Dr Trishan Panch

Day 1.

It is good to be back in old India. That said, there is nothing old about what I have seen today. It is my memory that is old I suppose. India of my youth; of back packing, of crap hotels is out there somewhere but I am not. Today I am here with some kind of purpose other than some loose mission of affordable self-discovery. Today, New Delhi airport is a symphony of India’s double digit development played in glass and steel. As you step into the midnight air, still dusty and close there are people sleeping on the floor but they are waiting for a flight I presume, coming from somewhere and going to do something else rather than just waiting for a better place to take shelter.  The lazy police officers with their unspecified religious wrist bands and their clipped moustaches are still there. Still finding it difficult to fathom basic documentation but then letting it all pass with a wobble of the head. The wobble will probably never change – let’s find out what else has.

Day 2. 

OK so loads has changed but airports, roads, cellular networks and world domination fantasies aside there is still a country of a billion people doing a billion different things in an explosion of colourful industry. It is becoming ever clearer that there is a new India : modern and emboldened with visions of world domination but scratch beneath the surface and the soul of legend, chaos, artistry and corruption is thankfully still here…

Hung out with the boys yesterday – Sid, Michal and Archit in a rented Hiace (my second most desired vehicle after an NSX) and sped down virgin freeways to Mysore and the Tipu Sultan’s various palaces. The Tipu Sultan was a Moghul maharaj who became a vanquished terrorist as he unsuccessfully fought off the British from his grand fort in Mysore. He is now a hero of the new India, a country that is still looking backwards (of course - aren’t we all?) but now skipping over the colonial stain and rejoicing in a bygone age of dominance stretching from mythology to maharaja’s. The Maharaja life seems really appealing. Concubines, seriously good food and pimped out palaces – what is not to like. I don’t blame the Tipu for not wanting to give that up to any Johnny foreigner who comes ambling over the horizon. 

The roads in Bangalore are another emblem of the shifting sands.  The ones that circle Bangalore and connect the IT hubs of Bangalore and Mysore are amazing but stray off those and you are in for some skull shaking. Pristine black dual carriage ways where the car’s tyres gently kiss the newly lain asphalt carpet give way to potholed single stips where you might as well be in a bullock cart. Apparently there was loads of money to make all the roads better but millions disappeared with some corrupt state politician.

Bangalore itself seems like the perfect blend of ramshackle and modern-shackled. A little boring perhaps but exactly what I needed. Not as immediate as the fibrillating pulse of Mumbai or Delhi but a much kinder introduction. Let’s see what is next.

Day 3.

Yesterday was a long day. Time awake punctuated by stolen comas in planes and cars. I was super grateful to get to my friend Maya’s at midnight and promptly pass out with the help of the traveller’s friend: Diazepam. It is like red wine without the hassle or the fun. It’s appeal gives me a little insight into the intoxicating power of sedatives to make life liveable for the chronically anxious or down trodden. After nibbling half a little white pill I drifted gently onto a soft cloud which rocked me gently for 12 hours and then left me up to gently open my eyes at midday. It is best to avoid drugs kids but they do bloody work sometimes.

I tried to use Google maps to get from where I am staying to the centre of Bangalore but there were two problems with this. The first is that in India there are no pavements and so you walk in the road which means following a printed hymn sheet and avoiding serious injury is difficult and secondly the whole Google maps approach just doesn’t fit here. Even in shiny new Bangalore. The whole way of things is more fluid, less planned; by its nature imprecise. There are no signs, few obvious landmarks and no clear place for people versus animals versus construction workers versus vegetable traders. It is best to leave this navigating stuff to the experts I thought.

I gave up wandering and took an auto rickshaw through rush hour traffic. The driver was dark as night with neatly slicked back white hair. He smoked his beedhis and barked into his cellphone as we crawled along a swamp of largely stationary vehicles.

The presence of traffic jams is an inevitable consequence of rapid economic development and one would hope a powerful instigator of change. The thing is that there is a manifest quality to these jams. They are sometimes the result of simple diversions or hour to hour peaks in capacity but the general tendancy of traffic to jam can only mean that there is a mismatch between people’s willingness to do stuff and their governments ability to help them do it. People of their own accord want to travel, to shop and to trade and the government is either not willing or not able to build enough roads to let them do it or to provide greener, cheaper forms of public transport to ease the load. Inevitably what you get instead is grid lock. Exchange unfastened everywhere until enough people complain or more importantly important people complain and then the wheels are set in motion to convert money into possibilities. This process takes ages, of course, and in the interim you have traffic jams. Traffic jams bloody everywhere, all the time.

The thing is that there are mismatches everywhere but we can’t see them or if we can they don’t motivate us as immediately as the futility of the sight a static procession of cars and busses belching soot and carbon monoxide in front of us as we impatiently inch forwards. There are traffic jams in healthcare as people die of diseases that are preventable and suffer from conditions that are treatable if there were a practicable way of creating a more robust delivery mechanism.

I passed a 70 year old lady today who was building a pavement with a 10 year old boy. She was barefoot and stout, wearing a lilac sari, he was wiry and dark already with tough calloused feet. They were doing what they needed to do to make ends meet, swimming with a weak tide and probably against a very strong one. In major Indian cities, up to 60% of the population live in slums with no amenities. In the UK and the US we have more spent on us by the state in a month than these two people will have had in their combined lifetimes. The story of economic development is well underway in India as it is all over South Asia but where does this story go from shiny new airports, powerful new cars and new toys for the new rich. There is a mismatch, a distribution problem, a traffic jam and it needs to be seen for what it is.

Day 4.

It is nice to wake up late (before midday today.) It is nice to have space, physical and mental to roam. I am reading this great book called “myth=mythia” by Devdutt Pattanaik which is basically the ladybird book of Hinduism. He is a doctor by training and therefore he is very matter of fact, very clinical in constructing simple formulations of the relevance of myth to man and complex flow diagrams of the relationship between the different gods and the meaning behind all these rituals that I have taken part in but not really understood.

Unsurprisingly, last night I had dreams that were all about re-interpreting the stories that have become my personal myths: arbitrary events interpreted a certain way and then embedded as feelings. Maybe all this reminiscing is because I spent last night drinking whisky with a recovering alcoholic. A great guy who is a mathematician and more specifically a group theory specialist (nope, me neither) who when not playing with his beard explained his new venture to me. I didn’t quite get it but it was nice to get back to the familiar MIT rhythm of throwing around ideas that might change the way people live if only we could get some bloody money to realise them. There is not much of a culture of venture capital and speculation here though it seems. There is some but considering the number of smart people with great ideas there is way too little .

In a way the colonial ties run deep or more specifically the Indian and British tendency to hierarchy and conservatism have always been a natural match. In America, it seems like a good idea and a fierce work ethic are enough to make it. Of course, that is hopelessly naïve, if your horizons have been narrowed and your wings clipped by growing up having to rely on the public school/health/housing system for your essential social goods then your chances of success via the mainstream are limited. In this simple formulation though, in Britain or India a great idea and hard work do not seem to be enough: you need patronage as well. Someone who is in power needs to point their big finger onto your humble head and proclaim national lottery style “it’s you.”  In India public services are even more of a joke than in the US and in Britain though we bitch an moan about them, comparatively, they are really very good; so what I am really talking about are the opportunities for people already in the “middle class” (define that as you want – I think it is a group of people where essential needs have been met and there is a small to large discretionary surplus) to get richer are more prevalent in the US than in India, which I suppose is not really news to anyone.

So, what about the new rich? What about the democratising effects of technology, particularly web and cellphone technology? What about bringing the means of production to more? What about the bottom of the pyramid? My bearded companion last night argued that growth has benefited those who were already well off and made them better off, some much better off. India is full of huge conglomerates which had entrepreneurial roots but now have a stranglehold on politics and possibilities. Another argument, a more economic one is that one persons expenditure is another’s income. Each of the million new “cyber coolies” (great word – bit rude though) spends more of their discretionary income on X which gives the person who makes X more discretionaty income themselves which they spend on Y etc… As far as I can see, both arguments hold but you still have shit in the waterways, kids begging amongst rubbish on the street, a laughable public education and health systems and  a broken and corrupt political process that is controlled by the interests of the super rich. Maybe it just takes time or maybe time just serves to further ossify. It is important to realise that this is the world’s largest democracy and there is no precedent to re-distribute fairly or efficiently amongst over a billion people using the democratic process. The Americans or the Australians can’t do it, the Scandinavians and Singaporeans seem to have worked it out but there are unique non replicable features in their model. Maybe, India is working all this out for the rest of the us somewhere in the middle. Just like the global redistribution argument goes: we would all have to give up some cash so that others could have more cash and then local political systems would fairly redistribute resources as we see fit. They don’t and we don’t and the Indian middle class are just the same as the rest of us. Maybe India is working all this out for the rest of us, or maybe China is…

Day 5.

I had a few days of wandering, sleeping and a couple of flights. I am now writing this from the back of a Tata jeep speeding southwest through the Punjab from Chandigarh to Bathinda where I am going to stop pontificating and do a little bit of work for a week. It is good to be in the fertile plans of the Punjab: the garden of India, the place where the Singh is King and the Kaur is queen; where the curries are hot, the naans massive and it has been noted that some people have whisky with their cornflakes and others often fight at weddings (wait a minute, there might be a connection….)

I have been to Chandigarh before and it has grown immeasurably since then. Roadside Dhaba’s, anaemic looking cycle rickshaw wallahs, holy cows hanging out in the central reservations and a liquor store on every corner persist but also shiny new buildings and adverts promising “100% guarenteed placement.”   No stopping this time as my driver with a cheeky wobble turns on some blazing Punjabi beats and heads for the freeway. As we leave the city, deep green swaying rice paddies emerge with wiry old Sikh men dressed in bright turbans flecked against the iridescent green. The odd game of cricket, farmers ferrying stuff somewhere and people crammed onto the tailgates of trucks.  Majestic meandering trees line fresh two lane highways where the fluid mechanics of traffic owes more to Jackson Pollock than it does to Isaac Newton. But such is India, deliciously random and surprisingly functional. If there were any doubt, this really is a majestic land: widescreen scale and dancing pixel detail in every moment, the land of the myth and of business.

It will be interesting to see how my model of primary care translates here. Does what I have cutnpasted  from Hackney and Harlesden, from Harvard and MIT  have any place? Is Medicine still a service industry informed by science here? Is it still about managing uncertainty or is it about sweeping paternal declarations? Do people want healthcare to be evidence based and data driven or just local – guidance from someone they know and trust or even someone they half know and are afraid of? Should it healthcare be looked at systematically and focused on prevention or is it better to treat problems as they arise and keep quackery out of life otherwise. Is it better to intervene when aches become fears rather than just grumbles?

The light is fading and I can’t really see the keys anymore and furthermore I really don’t think it is safe to overtake between two lorries speeding in opposite directions on a thin one lane highway. It is time to close the lid and pray...

6.

Things in India seem to be done incredibly well or intentionally badly. I really can’t understand why. Take the hotel that I am staying in, on first impression a standard business hotel but dig a little deeper and behind the bland façade lies a million creative expressions of incompetence. Expand outwards and neighbouring the hotel is  a new “luxury” mall with a “super bazaar” but most of the units stand empty, the ones that are open sell very expensive fast food or limp sandwiches, the escalators do not work and the luxury shopping environment is defined by the persistent blare of 80’s  arcade games and dim blinking neon lights that create the “intoxicating” sense of cheap and shit.

I spent most of yesterday visiting the villages of the southern Punjab with Healthpoint services who are bringing high quality, data driven, technology enhanced healthcare to rural India with yours truly. I found out that the expectations of medical care here are drastically different to those of the more cosmopolitan urbanites of Delhi and Bangalore. Farmers and housewives have more important things to worry about I suppose and the maxim seems to be that unless it bleeds or significantly limits bodily function then it is best to leave well enough alone. This makes even more sense when you have a nose around the public medical clinics: crumbling buildings, dark grimy consultation areas and waiting rooms filled with the overpowering stench of ammonia. Initial impressions are not entirely informative though as there is a lot of good work going on: vaccination campaigns, free antenatal care and family planning clinics all supported by the government and delivered by villagers (asha workers) paid and trained by the government. Chronic disease management leaves a hell of a lot to be desired though and there is a lot of work to be done here. I suppose if it is not a problem now then why pay for medication to prevent something that might or might not happen years from now. It made me think that the whole preventive model is an expression of our aversion to the acceptance of the senescence of our mortal selves and is also embedded in an enduring contract between people and their state. Supplanting this care model without evolution of the values that it depends on is not going to succeed and many programs even for seemingly urgently life threatening diseases like HIV have thereby failed. Healthcare is ultimately a service industry informed by science. 

The healthpoint clinics themselves standout from the assembled shacks, small holdings and herded animals that make up villages in this part of the world. Squat blue purpose built clinics adorned with rows of shiny taps dispensing clean water (of equivalent quality to commercially sold bottled water for a subscription fee of 50c per month) and topped with a satellite dish delivering high speed internet. As Amit Jain, the hugely impressive yoda-like CEO of Healthpoint services says “India is growing quickly and people in the villages want a piece of it just like the people in the towns. They want water that does not make them sick, they want TV and they want internet in their homes just like everyone else, they want good education for their children but unfortunately at the moment they don’t want what we call “modern” healthcare.”

Whilst healthcare has become super-specialised into a myriad of impersonal process delivered at scale, healthcare in the village healthpoints is still very much personal and social. As is still true the world over the consultation remains as the fundamental unit of care delivery but here it is not just about the doctor and patient locked in pastoral privacy but the door is open throughout and passersby  wander in and out whilst the doctor holds court and the sarpanch (elected village leader) nods sagely in the corner. From what was explained to me a lot of what the doctors say is  scientifically implausible and the examinations, investigations and treatments they perform largely unfathomable to my mind at least but inspite this the patients seem to leave with a smile on their face and a cheeky head wobble of satisfaction. I am sure that it is different at the thinner end of the disease wedge where people are more sick and in need of immediate care. Here healthcare like life is neither urgent, standardised nor atomised; it is about acceptance of imperfection and about relationships.

The villages themselves are not bucolic as in other areas of India such as Bihar where rural areas permanently look like the plague has just washed through, after all the Punjab with its fertile soils, (relatively) stable government and hardworking people is a rich state in a growing country. As we drove back through the swaying paddies and neat cotton fields, the air became thicker and the sky darkened to an ominous grey. Rain began to beat like fists against the steel roof of our little van, Hardeep (our driver with an elegantly curled moustache) drove like a crazy man making the vehicle dance around potholes and aquaplane through dirty swathes of standing water. Dr Thakral , the retired chief medical officer of the state of Punjab,  a Rajastani naturalised to the Punjab with bushy eyes brows and a permanent smile, sat next to me like a visiting maharaja and detailed the virtues of India and all things Indian. In summary, India is going to rule the world for longer than the British did, India is the most multicultural and tolerant country in the world and, in general, all things good or holy in the world are in some way associated with India. He reminded me a little bit of what I imagine Col. Ripper from Dr Strangelove would have been like after treatment.

When I got home shaken and stirred, my room was amazingly tidy, even my  computer cables had been neatly coiled (probably for the first time since I bought them) but the internet did not work and the bathroom, for some inexplicable reason, was totally flooded. Its all good though, some things work and some things don’t I suppose.  

Day 10. Going home

New Delhi is a maximum city. Infinitessimal and seemingly infinite: detail at scale. Obviously, it is India so is simultaneously wonderful and totally shit, simultaneously reaching for the 22^nd century and rooted in the 19^th.  

Nothing illustrates this better than New Delhi train station. 15 never ending platforms with trains passing through from exotic destinations with names like Punjab mail and Shatbadi express.  Wiry people hanging out, bedecked in whatever looks normal wherever they are from and parked on the criss-crossing walkways that dissect the neural network below. The familiar swarm of street boys are now gone from the station as police with machine guns and sandbags have moved in. The Mumbai attacks have left a deep scar on the Indian metropolis: their 9/11 I suppose.

Leave the station from the Paharganj gate, there is old India: grimy, teeming, aromatic and fun. Instead choose the Ajmer gate and the incongruous citadel of New Delhi metro presents itself: precise, air-conditioned and on time. But obviously this is still India and Indians are the world champions in occupying confined spaces. The metro at any time during the day is packed with swaying hordes, all limbs and eyes peacefully filing into and out of the metal tubes.  

I had flight issues again – there is always a saga – in this case BRITISH AIRWAYS ARE TOTAL CLOWNS WHO HAVE NO RESPECT FOR THEIR CUSTOMERS (still a little raw). I had to spend the night in Delhi and got a hotel in Paharganj. I have not had to go there for 10 years and it has not really changed that much: it is still packed with geezers seemingly celebrating a perpetual festival of dodginess.  

As I left the hotel, the streets were just starting to stir, a young boy came tearing past me. I thought it was a bit weird that he was running (and barefoot too) and I noticed that he had a big smile on his face as he disappeared through an alley and into the morning light. Paharganj is not really the kind of place for keep fit. In fact, like the streets around major train stations the world over, Paharganj caters more for those interested in  keeping high with glass eyed junkies, twitchy dealers, dissheveled hangers on and pickpockets skanking through the murky passages.

I thought that maybe this little boy was robbing and running because the cash was useful of course, but also maybe because for him, I guess it was fun. Maybe people steal stuff because they can even though they know they shouldn’t, because it feels more like being in control than being under control, because it feels like freedom and freedom feels like running full pelt into the morning sun. It made me think of London and the nonsense that has been occurring in the last couple of weeks.  

So it is the end of this little journey for me. 2 weeks packed with intrigue and adventure. Daytime wandering and night time working on Diabetes data systems. I think it is the last trip that I want to do like this without Caterina for a little while. Mention of her name alone makes me smile and from today, tenderness will no longer transition to sadness as I miss her. Goodbye India and challo London. Going home. Out.