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Indian paradoxes and beer pong -- a paradox in itself

The New York Times has a good story today that explores the wide gap in the quality of living in India between the haves and have-nots. One of the most striking things about this country is how a portion of the population lives in the 21st century with all its technological advances and comforts, while a substantially larger portion lives an existence the developed world shed three generations ago.

I've been to clubs in Hyderabad that charge a $5o cover. Of course, I didn't pay that. I wouldn't pay that in the U.S. But there was a line winding out the door. Just behind that building, a family might share a 10X10 hut with a leaky roof and no power or running water.

Income disparities certainly exist in the U.S. and they have greatly increased in the last decade or so if you believe John Edwards or Paul Krugman. But the disparity is much more obvious here. Maybe that's because the poor are so numerous or the malnourished children are painful to look at.

A week or so ago, my roommate Aparna told me that all my pictures make India look poor and that I should take pictures to show the rich side of the country. Now, Aparna (who likely will read this) has been a fantastic roommate, and I'm glad to say we've also become good friends. She's a kind, intelligent person. But something she said to me in my first two weeks in India has stuck with me.

We were walking through the Gandhi Government Hospital, and I was struggling not to show shock at the abysmal condition in which the sick people were being treated. Aparna explained to me how difficult it was to become a doctor in India because of the strict quota system. (India grants a certain percent of all government-funded schools, jobs, etc. to people from lower castes. It's one of the most aggressive affirmative action policies in the world and heavily criticized.) I asked why doctors would work at Gandhi when they could work in the private sector and make much more money. I asked if they did it out of compassion for the poor.

Aparna looked at me with a completely straight face and said matter-of-factly, "No one in India does anything out of compassion."

I've thought about that phrase a lot. I thought about it this morning when someone emailed this link about an Indian man who is building an $1-billion home in Mumbia. It's a 60-story skyscraper that will have six floors just for his family's cars. How can a man completely ignore the destitution around him and devote such a great amount of money to such opulence? I think it's disgusting.

Which brings me to my last Saturday night in India, in which a large group of expats played beer pong until the wee hours of the morning (rough transition, I know). Check out the photos here.

Here's a post that I wrote this week for The Health Care Blog about hospital care in India. Sorry, it's kinda long.

Walking through the government-run Gandhi Hospital in Hyderabad, India feels like stepping back 50 years in time. The nurses wear white dresses with those funny paper napkin hats. Exhausted people overflow the stuffy waiting rooms. Family members sleep and eat on the hallway floors while waiting for their sick loved ones, who lie on thin cots crammed together like sardines in the dim wards.

Before you get the impression that this scene depicts all health care in India, follow me to Rainbow Children’s Hospital or Apollo Health City located an hour away in the most affluent neighborhood of this city of 7 million. These corporate hospitals offer sparkling clean facilities, the latest technologies and even luxuries like flat-screen televisions in the super-deluxe patient rooms.

Apollo is the largest hospital corporation in Asia and a significant player in the international medical tourism industry. On a recent sweltering afternoon, Radhey Mohan, general manager of international patient services, gave me a tour of Apollo’s Hyderabad campus and told me about future plans to expand Apollo’s medical tourism business.

While these corporate hospitals offer state-of-the-art medical services to foreigners seeking a bargain, such care is a dream for most Indians.

Despite the media frenzy around medical tourism, I believe many Americans envision health care in India exclusively like the scene at Gandhi Hospital. I know my mom does. She fretted that I was going to India without health insurance. She didn’t believe me when I told her that if I had an accident or became ill, it would be a better deal to pay cash for treatment here than fly back to the U.S.

The reality is that there is a gap the size of the Pacific Ocean in the quality and availability of health services in India. Many villages have no health care services, and at under-funded government hospitals like Gandhi, equipment is archaic and the staff is overworked. There is no government safety net for the one-third of the population living on less than $1 per day. According to the World Health Organization, India spent only 5 percent of GDP on health care in 2005, and 75 percent of that came from individual pockets. While it has made progress in the last 50 years, India ranks near the bottom on many public health indicators, such as infant and maternal mortality rates.

Yet, Middle Eastern oil magnates come here to hospitals like Apollo to undergo Pet Scans and nuclear medicine tests. Apollo nursing stations all have computers, and in a few years, Mohan told me the entire hospital will be outfitted with an electronic medical records system. Many of Apollo’s physicians have worked in the U.S., and following the recent trend of the reverse brain drain have returned to India to develop thriving practices.

One of the first things many foreigners notice while traveling the streets of Hyderabad is the incredible number of hospitals here. It seems you can hardly go more than a block without seeing a sign advertising hospital care. Typically, the facilities have fewer than 30 beds and focus on a particular specialty, such as maternity or heart care. But given their volume, it’s difficult to imagine that just 25 years ago, India had no private hospitals. In fact, banks were prohibited from financing corporate, for-profit health care.

In the early 1980s, Dr. Prathap Reddy returned to India from the U.S. with a vision to open a private hospital. Through an aggressive lobbying campaign, the founder of Apollo Hospitals convinced government officials that the public sector could not meet the health care demands of India’s increasing population. Over the last two decades, Reddy built a monolithic brand that now operates more than 40 hospitals, hundreds of pharmacies, dental offices, nursing and hospital administration schools and more. Following Apollo's lead, India's private health care sector has exploded in the last decade.

Like most corporate hospitals here, Apollo has a mixed reputation. While I have heard no one dispute that the chain provides high quality care, I’ve heard many critical comments regarding its intensively corporate culture. Making money, many have said, is above all its chief concern. Treating the poor is a matter of "corporate social responsibility," and its services and prices, like those at most high-end hospitals, are far beyond the reach of most Indians.

Mohan and I talked a lot about the changing health care demands of Indian consumers in the growing middle class. As incomes rise, so do expectations. Middle-class consumers will no longer tolerate long waits and inadequate care at underfunded hospitals. They know about the latest technologies and demand them, Mohan said. “The consumer in the Indian market has changed,” he said.

At Apollo, 60 percent of patients don’t have insurance and pay cash for services. That’s an extraordinarily low percentage considering only 2 percent of India’s 1.2 billion people have health insurance. The insurance market, however, is also undergoing a revolution. Many of the nation’s major banks now offer insurance products. Apollo tied up with the German-based DKV Group to offer insurance. Certainly, more foreign health plans are eying the Indian market. United Healthcare recently teamed up with ICICI Bank to offer a health insurance product to Indians traveling to the U.S.

McKinsey released a report recently saying the current market for medical tourists is smaller than the media hype would lead people to believe. A previous report by the consultancy, however, estimated that more than 150,000 medical tourists
visited India in 2002, and the number would grow 25 percent annually. Mohan told me Apollo has targeted it as a key growth area. Company wide the firm had more than 20,000 foreign patients last year.

At the Hyderabad campus, Apollo is building an entire new wing for international patients. The new building is across from the building that hosts the Apollo Health Highway, which is a tie-up with IBM to connect doctors across India to an EMR system using mobile devices, such as cell phones. It’s an interesting and ambitious project. On the second floor of that building, dozens of Apollo employees process medical billing claims for U.S. doctors.

Apollo has apartments on the hospital campus for family members of foreign patients to stay in and for the patients to recover in after the procedure. Patients can choose between super-deluxe private rooms or shared rooms, depending on their budget. Before arriving, Apollo doctors review electronic copies of the patients’ CT scans and MRIs sent over the Internet and discuss the patient with their regular doctors at home. Once they arrive, hospital staff greet them at the airport and guide them through immigration to the hospital campus. Really, if they don’t want to “experience” India, they don’t have to.

In Indian hospital care, the past and the future co-exist. The lucky tourists and Indians who can afford to go to the corporate hospitals with new technologies and excellent medical staffs can be assured they will receive top-notch care. But far too many Indians have no care and inadequate care. Certainly, the private health sector expansion in the last two decades have benefited the country, but it hasn't eliminated the embarrassing gap in quality and availability of health services. Some say the government must intervene, and whether and how it chooses to do so will be interesting to watch.

Photos from Kerala

Here are some photos from my recent trip to India's southernmost state, Kerala. To see more go here.







Yes, the bathrooms I am often forced to use look like this one.

Certainly not a nanny state

I went to the store after lunch today to buy some chewing gum. While I waited for change, a small, barefoot child came in and stood on his tippy toes to put one rupee on the counter. He was no older than three and could not see above the three-foot counter. The cashier gave him two small chocolate candies for his rupee, and the satisfied boy wandered outside.

I followed him outside and looked for his parents. He didn't appear to belong to anyone. This store was on a very busy street and traffic in India doesn't exactly obey lines, speed limits or rules of any sort. As the child walked, he looked down, focusing on opening his chocolates. He was oblivious to the honking rickshaws, and nobody paid any attention to him.

What's striking here is that his three-year-old child was alone amid heavy midday traffic, and nobody thought it was abnormal except for me. I feel confident, however, that this barefoot toddler will be just fine. So I left.

Several scenes here have made me wonder whether the U.S. truly is a "nanny state." In California, lawmakers proposed last year to ban smoking in cars with children. Here, entire families of four -- mom, dad and youngsters -- ride without helmets on one motorcycle. In the U.S., parents would probably be jailed for such behavior.

I'm not saying riding without helmets is a good thing. Likely some one, some day will get hurt. But accidents happen here and everywhere. We can't pass laws to prevent them all.

I would never let my nieces and nephew wander along a busy street alone, but I've come to realize what a luxury all our American coddling is.

Mangoes galore

Who knew there were so many varieties of mangoes?


Just like apples, there are many kinds of mangoes and each has a slightly different taste and purpose. There are mangoes for cutting and eating fresh, mangoes for sucking the juice, mangoes for making pickles and mangoes for making dahl.

Oh, how I will miss the mango when I leave India!

Training videos

Part of my work at LifeSpring is to turn parts of its procedural manner into training videos. Here's my first one about how to properly dispose biomedical waste. Thrilling, right?

RAIN!!!

It rained this morning and the temperature dropped at least 15 degrees. I doubt it will stay that cool, but the short relief was wonderful.

I'm going to Kerala tomorrow for a week, where it is raining a bunch. I'm not sure if that's a good thing or bad thing. Kerala is known for its backwaters, which essentially are a system of rivers, that people use as roads. Kind of like Venice. There are also some jungle areas, which I'm going to check out.