AMU Aligarh, the rural health care experience

I find it almost impossible to fully synthesize all that I witnessed in Aligarh. It was exhausting, heart-wrenching, impressive, exciting, delicious, stomach-turning, crazy, overwhelming, fun, uncomfortable, wonderful.

Incredible.

I’m not going to lie… this is a long one. If you just skim through and look at the pictures, I don’t blame you. Our trip to Aligarh was absolutely incredible, and I really enjoyed writing about the whole experience, and felt that leaving things out didn’t do it justice. Up until now my posts have been about general study abroad stuff characteristic of EVERYONE’s blog: host fam, new country, food, the fun parts of travel. Now I’m getting more into the reason why I’m here – studying health and human rights. Public health nerds like meself will enjoy this post. Hopefully you will too…

But first some fun stuff! Last Friday before we left for Aligarh I got to see Connaught Place. It’s the really famous downtown location that, while super tourist-y, is a really popular hangout. Molly and I had a guy follow us around for a while, and after completely ignoring him, it was the first time I had to do what they taught us to do in orientation: “I don’t want to talk to you.” He looked at me like I had just slapped him across the face. While he was our age and a student and seemed pretty harmless, unfortunately you never know and have to go with what they have taught us to do. Still, it felt really mean… L I did get to take some cool pictures though. At one point we got a little lost and walked down a road that was clearly more residential – it was a photographer’s dream – so much stuff crammed into a small space… religious temples, stray dogs, street food, crumbling houses, so much trash, tailors, chemists, chai wallas, all stuffed into a tiny corridor with telephone and electricity wires hanging low above our heads and the occasional motorcycle forcing its way through the busy alley and forcing us to jump out of the way. It was incredible. So much color and noise and so many smells. Just like all of India, it was a crazy and beautiful combination of pleasant and unpleasant stimulation.

So last week I left off right before I went to the drum circle with Jasmeet and her husband Krishna and their two boys. Last Saturday I met them at their house and we went to "Deer Park," about a ten minute drive away, which was filled with, well.. about 300 deer and more peacocks than I've ever seen in my life. It was pretty bizarre to see an animal we consider more or less to be a pest at home in a reserve-like facility, but I realized I had never seen so many that close before. The drum circle was in the middle of the park, and about 100 people showed up over the course of the next hour and a half. Kathleen - you would have LOVED it! There were a ton of people playing djembe, a few other instruments, and a Indian singer and dancer. I also got to pet a 20 day old puppy when I was there... there are TONS of puppies in Delhi, but you can only pet the ones that are actually pets (no rabies fer me...):

Afterwards, Krishna took the two boys for food and Jasmeet and I walked around Hauz Kauz Village, which is filled with galleries and clothing stores. We checked out some art, and found a kurta store that was selling things half price! Jasmeet helped me pick out two tops, some pants and a scarf all for less than $12 USD. I love India...

Jasmeet and I walked around the Village and then through a park that has some of the buildings left from when the Mughals ruled Delhi. History just kind of pops up everywhere here - something America is just too young to have!

We met back up with Krishna and the boys and had delicious South Indian idli (basically rice cakes) and dosas (an indian style crepe stuffed with potatoes). Mmmmm. 

Sunday I was supposed to go rock climbing with Jasmeet's family, but I felt like I had already encroached on so much family time, so I spent most of the day home with Molly packing for the week's trip and working on homework. On Monday morning, we left from the house for Aligarh at 5:00am. Right before I got in the taxi to the train station, I noticed Coco was waving us off:

Before I get into my trip to Aligarh, there is one thing I wanted to set straight... though our program has never said this is a problem, and has said that unlike in America, most Indians have no problem with having their picture taken, I take issue with shooting pictures/clips of people we don't know, especially the poor/poor children. Because of this, unless I'm taking a picture of people we have interacted with outside of a cultural-tourism way (like someone giving a presentation or children at a school who we have been interacting with), I choose not to bring my camera. The students on my trip have varying opinions on this, and to be honest it's complicated when 50 school children are screaming for you to take their picture and you have a camera in your hands... I'm trying to strike a balance without parading through a slum and shooting footage of peoples' homes without their consent. In the end, I left Aligarh for my reliable electricity and comfortable homestay apartment - I could choose to leave the slums. These people don't have that choice, so I choose not to exploit their surroundings. Maybe I'm overreacting. Maybe not. To be continued, I'm sure.

Soooo, back to the story.. We returned to New Delhi railway station, which I talked about in another entry as being the CRAZIEST THING I HAVE EVER SEEN, and that is no different at 5am! It was just as nuts as 5pm had been the week before. We got into the Aligarh station around 9, and boarded a University bus bound for the unfurnished apartment building that we stayed in all week (complete with mats on the floor as beds and "Indian-style" toilets aka holes in the ground). My first impression of Aligarh was that I was definitely not in Delhi anymore... We would drive through sections that were green and absolutely beautiful (and probably maintained by the university) and then through markets covered in trash. Because the area is primarily Muslim, there were lots of pigs running round (Muslims do not eat pork so these guys are off the hook) and lots of cows nosing through the garbage on market side streets. Over the course of the week I saw a LOT of chickens' lives come to an end via streetside butcher shops... it has been enough to put me off of meat dishes for a while... especially when you realize what the animals are consuming...

After a little bit of down time in the apartments(an unfurnished apartment with Indian style toilets and mats on the floor, but at least no bed bugs!), we made our first stop at AMU: a discussion by a professor from the Department of Social Work and a professor from the medical program. After a brief introduction to hos things work (it's a publicly funded university that serves millions of people in three "districts" and is the tertiary level of care in India - the secondary being several smaller district hospitals, and primary being village community health centers), we got to split up with different medical interns and doctors and tour the hospital based on our departmental interests. My main interest is in health care delivery disparities, so I chose to visit Pediatrics and Immunizations. It was absolutely insane how many people were waiting for care in such a small space (I would guess about 70 in a space meant for 30), but for the craziness of the surroundings, it was surprisingly efficient. The interns told us that within 1-3 hours of registering, a patient is seen my a doctor. It costs Rs 15 (about 32 cents) to register, but after that, a consultation and prescription  are free. I made sure to ask about what happens to those who can't afford the 15 rupees, and they were kind of weak on the details about how that works, but were insistent that everyone who comes to the hospital will be seen and will not be turned away. Again, it was unclear how some of the details worked out (what about people who can't afford to get there? what about people who don't make the registration time - 1pm - is there a place for them to stay until the next day? where can families of patients reside during care?) but I am working on just taking details in before making judgement calls or trying to find the chink in the armor of systems that I don't know much about. It is so easy to start asking worst-case-scenario type of questions, so i am working really hard to just try to be a sponge to my environment and let the details soak in and leave time for questioning later. I've noticed that all of us as students tend to do this - a product of our education that is not always the best device for experiential learning in the field.

The interns rushed us through the hallways and took us into the pediatric clinic, where tons of families were waiting to see either the consultant (a tenured professor and doctor) or a room full of grad students and interns who could also write prescriptions. It was crazy - the patients and doctors were used to students coming in and out and cutting through huge lines of people so we went and sat in on a session with the consultant. A man had brought his two sons in because one was showing symptoms of whooping cough, and had had already had one seven year old son die of whooping cough.  I know that they say they are used to students coming in and out of consultations, but it still felt very intrusive when the doctor wanted to go around the room for us to introduce ourselves in the middle of the appointment where they were discussing his son's life. The doctor was searching through a box of trial sized medications to give him so free meds, because for some reason he didn't qualify for free medicine to save his son's life (though we had been told everything was free? hmmm..).

We were then whisked to another part of the medical college where we were put in front of a panel of important people from the hospital and the college portions of the university. This session was a bit of a let-down because it was the first of many experiences on this trip wherein I felt like we weren’t getting real answers to our questions – they were very political, and usually reflected the need to show the best possible side of the university. This could partially be due to the fact that we kept getting confused with people far more important than we were… I guess that comes with the situation when you’re dressed in shiny new traditional Indian clothing and are carrying around notebooks and pens to analyze what you are seeing – they don’t what you to see anything bad.  In one particular situation, I asked the panel what the biggest challenge or problem that they are working on is… a nice way of asking “what are you doing wrong, and are you self-aware?” The answers were predictable: it took about ten minutes for one man to tell me that the main issue of the hospital was too many patients coming in the door, another said something about graduate research (what?) and a third told me that the biggest challenge was implementing the WHO/governmental efforts to eradicate polio. None of these answers addressed the question that I was asking, but then again, how can I expect people to be transparent? Especially when it comes to money and health, no one ever is 100%.

We then went back to the university guest house for lunch, and then to the apartment to sleep for a few hours. Most of us slept through the optional tour of the university, including yours truly. Whoops. We had dinner late and then came back to synthesize what we had seen that day and get a good nights’ sleep, as we started Tuesday off with a 7:45am Hindi lesson in the apartment.

After Hindi on Tuesday morning, we got breakfast at the guest house, and headed to the next level down of the health care delivery levels in India: the secondary level district hospital. We had a meeting at 9:30am with the hospital superintendent, in which we crammed all 18 of us and our 4 teachers into his office (it was pretty comical... somehow they fit in all of the chairs, but most of the room was taken up by a gigantic desk you would think would better fit a NYC banker and not a hospital director in rural India). He was not the best speaker , and as almost every Indian speaker we have had, spent about 10 minutes thanking us for coming yadda yadda yadda (also, almost every speaker wants us to introduce ourselves, and it’s a nice gesture but takes SO MUCH TIME… oh cultural differences…) and sent us for a tour of the hospital with two different doctors, the head of orthopedic surgery (not on call, obviously) and a pediatric specialist. We walked through every ward of the hospital including the women’s, children’s, and men’s wards, the burn unit (VERY intense, I saw a man whose had been badly burned in a work accident, and there’s no OSHA equivalent here..), immunizations, physical therapy department (Kira you would have loved it!!!) and even the food stations where even the families of patients can be seen and given food. All of this is paid for by the government, and besides the problem of understaffing, it works pretty seamlessly (they’re fully capable of performing brain surgery in facilities that don’t resemble anything that looks like a hospital by western standards… and that is pretty damn impressive). They see a lot of patients with burns, dog bites, infections, and other chronic diseases that their immunizations department is working on, all with the message that prevention is key (something that we just haven’t fully caught on to in the west, unfortunately).

Health care in general has just a totally different scheme in India… it’s not the same health care “industry” in the US that capitalizes on the sickness of populations to make money off of them by grossly overpaying specialists and profiting off of the denial of care through the mess that is health insurance… in the Indian constitution, constituents are guaranteed the “right to health,” and are all insured up to Rs 32,000 by the state. Yes, of course this system has its own problems too, but at least their problems lie in medical access and cultural norms that are shifting and improving every day, and not in our system where we are perfectly capable of providing much greater access to health care and chose to capitalize it. Sigh.

They are also doing amazing work on immunizations of children AND adults, both people who are infected and immunizing every child with polio drops (at least those families who trust them enough). They do a lot of counseling and information dispersing too, which again, is just so impressive. The other cool thing about the hospital (albeit a bit unrelated) were these giant billboard-sized maps written in Hindi that clearly mark all aspects of the hospital, which to me is a clear sign of a competent facility that is there for its patients (in comparison with facilities in the US that are intentionally unwelcoming and aim to turn families of patients and sometimes extra patients themselves away).

After the district hospital, we crossed the street and went to Zanana, the women’s facility that is primarily used for family planning services, deliveries, and a place for women and children to come and have a safe place to be seen by specialists in women’s health. We crammed into another office with the director of the hospital who was extremely frank about the obstacles her facility faces and was willing to have a straight talk about the issues in the hospital. She explained that the labor/delivery rooms were a-shambles as they were building a new one, and how frustrating it is to rely on government funds, government employed record keepers, and the huge social stigma that surrounds the female gender concerning everything from giving birth to a female child (sex-selected abortions are illegal but it is still a widely-occurring practice) to the tendency for a husband to tell the hospital that he is a neighbor so that he does not have to give blood for his anemic wife.  After a brief question and answer session with her, she took us on a tour of her facility. Again, there were people EVERYWHERE, and like the last facility, it is not like a huge white hospital building like the medical college or like we have in the states, but instead several extremely colorful (it is India after all) smaller buildings grouped together. She took us into the labor rooms, and right as I decided I was too queasy to stay in there, and turned my back for a second, half off our group saw a baby girl be born! That is just one example of the different concepts of privacy around here… the medical superintendent gave us permission to go wherever we wanted in the wards, but that would probably be a lawsuit waiting to happen in the States.

Breastfeeding instructions at Zanana in Hindi:

After a brief lunch, we were taken back to the medical college and served tea in the Social Work Department Library. Abid-ji, my favorite of our teachers who is one of our teachers for the Health and Human Rights seminar, is alum of the AMU Social Work grad school, and ran into the librarian who remembered that Abid-ji never returned his library books from 9 years ago. He actually had to pay up right in front of us! What makes this especially funny is that Abid-ji handles so much of our finances for stipends etc. Teehee.

They took us from the library after tea and led us to a large lecture hall where Social Work grad students made presentations on the government polio programs. These students (including several women!) were about our age, as you do not need an undergraduate degree to pursue a Social Work grad degree. The polio programs in India are pretty incredible – a few years ago there were still hundreds of cases of polio in India, and this past year the incidence was zero. They’re hoping that this number will continue so that eventually this program can be deemed as successfully having eradicated polio from India. Where the social work students come into this is in their work in community organizing and disseminating information about how to prevent polio and why you should immunize their children. One of the most interesting/heart wrenching parts of this is that there are myths in India that the polio drops will make your children sterile… After one of the presentations, I spoke with a student about the information, and asked if it was possible that these ideas exist because of the forced government sterilizations that have happened in the past in India among the poor… he didn’t really agree with me, but I think that wasn’t a huge surprise considering that we were at a public institution. What bothered me was that he was kind of condescending about people who believe the myths… he viewed them as stupid more than scared. The other obstacle is what I learned at Tufts as the “transparency doctrine.” The transparency doctrine in public health says that if people know that a behavior is bad for them, they will not do it anymore. Obviously, if you look at examples like smoking, the transparency doctrine is false. Here people are told that they need to fight polio, but since they can’t see the problem with not immunizing their child (they’re probably more concerned with malaria and the day in and day out struggle of poverty), it means they don’t have the compulsion to travel long distances and “risk” the health of their child. The tragedy of the commons, Greg Hardin would say.

Dr. Azim introduces SIT to the Social Work students:

After spending a long time with the Social Work students (which felt a little bit like speed dating – a lot of us got facebook friend requests within a few hours), we had high tea with the registrar of the school. It was a lot of bs, and just further proved to us how much we were being shown off for bragging rights for AMU. Fortunately the chai was delicious and it was pretty brief. It’s great that such important people to the school were taking out time for us, but so much of that time was spent thanking one another for visiting/for the opportunity to visit. But, in the end, it’s a small price to pay for the experiences we had in their facilities.

After tea (our 8^th or something ridiculous cup of the day), we had some free time, and then were invited to the women’s dorm for a before-exam celebration! It was easily the most fun we had had as a group in a while. They reserved a row for us to watch a Hindi song competition (ALL of the popular music here is from movies, and people are really really REALLY intense about Bollywood). It was so much fun.

There were two girls my age who were trying to take a picture of me, so I asked if maybe we could have a picture all together. We ended up talking for a long time about their degrees in Unani medicine (a Greek system of medicine that involves natural remedies to major illnesses) and about my studies in public health.

We had so much fun that they invited us back for the following night!

On day three, we visited the primary level of health care – the local and community health centers. They first took us to another district health center, and then to a small village where we got to interact with an ASHA (Accredited Social Health Activist  -part of the National Rural Health Program), a woman who works for the government in the village where she lives, serving as a liason between hospitals and families in the village, administering vaccines, taking pregnant women into facilities to give birth, and handling emergency situations. Status as an ASHA also does good things for the women themselves: it gives them a coveted paid government position, a respected place in village society, medical knowledge, and an income. They are also trusted in the villages they come from because you can only be an ASHA of a village you come from. This makes the polio drops myth, among many other things, easier to combat. We watched her give vaccines to several children. For all you public health nerds out there, this was cool: all of the vaccines lock after use! What an incredible idea to prevent blood-transmissible diseases, huh???

Dr. Azim and "all my children!!!"

We were then taken to another village where a mobile health clinic had set up shop for the day. There were four doctors taking patients in the village, and two pharmacists working on board a bus from AMU. Everything from the bus and the doctors is free. While this was awesome, I was really thrown off by the fact that usually only one or two doctors visit, and because we were there, they brought five. Although they said they visit often, no one could tell me the last time they came to the village. AND, the mobile health clinic said they were supposed to be in a different village that day, but had decided to come to this one because it was closer for us… so what happened to the other village and the people who were expecting the mobile clinic?? Despite these concerns, it was an impressive function of the state health system, and meds on wheels is a model that is often talked about in public health courses, so it was very cool to see it at work in person.

Riding side saddle: 

As we boarded the bus, an ASHA came to the side to say goodbye and told us that if she had known we were coming, she would have “prepared some sugar cane for us.” That was pretty cool. Again we’re perceived to be more important than we are, but still, pretty cool. Indian hospitality is unlike anything I’ve ever seen at home.

  

They then took us to the rural outpost in Jawan for AMU Aligarh. We got a tour of the facility, and again saw the very same interns we met the first day. This REALLY bothered me, because what were the chances of them getting moved around that much on a typical week? It just further proved how much they were showing off for visitors. Still, it was interesting to see the university clinic, and we met a med student from Jersey who decided to come here for med school thereby skipping his undergraduate work completely and becoming a doctor at 24. He was SO cocky about his accomplishments (stereotypical med student) and I think was confused about what kind of background we came from, because when we asked him questions about his involvement in public health, he insulted the field and talked about how biomedicine is where it’s at… whoops. It seems like everyone has their own view of the definition of and importance of the term “prevention.”

Oh look, the Epidiomological unit:

We then had my favorite experience of the trip: we sat in a training session with future village ASHAs – women not much older than we are who are training as government liaisons for public health of their own neighborhoods. They spoke about how they felt empowered in their duty, and felt that it was their calling to help end the structural violence of maternal mortality in India. Amazing women.

After lunch back at the guesthouse (by the by, I avoided all meat dishes all week… I saw so many chickens’ lives end when we passed the village market that it was pretty hard to turn around and eat it for dinner...), we went to a neighborhood in Aligarh that is an unofficial slum – unofficial slums do not receive any government benefits like trash pickup, so these people are forced to live in their own filth. It was awful.

We got to walk through the slum with the social work students, who called a meeting with locals to tell them about polio prevention. However, I get the feeling that usually people don’t really show up for these things (they were more curious about the random college kids walking through their neighborhood) and it was a pretty condescending atmosphere… when one man asked (in Hindi) “Why are we talking about Polio? Polio doesn’t affect us. When is this trash going to get cleaned out of the street?” the social work students told them that it was their own fault and they should collect their own trash. Are you kidding?? Who would willingly begin to clean this mess up?? And what kind of horrible diseases would those people contract who started to clean it up without the equipment that the government would have access to?? And how can we ask people to “collect their own trash” when the government won’t give services to unofficial slums? What a literal and figurative mess. Living in my own trash was never something I had to worry about in Hereford. These people have never known anything different (most of the village is around my age, and the street has been like that for 15 years).

I forgot to mention… we also visited an “unslum” (that’s what I’ve decided to call it) two weeks ago (last Tuesday the 15^th) in East Delhi that had been reconstructed by a NGO called Hope International. It was not what I was expecting… since we had never visited a “before” situation, it was difficult to understand why the new concrete buildings that HOPE had built for the inhabitants was much better. The drainage was good, and there is a health clinic that supports the large number of lepers living in the neighborhood, but the experience in Aligarh taught us more about the crazy, fragmented, dirty, noisy atmosphere that stands in the way of health.

We all gathered in the slum school building and the village religious leader (ALSO associated with the University, it’s important to note) talked all about how indebted their neighborhood was to the social work students. The thing is, we never heard from the people in the slum themselves… were the social work students actually effective? How could their effectiveness be measured?

After resting and just trying to process what a stimulating day it had been, we were invited back to the women’s dorm at Aligarh that night for dinner and more of a show. This time it was a trivia contest, and we just didn’t get a lot of the Indian trivia/humor it wasn’t as much fun as the songs had been, but we did get to tour the facility and meet lots of cool girls our age!

Some kind of floor design competition made from powders: 

Saying goodbye to the girls' headmaster:

And if you’ve ever wondered what 300 Indian women waving goodbye to you looks like: (well, i was about a second too late)

On our last day in Aligarh, we visited a primarily girls’ school and got to see eye exams performed by (shocker) the SAME INTERNS. Again, no one could tell me the last time they had been there even though they said it was often, and the status sheets were brand new with no previous record of testing. Sketchy.

But little kids taking eye exams were probably the cutest thing I’ve ever seen.

One child came up, covered one eye, and started “reading” “A... B… C… D…” before the intern could tell her to read the chart! Too cute.

We then traveled to our last stop: a Unani Medical hospital. Unani medicine is an ancient Greek system of medicine that very effectively treats chronic conditions dealing with things like digestion and arthritis and even cancer! They use all natural remedies, and it is a true science and not like the fluffy expensive acupuncture clinics in the States. It is an extremely cheap and low risk way to treat painful chronic conditions, so the government is really pushing its importance. People think it will be a new wave of medicine to hit the West as well! Its central philosophy is about treating the human being in totality.

We got to tour the wards as well as the pharmacy, and try some digestives (ewww). We also saw the raw ingredients being turned into remedies. Mikey  - bro, you would have really liked this part! The machines were old and really cool.

We took a trip to the museum of Unani medicine. Gold is apparently used to cure cancer, and beaver testes are used for the Unani Viagra… poor beavers…

After an extremely boring presentation on Unani medicine that the college made us sit through (it largely consisted of encouraging us to train as Unani doctors), we came back to the apartment to synthesize and talk about everything we had seen over the past four days. It was a long, intense discussion (we take turns running a student-led synthesis of what we have learned every week). While we largely agreed on the best parts of the trip, there were extremely strong emotions and opinions when it came to interpreting different aspects. I love that everyone on this trip comes from different academic backgrounds and passions – I am getting a lot of exposure, and I think we’re all benefitting from the combined brainpower.

Dr. Azim chimed in at the end, and agreed with us that a lot of what we had seen was political – he reminded us to not expect people to reveal everything, and to remember that what we had seen was the best side of the public health provided by the government. He said we can expect more criticism from NGOs we will visit in the coming weeks. I am looking forward to a different perspective.

He also said that it was hands down the most successful excursion he had planned in the seven semesters he has been an SIT academic director. We couldn’t agree more! It was my favorite thing we’ve done so far, even if some of it was hard to stomach and if it wasn’t the most comfortable of locations.

Chilling out at the guesthouse:

And that was that – we packed and boarded the buses bound for the Aligarh train station. A few hours later, we were back in Delhi, exhausted and looking forward to our first showers in four days (ahhh…).

This has been an extremely long post, but it was great to wait a week and fully digest what I saw in Aligarh. Even if it was boring at times… I hope you enjoyed it too! If you’re still reading this, you’re probably my Mom (love you mom!).

I miss home in some ways. I am REALLY craving pizza…

Love,

Laura