The Grand Finale: Where Do We Go From Here?

It has been a week since the Indian Health Field Seminar ended. Between the struggles of dealing with jet lag and the sometimes echoing question, “Did all of that just happen?” I found myself reminiscing, wincing, and missing the following things about India:

1. The amazing maneuvering capabilities of tuk tuks (auto-rickshaws).
2. The sometimes overwhelming smells (you have to experience them to truly understand what I mean).
3. Amazing hospitality.
4. Unique perspectives on american food.
5. The rich culture and sites like the Taj Mahal.

But, more importantly, this trip also gave me a new perspective on not just how we live here in the US, but also how much we may take for granted. And, as we see healthcare systems like that seen in India, it will be our ability to apply some of what we experienced and learned about the Indian Healthcare System to our own U.S system that will be paramount to our success. I know that it will take a collaborative effort across a spectrum of industries and disciplines.

From what I learned at our last visit with GE Healthcare, many instances of wiping the “slate clean,”“building from the bottom up,”and building products specific to the market and the market’s needs have allowed GE to create products in the Indian market at 1/6 the cost seen in the U.S. For some, that may sound too easy, or too “big picture.” But, maybe not. Right now, our healthcare system is not tailored to the needs of the market, resulting in inefficiencies and wasteful spending. I do believe that we can deliver a substantially lower priced and more efficient system; it can surely be done. It’s just a matter of when? And, if we can arrive at those changes sooner, rather than later, will be the ultimate question with an answer that will dictates our fate.


As a first year MBA student in the Health Sector management program, this was an invaluable professional and cultural experience to have early in the program, and I am so excited to build upon this experience in the upcoming semesters.

Jobs in India

There were many things to adjust to during our trip to India – many were things that I had anticipated: the lack of Western toilets (or “squatters”, as we so fondly dubbed them), the spicy food, the crowds…but one of the things I didn’t expect to witness was the intense level of service and number of employees (both official and unofficial) assigned to one particular job or task.

When I first landed In Kolkata, a boy who couldn’t have been more than fifteen years old insisted on carrying my bag and helping me find my pre-paid taxi. And when leaving Bangalore, Jim, Rachel and I experienced something similar where an airport employee trailed us throughout
our entire check-in process, leading us to the airline desk, the security line, and ultimately asking for a tip. Later in Kolkata, I went to a salon to get my hair cut for the wedding I was attending and was surprised to see that I had not just one but two (or sometimes three) stylists working on my hair.

Three weeks ago, I would have not accepted this kind of assistance, insisting that I am comfortable carrying my own things and finding the taxi myself, or I would have balked at the number of people tugging at my hair in the salon. But in India, I had to look beyond this and just give in to letting someone else (or in some cases, several others) do certain things for me, of which I am completely capable myself and would normally prefer to not burden someone else
with. But this is not an exercise in etiquette. Rather, it’s acknowledging that those who are insisting on helping me are doing so because they really do need the [tip] money, and that it doesn’t help either party to deny their assistance.

We’ve seen how excessive the service can be in India and we have seen many instances where there appears to be at least two people doing the job of one person; this seems to be at least one of the ways in which India has chosen to respond to its massive population and the jobs that such a large number demands.

In Kolkata, the sidewalks were being dug up to lay piping that ran straight up and down one of the city’s biggest avenues. The road work evidently provided jobs for dozens of workers that dug through bricks night and day. These workers were doing the job that one backhoe could have quickly done in a few hours. Again and again during the seminar, we recognized that India is extremely tech-savvy and has a lot of talent, but hindered by its lack of infrastructure. The flip side of this, I’m thinking, is that while the lack of infrastructure seems to prevent or delay the creation of more “sophisticated” positions (and consequently filling them), it does create jobs
that require less education, less skills (road work, digging, the high number of street food stalls, etc.). I am therefore wondering about how deep of an effect will technology-advancement, increased automation and improved infrastructure – when and if achieved – will have on
job availability and unemployment rates in India, particularly to this one very large part of the population that depends on this type of labor for work.

Revisiting India

Between fighting jet-lag and trying to keep up with the reading for my public health classes, I've been revisiting pictures from India. I'm glad I had a really great time on this trip because I left for India feeling rather anxious. It might have been the post-finals daze or the relentless reminders to avoid the tap water, dairy products, fresh fruits, meat, the street children, mosquitoes...the list goes on. Honestly, I think I managed to break all the rules within the first week, with the exception of avoiding tap water.

During my time in India, I managed to place myself in rather uncomfortable situations. For example: being the fourth person in a tuk-tuk ride in the middle of heavy traffic, having to use a squat toilet in Old Delhi, navigating the small alleys of the Dharavi slum, and crossing the traffic-laden streets of Bangalore during rush hour. The discomfort of these situations and many others while on the trip helped me to become a more resilient traveler and less high-maintenance overall.

While I can't say I learned the art of crossing an Indian street, I did learn to love the energy that pulsates all throughout India. Despite the sometimes chaotic conditions of the country, the Indian people are welcoming, highly innovative, and tirelessly entrepreneurial. As I progress through a career in global marketing, I really hope I get the opportunity to live and work in India in the near future.

ASHAs

Of the hundreds of pictures I've taken on this trip, this image of the ASHAs from the National Rural Health Mission is one of my favorites. The ASHAs are Accredited Health Activists who are selected to act as intermediaries between their villages and the public health system. The photo reflects the positivity with which the ASHAs approach their duty of educating and engaging members of the community, despite the dire public health situation that surrounds their village. It is empowering and inspiring to see these women take the health of their community into their hands. As the ASHAs show us around the village they nurture with dedication, the effectiveness of their work becomes more and more evident. They are more than happy to showcase their spirited community, filled with healthy mothers and lively children.

In some ways, these ASHAs represent what we all desire and find difficult to obtain in the US - a personal health advocate, who is culturally competent and sensitive to one's changing needs. While the ASHAs live in a world so drastically different from the one we are familiar with, we can learn a lot about delivering care just by observing their enthusiasm and passion for health in their community.

Dharavi

During our trip in Mumbai, we visited Sion Hospital where we were briefed on their Urban Health Center. The center serves the people of Dharavi - a slum in the heart of Mumbai. We also had the fortune of touring Dharavi to see the conditions of the slum and the people the clinic serves. Although Dharavi is home to a middle class, we only saw extreme poverty. The slum was dirty, unsanitary, overcrowded and there was a lack of clean water. One of the larger homes we saw was a 300-400 sq ft loft that housed a family of at least 6.

Despite the deplorable living conditions, Dharavi is a self sufficient community. Most people make their sole income from the various industries that were set up in the slum such as recycling, pottery, and textiles. We only witnessed the pottery trade, but it was amazing to see how much they could produce and how they could sustain themselves with so little. However, the success of the pottery industry comes at a cost to the community. The kiln sits directly underneath multiple homes and emits toxic smoke into them, further polluting the slum environment.

UHC provides a multitude of services to the community such as an advanced maternal health clinic, STI clinic for men, cancer screening, and they are even making their own version of plumpy'nut to curb malnutrition. I spoke to a doctor at the Urban Health Center and she said that all outreach services are provided for free and medical services cost only 10 rupees (about US $0.20). Medical services include all meds and the ability to use the clinic for 15 days. The government subsidizes the costs since Sion is a public hospital. Regardless, it was surprising to learn that the government covers such a large portion of Dharavi's healthcare costs since so much of India's healthcare is paid for out of pocket. The programs are promising, yet I worry about its funding. Knowing how corrupt the Indian government is, I wouldn't be surprised if corners were cut in the development of the clinic and the services provided. It's a pessimistic view, but often the case in this country.

To Copy or Not To Copy

During our time in India, we saw two different sides of the pharmaceutical battle. On the one hand, we visited Anand and Anand, a law firm specializing in patent law that represents many multinational pharmaceutical companies in India. On the other hand, we visited companies like Cipla and GSK, which produce generics in India, both for local use and exportation.

The battle between the two sides does not really have a good and an evil; rather, each side has its valid points. The multinationals feel that they need patent protection in order to recoup the costs of developing drugs, which takes many years and a large amount of capital investment.

The companies that create generics view their job as to feed affordable pharmaceuticals into the market, allowing those who could not otherwise afford medicine access.

Both sides make good points. The generic companies and the market would not have access to any pharmaceuticals if the multinationals did not spend money developing those drugs, which necessitates them to recoup their costs in order to reinvest. But, at such high costs, the middle- and low-classes in India can not afford access to those drugs.

One option which was discussed during several of our visits was the system of licensing patents. Generic companies would pay fees to multinational developers in order to have access to the patents for specific drugs, allowing the multinationals to recoup some of their costs while paving the way for generics to send low-price drugs into the market. However, this system would naturally raise the price for drugs coming from the generics - though likely not as high as those from multinationals with monopolies on the market.

No system is perfect. Heavy patent controls make pharmaceutical costs too high, low patent controls eliminate margins for multinational developers and would eventual eliminate innovation. India must find some middle ground in order to provide access for its people while still making pharmaceutical development worthwhile for multinationals without placing the burden of cost on other nations.

Coming into focus

This view of the beach in Goa is a perfect example of India's perspective problem. From afar, it looks pristine and idyllic. However, as you get closer and closer to the action, the picture gets less rosy. Sitting on the beach you'd observe a decent amount of trash and general debris. You might be lucky (or unlucky) enough to see the people in charge of cleaning the beach burying all the trash the collected in the sand.

As we toured the wide array of healthcare facilities in India, I was constantly reminded of this example. Even at the high end hospitals (e.g. Max Healthcare), things looked great until you got up close and personal. Solely looking at infrastructure, its easy to see the lack of attention to detail in the construction. While the challenges to the Indian healthcare are many, a focus on and commitment to quality throughout the system seems to be one of the keys to improving the system. Many of our hosts (e.g. Narayana) espoused a consistency in purpose and values, which was encouraging. Hopefully this is a trend that continues with a renewed focused on quality.