Pleasant and unpleasant surprises...

After an exciting journey through the Indian countryside, gripping the edge of my seat as we drove up misty mountains with poor visibility exacerbated by the glare of headlights on the road, my fear undimmed by the cautionary government signs warning of such catastrophes as falling rocks up ahead and tyres bursting due to overspeeding, I arrived in the busy traffic of Mumbai city once again, where the silent feud between myself and the driver over our choice of listening material - Saturday night Bollywood pop or Indian classical music - became entertaining as we flipped from radio station to radio station. And yes, I know that was a really long sentence.

A paragraph composed of just one sentence! What an interesting thought! (a la the flirtatious Ms Briganza of the classic Hindi film Kuch Kuch Hota Hai in response to one of her students' declarations, 'pyaar dosti hai' - love is friendship. Ms Briganza has a very interesting, upper middle class Anglo Indian accent.) Yes, an interesting thought indeed, but how else do you symbolise that you have so much to say and so little time and space? Circumstances are pressing me forward to move the frame of my narrative away from the Indian subcontinent, and yet I still have so many stories to tell about elective. There's my searing village visit with the mobile health team on my last day when I was called upon to use previously taught skills for the first time in reality -breaking bad news, multicultural communication skills, clinical data interpretation, facing ethical dilemmas - as I discussed a diagnosis of metastatic lung cancer with the social worker, who served as an intermediary for the patient's mother, while the aged patient herself sat in front of us, her true state of health kept concealed from her by everyone - even the big city doctors who charged exorbitantly for a battery of tests but didn't bother to explain them to the illiterate patient. But which dying person doesn't know deep down what is really happening? So many interesting clinical stories to tell, so much analysis and so many learning points, and yet I have to move on - condense them with commas and hyphens and overlong sentence, condense them because

I have already been in Chatrapati Shivaji intenational airport, gateway to India. I have already waited over 5 hours before my flight is open for check-in, watching the departing families, classifying the travellers into business and holiday and long term emigration. Seeing the other side of Heathrow and JFK and where else, appreciating that everyone comes from somewhere. I've already seen the builders in the Qatari Ramaddan heat and felt the movements of the earth, as people go round and ceilings go up. I've swapped my red passport for a green one now, wondering at the unfriendliness of my newfound compatriots. Compatriots? It seems like the word fellow is alien to here - nobody smiles, people only stare. There's no courtesy between strangers; are people recognised as fellow travellers, let alone fellow citizens? The flight is funny: bawling babies, women singing loudly, hand luggage that would form the entire export output of a small nation, people chatting on mobile phones even as the plane taxis, others exclaiming in aghastment...and yet, we press on. I've moved on.

Then there's the return to the motherland, the surprise at the landscape; yes, the red earth and the forests are recognised, but why does everything look so small? The tin roofs of buildings two stories high swarm the eye view, red like the earth. Is this the megacity? Still we press on, into the crush of arrivals, the escape from officials asking about Yellow Fever Certificates, the confused mess of immigration, the loving arms of family, the horrendous traffic, the cleaner city (but apparently only in some parts), the overwhelming sense of selfishness, the sapping of energy. This is not just metaphorical or personal: the constant drone of generator sets is part of the backround melody in this city's cacophonous song, if you would call it that, and I wouldn't, for by now I am cynical at the sophistry of the litterati and refuse to be a part of image moulding, white washing. So I can say categorically, frankly, and without any reservations, that I hate Lagos. Yes, I said it. But that's OK, because already it's time to move on to another city, which is to Lagos what Pune is to Mumbai. If Pune is the Oxford of the east, what is Ibadan? We'll see...

Bombay: a great place in which to practice your poker face

Imagine you are sitting in a bus in some very busy traffic. The heat is overwhelming and your mind is preoccupied with all the things you could be doing right now - more productive things. The congestion shows no sign of easing off any time soon. Slowly, slowly, you start to drift off. Now you are floating in a pool on a beautiful beach resort. Water from a nearby fountain sprays gently in your face. Your reflexive licking of your lips uncovers a surprise, for the fountain jets taste sweet! What tropical paradise is this? Suddenly you hear fumbling, and some shouts: 'I'm ever so sorry'. Your raft is capsizing. You get up with a start, only to discover that it was all a dream, unceremoniously cut short by a nearby accident with a Coca-Cola bottle: the fizz of the drink still sticky upon your face. A rude awakening indeed...

This, metaphorically, was my experience of Bombay. A rude awakening. A slap in the face jolting me out of my hitherto false sense of security about the world we live in. Bombay, Mumbai - the city that made me cry. That made me weep tears of frustration and sorrow and anguish at the utter depravity of the world we live in. Which was ultimately a good thing, for I cried out to God and got the salvation and comfort only he can give. But Bombay shook me up something silly. Perhaps this is a good place to start my story.

I have always been fascinated by Bombay - well, ever since I first read about it as a school child. Megacity of megacities, with perhaps unparalleled diveristy, Bombay captured my imagination. Its landmarks existed as real places in my head, thanks to its deracinated global offspring and their chronicles of early life. I dreamt of eating Kwality ice cream while walking on the pier to Nariman point. Perhaps I would encounter a family building sandcastles at Juhu beach, or watch a cricket match on the Maidan. All in the setting of a beautiful blend of colonial and contemporary architecture. You get the picture. Romanticism unbridled. I would taste some bhel puri and blend into the melting pot of this complicated city of culture. Who knew, perhaps I would even fall in love, just like in the movies....

(Never trust fantasies woven by writers, particulary expatriates or emigrés. Always take the fact of their displacement as a warning sign. Let them sort out their contradictory homesickness-bitterness on their own.)

How would I describe Bombay? Interesting. Overwhelming. Not unfriendly - in fact, the people in the city were mostly helpful. The things that disturbed me about Bombay did not have to do with the city itself per se, but what it showed me about the world we live in - after all, this is our future, is it not? Bombay is the financial capital of India, one of the world's next big economic superpowers. It teems with people. One of the things I love best about travelling is becoming anonymous for a while, getting to see how other people live and by so doing understanding more of the human condition. As we approached the city it occured to me that a person could die in a place like this and the world would keep moving. Nothing would change. Even the people for whom you were sacrificing your life would continue with the daily grind, for isn't that the harsh reality of existence? Why then are we here? I felt nearly suicidal at the thought, and remembered my loving family. Love and family are the most important things in the world, I'm realising. They are our greatest gift from God. This is probably the biggest lesson of all my cherished solitary travels in my short life.

I did not fall in love with Bombay at first sight as I did in Belfast and Paris. Nor did I beget an initially wary but eventually wholehearted admiration as I did in Geneva. I couldn't engage with the city at first contact. As a visitor you are advised to keep your head down, to ignore the calls of attention of people trying to sell you their wares or simply asking you for money or food. Refusing to acknowledge the existence of other human beings was terribly disconcerting. This, and the casual disregard for human life, the blatant discrimination between haves and have-nots in the city, were what chilled me. It is not easy to cross the road anywhere in India, as far as I can see. Everybody flouts traffic rules whenever they can get away with it. But the dog eat dog style of driving here, where big car trumps smaller car trumps three-wheeler trumps two-wheeler trumps pedestrians, was perhaps at its most dangerous here. At one point I was crossing the road with my travelling bag behind a mother and her two small children. We were standing at the crossing waiting for a break in the traffic. Suddenly, the flashy car that was parked behind us began to roll back - the driver was actually reversing into us, without so much as a by-your-leave! He was a bully, and knew that he could intimidate us off our patch of the road. Along with the driver, a wealthy looking man sat complacently in the back seat of the car, in the 'owner's corner'.

Bombay is a rich city, and bullying is routine here. It's the constant degradation of people who aren't paying customers. The lack of dignity for those who have the temerity to be in need. My friends and I were walking to the gateway of India in the pouring monsoon rain. I wondered if we could walk on the pavement adjacent to the Taj Mahal Palace Hotel, which was ringfenced by potted plants and a chain link. My knowledgeable friend said that the land belonged to the hotel and we probably would not be allowed to. I couldn't believe such a gross misappropriation of public space (how can a pavement be off limits to the public?) and convinced the group to try our luck anyway. It turned out he was right, we eventually got turfed out onto the rainy road and my Indian friend received a torrent of abuse from the security guard.

Before I arrived another Indian friend had warned me about this colonial mentality, but it was still shocking to see. What is even more shocking is the widespread cavalier response to this attitude, as if it is OK to accept prejudice. Isn't that what it is when we judge people on appearances only, presuming attributes without any evidence? Is it enough just to acknowledge these issues without challenging them when we see them? Prejudice is pernicious. It undermines our very value as human beings. I'm beginning to realise how important it is to accord people the respect that is falsely denied to so many, rather than demanding it for ourselves. Not in a simpering or exaggerated way, just in a way that recognises the worth of all people. If this means giving up special privileges which we may have received, then it's a price worth paying, because it'll make our world a safer, more joyful place to live in.

According people with respect is easier said than done. Or is it? It's easy enough to be polite and well mannered, but what about giving graciously and not assuming the worst of others? Being a newcomer in a city like Bombay really pushes you to the limits. The necessities of survival and security make you suspicious; they brought out the worst in me. How could I be so concerned by the gross disparities between the rich and the poor and yet refrain from giving money to the child begging for it on the street, finding sanctuary instead in an air conditioned cafe? The only word for that is cruelty. Now you see why I cried - for the world, for myself, for what we are becoming. I begged God for forgiveness and repented of my sin. Sin, which we are all complicit in, when we pursue our own narrow interests. I had previously been yearning for egalitarian Europe, built on a foundation of human rights - I realised that this is the true marker of development, not wealth or even happiness, which is a red herring - where there may be subtle undercurrents of class and racial prejudice and hypocritical discrimination but at least everyone has rights in the eyes of the law, and just as importantly, the opportunity to exercise them. And I cried for the piecemeal dismantling of these rights that is happening in the West - all over the world, our leaders are selling our birthright for a mess of pottage.

Today is India's independence day. The country has a solid, progressive constitution, drawn up by the nation's founders and enshrining the rights of all individuals - rich and poor, male and female, high caste and low caste - equally on paper. A lot of good work has been done. A lot of people have done well since independence. But there is still much economic deprivation and marginalisation of millions of people due to poor implementation of these laws in many places. I believe a lot of this is due to attitudes - to the way we see and treat each other. It starts with the child snatching things from other children, and ends with the rich and powerful oppressing the poor and denying them their rights - basic rights of life, liberty, shelter and good health. We need to learn to value the other. We need to truly learn to namasté - not just as a cursory greeting, but seeing our relations with others, even strangers, as an extension of our relationship with God. This is what I believe as a Christian. God himself came and died for our dark and broken world, because he cares for each person. It was only the reality of Jesus that brought me back from the brink. Jesus cares. He alone can save me from my venality, my betrayal of righteousness for comfort. He accepts me as I am, and I know he's sufficient for me - to guide me through difficult decisions, to show me how to live, to entrust with the lives of all those I meet and am concerned for. Like the half naked little boy jumping for joy in the middle of the road, gleefully showing his mother the ten rupee note somebody had given him from a passing car.

The more familiar I grew with Bombay the more I came to appreciate the city. People here are nice and will go out of their way to help you, without asking for anything in return. Twice I came across the same man who showed me to places I was looking for. Another man walked me to the train station. I missed the greenery of the countryside, and while I appreciated the city's beautiful architecture, the density and heat were uncomfortable. But those cannot be helped and are merely attributes of urban life. The place is a hustler's paradise; too fast paced for comfort. It seems I am not the city sophisticat I thought I was...

My favourite thing about Bombay was the press. India's literary tradition is reflected in an intelligent, analytical, free press that seems to value objectivity over tribal loyalties. The scope of imagination was encouraging. Surely, with such values it's only a matter of time before what appear to be idealistic dreams become reality. So I'm glad I went to Bombay. I did find the inspiration I was looking for, even if it didn't present in the way I expected.

Culinary diplomacy

'I just wanted to see' - that's what they always say, isn't it, when they're caught? By way of explanation, justification, or even apology: 'I just wanted to see...' But seeing gives way to more compelling senses - touch, smell, taste, intimate exploration of the forbidden. Until time silently runs away, leaving the culprit inextricably linked with the evidence of their dirty deed and mealy mouthed excuses. 'I just wanted to see'.

I just wanted to see what was for breakfast this morning. My relationship with food has taken an interesting turn since coming to India. I like to think it has matured somewhat; the cries of my stomach no longer imperative as I've gained mastery over my tastebuds. My appreciation for good food is healthy, respectful, but not indulgent or slavering. Whatever comes later goes, and all that jazz.

It hasn't always been like this. Like many people where food is over abundant, I used to comfort eat, using food to fill any void identified at each particular moment. Bored? Have a bar of chocolate. Unhappy? Have a piece of cake to cheer you up. Happy? Have a celebratory doughnut. Angry? Have some ice cream to take your mind off things. Lonely? Go out for dessert with friends. And so on ad nauseum (not literally though, thankfully - although that phenomenon is sadly all too common). I decided that something needed to be done, starting a strict new regime of healthy food and regular excercise. 'Don't worry', reassured all my peers, 'you'll lose weight in India'.

I was bound to lose weight in India, I was told, because of Delhi belly. I'd definitely get some form of gastroenteritis at some point in my 6 week stay. I'd return gaunt, having lost essential calories. I wasn't so sure of this. Surely anyone with a basic education and access to good sanitation and potable water had enough to protect themselves from deadly tummy bugs? Remember, I was surrounded by public health posters from numerous government and non governmental organisations when growing up. Their directives were habitual: wash your hands before and after eating, wash your hands before and after toileting, before and after touching animals - in fact, before and after everything. Always cover food. Don't eat food from an unkown source. Only drink water that has been boiled and filtered. Do this and live.

No, I wasn't going to lose weight because of infection. I would lose weight because of discipline. I knew that out in rural India there would be limited opportunities for snacking on confectionery and pastries and all the other energy dense, nutrient deficient treats that have become routine indulgences. I would miss them. But it would do me good. It would be just like boarding school in Nigeria, 25 acres in the middle of the bush separated from the nearest village by a single dirt track - the only shop run by female teachers whose foremost priority was not financial gain, but the health of the children for whom they were in loco parentis. Little potential for pigging out there. Thankfully, as an adult I would have more freedom. There would be no compulsion to eat what was set before me. And why should there be? I'd have the maturity to eat it all anyway, the adventurous spirit to subsist only on the local cuisine of my new home (ignoring my mother's entreaties to at least take some cereal to snack on in case I didn't like the food) and even enjoy it. I would live as the locals live. 'Don't eat too much curry', my sister advised as I left, 'remember what happened last time you had really spicy food' (I had ended up in A&E with crampy abdominal pain). I laughed.

The first few days were difficult. I realised that as is almost always the case, my mother was right. I hadn't anticipted skipped meals as a cause of weight loss, but as I adjusted to the diet, this was precisely what happened. Rice for breakfast? Mba, no thanks. Bread? Boring. Eggs? Odikwa risky risky risky. Rice and dal fun onje osan l'ojojumo? No meat at lunchtime? The same watery lentil soup everyday, not at all what I associated with dal back home? As someone else asked, were we Oliver Twist? I was nearly glad my previous attempts at weight loss had turned out to be perfunctory. These fat reserves would need to last a long time. Or so I thought as each day I looked forward to dinner and the promise of meat. It was like a new slim-fast diet: water for breakfast, 2 chappatis at lunch and a proper dinner! Having to coordinate my meals with my antimalarial prophylaxis meant I was never in any real danger of starvation. But now I was eating out of necessity and not from desire. I picked at my food like an anorexic, struggling to maintain the impression of enjoyment.

You see, people in India are incredibly hospitable. Everywhere you go you are offered a cup of chai - incredibly sweet and milky hot tea that is thankfully served in plastic shot glasses or miniature mugs. Coming across an acquaintance who is eating merits an invitation to join in (just like in Africa). The kitchen staff here are solicitous about your well being: have you got enough? Would you like some more? While there's no one standing over my shoulder making sure I don't waste food, my conscience itself would prick me: not just because of all the starving children, but more because I don't want to waste the labour of the kindly souls who made the food if I'm being honest.

If I'm still being honest then I have to confess that this didn't stop me from surreptitiously wasting a lot of food when I first got here, before my senses adapted enough to distinguish between what I would like and what I wouldn't, making me game to try everything but loth to finish it all. I would load my plate with helpings of all the food on offer at mealtimes and inevitably by the end of the meal what I'd discovered repulsed me would be left on the plate. Trial and error - an initially wasteful, but eventually effective way to learn.

Before I knew it I was no longer discriminating between meals - food was food. I knew what to avoid and what to anticipate. Pancakes some mornings, potato pottage and fried dough reminiscent of Yorkshire puddings -puri- on others, these things I anticipated. I timed my sleep-ins to coincide with breakfast rice. Scrambled eggs and bread would depend on my mood. And I grew to love vegetarian food. What do they say, that after the initial discomfort it takes about 6 weeks to form a new habit? I discovered some new condiments to help me along the way. Halopenos and steak sauce would accompany chapattis for a simple lunch devoid of the disliked deadly dal (which I have to say I am alone in maligning). I soon began to put on weight. I remembered what my warrior ancestor, the one from whom we get our surname, was called: 'Ayogunmaru'. The one who goes to war and doesn't waste away. I used to think maybe it was some genetic quality, slow metabolism perhaps, that explained my stable weight levels. Now I'm thinking maybe he was just adaptable too. Adaptable and resilient.

I just wanted to see what was for breakfast this morning, just in case we'd been served pancakes. I didn't really plan on eating if it was anything else. But I lingered a little too long in front of the empty pot of scrambled eggs until she saw me - the friendly member of kitchen staff who always smiles graciously when I say namaste. She wouldn't take no for an answer when I assured her that toast was quite OK for my breakfast. Instead, she went to the kitchen to get some more eggs. What could I do? I had to eat. The proof of the pudding is in the eating.

Fever

'We are living in the jungle', intoned my American friend. Not quite, I thought, picturing dense rainforests impenetrable to any form of human habitation. This ordered life with its potential for familiarity and even comfort was chicken feed compared to that existence. Yet I knew what she meant - here, in the midst of the numerous ecological niches, it was easy to feel insignificant. It's impossible to forget that we are not alone as a species when there are so many other populations here vying for environmental dominion, each seemingly oblivious to the others' existence until their boundaries blur. A whole village of crows caws a strange vespers and mattins; they share the trees lining the paths with gargantuan bats that stink up the ground with their urine. Frogs hop in the puddles, relishing the freedom of long awaited rains before the baking sun once again routes them to unknown hiding places. Bushy-tailed squirrels with their confusing skunk like markings flit from bough to bough. And inside there's more - geckos on the walls, mosquitoes in the air, beetles the size of two fingers. Rats and ants stealing food: wild, untameable - and sightings and rumours of snakes. The flies, carrion even of carrion, lord it over all, feasting on a dead crow that appears to have been lynched as it hangs from a dried bark. Truly, we are not alone.

Nature above is just as awe inspiring as nature all around. As I walked back to my room I saw the stars and was once again amazed by their beauty and intrigued by a solitary red star shining more brightly than any of the rest. Was it closer? Was it dying? The stars envelope you as you walk down a dark path, making you feel secure. Until you notice the black thing lying in wait. What was it? Another dead crow? A black cat? I stood and watched, bending over to peer into the eyes of the creature. It was still. So was I. The bats began to flutter in the trees. I shuddered. There was no going back now, for I had just said goodbye to the group of men I'd left behind before embarking on this solitary walk and did not want to display my fear. I could not raise my voice to call for help. So I stood, watching, knowing that the last one standing would win. I could wait all night for the creature to move - or for a protector to come my way - if that was all it took. The bats, fully awoken by now, began to fly in various directions. I reminded myself that they were just animals flying as is their prerogative. Then they woke up the crows, who also cried out and flew. I stood watching. So did the black creature, of whose feline identity I was by now certain.

Somebody came out of a bungalow and onto the path. The cat scarpered and I strolled my merry way along to my room. My bacon was saved. Fortune may favour the brave, but the patient cowardly aren't very far behind.

Sir Nose Devoidoffunk

Conversation between two doctors in the hospital, one my elective supervisor and the other another doctor seeing a patient with ischaemic heart disease in clinic:

Dr A: 'The ECG shows ST depression - she has ischaemic heart disease. You shouldn't just treat her medically, advise her on diet and excercise as well. And you too need to lose weight - why do you always ride the motorbike to the hospital? You should walk from time to time. You need to be fit so you can advise your patients on lifestyle.'

Dr B, protesting: 'Just because I'm big doesn't mean I'm unfit. I mean, look at Steffi Graf - you know, the tennis player? She's big too...'

Dr A: 'Don't use that excuse with me, Steffi Graf is big because she has an athletic build - are you an athlete?'

Both of them look at me, laughing. I smile nervously. My own body has gone to seed here, driven by a carbohydrate based diet of rice and chappatis and long afternoon naps that drift all the way from lunch to dinner. Who am I to pass comment? I remember the conversation with my new GP nearly 5 years ago when I first enrolled at medical school. 'Do you do sport?', he had said. 'You should - there are too many unfit doctors out there'.

While community based primary health care is the core philosophy of the work that the CRHP does, there are still many things to be seen in the hospital here. In a way, a visit to the hospital illustrates the main social problems in an area and Jamkhed is no exception. I have made a list of at-risk groups most likely to require hospital treatment here:

• Children
• Young women
• The elderly (male>female)
• Migrant workers
• Members of nomadic communities
• People with chronic debilitating conditions (e.g. post stroke)

There are several reasons for the above. Children are really susceptible to infections, and in the rainy season are prone to malaria, viral upper respiratory tract infections and pneumonia and mostly present with these three conditions. They are also the single most vulnerable group to one of the main causes of acute (as opposed to planned) admission to hospital here: road traffic accidents. Another main cause of acute admissions at the moment is snake bite and this tends to affect older members of the population, with quite a few cases happening after dusk or in the bushes when people can't see to protect themselves. The hands and the legs are the most commonly bitten areas. A third cause of trauma, bull gore injuries, occurs much less frequently in the working population.

I have seen a number of the classic 'exotic' conditions you expect to see in the tropics: leprosy, tuberculosis, typhoid fever, hepatitis A....these cases are generally treated with routine anti-infective prophylaxis as appropriate and tend to make a good recovery quite quickly. Particularly at risk are migrant workers due to their precarious financial situation which serves as a barrier to accessing care since they have to move to find work, making follow up, monitoring and management of chronic conditions difficult. They are also understandably reluctant to do anything that will jeopardize their jobs such as taking time off work to have an operation done. In addition, migrant groups are more likely to be marginalised from health promoting activities, making them less informed on important issues such as vaccination. As you can surmise, control over the external environment is crucial to prevention of many of these conditions, and this requires social cohesion and economic power. I wonder if this accounts for the differences I have noticed in sanitation levels which vary so greatly from one village to the next.

Another main service provided by the hospital is antenatal care and maternity services, although the bulk of antenatal visits are carried out by the village health workers in the expectant mother's village, saving her a long trip to the hospital. Only high risk pregnancies are referred for more advanced investigations like ultrasound scans. At the moment there is an issue regarding new legislation that means only government hospitals are registered to carry out emergency Caesarean sections. As the nearest hospital where C-sections can be carried out is at least 2 hours away, this presents a major risk to women in labour in this area who may need emergency C-sections for any reason completely unpredictable pre-natally: for example, prolonged labour causing maternal exhaustion, obstructed labour and cephalo-pelvic disproportion and foetal distress. Clarification is being sought on this issue at the moment, which cannot be resolved a minute too soon.

There is an increased incidence of chronic non communicable disease - diabetes, ischaemic heart disease, chronic obstructive pulmonary disease and cerebero-vascular disease - worldwide. It has been interesting to see how these blights are presenting in rural India. Along with the routine myocardial infarction, I saw my first skinny patient with type 2 diabetes, malnourished due to insulin deficiency (we are drilled into associating type 2 diabetes with obesity). She had very poorly managed cellulitis that had spread deep beyond her skin into her subcutaneous tissue, needing surgical debridement. A lot of the patients who have poorly managed chronic conditions come from villages that are not involved with the CRHP (non-project vilages as they are called here) and so do not have village health workers to take care of the immediate health needs of the vilagers. This underscores the necessity of having someone local and available to attend to basic health needs in remote rural areas; without such people, these needs are neglected until people are in too much pain to function, by which time more extensive (and expensive) work is necessary.

Some screening work done while I've been here has shown quite a number of people to have previously undiagnosed hypertension, with some systolic blood pressures being in the high 200s (levels this high are classified in textbooks as malignant hypertension or hypertensive crises, requiring urgent medical treatment). This may account for the increased number of sudden deaths and strokes being seen here (hypertension is one of the main risk factors for cerebero-vascular disease). Although stroke patients who are brought to the hospital in time get prompt and efficient treatment, the challenge does not end there. Rehabilitation and continued care after medical discharge is crucial for the continued well being of the patient, socially and medically. I saw one such patient who had previously suffered a stroke come in with diarrhoea; what was the source of the infection? Gastroenteritis due to drinking water from the local stream instead of the well? A urinary tract infection due to stasis and immobility? It's hard to tell. Community based rehabilitation for the physically disabled is something I've been thinking about a lot recently; an estimated 70-80% of India's disabled population live in rural areas.

The best thing about this hospital is that almost everyone gets what they need in the end. There's a lot of elective surgery done here: tubal ligations for contraception, hysterectomies for menstrual problems in older women, hernia repairs, cataract repairs, mastectomies for patients with breast cancer, rehabilitation surgery for patients with leprosy who have sustained deformities, and so on and so forth. Treatment is given to all without prejudice and regardless of ability to pay, yet it is not free either. Generally the hospital and the patient work something out on a sliding scale based on what the patient can afford. I would still love to see a system where all healthcare was free at the point of delivery, but within this community this system is the most humane, feasible (enabling the continued functioning of the project since most people are casually employed in the informal sector and so can't take part in insurance schemes) and works very well. The teamwork definitely fosters trust between the medical staff and the communities they serve, an indispensable requirement for maintaining good health.

I thought I was going to spend this post writing about the things I've been learning in hospital - interesting clinical experiences that remind me of why I love Medicine. It was going to be a funny post. But I was wrong and that post will have to wait, because this one is more important.

A friend once told me when I confided in her about my pervasive self doubt, that my elective would be a great boost for my self confidence. I didn't understand what she meant at the time, but she was right - it's out here that I'm finally beginning to realise that I actually know stuff, that I'm good at what I do and can be even better if I just believed in myself. When you see people that really need your skills (or the skills of any physician), there is a passion borne out of your compassion for their situation that makes you overcome your own shyness or fear.

It can also lead to profound sadness. I made friends with one of the girls who attends the Adolescent Girls Programme here (a project set up to help young women interact with their peers, have fun, give them personal, social and health education and educate them on self defense and self esteem - to help them see themselves as young women full of potential and not just mere chattel or somebody's future wife). I was walking to get dinner when I bumped into a friend who is one of the interns here, chatting to the girl (henceforth referred to as N). She was impressed by how good her English is (in this area children are educated in Marathi); while not fluent the three of us managed, with much gesticulation and clarification, to have a long chat. N told us she had an English-Marathi chart and she would teach us Marathi. She is a friendly, bubbly, intelligent girl.

I bumped into N the next morning and went over to say hello. She was holding her little brother, who was very friendly and playful. I could tell just by looking at him that he has cerebral palsy. His legs were thin, somewhat atrophied and hypertonic - I was guessing he had a spastic diplegia. This was confirmed when N told me that he can't walk and put him on the floor to demonstrate - his legs went into the characteristic scissors position. He had communication difficulties - N said he only had 3 words and couldn't hear; he drooled constantly. But he was a lively child who gesticulated wildly with his hands when excited. He always returned your smile, laughed a lot, and gained a lot of pleasure from the passing vehicles (showing that his communication problem probably isn't due to a lack of hearing) - he seemed to be really stimulated by motion.

I asked N if her brother liked to play. She seemed confused (remember, we were dealing with a big language barrier, and most of our conversation was helped with body language. How do you act out the word play?) and we went on to talk about other things. We were standing outside the preschool at the time. When the children arrived with their squeals and their mirth, the conversation turned back to play, this time led by N, who asked what games I knew. I seized the opportunity to ask if her little brother played any games. No, she said, because he couldn't walk. But could he sit and play? I asked, what if you sat him on the ground and played with him? He couldn't sit either, I learned, because he couldn't maintain his balance. He had to be carried all day.

I can't get N's brother out of my head. He is a delightful little boy with a family that obviously loves him very much and shows him a lot of affection and consideration, for which he is fortunate. But I feel sad that he hasn't had all the opportunities he could have had - therapy that could preserve some independence for him: physiotherapy for balance and posture, occupational therapy to help him move around, speech and langauge therapy to assess how much verbal communication he is capable of and help him to express himself. Consequently, his intellectual potential remains untapped and I am concerned that this may be irretrievable. Most of all, I feel sad that this beautiful boy is deprived of play, such an essential component in the life and development of any child. I feel for his father, mother and sisters who unselfishly look after him, holding him all the time, but am also aware that this comes at a price of the welfare of the family since it prevents them from attending to other matters. I wish they had more support.

I think of all the support that is available at home for families of people with disabilities - financial assistance from the government, day centres where people can go and have a full, stimulating and rewarding day with physical and intellectual stimulation and social interaction. The nearest such place is 4 hours away in the city of Pune, completely unfeasible for this little boy, unless he were to stay there residentially. And how would ripping him away from the family that loves and cares for him help? They need local services and a local source of support. These are the challenges of life in the rural area. This is the challenge of the vulnerable in the developing world. It's not just theoretical. It's people's lives that are at stake.

I'm going to try and find out more about the wider issue in this area, but even if I achieve nothing else, I hope that by the time I leave N's brother will be playing. I think I have an idea...

My mummy said it, so it must be true

A memory of the week before it all began, recalled from the ether. It occurs somewhere south of the Home Counties, near a railway station, in the town that is for me, 'home-home'. I am sitting in a leather chair in an Indian takeaway, watching the Ghana versus Uruguay world cup match, the important decider that will determine whether Ghana makes it to the semi-finals. So is the man at the counter. Naturally, we converse.

'Who are you supporting then?' One of us asks. We discover we're both supporting Ghana. I tell him Ghana's my chosen country since my native country's shambolic performance, besides, they've played well. He agrees. He'd like to see them go far. I learn that he's originally from Sri Lanka, a country that's not in the FIFA World Cup. It's a cricketing nation, just like India. But football is quite popular; it's only a matter of time...

We are soon joined by another family, here to get a quick takeaway meal so they can go home and beat their aunty to the TV - if they don't put the match on in time they'll miss the second half because Aunty doesn't like football. Mum, dad and teenage daughter are here. Daughter comes to sit next to me. She asks who I'm supporting. 'Ghana', I say, 'you?' 'No one really', she says, then adds as a quick afterthought, 'but Ghana now!' We watch on tenterhooks as the match heats up. I am savouring the beautiful moment - here we are from 3 corners of the globe, all supporting a small country from the beautiful but oft sidelined continent that I still call my home.

The family decide on their order. 'What do you want?' mum (or dad) asks teenage daughter, who vacillates between choices. 'I don't know, what's healthy?' she asks. 'This is Indian food, it's all healthy', replies dad. We all laugh. That's the cuisine of my future home we're talking about. It's a small world, and I'm glad to be a part of it. I realise that this place too is special: this small island, on the western outskirts of this ageing continent, is my home and I love it. I feel a twinge of nostalgia for what I am about to leave.

'You're a real global citizen', my mother often says to me, sometimes admiringly, sometimes exasperatedly, sometimes resignedly, but always heartfelt. It took going to Pune, once a British military cantonment, now grown to a full fledged member of urban India, to discover that she truly is right. Born in the 1980s, that fulcrum of globalization, in a decolonised country in urban West Africa where foreign cultural influences were equally if not more likely to come from commercial marketing than colonial influences, where the lines between 'ours' and 'theirs' -values, speech, taste- were incredibly blurred, is it any wonder that everywhere but nowhere is where I belong? Everyone is kin, in some form or another. In a bookstore in Pune I was confronted with staples from childhood - Asterix and Obelix, Tintin, Nancy Drew and Hardy Boys, The Famous Five, Archie comics....enough to make me wonder just how different my life would have been if I had grown up in India. Perhaps not as different as it may seem at first thought.

Pune was eye opening - thought provoking. I finally started to see and process the rural-urban divide up close, having lived rurally for the past 3 weeks. It is initially subtle but eventually seismic. Tell tale signs of disparities in wealth - the size of the average inhabitant. In Jamkhed I had to buy an extra-large outfit to get one that would fit; I considered myself obese by Indian standards. In Pune the reverse was the case, I had to buy a small outfit to get it to fit; most people were easily bigger than me. Food is more easy to come by in the city, particularly that of the energy dense variety - chocolate, ice cream, cake... And it is a sign of wealth - the wealthier people, shopping in the air conditioned malls, really were bigger than the average Joe walking the city's streets. Jamkhed and Pune are only about 4 hours apart by road, but the variance in infrastructure makes you understand current migratory patterns.

Pune impressed me with its combination of modernity and civility. It was by and large clean, though where Jamkhed has pigs, it has dogs. It has municipal services. No rubbish tips lying around the place. Pavements on the roads. Pedestrian crossings (often ignored, but still...) and functional traffic lights. The streets I walked on were quiet. And it was definitely a city - people who dealt with you were cordial, but strangers generally ignored each other. No routine namastes here.

Pune impressed me for another reason too - it showed me the new India. The new, vibrant, up and coming India with a booming economy and an ebullient, youthful population with enough aspiration to dampen some of its more depressing features, like the poverty that has people begging for alms on the roads - some disabled, others through circumstance, and yet others through cynicism? One minute a woman was asking for money, the next to have her photograph taken. 'What developed this learned helplessness?' I wondered. I remembered learning about how disability is relative - to the accommodation of society to an individual's impairment. What would David Blunkett, erstwhile Home Secretary of the United Kingdom, think of the idea that blind people are only able to make a living from begging and giving them alms is an act of charity and helpfulness? Or Stevie Wonder, international musical maestro -some would say genius-? Both men are blind. A wise society it is that enables all its members to fulfil their potential despite other limitations they face. 'Adjust' is a popular expression in India, meaning exactly that, but used in broader contexts. Can the new India adjust to the needs of the weak for the benefit of themselves, their communities and wider society?

The new India is fascinating, proudly and distinctly Indian, yet absorbing what the world has to offer. I got carried away with wonderful fusion jazz incorporating some of the best of contemporary classical Indian music. The majority of vehicles that ply the nation's roads are locally produced Indian brands. You can enjoy a traditional Pav bhaji on a side street or a tasty raclette in a Swiss restaurant, amongst other things. Eating Punjabi food in the down to earth juice bar in Pune's old town, I remembered the Ceylonese takeaway owner. 'What is it like to leave your business at home to start a new one in a new home?' I wondered, watching as the cooks mashed together potatoes, tomatoes, vegetables and herbs in open view of diners.

I like the new India's secure open mindedness, yet the media and other sources - security guards complete with metal detectors at major outlets, the memories of a recent bomb attack only months ago - remind me that this too is under threat. I wonder what life is like for the people of Pune. What are the living standards of the people who service the lives of the fortunately affluent? The security guards and checkout staff at malls, the waiting staff at restaurants - what do they go home to? Can they afford to avail of the services that they themselves provide: to shop in the same stores, eat in the same restaurants? They are probably more highly skilled than their Western counterparts, since fluency in the English Language (required for such service oriented positions) is a skill that is the preserve of the well educated in India. Do they have good job security, pay, respect, benefits? Do their current circumstances live up to their earlier expectations? I don't know the answers to these questions, but I aim to find out.

This journey is like a study in globalization. It's exciting. I'm seeing the process and its products: the boons and the fallout. Perhaps I can help to understand how to secure a good living for the most vulnerable in these processes and then go ahead and do so: that is my dream. What does the future hold? I don't know. But I do know this - I want a piece of this pie...

Chalo

'And further, by these, my son, be admonished: of making many books there is no end; and much study is a weariness of the flesh.'

~ Ecclesiastes 12:12

The library at CRHP Jamkhed is well stocked and I am taking the opportunity to read books I've always wanted to read but couldn't bring myself to buy. (I cynically joke about expensive tomes named like Sociology textbooks which discuss the plight of the poor when ironically, they are so expensive that a copy would probably pay for a week's worth of grocery shopping for same impoverished folk. Meanwhile, they are set to become coffee table reading for the intellectual elite, subjects for light -if impassioned- conversation. Knowledge is power, eh?) This may be a(n admittedly slightly bitter) joke but it does highlight the much darker issues surrounding research of the marginalised. Who gets a voice? Who pays the piper? And to what ends? What is the role of academia in society and how do academics make ends meet? There are plenty more questions where those came from but I will spare you the inquisition: besides, that is not the purpose of this blog post.

When this morning I started reading a book I had yearned to read since it was first published three years ago and broke through the charts as an incipient classic of Development Economics, I realised that things have changed. I have changed in many ways - in my thinking, or more precisely, my perception of events and assertions. That was when I realised that I'm nearly halfway through my elective and it's time to write about what brought me here and what I'm learning - the 'on which more later' of previous blog posts. Alors, on y va. Chalo!

'Why Jamkhed?' I've been asked many times, in association with, 'how did you find out about this place?' I chose to come here on my medical elective because I was interested in learning about how you combine healthcare provision as a clinical service with preventative Medicine in the form of public health planning for a community. I am firmly convinced that the two should go hand in hand and are unnecessarily fragmented a lot of the time. The health of a society is a hugely underestimated (and thus neglected or even ignored) resource, driving the behaviour of almost all of its inhabitants - or this is what I think anyway, and I believe from personal experience that I am right. So I was excited to finally find somewhere that had good health as the centre of the agenda for community development, somewhere that had an encompassing definition of good health.

Why is health so important? The answer is self evident - good health means well being, which means productivity: the ability to get a good livelihood, to secure a safe living, to live well. But it's not as linear or simple as that: insecurity, the lack of a good living, they also contribute to poor health. People will do anything to preserve or safeguard their health. This is often felt subjectively as happiness or even contentment - although herein lies the rub: often our bodies conspire against us in our pursuit of happiness, causing us to indulge to excess in ways that are detrimental to our health, while we still feel good. The cause of this confusion? The electrical wiring of our brains. Dopamine, the 'happy hormone' operative in the reward centre of our brains, can be rather indiscriminate when it comes to identifying pleasure, failing to distinguish indulgence from reward. Or at least this is the current thinking of neuroscientists. The result is that want becomes synonymous with need and we are driven to increasingly dangerous extremes of the pursuit of happiness. It's almost like the mechanical theory relating to tensile strength: when a material is stretched beyond its elastic point, it is permanently deformed and no gain in energy is achieved from stretching it further. And still we stretch, for there is something awry in the feedback loop - we continue to feel the illusion of gain.

That is the world I'm coming from. A lecturer once said that we would do better to focus on improving the health of the poor in the world than straining for the unattainable (and unfeasibly exclusive) El Dorado of immortality. I was inspired. We live in a world where there are huge disparities between the lives of the rich and the poor, where poverty dogs people's attempts at self actualisation like shadowy spectres, spiriting them away before the promised change. Is this not injustice? And there are degrees of poverty, often related to the external surroundings. People will do anything to safeguard their health and livelihood: often, the only thing to do is to change the surroundings. For an individual, one way to do this is to physically remove yourself to a better place.

So we have this sequence. It starts with the rural poor, invisible to the power brokers, lacking representation, under served, toiling to survive and lacking the infrastructure to make their work and lives easier. Those with opportunities, with education, or skills, or simply savvy to serve the needs (or better described as desires) of society beyond their own survival, can capitalise on this to make a better life, moving to where they will be well remunerated. It continues with rural-urban migration and its entailing stresses - a few make it big, many join the masses of cheap labour ripe for exploitation, living in straightened circumstances and coping with the psychological stresses of displacement. There are other stresses too: communal tensions, what happens when people from different walks of life with different ways of life, have to share living space. And then there is politics and power, complicated by prejudice, affecting what solutions are effected to these challenges. Stigmatising communities? Or stereotyping them, for good or ill? Battening down the hatches? Focussing on social mobility? It's a Pandora's Box.

This sequence is replicated worldwide and on an even larger scale with migration between countries, between continents. Inter-country inequalities become intra-country issues, as when a Western medical student is taught about Tuberculosis - '1 in 3 people are infected globally, but largely in the developing world. It's been more or less eliminated here, but is starting to show a resurgence -mainly in the immigrant population with the rise of HIV'. True, but the framing bugs me. Does this mean it's not a problem? Or that immigrant populations don't really belong - they only exist as reservoirs of infection? How do we define ourselves? I believe inclusivity matters.

What if you change the surroundings themselves? What if you change the physical and the cultural mileu so that life and health are better for the poor - and the very poorest of the poor? What if you remove the link between socio-economic status and good health, looking at it as a fundamental human right, so that social mobility and migration are no longer prerequisites for good health and nobody is left behind? How do you do this? Is it a paradox, an impossible ask?That is why I am here, living and observing and learning from this project that has aimed to do just that over the past four decades, working with communities that have experienced the worst forms of deprivation, discrimination and poverty: whole communities, but also sections of those communities, illustrating the pervasive degrees of poverty. How do forgotten communities pull together to improve their lot?

Any good Scheherazade will tell you that you never finish a story as soon as you begin it. And so it is with this story. More will come later.

Clichés

'Thing's aren't always as they seem', they say - and, 'travel expands the mind' - and, 'it's good to step out of your comfort zone' - and, 'we live in a global village; it's such a small world' - and, 'globalisation is making the third world Western: development will come at a high cost to the planet because this is unsustainable'.

And so on and so forth. Sometimes, it seems the world is like an open book, teaching lessons in an instant that would otherwise take ages of struggle with reams of words.

Take for example this issue of meat. Increasing middle class lifestyles are a corollary to development in the third world, it is argued, leading to increased consumption of meat in imitation of Western lifetyles. This increased demand for meat spells doom for the agricultural industry: animal husbandry is a lot more wasteful than cultivation of crops, since it takes more land to cultivate crops for animal feed. This, coupled with the metabolism of commercial farm animals (specifically cattle), also contributes to global greenhouse emissions. So the problems of increased meat consumption are manifold - increased food insecurity, famine for the poor, environmental degradation and struggles over diminishing land which may easily become violent, causing conflict in already fragile areas. What is the solution? To eat less meat?

The problem is that meat tastes so good. I'm not so sure meat is an acquired Western taste for the majority of people in the world. Being here where meat is so scarce (because it is so expensive) and I am eating very minimal amounts of meat (and very rarely beef) has led me to the conclusion that the taste for meat is a primeval one, latent in most people, and the reason many people in the third world do not eat meat (other than those for whom it is proscribed for religious reasons) is because meat is so expensive. The growing middle class do not eat more meat in an aping of Western lifestyles, they do it because they can finally afford it, and it tastes so good.

Clearly, the solution to the issues outlined earlier are much more complex than simply coercing, manipulating, or otherwise imploring a mass conversion to vegetarianism. More equitable relationships between people, better land rights for the poorest, and other policies to reduce insecurity of the most basic of human necessities for the vulnerable (food, clothing and shelter: not just from the elements but also from those who would seek to exploit them and from violence) -in baser terms, a piece of the pie for everyone- or, if you would like, justice, are much trickier, but ultimately more sustainable -and feasible- not to talk of effective, solutions.

So

There are villages and there are villages. The longer I stay here the more I'm learning about generalisations, about how things are not always as they seem, and how taking a position of relative ignorance is often the first step in gaining understanding. Not all that is rural is idyllic; there's a lot of hardship here too.

Today I went with the paediatrician, the pre-school teacher and another medical student to pick up children from the villages and take them to the pre-school on the CRHP complex. It was a fun day; I enjoyed being a child all morning - in fact the pre-school teacher mistook me for a child when getting off the bus, she gave me her hand to help me out and waved me into the group of children, counting me in like you do children to make sure they're safe and feel secure! We had a good laugh about that. The children also made a nickname for the other medical student, 'Bishi walla baba', they shrieked in that delightful way that only children can, on account of his impressively ginger facial hair (I'm told in good faith that the nickname means something akin to 'bearded guy').

In addition to playing and taking part in the joyful learning program, I got to sit in on the paediatrician's examinations of the children in the school. One of the things that impresses me about the CRHP is how they've managed to build a health service that works around the needs of patients. So often it's the other way around; patients are made to manoeuvre around the complex workings of a health service that penalises them for not understanding how things are operated. For example, they have to cancel other engagements to make an appointment which they are then kept waiting for, while being denigrated if they are late for the appointment or even taken off the books if they miss consecutive appointments for any reason. It sometimes seems like provision of health care is a privilege and the time of professionals more precious than that of patients. Obviously this is not necessarily deliberate and is merely an inevitable consequence of the pressure that hard pressed professionals are under to spread their services very wide, but it's helpful to see another model where communities play an active role in their own health and their participation makes them equal partners and not just passive recipients. I like the fact that rather than having the children skip school to go to the hospital, the doctor goes to school to see the children. This is possible and efficient because of the ready accessibility of the health care facility within the community, not in the form of a (physically and metaphorically) removed hospital that is in some senses a law unto itself. That's the beauty of community based primary health care.

The children themselves come from a diverse range of backgrounds. As an ignorant foreigner it is easy to wonder, 'how can there be such heterogeneity in such a small geographical location?' forgetting that even the most modern cities have gross disparities of wealth and living standards existing side by side. For some of the villages we went to today were extremely poor. Filth was strewn everywhere and pigs swam around in puddles, procreating openly in the rubbish. Every second sow you saw was pregnant. The chickens were scrawny and as for the domestic cattle - well, the one cow I saw in one hovel lay lethargically on the ground, its eyes encrusted with as yet unknown detritus. It is difficult as an outsider to pick up on the subtle structural inequalities that cause such differences in living standards - gender and caste prejudice and discrimination, land ownership, employment differences, and historical factors - but it is my aim to learn more about the stories of the local communities during my time here. Already I have been learning about the influence of agricultural factors and cultural issues (including the caste system) on the face of rural poverty from Dr Raj Arole, one of the founders of the CRHP.

Despite the wide range of backgrounds (and some of the children's stories are heartbreaking - one little girl lost her father to suicide over financial difficulties) the children are all bright, playful and keen in the pre-school. Even the ones who cried when leaving home had fun - and who wouldn't, in a place where you are treated with love and respect by your teachers, and have many friends to play with? They all have two nutritious meals at school, militating against malnutrition. It's inspiring to see such hope for the future.

While we are here on elective we have to write three papers - one on something that has caught our interest at the hospital, one in the community, and one as a personal reflection. I think I might write the second one on sanitation. The contrast between the beauty I have seen in some places and the squalor in others intrigues and disturbs me. I have a feeling that this issue is going to become a hobby horse. Perhaps it's because in childhood I lived in a military dictatorship that decreed every other Saturday environmental sanitation day, or maybe it's the fact that I was health and sanitation prefect in primary school, or it could just be down to personality - whatever it is, I am passionate about the physical environment in which we live: both the built environment and the surrounding landscape. Surely it is one area where collective action is possible, inexpensive, and can make a big difference...we shall see.

I am yet to write about the things I've seen and learnt in the hospital and outpatient clinics and a recent visit to a tribal community up in the hills, but that'll have to go in another post because it's way past bedtime already. Here's a little interesting fact before you go though. Did you know that the entire nation of India, despite being big enough to justify being called a subcontinent in its own right, is just one time zone? That's why the sun rises at different times of the day depending on what part of the country you're in here....

Ten minute post

I have ten minutes before the hospital rounds and have decided to spend it filling this blog with more background in the build up to writing about lessons learnt. On a walk yesterday I discovered more about the stark differences between town and country. The villages surrounding the CRHP seem relatively affluent in comparison to the market town. The yards of the farmhouses are swept clean; there are beautiful flower bushes (which the local children pillage for bounty to give to friendly visitors as they harangue them to take photographs - ' hi! one photo please' is the favourite salutation of children here). They have come up with an ingenious way of dealing with the massive puddles that cause water to stagnate and make ecosystems of mosquitoes an impasse on the roads - the puddles are piled full of rocks, draining the marshland. There are no stray animals save for foraging goats, and the cattle are tied up next to the barns which contain the yields of surrounding fields - it seems onions are in at this time of year. Work and leisure appear intermingled - women sit in the fields harvesting, but also chatting and laughing, while the children play and the younger women attend to domestic chores, coming out to say hello. And the men?

If on your walk you ignore the inevitable insects that this climate brings, you will begin to experience a rural idyll. So it seems that people are capable of coming up with the solutions to the challenges of their environment. On which more later, for my ten minutes are up.

Sleepy Saturday

I have now been in Jamkhed for a week and I suppose it is time to talk a little bit about the things I'm learning. But no story is complete without a mise en scene, so before I go into the medical stuff, here's a bit of background... or first impressions, if you like. They will be brief, for I am sleepy, and in fact the only motivation I had to write this was the energy of the adolescent girls running up the stairs in the training centre. I am quickly falling into the slower pace of life here: walking leisurely, taking afternoon naps...it compels and frustrates me in turns, depending on my frame of mind.

While I have on the whole settled into life here, and feel blessed to be a part of such a loving community, I have found my response to life in the developing world quite interesting. For someone (and perhaps because I was) born in tropical Africa I am remarkably intolerant of some of the negative features of the landscape - stagnant water providing breeding grounds for mosquito larvae, ubiquitous flies perching anywhere and everywhere serving as vectors for all kinds of disease, wild sows and their piglets roaming among the rubbish, stray dogs exhibiting odd behaviour, pockets of mini landfill sites littering the place, and last but not least, non existent road safety for pedestrians. These are all threats to the health and sanity of the local population, and are ironically to be found in the town- the main economic nexus of this area.

I do not believe that these blights are inevitable; they are easily overcome with proper planning and foresight - municipal services like proper drainage and water run off, roads, waste disposal facilities, pavements and pedestrian crossings, animal safety and pest control, law enforcement - they all require local government, or at least local leadership, some form of collective action to institute order. The town is where we have to go to do most of our shopping (of which thankfully little needs to be done) and I have started to avoid it as far as is reasonably possible - it seems to bring out the worst in me. My inner Pol Pot is also being stirred, I foresee that I may soon be yelling at people to cover food - actually I'm doing a good job avoiding uncovered and other suspect food. I haven't even started drinking tea yet, which I was assured I would have to embrace in India to avoid causing offence despite surviving years in England and Ireland without taking up the habit. Or perhaps people here are just very polite (in fact I know that they are, which is a win-win situation). Thankfully, I have enough subcutaneous fat stores to last me a while...

The country, by comparison, is an oasis - and the CRHP where I am based in particular. The complex of the Comprehensive Rural Health Project houses a small hospital, a training centre, accommodation for resident staff, students and village health workers, a mess hall, some sports grounds, and my personal favourite - lots of beautiful gardens and even a fountain. It is a 10 minute drive from the town and surrounded by farms. When the CRHP was first set up 40 years ago, Jamkhed was not a town - it was a village in one of the most deprived areas of the state with poor health and economic indices. The improved health of the local community achieved through the service of the CRHP, largely through the work of the village health workers and the farmer's clubs, has contributed to its evolution into a market town. But I'm jumping the gun here, I'm supposed to be limiting myself to descriptions of first impressions in this post.

The most important first impression I have had so far is the spirituality of this place - and I don't mean spirituality as a theme to be confined to a section of a bookshop, I mean an organic way of viewing people as living beings, not just sources of material income or manual labour. People here really do seem to care about other people and there is a genuine sense of relationship in the way even strangers interact with each other - and with foreigners like me. I feel that this is desperately missing from the Western world, which, ironically, despite its much needed (and vaunted) social order and social welfare, has an immense social and spiritual poverty: we neglect the totality of our existence because we choose to measure ourselves only by defined parameters and limit what we are capable of in the name of convention. I think this sense of genuineness, of people being more important than ideas, of kindness being routine, is the best thing about being here. On which more later.

Rural Life

Sometimes your memories choose to come at inapposite times though, when they are too late to be of any use. Like last night. I killed an insect with my shoe just before I went to bed and thought nothing of it. By the time I came back to my room for my afternoon siesta the floor was crawling with ants. They'd even made it into my laptop. Nature at its most elemental is here - wild and unsettling. My mother told me that once, when I was baby, she left me on the bed in the room in the bungalow in the peri-urban Nigerian town we lived in at the time (which Jamkhed reminds me of a bit). She returned to find an army of ants swarming around the bed.

It is also beautiful - there are many well ordered gardens in the vicinity, including one opposite my bedroom that has a calming fountain. For all our rapacious greed, I think the earth is a better place with humans in it. We introduce order and peace. I do not think that the similarities between the words sanitation and sanity are coincidental.

I planned to write about the many things I've been learning but have found myself too tired to do so. A synthesis is coming your way soon...

Where is home? Everywhere...

You never truly forget anything. Once formed, your memories are part of you forever, deposited in your DNA by your skin, muscles, bones, nerves. You often misplace them, it is true, and sometimes you can never find the key to their repository, but that is - they are - neither here nor there: that is to say they are with you all the same in some way, even when unconsciously. By the end of a week I had acclimatised to the Abu Dhabi heat and my skin could remember the feeling of walking out into baking sunshine in humid heat - it felt like a hug from the past. How anodyne. Anodyne, but true. And now it was time to say goodbye to my family and head off on the next leg of my trip - the main bit, and the truly solitary one. I was heading to rural India.

I tried to describe Jamkhed to people I'd spoken to about my elective. Even Indians didn't recognise it (India is a very big country after all). It is quite remote (I was soon to discover that was an understatement). 'You're going to Ikoro Ekiti!' my aunty exclaimed when I told her. Ikoro Ekiti is my father's ancestral family home (though he was neither born nor brought up there) and in Nigerian parlance, it is technically my home town (though I've only been there once, for this same aunty's wedding, when I was three - and she herself was neither born nor brought up there). I have no memories of Ikoro. I get conflicting reports as to the state of its development - is it a small town, a village, or a mere hamlet? I've seen photographs. They have electricity. And storey buildings. That doesn't seem so bad. Yes, that's right - by my ignorance you can tell that I am a townie. I have a great love for the tranquility of the countryside, but when it comes to it, I was born in one of the great megacities of the world, which is expanding by the minute - Lagos. I was transplanted from Lagos too early to realistically be called a city girl, and did a lot of my growing up in small town England and provincial Northern Ireland, but still, my knowledge of rural life in the developing world is rather limited. Or is it? I may yet have a joker up my sleeve...

Anyway, beginning at the very beginning is a very fine place to start. I lost my kitab (pen) on the plane and had to share one with the other guys sitting next to me as we filled in our landing cards. I started chatting to the guy on my left, a previous non resident Indian who had lived all over the world - Russia, America (that is the great thing about the third world: they are by definition politically non aligned nations - pragmatic to the max. You know it was the first Indian Prime Minister Jawarhalal Nehru who coined the phrase?)... and had now returned to India. We had an interesting conversation about justice and he was full of advice for me on my travels, the main indication being to stay safe. I was beginning to get the hang of this urban rural divide. City dwellers are terrified of the countryside. 'Rural India?' my mum had exclaimed when I told her about my elective, before resigning herself to her fate - 'well, we've always known you're an adventurer, just like your father...' (truth be told my mum is an adventurer herself - some of the stories she could tell you about her travels would make your hair stand on end. Maybe this is why she was so concerned, despite being my inspiration). When I grow up, I'm going to marry an adventurer just like my dad, masha'allah (I learnt this in Abu Dhabi - it's Arabic for 'by the grace of God', just like insha'allah. I think the difference between the two is that the former, a conditional, expresses a desire, while the latter qualifies an actual plan - but I stand to be corrected).

(Interjection from the future: I stand corrected. Insha'allah is actually conditional and expresses a desire, as it means God willing, so it would have been more appropriate in the above sentence. Masha'allah expresses a certainty and means thank God. I have this on good authority - well, from my Egyptian friend.)

After a long wait at the conveyor belt for my luggage where I again encountered my disabling passivity (I waited ages before reclaiming the bag I had recognised as my own being removed by a member of airport staff because I didn't want to offend anyone), I was finally on my way. In Abu Dhabi I had felt really European, in Bombay I was beginning to feel really Yoruba. 'Emi naa ni mother tongue (I too have a mother tongue)', I thought as all the hitherto anglophones chatted away in Hindi. Also, my inner Lagosian started to emerge - at least on the inside. The sarcasm and aggression gives you the patience of a saint when dealing with a mean (that's the only word for it) customs official - 'you think your rudeness fazes me? I was born in Lagos!' became my inner refrain. I stepped out of the building into the unknown. The plan was to get the shuttle from Bombay to Pune where I would be picked up by somebody from the Comprehensive Rural Health Project in Jamkhed where I am to spend the next 6 weeks. Easier said than done.

As I stepped into the crowd of welcoming families and alert travel representatives I scanned the placards quickly for my name and walked briskly, not wanting to look like a Johny Just Come (self explanatory Lagos slang for a green person). This is stupid, as a JJC is precisely what I was - or am. Having not spotted my name anywhere I must have looked very lost for a member of airport staff came up to me and asked what I was looking for. I told him I was supposed to be getting the shuttle to Pune. He told me there was unlikely to be a bus at that time of night, it being 3 o'clock in the morning - did I have a contact telephone number I could ring? I needed to look it up on my laptop (I can be rather hapless at times, another one of my personality flaws). He kindly acoompanied me to a safe place where I could find the number, then helped me dial it on his phone. It rang to no reply - unsurprising, as it was the office number, and what office is open at 3 o'clock on a Sunday morning? We tried a couple more times, and were faced with a dilemma - what to do?

A colleague came and advised me to get a hotel in Bombay and rest for the night. They would sort me out in the morning when it was safer and make sure I got a bus to Pune. There had been an accident on the expressway to Pune, he said, and this had probably held up all the traffic from the city. He wouldn't advise me to go now. He left us to ponder my options. With the helpful official I tried the phone number again. We made small talk as the phone rang. 'Are you a Christian?' he asked me. 'Yes', I said happily, 'are you?' 'Yes', he replied, 'I'm Roman Catholic'. 'That's great', I think I said (or wow or cool or something else stupid sounding like that even though this was very good news to me). I explained to him why I didn't want to stay in Bombay that night - I had been assured that somebody would be picking me up from Pune, and I didn't want them to have come all the way for nothing. Could he please come with me to have a look at the people at arrivals again? Certainly, he said, he was here to help. So we went once again, and this time we saw the placard with my name on it. Gratitude flooded over me. 'Thank you so much for all your help', I must have said over and over again. I've been so blessed on this trip by helpful strangers that I'm learning the importance of prayer - not for ourselves, but the people we meet in life who help us along the way. Who knows if we'll ever meet again? But God is watching over us all.

My adventure was only just beginning. By this point I was already in love with India - it was just like I had expected it to be - the monsoon, the tropical plants, the red puddles from the red earth - just like my childhood, but different. I was grinning from ear to ear as we (myself, the shuttle staff and the other booked passengers) made our way to the car park. 'Where in Pune do you want to be dropped off?' we were all asked. I didn't know. I had assumed that the shuttle was a bus which stopped at a defined desination, but it wasn't - it was more like a taxi to which you dictated where you wanted to go. So I kept repeating myself like an idiot: 'I don't know, I was just told to take the shuttle to Pune and someone from Jamkhed would pick me up from there.' 'Pune's a very big city', came the inevitable reply, 'where in Pune are they picking you up?' Along with, 'where precisely is Jamkhed?' 'Ahmednagar?' (after repetition about 3 times, making me realise I would need to lose this RP accent, and fast) - 'ahh, Ahmednagar! But that's really far from Pune you know!' Dear oh dear oh dear...

Thankfully, God was still watching over me. A helpful couple also traveling to Pune became my intermediaries, explaining what was going on to me in English, and to the driver in Hindi. 'Don't worry', everyone kept reassuring me, 'everything will be fine'. No one was going to leave without me. Meanwhile the mobile number used to make my booking was switched off, so there was no way of finding out where to drop me off, and to whom. One of the cars (there were 3 people carriers - 4 wheel drives going to Pune from the same company) was about to leave, taking the helpful couple with them. The other driver assured them that I woud be fine. Now it was just me, the host of drivers, and another male passenger left. The driver settled me in the front seat with my bag. 'Just relax, sit down', he said. 'You are a lady, so you should have the front seat'. I did as I was told. Then he came and asked me for money. 'Do you have any money?' he asked wheedlingly. 'No, I'm sorry, I said.' I am by now used to denying money to people who ask me for it because of my experiences on the streets of Belfast. 'Just a little change', he said. 'Any spare rupees' - I didn't have any rupees. 'Or dollars.' The only cash I had on me was to pay for my elective, and I wasn't about to flash any of it around. So I told him firmly that I didn't have any money, and eventually he left me alone.

After waiting a while I decided to get out of the car and see what was going on - I felt uncomfortable sitting when everyone was trying to sort stuff out. The other passenger, who had been watching me for a while, came to chat. After establishing that I'd just come from Abu Dhabi and he from Hong Kong on business, he asked where I was from. I told him my usual Nigeria via the UK story. This got us chatting about football and the World Cup final later in the day. 'Nigeria has a good team, hasn't it?' 'No', I replied, still bitter. 'We did in the 90s but our performance this year was a shambles. Is football really big in India?' He said it was. I asked where he was from (he looked Caucasian, although he spoke English with an Indian accent and fluent Hindi) and he pointed here, to the ground, 'India'. I was intrigued but didn't ask any more, not wanting to turn into one of those, 'no, where are you from originally?' people. 'Are you a Christian?' he asked me. 'Yes, are you?' I replied wondering why I kept being asked this. Was it because I'm African? Or was my constant prayer so obvious? Or maybe, and I think this is true, faith matters a lot in India. 'I'm a muslim', he said. Once again I must have said something stupid like 'wow', or 'cool'. I was goin to talk about the similarities between the two religions, but caught myself. It was nearly 4 o'clock in the morning. Neither of us had the energy for that. We were waiting for the last passenger to arrive. I was relieved to find out that she was a woman when she finally came. The two of them became my intermediaries in the next phase of the journey.

When the lady arrived and handed over her payment, my eyes met with the driver's (the one who had asked me for money for himself earlier) and he gave me a look. He said I hadn't paid. But I hadn't realised I was supposed to pay upfront, I had assumed payment had been made when the booking was made in my name. Because I was quoted the cost of the journey in dollars I'd thought I was meant to pay for the shuttle along with my elective fees when I arrived. I told them this (or rather, the lady translated for me). The drivers argued amongst themselves. Somebody wasn't going to let me on. The kind man I had chatted to earlier offered to pay my fare. I thanked him kindly, but said if it came to that I would go back into the airport to get some rupees and pay for myself. I didn't want to deprive somebody of his hard earned money, especially if the actual situation was unknown. The lady offered to accompany me to get the money. The bluff was called. I could go on the shuttle. Finally, we were off!

As we drove through Bombay I was reminded more and more of Lagos, but with subtle differences. I was excited. The first song that played on the radio was from one of my favourite Bollywood movies (Kal Ho Naa Ho). I knew all those years of listening to the BBC Asia Network and reading Indian literature and even following soaps on Star Plus hadn't gone to waste! Meanwhile, things were still being sorted out behind the scenes. The driver (not the suspicious one - another person was our designated driver) got a phone call to say they'd got the correct mobile number of the person picking me up, and they'd confirmed where I'd be picked up in Pune. The other passengers relayed this to me. I was so thankful to them both, they had been so kind. They really had stood up for me and protected me on their own soil. I kept saying thank you. 'Stop saying thank you', the woman said kindly. 'We also know what it feels like, this is what it's like for us when we go to countries where nobody speaks English'. This is why I love travelling. It reminds me of what it means to be human - to be generous, to have an open heart, to put yourself out for strangers because they are your brothers and sisters.

What more can I say? Of the unexpectedly long journey (we didn't get to Pune till about 9, I didn't get to Jamkhed till about 12 noon), the breathtaking beauty of the Indian hills, teeming with life, the hospitable climate with the refreshing monsoon rain, the evocative bus of the Indian arm of the multinational company my dad used to work for, making me feel safe, and the surprising number of dogs, making me feel less safe (cheapskate didn't get the 120 GBP rabies vaccine because I was reassured it wasn't necessary). This included the dead dogs - I counted at least 4 - on the obstactle courses that are Indian roads. Once you realise the basic rule of the road - that it is to be treated as an obstacle course to be assailed with as much speed as will get you to your destination as quickly and safely as possible, the hair raising nature of the journey becomes more exciting than scary. You basically overtake anything that you don't like the look of - cars, lorries, tuktuks, cyclists, protest marches, processions - beeping your horn really loudly as you do so. It's only polite. Even the lorries all have written on them, beneath their number plates: 'Horn OK Please'. The only exception to this rule is cattle. They can come and go as they please on the roads. In the cities you wonder why cows are such a protected species, other than the obvious religious reasons (cows being sacred in the Hindu religion) - there surely is a reason for this. Why are there so many cattle when you're not allowed to kill them or eat them? I wondered. Wouldn't that be a waste of resources in taking care of the cow? What is their financial value other than milk? It's only when you get to the countryside that it starts to make sense: cattle are a beast of burden. They plough the land. It doesn't make financial sense to kill your beast of burden. You see, everything has a reason...

Anyway, I finally arrived at Jamkhed, got settled into my room, had a shower, made some new friends, ate food, had a much needed nap, phoned my mother...but I'll write about that later. This has already gone on too long, and I'm very hungry.

Have a blessed week!

Call the man a girl and you've pretty much got my story...

The night before the night before...
I had a headache. A terrible terrible headache. And waves of nausea gripped me like an abortive surf - always threatening, never fully breaking through. I often get migraines, but this was worse than anything I'd felt in a long time. It took me back - way back to my childhood, when I used to get the dreaded disease that makes you weak and anorexic as the taste of your food turns to ash in your mouth; even my appetite was gone. Forget Delhi Belly, if I lost the fabled Belfast Stone(s) in India it was unlikely to be from diarrhoea. This was what what would do it - doxycycline. Not even malaria itself: its prophylaxis.

When my doctor prescribed me doxycycline he told me the side effects were mild, but to make sure to take it with food and wear sunscreen - because it causes photosensitivity even in someone of my skin pigmentation. I couldn't believe it. Me, wear sunscreen? What is all my melanin for? Am I not an African? Why did I need protection from the 'third world' - sunscreen, insect repellent, anti-malarials, don't drink this, don't eat that, be careful who you talk to? I'm cautious by nature but all this seemed a bit OTT. Until the doxycycline hit and I remembered that I am not as sturdy as I like to think - in fact, I was quite a sickly little child in Africa. It's strange how little control you have over your own body. So, precautions it would have to be, with the following song sounding eerily familiar (as you are to discover in subsequent posts). Enjoy the video link! http://www.youtube.com/watch?v=ULjCSK0oOlI


You Can Call Me Al

A man walks down the street
He says why am I soft in the middle now
Why am I soft in the middle
The rest of my life is so hard
I need a photo opportunity
I want a shot at redemption
Don’t want to end up a cartoon
In a cartoon graveyard
Bone-digger, bone-digger
Dogs in the moonlight
Far away my well-lit door
Mr. Beerbelly, beerbelly
Get these mutts away from me
You know I don’t find this stuff
Amusing anymore

If you’ll be my bodyguard
I can be your long lost pal
I can call you Betty
And Betty when you call me
You can call me Al

A man walks down the street
He says why am I short of attention
Got a short little span of attention
And woe my nights are so long
Where’s my wife and family
What if I die here
Who’ll be my role model
Now that my role model is
Gone gone
He ducked back down the alley
With some roly-poly little bat-faced girl
All along along
There were incidents and accidents
There were hints and allegations

If you’ll be my bodyguard
I can be your long lost pal
I can call you Betty
And Betty when you call me
You can call me Al

A man walks down the street
It’s a street in a strange world
Maybe it’s the third world
Maybe it’s his first time around
He doesn’t speak the language
He holds no currency
He is a foreign man
He is surrounded by the sound
The sound
Cattle in the marketplace
Scatterlings and orphanages
He looks around around
He sees angels in the architecture
Spinning in infinity
He says Amen and Hallelujah

If you’ll be my bodyguard
I can be your long lost pal
I can call you Betty
And Betty when you call me
You can call me Al

Na na na na …

If you’ll be my bodyguard
I can be your long lost pal
I can call you Betty
And Betty when you call me
You can call me Al
Call me Al

leave space here...

for Abu Dhabi post - will come back to it later!

New new hemisphere

Even our fantasies are haunted by our nightmares. I was talking to my little sister about the fictional country of her own making. 'It's very warm there, and it hardly ever rains', she said. 'The most popular job is to be a plumber...to fix their water problems. Also, you know how we have a war that's been going on for a very long time but doesn't happen here? Well, when they have wars, they don't go on very long and they always happen elsewhere.'

We were sitting in the library of the Nigerian High Commission, waiting to have our new passports issued and getting an education in the meaning of the term 'echelons of power'. The busy consular staff varied from being unbelievably attentive to blankly obstructive; humanity and bureaucracy make a turbulent mix. Meanwhile, the displaced waited. Waited for proof of identity, of existence, for movement, for livelihoods, for legitimacy - in wealth and poverty and middle income, in good health and ill, contented and restful, vocal and disenfranchised - all waited at the behest of the Mother Country or Father Land and its agents for a place at the family table. We waited in alert silence and competitive watchfulness, and later in jovial camaraderie, brought to us by the children. Lesson 1: in Africa, it is not possible for children to be seen and not heard. Children are our light - our biggest challenge and our greatest hope.

They crawled on the floor, ballet danced around the room, sang loudly, made escape attempts and generally exhibitions of themselves with no recriminations from the generous adults, brightening up an otherwise very dull and tense wait. Here's to you African children, all over the world, young and old...

After my short stay at home I began the second leg of my journey out to the middle east, filled with some trepidation. Why did I lurch myself head first, alone, into such uncertainty? Well meaning advice churned in my stomach - what to eat, what not to drink, who to trust - and my little sister's tears dripped behind my own eyelids. Homesick already? Surely not as heartbroken as the Australian girl behind me on the flight, singing morosely to herself in a very loud voice - 'leaving on a jet plane...' For by now I had found excitement. This was a new hemisphere, a different country - they do things differently here. An advert for designer burqa sunglasses in a magazine was the first harbinger of this, followed by the view from the plane of a different kind of architecture - most buildings white or terracotta, the famed symmetry of Islamic art adorning the landscape, abounding with domes and cubes. Even the natural habitat was different - shrubs peeping through the sands in the perpetual struggle between life and barren desert, and lots of palm trees, evenly spaced, carefully planned. At seven o'clock, the sun was already setting, confusing me about the nature of the darkness - was this foggy snow I could see? Should I have brought a coat? I needn't have worried - stepping out into a sauna which steamed my glasses up reassured me that the 'foggy snow' was in fact white desert sand.

I was given a warm welcome at immigration to the United Arab Emirates as the customs official tried to learn how to say my name. I had a joyful reunion with my family and am glad to be in a new hemisphere - with new news, a fresh perspective, different priorities and a temporary reprieve from the big adventure up ahead. I am not alone just yet. Thankfully. Still, I am a bit excited and grateful for the opportunity to see the diversity of this world we have been given.

Home and tranquility

Leg two done. There's a momentary stillness after 20 hours of travelling and 'se débrouiller tout seul', lugging a big suitcase across train stations in big cities, being stimulated to think - about helpfulness and neighbourliness and community and family and friendship and privilege and discrimination and fear and sacrifice and love. And sleep. It's good to see the family. I could sleep forever. Intrepid now, prayers valued...

Elective chronicle - the first leg

Ireland - Scotland: on a ferry on the open sea, savouring the sweet scent of freedom, incredulous about the fact that there is free wi-fi provided and wondering why the guy sitting behind me is whingeing very loudly about the slow connection rate (and in the quiet zone at that), when whingey thoughts start to enter my own head. Who builds a quiet zone next to the movie theatre and in front of the gambling arcade? From my right I hear people shouting, wind instruments blaring at intervals. From behind comes thudding dance music, and an android voice - 'place your bets. Dum dum dum. Name your bets....' The ching ching ching of coins sounds like the opening salvo of the revolution. The revolution of hell. Not quite, but nearly.

Thank God I can fall asleep at the drop of a hat. I like the ferry; it is cheap (less than half the cost of a flight, with a fixed price that can be paid even on the day of travel), scenic (you get to look out at the sea and occasional surrounding mountains), spacious (you can go walkabout and reduce your risk of a DVT) and comfortable. And did I mention cheap? My fixation with cheapness is maybe not a good thing. Taking a 20 hour journey to England from Northern Ireland via Scotland when you could just fly in an hour may signify questionable judgement, like my getting the vaccine against swine flu just because it was free. At least I get to see my brother...

Last time I went to visit my brother (which was also my last impromptu trip), I took the ferry as well, and ended up waiting for him on a park bench for nearly 4 hours, shunned by all and sundry. I include among the sundry the dog which defecated nearby whose owner neglected to clear up after it, leaving a disturbing smell. It was a snowy winter's day and I was too cold to get up from the metal bench to warm another one with my body heat, so I stayed where I was with only a weekend bag and Ray Charles on my MP3 player for comfort. I was far too cold to take my hands out of my pockets and read the book I'd brought for company. I'd never been so happy to see an Afro haired boy in a brown corduroy jacket in my entire life, and jumped up to meet my brother from afar when he finally arrived. 'Don't tell me you've been waiting there like a bag lady for the last four hours', were his first words. I had suspected that it was my apparent homelessness which had led to my universal shunning.

But hark! What is this I see on the horizon? It's the Scottish coast! We are nearly there, already the cleaners are starting to tidy up. The adventure is about to begin...