I have struggled for months to put into words how this time in India as an iCats fellow has made me feel, and today, I will try to express what seven months of living in India has felt like.
This is not my first time working in this country of wonder and chaos. When I was a little bit younger, a little bit “greener” and a lot more idealistic, I came to this place to start an initiative that ended up fizzling out, started way before the country, or even I was ready to commit to make sure that it panned out.
When I was that “fresh” and wide-eyed about social entrepreneurship, it was easy to see the beauty through all the chaos that defines this place as the norm. I even went so far as to normalize the chaos in my mind – the ups and downs and trials of living in a developing nation in flux became second nature. I navigated unnamed cow-filled streets, learned to drive a scooter, and bargained down to a “local” price, and blended in in a way that felt like I had accomplished learning enough about this culture to become a part of the community.
This time around, living in Delhi had been a different. No longer wearing the rose-tinted glasses of my early 20s, I knew that this foray back to my “homeland” would be something I was not prepared for entirely. As an iCats fellow, I expected an experience that was professionally enriching and that gave me the ability to grow into a more strategic role providing support to social enterprises, and even giving me the tools and the boost needed to start my own social venture. I definitely had all of those benefits after coming here, but with some additional life lessons that I’d like to share here.
Firstly, when you go to someplace to make a difference and you realize you are lucky to be able to get to and from work alive when the following things happening to you, you feel blessed; 1. Getting so much dust in your eye that you look like you went on a 6-day whiskey bender, 2. Knowing that the “runs” does not mean some type of Olympic sport and, 3. Getting jostled and tossled so much in auto rickshaws, getting in and out of the metro, and walking on the roads that you feel like life is a constant earthquake.
Secondly, when you are doing strategy work, it’s not the same as taking to the villages wearing your home-spun cotton “khadi” that Gandhi extolled. This is a different type of service, and one that is not less needed that the on the ground activism. When I thought of all the “good work” going on in India before, my mind would automatically think of grassroots activism, hunger strikes, and rural schools in the middle of the Rann of Kutch desert in Gujarat. I thought of the hundreds of social activists I met and that made me their family the last time I spent time in India.
This time around, I am a cog in a larger operation, one that plans to revolutionize the way tuberculosis is treated around the world. The seed of that work started in India, but the scope and the dream is a far cry from a single village in a sleepy desert location in North India. The world is the stage for Operation Asha, the organization that I am proud to help get to the next level with my work. (www.opasha.org)
Undoubtedly though, the nature of this work, looking at development and changemaking from 30,000 feet, feels like I am out of touch with my former conception of doing good work. After all, I am a grassroots gal at heart, deriving energy from being with people and learning from them and their local wisdom. In fact, it is easy to forget sometimes, sitting in my air conditioned office, sleeping in my nice fancy bed at night, ordering non-Indian food (aka anything with CHEESE), and having access to the nicer things in Delhi – that the country I am living in is in a state of incredible change and sometime turmoil.
I’ll give you an example: Since coming here in February, my eyes have been opened to exactly just how bad this place can be for women. As a young-ish woman myself, I will sometimes face mild harassment on the street, or have to take extra precautions when meeting friends or returning home at night to stay safe. A system of calling and texting friends when we leave home for the evening, and return home late is an unspoken rule enforced without much protest – it’s necessary for safety. I have dared to wear a dress only once, exposing my knee and my calves, and even in such a modern city such as Delhi, decided I will never do it again for all the ridiculous negative attention it garnered. My relationship with space – especially personal space, is tested every day. As a woman in this country I find that it is easy for every man to play a game of chicken with me when I walk. I am the one expected to move to the side if a man is approaching opposite me, or I am standing somewhere and he wants to be in that space. And often, I find myself making the accommodation, so I don’t have to deal with an argument, additional leers, or an unwanted grope. I come home exhausted from reorienting myself with the world, where I once thought I could walk with pride and felt safe, I now see that I am always trying to make myself smaller to avoid calling attention to myself in a way that puts me in danger. (sad, but true – as this is a far cry from my natural personality)
Women have been beaten, raped, killed, stalked, and groped since I came here with alarming frequency – some for no other offence than being a woman in a bar. In the northern town of Guwahati (see the story here: http://www.dnaindia.com/india/report_guwahati-molestation-what-really-happened_1714657) a particularly atrocious case was caught on film – a mob of men, pawing at, groping and pushing a young girl in the street with onlookers nearby and NOBODY STEPPING IN TO HELP HER. And it seems like every day there is a story on the news of on Facebook, reminding me – in this place with its incredible growth story, in this land of a billion people, I am just another woman fighting to maintain my sense of strength and resiliency – just like all the other women in India – outraged by each news story that yet another one of us had succumbed to the callous treatment of women that is still so ingrained in this society.
The things that gave me hope as a young women in my 20s in India – I can no longer see through my airconditioned gaze – the joy of drinking water from a handpump, being followed by hundreds of children asking for me to take their picture during a visit to a small village, going to eye camps to screen people for cataracts – those experiences are not there for me now. Instead, I can only make the connection in my mind, back to the work of organizations here that are scaling solutions to improve the overall human condition, those like Operation Asha – that if they (we) are successful, that this place will be a lot better for people like me, those that feel like they are invisible among the billions.
Social entrepreneurship is a tool that can give lives meaning and freedom from just existing. I think the biggest lesson that I take from this year in India, is that the world does not always give any of us space to live fulfilled lives; sometimes you have to create that space for yourself and for others. For me, that space was starting a social entrepreneurship meetup in Delhi. For Operation Asha, it was creating hundreds of low-cost centers in disadvantaged locations in India and Cambodia to help serve tuberculosis patients that are the poorest of the poor. Maybe for you, it’s deciding that your life can be lived differently – who knows?
While all of these emotions swirl, it’s easy for me to forget that even being one in a billion is a lucky chance. My hope is that by the end of this experience, I will be able to reconcile my feelings for this country that simultaneously gives me hope, and also exposes the harsh realities of life. At the end of writing all this I came to this conclusion – the space that we have been given to live is a gift. Make it your own, and leave it even better than you found it. And this is exactly what I will spend my life doing.
Onwards and upwards, dosts (friends)!
Avani Parekh-Bhatt is an International Fundraising Strategy Consultant at Operation Asha. She loves to see baby cows in India, and hear the parrots outside her room in the morning. And she’s greatful to whoever invented air conditioning. Watch this, it will make you smile: making friends in the field
“Treading heavily on each other’s toes, bickering violently amongst themselves and competing in sometimes unseemly ways for ascendancy…” - Graham Hancock, Lords of Poverty
In last few months of the fellowship, I have had chances to meet top management of other NGOs, decision-makers in central health ministry and country heads of international development/aid organizations in Cambodia. With an aim to build partnerships to combat tuberculosis in the country, I tried to approach these meetings objectively. But many a times, I got to hear subjective opinions from the other side. The situation got worse in one such meeting with one of the world’s largest bilateral aid organizations; I was taken aback by a question from the Country Head on the definition of ‘default’ in tuberculosis treatment (one of the most important KPIs for the evaluation of a TB program).
There are numerous accounts on how multiple development and aid organizations with their own agendas and specializations (plus ignorance) are at the core of third world catastrophe. With funding tied to regular appraisal of targets, non-profits race for the results every day in isolation.
Imagine the scenario where impact investor funds a non-profit to treat patients and measures impact simply on the basis of number of patients and population under coverage. Now take the non-profit (investee) out of this scenario and 60-70% of patients end up receiving healthcare from the public sector. So the impact gets reduced to 30-40% in terms of patient numbers. In an ideal scenario, the investee would deliver solutions [through service models], which or where the government is not able to provide, there by complementing the existing system. Though it’s a simplistic example and real world systems are very complex, but it does give a sense of direction.
Working as a single agent to create impact may not be efficient and in some cases, the work may actually prove to be overlapping or damaging. In contrast, a complementary set up of impact investors working between philanthropists and governments might be better equipped to create long-term effect on policies and models employed by the public sector. Knowingly or unknowingly, I am also a part of the system now. But the current state needs a change and impact investors, prioritizing social returns, would required do so in future. Otherwise, they might be reduced to yet another agency funneling thousands of dollars into a country on a program doing temporary work but failing in bringing a long-lasting change in peoples’ lives.
Imagine a village of 1000 people who don’t have the access to private clinic or a proper pharmacy. The nearest primary government health center is located at 10 km. Take 20 such adjacent villages which fall under the catchment area of the same health center with a combined population of 20,000. Assume one district would have 15 such aggregated areas with a total population of 300,000. Add the unpaved roads (>90%), non-existence of public transport, low density of population, daily per capita income of less than $1, lack of dedicated & skilled healthcare workforce plus low medical infrastructure resources with the government – and this gives us a mass public health problem yet to be solved in most parts of the world; or at least in country like Cambodia where 80% of population is rural. For the treatment of tuberculosis (TB), this scenario is no less than a public health disaster.
Cambodia, a country of 14+ million people in South East Asia, went through a tragic phase in 1970s which continued till late 1980s. The war and genocide dismantled the health system of the country. Hospitals were destroyed and skilled healthcare workforce was wiped off. Per capita government expenditure on health in 2009 in Cambodia was $28 (vs. $3426 in US, 0.8%). Treatment of tuberculosis in the public sector of such a country is definitely not an easy task considering it typically takes six months of daily treatment (DOTS).
The model employed in high density urban slums of India involves setting up stationary centers within poor dwellings which are visited by the patients to receive their TB medications as per the plan of WHO-approved DOTS. The centers are strategically placed at locations which are accessible and surrounded by large population. This set up failed to pick up enough patients in Cambodia as the centers were not easily accessible to a sufficiently large population. So, after the first six months, the organization changed the model and employed counselors on motorbike.
Mobile DOTS Model
The mobile model encompasses a counselor traveling from village to village on a motorbike, carrying anti-TB drugs & other supplies. The counselor dispenses the medicines to patients at their homes, as per DOTS guidelines and spends substantial time everyday looking for those potentially suffering from TB.
Due to fewer resources for medical technology in Cambodia, smear microscopy tests for TB diagnosis can only be performed in the lab at referral hospital (one in each district). So for detection, the counselor collects sputum samples from each of the suspected carriers and carries it to a pre-assigned location, where another staff ‘Sputum Collector’, again on a motorbike, is waiting to take sputum samples to the government lab for diagnosis.
The result is an effective, closely-knit and dedicated network of mobile healthcare workers bringing the cure to the doorsteps of people who otherwise don’t have ‘practical’ access to medical care.
Today, Operation ASHA has enrolled nearly 1300 patients covering 1+ million population in four districts. More than 95% of these patients were enrolled after the mobile operations began one year back. In the last four months, 35-40% of new tuberculosis patients being treated through the public health sector of each district have been enrolled through Operation ASHA. This is not only the testament of the success of the model but also an opportunity to study it further and change the way public health is delivered in the resource-constrained developing countries.
Amandeep Singh is an LGT Venture Philanthropy Fellow working with Operation ASHA to manage and expand their operations in Cambodia. Operation ASHA is part of healthcare portfolio of LGT VP and is an India-based NGO with a mission to eradicate tuberculosis worldwide.
Floating Tuberculosis Centers – A Step Deeper in Mobile Healthcare Delivery by Adapting to Local Conditions (Part I)
Author’s Note: This is the first post in series of two blog posts on floating centers of OpASHA in Cambodia
Long ago, Cambodia was under water, except for a small island with a tree on top, called Kok Thlok.
Today, Cambodia is growing and Kok Thlok is an area of stilted villages along the banks of a river channel and floating huts within the channel itself. With a population of 2775 near Vietnam border. Kok Thlok can’t be searched on google maps and distance to it from any place can’t be calculated because there is no paved road or road, least to say, which leads to Kok Thlok. There is just water, which also takes the villagers to nearby Vietnam for selling vegetables et al and earn them their living. Kok Thlok has thousands of acres of rice fields and flooded/barren land on one side and a small river channel flowing on the other side which is their gateway to rest of Cambodia and Vietnam as well. This part of the country is flooded at least five months of the year. Last month, Operation ASHA (OpASHA) moved one step deeper in mobile healthcare delivery when it opened its first floating center and enrolled a tuberculosis patient in Kok Thlok.
Khok Thlok is one of the centers started recently by OpASHA in Takeo province (rural Cambodia; South). After one year of operations in urban Phnom Penh, OpASHA begin the expansion in Takeo in Jan 2012. The population density of the province is 250 per sq. km as compared to the capital, Phnom Penh which is inhabited by 5400 people per sq. km.
Because of the dispersed population in most parts of Cambodia, OpASHA uses a mobile healthcare delivery model in the country. Mobile model encompasses a counselor traveling from village to village on a motorbike, carrying anti-TB drugs & other supplies. The counselor dispenses the medicines to patients at their homes, as per DOTS guidelines and spends substantial time everyday looking for suspects. He/She also collects sputum samples from each of the suspects and carries it to a pre-assigned location, where Sputum Collector, again on a motorbike, is waiting to take sputum samples to the government lab. As Kok Thlok can be accessed only by water, the counselor makes use of a boat to travel from village to village. That explains the name ‘floating center’.
With nearly a quarter of population living on (or near) water in Cambodia, Kok Thlok is set to test the mettle of our mobile model. Results have been encouraging so far. Kok Thlok had only one TB patient registered in the local government health center in entire 2011 whereas OpASHA has enrolled four patients in the first one and half months.
Namaste from New Delhi! My name is Avani Parekh-Bhatt, I’m a 2012 iCats fellow from the United States, placed in New Delhi India in a wonderful organization called Operation ASHA. Operation ASHA (OpASHA) brings tuberculosis treatment to the doorstep of the disadvantaged using an innovative model providing treatment, counseling, education, and supportive services to tuberculosis patients in India and Cambodia. OpASHA’s work is so interesting because they’ve revolutionized the way this “poor people’s disease” is treated – by tracking patient’s adherence to the strict medicine protocol through the use of fingerprint scanners.
Tuberculosis is a CURABLE disease - but those that die from do so because they don’t receive treatment in a timely manner, OR they fail to adhere to the strict treatment schedule, they perish. As an introduction to the work that OpASHA is doing, we have a short video we’d love to show you.
If you click on this link, you’ll see a three minure presentation that might just bring tears to your eyes, Learn more about what we do here: Operation ASHA: Ending Tuberculosis in Disadvantaged Communities
If we maintain first place, we can win $10,000, allowing us to treat 300 people suffering from this debilitating disease.
More on me and why I am here in another post. Let me know what you think in the comments.
Signing out from hot and dusty Delhi,