Baazars and birthdays

It’s Monday morning at the hospital. When we arrive we are met with the usual mob of patients and their families anxiously waiting to see Dr. Subodh. There is a growing crowd at the receptionist counter where the staff is desperately looking for Dr. Subodh only to find he has already entered into a busy day of cleft and burn operations.  Despite lingering sleep deprivation from the camp, the team was energized after successfully launching the first telemedicine pilot in the field. Before we begin compiling our “Comprehensive Telemedicine Plan” that will include an overview of our activities and insights, patient interview data, requirements for technology, steps to implement and measurement telemedicine, staffing, revenue and cost models, etc. we decide to get feedback from those on the other end of the telemedicine Skype call. Dr. Gaurav and Mrs. Poonam Sinha were both involved in the telemedicine prototype and provided us with valuable feedback on their experience with telemedicine. 

We first met with Dr. Gaurav, one of the surgeons, who enjoyed the telemedicine experience because it helps patients save time and money by not having to travel to Varanasi. He also likes the opportunity to provide daily consultations to patients. His main area of concern was video quality. He showed us a video that he took on his cell phone during the Skype calls with patients. The video quality was poor and continued to decline whenever patients moved to show their burned arm or cleft palate. As a result, he was unable to properly diagnose patients using video alone. Another concern was scheduling telemedicine given that he performs 4-5 surgeries per day, which starts and ends with rounds. This was helpful as we began discussing potential ways to schedule telemedicine without disrupting current hospital operations.

The next follow-up interview was with Mrs. Poonam Sinha, the speech therapist that already has experience Skyping with patients for speech therapy sessions. Not surprisingly, her concern was the audio quality. A majority of the time she was able to hear the patient, but there was a lot of background noise. We think this should be improved when there are not 300 patients clamoring for Dr. Subodh in the background. For scheduling purposes, she has the capacity each day to complete additional speech therapy sessions via Skype. Overall, G S Memorial employees love the idea of telemedicine and are willing to put in the time and resources to make it a success!

After a great day at the hospital we decide to keep the momentum going by touring Varanasi at night with a local. The walking tour was called, “Birth, Death, and Rebirth” and our guide led us to many of his political party’s favorite historical sites. As we removed our shoes to enter one of the temples where Buddha had once taught, our tour guide asked if wanted grass to make the walk better. We were sorely disappointed to learn that he wasn’t talking about the type you walk on, and declined.  Thankfully, cows are not permitted in the temples, and trash is removed regularly, so our feet got off lightly, as we wandered through the peaceful and shockingly quiet temples. We also ventured into busy bazaars tucked away between narrow streets lined with old, brick-exposed buildings. We were amazed by the vibrant life that existed in these hidden alleys and have since braved them on our own.

The remainder of the week we continued to work on our telemedicine plan, spoke with more of the hospital staff and of course did some extensive data mining. Two meetings this week were very informative. The first was with the hospital accountant, Mr. Yadv and the second with the social worker, Mr. Pankaj, who was also at the screening camp. The accountant gave us all the necessary information (balance sheets, income statements, etc.) for us to do a deep dive into the hospital’s finances and input some of the information into our financial model for telemedicine. Overall, it’s looking great! Our conversation with Mr. Pankaj (world renowned lead actor from the Oscar winning Smile Pinki) centered on his experience with telemedicine at the screening camp and the hiring and advertising costs associated with marketing such activities. We also asked him how he thought telemedicine might affect his work.

That night was the Dr. Subodh’s birthday bash for his daughter Nimisha’s 20^th birthday! We had previously been to Dr. Subodh’s house for Holi only last week, but the house was completely transformed this time with pink and white balloons lining the grand staircase and walls, rose petals adorning tables, beautiful flowers in vases and staff that served delicious Indian appetizers and virgin cocktails. We saw many employees from the hospital dressed up for the occasion. After mingling we all watched a traditional birthday ceremony, which involved the grandmother and mother blessing Nimisha and ended with lots of confetti showering the guests. As we feasted on appetizers and cake, as American college students are apt to do, we were mortified to learn that there was an entire dinner waiting for us on the roof. We were ushered to the rooftop for a delicious dinner buffet with food from every continent (Antarctica being represented by popsicles) and an elaborate Indian sweets table. The night ended, as all good ones do, with Dr. Subodh and Daniel singing karaoke in Hindi and the rest of us dancing along.

Many exciting things happened this week from the telemedicine prototype to our adventures in Varanasi. Today was no different, as some of the team went for another boat ride on the Ganga River and came back with an unforgettable experience. They say the river is never the same twice.  

Telemedicine gone wild

The train was supposed to leave at 7 pm. When, in fact, it didn't leave until 8:45… no one made a fuss. Many people in India, according to our host, are the wealthiest in the world. Not in the sense that they have the most money, but they have unlimited access to the most valuable good in the universe that money cannot buy - time.  As a result, everything runs on IST (India Stretchable Time), which seems to be more of a philosophy than an exact science.  Varanasi, among other attractions, is at the intersection of several train routes, so people from all over India wind up with day long layovers here.  The train station was so crowded that families lay on mats all over the ground, resting or eating a homemade Indian meal packed for the journey or cooked between the cows and motorcycles on the platform.  

Finally, the old blue train pulled along the platform and we looked through the open, barred windows to see crowds of people sitting, standing and hanging out on open car doorways. Seeing the worried look on our faces, Dr. Subodh reassured us that we had the best seats on the train in the "AC 2 tier".  These high class cars permit reservations with fold out beds, whereas the general class ticket is a complete free-for all. An unlimited number of general class tickets are sold and some people must stand for an entire 36 hour trip to Mumbai!  

Once onboard, our car was nice and cool, and we each had a bed in a sort of cubicle looking space which had a curtain for privacy.  Dr. Subodh and his staff unpacked a gourmet feast put together for us by Dr. Subodh's talented wife.  Yum!  We ate and chatted with them about the camp the next day and then everyone “slept” for a few hours.  

We arrived in Muzaffarpur around 6:30 am and went to a hotel across the street from the train station to clean up and eat breakfast before heading to the charitable hospital where the camp was held.  Once at the hospital, we met with the chief administrator and trustee who told us about the hospital, which has been a great partner for G S Memorial.  The hospital specializes in pediatric and gynecological services offered at a steep discount to Bihar's poor.  The hospital is set up as a trust and though it operates on razor thin margins to provide incredibly high value care, like GS Memorial, it also boasts impressive financial stability. It was standing room only as we followed Dr. Subodh into the hospital. His entrance was prolonged by the large crowd extending from the hospital entrance to his office, as his patients blessed his feet as a sign of respect. Some even blessed our feet by association with him.

We set up our telemedicine clinic in a room near Dr. Subodh’s. The hospital had set up a new table and office chair and they had brought in a computer and internet wiring the day before.  Word of the talking computer spread like wildfire and before we could finish setting up, a crowd of patients anxiously surrounded the room pushing towards the entrance. It was at that point that KC quickly and naturally transitioned from surgical resident/MBA student into bouncer. We were so surprised and so thrilled that the patients adopted telemedicine so quickly!  Especially since in this region, not only had many of these people never seen a foreigner before (let alone 4 in a room!) but they had never used a computer or accessed the internet.  

After a few technological hiccups and dropped internet availability, we started telemedicine.  Parents came in and encouraged their children, who were follow-up cleft lip and palate surgery patients, to speak loudly to the speech therapist on the screen. The therapist analyzed the patient’s speech and introduced some to the concept of speech therapy.  After each patient had their telemedicine session, they were directed to a table where Cassie and Michelle conducted post-telemedicine interviews.  Due to a stroke of genius by clever Cassie, we had the G S Memorial social worker translate our interview questions to Hindi and recorded his voice so we could play each question to the parent or patient. Since most of the answers to our questions were either yes or no, we had the social worker write out yes/no in Hindi on a paper so patients could point to their answer. Our workaround for not speaking Hindi worked like a charm to get answers to all of our questions…except when they only spoke a local dialect and did not understand the recorded questions in Hindi…then there was a lot of confused looks on both ends! Luckily the social worker stepped in again to help, what would we have done without him!?

Even after the surgeon and speech therapist at GS Memorial logged off and we closed up our telemedicine pilot for the day, people were still coming to our room hoping to get a glimpse of the talking computer.  Our results…patient adoption couldn't have gone any better!  People love it!  And, they're willing to pay to use it (because it’s cheaper and more comfortable than a 9 hour train)!  This is great news for Dr. Subodh and his plan to launch a robust network of telemedicine clinics.

Between patients, we had the chance to walk around the camp and take it all in. Dr. Subodh expected about 150 patients, but ended up with 300!  They were mostly follow-up patients, but he did have plenty of new patients as well.  With about 6 hours to see patients, he was only able to spend about 1 minute with each patient, but that was enough for him to analyze their condition, note their charts, and, more importantly, build a connection with the patients and their families.  At one point the crowd around his door, so eager to see him, could not be contained by the guards and army officials.  It was time for Dr. Subodh to maintain the peace, so he emerged from his room to address the crowd, promising to examine every patient, regardless of how long it may take. Order had been restored at least temporarily…        

It’s clear to anyone who has the opportunity to meet Dr. Subodh that he is truly passionate about his work.  He improves patient lives and those of their families, to him this impact is the ultimate reward. He feels as though he has been given a gift and should use his talents to help as many people as he can.  An otherwise joyous and friendly doctor, Dr. Subodh scolds patients when they return for follow-up and are clearly not taking the right care of their children or themselves. This sternness is out of love because he deeply cares about his patients and their wellbeing.

With only 1 hour until our train departed we left the camp with one of the hospital staff.  We were onboard and all settled in, convinced that Dr. Subodh would remain at the camp until midnight evaluating patients. The conductor released the brakes and the train started crawling forward when, suddenly, we heard a laugh and saw a familiar smile. Dr. Subodh saw three patients per minute for the last hour of the clinic and miraculously made the train!  Both children and adults spent the next eight hours peeking around corners to catch a glimpse of the foreigners. Just before midnight, we reached Varanasi, tired, dusty, and elated that telemedicine would soon help us bring the specialized plastic surgical care to the people of Bihar. 

Swimming in the Ganges and learning Hindi (only one is true)

The sun rose early this morning as we sat in a boat on the holy Ganges River overlooking the Dashashwamedh Ghat. Yellow and red sun rays illuminated the ancient buildings and marked the beginning of a new day. For locals, it was a chance to bathe in the holy river next to a dead cow for good karma and to cleanse their sins. For us it also marked an end to our first week in Varanasi.

Our work at G S Memorial began days earlier with introductions to hospital administrators, staff, nurses, and surgeons. On the first day we met with Dr. Subodh in his office to review our interim report, further discuss the project scope and our plan for the week. Ansari, the hospital ward master, and our new friend, gave us a tour of the six-floor, 80-bed hospital and showed us what would be our office for the next two weeks. We received a very warm welcome from all the G S Memorial staff as well as curious looks from many patients. Before the day ended we spoke with the in-house speech therapist to understand how she is currently using telemedicine for follow-up appointments.  She and Dr. Subodh also created tutorials on DVDs and cassette tapes to complement the therapy sessions.

Overall, some major accomplishments this week! Daniel learned Hindi in an afternoon and almost completed an interview in the foreign language, but the patients were laughing so hard that the linguistics lesson was called off prematurely. He resorted to English (with a Hindi accent of course) to complete the survey, which created a window into the patients’ lives and experiences. Legends of Dr. Subodh and his gifted hands bring people from all over India to the clinic. While some live down the street, many have traveled the larger part of a day or longer seeking his expertise. Open cooking fires increase the prevalence of burn injuries in this region of the world. Others travel from afar with cleft lips and palates, which have prevented them from speaking clearly, kept them out of school and resulted in malnutrition.

Yesterday was an important day for the team and Dr. Subodh as we launched the hospital’s first telemedicine prototype. With the help of IT staff we set-up two rooms equipped with 3G wireless connection and laptops with cameras. Dr. Subodh remotely assessed five patients in between his scheduled operations. The prototype proved to be successful and taught us how we could improve from both a technical and patient management standpoint. The patients responded enthusiastically to their first telemedicine experience and even said they would pay for the service if it was located in a clinic near their home. Our learnings will allow us to adjust and prepare for our second telemedicine trial in Muzzafapur, 10 hours north of Varanasi, during a G S Memorial Sunday screening camp. 

Happy Holi!

Holi!! Playing Holi! Daniel and KC made friends with the tour group staying at our hotel and decided to play Holi with them first thing in the morning!  Michelle and I played paparazzi, taking pictures of them getting covered in colored powder when one of the women came at us with handfuls of green and red paint—and the next thing we knew we were part of Holi in the hotel parking lot! 

Later in the morning, we were picked up by a small yellow car with Smile Pinki on the side to head to Dr. Subodh’s house to celebrate Holi with him and his family!  The excitement was contagious and next thing we knew we were tossing colored water and powder at everyone, jumping and dancing and running around the back yard.  Pink and yellow and green and purple and red strewn across our faces and clothes, dying our skin and hair all while laughing and breaking the ice with our host! 

After everyone was done with the “wet colors” Dr. Subodh set up the microphones for us to sing and dance along to the music.  Other doctors came by to visit and we did more Holi with them, including learning a few hip-shaking dance moves from a friend’s son.  We’ll definitely be taking that back to the C-function!

We all attempted to clean up a bit and then got to spend some more relaxed time inside with Dr. Subodh.  We held his Oscar for Smile Pinki and heard about his experience with the movie and the Academy awards.  We ate some delicious Indian food (his wife is an incredible cook) including a chickpea dish, fried bread and a pastry filled with dried coconut. 

Holi was incredible and we enjoyed spending the day with Dr. Subodh and his family at his home.  Day 1 with Dr. Subodh—AMAZING!

The oldest city in the world and the holiest city for Hinduism - Varanasi!

Varanasi, here we come!  Today we traveled from Delhi to Varanasi. After a final breakfast at our Delhi hotel, we went outside to load up our taxi to the airport.  We were surprised to find that our taxi to the airport was even smaller than the one that had taken us to the hotel two days earlier.  Luckily, we only had two pieces of checked luggage for the group (Daniel is the world’s lightest packer and Michelle still hadn’t seen her bag since Boston), so the luggage fit strapped to the roof.  Despite telling the driver multiple times that we had to go to the arrivals areas to find Michelle’s bag, he proceeded up the departures exit—and when we exclaimed “arrivals!” once again, he tried to back-up down the exit!  “No! No!” we yelled, fearing for our lives, and we proceeded to departures.  Michelle and I (Cassie) had to talk to every Air India employee on duty to find her bag that had finally arrived from JFK before we could check in for Varanasi. “Go upstairs to departures to get a pass to get through customs in arrivals” said one, “Talk to the people in Gate 8” said the next…when no one was working at Gate 8, we were pointed to the opposite corner of the building. The next Air India employee pointed us back to Gate 8, informing us that “someone will come after some time”.  Given that time was running out to check in for our flight to Varanasi, that wasn’t going to cut it.  After a few firm words with this gentleman, we finally convinced him to get someone from the baggage office to bring Michelle’s bag up to us.

Security posed another whole set of issues.  First of all, they emptied everything out of my bag (Cassie) and scanned it twice.  After finally approving all of the items, and re-loading them into my bag, they were convinced that I stole the plastic numbered paddles that match passengers with their items…in reality, they had already collected them, but they were absolutely convinced I packed them into my bags. Luckily they checked their stash of numbered paddles and found that they had, in fact, collected them before they made me unpack everything again.  Also, they had made a big deal of putting name tags on our bags at check-in, and they were stamping these tags after security—when Michelle’s didn’t get stamped, they waived her on indicating it didn’t matter…luckily she made them stamp it, because they were once again searching unstamped bags when boarding the plane.

Finally in Varanasi, Dr. Subodh greeted us with flowers and warm hugs.  It was exciting to finally meet the man we had heard so many wonderful things about.  He was so hospitable already, letting us know he would be happy to answer any questions or stop for anything we wanted to see on our way into the city.  Driving in Varanasi was approximately 10x crazier than anywhere we’ve been in India so far! Cars, bicycles, motorcycles, tuk-tuks, pedestrians, and cows were weaving all over the road, head-on and swerving at the last possible second.  According to Dr. Subodh, there is only one rule of the road, “convenience”.

Our first adventure in Varanasi was a visit to the mall to get traditional Indian clothes.  We decided to walk the 1km to the mall.  Every tuk-tuk that saw us lined up to ask us where we were going and offering a ride...the line up was causing a tuk-tuk traffic jam!  The most treacherous point in our journey to the mall, well…besides crossing the street…was trying to get around the hoard of cows feasting on the trash strewn across the street and sidewalk.  KC and Daniel bought traditional white Indian suits that they could wear for Holi while Michelle and I bought more colorful dresses.

After shopping, we came back to the hotel to drop off the purchases and rest for a bit before heading out to the river to see the bonfires signifying the start of Holi!  Unfortunately…all four of us completely passed out and never made it anywhere!

Our journey to the Taj Mahal: the rules of the road are “Allah, luck, and a brake”

“In India, everything’s possible” said our driver as a biker approached us head-on on the highway on the way from New Delhi to the Taj Mahal.  It was a phrase he would repeat often throughout the day as an explanation for a lot of behaviors we found risky or peculiar.  Traffic flows throughout Delhi, weaving in and out of bikes and tuk-tuks, honking horns and ignoring any indication of lanes painted in the streets below them.  Men stood on the back bumpers of the local, overcrowded, public transport, hanging on as the vans cruised down the highway.  On the sides of the road we saw a wide variety of lines of work from brick making and farming to an enormous race car course and construction of new cities.

Once in Agra, we weaved through traffic that proved even more chaotic and disorderly than Delhi.  Our driver told us the rules of the road are “Allah, luck, and a brake”.  On the sides of the road, small shops lined the sidewalks, a man bathed in the water spouting from a broken main, horse drawn carts moved heavy objects and a few monkeys played on the rooftops.  We picked up our guide for the day, K.D., an Agra local, who would show us the Taj Mahal and the Agra Fort.

Our first stop was the Taj Mahal.  Just after entering, we ran into a few of our classmates from MIT here in India for India Lab.  Small world!  The Taj truly is a wonder of the world.  The beautiful white marble, carried across India and erected into a beautiful, symmetrical, structure by hand hundreds of years ago, looks just as immaculate today.  Within the white marble stones, scriptures from the Koran and ornate flowers blending the Hindi, Persian and Muslim cultures were intricately inlaid using precious stones to decorate the mausoleum.  The designs and flowers represent the detailed planning that went into building the structure, a representation of the Shah’s dedication to his wife. 

After the Taj Mahal, and a quick stop for lunch where we saw a man sitting on the sidewalk, playing his flute and taming a python, we drove over to the Agra Fort.  The Agra fort was another display of intricate stonework, carvings and inlaid stones as well as an antique air cooling system (hollowed walls that were filled with water).  The fort also revealed a beautiful view of the Taj Mahal across the river.  With her majestic dome reflecting in the river below us, we snapped one last group photo and headed back to Delhi.

India t minus 14 hours...

We boarded Air India flight 102 with an optimistic outlook on our upcoming two weeks in Varanasi. We were eager to immerse ourselves in a new culture and experience our first Holi. Most of all, we looked forward to meeting Dr. Subodh, founder of G S Memorial Plastic Surgery Hospital, who won an Oscar in 2008 for his documentary, Smile Pinki. Our excitement was met with some anxiety because we wanted to meet Dr. Subodh’s expectations and provide him with valuable recommendations. For the past two months, we spoke with Dr. Subodh consistently to learn about the hospital, scope the project, and complete independent research to familiarize ourselves with healthcare in India.

The majority of healthcare in India is privately run, making it much too expensive for most people to access care. G S Memorial partners with Smile Train and Wonder Work and provides state of the art plastic surgery and burn care at an affordable cost to poor Indians.  To date, 25,000 patients have received cleft palate reconstructive surgery at no cost and over thousands have received care at a low-cost. By restoring smiles, G S Memorial is helping to provide equal opportunities for patients. In an effort to continue Dr. Subodh’s amazing work, our project will focus on how to leverage telemedicine in unmet areas to improve clinical operations and increase burn patient volume, while maintaining quality care.

After four movies, an Indian dinner, and some sleep we landed in Delhi. Unfortunately, not all of our bags made the journey. Nevertheless, we headed for our hotel and that’s when the adventure began. Rush hour traffic gained an entirely new meaning. Horns honked constantly as our driver maneuvered his way through the city. After what seemed like hours, we arrived at our hotel. That night we braved the city and walked to dinner. The streets were lively with vendors as we searched for our first authentic Indian meal. We were welcomed in to one restaurant by a man in traditional garments. We ordered more rice, curry and naan then we could eat. Nevertheless, it was the perfect ending to our first day as we headed back to our hotel to rest for the following day’s trip to the Taj Mahal.