The World Bank in Transition

Taken From: Global Development: Views from the Center by Nancy Birdsall from the CGD

With Robert Zoellick’s announcement that he will step down from the World Bank presidency at the end of June, now comes the question of who his successor will be, particularly whether it will be an American.  Just a few days ago I commented on the awkwardness of the situation for the White House. The White House has committed in international fora to an open, merit-based, transparent process, but domestic politics (including some would argue continued support for the World Bank from the Congress) dictates  that it make every possible effort to place an American once again in that office.

It does matter who runs the World Bank and how she or he arrives there.  Why?

First,  the president of the bank has immense power. The bank is big and complicated (more than 10,000 staff in Washington and 130 countries around the world, and an annual administrative budget of about $2 billion).  It houses impressive technical and financial resources. Last  year it disbursed more than $20 billion in loans and grants; in 2009 when a global recession loomed the bank disbursed about $45 billion in response to G-20 calls for a global liquidity push.  On one hand the bank’s size and decentralized structure make it hard to manage; it is famously, unlike the orderly IMF, full of upstarts and entrepreneurs at the staff level.  On the other hand, the bank is a highly merit-based, performance-based bureaucracy.  The staff respond to a fault to the priorities a president sets. Moreover the bank’s governance structure gives most of the “do” power to management; the large resident Board can at best slow things down – and because the president chairs it, the Board has minimal formal ability to hold management accountable.

Second, it matters who runs the bank because the world has big problems the bank can help to address, and big opportunities the bank can advance.  In a 2006 in CGD report, we outlined five tasks for the then-incoming president (who turned out to be Paul Wolfowitz).  To a large extent, despite Zoellick’s impressive performance in calming the waters and putting the bank back on course in the last five years, he did not manage to steer the bank in the new direction those five tasks represent.  Let me mention three of them.

• The global commons and global public goods.  The possible deterioration of the global commons puts at risk the bank’s fundamental mission of supporting sustainable, poverty-reducing growth and development.  Consider these examples: climate change, increasing cross-border health risks ranging from pandemic flu to drug resistance the collapse of fisheries, and politically and economically destabilizing water and other natural resource scarcities. There are many experts and many UN, civil society and academic institutions concerned with these problems. But the World Bank may be the only single institution that can bring the combination of financial, technical and political clout to help shape a global response. So far that hasn’t happened.  The bank is involved in all those areas, but its involvement is ad hoc, heavily constrained by its dependence on the country-based loan instrument (e.g. no financing for intellectual property licensing, no mandate to provide independent verification of forest changes) or on special rich country donor initiatives (its climate investment funds are trust funds dependent on UK and other special contributions).  To address these problems of the global commons and global public goods, the next World Bank president will need the legitimacy and the persuasive powers to corral the bank’s members, to win a clear mandate and associated tools and financing to play a more central role – as catalyst, provocateur, and innovator.
   

• The high hassle costs of borrowing for middle-income countries.  History and habits make the bank still too much of a nanny in countries like Brazil, China, Turkey – even Peru, Morocco and Mauritius.  Yes, those countries often seek and indeed welcome the technical know-how of bank staff.  But it takes multiple “missions” and many months – sometimes many years – to go from a request for a loan to actual disbursements.  That is why countries with access to private capital go elsewhere whenever they can. The bank needs to find a way to pass more of the risks of poor performance on a program or project it finances from its own staff to the borrowers.  It needs to act more like the credit cooperative its founders envisioned. It needs to rely less of detailed planning of inputs ex ante to sensible performance audits during implementation.  To deal with the risks of waste and corruption it needs to rely less on ex ante “safeguards” and more on third-party independent audits, with the legal ability to cut off funds where there are serious problems.  It needs to treat its borrowers more like clients taking on the risks and responsibilities of programs, and less like children.  The high administrative costs of a nanny bank could be better used elsewhere.
   

• Fragile, flailing, failing, weak states.  No one really knows how to help the people of Somalia, Afghanistan, Congo, East Timor and other troubled countries rescue their societies.  The World Bank needs to shift from a culture that feels it must pretend what it knows what to do to a culture of trying, failing, adjusting and trying again.  To a culture in which the ideas and initiatives of others are welcomed.  As a simple start, the bank could revisit altogether its performance criteria for soft landing and grants, and focus more, as my colleague Alan Gelb has proposed, on project and sectoral performance than on overall country performance.  That might help create space for municipal officials with outside support to get something right in their own cities, or for central bank or education officials to innovate in their management of troubled school systems.
   

Bottom line: The World Bank president has a near-monopoly on “do” power.  A person with vision and a commitment to the institution’s missions can use that monopoly to corral the member governments and inspire the management and staff to do what should be done.  Without that leadership, the bank may stay pretty much stuck in the 20th century – when what the world needs is for it to move on. It matters a lot who runs the bank and it will matter for her or his legitimacy that the selection process be as open, merit-based and competitive as politics will allow.

An excerpt from "Investing in Our Common Future", a background paper of the Innovation Working Group under the UN's Global Strategy for Women's and Children's Health:

 

http://www.google.ca/url?sa=t&rct=j&q=rohit%20ramchandani%20%2B%20asia&source=web&cd=8&ved=0CFIQFjAH&url=http%3A%2F%2Fwww.who.int%2Fentity%2Fpmnch%2Factivities%2Fjointactionplan%2F100922_2_investing.pdf&ei=GSQ9T4L2J6nL0QGcg8C_Bw&usg=AFQjCNG_tJul1hfvf1ZH5tWRb0958396CA&cad=rja

10. Innovation in Service Delivery, 2009

Rohit Ramchandani, MPH. Senior Health Analyst, Strategic Policy and Performance Branch, Canadian International Development Agency (CIDA) and DrPH Candidate, Johns Hopkins Bloomberg School of Public Health

At no point in history has the world been so focused on improving health and averting unnecessary loss of life. Millions of preventable deaths occur each year throughout the developing world from diseases like malaria, AIDS and tuberculosis, and because many of the world’s poor lack access to appropriate maternal and child health services. To counter this, major investments are being made to provide care and discover new treatments and technologies for the future. This new paradigm has the potential to save millions of lives, but it also draws attention to our ability (or lack thereof) to utilize new investments effectively, and to deliver health services systematically to those who need them most.
This paper aims to highlight examples of innovations in service delivery based on the experiences of the Canadian International Development Agency (CIDA). Under the Innovation Working Group’s working definition, “innovation” is:

“ ... generally understood as the successful introduction of a new thing or method ... Innovation is the embodiment, combination, or synthesis of knowledge in original, relevant, valued new products, processes, or services.”
In addition, we highlight “innovations” that, while not necessarily “new”, could have benefits through replication and/or scale-up at the global level.

Innovations

The Reach Every District (RED) approach69
Developed by WHO and UNICEF, the RED approach addresses common obstacles to increasing immunization coverage by building district capacity and focusing on planning and monitoring. The approach emerged from a search for innovative strategies to improve stagnating immunization coverage. Based on the successful approaches of the Global Polio Eradication Initiative, and taking the district as the operational level, RED includes five components: 

 Planning and management of resources
 Supportive supervision 

 Re-establishing outreach services  
 Linking services with communities  
 Monitoring for action 

Previously, regional and other inequalities in access to vaccines within a country were masked by the focus on national immunization coverage rates.70 However, the RED approach increases equity of access within countries by concentrating efforts, and setting targets, at the district level. Within each district, it improves the targeting of hard-to-reach populations with limited or no access to health services. 

Focus on the poorest quintile and mobile services 

It is of paramount importance to improve access to care, particularly for the most vulnerable and hard-to-reach populations, if we are to accelerate progress towards the health-related MDGs. Mobile services have an important role to play here. 

Engaging civil society organizations (CSOs)
Essential health interventions are still not reaching the poorest fifth of the population in many areas that account for the highest number of deaths. To counter this, CIDA has a program that engages in-country CSOs to deliver life-saving health services, such as anti- malarial drugs, antibiotics to treat respiratory infections and oral rehydration therapy (ORT) to treat diarrhea-related dehydration. CSOs already deliver a large proportion of front-line health care throughout the developing world71, in countries such as Sierra Leone, Uganda, and Indonesia. Their involvement alongside government institutions is expected to have a catalytic effect on strengthening the reach of programming and research72, and is expected to increase sustainability.

Using mobile clinics
Mobile clinics are run by teams of multi-disciplinary health professionals, such as community health workers, nurses and midwives. Their use during periods of humanitarian crisis has the potential to deliver maternal, newborn and child health (MNCH) services effectively in conflict areas and fragile states. As an example, CIDA and UNICEF are collaborating to expand coverage of child survival interventions by establishing sustainable outreach services (SOS) in under-served and rural communities of Kandahar province in Afghanistan. 

Local involvement is key to the success of SOS. Accordingly, community elders are encouraged to participate in planning and to help identify community focal points. Mobile teams of health workers go from village to village providing services at least four times per year. During these visits, health workers deliver immunizations and bi-annual de-worming tablets for children under five, and insecticide-treated bednets (ITNs) during seasons of high malaria transmission. They also identify suitable local individuals and train them to establish bases for the demonstration and distribution of ORT salts, micro-nutrients and zinc supplements. These services are building on the earlier experiences of the Pulse Immunization Campaigns, which used community structures as partners for planning and implementation. 

Along with existing health facilities, SOS are ensuring access to health interventions for over 156,000 children under five, and approximately 29,000 pregnant women living in Kandahar province.73 Through these mobile services, UNICEF is now able to reach 15 of Kandahar’s 17 districts.74 

Community support and strong connections to the national system are essential, especially as the security situation remains a central challenge. Moreover, discussions with community leaders have helped to improve the reach of services. Nevertheless, there are still issues to overcome, such as the difficulty of recruiting female vaccinators due to cultural barriers and insecurity. These issues need to be addressed if services are to be expanded to include more comprehensive disease prevention, health promotion, family planning and reproductive care. 

Integrated community case management (iCCM) 

iCCM is a cost-effective, high-impact approach that aims to prevent and treat those diseases that kill the most children, including malaria, pneumonia and diarrhea. It works by training and equipping community health workers to diagnose and treat these diseases, which together kill approximately four million children each year, and account for over 40% of deaths among the under-fives.75 Malaria and pneumonia can be fatal in children within 24 hours of symptoms developing, so treatment must be made available promptly if lives are to be saved. 

iCCM is a proven strategy for reaching children at the community level and overcoming barriers to accessing care. It supports programs that achieve high equity because they reach the most vulnerable. They can also be a platform for other key interventions, such as screening for severe acute malnutrition, delivering vitamin A supplements and injectable antibiotics (for neonatal sepsis), and supporting immunization and ITN campaigns. This type of programming is also a focus of the Catalytic Initiative to Save a Million Lives, which is being implemented in countries including Rwanda, Southern Sudan, Malawi, Mali and Sierra Leone.

Child Health Days and Weeks (CHDW) as a service delivery platform

CHDW programs provide the main mechanism for distributing vitamin A supplements. They involve events organized to deliver an integrated, community-based package of low-cost, high-impact health and nutrition interventions for children aged from six months to five years. Other services, such as malaria prevention and immunization, are also provided and have helped to reduce inequities in service coverage by increasing the access of communities in poor and low-performing districts. In fact, the average coverage achieved by CHDW programs has been over 80%.76 Canada was one of the first countries to fund CHDW and provide it with the impetus to reach countries such as Ethiopia, Madagascar, Mali, Mozambique, Tanzania, Zambia, Nigeria and Niger.

Studies should be undertaken into costing, cost-effectiveness and impact to consider CHDW as a platform for other health and nutrition interventions for MNCH. These might include: distribution of ORT salts to combat diarrheal diseases; promotion of iodized salt consumption; screening for and treatment of severe acute malnutrition; promotion of hand washing with soap; antibiotics to fight pneumonia; family planning; promotion of exclusive breastfeeding; complementary feeding; and/or provision of antenatal care.77

Global Polio Eradication Initiative (GPEI) – an established program leads to innovation in service integration and health systems strengthening

GPEI is the largest single public health project the world has ever known. Coordinated internationally, it is spearheaded by national governments, WHO, Rotary International, the Centers for Disease Control and Prevention (CDC) and UNICEF. Its work to strengthen immunization services can accelerate progress towards the Millennium Development Goals (MDGs) by:

 Increasing coverage with the full range of Expanded Program on Immunization (EPI) childhood vaccines (especially for measles)
Facilitating the timely introduction of new vaccines against pneumococcal and rotavirus infections
Assisting with the delivery of other important child survival interventions such as vitamin A, zinc supplementation, and distribution of ITNs 

The infrastructure that has been established by the GPEI for the purposes of polio eradication encompasses both physical assets (including skilled human resources) and a combination of institutional arrangements and operating procedures that can be leveraged in new ways. 

African Health Systems Initiative – Research (AHSI-Res) partnerships
AHSI supports African-led efforts to strengthen health systems by emphasizing the scale-up of human resources for health. It also promotes synergies between multilateral, bilateral and research mechanisms (Canada's contribution under the Catalytic Initiative supports the AHSI). 

Another component of the AHSI is support to African research partnerships (AHSI-Res). This is funded through the Global Health Research Initiative (GHRI), which is a unique research funding partnership of five agencies and departments of the Government of Canada. These include CIDA, the Canadian Institutes of Health Research (CIHR), Health Canada (HC), the International Development Research Centre (IDRC) and the Public Health Agency of Canada (PHAC). GHRI funds research on global health and strengthens the capacity to conduct global health research and apply findings to address real-world problems. 

AHSI-Res brings together both decision-makers and researchers to look for innovative ways to strengthen health systems. Each team is co-led by a researcher and a decision-maker and works to connect research, policy and action to improve knowledge translation, health decision-making and programming across the sub-Saharan region. All solutions are aligned with government priorities. 

In Malawi, for example, Dignitas International and the REACH (Research for Equity and Community Health) Trust have partnered with key stakeholders to test a novel intervention for the training of primary health care workers (HCWs). Called PALM-PLUS (Practical Approach to Lung Health and HIV/AIDS in Malawi), it is designed to simplify existing national guidelines for the management of HIV/AIDS, tuberculosis and primary care conditions, and integrate them into a single, simple and user-friendly guideline. This approach has the potential to be scalable within the country and beyond. Given that the ultimate purpose of the research is to inform policy-level decisions around the training of HCWs and the integration of HIV/AIDS care into primary health, it has been beneficial to have a team comprised of both policy makers (decision makers) and researchers.78

Leveraging Web 2.0 technologies 

Knowledge translation has continually been cited as a challenge in global public health. Information abounds but access is often limited, and only now are barriers being removed that in the past have contributed to the inaccessibility of information. In large part this is due to information and communication technology (ICT)79 and in particular to Web 2.0. The latter is a form of ICT that facilitates interactive information sharing, interoperability and collaboration on the World Wide Web.80 Web 2.0 holds great potential for enabling health information (once restricted to individual organizations and people) to flow rapidly to all parts of the world – from the halls of CIDA to rural communities in sub-Saharan Africa and back again. 

Forward-looking organizations can use Web 2.0 to harness their collective capability and knowledge to spur innovation, collaboration and problem-solving in order to address global health challenges in creative new ways. Policy and programming are often set by experts and vested interests, and this can lead to excessive partisanship, gridlock and stagnation of policy and programming.81 Experts and individuals outside of the traditional global health systems should be engaged in the process of finding new solutions. This does need to constitute a risk if efforts are made to support the appropriate checks and balances. 

One example of how Web 2.0 technology is being leveraged to improve global health is the website DevelopmentWell.com, which will showcase development solutions via online profiles. It will include resources such as videos, images, links to evidence, results/impact information, cost-effectiveness data and related contact information. The website is expected to launch in 2011 and will allow users from around the world to create profiles of solutions (e.g. technologies, service delivery models, innovative financing methods, interventions) that can be ranked and sorted by various categories (e.g. country, disease, affiliated organization).82 Another site to keep our eyes on is the Centre for Health Market Innovations (CHMI).

Global Health Innovation: Tracking the Best/Most Popular Sources of Information

• Social Franchising for Health - SF4Health.org
• Results based financning for health - http://www.rbfhealth.org
• Center for Health Market Innovation – healthmarketinnovations.org
• Strengthening Health Outcomes through the Private Sector - shopsproject.org
• The Alliance for Health Policy and Systems Research – http://www.who.int/alliance-hpsr/en/
• Next Billion – nextbillion.org
• IFC Health in Africa - http://www.ifc.org/ifcext/che.nsf/Content/PromotingHCStandards
• Future Health Systems – futurehealthsystems.org
• Eldis on health systems - id21
• healthunbound.org
• http://www.economistconferences.asia/event/healthcare-asia-2011
• Price Waterhouse series on health markets in emerging economies - http://www.pwc.com/en_GX/gx/healthcare/pdf/emerging-market-report-hc-in-india.pdf
• Development Innovation Ventures - http://idea.usaid.gov/organization/div/overview
• DevelopmentWell.org (current presence on Facebook page and Youtube channel)

ColaLife: piggybacking simple medicines on Cola supply chains, to save lives in underserved rural areas in Africa

We have just been selected as Finalists in the Ashoka Changemakers Making More Health competition. Vote for us here:

ColaLife: piggybacking simple medicines on Cola supply chains, to save lives in underserved rural areas in Africa

PRIVATE CORPORATIONS HELP AID GROUPS IMPROVE DELIVERY
by @Ivy Mungcal/Devex on 26 August 2011

 
The use of bar codes and electronic way bills, among others, has long been practiced by leading private corporations such as Wal-Mart and UPS. These companies are now transferring knowledge of these trade crafts to aid organizations like the World Food Program to help mobilize humanitarian aid faster and in a cheaper manner.
 
“If you bring company thinking and company skills to a place like WFP, you can really make an impact,” Peter Bakker, former head of the transportation firm TNT and now a U.N. ambassador against hunger, said, according to The Associated Press.
 
Bakker recently visited hunger sites in Kenya and Somalia with WFP Executive Director Josette Sheeran, who shared that her agency is currently transitioning to a computerized delivery system that attaches bar codes to aid products and uses electronic way bills. Sheeran noted that various companies are donating the technology WFP needs to set up the system, allowing the agency to save millions of dollars.
 
“It’s another form of corporate responsibility that I think is really key,” she told AP. “Can you help us be as good as you are — in our world of savings lives and hunger — in all these efficiencies and controls?”
 
Among well-known companies that donate logistic support to aid organizations is UPS. A spokesperson for the company said UPS is sharing its logistic expertise for free to UNICEF, WFP, the Red Cross and Care USA.

Addition by @Antara - Similarly, ColaLife is in the process of developing a trial to test to what extent Coca-Cola's "last mile" distribution chain can improve access to essential medicines in rural, under-serviced parts of the developing world. The current trial will focus on improving access and utilization of ORs and zinc in rural Zambia. ORS/zinc is the globally recommended treatment for diarrhoea, a leading cause of mortality in children under 5.

Chapter 6 - The end of an epic journey - Summer 2004

(note: most names have been changed)

All good tales must come to an end....

Once again a reminder... If you are reading this for grammatical correctness you are in the wrong place... Enjoy...

I have watched the sun turn a waterfall into a cascade of falling diamonds in the midst of dense green jungle; I have tasted the molten sweet ripeness of a green mango kissed by the golden sun..... I have experienced the heat and dust of an Indian summer for the first time and have been exhilarated by it all.

It is difficult to live in India, to visit India even, and not celebrate its warmth, cultural and natural beauty.

This will be my last entry. As my journey through India draws to an end, I am filled with a great sadness, and yet, I have never felt better. My heart yearns for home and the people I love; yet a part of me will remain here eternally. As UWIHDAs 2004 project comes to a close the 3 of us will leave Hyderabad with a unifying memory of a lifetime that will connect us forever. No one will ever have the exact same experience again... the people, the places, the incidents, the situations, the communities, all will be unique to UWIHDAs first project.

This will be a long one. Hope youre comfortable.

As the heat of Indias summer penetrates every pore of ones body, life withdraws and retreats into the cool recesses of shady verandahs, into air conditioned rooms or under the leafy canopy of the neem tree. Water may become scarce, vegetable prices may soar, and the dehydrating drafts of the loo may drain you... but there is still much, much to take delight in. It is a place for indulging the senses.

Now I have to take you back its been a while.


June 21

There are only so many times one can say wow. But wow!!!! An amazing couple of days

On Sunday, Prasad, one of the students at BLSO, invited us to his village. We were quite keen on getting another perspective on village life (aside from that experienced in Mudhol) and so agreed. He called his family the night before to confirm that we would indeed be coming the next day.

We left around 7am the next morning and took a couple of city buses. This is the cheapest and most vigorating means of travel in India for relatively short distances. The journey was about 2 hrs, but as usual, filled with plenty of offerings for the senses. You name it....sound - the relentless honking of horns; taste - we bought a bunch of bananas at Mehndi Putnum (junction) from a street vendor; smell - diesel fumes from the trucks ahead, jasmine flowers being sold on the road side, public urinals, sandalwood carvings bazaar...; and touch - the continuous jolts brought by the speed bumps every (well, what seemed like every) ½ km.

The visit to Prasads village was very interesting.We felt so welcomed by his family and got a true glimpse into the politics and culture of village life in Southern India.

One of the most striking aspects of the visit for us was the role of the caste system. Although this class system no longer holds all that much importance in the more modernized cities like Delhi and Bombay (Mumbai), it still defines social structure in most rural areas and villages; places where older traditions have been preserved and unchallenged. "Society's" impact has not made its way out here.

Prasads family belongs to the highest caste in this area. This immediately became clear when Prasad paid the driver of the jeep taking us from his home to the nearest bus stop an extra 10Rs so not to have anyone else sit in the back with us (because they were from lower castes). The people we picked up along the way squeezed into the single front seat and some sat on the roof

Prasad explained that he doesnt really care much for the caste system, and that it has virtually no significance in his life in Hyderabad, but when he goes home to visit his village he follows the system, "More for my parents sake", he said

A walk through the village with his father later in the day showed us why it was important for Prasad to preserve the tradition in his eyes. The respect shown to his father was like that of a pupil towards a teacher (at least back in the day). No one called him by name. Villagers passing by referred to him as Saab.

Prasads father greeted us at the door to their simple home upon arrival. Dried mango leaves hung from wires above all the entrances an old superstition (a good omen) with recent scientific support (look this up later!!! Something related to bacteria)

Prasad then introduced us to his mother, cousin, and his fathers right hand man. His mom prepared us an amazing breakfast - the softest chapattis I had ever had, curried eggplant, Mutti, and a killer daal. Every ingredient 100 fresh and direct from their farm (a.k.a. their backyard).

After lunch we got a tour of the farm and all the crops they grow - eggplant, cauliflower, kakri, tomatoes, rice, lentils, mangoes, custard apples, green chilies and more. In total, this agriculturally dependant family owned ~20 acres of land passed down from generation to generation We got up close and personal with his buffalo, saw the oxen, as well as their guard dog that wouldnt stop barking at us.

After returning to his house we ate again. It seems thats all one does in India. I asked where the washroom was and he showed me to a walled off, open-air area outside with a small elevated hole in the ground. Below was a trench; a latrine of sorts. A group of children watched and pointed from the adjacent street as I releived myself...For a second I wondered if I was doing it wrong.

Lunch was delicious, and topped off with a giant papaya and mango grown on the farm. Both were ripened to perfection, the juices dripped from our mouths as we bit into the soft orange fruits - the mango, as usual, was a success, the papaya did not impress Jenna or Dave. It wasn't the sweetest of papayas and it is somewhat of an acquired taste. Served best with freshly squeezed lemon and some black pepper (moms way of serving it).

After saying our goodbyes and heart felt thankyous, we headed back to Hyderabad in time to reach by late afternoon. We decided to visit Golconda Fort considering this was our second last weekend in Hyderabad. This is one of the must sees of the city .

This majestic monument lies on the western outskirts of the city less than 10 minutes from Kismatpur campus (where we were staying). It speaks of a great cultural heritage of 400 years and is regarded as Hyderabads main attraction. Built by Mohammed Quli Qutub Shah in 1525, it stands as the epitome of Nawabi culture and grandeur. It exemplifies the power and lifestyles of the Maharajas of Indias rich history.

"Shepherd's Hill" or "Golla Konda", as it was popularly known in Telugu, has an interesting story behind it. One fine day, on the rocky hill called 'Mangalavaram', a shepherd boy came across an idol. This was conveyed to the Kakatiya king, who was ruling at that time. The king had a mud fort constructed around the holy spot. Over a period of time this lowly construction was expanded by the Qutub Shahi kings into a massive fort of granite, which has been a silent witness to many historic events.

One of the most remarkable features of Golconda is its system of acoustics - a hand clap at a certain point below the dome at the entrance reverberates and can be heard clearly at the 'Bala Hissar', the highest point almost a kilometer away. Other faetures include various palaces, factories, water supply system and the famous 'Rahban' cannon, that was used during the last seize of Golconda by Aurangazeb, to whom the fort ultimately fell.

There is also supposed to be secret underground tunnel leading from the 'Durbar Hall' to one of the palaces at the foot of the hill. The tombs of the Qutub Shahi kings, built with Islamic architecture lie about 1-km north of the outer wall of Golconda. These graceful structures are surrounded by landscaped gardens, and a number of them have beautifully carved stonework. In the evenings there is a Sound and Light show conducted by AP Tourism and narrated by Amitab Bachan (Bollywoods Harrison Ford...Sean Connery....take your pick).

It blows my mind how an architectural marvel like Golconda could have been built without any machines. Built of solid stone, Golconda sits atop a hill that overlooks all of Hyderabad. The fort covers the entire hill, from top to bottom, and includes stables (not just for horses, but for elephants as well). Oh to be a Maharaja and have an elephant instead of an elevator.

We were lucky because there was a festival going on that day and so admission was free; otherwise something like 50 Rs. for Indians, and 200 Rs. For "foreigners"

Upon our arrival, we were swarmed by tour guides who wanted to take us through the fort. Prasad said he knew everything there was to know about the place so we opted for him to be our tour guide. We climbed to the top of the fort about 150m high in awe of what was around us and spent some time admiring the view. On the way down we got a lesson in how small the world really is (one of many similar instances). We bumped into a Canadian couple who had arrived in Delhi on the same plane as we had. They were in India working on a literacy project in rural areas. The couple was retired and they now spend their time traveling the world and doing this kind of work. A perfect example of you're only as old as you feel and a great retirement plan.

We also ran into Anna, another Canadian (first yr. medical student at Dalhoussie) who will be here till August. She was with two Australian optometry students who, like Anna, were also here for observation.

As we were leaving the Fort we got a chance to see the festival in full swing. Drums beating, people dancing, and men painted from head to toe. Hundreds of people were crowded around the exit/entrance to the fort. I saw a great opp for a picture and told the others I was going to go around the corner to see if I could get a closer look. I did so without knowing Jenna had followed me.

What happened next was a lesson in International work, in particular regarding women working overseas. As has been demonstrated in literature regarding working abroad there are extra precautions women must take. Not only health related but also in terms of certain social situations. We will be posting some of this literature on our website shortly under Resources.

As I was positioning myself for a great shot I realized Jenna was behind me. I had it in mind to tell her it wasnt a good idea for us to stand here, but I suppressed it. Big mistake. As we were standing alongside the rambunctious crowd trying to get the perfect picture, the scene quickly changed from what seemed like happy go lucky party at first, to drunken bachelor party. Suddenly the crowd, like a tsunami started moving towards us like a wave. The sudden shift was unexpected and we had no where to go. The dancers got closer and closer, within seconds we were in the eye of the storm so to speak, and I put my camera up for a shot of the painted dancers. I clicked turned to get us out of there, but it was too late.

From the mass of people (you couldnt tell where one body began and another ended) two hands shot out from the homogenous (Im such a science student) entity right onto Jennas chest. Her reaction brought my attention to what had happened obviously a fairly traumatic experience (unfortunately common nonetheless). Jenna was a little shaken up. I began pushing our way out while screaming in Hindi at the area of the crowd from where the hands had come. Others were helping to clear a path off to the side and random people were apologizing for the crude behaviour of a few deprived "gentlemen".... The whole scene was a lot more dramatic than I'm able to describe it here...

We quickly cleared out and caught a bus home, Jenna seemed fairly calm, collected and cool after a short time, while Dave and I were apparently having more of a difficult time with the whole situation.

I kept running the scene over and over again in my head wishing that I had turned around a second earlier and grabbed the guys arm (see in my head Im like Jackie Chan) and Dave just kept repeating, "I should have been there".

Lesson: No matter who you are, but especially if youre a foreign female, be extra vigilant in these types of situations avoid large crowds (mobs is probably a better word to use b/c who are we kidding you cant really avoid crowds in most of the developing world).

We started our rotation in the LV Prasad Eye Hospital on Monday morning. This would be the final phase of our internship with the World Health Organization (WHO)

We got up and discovered that Jenna wasnt feeling too well. The inevitable had arrived. The "Hyderabad Hangover (c)" had struck. I was getting a little worried there, as I would have been de-Indianized if I was the only one of us to have suffered a little Delhi Belly. We got Jenna comfortable, asked her if she wanted us to stay, gave her all the meds she would need for the day (CIPRO, Lomotil, electrolytes, etc.), and collectively decided it would be best for her to rest for the day and sit the first hospital shift out... in retrospect a good plan. She kept the cell phone and we checked on her intermittantly thoughout the day.

Dave and I had some Kellogs Chocos cereal we had purchased two days earlier and mixed it with Amulas powdered milk and Mahanandi mineral water. Mmmm mmmm.

We then went across the street to the International Centre for the Advancement of Rural Eye Care (ICARE) and met with Mr. Jachin Williams, a jolly, plump, mustached man, whom we like to think of as the Indian Santa Clause - always smiling, laughing, and forever friendly. Very well respected in the institute, he would be the one arranging our hospital rotation. He asked us what areas we would be interested in and arranged for our three days in the hospital: Operating theatre (OT), Pediatrics, and various Out-Patient Departments (OPDs).

Dave and I then headed for the hospital in the TATA Sumo for our day in the OT.

This about as close as one can come to a surgery without performing it or being the patient. Today we were essentially residents. In fact, we did the exact same things as the residents, as we were with them for a number of the surgeries. The day was intense - full of drama, excitement, and success.

We arrived at the hospital and reported to the OT. They were expecting us. An Ophthalmic assistant lead us into a changing room were we were to decontaminate, change into scrubs, and wash up.

We were then given a quick tour of the OT (theatres for various types of surgery (oncology, glaucoma, corneal, cataract, etc.). We were then lead into one of the theatres were we met Dr. Santy. He was a specialist in cancers related to the eye and was in the process of removing a benign tumor. He was just finishing up, showed us the patients CT Scan and told us to come back in about 20 minutes as there was a very interesting case coming in next. (Our video will show more of the gory details of all the surgeries).

We returned to operating theatre 5 after some time and spent the next 2 ½ hours observing a carcinoma removal. A cancer had virtually destroyed a good portion of the patients eyelid. The surgery involved removing all of the cancerous tissue and reconstructing the eyelid. After the tissue was removed, labeled, and the steps were explained to the residents and us, the removed tissue was sent to the pathology lab to confirm that all of the cancerous tissue had indeed been removed. It was confirmed and a donor sclera was brought to the theatre. The next step was amazing. Dr. Santy used the donor sclera to reconstruct the eyelid. The tissue, we were informed, was also collagen based and was, therefore, a suitable substitute. He stitched on the sclera, which he had cut to match the removed tissue, and stretched the remaining skin over the sclera, recreating the previously deformed eyelid. Pretty amazing stuff (our oscar worth y video captured the whole thing).

The next surgery we saw was in the Glaucoma theatre. We met with Dr. Mandeep who was quite the character. We entered the OT in time to catch the last half of a Phakotrabeculectomy (a combined surgery to treat glaucoma and cataract).

As the surgery was winding up, the nurse asked him if he wanted to use an antiseptic solution commonly applied at the end of surgeries of this type. Apparently this was a mistake. Dr. Mandeep took offense and went off on her. "Whos the Dr. here. Ive been doing this for years, I know what Im doing. I dont need you reminding me of this step. Ive done the entire surgery." The surgery was over. He left the theatre. Dave and I had a laugh with the nurse. "Kind of sensitive isnt he", I said. Before she could respond, Dr. Mandeep walked in again and continued... "You know I choose not to apply (whatever the solution was called - I think it was just iodine) at the end, and yet you insist on asking every time. you're annoying." The nurse left indifferent to his words. A sign that this was probably not too out of character.

His attention then turned to us, noticing us for the first time. Dave and I laughed nervously as if to agree with him. I introduced us and thanked him for allowing us to observe. We spent the next 45 minutes speaking with Dr. Mandeep who was suddenly the nicest man in the world about glaucoma, his research, my previous glaucoma research experience, etc.

Later that day, when we were telling the students about our day, they began to laugh when we mentioned Dr. Mandeep's name. They explained that Dr. Mandeep was known for his outbursts but that hes a phenomenal ophthalmologist and a leader in his field.

The final surgery of the day was a corneal dermoid removal and corneal transplant The patient was a 1-year-old boy

Dr. N, the surgeon, was very friendly. He was happy to have us there, and explained the procedure throughout. During the surgery, Dr. N asked for a pair of surgical scissors. The nurse handed him a pair and he began to cut...

As I was saying, the day was full of drama...

As he began to make the incision he stopped. He suddenly threw the scissors against the wall and screamed at the nurse (a trend?), but I think it was justified. "How many times have I told you to throw out these pairs!!! Get me another", he said.

The nurse left the room and brought in another set. He took the scissors and began to cut. Again he threw the pair against the wall. This is someones child!!! For Gods sake!!!

The nurse brought in a brand new set and the surgery continued as though nothing had happened. Dave and I stood in the corner feeling like we were on E.R...... Intense Drama

When we got home, Jenna was feeling much better.



June.22

A day that I will never forget.

Today we spent the morning in Pediatrics

One of the cases I followed will stay with me forever...

I was speaking with one of the doctors when Jenna came and told me that I needed to see something. I followed her, walked into one of the consultation rooms and saw what is perhaps one of the worst medical cases I have ever seen in person, on TV, or in a book....purely based on looks....not necessarily complexity.....although this particular case was about as complex as it gets.....

The patient was a 4-year-old boy with retinoblastoma. Retinoblastoma is a rare (more so in North America. Dr. Santy said he sees approximately 1 case a month. A doctor back home would be UNlucky to see 1 case in his/her entire career.), but life-endangering tumor of childhood. In this case the tumor was bilateral which occurs in approximately 30% of cases - these are the heritable cases (which can be caused by inter-familial marriage - a common practice in Andrah Pradesh's rural communities and also related to an interesting social reason keeping farming land within the family).

This case of retinoblastoma was exophytic (it grew outward). Both exophytic and endophytic types gradually fill the eye and extend through the optic nerve to the brain. This was the case here. The cancer had spread to the brain. The prognosis was poor.

The childs eyes, or rather what used to be his eyes, were completely scabbed over. Scar tissue, etc. was protruding outward maybe an inch or so past the tip of his nose. It is an image that will forever be burned into my memory.

The boys father waited too long to bring his son in, having been worried about finances, when a doctor recommended surgery a couple of years back. Now, after finally getting to LVPEI and finding out the surgery would be free it was too late.

The rest of the day went by slowly with not much else going through my mind.

In the afternoon we were given a tour of the eye bank on the 5th floor as well as the microbiology lab.


June. 23rd

We spent the next day in three of the major OPDs: Cornea, Glaucoma, and Low Vision. All were extremely interesting. We shadowed the consultants in each department and had the opportunity to speak with a number of the patients, all of whom were very interested in hearing about why we were there. They had a lot of questions about Canada and each and everyone said, God Bless you before they left the consultation room.

Before heading for the hospital, Youssuf took us to see Charminaar in Old Hyderabad. Another one of the must sees of the city and a historical marvel immortalizing the Nizaam Dynasty.

This was our last day at the hospital and the last day of project work



June 24th

Although it was supposed to be a fairly light day, Thursday was pretty hectic. I began the day by working out finances with Mr. JW and RS.

We went to the Administration Program's convocation ceremony (which was nice since Dave and I werent there for ours). We congratulated Sudeep and Flash and finally met Dr. Rao the visionary behind LVPEI.

During the ceremony Dr. Rao asked us to introduce ourselves. I introduced our team and thanked LVPEI on behalf of UWIHDA for this amazing experience.

We spent the remainder of the afternoon posing for photographs (official and not), and spoke with some of the major contributors from Vision CRC, an Australian based organization.

June 25th

We didnt get to sleep till 4am because of chit-chat with the students, goodbyes, and the Portugal vs. England match. On a side note, Euro 2004 has been amazingly exciting and its a shame football isnt more popular back home.

We woke up at 6am so that we could say our final goodbyes to all the students on the bus going to the hospital.

Youssuf showed up to pick us up at 8:30 in a Sumo. He wasnt supposed to be the driver but he arranged to swap assignments with the driver who was going to take us to the airport

We checked in at the airport with no problems and left for Delhi. My Masi (Aunt) and cousins were there to pick us up and we went home to drop off our bags. We then headed for Janpath in CP and shopped till we dropped. well, Dave and Jenna did.... I still have a month

Jenna and Dave got to see the artistry of India and all the hand-made wonders produced throughout the country....definitely some nice gifts.

Dropped them off at the airport in the evening. It was hard saying goodbye and Ill leave it at that.

Another Month.

From this point on, I was alone. no more 24/7, constant companionship. The nature of the trip changed drastically... now, one more of self-discovery and family.



Randoms...

Sweet Deliverance

The week was scorching. The promised rains hadn't yet arrived (they still haven't, and they are no longer expected to. This was a one time event.) and neither had the relief that was to be brought by the beginning of the monsoons in Delhi. The heat made one pray for rain.

They came without much warning. We were lying on the bed inside my Nanis (grandmothers) house and the tip tap, pitter-patter slowly began. As though Zakhir Hussein himslef was in the next room playing the tabla, the beat began..... The beat of the monsoons

We ran outside onto the verandah.... the air had begun to cool. It was sweet deliverance....

The rain was light at first. We could see little puffs of smoke forming off the power lines across the street as the raindrops hit them every couple of seconds...obviously high quality insulation!!!

It slowly got heavier. The skies filled with the rumble of thunder...louder and louder... closer and closer.

Soon it was a full on downpour. Children were walking home from school, their uniforms, pigtails, and book bags drenched right down to the last fibre of khadi.

5 Boys, apparently drunk from the rain, were screaming, laughing, dancing in the downfall.

The streets quickly filled with water. Delhi's drainage system isn't so good... literally a pool was made of the streets

At the deepest points, sometimes in the middle of the road, children were lying on their stomachs, throwing one another around and splashing each other as random sandals floated around them

As people walk by, water up to their knees, theres a certain satisfaction to be noticed on their faces despite being soaked to the bone

Miniature tsunamis beat the street sides as cars, trucks, buses, rickshaws, and scooters drive by.

With my grandmother I sit on the verandah and look out at the water world that is currently Jungpura.



July 21st

Yesterday we returned from an amazing 3 day getaway to Rajisthan The dessert state of Indiaan extremely culturally rich areaEnter the 15th century.

We stayed at the Neemrana Fort PalaceBuilt in 1464, Neemrana Fort-Palace became the third capital of the descendants of the Chauhans. They had fled Delhi after Prithviraj III was killed my Mahmud Ghori in 1192. Neemranas proud rulers, heady on their ancient lineage, continued to assert themselves, even under British rule. Thus, their lands were clipped and given away to Alwar, Patiala, Nabha and others who entertained them with champagne breakfasts and shikar (hunting). In 1947, Raja Rajinder Singh of Neemrana moved as the façade of his Fort-Palace crumbled and its ramparts began to give way. For forty years he tried to rid himself of his liability but there were no takers. In 1986, the ruins were acquired and their restoration begun. The fort recently won an award for being the foremost example of how we can pick architectural treasures from the national dustbin and turn them around.

By 2003, Neemrana Fort-Palace was finally ready with 45 rooms/suites. An additional wing now houses a health spa, an amphitheatre, the hanging gardens with a lounge, a restaurant, a conference room, and gym and four special suites. What was once a grand ruin, now stands resplendent.

Only the pictures will provide an idea of how gorgeous this place was. It was amazing. We stayed at a palace!!! This would be an amazing place for a wedding. They rent the entire place out for 5 Lakh Rupees for private functions - only in India


All Good Things Must Come To An End

It would take a lifetime to really fathom the depth, the diversity, the distinctive Indianess inherent in every little experience this country offers simply because each experience is so startlingly different, so encompassing, that it challenges your senses and carves for itself a niche in your mind

Mark Twain once said India is the one land that all men desire to see, and having seen once, by even a glimpse, would not give that glimpse for the shows of all the rest of the globe combined

After the soul-enriching experience of this visit. the internship and all of its eye-opening offerings, the magnificent temples, the vastly different landscapes, the mantras being chanted and carried across the golden shimmer of the skies at dusk by the cool water breezes, the people. I am ready to come home.

Thank you for being a part of this journey with me

Chapter 5 - The exciting world of international health and dev't - Summer 2004

June. 4

It's only been about 10 days and already the value of rain is crystal clear. It has been hot. I woke up this morning at about ten past six to the sounds of a huge thunderstorm. It's pouring outside. The raindrops are huge. I opened my window and the cool air brought by the rains hit me like a wall.. The most refreshing thing ever.like diving into an ice cold pool on a sweltering hot day.. The smell in the air carries signs of the monsoons.they have begun..

Last night before bed was quite the ordeal. I was brushing my teeth in the washroom when suddenly, from the corner of my eye, I saw something - a shadow - bolt by. I turned and standing by the open door to my room, I saw it. The biggest lizard I had ever seen.teeth so sharp the crocodile hunter would think twice, a tail so long Dickins would be humbled, and eyes like ice cold daggers peered back at me. I quickly tried to close the door, but like a flash of lightening it was gone..around the corner AND INTO MY ROOM. I peaked around and saw it scatter under my bed. I knew this would be a worthy adversary. I quickly ran and got Dave and together we attempted to vanquish the beast.

So basically a 1 inch lizard got into my room, scared us like little girls and we had to get to of our Indian floormates to scare it away.

Today we spent the day in the slum of Shivashankanagar. We went from home to home and spoke with the residents of the slum. We asked them questions about their ocular histories and if them or anyone in their household had any visual problems. we informed them that we were from the LVPEI and that we would be providing transportation from their village and a free vision screening the next day. There was a lot of interest. Shankar, the field worker we were working with, informed us that our presence was sparking a lot of interest and that people were a lot more inclined to hear what we had to say. T hey were much more receptive, which was great for us, but, in the end, will be of greater
benefit to them.

You know what would be a good new REALITY TV show. "Survivor Poverty: The Slums of the Developing World - The True Survivor"



June. 5

Today we held a community screening camp at the Sri Sai Baba Old Age Home in Miyapur, part of the Deepti Sri Nagar Colony.

A lot of love, yet a lot of problems. It quickly became apparent that there are no regulation boards monitoring Old Age Homes. Although much less common in India (the elderly normally live with their children), the centre could definitely use some money.The caregivers were obviously there for the right reasons and the residents seemed happy (we spoke with many of them: hearing tales from their pasts, how they learned English, their experience with white people, and the like). However, the safety standards were, by our measure, somewhat lax. Some of it seemed to boil down to resources, but other things just seemed like neglect..

A woman being pushed to our screening room in a plastic lawn chair. No wheelchairs..

One elderly woman.very frail. had a terrible eye infection. what seemed like an ulcer of the eye. We were told it had shown up a couple of days earlier and they were waiting for the doctor who visits once a week. This was not something that could wait. It was too late and we were told her eye would have to be enucleated.

We placed an eye patch over her eye in order to prevent the infection from spreading to the other eye and arranged for her to go to the hospital the next day. We then told the staff to contact her family. We were informed that her son had left her with his wife while he went to the States and his wife had put the mom in the home after the son left. the son apparently doesn't know.. We arranged for someone to go with her and stay with her. There is an overriding feeling of helplessness.. You want to do more and ensure that every story has a happy ending.but it soon becomes clear that there are so many stories.one the same as the next.A system wide, mass intervention is needed.that is clear.population health is essential.but until then you do what you can. The value of NGO's (and we've been exposed to others besides LVPEI) is immense in the developing world.

Who's to blame here? The government? I don't have an answer to that yet.and I don't know if I'll find one, or if that's even the question I should be seeking the answer to..


June . 7

An interesting couple of days. After we left the old age home we headed for LVPEI. A good fundraiser might be to send a donated wheelchair over and pay for the shipping..

Although some of what we saw was hard to swallow, the patients generally seemed happy and enjoyed each other's company. Definitely a number of interesting characters to keep things interesting.

Got to the hospital and waited in the second floor field testing room for some of the students (Ajay, Marveen, Anton and Dikshit). This was apparenlty the most air conditioned room in the hospital and for the first time in India, I actually felt cold. The others arrived and we all jumped into an auto and headed for Lifestyles, a new mall and "the top spot" in town. A lot of fun. The mall was very westernized except that everyone was Indian.you could have been in Brampton and you wouldn't have known the difference. The culture and magic of India disappeared within these walls, but nonetheless, it was worth seeing and a good time.

We went for dinner at a little Punjabi Dabha called Leeds. Had some amazing Alu and Onion Pranthas. Some of the guys ordered Lassi . Just to be careful, I only had a sip.. but it was sooooo good.. Damn Canadian immune system.. If only it were pasturized.. Maybe in a couple of weeks. We then went to a little pub called Sparks.It was couples only but the guard remembered us from the other night and let us in. We enjoyed a pitcher of Kingfisher and some hip-hop by request. A good time was had by all.

When we arrived back at campus the guard informed us that our Karam Cherdu (satellite station) plans had been cancelled due to heavy rains in the area. In addition, I had to change my room b/c some elderly guests were arriving the next day and the only other guest room was two floors up. I gladly switched rooms. It rained pretty heavy that night. Once again the breeze was wonderful.I had to take advantage. I taped up mosquito net over the window and created the best Ghetto AC ever. slept like a baby. There was an extra bed in the room so Ajay slept over. A nice change for him I'm sure. The guest rooms are nothing like the student rooms.

We woke up late Sunday morning and went for breakfast - Channa ; ) Batura At breakfast we made plans to go see a movie with a bunch of students in the afternoon.

I had to change rooms again for the day b/c there were a number of guests here for a meeting hosted by Dr. Rao's wife. They wanted to offer rooms to the guests to freshen up after lunch.

We wnt to the IMAX theatre in the afternoon. The pride of the theater industry in Hyderabad. and interestingly, also owned by LV Prasad. This was a huge entertainment complex (Prasads) with the latest equipment. Dave went wall climbing as we all cheered him on from the crowd below, we played video games at the arcade, and then watched Bollywood's latest hit - Mei Huhn Nah (somewhat of a take on the matrix, but with all the classic Indian touches - action, adventure, comedy, romance, and of course.random musical outbursts). Dave and Jenna both enjoyed too. Ajay and I translated throughout.

Went to Universal bakery for dinner and had Chicken burgers..delicious Got back to campus and got put in another room because the guests decided to stay the night.



June. 8

This morning I moved back into my original room. Spoke with Rajashekar and found out we would be going to Mudhol, another satellite station, on Thursday. It's supposed to be a really nice centrewith gorgeous surroundings. We'll be there for approximately one week and spend our last week on rotation in the main hospital.

Today we got a lesson in lensometry and began testing the prescriptions of the approximately 1000 pairs of glasses we brought to donate. These glasses will then be donated to members of the communities we have been working in, who would otherwise be unable to afford them . very satisfying!!! After lunch I had a meeting with Flash. I think I may have found one of UWIHDA's future projects. Flash is Namibia's National Coordinator for one of Africa's top ocular institutions. They run a number of community/public health programs and they sound wonderful. Flash described Namibia, the programs, the logistics, the wildlife, the work.and invited us to partner with his organization for our next project. I will definitely be following up on this.

Went to a really great shopping area/bazaar. Jenna wanted to buy a Salwaar Kameez. Shopping with women is hard as it is. now add a white woman in India with hundreds of people watching... Quite the experience..Good times.. We also bought a new SIM card.we can be reached at 011 91 9849679883

Had a good argument with the auto driver, grabbed a bus home from Mehndi Putnum, had some mango and went to bed.



Interlude

While the 5 star hotels, crystal clear swimming pools, free drinks, and sandy beaches have always delivered a good time. they fall into a different category of travel. This type of travel is different. It is an adventure. It's an experience from start to finish. Some of the aforementioned things MAY come into the picture somewhere along the way, but by no means define this type of travel. This type of travel is putting yourself in a different world; it is learning; it is meeting new people; experiencing new cultures; trying new foods. This type of travel is adapting; it is flexibility and openmindedness. It is being cautious but not paranoid. It is meeting every new challenge with a smile. This type of travel is heat and bugs and rain and animals. It can be snow and sleeping bags or tents and repellant. This type of travel is experiencing life to the fullest and being a part of what this vast planet has to offer. New sights, new sounds, new people, new cultures, new smells, new friends. It is exploration, curiosity, wonder and awe.It is amazement and passion and anticipation. It is jungles and monuments, Kayaks and canoes, caves and waterfalls, mountains and snowshoes (that was my poor attempt at a rhyme).. It is meds, trail mix, and a good book in your bag. if people are waiting on you hand and foot it can really be a drag (my name does rhyme with Poet after all). Its friendships, tiffs and laughing all the way.its listening and language and knowing what to say.. This type of travel means being a part of the best and worst life has to offer..



June. 10

My words will always fall short. The best I can do is try and describe the bitter sweetness of India to you.. But until you come and see what we have seen, and do what we have done. it is impossible to know.. Surreality. Not just a feeling any more.

Tomorrow is my sister's Birthday. She's turning 19..19!!!!

Spoke with my family. they called at 4:30am. They're Indian.they're supposed to know what time it is here. Glad they did..It was an energy boost and just what I needed to start this day.. As I spoke with my father on the phone the song of Koyal birds could be heard...then, the sounds of Muslim prayer filled the air (as it does four times daily) with words from the ancient Quran being recited. a sense of mysticism is inescapable here.

Today we leave for Mudhol. anticipation sets in.

I hope and pray that my English skills are fit enough to adequately share some of this. It is essential that people back home are exposed to what is out there. here.

This morning. Déjà vu.

As I was removing my home made AC (a.k.a. mosquito net) from the window. I thought I saw something fall from the net. Before I could register what I thought I had seen, I felt something scamper over my left foot. I turned to my left, and there, at the entrance to my closet was the lizard we had evicted from my room days earlier. Before I could close the door to my closet he bolted inside. My nemesis had returned. and I had to catch a bus. I had no choice but to leave.. And so I locked the door to my closet and will return in 7 days to face this formidable gecko.

The journey to Mudhol was a good 5 hours. including a stop at a dabha for puri alu for breakfast. Anlong the way Jenna and Dave finally got to see some monkeys that I had assured them would be all over the place.I was getting a bit worried there. A long awaited sight had finally come to be.

We arrived at the satellite centre and were greeted y a number of staff from the small hospital. Our bags were carried to a guestroom within the hospital with two beds, a fan, a closet and a washroom with an old school Indian toilette. No pleasant scents here.

We freshened up and were then given a tour of the facility by Babu Rao, the hospital's director. We had lunch, relaxed for some time, played an intense game of ping-pong and were invited to go see the guesthouse we would be staying in starting the next night.

We were forewarned that the guesthouse was in a village and that it was unlike our guestrooms at BLSO or even at the hospital. Baburao made it quite clear that we would need to be a bit "flexible". I responded by saying flexibility is our motto.

The drive was short, but interesting. we weren't 100 ure how far it was, so when we were driving through a failry run-down area. what we would percieve as a bit better than a slum. we didn't pause to think that this was the village we would be staying in. We drove, honking all the way, through the narrow, dusty streets of the village. Pigs to the right of us, chickens and cows to the left. Narrowly missing a donkey, we turned a corner as the eyes of passer bye's (?) peeped through our TATA's windows.

We pulled up in front of what was a quaint little house with yellow bordered doors. what had to be one of the nicest homes in the village. Which by "Canadian standards" isn't saying much. we got out and walked to the gate. A young man opened it and greeted us.

Baburao quickly added, "I'm glad you guys are so flexible," and with that we entered the house.

We walked through an empty kitchen into a room with three cots and no fan. We then walked through another door at the back of the room which lead back outside. We turned the corner and faced a metal door. The young man pushed it open. some lizards scurried away and he introduced the washroom - a small shed like room no more than 5ft by 5ft with an old school Indian toilette and a bucket with a scooper for bathing.

Awesome!!!! We are totally psyched for this week. This will be an experience we will not soon forget.. Villagers for a week.

Never could I have imagined..never would I have expected.to find insects that were larger in India than in the rainforests of Guyana. I was Wrong!!! My mosquito net is my salvation. It is my fortress of solitude. beneath it I feel safe. protected. unpenetrable. although the size of some of these bugs have got me a thinking twice.. Trying to bathe while insects of all shapes and sizes fly at you is not my definition of a good time. but for now, it will have to do.


June. 12

We ended up staying in the hospital again last night. The heat was unbearable. We had put up a mosquito net over the window so that we could leave the window open over night. It began to rain quite heavily during the night and our excitement reached a new plateau in anticipation of the cool air the rains would bring in combination with our replica window screen. But it was not to be. Instead of bringing a cool flow of air the rains brought power failure after power failure..The night introduced a battle of epic proportions (not unlike the Mahabharata) between the storm and the generator that was feeding our ceiling fan. inevitably, mother nature won. Although the fan would occasionally start up and provide a glimmer of hope bringing with it the sweet salvation of a cool breeze, it was always short lived.the night went on like this.fan on. (sigh of relief).fan off.(lying in a puddle of sweat).fan on.(Yes!!!).fan off .. (Nooooooo!!!!!!!). fan on... (thank you God!!!). fan off. ("it's only 1:30!?!?!).

Jenna was on the verge of a reakdown, Dave, quite surprisingly slept fairly well with the occasional, "damn it!!!" when the fan turned off. I found it all quite amusing. uncomfortable, but amusing. waiting to write the story down in my journal.

It's a good thing that the majority of today will be spent at the hospital shadowing the ophthalmologist.we're all a bit tired. Random thought. To be as educated as we are and still be indifferent shows the failure of our education.



June. 13

Went to Saraswati temple today. One of two in all of South Asia dedicated to this Goddess of education. We asked her to bless our intellect and watch over our educational pursuits.. The statue of Saraswati Mata was gorgeous.a famous solid gold statue adorned with and surrounded by flowers, fruits, incense, ganga jaal, and various coloured powders.. We were there for the evening aarti.

It was..enchanting is the word that comes to mind. The sounds of the priests

chanting mantras was hypnotic; mystical; healing.. Over the past few days we have received the opportunity to truly see rural life in India. The life of the Indian farmer. And his dependence on the land.. The hospital finds that during these three months (June, July, August) there is a substantial decrease in the number of patients. We determined the answer to this decrease first hand during a community screening in one of the villages we

visited. a little epidemiological investigation if you will... It was clear, after speaking with a number of the villagers we screened, that their priority during these three months was work.even if at the expense of their vision. These three months constituted their livelihood.

Yesterday we visited two of the tertiary vision centres near Mudhol. one was in the middle of the nearest town and the other in a small village far out in the middle of acres of open farmland. In the 2nd town, as we were exiting from the vision centre, a crowd had gathered due to word of foreigners in town. While hundreds of eyes gazed at us,

one man, obviously drunk, started yelling something at us. he touched Jenna's feet and then mine. In Telegu he said, "I am a donkey compared to you" with a heavy tone of sarcasm. he continued on and said something about us "living in our castles whilehis family was dying". There was a definite sense of resentment. It was humbling. Nothing we didn't already know.the inequality that exists in this world is mind boggling.. But, nonetheless, a rude awakening.

We had a great conversation that night which was sparked by the events we had experienced over the last couple of days in this remo te, secluded area.our conclusion wasn't directly related.we covered a lot of topics during our nightly debriefing session (I started holding these after our second night here). but we agreed that people back home. in the society we live in. don't get enough opportunity. or don't take the time. to reflect. to think about and discuss life. there are undoubtedly exceptions to this , rare as they may be. but generally self-reflection, time on your own away from the hustle and bustle

of daily life. is rare.. Opportunities like this . being in the middle of nowhere; little to do when not working; gorgeous surroundings. and other elements that have come with this experience have allowed us this time. People need opportunities like this.

Animals seen in the past 2 days: mongoose, langurs, scorpions, giant mother super cockroaches, and the usual suspects - goats, water buffalo, pigs, cows, dogs.


June. 15

OH what a night!!!!

"The rooftop is a good friend out here."

-Baburao


This morning we were talking about how we were going to miss Canada Day and the fireworks, etc, etc..and then by some weird twist of fate.. Dave and I ended up on the rooftop of the hospital just in time for a light show extravaganza. A symphony of fire, not presented y Benson and Hedges, but by God himslef. As the sun was setting over the Savannah-like backdrop of rural Andrah Pradesh we could see lightening in the distance just over the horizon.

The winds were strong and the cool air was refreshing as usual.good time for contemplation.

The past few weeks have reinforced my desire to pursue my MPH in international health. It would be a mistake to opt for the more financially sensible MHA at UBC option, when my heart and mind are in line with international health.Thus Boston is the right choice for me and I will check the no box for UBC.

Baburao joined us on the roof. After a while we noticed a certain tranquility that had come over him. As he looked out at the surroundings of the hospital, Dave and I wondered if this was one of the first times he had done this.

It is fairly easy for us to find the beauty of this place. As visitors in a new and amazing place we are actively searching for the beauty of the place. that's really what we are here to do. it's a natural progression for us to seek out spots like the roof.

We then thought about how for Babrao, who works and lives here, it is his daily existence. This is the place he works. it's a job and it's in a country that he has been born and raised in. He confirmed that this was only the second time he had been up there.I think Dave and I were able to offer him. quite serendipitously. a new perspective of

his everyday environment. to us a spectacle. people don't find things unless they're looking for them.

Today was an amazing experience and opportunity. For the 2nd time on this trip we got scrubbed up and for the entire morning we were in the operating theatre (OT). We witnessed 3 cataract surgeries as well as their pre and post operative procedure which we aided in. To see someone's sight restored.their windows to the world reopened.was moving.powerful.inspiring.

It was easy to lose sight of the fact that the surgeon was working with man and not machine. her movements were so mechanical and precise. I was surprised at the lack of gentleness. I expected something far more fragile. the patients entire body was covered and only the eye exposed. a suture was placed through the sclera above the anterior chmber (superior limbal incision) so as to stabilize and position the eye for the cataract removal. the method used was small incision cataract surgery (extracapsular extraction). The anterior portion of the capsule (of the lens) was then cut and removed (capsulotomy).

The nucleus of the lens was extracted thro ugh the previous incision.The IOL implant was then placed in the remaining posterior portion of the capsule..


June 17

Sometimes you can't help but wonder why there aren't more types of programs to help those in need. But the reality is that there are more people in need than not. It brings a quote I recently read to mind: "when your own life Is threatened, your sense of empathy is blunted by a terrible, selfish hunger for survival." -Life of Pi

People may feel pity, but then they move on.

After a week in Mudhol we are back in Kismatpur, and after a week in my closet Godzilla is still in alive and well in my closet.

Today is my convocation at Waterloo. Its probably going on right bout now actually. As much as I'd like to be there, being here using what I've learned over the past 4 years seems somewhat appropriate too. It's a great 2nd. Thats it for now. Much love to all.