few surveying organizations for advice, and I think it’s my roommate Kiran’s task to come up with a standard age determining protocol.

Friday: Chotisadri, Barisadri; Udailal’s Story

(Disclaimer: Almost everyone I met Friday and Saturday spoke little to no English, and my Hindi is still pretty bad, so everything I say about them was learned through a language filter.)

I went back to Chotisadri in the late afternoon, and then rode on a rickety old motorcycle to another town called Barisadri with one of the health workers, Udailal. The route included a bunch of small dirt roads that wound through villages, and it was very beautiful during sunset. Udailal’s story is pretty incredible: he’s the youngest of 7 children, and the only one to get any sort of education. I think he is from the Dalit or untouchable caste. (I base this mainly on the fact that he had a huge picture of Ambedkar on his wall. Ambedkar was a Dalit nationalist who got a PhD from Columbia and wrote the Indian constitution, among other cool achievements.) Udailal was educated through 11^th grade, and has been working with Prayas as a field health worker for the past 18 years. The rest of his siblings are working in agriculture. Two years ago, he registered his own NGO in Udaipur to work on health, education, and development in this district that is 95% Dalit. It might actually be the same district he grew up in, but I’m not sure. He’s also teaming up with a Harvard anthropology PhD student named Andy, who’s been coming every summer. There’s a lot of NGOs in Rajasthan, so he’s having trouble with funding right now, but his story is still pretty inspiring. He was doing meaningful work, and it was clear that everyone in Barisadri and the communities we visited the next day loved him. My mom said his story sent shivers up her spine. I slept in Udailal’s small flat in Barisadri for the night.

Saturday: Barisadri; Visiting Centers and Clinics, Drive to Udaipur

In the morning, Udailal took me around to a bunch of villages in the tribal areas surrounding Barisadri. He showed me a few Anganwari Centers, which as far as I can tell are day-care centers that also dabble in nutrition and maternal health. One of them had used their “Untied Funds” (10,000 rupees provided annually to each village as part of the National Rural Health Mission) to buy a cot and a weighing scale, which were the only two objects in the center. Here are some pictures of Anganwari Centers:

I also visited a “Sub-center” clinic, and met two ANMs (auxiliary nursing midwives), who gave me some orange soda. Sub-centers are one step below Primary Health Centers, and employ only nurses, no doctor. They existed before the NRHM, but the NRHM increased the number of ANMs from 1 to 2 per Sub-Center. There are also some Sub-Centers called “modal” (or something similar) which employ an additional GNM (General Nurse Midwife), and have a bigger facility for delivering babies. The Sub-Center I visited said they had about 10 patients per day. None came while I was there. One of the ANMs said she didn’t really like the work, and wanted to join the police force. But apparently it was too late for that kind of career change. Here are some pictures:

On the way we also went past some workers building a road as part of a National Rural Employment Guarantee Act (NREGA) project. This is a public works rural jobs project, somewhat similar to FDR projects during the Great Depression. Here’s a picture.

After visiting all these places, I returned to Barisadri, ate lunch, and then caught a three-hour bus back to Chittorgarh on bumpy roads. These bus rides are amusingly awkward, as they’re mostly filled with poor farmers, and I’m sure I look outrageously out of place.

When I got to Chittorgarh, I learned that Dr. Narendra was coming back from Jaipur in a car with people from another NGO, who were dropping him in Chittorgarh before continuing on to Udaipur. I was considering going to Udaipur on Sunday because its our day off. So I quickly got ready and hitched a ride in the car to Udaipur. One of the guys, Ranvir, is part of an NGO called Jatan, which partners with Prayas to do community health monitoring trainings in the Udaipur district. It also does a lot of work with youth, and Ranvir was actually part of one of the youth groups before joining the organization. He spoke English very well, and blasted Akon and Celine Dion for most of the ride to Udaipur, which was on a very smooth, fast, and huge highway. It was a totally surreal transition from the beginning of the day. I slept in the Jatan office Saturday night.

Sunday: Udaipur, Jatan, Migrant Health Workers

I spent most of Sunday going around tourist areas of Udaipur, which was nostalgic because I came here with my family in 2004. I also had a lot of opportunity to talk with Dr. Kailash, who runs Jatan. Part of their work is with migrant workers from villages, who have a huge array of health problems, particularly with communicable disease. I read Jatan’s annual report, which discusses how HIV and STD transmission to migrants when they are in towns and cities (many of them are early to mid-teenagers, and use commercial sex), and then back to women at home when they return to their villages. It was pretty similar to the Paul Farmer’s descriptions of truck drivers in Haiti, and the women they date or marry. Anyway, one of the Jatan projects is to give migrants wallets filled with health information and a condom. Dr. Kailash gave me a sample, which I’m now using as my regular wallet.

Dr. Kailash also broke down the pre and post NRHM differences for me: the main things the NRHM added that wasn’t universal before were the ASHA (Accredited Social Health Activist) and the VHSC (Village Health and Sanitation Council). This was basically the government accepting that the community health model and making it universal, which a lot of people in the NGO community are happy about.

I returned to Chittorgarh at night on an incredibly fast bus.

Monday: Chotisadri; Community Health Projects

I went to the annual project planning meeting of the community health group in Chotisadri, which was mostly in Hindi, but I got a better sense of what the community health group does. Here are names of some of the projects and meetings they are involved in every year, which were thankfully said in English:

Network for Health Equity, Health Awareness Program, Adolescent Health, HIV/AIDS, Village Health and Sanitation Council training and formation, Accredited Social Health Activist training, Women’s Group meetings, meeting with Primary Health Center and Community Health Center, meeting with ANMs, Women’s Health Assembly, Boy’s Health, Jan Mangal Couple Assembly, PRI workshop (head of VHSC)

Also, they plan celebrations/meetings for World Health Day, International Women’s Day, International Breast Feeding Week, World Population Day, and World AIDS Day

The details were mostly discussed in Hindi, so my understanding of what each of these things entails is still hazy.

Final Anecdote:

There’s a few other American students hanging around, and last week a villager asked one of them where he was from. When he said America, the guy said he’d never heard of it. Someone asked him to list all the foreign countries he knew, and he said “Pakistan and Gujarat”. Gujarat is another state in India, which borders Rajasthan…

World Health Day

Prayas celebrated World Health Day 2010! The theme was urban health, but Dr. Narendra didn't really like the theme for some reason.

They had a celebration in the district hospital in Chittorgarh, but I instead went to Chotisadri, the smaller town I've been trying to go to for a week. Chotisadri is where most of Prayas' health activities are centered, and they work with all villages in the Chotisadri "block". As soon as I got there, Govardanji, the head of the Chotisadri activities, picked me up on a motorcycle and drove me to the Community Health Center (see earlier post for organization of government clinics). There was about 100 women lined up with signs, and they started marching and chanting various health slogans in Hindi. Here's a picture:
We marched through the streets of Chotisadri for a while, continuing to chant. One of the nurses (who were all wearing white) gave me a hat, then giggled with all of her fellow nurses. We ended at a hindu dharamsala, in a large room where a bunch of other people were waiting. I think it ended up being over 300 people in the end, according to the woman sitting next to me. Almost all of them, except for some of the organizers, were women.

(Sidenote: I totally see what the EPW article on Tamil Nadu public health was talking about. Gender is super tied into health here, and a lot of the respected community health figures (ASHA - Accredited Social Health Activist and ANM - Auxilary Nursing Midwife) are necessarily women. On the other hand, the Block Program Manager, who was also at this meeting, was a man, as was the ASHA coordinator for the district of Chittorgarh, as was the District Program Manager.

Also, I see what they were talking about when they said the predominant view of public health here is clinical. In the National Rural Health Mission website, the "public health standards" is a lay-out of clinical setups and what they expect of a clinic at each level. There are things on the NRHM website about vector control, disease surveillance, and other public health associated things, but nothing about sanitation or nutrition, which the article thinks should be a much bigger focus.) End sidenote.

Anyway, a bunch of people stood up to speak, but I could only vaguely understand what they were saying. I had to get up and introduce myself to over 300 women in broken hindi, which was hilarious and awkward. Then Govardanji went on a super long explanation of who I was and drew some sort of conclusion about "world" health, but the details were lost on me. At some point his wife mentioned me again, in connection with sitting, or asking people to get up for you, or something. The best understanding I could arrive at was that she made fun of me for constantly shifting because I'm american and not used to sitting on the floor for hours (all large meetings in India seem to be conducted on the floor), but still wouldn't ask for more comfortable seating. But I have NO idea if thats actually what she said, nor how that would at all related to world health day. I think I served as a source of fun and ridicule, which is fine, because at least I served some purpose!

After an hour or so they seemed to run out of speakers with things to say, so they kept asking for people to come up and say something. Women kept being pushed up reluctantly by their laughing friends to speak. Some of them talked about health, but others cracked jokes, and some just sang songs, which were potentially related to health, but I'm not sure. Apparently I was mentioned in the local newspaper covering the event!

Today I'm going to a monthly planning meeting of Prayas health workers in Chotisadri. I think this will be a meeting between government ASHA workers and Prayas workers, because I think as NRHM/ASHA work gets up and running in an area, Prayas pulls its health workers out. The government/NGO communication and collaboration here is remarkably tight, considering this type of meeting and the Prayas role in training of community health monitoring mentioned in an earlier post. In fact, I think each Village Health Council contains 1 NGO member that has been working in the area. A lot of the people I've met in the area now serving NRHM-associated government positions actually got their start at Prayas.

Tomorrow I believe I'm going to one of the Prayas "field sites" in the Chotisadri block, and staying 1 or 2 nights. Should be adventurous! Hopefully I figure out my water situation and don't get terribly sick (another American got severe diahrrea last week and got hospitalized overnight). I wish I had remembered to pack iodine tablets.

So my plans to go to the remoter district were put on hold until I think tomorrow, but I've spent a productive week compiling an FAQ on Indian drug pricing and access to treatment. It basically talks about generic vs. brand name drugs, profit margins and mark-ups to retail prices, affordability of the government becoming the primary provider of medicines, and so on. It was really fun to write, as I got to read a bunch of background papers and Prayas presentations to put it together. I also got to make it look pretty with the wonderful visual powers of Microsoft Word. It's being proofread by various partners of Prayas, and then they're going to publish and distribute it all over! I feel cool.

I also proofread and edited a letter Dr. Narendra was sending to Sonia Gandhi, who is the head of the UPA party that is currently in power in Indian government. It was about access to medicine issues. Dr. Narendra thinks Sonia Gandhi is the last hope, because everyone else in power positions in the government wants to "privatize everything."

I attended parts of a two-day training session that Prayas people were holding. As part of the National Rural Health Mission, there is a plan to have Village Health and Sanitation Councils monitor health services provided by the government. This training was held by District Trainers for Block Trainers, who will then go on to train every VHSC in Rajasthan over the next 10 months how to do the monitoring. Let's see how it works out.

I think tomorrow I'm actually going to a remoter district, so I think I'll actually have some interesting pictures to post. I took some pictures of the office and the training session, but the internet's too slow right now to upload them.

Interesting fact: My roommate Kiran is a doctor who also went to a Health Management school in Rajasthan. Apparently his friends, fresh out of their program, are placed into Hospital Administrator positions immediately out of graduation. They head an entire hospital at like age 24-25, which is incredible. It's interesting to value management education/training over experience. Or rather, it's interesting that there's not enough experienced administrators to choose from. Kiran said that the idea of health management being important is relatively new.

My first two days at Prayas have been great. Dr. Narendra Gupta, the leader of the project, is a very interesting and cool guy. He's very much into medicine pricing type advocacy right now, so we had a lot to talk about when I arrived. He had me over to his house for dinner, which was very nice of him. Food here is on the upper range of my spice tolerance, but I'm fine if i have something milk/sweet like after.

Also, some young dudes who speak English showed up, so I actually have people to hang out with! This has been a welcome change. That being said, it slightly detracts from my impetus to keep studying hindi, so I have to be disciplined.

I've spent the first two days learning a lot of about the current medical/public health system of India. The Indian government does somewhat ascribe to the idea of ensuring medical care for all. With the launch of the National Rural Health Mission (NRHM, http://mohfw.nic.in/nrhm.htm) the current set up is roughly as follows (some of this was in place before the NRHM, but it modified the system a bit): each village has an ASHA, or Accredited Social Health Activist, who is a member of the village chosen to be the liasion between government and village health. She also gets minor reimbursements for finding sick people and bringing them to the appropriate treatment place. For every few villages, their is a Sub-Center, which employs an ANM, or auxilary nursing midwife, who is trained to attend births and do a few other things. Above this there is a Primary Health Center, which employs two doctors (one in allopathic, one in AYUSH - ayurvedic, yogi, unani, siddha, or homeopath), a few ANMs and some support staff. Above this is the Community Health Center, which has a wider range of services, then the District Health Center, where you start seeing true specialists and a high-tech hospital format. The only thing above this is academic medical centers linked to medical colleges, where you might see leaders in a field or subspecialists.

This format seems logical, but its unfortunately drastically underfunded. There's a decent amount of absenteeism from staff at various positions along this hierarchy, and otherwise attempts to extract money. Also, about a year after the launch of NRHM, it was decided that they would allow staff to charge user fees (http://mohfw.nic.in/NRHM/RKS.htm). Only the state of Tamil Nadu has banned all user fees, realizing that this would probably be a terrible idea when you're trying to expand access to healthcare for super poor people. Which gets back to that article from my earlier post, which says Tamil Nadu is a model.

Check out this graph, which breaks down public vs. private spending on healthcare as a percent of GDP for various countries or groups of countries. Its taken from the 2008 World Health Report from the WHO:
India's public spending as a percentage of GDP is super low. I think it's only comparable with like the Democratic Republic of Congo and a couple of other countries that are really poor or struggling with unstable governments or both. Other interesting things to note are that external resources (essentially donor funding) play a miniscule role in India, and not as large as I would have expected for other low-income countries. Also note the outrageously high overall spending in the USA. The public spending is on par with other G8 countries, but private spending is huge. Our health outcomes are also way worse than most G8 countries.

Anyway, one consequence of this lack of India's public funding is that even if poor people go to government health clinics listed above, there's often not enough medicine for them, and they have to buy it out-of-pocket from a chemist. Dr. Gupta has been doing a bunch of research on pharmaceutical pricing, and has found that there is, expectedly, an enormous mark-up in pricing. An Indian pharma company will sell pills to the local chemist for 8 or 9 rupees, but the pricing on the bottle will say to sell it at retail for 70 rupees. I'm not sure if the local chemist actually captures a whopping 7 fold profit, or if some of this kicks back to the pharma company after sale to a customer. Whatever it is, this level of mark-up is clearly a huge burden to patients. (By the way, these are prices for generic medicines produced by India's generic companies - see earlier post. There's probably a different story entirely for brand-name multinational pharma companies operating in India).

Dr. Gupta has gone through estimates of Indian disease burden in every disease category, the rough amount of medicine needed to treat this burden, and the price of the medicine if procured at the 8-9 rupee price sold to chemists and government bodies. He has estimated that it comes to something like 6600 crore, which is actually a small amount when compared with the entire budget the government is putting into the NRHM. It would also likely drastically increase the success of the NRHM. So he's been doing government advocacy on that front recently.

Another thing that is part of the NRHM is a community monitoring program, where Village Health and Sanitation Committees (VHSCs) in each village give quartly report cards on the various services the government healthcare providers are supposed to be supplying. This is a pretty cool idea, but difficult to implement. The gov't is teaming up with local NGOs to help in the training of VHSC's, and Prayas is one of these NGOs. I hung out with the group that's doing this yesterday, and helped one of them flesh out a research study that is evaluating the training programs. The study will be his dissertation for his master's program in health management.

I think I might be going off to one of Prayas' projects in a remoter district for a few days, so I'll try to take some pictures for a more colorful next post.

Chai

I arrived in Chittorgarh this morning, and have been offered chai 6 times, of which I consented 3 times, because I felt bad. It's only 4 30 PM. This is a tough country to not like chai in....

So I finally have a rough itinerary.

I'm leaving today to go to Chittorgarh, Rajasthan to work with the Prayas project (http://www.prayaschittor.org/). I'll take an 8 hour bus from Dehardun to Delhi and an overnight train to Chittorgarh, arriving tomorrow morning. I will stay with the Prayas project until April 20th, when I leave on an overnight train to Delhi, arriving the next morning. I'll stay in Delhi until April 23rd, at which point I'll fly to Bangalore and stay the weekend with Aman (my cousin). On April 26th, I'll start working with the Vivekananda Girijana Kalyana Kendra/Karuna Trust (www.vgkk.org and karunatrust.com), in the B.R. Hills (http://en.wikipedia.org/wiki/Biligirirangan_Hills). I'll then somehow get from Bangalore to Mumbai on May 15th, and stay with all my relatives. On May 19th, I'll fly to Dharamsala, and begin working with CORD (www.chinmayamission.org/cord.php). I'll finish working with CORD on June 13th, when Ariel will also arrive in Dharamsala. We'll bounce around various places in the North until June 27th, when we fly back to the US from Delhi.

Hooray! I was planning on taking ridiculously long train 2-day train rides in place of some of these flights, but all the trains are booked crazy in advance, especially as May is peak holiday season. On the plus side, it gives me time to hang out more with family.

Fun-filled articles!

Been reading a few articles that my uncle's been shuttling to me.

One of them was in this morning's opinion section of The Hindu: (http://www.hindu.com/2010/03/25/stories/2010032563771200.htm) by K.S. Jacob.
It's basic point is that India's public health should try to shake off the domination of international agencies and expertise, because it has enough nascent training and expertise to do a lot of its own independent thinking about public health. I feel like not every country can actually say this, cuz many are faced with either donor/internationally funded public health work, or no public health at all. It's cool that India actually has the resources and intellectual expertise to claim more public health autonomy. or at least for certain article-writers to want it to. I don't know if this is really a "stage of development", because I think this has been partially true since its independence. Britain invested more in India than many colonizers did elsewhere, and left somewhat of an institutional public health infrastructure for Indians to take over. During colonial times it was geared more towards protecting British health than the population at large, but its still a higher starting point than many others have had.
Also interestingly, this guy thinks the whole swine flu thing was hyped, with pharma happily reaping the benefits. Not sure I'm ready to jump on a "flu's overrated" bandwagon. Reading about spanish 1918 flu has scared the bejeezus out of me.

Also read an article in Economic & Political Weekly (Mar. 6 - 12) about strengthening Indian public health systems ["How Might India's Public Health Systems Be Strengthened? Lessons from Tamil Nadu" by Monica Das Gupta and other folk] I can't figure out how to link a pdf, but if you go to http://epw.in/epw/user/fullContent.jsp and search in Previous 4 issues for "Tamil Nadu", it should come up. or i can email the pdf.
They basically gripe about clinical health way overshadowing public health in budget and attention, and within public health, single-issue programmes like vaccination/eradication campaigns overshadowing less politically sexy interventions like clean water and sanitation. They say that the amalgamation of public health and medical specialists into mass under the ministry of health diminished career incentives for public health specialists and thus overall expertise in India. They also have a cool breakdown of central and state ministries of health, and how the former influences the latterses.
They have a surprising gender breakdown in public health roles, and talk about the glorification of women workers and the diminution of male workers, because women work on prioritized and glamorous maternal and child health , whereas males work on less sexy tasks, and have been unified under the body of "multipurpose workers." They advocate increasing the balance in prestige and funding. Interestingly, they don't try to contest the gender roles, and claim near the end that certain tasks are just too dangerous to be meant for women. I can imagine that in the US this would piss some ladies off, but I don't know India well enough to know how legit it is here. It seems like the lead author is female.
The domination of single-issue eradication-style interventions is super interesting, and as also criticized a bit in the Hindu article. I'm still not sure where I stand on this, other than some vague generalizations about there needing to be more balance. Atul Gawande touches a little on this in Better in the chapter on polio eradicators. He doesn't really have much to say about it either, though, he's more impressed at the eradicators' vigilance and attention to detail. Which I agree, is totally cool. Although according to the Hindu article, its doomed to fail without water and sanitation efforts as polio has feco-oral transmission, and according to this article, a lot of polio vaccinations have failed because kids are too malnourished to actually absorb the vaccine. So, more balance?

Also from the same issue of Economic & Political Weekly (Mar. 6-12), there's an article about price controls in Indian pharmaceuticals. ["Prices of New Pharmaceuticals in India: A Cross Section Study" by Ravinder Jha]. India's pharmaceutical industry is going through crazy changes, because India' now recognizes product patents. Before 2005, Indian pharma more or less ignored international product patents, and produced generic versions of a bunch of drugs developed in the US and europe. These were mad cheap, and India supplied a lot to other developing countries. After joining the WTO in 1994(5?) though, it had to consent to recognizing product patents by 2005, and so now everything's different. This was something that tickled my fancy for most of my undergrad years.
Anyway, price monitoring and control was phased out in the pre-2005 era under the argument that generic competition would eliminate the need for controls. This article looks at price-drop patterns before 2005 for various drugs, and finds that price controls were more necessary for drugs whose therapeutic advantage was high, because they had high initial prices and fewer competitors of a similar therapeutic value. It then says that post-2005, when intramolecular competition (different companies producing the same drug) disappears because of product patents, this effect will be heightened, and the need for price controls will definitely be higher for drugs of high therapeutic value. Their economic analysis might be interesting, but I'm too ignorant to understand it.
Also, they reference a random book by Sudip Chaudhuri that I picked it at a book fair in downtown Dehradun when I was last in India in 2006. This irrationally excites me.

Okay back to reading harry potter.