Health care, a la carte

Editor's Note: Like last year, I came back home from India being totally behind with blog posting. So I'll be posting a few retroactively, with the following being the first in the series. Anjoy!

Getting health care in India is very different than in America. Because of the health insurance system, in the U.S. I always feel like my health care is not in my hands. It's controlled by entities in the foggy distance; there are these big institutions that know all about my medical history, control how I interact with my doctor, give their permission and approval to do anything, and require me to update them when I have availed any service.

Not the case in India. If you want to see a doctor, you just call one up and make an appointment, or better, just show up to his office. And he's not going to ask you what coverage you have and to fill out this or that form. He just sees you like you would go to a barber for a haircut. No strings.

It's all very raw, very street. That's exactly how I described my experience last year when I had to get my elbow stitched after falling off of a bus, walked into a local doctor's office, laid down, stuck out my arm, and got sewn up with no anesthesia and no doctor's gloves, and walked out an hour later for Rs.150 (post mortem: The doctor had told me that my stitches didn't need to be removed because they would dissolve on their own. After weeks they were still there and so I had them removed. Now that patch of skin on my elbow is all gnarly coagulated looking and I feel a pain every time the skin gets stretched. So yeah, I paid Rs.150 for stitches, and I got what I paid for).

Recently I was sick and had to get some blood tests done. I used a service called Green Cross, which is basically a consumer pathology lab. They send over a dude with a bag full of needles and vials to your house. He takes your blood, sends it to the lab to have whatever tests you want on it done, comes back later that day with a full printed report with a doctor's number for referral, and takes your money. And all actually on time, and all at affordable cost (basic CBC blood test costs Rs.170 all in)! It is such a delightful service.

And it's unlike anything in the US because it is health care a la carte. There was no doctor or institution telling me how I should interpret my blood test, or even that I should have gotten a blood test in the first place. Self-diagnosis. I look at the report which shows my health reduced down to numeric scores, and see if things fall within the given arbitrary ranges. Then I can go online and find out what it all means, and even walk down the street and buy my own medicine. No doctor necessary. It's like going to the barber shop, sitting in the chair, grabbing the scissors and cutting your own hair as the barber just stands idly by. There are no people or institutions that are gatekeepers to your health care needs. It's all up to you.

It's both empowering and scary. What the hell do I really know about my hemoglobin count? It all seems a bit dodgy because you're dealing with something (health) that I've come to believe an expert should be consulted for. After all, in the U.S. kids spend thousands and give a decade of their lives to be able to put on a white coat and be an authority. Can it all really be bypassed? On the other hand my experience with doctors in India is that they don't really tell you much you don't know, like they work from common sense more than any specialized education. And usually the conversations are you speculating about what's wrong with you and what you should do about it, and the doctor just agreeing with anything you say. Madhu was on the phone with his doctor and even prescribed himself medicine. The doctor just said, "Yeah that's cool".

On one hand it's the way it should be. Our health is our own responsibility, and doctors are not magicians. On the other hand, one's health is a pretty risky thing to be mucking around with, and there is a need for specialized expertise. My feeling: bring on the a la carte health paradigm, as long as I have access to insights about my urine like this:

Not Your Average Farmer

Friends,

I am proud to announce that my first-ever magazine article has been published! I was invited to write for Interactions magazine, which is published by the Association of Computing Machinery (ACM) and has the vision of providing "timely articles, stories, and content related to the interactions between experiences, people, and technology." Granted the magazine is no Salon or New Yorker, but I still consider it an honor. Although it's geeky and quite academic, I enjoyed writing for the magazine because it was less restrictive than typical scientific writing. I could write in the first-person and add a bit of humor, and it could be about a topic that is not necessarily scientifically interesting, but interesting nonetheless. In the end I'm quite happy with how it turned out, hope you enjoy!

Not Your Average Farmer: Designing for Lead Users in ICT4D Research

Thirsty?

We have a wide selection of "Cold Drinks", including...

Only. In. India.

Multivariate Bridges and Metaphysical Mangoes

Last weekend Nimo came to the group with a problem. On the main pathway between a slum in Ranip and Manav Sadhna, a stream had built up due to the persistent rain we've been getting lately. The stream was pouring through the passway from a storm drain that also contained waste water from the locality. The issue was that kids from the slum trying to get to MS had to cross the stream daily or more with no proper way to walk, and between the water's filthiness and the pressure it was rushing with, it was becoming a dangerous situation. Rumor even had it that one kid had climbed a parallel drinking water pipeline to cross the stream and had fallen from a considerable height.

So our Sunday project was to go down to the stream and fashion together a safe walkway across the water. Nimo had prepared 3 sandbags that he figured we could place over a bed of well-placed rocks that we could collect from around the stream. Seemed straightforward, but that's about where it stopped being so simple.

We got to the slum in the morning around 8. Our team consisted of myself, Nimo, Anjali, Jeego, Jesús (a volunteer from Spain working with MS through Australia-based Arichtects Without Frontiers), and Sachi. We also recruited some of the local kids to help. They were overjoyed to see Nimo and Anjali, I think half of them thought we were just there to play. We were, but the game was going to be carrying around heavy rocks and wading around in filthy water for a few hours.

When I got down to see the stream for the first time, my mind turned quiet. This was not going to be a rinky-dink Sunday morning project. This was a serious stream, clearly a hazard for a kid, an adult carrying supplies or vessels, animals, or any other entity trying to cross. Building a durable bridge was going to require some smarts and creativity. That was my first reaction. My second reaction was that I wish Jay was here, because he has a lot of smarts and creativity, especially for engineering puzzles like this. If he was there he would have MacGuyver'd the optimal solution. Alas.

At this point, the elements of a multivariate calculus problem began revealing themselves. First, there was the practical issue of our bridge solution. Clearly we needed something that was sturdy and safe. Couldn't be too high in case someone falls, can't be too low to be pounded by the water. And clearly we had no money, so it had to be cheap. A local man living right next to the stream said straight away, rocks and sandbags were going to fail. The pressure of the stream built up in the afternoon, and with any decently hard rain the structure would get washed away. He even pointed out the remains of previous ill-fated attempts scattered on the banks a bit down-river. Go ahead, he said, spend your morning doing a bunch of heavy, dirty lifting. It will be a waste of your time.

I agreed, we needed a better solution. Talking to some of the local boys, I found out that there was a cache of wood in the slum, kept by one of the kid's fathers. I went with two of the boys to go to check it out. We got to the home and on top of the roof was piles and piles of long, straight bamboo. Now we're getting somewhere, I thought. There were even some ladder-like structures fashioned out of the bamboo with some twine. Build two of those babies, I thought, lean one off of each bank, anchor where they meet down in the middle of the stream with rocks and sandbags, and you could have a simple v-style bamboo bridge.

I really wanted to just take the wood down with the boys and be on our way, but of course it would not be so simple. Vinubhai, the kid's father and keeper of the bamboo, had just gotten back home and needed to know what was going on. I explained what we were doing, and he seemed to generally be on board with using the bamboo. But, he said, I had to go over and get permission with his brother a few houses down. So I go over there, and there's more smiling and explaining. Then I get sent back to Vinubhai, who has now decided to come with us and assess the stream himself. And with him a third relative joins. So we head back down, no bamboo in hand, but more people from the slum. New variable: the community must be bought in.

Vinubhai looks things over and agrees that bamboo could work, but we would need longer pieces to stretch all the way across plus 5 meters of additional slack for support, proper fastening, mounting, etc. Then the money issue. Who's paying? And now that money is in the conversation, more expensive solutions are tossed out. What about a steel-based solution? Which introduces another variable: bridge security. If we use steel, someone will attempt to steal it, it fetches a high resale price. Even if you try to anchor it, theft will find a way. So, the bridge will require spending, but it can't be too expensive. Then another variable: animals. If they step on your bamboo bridge, it will surely collapse. You have to keep room for animals to cross separately, or build with the assumption that cows will be passing through as well. Then another variable: longevity. Is this a short term or long term solution? Maybe we just build something to last the winter, and then take the time to raise money to get professionals to come in and build something legit. But then what if that doesn't end up happening? We're stuck with a short-term bridge for the long term. Then another variable: environmental-friendly solution. If we get professionals to do something with concrete, it's not as sustainable as bamboo. Earth-impact should be accounted for. Then another variable: community engagement. How many people do we want to involve? The more that come to the table, the more opinions and less chance of consensus. But you need people in the community to feel a sense of ownership over the solution. Ideally they should contribute to it themselves. But then if it gets to be too big of a deal, and the government or media catches wind, then the bureaucracy machine could get involved, and that could lead to more overhead and delays. Peepli live. And then people will propose more and more elaborate solutions, requiring more money and deeper involvement from more people. Didn't we already bring up the money variable? Vicious cycle. Wait a minute, what are we doing here again? Building a simple bridge across a simple stream to simply walk!

At this point our team was less interested in vetting the issues and more interested in doing something, so we cut all the crap and started gathering rocks. As big and as many as possible from the surrounding area. Meanwhile Jesús embedded in the stream to receive the rocks from an assembly line of workers and fashion them into a sturdy foundation. This was grueling work, standing knee-deep in rushing water ripe with bacteria and fecal matter. Once we had gathered most of the big rocks around, we found discarded burlap sacks and filled them with smaller rocks. Then, one of the youngsters came up with a genius idea... lead pipes! There were a few laying around the banks, and a few that we dug up. The nice thing about the pipes was that they don't absorb the full force of the water pressure. You set them parallel to the stream so water can just rush through. So the bridge took the form of a rock/pipe medley, and was looking great. One more pipe and a bunch more rocks and we may have something. Until...

Another local man living near the stream arrived on the scene and took particular exception to us using the pipes. These pipes belong to me, he claimed, you cannot use them like this. And then just like that, as we are working on one side of the bridge, he wades into the stream and dislodges a pipe from the other side, sending it rushing down the stream. Later we are able to talk him down and even get him on our side to help build the bridge according to (of course) his own pet design, but the damage had been done. Now we're scrambling to make due without the pipes, racing against the rising tide as the morning gets older.

And we are losing the race. The rocks don't seem to be holding well enough with the rising tide, and the sandbags instantly get punctured and flimsy once we set them down. In the end we had something of a bridge, but it seemed mildly worse than whatever was there for walking before we got there. An illusion of a strong bridge is more dangerous than no bridge. So along the bridge we did our best to dislodge what was loose and strengthen what was strong, and left it at that.

There was much food for thought from this experience, but I'll focus on two personal key takeaways. The first is the insight that in life there are rarely simple solutions, and there are a lot of complicated problems that are deceiving. I came in with the expectation that building a bridge is a self-contained problem, mostly involving engineering the right physical solution. But really it was a people, money, motivation, even political problem, at least as much as it was technical.

Second takeaway was a question to ponder: When performing actions, is the right intention enough? We came to the slum on Sunday morning with the more or less pure intention of serving the community in a small way. The problem was we were carrying a slingshot into a war where everyone else had Uzis and grenades. In retrospect it was naive to think we could come in with a few sandbags, a shovel, a bucket, and a few hours of time and expect to come up with a satisfactory solution. I told our team how I thought we should either have come with everything we would ever need (hundreds of sandbags, thousands of long thick bamboo, rope galore, a concrete machine, a suitcase of cash) or nothing at all (just to observe and understand, to come back later with proper preparation). Anything in the middle would be half-ass. And what about the fact that we walked away leaving the situation we came to fix 5% better off, plus-or-minus 10%? This was my mind's competitive, ambitious, practical impact side, yelling impatiently.

But then there is a case to make for simply acting with a pure intention. This is the long-view, million-lifetimes side of my mind, calmly whispering. Sure we only brought a slingshot, but we showed up to fight with spirit and fearlessness, didn't we? It's the William Wallace way. And just our presence there surely mattered. We showed ourselves and others around that we cared. The ripples that pure-intentioned presence creates is hard to either capture or predict. One of those kids with us, taking a lesson in determination and seeing things through, could have gotten the inspiration to do so. Or a community member, observing how much outsiders care, could start caring more herself and eventually act.

Where do these two sides of mind reconcile? I think the middle ground is paved by qualities I have come to learn about and appreciate through meditation: patience and persistence. There is not a quick-fix solution here - be patient. You want there to be a successful outcome, you don't want to develop a half-assing habit - be persistent.

On that Sunday morning, though we weren't able to bear fruits, we did plant seeds. As Goenkaji says, you can't plant bitter neem and expect to get sweet mangoes. You reap what you sow. One thing I know for sure we accomplished that day: we planted a forest of metaphysical mangoes.

So if I don't die, is the ride free?

Only in India.

Pizazzed

This summer Tap and I opened up an office in Ahmedabad, our own space to keep our servers and work from whenever we are here. The office is property of Tap's father-in-law, who generously let us move into the prime location in Navrangpura. I absolutely love it, a place to call my own, and it lets me live out the cliché of a computer technologist starting a new venture from humble garage-like beginnings.

When I first moved in, the office was spartan and a bit unkempt. We had our server on a plastic table with plastic chairs, the walls were barren, and there was a stubborn ant problem. Save for a decently comfortable couch and an A/C, the place had nothing interesting going for it. This was not lost on a certain few roommate-neighbor-friends (who for security purposes will remain nameless) who came and visited the office over the last few weeks. Amongst those friends, a particularly articulate one said how the office was great, but needed 'pizazz'. Yes, I thought to myself, you are tiny, but you speak the truth.

I didn't think much more of it until earlier this week after returning from my trip to Madhya Pradesh. I got back from the airport in the evening and went straight to the office to take care of some pending work. As I opened the door to the room, it was dark so I couldn't see anything. But a zen-style bell attached to the door chimed to welcome me. That got me mildly confused, but when I switched on the light I realized what had happened. While I was away, my office had been pizazzed:


The walls had posters with inspiring quotes, there was a framed picture of Gandhiji and Kasturba above the desk, a huge "Be the Change" canvas, a map of India, some inspiring trinkets here and there. I didn't notice it that night because it was dark, but in the porch/otalo area out front, some lovely flowers had been planted along the pathway:



Seeing everything that first night, I couldn't stop smiling. I had come to the office to do work, but all I could do was smile. I wrote exactly that in an SMS to my roommate and neighbors (who, again, for security purposes will remain nameless). Later I asked each of them whether they happened to know who was behind this wonderful act, but they were conspicuously silent. Verrrry interesting, because silence is not the strong suit of certain individuals. So be it, my friends, I only wish you the best in the future as what goes around inevitably comes around. I have tried not to compromise your identities here, but only so much is in my hands. May God protect you.

And so I am left to offer my gratitude to all the silent angels of the world (including those living at Shreeji Krishna Apartments, Keshav Nagar, Ahmedabad). Thank you all, for bringing a smile to my face and the warm embrace of noble friendship whenever I sit down to work in this space.

Unnati

Last week I was in Madhya Pradesh visiting PRADAN and Digital Green, two organizations we have partnered with to provide voice information services like we have in Gujarat for PRADAN's operations in Dindori district (you can read about last year's visit here). I went there to co-facilitate an orientation on the voice system we had set up, which they named Unnati Kisan Seva (Unnati means "progress", also the name of the farmer's cooperative they had recently formed; kisan seva means "farmers' service").

With me in MP were Rikin, a good friend and founder of Digital Green, and DG's CTO Saureen. Both had flown down from Delhi to attend the orientation and also get updates from the field on their own collaboration with PRADAN. As a quick summary, PRADAN is an NGO working in several states in India to develop comprehensive livelihood enhancement programs in rural areas. They work on agricultural productivity, natural resource management, self-help group promotion, and other related programs to improve livelihoods. Digital Green is an innovative organization that has developed a technique for disseminating technical agricultural information in rural India using locally produced videos. They have a process developed in which they train local people in villages to produce films, organize screenings, and provide follow-up support to farmers in their area in adopting the practices in the videos. The kicker is that the videos feature local farmers themselves demonstrating the practices, which they found to be more effective than traditional agricultural extension where outsiders give top-down advice.

The day we got to Dindori we went out to to observe video production and a dissemination (i.e. a screening of a locally-produced video). I was thoroughly impressed with what I saw. The farmer being filmed for the video was a quintessential lead farmer: innovative, confident, eager to share. I was happy to learn that out of 10 videos they produce in Dindori, 6 come from first-time farmers, so it is a pretty diverse group. The dissemination, held in a church, was really well attended, and the trained local person tasked with hosting the video screening and providing support (called Agriculture Specialists, or Agri-SPs) was patient and thorough. The screening started with a recap of what was shown in the last screening and updates on whether anyone adopted those practices. Then the film was played once with the Agri-SP interjecting and emphasizing key points every now and then, then the film playing one more time uninterrupted. After that there was review of what was seen and learned in the video, and some encouragement to adopt. I later talked to Rikin about how I thought the key to these videos was striking a balance between showing something substantial (big enough so that a clear benefit can be realized) and digestible (small enough so that the practice can be readily implemented). It seems that DG has developed an effective feel for taking highly complex practices like SRI and breaking them down into self-contained sub-practices, each with their own immediate and independent benefit.

With voice-based information services like Avaaj Otalo, Rikin and I both see a potential complimentary technology to video-based information dissemination. With voice-based information access, the Agri-SPs can share common problems and experiences, quickly escalate questions from farmers to agricultural scientists working with PRADAN, and have more steady communication with the central PRADAN offices. With these goals in mind we soft-launched UKS in July.

To kick things off formally, we held an orientation for all the Agri-SPs last week. My framing for the orientation was to have it accomplish 3 goals for the Agri-SPs: awareness (about UKS and the nuts and bolts of how to actually use the automated phone service), utility (establish the need for UKS with Agri-SPs and articulate concrete benefits to using the system), and ownership (engage with the system as their own, create a sense of team amongst all the stakeholders, and put faces behind the process to bind the system together).

The orientation brought together about 40 Agri-SPs. We all sat in a hall in the PRADAN office and began the day with a lovely poem read by Archana, the head coordinator of PRADAN in Dindori. I don't remember the name of the poem, but the gist of it was a message of empowerment: "When you tell yourself you cannot do something, you hurt yourself and others. You can do anything you set your mind to". It was like a Hindi folk version of Nas 'I Can', and I thought it set the tone wonderfully.

From there Satyam (the DG coordinator in Dindori, an absolutely awesome guy) and I led the group through a full day's exposure and orientation to UKS. I'll just summarize what we did with a couple noteworthy observations. First, in the phase where we wanted to establish UKS as addressing a real need and providing actual benefit to the Agri-SPs, we tried to elicit ideas about what those were from the group itself. Better if the group comes to the conclusion that they need UKS for X, Y, and Z reasons themselves, rather than us telling them what they should think. Good idea in principle, but this ended up more or less failing. The group had difficulty articulating their own needs, and when they did, they were not what we had in mind. Another noteworthy observation from the orientation was when we had the group get hands-on with UKS by dialing the number, navigating around on their own phones, recording messages, listening to messages, etc. As my work on this project has gone on over the last couple years, I regularly get suggestions from people on ways to improve the system with new features. "Just add the ability to search through messages, that will be fantastic!", or "People should get SMS sent to them as alerts about new content", or "People should be able to upload videos". For all of those people, I wish they would have attended this orientation and watched this group of relatively savvy rural Indians call an automated system and navigate a few measly prompts to just record a message. They were confused, lacking confidence, at times completely lost. It was a vivid reminder to me why our system is so simple. If the goal is to broaden access, the barrier to entry for first-time/new users must be extremely low. They should get value from the system even if they are confused, hoping that over time they will learn how to use it. But losing them from the beginning through overly complicated interface would be a fatal mistake.

My favorite part of the session was at the end, when we summarized UKS work flow and its ecosystem of stakeholders. I had prepared this diagram to illustrate the work flow, but it really didn't come alive until Archana had three people stand up and play the roles of the various stakeholders, acting out how the system would work in a playful way. It was funny and light-hearted, and I think it helped humanize the whole system. In my mind that is key.

Despite the challenges, the orientation as a whole was a success. The group enthusiastically approved UKS with a roaring round of applause and they even had me cut a cake to celebrate the 'birthday' of UKS. Though I felt satisfied with the outcome of the orientation, I am cautious about the uptake of UKS going forward. It will take sustained effort from all stakeholders to make it all gel, which can only come with the right incentives and motivations. In fact over the summer the feeling has been growing in me that the next big question guiding future research on Avaaj Otalo should be the non-technical, human-focused aspects of making the system work. What motivates people to really engage with the system, both for information consumption and production?

This visit was a great chance to spend time with Rikin, whom I really admire. Here's a guy who graduated from MIT and started out wanting to be an astronaut, came to India to work on a bio-diesel venture, spent six months in a village in Karnataka working on agricultural extension, started DG based on what he learned, and has not looked back since. I consider Digital Green to be one of the few real success stories amidst all the recent hoopla around information technology applied to rural development in places like India. Rikin is now starting to get some recognition in broader circles, which is absolutely well-deserved. As my own work has started to gain momentum, people often suggest that I tie up with large agricultural companies, phone carriers, the government, etc. to really scale up and take the project to the next level. I'm usually quite cautious about such things, because to me it's not where your work goes, but how you get there that matters. It's why ten times out of ten I would choose to work with someone like Rikin, who may be doing something smaller-scale but does it with values and commitment that I align with. In Dindori, we've tried to do things the right way; I'm interested to see what fruits that will bear.