Poverty, poor education, and the re-emergence of caste in India

Date: 07/24/2011


“Poor people are usually very uncivil in their behaviour...... they would have hazy scruples, usually resorting to base activities (theft, crime, rape) to get by....Indians seem to be so used to living in low quality surroundings, they have become low quality people..... poor kids have been allowed to grow into poor adults, and what their value system is like is anyone's guess.... bad civil engineering, slums which are allowed to propagate[SIC], uneducated people being allowed to have a say in the decision making process by allowing them to vote, all have resulted in a society that more resembles a bacterial colony than a human civilization....So it would all have to start with forming a new megacity like bangalore or mumbai in some new place...... Restrict the number of people per square kilometre. NO UNEDUCATED B*******S ALLOWED.”

I blinked in disbelief as I finished the email. I re-read it again to make sure I hadn’t imagined it. No, I was bang on the first time. It wasn’t the first time, neither in my life nor during this trip, that I had come across such sentiments from Indians in my age group. Every time such opinions are aired in my presence, I get a really unpleasant deja vu. I hadn’t been able to place this sense of deja vu until yesterday: this was exactly how I had felt, in the 6th grade, when I had seen a picture of an “untouchable” being beaten to death by members of a so-called-high caste for casting his shadow on their food. Are we about to see the rise of a new type of caste system, one that marginalizes and exploits the poor and the uneducated?

The conditions couldn’t be more favorable! As I mentioned in a previous post, the newfound prosperity of India is limited to a population of about 60 million. Of the remaining 1.14 billion, 638 billion are so poor that they’re forced to defecate outdoors. These two types of Indians live in two distinctly different worlds: while the women in one set plan trips to America and Europe, women in the other plan trips to the fields to at night to defecate with a modicum of privacy. It is easy to imagine, for me at least, how the disgust of one group can be easily matched by the resentment of the other. Indeed, such is the case. I’ve heard poor men complain about the avarice and the immorality of the “big people from big cities” and I’ve encountered disgust at the lifestyle of the poor from my rich friends and a concern that they’re dragging down their quality of life. The poor judge the rich on their abandonment of traditional values whereas the rich make cruel jokes about the poor for their lack of “polish” and finesse (as described by our erstwhile British masters). A frequent complaint I’ve heard is that the poor shouldn’t be allowed to vote because they are uninformed and easily manipulable. This is madness! We’re all citizens of India. Our status as humans is not contingent upon our income or education. We can’t allow our society to be ripped apart like this.

Yes, the differences are steep.

I have written this post to beseech my educated Indian readers to be aware of this us-and-them feeling that is ingrained in Indian society and may lead to another caste-like divide even if it is not called as such. At least in the short term, I don’t see the vast polarities in India changing. We must not let the polarities change us in our approach to the disadvantaged. All this nonsense about the poor being morally corrupt and acclimatized to subhuman living conditions is precisely that-- nonsense. The person who treated me most graciously this summer could not have made more than Rs. 4000 a month ($100), which is really not that much. Embarrassingly, I probably had twice that much money in my wallet when I met him. At one of our community screenings. I mentioned that I was a bit hungry since I had not had breakfast. Traditional Hindus hold the view that guests must be treated like gods. This man, a senior resident of the village, promptly took out his own humble breakfast of idly and sambar and forced me to eat it. I felt horrible taking his food, but he absolutely refused to accept my “no, thank you” or my money. What’s more, he insisted on waiting on me and even helped me wash my hands with water that he had gotten out of a water pump. I know from experience that this is the rule, not the exception. So, please, don’t vilify the poor. They’re more sophisticated than they’re given credit for.

 I don't think it is possible for anyone with the means to read this blogpost to imagine the life of a truly poor individual. Consequently, we have no right to make blanket statements condemning or belittling the poor.

Another frequent accusation about the poor is that they reproduce quickly, put increased pressure on the already limited resources, and increase the congestion. Yes, this is true. A popular theory behind this is that, given the high infant mortality rates among the impoverished, parents decide to have a lot of children so that at least a few are left behind to take care of them when they are old. This has been shown in numerous studies. Children, after all, are the traditional retirement plans for parents in countries like mine. Even my parents, who are not at all poor, think of me as their retirement fund and are counting on me to take care of them when they are unable to do so themselves. Most people approach this population problem in a Malthusian spirit which is incredibly dangerous. History has repeatedly testified that reducing poverty also reduces the fertility rate and the infant morality rate. Dr. Guerrant loves giving the example of New York City which had a higher fertility and mortality rate than present day Bangladesh(2). On the graph below, you can see how they fell with the increased prosperity of New Yorkers. So, if you want to reduce population and congestion, help the poor get out of the poverty trap and keep them healthy. It’s literally the only thing that works.

Note how regions infamous for high mortality inevitably also have a high fertility rate. It is a compensatory dynamic. (2)

One thing that the poor demonstrably do lack is education. This leads to superstitious beliefs and an inability to fully utilize the resources that are available to them. Every extra year of school education, adds about 8% to an individual’s earning capacity(1). Therefore, not being able to receive a complete education is a recipe for remaining poor. Reading Poor Economics by Abhijit Banerjee and Esther Duflo really made me appreciate the things that influence a poor man’s ability and decision to send their children to school. They do so amidst immense hardship. Education is a privilege and if you manage to get a good one, that’s your great good fortune. All the Indians who’ve ever launched into diatribes about our uneducated countrymen went to school in buses. The kids they rip on had to walk many miles to school and not always with shoes. In fact, Gemlyn, one of my coworkers this summer, helped formed an NGO that enhanced school attendance amongst children in remote areas by buying them shoes and hiring auto-rickshaws to carry them to good schools that were 16 kilometres (ten miles) away from their villages.

Unfortunately, even if they get to school, many times the education is terribly sub-par. Sister Eugini, the principal of Auxillium College in Vellore, told me about the horrendous schools in rural Tamil Nadu where the teachers come late, if at all, and refuse to teach. The children spend their time polishing the teacher’s bike instead of their maths skills. The teacher leave the school on seemingly luminous bicycles, leaving behind children who are doomed to a dark academic or economic future. Surprise checks did help a little, but they’re not always possible. Some fundamental changes are needed, but I am not qualified to prescribe any(3).

Yes, crowds can get frustrating in India.

Many of us make these “us-and-them” comments about the poor and uneducated without sufficient thought. I don’t actually think malice lies at the root of it for the most part. Frustration? Perhaps. India is decidedly overcrowded, overcompetitive, and not always clean. People coming back from a sojourn abroad, like the friend who wrote me the email, do suffer from reverse culture shock. I wrote this piece to make them aware of this tendency and how it can lead to fissures and intolerance in our society reminiscent of the abhorrent caste system that still lingers in India like a metastatic cancerous lesion. In conclusion, I’d like to present a Thomas Jefferson quote that I found paraphrased in Dr. Guerrant’s article (2):

“The power of society belongs in the hands of the people. If the people should ever seem in-adequately enlightened to exercise this power, the solution is not to remove the power from the people, but to educate them.’’

I think our work is cut out for us.

----

Disclaimer: The guy who sent me the email is an old friend. I respect him deeply as a scientist, but he has just returned from a very well designed and run European country and is almost certainly in reverse culture shock. Please don’t criticise him in the comments.

Bibliography:

1. Banerjee, AV and Duflo E. Poor Economics. Random House India. 2011
2. R.L. Guerrant Why America Must Care About Tropical Medicine: Threats to Global Health and Security From Tropical Infectious Disease. American Journal of Tropical Medicine and Hygeine. 59 (1) 1998.
3. Personal communication. 07/01/2011

A brown sahib in a bus

Date: 07/19/2011

The bus starts out empty.

“Pranay, like it or not, you will be a gringo in India.” Dr. Guerrant warned me as I got ready to fly to India, my own country. Gringo is the picturesque Latin American term for foreigners. Personally, I had felt slightly outraged. I am, after all, a passport carrying citizen of India! Born in humid Kolkata and raised in the dry heat of New Delhi, I did not consider myself a brown sahib, a term reserved for the educated Indians who served the British raj in India. Brown sahibs were often more English than the English.

I was still bristling at Dr. Guerrant’s warning when I boarded the bus this morning. After tossing three well-worn one rupee coins to the conductor, I curled myself into a window seat. I say curled because it is impossible for anyone taller than 5 feet to sit in those seats without an impromptou display of contortionism. Reading on the bus is physically impossible-- the customary jerks are colossal enough to rearrange your visceral organs. If this were not enough, the imaginative interpretation of traffic laws by most bus drivers is sufficient to reacquaint any traveling atheists with the deities they staunchly deny.  I have learned my lesson and now just sit and commune with my fellow Indians quietly.

And ends up looking like this.

Five minutes into my jangly bus ride, I saw a lady, in a gorgeous saffron sari who was squatting behind a small bush. She was defecating. Seeing the bus approach, she made a few perfunctory moves to conceal herself, but she knew as well as I that it was futile. I averted my gaze to give her some privacy. Though I had seen similar sights hundreds of times before, it shook me up in a way that the bus could not. I was struck by the thought that my India was so different than hers.

“India’s economy will soon overtake China’s,” is the proud boast of a vocal minority in India, a minority I regrettably belong to. Indians like me suddenly have the capacity to patronize brands such as Bvlgari and BMW. You know you’ve been left out of the prosperity party when you cower behind bushes as you carry out you basic bodily functions, clutching at the last vestiges of your dignity. This is the case for 638 million people in India. That’s twice the population of the United States.

Two schoolgirls were sitting in the sear in front of me. They were attired in white shirts and navy blue skirts. I got occasional whiffs of coconut oil from their well-oiled braids secured with ribbons that matched their skirts. The braids oscillated in phase with the stochastic shudders of the bus. A wave of nostalgia gripped me as I heard them chanting the preamble to the Indian constitution, a feat every good middle-schooler in India is expected to master:

What do I have in common with these men?

We, the people of India, having solemnly resolved… to secure to all its citizens:

Justice, social, economic and political;

Liberty, of thought, expression, belief, faith and worship;

Equality of status and of opportunity;

and to promote among them all

Fraternity assuring the dignity of the individual and the unity and integrity of the Nation

I couldn’t help but wonder: if Justice, Liberty, Equality, and Fraternity are the lifeblood of modern democracies, is India, with its extreme inequalities, truly a democracy? If we, wealthy and educated Indians spout clichés, act fashionably desensitized to the poverty in our faces, and allow the creation of a permanent economic underclass, won’t our democratic claims ring unforgivably hollow? Won’t history judge us harshly for this denigration of our fellow humans?

 “Doctor sahib, can you help me?”

My reverie was suddenly broken by my young co-passenger who had had spotted my stethoscope. I clarified that I was a lowly med student, but agreed to look at a leg wound that he wanted to show me. The wound looked dirty and was crusted with some dried exudate. A fly promptly buzzed in and began probing the injured area. I swatted the fly away with my hand and suggested some simple wound care and tetanus prophylaxis to the lad.

Often Indians communicate more by jiggling their heads than they do through their words. There is the ready sideways head-jiggle of the Indian who is on the same page as you and then there is the slow, tenuous cranial swaying of the Indian who is mystified, but too proud to admit it. From the amplitude and frequency of the boy’s head, I could tell that my vocabulary and accent were impenetrable for him. My English is inspired by Oscar Wilde. His was inspired by necessity. I broke into Tamlish (a hybrid of Tamil and English) and descriptive gestures to communicate with him.

We need the optimism and perseverance of this man. He knows the street will be dirty within hours and yet he sweeps undaunted.

As I clumsily counseled the boy with broken words and jerky gestures, I felt a sickening twinge: I truly was a wretched brown sahib, a gringo. Dr. Guerrant was right. I spoke, essentially, a different language. As is the case with visiting Americans, the rupee had a completely different meaning for me-- the 3 rupees I had paid thoughtlessly to the conductor are almost 10% of the daily earnings of millions of Indians who subsist on 99 cents a day. My parents, both Doctors, kept saved me from debilitating malnutrition and paid for expensive athletic abilities. No wonder I look physically distinct from the emaciated poor who comprise the bulk of India’s population. In that moment, I resented and despised everything from my expensive education to my posh-sounding accent. They were exposed as the products of inequalities deeply ingrained in Indian society, the same inequalities I vehemently decry. I felt like I had somehow swindled the man next to me.

If you want to meet an optimist in India, shake hands with a traffic policeman. They deal with chaos beyond imagination.

There is, however, a glimmer of hope. My brain is unimpaired by malnutrition. My education hasn’t been discontinued at an early age due to lack of funds. My body is not crippled by preventable diseases. I have the capacity to advocate for my voiceless Indian brothers and sisters. I owe my country and my fellow citizens at least this much. This will be my atonement.

The progress made so far has been at the pace of a bullock-cart. This is simply unsustainable. We, the privileged children of India, can hasten the process of change.

A muted sort of triumph

Date: 07/18/2011

I wish I could have done more

We were only two thirds through the camp and I had already seen over a hundred patients. Kartik and Gemlyn, my fellow medical officers, had seen even more and they had been keeping an eye on me the whole time. It isn’t as herculean as it sounds, really. In most cases, we just do some TLC for people with a motley collection of aches and complaints. We put them on calcium, iron, and multivitamins. Treat their heartburn with H2 blockers, deworm children, treat symptoms of cough and cold, provide antibiotics, antipyretics, and painkillers to the needy, check their hearts and lungs, counsel them on health-related matter, make referrals for ophthalmic, dermatological, and neurological conditions when we're out of our depth, etc. Some people just need to be able to chat for a few minutes with a guy armed with a stethoscope. People really just use us as a one-stop shop. I had a boy come to me with complaints of shortness of breath. Taking a history revealed that he sighed deeply from time to time and his mother freaked out about it. I probably shouldn't have burst out laughing- bad manners. Still, I don’t resent it. India has 70,000 doctors to care for her 1.2 billion citizens. With this insufficient ratio, It’s little wonder why people hoard up their problems-- big and small-- and bring them to community screenings like ours. We see a very wide range of medical problems in our camps in terms of severity.

Yesterday I saw a woman who had lost the use of her left hand after she got a serious electric shock. The hand was a claw. I suspected an issue with the ulnar and the median nerves, but couldn’t do anything. I also met a man whose body was paralysed on the right side. His steppage gait and asymmetric smile gave it away immediately, but there was nothing I could do about it. A wrinkled old lady with only one eye hobbled up to me with a cane next and complained of joint pain. I provided her calcium supplements for her bones, iron, B12, and folate tablets to correct her deficiency, and turpentine ointment for her joints, but-- basically-- I couldn’t do anything substantial for her. Kartik, Gemlyn, and I know that this is not simply not enough. Perhaps this is why we call ourselves “Quacks R Us” or “Two and half quacks”.

We can't blind ourselves to the horror of the health situation.

Soon after the lady limped away with her creaky cane and even creakier joints, a mother approached me with her son and daughter. Over the past three weeks, I’ve learned to quickly scan my patients for a few obvious pathologies. Here’s what I remember thinking in the 5-10 seconds they took to walk over:

Young woman. Looks a bit weary, though. Has the expressions of an older woman. Two children: boy and girl. Girl looks healthier than boy. Mother doesn’t have a patient form. The children do, though. The worry might be because of the health of children. The boy’s shirt is bulging just a tad. Protein Energy Malnutrition (PEM)? Make sure to check. What about the daughter? Anemia? Vitamin deficiency? General Malaise? Naah. Looks good. Let’s look at the boy. Looks a bit tenuous. How old is he? 9? 10? He’s walking a little bit awkwardly and unsurely. Is that just me? Am I scaring him?

I put on my warmest smile for the mother and the children to allay their fears. The boy was indeed tiny. I’m known to have a short torso and I still towered over him even when I was sitting down. The kid was actually 13 yeas old! Clearly, he was the victim of grave malnutrition. The mother complained that he had a weak heart. Having heard the same complaint from a couple of different mothers earlier that morning, I have to admit, I sighed silently and took off my stethoscope somewhat perfunctorily. I had to check for the kid’s PEM anyway so I unbuttoned his shirt. As expected, the PEM was there. Shobana, my translator and a dietician, began counseling the mother on the kid’s nutrition as I visually approximated the location of the the apex of his heart. I found it, placed my steth’s diaphragm on it, and closed my eyes to block out the other stimuli.

Does he look 13 to you? Note the distended belly characteristic of PEM.

Lub..swoosh...dup
Lub..swoosh...dup
Lub..swoosh...dup

My eyes opened wide with shock. It couldn’t be! I moved my steth systematically from the apex to the left of the manubrium sterni then up to the region under the clavicle and then back near the sternum at the second intercostal. To confirm the diagnosis, I checked for the sound in his left axilla. It was there. I had only heard this sound once before. I spun in my seat and decided to consult Kartik, a fount of all medical knowledge: “Kartik...pansystolic murmur...present in axilla...could be MR...please confirm.”

Kartik auscultated the boy and confirmed my suspicions in a minute: “It’s either Mitral Regurgitation (MR) or Ventricular Septum Defect. Tricky. You can feel good about it. Nice catch.” Considering, I had basically picked up rudimentary auscultation by reading in my spare time and with the help of some impromptu tutorials from my father over the phone and a Tanzanian doctor in my bungalow, I glowed with pride. Then, putting aside the glow for later enjoyment, I asked the pragmatic question: “So, what do we do?”

Kartik: What can we do?
Me: Refer to cards?
Kartik: I’m not sure if he’ll meet the requirements for free surgery.

And there we were. The familiar feeling of utter and complete helplessness darkened any remaining glow from a few minutes ago. Judging from his ripped shirt and malnourished frame, it was pretty clear that there was no way this kid’s parents could afford a valve repair or replacement. I hate not being able to do anything for the people who come and see me with hope in their eyes! For instance, I see 60 year olds with classic signs of radiculopathy and have to tell them that there’s nothing I can do for their pain. If they're 30-40, I can refer them to the orthopedics department, but 60 is considered so old that the number of DALYs saved do not justify the cost of the surgery. If these poor people persist, I have to send them off with calcium tablets. I sometimes worry that doing so might shake their faith in doctors and drive them to quacks and witch-doctors that lurk the countryside, preying on those neglected or disillusioned by India’s healthcare system.

 It's not like I think we do more bad than good. We've been able to help an enormous number of patients and catch some tricky diagnoses early. For instance, I caught a breast lump and a nasal cancer in two women yesterday and urged them to get them checked out before they grew any more. I suppose my frustration is just that I am not convinced that the work I am doing in my current capacity is bringing us very close to the utopic future people in global health envision and long for.

They're waiting to get the healthcare they deserve. We can't fool them. We can't cheat them. Not anymore.

Ultimately, we directed the child’s mother to the paediatrics department at CMC where we figured at least his PEM would be treated. We think there may be a chance that his heart problem will be attended to given his young age and CMC’s charitable mission. Thank god, for Christian charity! However, I have never ever been good with uncertainty and the very real possibility that that poor child will be left untreated for petty financial reasons bothers me and makes me smile wryly when anyone tells me I’m doing good work in India. I love diagnosing patients. I love being right. But what’s the point of it if treatment and resolution don't follow?

Fixing leaks

Date: 07/10/2011


With my eyes scrunched up and my forehead crinkled, I listened like I had never listened before. The only thing I was aware of, apart from the drop of perspiration slipping slowly down my nose, was the beating of my patient’s heart in my ears. I moved the stethoscope to a different location to confirm my belief that there were no abnormal S3 or S4 sounds. A drop of perspiration fell from my the tip of my nose to the cement floor. I was tempted to take a break and wash my face at the tap outside.

Leaky tap outside the screening venue....fitting imagery for our global health situation?

We were in the midst of another community health screening. Our goal was to provide TLC to the population of the village and draw blood samples to test for the prevalence of Celiac disease in the community. This information is vital to avert an impending epidemic of the disease in India. We were planning to do screenings in two different villages and were expecting about 400 people to come by and ended up being overwhelmed with 500 attendees whom we saw over a course of 10 hours. Kartik, Gemlyn, and I were working as the medical officers. Our work was to quickly elicit a history and prescribe simple medicines ranging from multivitamins to famotidine (an H2 inhibitor to reduce excessive stomach acid production) to ameliorate their suffering. We also referred them to specialists when we realized that we were out of our depth. Suresh and Shrikanth were drawing blood samples, Bala was directing the whole show. Vettri was measuring heights, John and Murugan were drawing in the crowds, and Gowri was helping me with the translations.

Bala being a dynamic leader as usual

You can see how crowded it was getting.

My stethoscope had been repositioned and I was about to re-scrunch my eyes when I noticed the lady’s son staring at me. My eyes scanned his tiny body. I took in his bare feet and his hair which glistened with the coconut oil his mother had put in lovingly. His shirt was buttoned in two places and held in another place by a safety pin. It was only then that I noticed how his shirt was stretching over his distended belly. After another few crinkled and scrunched up seconds, I determined that his mother didn’t have any obviously abnormal heart sounds. She turned to go, but I took the moment to swoop down on the kid. A quick unbuttoning (and un-safety-pin-ing) later, my suspicion was confirmed-- his belly was distended and his limbs were stick thin, a sign of protein energy malnutrition (PEM). With Gowri  translating rapidly, I immediately counseled the mother on the child’s nutrition and gave him a deworming pill (Albendazole, single dose) for good measure. His brother turned out to have the same problem. Fixing PEM early in childhood has been shown to increase the income and productivity of individuals. Abhijit Banerjee and Esther Duflo remind us that Kenyan children who were dewormed for two years earned 20% more than children in schools of equal quality who were only dewormed for one year.  I was immensely pleased to have a crack at this high yield intervention. 

A little girl in the next village. Her prominent pot-belly and stick thin limbs helped me diagnose her protein energy malnutrition from across the street.

A few minutes later, I cautiously pulled a young man’s eyelids down to check for pallor in his conjunctiva which, if present, is indicative of anaemia. I felt my shirt being pulled out of my Jeans. With some irritation, I wheeled around to face the scoundrel perpetrating this sartorial outrage on me. I came face to face with a fourteen month old girl with big brown eyes and half open mouth in her mother’s arms. My irritation morphed into a smile as I greeted the little girl. However, within a few seconds, it was apparent that she too suffered from PEM. My mentor, Dr. Guerrant, had demonstrated that the window of opportunity to do something about malnutrition and the subsequent stunting ended at 2 years. She was 14 months old! I still had the time to fix her trajectory of growth! I did so with great gusto and optimism. Over the course of the day, I did this again and again. Interestingly, many of the parents hadn’t brought the children to be checked and I only caught them because I was looking for signs of malnutrition in the kids. 

This is the sight that greeted me when I spun around in irritation.

Handing the baby back to the mother after inspecting her.

I know I often write very dejectedly and bitterly about global health issues. Even today, I met people I could do nothing for like a gentleman and a lady with severe chronic obstructive pulmonary disorder (COPD). For them, it’s de facto a death sentence because they don’t have the economic means to secure treatment and the public health system is too overwhelmed to subsidize it for them. I see the global health issues our world faces as similar to the leaky tap in some respects. Bit by bit, we lose human capital to stupid and preventable conditions like malnutrition and malaria. It may not seem like a lot, but the drops and the lives being wasted both add up to a burden the world can ill afford. By helping those little children today, I feel I plugged the leak on a nano-scale and I don’t see why we can’t do it on an infinitely larger scale. 

He had severe COPD. I heard the wheezing through my steth and asked Gemlyn to confirm the diagnosis. We couldn't do anything for this poor fellow. He simply cannot afford the Rs. 10000 per month ($750 USD PPP) that are required for the best treatment. Still, sometimes it's important to focus on the good we can do as well as the areas where we feel helpless.