One of my project teams traveled to India recently to conduct research on the burden of and response to non-communicable diseases (NCDs) in the country. Being in-country helped me make a more personal connection with the visible needs of India, but it also helped me recognize the tremendous challenges of implementing real social change.
Our time in India was filled with tremendous contrasts. One moment, we’d be looking up at the sleek glass and steel skyscrapers and five-star hotels in Gurgaon; the next, we’d realize the humble bases of small houses and buildings from which they rose up. In the heart of Old Delhi, a rickshaw ride reveals narrow but crowded pedestrian alleys crossed by hundreds of loosely bound electrical wires and winding haphazardly through tightly packed buildings. A web of roads connecting these and many other disparate parts of the booming metropolis that is Delhi are jammed with masses of semi-trucks, cars, rickshaws, tuk-tuks, tractors, and scooters at most every hour of the day. A twenty kilometer trip on some of the newest and widest roads in the city can take anywhere from an hour to much longer, depending on traffic. The air is filled with unending streams of horns used more as traffic signals than displays of frustration as vehicles swerve across the road without any concern for the traditional use of lanes. As my colleague put it, traveling by car in India is more of a constant contest for any open space than driving.
Riding as a passenger on these roads drove home for me one of the key insights we learned during our time in India. Within India, communities of wealth with access to first-rate care and (large) areas of extreme poverty with much poorer treatment capabilities, particularly for NCDs, are packed tightly together. You do not have to go far from the shiny towers of Gurgaon to find the dull aluminum roofs of slums. And despite the much higher availability of doctors and medical facilities in large Indian cities than in other areas, challenges of confronting health issues like NCDs in peri-urban slum areas connected to cities are in many ways greater than those related to health delivery in rural settings. Reasons for this include poor diet, lack of exercise, lack of community leadership or cohesiveness that can enable effective education and prevention efforts, work and life schedules which make seeking treatment difficult, and transportation difficulties that can isolate patients from treatment resources. It was these last two reasons that creeping along the crowded roads of Delhi helped reinforce for me in a direct way.
Efforts in India to increase access to any piece of patient care (diagnosis, treatment, counseling, etc.) must take into account these constraints which our team was fortunate to tangibly experience, and which will continue to inform our thinking as we strategize about potential interventions within the country. The erratic hours of occupations such as rickshaw peddler or side-of-the-road vendor, and the even more erratic condition of transportation in many parts of the city, are clearly hurdles for patients seeking regular or specialized treatment for NCDs.
Readers, what kinds of insights have you gained from on-the-ground experiences that you might have missed if you had only studied the situation from a distance?