Post #13: knee problems in India

Ken's good knee (with replacement) is on the right -- and the new bad knee on the left.

During the first week in India, Ken tripped into one of the famous Delhi potholes and screwed up his knee -- not the replaced knee, but the other knee. Six weeks later and still in a fair amount of pain, we asked the Fulbright office for a good MD, and they immediately recommended one to us.

We very quickly had an appointment with a well known family doc living right in our little community. We saw her at her home during evening office hours, and she referred us for an MRI. The MRI unfortunately showed partial tears to two of the ligaments as well as cartilage tears. She referred us to a high end ortho-surgeon in a classy private hospital, who also saw us immediately, had some x-rays taken, and indicated that a surgical repair was needed, but happily not another knee replacement. We didn't want to lose three of our remaining weeks in India in recuperation, so surgery is certainly off till we are back in the USA.The doc gave Ken a cortisone shot, and the pain is pretty much gone for now. So we're back on track.

During the hospital visit Caroline chatted with two docs while waiting for Ken. While both doctors would choose a public hospital for treatment of a rare or complicated condition, they praised the efficiency and the personal and courteous treatment at the private hospitals. There is little or no wait for service at the private facilities and substantially longer waits at the overburdened, financially starved and dirty public facilities.  In India one can go directly to a specialist, and without gatekeeper patients utilize higher level services when primary care services are sometimes all they need.

An interesting experience. Very little hassle arranging visits. Excellent facilities everywhere. Incredibly busy and well staffed facilities. Exceptional treatment.

And (drumroll): the entire cost to us for two doc visits, one in the hospital, the MRI, X-rays, pain killers and a cortisone shot: less than $200!  Unreal.

MAX Super Specialty Hospital in New Delhi -- classy! It could easily be part of Anne Arundel Medical Center

Max Hospital even has a classy Whole Foods Cafe in  the lobby.


BUT IN INDIA, THERE'S ALWAYS SEEMS TO BE ANOTHER STORY JUST AROUND THE CORNER:

After leaving the hospital - feeling like royalty - Ken quickly got brought back to earth. Just outside of MAX Hospital, actually right off the entrance ramp just around the corner, several squatter families were living under tarps.  

The average Indian rural family lives on $400 a year, just double our little medical experience, and none of these squatter families are making close to the average income levels. There were of course lots of Indians served at MAX Hospital -- indeed 95% are Indians, but services must be paid before you see anyone. 

These squatter families may live just outside of MAX, but they may never get inside MAX.

After meeting with staff members at Brookings India, we were told that MAX hospital treats patients from all over India. Families often come along but have no place to live.  While there may be money to pay for the medical care, or the family borrows for it, the family must live on the street while the patient receives long term treatment.  So some of the street people we see may only be temporarily homeless while family members are under treatment -- that's probably not the case with the folks in these pictures.

We will have a lot more to say about Indian health care in future posts, since we are spending a lot of time digging into health reforms in India. Suffice to say here that inequality in health care runs deep in India, as it does in America. 

Post #12: Indian democracy: a stabilizing force, a reflection of the chaos or a circus (or all three)?

"In India, the choice would never be between chaos and stability, but between manageable and unmanageable chaos, between humane and inhumane anarchy, and between tolerable and intolerable disorder..."    ---Ashis Nandy, 20th century Indian political theorist

"Just consider how terrible the day of your death will be. Others will go on speaking, and you will not be able to argue back..."   --Ram Mohun Roy, 19th century Indian reformer 

              

Indian elections are in about 2-3 months, and passions run deep. Voter turnout is very high in India, and it has been since Independence. Indian politicians have strongly held views that run the gamut from communist to hard right, from inclusive to cast-based.

India seems to be in a continual argument with itself, and just about to come apart at the seams. Passionate politics, passionate views. We've been struck how often we witness vocal disagreements. Even in academic presentations, speakers are often interrupted and disagreed with, pointedly and aggressively.  This ain't China, that's for sure...

This place is kind of nuts. We need to let some things just kind of blow over us if we want to live connected yet still serene lives. That's not easy in India. There is a gentleness and even tenderness evident in so many small interactions, and there's a real focus on working towards common goals. Indeed, the Congress Party - the party of Jawaharial Nehru - has been in power on and off since Independence, and it has consistently focused on the commonalities that hold India together. But that is not the whole story in India. Nehru's daughter Indira was assassinated after her decision to attack the protestors in the Golden Temple in Amritsar, and her son was assassinated in protest of his sending troops into Sri Lanka.  The long, long history of tensions and violence between religions, castes, languages, sexes, and classes is close to overwhelming.

Political differences are front and center in India, and the next election is always just around the corner, and mud fights continue unabated.  People think politicians are all crooks, and they are somewhat correct about that observation. Corruption is rampant and corrosive. Everyone has a strong opinion that they are only too willing to share about individual politicians as well as the people that they represent. There is more and more identity-based and caste-based politics -- as well as much more protest by those out of power.

       
"At the slightest excuse, political parties organize strikes, shutdowns, marches and fasts, seeking to have their way by threat and intimidation rather than by reason or arguement. The lawmakers in India are, more often than not, its most regular lawbreakers..."  ---Ramachandra Guha

The latest example is Arvind Kejriwal, the anti-corruption activist who was recently elected chief minister of Delhi. He lasted 49 days before he resigned in protest when his anti-corruption bill did not pass. During his brief tenure he lead a major demonstration which lasted 2 days, shutting down parts of the central government, disrupting the city metro system and in the end doing little to change the affairs of state.

Is India's democracy about to implode?

Every decade since Independence in the 1940's has been called the most dangerous for the Indian democracy, but somehow the democracy continues amid the chaos and differences. It continues, and it  frays but it holds. And then it seems to actually strengthen over time.  Not easy to understand.

American democracy also looks to be about to fall apart, but then it also seems to strengthen. That is one parallel between our two countries. But there are also differences.

One of the core elements of American culture is anchored in assimilation. America the melting pot; out of many, we become one.  If anything, an Indian core belief system seems to be that pluralism -- even with all the chaos and even some violence--contributes to India's core strength. After partition, states were often formed based in part on their separate cultures and their distinct language preferences. India right now is creating a new state -- Telangana -- that is being carved out Andhra Pradesh to provide greater identity for the local population that speaks Telagu.

Historically, outsiders have invaded or threatened invasion throughout much of India. By remaining as a separate states within India, their identities can be somewhat maintained safely.  Thus it appears that the people in the states that were divided by culture and language feel more connected to India, not less.  Dual identities -- one state and culture-based and the other national in nature - coexist and reinforce each other. Often times Delhites will tell you where they are from in India, assuming that that describes them in a way that being a Marylander or even a Texan does not.  With all its differences, India seems more cohesive than multi-cultural Europe -- even with all of India's passions and arguments and violence. We have yet to figure why this all is, but one Indian we know says that India's democratic legacy represents the true glue that brings together and binds the nation.

We love to promote our form of assimilationist democracy in America, but maybe we in America could learn a little something from the pluralist democratic culture of India. This place can be an absolute pluralist mess, with deep factions fighting fiercely, but out of the mess seems to come a greater cohesion and commitment to democracy -- and to the greater India.

Campaign posters are EVERYWHERE for every party. Note the Communist poster above; the Communist Party has been in power in Kerala about half the time in recent years. 

A campaign poster of Sonia Gandhi, the current Congress Party leader, with the heir apparent, her son Rahul.  It looks like the Congress Party is going to get blown away in the spring elections, but if past is prologue, the Congress Party and the Nehru/Gandhi clan will likely come back to power again some time in the future.

Rahul Gandhi is not inspiring a lot of confidence with the public. We recently went to see a stand-up comedian who urged the audience not to have children, because they never live up to your expectations. In a criticism aimed clearly more at the political situation than at prospective parents, she said:  "...I know you think your kids will turn out to be wonderful. You all expect a Mahatma Gandhi, but you will probably end up with a Rahul Gandhi!".

Narendra Modi, head of the BJP party and currently governor of Gujarat, considered the leading candidate for the next prime minister. He was campaigning in Kerala while we were there. Wild crowds of supporters.

Modi billboards, including lots of prominent and visible support from Muslims, Sikhs, women Dalits, etc.
Modi trying hard to be Mr. Inclusive! 

Modi has his own skeletons. The Gujarat massacres in 2002, televised worldwide, resulted in a coulpe thousand deaths, primarily Muslims as well as widespread rapes and violence. The center of the violence was spurred by Modi's base, the Hindu right, and Gujarat state officials were also accused of complicity in the violence. The BJP and Modi have struggled with this in the current elections. No one's hands are clean in Indian politics. It will be fascinating to see if Modi can transition from a factional leader with ties to the Hundu right to a bridge-builder across the Indian cultural divides; if he's successful in this, he will almost definitely be elected the next prime minister. 

----- We have said some of this in an earlier post, but it's probably worth repeating here:  Over the main entrance of old British "Central Secretariat"-- carved by the Brits in stone -- are the words: "LIBERTY WILL NOT DESCEND TO A PEOPLE. A PEOPLE MUST RAISE THEMSELVES TO LIBERTY. IT IS A BLESSING THAT MUST BE EARNED BEFORE IT CAN BE ENJOYED."  India certainly paid real dues for liberty, and has earned its place as the world's largest and most diverse democracy.  Obama said in his State of the Union this year that "Democracy never comes easy." It certainly isn't easy here. It is a madhouse. But the British words in stone actually seem very fitting here -- after a hard won Independence and the continual fight over the decades to remain a vibrant and cohesive democracy for more than a billion people. Hats off to India.

"In India, the choice would never be between chaos and stability, but between manageable and unmanageable chaos, between humane and inhumane anarchy, and between tolerable and intolerable disorder..."    ---Ashis Nandy, 20th century Indian political theorist

"Alexis de Tocqueville pointed out in the 19th century, democracies always look weaker than they really are: they are all confusion on the surface but have lots of hidden strengths."  --The Economist, 2014 

Post #11: Kerala -- a very different world

We just returned from a week plus getaway to the far south of India.  First a couple days chilling out in a beach cottage in Varkala, followed by several days of meetings on health reform in Kerala's capital of Trivandrum, and then ending with time on the famous Keralan backwaters. Part of the trip mimicked Dana and Alison's trip to the backwaters.

Kerala is a different world from the hurly-burly, smog-filled world in Delhi. Laid back, serene, and absolutely beautiful.  And the best education and health care systems in India, with the lowest infant mortality rates, longest life expectancies, lowest incidence of many contagious diseases. That Lefty government structure in Kerala pays some real dividends...

Oh, and the food? Even better in Kerala than the great meals we've eaten in North India!  Dipu, the restaurant owner referred to Kerala as his paradise. He also said he would email us the recipe for his dry fried coconut prawns which were incredible (below). We have not stretched our cooking repetoir here but so that would be a first.

Keralan coconut prawns

Family recipe from Dipu at Casa Linda Restaurant, Fort Kochi, Kerala

Ingredients: prawns, coconut, salt, sunflower oil, turmeric powder, chilly powder, black pepper, fresh curry leaves, lime, green chilly, onion, ginger, garlic.

1) take a pan - put some oil, add one big red onion, ginger and garlic crushed - make it golden brown

2)add prawns ,coconut pieces, and turmeric powder (half teaspoon) add chilly powder (if you need more spicy add one greenchilly) and black pepper powder and salt

3) when prawns are cooked (prawns cook for three to five minutes) add lime juice to it and put on some curryleaves.

Your Keralan coconut prawns are ready.

Walking path along the Varkala cliffs. The water was clear and perfect swimming temperature. 

Groups of 12-20 men haul in fishing net a process that takes 3 hrs. and produces  10 kilos or so of small fish

Our simple cottage...

...and the view from the porch.

Chinese Fishing Net

Our own boat for an overnight on the Kerala backwaters- the same boat that Dana and Alison stayed on!

A feast -- Kerala style

Post #10: Bollywood!

Movies are gigantic here -- very much part of the culture. People flock to the movies and talk a lot about their favorite stars. Many politicians are former movie stars. Maybe it's not so different than America, but somehow it seems even bigger here.

People told us to go to a Bollywood movie to catch one particular the flavor of India -- not just the movie itself but the whole scene. So we put that on our early agenda.

We heard that the Raj Theatre in Jaipur was THE place to see Bollywood movies. After arriving at least an hour early to buy tickets -- and finally determining the correct line to be in, Caroline dutifully waited in the women's line to buy tickets.The line  was 1/2 the length of the men's line. Ken joined the husbands line and boyfriends and friends all joined the party during the wait. Bedlam.

In Caroline's line, there was a constant stream of men requesting women to buy additional tickets for them. Sometimes they were known to the woman, other times not.  When the line finally started to move, it crept. The men’s line moved more quickly with pushing, shoving, and some disputes verging on fisticuffs. Even as the starting time passed by 20 minutes, we believed the reassurances of an Indian man Ken had chatted with that we would likely get in.  We were down to fourth in line when the SOLD OUT sign was turned over.  We  shrugged in disappointment and left quietly along with hundreds of others.

The second time around we booked tickets online.  This time we went to a Bollywood musical play rather than a movie -- at Delhi's blockbuster venue-- staged about 30 km south of Delhi in a "Disneyesque" venue called Kingdom of Dreams. Not knowing what to expect, we went hours early, and found that we had plenty of time to take in multiple short ethnic dance performances and acrobatic shows, sample food from all over India and watch, not try, the bungee chair rides. Another real scene.

We watched the dancers perform before the show started (below):

 

  The show called The Gypsy Prince was over the top -- as expected -- with hundreds of performers, lots of high tech effects and a simple to follow story line. No need to know Hindi for this one.  So we had our Bollywood fix. Picture below are from google images, because we couldn't take our own pictures during the performance. 

Note: midriff covered by leotard. Don't show skin!

Post #9 Poverty and inequality - take #1

One evening, as we walked not two blocks from the elegant India Habitat Center, one of Delhi's premier cultural arts and convention centers, and we saw an alley alight with fires. Curious, we wandered in to find a large community of families living in the streets, warming their hands and cooking their food on fires stoked by scavenged wood and trash. Barefoot children played while others got haircuts. Makeshift tents of metal scraps and cloth provided minimal shelter from the 40-50 degree nights. Throughout there was amazing energy, activity and warmth.  Tiny mini-shops providing mini-services abounded. As we walked through a quarter mile block, we could not have been more alien to this world, yet seemingly we were totally ignored. The disinterest was striking.  If we were in their position, would we not consider jumping us, confronting us or distaining us, given what we represent?

There are lots and lots of urban slum pockets, ever changing in size and location, and often providing supports to the urban core. Just behind Ken's office, squeezed in between the railroad tracks and a riverbed, a slum goes on for half a mile. It will exist until the office needs of the city grow sufficiently to force its elimination.

"The sprawl of fragile huts spread outward like a shallow, tender root system for the huge towers that were to come... The squatters slum grew rapidly with a haphazard planlessness...  The kinship fostered in workers' slums guaranteed a sense of unity and family solidarity..."  
[But when the time comes,] workers set about the task of demolition. Each man had a rope and grappling hook that he swung onto the roof of a hut until it caught fast. He then tugged on the rope, collapsing the fragile hut. Everything was tumbled and raked into the wreckage..."
"They knew that the ritual they'd all seen so many times before would be played out: the ghetto would be gutted and burned, and a car park for limousines would take its place..." 
                        ---Shantaram, by Gregory David Roberts

Invisible yet co-dependent. What a two way gulf.

We all know that India expects to be one of the world's biggest economies by the mid-21st century. It is a hopeful, forward looking culture. But this sense of growth and optimism masks serious problems of poverty and inequality.

Ken's host institution for the Fulbright --the National Council of Applied Economic Research -- has conducted ground-breaking in-depth surveys and interviews with 40,000 India households to assess income, work, health, education, etc. The results are distressing.  Caste, religious, and regional disparities are still massive, and the current scenario for the  21st century world economy will likely widen these disparities. The core of the national agenda for the past half century has been to try to address these issues, and while real progress has been made, the success of these public endeavors is very disappointing.

The average rural Indian household lives on about $400 a year, and urban families about $1,000 a year. The top 10-15% of the population are doing well, with good incomes, pensions, health insurance, etc. But the majority of families are still in dire straights, and a quarter of families are in abject poverty. Over 50% have no toilets and no access to toilets.  Only 10-15% of the population receives direct government support, although a large share receives food and fuel aid.

The future of India, as with many other developing countries, lies in the cities.  India has a relatively small industrial and manufacturing base compared to China and most of Asia. About 85% of workers are members of the informal workforce. Only 2% of families have a car, and only 3% have a washing machine.  Less than a quarter have a flush toilet. For the vast majority of families, a major health incident leads to either a financial catastrophe or an absence of care -- or most likely both.

But this is key: the problem is not just lack of income. Compared to many comparable countries, India dramatically underinvests in education, pensions, health care, etc.  We will be exposed to a lot of very hard issues during our stay in India. Amyarta Sen asks whether any country wants to be the combination of Southern California and Sub-Saharan Africa. Can India invest it its future? Can it be a world powerhouse without investing more in its people? More on this in future posts.

Satellite discs on the roofs of the shanties in a very poor neighborhood.

Everywhere you go in cities, this is the life.

Life along the RR tracks

A tent city for the poor on the banks of the Ganges. The community springs up seasonally, when the river is low, to be disassembled in monsoon season. No idea where everyone lives when the river is high.