Anita

In the state of Maharashrta in the country India there is a town called Aurangabad. In the town of Aurangabad there’s a community called Mukundwadi and within Mukundwadi lives a woman called Anita.

Anita is different. She doesn’t conform to an outsider’s expectations of an Indian. Yet she is Indian. She doesn’t conform to the norms of her community, yet she is respected by it. And most importantly she does not live within the four walls identified with womanhood, yet she is still a woman.

Anita comes from a poor cobbler family that belongs to what is sometimes callously referred to as the untouchable cast. She started her education at five like any other child, but at the age of 14 she hit a roadblock. She had her first epileptic fit. She fell down and hurt herself badly on the way to school.

Epilepsy has an incredible social stigma in India, especially amongst the uneducated, and perhaps for her safety or for some other reason that we can not relate to, she was kept home from school. For two years she languished, un-stimulated, growing physically but not mentally. Waiting, like most other women her age to be married off to a husband that would take her off her parents’ hands for whatever meager dowry they could afford. But she knew her education was important; it remained in the back of her mind.

She approached a local social worker and started some drawing and tailoring classes. I spoke to the social worker and he said that the first time she came to see him she could barely bring herself to look up from the floor into his eyes or even to bare her face. After showing some promise she was asked to teach a class to younger girls. She refused. How could an uneducated epileptic untouchable girl ever teach anything? But her parents encouraged her and with the social workers support she taught. And she taught well.

Girls’ education is not a priority for most parents in the community. In fact a girl leaving their four walls after school hours is an uncommon event, but she knew its importance, and with her insistence, with her zeal, the students came. The taught tailoring and drawing to city girls and rural girls; and along with their new skills she taught them confidence. With boys on every street corner, most girls and their parents are fearful. What will they do? What will they say?

Anita now works a short bus ride and walk away from home. She sometimes walks with other women, sometimes alone. Every day she sees boys hanging around and on one occasion they started harassing her and her friends. She stayed quiet to see where it would lead. The boys kept teasing. The girls said nothing. She stepped up.

“Are you talking to me?” They boy was caught off guard. “Are you talking to me?” She hadn’t seen Taxi Driver. I asked. The boy stepped off. “Next time, make sure you know who you’re talking to” She told me she was prepared to slap him in the face if he talked back.
The transformation was complete. Anita has knocked down all four walls and has become free. She is seen and respected by all and is an example to all aspiring independent woman. That she exists is impressive, but that she exists despite being an unschooled epileptic untouchable is astonishing.

Unbalanced.

I’ve come to India with an open mind. Having grown up in an Indian family there are many things about the country and the culture that I already knew, but India is so entirely different that only now am I realizing how little that was. The country and the culture, like any, has its successes and failures but curiously Indians seem only to acknowledge one side.
Any one who feels the need to mount a vigorous defense or to loudly sing their own praises only does so because they feel threatened in some way. Unless threatened, no matter how strong or intelligent or rich or powerful you may be, flaunting it is a waste of time. Almost all Indians I’ve met both here and abroad love their country, but here that love takes on a very unusual character.
When George Bush went to war with Saddam Hussein, John Howard said that we had to support America because they are our friend. But if someone is making a mistake, a real friend does not just go along with it; they point it out.
There are a few issues in which most Indians will admit fault. Corruption is a key example. People have such little faith in anything government related here because they just assume that it’s been corrupted; be it hospitals, schools, the bureaucracy, police etc. The population is another pet complaint. But beyond this, a criticism of anything Indian is very easily taken in offence.
It’s very likely that by reading this, my Indian friends will be offended too. But if they are, then they’re in a bit of a jam aren’t they? Because if they admit that they’re offended then they will be proving my very point; that Indians are not sufficiently self critical, and that their views are unbalanced. Muhahaha

A key part of Indian culture is respect for your elders. It is unfortunate that many Australians do not share this value and as a result some elderly people languish unvisited and uncared for in homes across the country. But in India, you find the other extreme. Respect for elders and for authority has created an extremely hierarchical society in which you must call everyone sir or madam. The younger doctors in the hospital where I work are all literally scared of the consultants. If they want to ask a question they do it with so much apology, that every time they do, I’m reminded of Oliver asking “Please sir, may I have some more?” and the consultant replies “MOORRREEE!?!?!?”.

A similar situation exists between children and their parents, where a child will treat their parent’s instructions like the word of god, without question or argument. That’s not to say that the children are unhappy, most feel that their parents know best so it is wise to do as they say. Keep in mind that most parents here will choose their children’s spouses when they are of marrying age.

So? You ask. If both children and parents are happy with the arrangement then what’s the problem? I’ll tell you. This relationship creates an extremely stagnant (Indians would call it stable) social environment. You would be hard pressed to find a culture less open to change and growth. Children do what their parents tell them, and then they get married to who their parents choose, and then instruct their kids the only way they know how, the way their parents taught them.
When talking about arranged marriage, a balanced person would admit that there are many advantages. Some would say that they are more stable and thus, are better for the children. I was part of an interesting conversation yesterday with a girl whose marriage had recently been decided, and her parents. Not long into the conversation however, it became more of a lecture about the faults of western morals and ideals in relation to family values and the far more superior Indian ideals. The high divorce rate was cited as a clear point of evidence, and it was followed by the ridiculous assertion that divorce is just as available to an unhappy Indian spouse as it is to a western spouse. Its disadvantages were glossed over or ignored. Following a tradition blindly and not seeing both its costs and benefits is the very archaic mindset that this country will have to overcome if it wants to improve the standard of living of its people.

Some other unwelcome criticisms that I have are regarding the treatment of women. Tradition and what I consider the extremist social conservative views of many Indians are again to blame. My hospital does a fantastic job of empowering women, but even within it I see sexism. I get my lunch and dinner provided and delivered every day for a minimal fee. Most single people here do the same. When I ask the male married doctors however they say, “Why would I get my meals delivered? I’m married”. It is implied that their wife will cook for them. Many women will not leave the house on their own because they are genuinely scared about what boys will do to them. When confronted about these issues most brush it off. Some have the gall to suggest that thousands of years of tradition have created this culture and so it must be right. Others have the belief that all of these ills are related to the invasion of outsiders and their exploitative ways. Capitalism. OWN YOUR MISTAKES.

India has done so many things in its past to be proud of, but until its people adopt a more balanced view India’s rise will always remain firmly in its future.

community

Every night at 5pm a group of about 25 boys of school age get together at the center where I am based. They play for a while and then do their homework. These boys play together, study together, if they are studying late, sometimes sleep together, sometimes eat together and if history is any guide, will remain friends long after they finish school. Some will go on to college, others to jobs straight out of high school, but almost all of them will complete their schooling, and all of them will avoid the perils of drug and alcohol addiction.

I visited a boy’s family yesterday. On the way there, my volunteer friend and I started walking down a very narrow street. It was paved with bricks an on one side was a sewer drain that carried out all the waste from each house. Each house shared at least two of its walls with another and was connected to the street by a small bridge over the sewer. Although there were no street lamps the houses all had electricity and the light from each house was bright enough to make it seem like morning. As we were walking and talking two boys who were playing on the corner started following us. Seeing them, another few boys started to follow, and then another few. My friend put his arm around one of them and whispered something in his ear. The boy then turned around and spread this little bit of juicy gossip, obviously about me, to the rest of the boys who then went from looking and following with mild curiosity to looking with wide eyes and amazement. They were too shy to talk to me straight away but in their whispering amongst themselves I swear the only thing I could understand was “Ricky Ponting…. Ricky Ponting … Ricky Ponting” repeated several times.

When we reached the house we wanted to visit, my friend and I stopped and our entourage stopped behind us. They looked disappointed. It was an anti climax. A large group of marching boys need to be marching for a purpose; a protest or a parade maybe. Their original purpose was gone, but I think there’s something innate within us that loves a good march, so they kept going, about twenty of them, now with a new leader, heading nowhere in particular, but loving the journey anyway.

My friend knew our hosts very well, in fact he also new just about every kid that we came across by name and also their family. Our hosts were the boy, his father, his sister and her friend. The boy, lets call him Ralph, also had another sister and a mother, and all five of them slept and lived and cooked and ate in a house that was about 4m X 4m. I told them that although in my country we all have much bigger houses and cars and T.V.’s I literally don’t know the names of all my neighbors, and unless we need to build a new fence or cut down a tree, we never talk. I told them that I envied the kind of community that they had, and that they were actually rich, because they had all these things that no amount of money could buy.

Volunteers

Sanjaynagar Mukhundwadi is the name of the slum area where I’m currently posted. The hospital runs a clinic every night from five to eight in which patients can see a doctor and receive medicines for 5 rupees per visit, which is the equivalent of about 17 Australian cents. There are two doctors who sit either side of a small desk in a room that teams with mosquitoes after the sun sets. Together the doctors see up to 180 patients on a very busy day making an average of 2 minutes per consultation. The time is without a doubt insufficient but given the time constraints and lack of manpower, these doctors do an exceptional job of providing healthcare to a community who would otherwise have had to go without. Keep in mind that simple chest infections, skin wounds or dietary deficiencies would have literally destroyed lives and families were it not for these doctors.

That being said, the doctors are only a part, and not even necessarily the most important part of the centre. The doctors come from outside. They were born, raised, educated and now live outside the community. Everyone else who works there are volunteers who were born, raised and now live in the community. I could write endlessly about the centre itself, but this article is primarily about them.

Over the last two days I’ve met many of these volunteers; there are about 20. Most of them are around my age (some of them do not know for sure so they just guess). I got a chance to talk to one of them in depth. I was interested in what motivated this young man, who came from a cash strapped family, to forgo salary paying work and instead work for free for the centre. He told me that when he was growing up he was helped by volunteers from the centre. Young men and women gave him a hand and pulled him up out of the vicious cycle of slum life and now he felt that it was his turn to do the same.

I asked him, what he thought his life would have been like if he had not been pulled out.

He told me that staying in school and continuing his education was the most important difference that was made. You see many children, if not most children, come from families in which their parents are self employed. They are working selling fruits and vegetables, or shining shoes, or working as servants, cooking or cleaning, in the homes of the middle class. Basically in unskilled industries. Most parents want their children to stay in school, but sometimes their insistence is not strong enough, or they do not fully realize its benefits. The children who drop out realize that they too can work in these industries and make some quick cash.

Imagine being in their situation.

It starts off with you ditching school to go and help your dad shine shoes. Like any young kid that idolizes their dad, you feel proud to be doing the same job as him, to be at his level. Soon you realize that instead of working side by side, you can both make more money if you work separately. You’re now earning an income that brings home some desperately needed cash to your family. Your parents are thankful, and again you feel proud. Then you realize that as you get more efficient, if you lie about your income to your parents you can keep some cash for yourself. Cash that’s all yours and nobody elses. Cash that you can do whatever the hell you want with. Why not? After all, you earned it right?

You go watch a movie, you see all the movie stars that everyone always talks about for the first time. You buy your first cigarette, drink your first whisky, why not? All the other men are doing it. Don’t you want to be a man too?

The volunteer I spoke to told me that he can count the number of people in his grade at school that do not drink or smoke on his hands. There are five thousand school going children at any one time in the area.

He doesn’t drink or smoke, and now that he is 22 he no longer feels pressured either, his time is over. He has been saved.

Homesick

Today I was confronted with the trifecta. Squat toilet. Diarrhea. No toilet paper. Any western person’s nightmare. Needless to say I felt more homesick at that moment than at any other time. Ever.

Hinduism

I was recently involved in two conversations with two very different people about religion. They both claimed that they knew the authentic Hinduism.

The first was a man in the café where I eat breakfast every morning. He proved to me that, irrationality, extremism, ultra-nationalism and xenophobia exist everywhere. It is not only confined to Rush Limbaugh, Allan Jones and Fox news, but exists even in the outskirts of small town India. He told me that Hindus are the Indigenous peoples of India and that Muslims, Christians, Jews etc only exist because they forcibly converted millions of Hindus after invading the country. He told me that I should be scared of Muslims and Christians in Australia because one day they would force me to convert at gunpoint. He felt that all those who left India had betrayed the country and that he would rather die in the emergency room than be treated by a non Indian doctor. As you would expect from me I entertained his psychosis for far too long and sat and argued with him late into the night.

When so many rational, compassionate, and decent Hindus exist, there is obviously no way that he or his views could represent the true Hinduism.

The second conversation was the polar opposite. An intelligent conversation with a respected and admired doctor. He suggested that Hinduism was extremely broad and nowhere did it suggest that you had to believe in a certain god or live in a certain place or undertake certain religious practices. The only thing that his Hinduism required was a set of core values that involved working toward social justice, believing in equality and respecting all peoples. In this reading one can be a Christian or a Muslim and so long as they shared those values they were automatically Hindu whether they knew it or not. This Hinduism is more a philosophy than a religion, and it is one that I feel much more comfortable with.

However, when so many irrational Hindu’s exist why should this represent the true Hinduism? Didn’t they all read the same texts and come from the same tradition?

The name Hindu was given by an external power to a hodgepodge of religious traditions that existed around the Indus river. There is no central power in Hinduism, and as a result I propose that there is no true or pure Hinduism. Each person has their own philosophy and so calling oneself Hindu seems meaningless, so I don’t.

Imperfections

Every organization has its flaws. They are inevitable, and over the last week I have come to realize one here. I encountered it in a particular patient and then began to notice it everywhere. It is a problem that I, a student of psychology, see far more often than most, but whatever bias I may have it is real, and it costs the patients, this hospital and this country far more that any of us realize.

Last week I took a detailed history of a patient in our general ward. He was experiencing difficulty breathing on even the slightest exertion; and an X-ray showed a partially collapsed lung and several other abnormalities. I understood by talking to him that he had been to several doctors before without much success and had finally come to Hedgewar hospital because of its good reputation. It was suspected that he had a tuberculosis infection, but the existence of other possible illnesses was still in doubt and we needed a CT scan to understand them better.

As soon as the idea was proposed to him he became noticeably frightened. I talked to him briefly later and overheard some of his conversations with others. He had a bad experience some time ago where the electricity had gone out in the middle of the CT scan and he became trapped inside the machine in a pitch dark room. He was worried that something similar was going to happen again and was so scared that he even said ‘let me die, but I’m not going into that machine’ (obviously translated from Marathi). Without the scan we could not just blindly give him treatment so we discharged him.

He was not referred to another doctor and was not given any treatment. Nothing was done to understand the nature of his fear or to try and overcome it. If he dies, he will not die because of his tuberculosis, he will die because of an irrational fear. I do not blame the doctors involved but rather the culture; when I questioned his treatment the response was simple, ‘who has time to treat a psycho (yes, this description was used several times) when there are plenty of other patients waiting?’. This question, though callous may seem rational, but only to someone who is thinking only of the now. The patient has remained ill. He will likely see several other doctors for treatment. He will not get better, he will be readmitted to hospital, his family members will have to take care of him, they will take time off work, and their lives will be greatly impacted. He will cost the hospital, the health system, his family, the economy and the country more now, than if his psychological issues were addressed properly.

Yesterday a man came into the outpatient department with diffuse body pain, trouble sleeping and trouble digesting food. Many tests and investigations had been undertaken over two years and they had all come back normal. My preceptor astutely observed that there was probably a psychosomatic component to his illness so I asked whether I could explore the issue. I sat with the patient and his wife in another room. We started talking about his complaints and then his family, his work and his children. He told me that he had five children and his eldest daughter was married two years ago. Eventually, after a little prodding he told me that his daughter’s husband was severely beating her and that a year ago she ran away from him and returned to live at home.

Although the patient and his wife were absolutely practical about the issue and were in fact encouraging their daughter to run away they admitted that there was definitely a social stigma, and they were feeling the brunt of it. It appears that the wife is thought to bear a greater proportion of the responsibility if a marriage does not work. Furthermore, after she returned home, the husband would call every now and then and threaten her and the family. So as a solution they disconnected their phone.

As treatment my preceptor prescribed some anxiolytics, mostly to help with sleep. But there was really not that much more he could do. He didn’t have the time or the resources to counsel them, and the nature of their problems was only revealed because I had the time to sit with them for 20 minutes. Again, this is in no way my preceptors fault, but it is the fault of a culture that systematically and pathologically pretends that psychological issues do not exist and in my opinion is unknowingly suffering the consequences. If our patient’s somatic symptoms were indeed a manifestation of his anxiety, he will surely be back. If his anxiety is not treated his symptoms will get worse. He may be hospitalized; his family which depends on his income and support will suffer. His kids’ education and future healthcare will be impacted.

Given that the doctors here do indeed care for the community they serve; and given that they approach the clinical and social aspects of medicine with an impressive degree of competence, the psychological aspect of illness needs to improve to the same standard. I’m sure as they come to realize the burden it causes, its importance and emphasis will increase in their practice.