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.