Don Berwick

Don Berwick has been in the news quite a bit these last few weeks. For months, Republicans have been blasting Berwick's approach to health reform, which, like Obama's, promotes centralizing health care delivery and using government programs to affect change. Republican senators have therefore refused to confirm Berwick, who has been serving in a recess appointment as Administrator of the Centers for Medicare and Medicaid Services (CMS). He has recently announced that he is resigning effective December 2nd, one month earlier than expected.

I read each article with personal interest, as Don is the founder of IHI, the think tank / healthcare consulting firm that I'm currently working for. Until he stepped down to head Medicare and Medicaid, Berwick served as CEO of IHI. I came to know Don through the work that IHI did with LifeSpring, helping us improve clinical quality and reduce our c-section rates. At each meeting, I found myself learning so much just by studying what questions he asks, and how exactly he asks them. It's funny thinking of someone as your mentor after only a few meetings, but that's how I started to think of him (and thus the move to IHI seemed only natural).

There was a good article by Rosemary Gibson in yesterday's Huffington Post which, though it makes me sad about America's health care system, makes me proud to be working with IHI internationally:

Americans could not have a better champion for good medical care. I know this for a fact. I led quality and safety initiatives at the Robert Wood Johnson Foundation for sixteen years and had the privilege of working with Dr. Berwick and his smart, dedicated colleagues at the Boston-based Institute for Healthcare Improvement.

They worked tirelessly to bring the science of improvement to hospitals, doctors' offices and other health care facilities. In case you haven't noticed, they have been extreme laggards in implementing the most rudimentary process improvements that safety critical industries such as aviation and nuclear power deploy routinely to reduce the potential for harm.

Here is one of many examples of how Dr. Berwick helped save lives. A preventable cause of hospital death is called 'failure to rescue'. It occurs when a patient's condition deteriorates and doctors and nurses miss the fact that the patient is in trouble.

With Dr. Berwick's leadership, the Institute for Healthcare Improvement identified a possible solution and taught doctors and nurses in hospitals around the country how to implement it. Called rapid response teams, many doctors and nurses who put these teams in place reported that mortality at their hospitals dropped.

Dr. Berwick and his team made this and many other life-saving improvements possible. Without a doubt, many Americans are alive today because of the work he taught, inspired and led.

For full article, click here.

Jammin'

Now this is the Delhi I've been wanting to infiltrate... When I met one of Tyler's colleagues last year, he said that Delhi was so incredible due to its cultural scene. Try as we might, we never quite succeeded in finding something that met our expectations in this arena.

That all changed last night, when we checked out the Amarras Desert Music Festival at Siri Fort Auditorium. The event didn't bode well when we first arrived. The auditorium was about one-quarter filled (45 minutes after the show had started), energy level was low, and we saw some sleeping heads in the audience. Granted, the Rajasthani music was beautiful -- but felt more apropos in a lounge with a drink in your hand, talking to some friends.

We nearly left early, but am really glad we stuck around. After the requisite break (in India, even 90-minute long movies have breaks in the middle), Vieux Farka Toure from Mali took to the stage. Called the "African Jimi Hendrix," he was not only incredible with the guitar, but has a soulfully deep voice, and an amazing stage presence and charisma. By the third song, about half the audience was dancing in the aisles.

Perhaps the best part of the evening was towards the end, when Vieux Farka Toure invited the other musicians to come jam with him on stage. First came Madou Diabate (also from Mali), who is a 71st generation (!) kora player - which is 21-stringed instrument from West Africa, that sounds somewhat of a cross between a harp and a delta blues guitar. They played an up-beat West African song with lots of hand-clapping and dancing. Then they invited the Rajasthani musicians from the Thar: Lakha Khan, Nihal Khan, and Mangey Khan. By that point, Tyler and I were up as close as we could get to the stage, dancing away. Oh what a night!

Links to Vieux Farka Toure's songs: here and here (with Dave Matthews Band).

The Peace Dividend

This weekend, we're heading to the Amarras Desert Music Festival. I can't wait!! Held at the Siri Fort Auditorium, it's being billed as a musical journey "from Tibuktu to Jodhpur via Delhi." The concept is essentially: what happens when you take the American Jimi Hendrix, and have him jam with India's star traditional and sitar players? The concert will be comprised of blues and folk from the Sahara and traditional music of the Manganiyars from the Thar Desert. I can't quite remember the last time we went to anything written about in the NYT, but here you go: link to article (granted, it's a blog, and granted, it's NYT India, but still!)

And not only that, but we'll be going to a play on Saturday that Tyler's buddy is in, and seeing Tin Tin in 3D tonight! Tyler talked about a peace dividend after he took his GMATs and he found himself with tons of extra time. That ain't nothin' on this!!

A growing love affair with Delhi

It is difficult to put into words just how gorgeous Delhi is today. Considering I'm usually bashing the weather here (too hot or too cold), noise (I'm coming to grips that my hearing has, indeed, actually worsened these last four years), or pollution (my face collects a layer of grey every time I ride Tyler's motorcycle), this statement on Delhi's beauty is huge.

But it's true. 81 degrees outside, blue skies, lazy wind. One of those days you just want to be outside.

Went to a rural healthcare roundtable discussion this morning. Found myself sitting next to the president of Fortis Healthcare - really interesting hearing their foray into rural health, and the resulting tweaking of their business model. Always at these conferences, more questions come up for me than are resolved... the primary one always being a version of: How the heck will we make a dent in India's enormous healthcare challenges? One roundtable participant described the current system as though you were building a house, and invited ten architects to come and just start building their dream house. There's no coordination, collaboration, quality standards, or way to legally enforce any semblance of evidence-based guidelines. Still, I have hope, or what are we all doing here?

It was too gorgeous of a day not to just walk, after the roundtable concluded. And I'm so grateful I did! Who would've known I would stumble across the cultural side of Delhi I never knew existed? Just next door was the Alliance Francaise, which I learned not only offers french lessons, but shows french films each week. The Belgian Film Festival is currently in full swing at Lodi Estate this week, and next week there's a soul / blues concert at Magique Amphitheater at the Garden of Five Senses at Said-Ul-Ajaib (how awesome is that name?)

Then I stumbled onto INTACH, a little further down the road, which focuses on cultural and architectural preservation of historical sites around Delhi. Really cool organization, which I just recently learned does historical and architectural walking tours every Sunday of places like Lodi Gardens and excavations at Purana Qila, which is the inner citadel of Dinapanah - a city founded by the second Mughal Emperor in 1533. Turns out they have an incredible crafts store from various tribes across India, and also do public lectures (the next one, this Tuesday, is on Old Delhi and its traditions).

And that's the funny thing about Delhi! It's like this whole other layer exists, for people who are patient enough to find it. It's the complete opposite of New York, where everything is in your face, advertised on billboards and subways. Here, nothing is advertised. When I went to INTACH, there were no fliers of upcoming walks or talks. Instead, I had to sit down with my notebook as she told me the times of each tour.

No doubt about it, Delhi makes you work for her love.

True Thanks

This Thanksgiving, I'm learning to give thanks not only to everything that's good in my life, but perhaps more importantly, to also give thanks to everything that's "bad" in my life as well - or at least what I'm not as happy with: whether it's external frustrations with India, or internal impatience with myself.

Buddhists refer to four noble truths. Essentially, these were the primary teachings of the Buddha, after he reached Enlightenment. What really resonates with me about Buddhism is just how logical everything is. Through the four truths, everything is laid out in clear, user-friendly form.

The first "truth" is that life is suffering. It's significant that he doesn't start off with this idea that life is all happy and honky-dory -- but rather, that true suffering does indeed exist.

The second noble truth is that this suffering is based on attachments. This attachment may be to monetary rewards or to beauty or to one's own self-perception... even an attachment to meditation itself. I met someone who quit their job on Wall Street to come here to India and seek "enlightenment" -- not realizing that their quest or "addiction" for enlightenment is actually the same as their quest for promotions and more money... only dressed differently. During my yoga and meditation sessions, I've met quite a few of these "guru chasers" -- going from one retreat to another, still on an external quest on a purely internal journey.

The third noble truth is that "nirvana" (or an end to suffering) is possible by letting go of attachments. For me, this was the most difficult to bridge intellectually and emotionally. Intellectually, sure, it makes sense. Emotionally, however, it felt like letting go would somehow make me less "human" -- less swept in the highs of joy and the lows of despair, and instead being a flat line. Vipasanna (the 10 day silent meditation) teaches you to notice everything, and react to nothing (a lesson I could still use, when I jump to my blackberry at every slightest beep). Equanimity above all. Hard enough to do in an ashram, nearly impossible in modern society.

When listening to a Buddhist teacher today, however, something clicked. Equanimity does not actually mean indifference, although perhaps there is a fine line. Indifference is based on fear, while equanimity means loving and accepting all. Similarly, there is a fine line between love and attachment, and between compassion and pity.

The fourth noble truth is that the path towards this nirvana can be reached through a series of steps that the Buddha calls the "Eightfold Path." What this path essentially means is cultivating what Buddhists call "a compassionate heart" and gradually letting go of addictions (whether to a person, idea, or substance). There's a quote from a teacher I particular like that defines "compassion": "letting the world tickle your heart and discovering that everything is connected with it."

While I thought that Eat, Pray, Love was a pretty awful book and an even worse movie, I did really enjoy reading about the meditation the old Indonesian Medicine Man in Bali had her do each night: Sit and smile -- ensuring that not only your lips are smiling, but your whole body, right down to your kidneys and liver.

In other words, the essence of Buddhism is learning to love what is. In Buddhists' minds, suffering comes from wishing something is other than what is. Thus, the key to happiness is to love all the "bad", as well as the "good" -- realizing that it's only our own internal frameworks that assign good vs. bad.

I'm not quite sure I'm there yet -- loving all the frustrations here in India, just as much as I love the magic of being here. But this Thanksgiving, at least I can be grateful for them and learn to accept what is.

Giving Thanks

A lot to be thankful for this year: a wonderful husband, loving parents and in-laws, a job that enables me to travel the world learning about various healthcare models, continued adventures in India...

And now... a definitive answer to: "When are you moving back to NYC?" Tyler got into Columbia Business School! Woohoo!! I have to hand it to Columbia on impeccable timing: calling the evening before I arrived home (a day earlier than expected), so we could celebrate all weekend and have even more to be thankful for on Thanksgiving.

This year, we've gone all out. Last year, we celebrated Thanksgiving with the closest thing we could find to a turkey: Peking Duck at the Sheraton. That became our celebration dinner last Saturday night. Then Sunday, our friends had us over to their gorgeous house at the American Embassy for an early Thanksgiving feast.

The chef d'oeuvre? Without a doubt, the giant turkey smuggled into India from friends visiting from DC (It's illegal in India to bring in meat, poultry, etc). I must say, I was duly impressed: a two week vacation to India bringing their nine month old daughter and a giant turkey, from Whole Foods no less (not to mention fresh cranberries for sauce and a cake).

Four couples, seven children, ranging in age from 6 months to 6 years. When going around the table saying our gratitudes, it was touching that many of the kids said, "I'm grateful for living in India."

Tomorrow, we've invited a group of friends to the Living Room, a restaurant in the artsy (for India) neighborhood of Hauz Khas. Can't wait for another serving of stuffing!

On the subject of gratitude, I was shocked to learn in Hindi class yesterday that Indians don't really have an expression for, "I'm grateful for...". "May kritgya oo" may be the closest thing, but it is rarely used. I joked to Tyler that Indians don't send thank you cards after weddings (which perhaps is good considering a "small" wedding is 800+ guests!), and he reminded me that Indians rarely say thank you when you hand them a gift at all.

My Hindi teacher shed more light on this phenomenon yesterday, explaining that Indians don't thank others for actions or gifts because they see the gift as a gift from God -- working through mere humans. In other words, why should I thank my neighbor for bringing over food, when it's really God bringing me gifts through my neighbor. Interesting thought model to ponder...

Relatedly, Indians rarely use the future tense, instead using the subjunctive -- which, as we learned from 10th grade English, is used when the future is not known. My Hindi teacher recommended that I watch how often I use the future tense ("I will go to a movie tonight") and instead use the subjunctive ("I may go to a movie tonight") -- as using the future too much sounds presumptive and arrogant. Hmm... definitely gives insight to my frustrations when colleagues would say that a document "may" be ready in a few hours...

A last word on gratitude. I just read an article about research done by Dr. Robert A. Emmons, who found that individuals who wrote down what they were thankful for on a weekly basis were 25% happier, more optimistic about the future, felt better about their lives, and exercised 1.5 hours more per week than those who didn't record their gratitude. One of the best "rituals" that Tyler and I received advice about was from our pre-cana teacher in NYC, who suggested thanking your partner every night before bed, for the various things they had done during the day. We've been doing our "gratitudes" nearly every night for the past six months now, and I highly recommend it.

After all, giving thanks shouldn't just happen once a year.

Change of plans

Be careful what you wish for!

Our friends are hosting Thanksgiving at their house at the American Embassy on Sunday, and I was hoping to get back early to help Tyler shop for wine and bread (harder than it seems in Delhi). I was getting mentally ready for my flight back to India through Addis tomorrow, after a full day of meetings today.

Well, less than three hours later, here I am at the airport in Accra! I was printing out some documents for meetings today, when the receptionist asked what the date was. "The 17th," I replied. "No, it's the 18th" - another woman replied.

"That's impossible," I thought. After all, I should know because my flight leaves on the 18th! Double-checking my ticket, I nearly had a panic attack when I discovered that actually, my flight leaves in three hours!!

I of course didn't think this was a big deal, as my travel agent assured me I could change tickets anytime without a penalty. What I didn't anticipate, however, was that there would be no available seats on tomorrow's flight. Or Sunday's. Or Monday's. The earliest I could leave is Tuesday, unless I pay $2500+ to get on a Virgin flight tomorrow through London.

It's a good thing that I've gotten accustomed living out of my suitcase, because I ran up to my room in a flurry, and somehow managed to pack in five minutes.

Murphy's Law though. As I try to check out, it takes three women to add up all my bills, and the credit card machine doesn't work. I rush to the cab and realize midway to the airport that I still have my hotel key. The driver drops me off at arrivals, and I need to walk fifteen minutes to departures, all my bags overflowing. I must have looked like a cartoon.

But as I sit here near the gate, I'm just thankful that everything has worked out. I'm just sad to be missing my meetings, as well as drinks with a friend I had met during my last trip here, who drove five hours down to meet me and even brought a wedding present! That's the thing with Ghanaians. You meet them once, and they're friends for life.

Facts about Ghana

Reading "The Report: Ghana 2011" on my way to breakfast and learned two interesting facts:

(1) A recent Forbes poll voted Ghana the 11th friendliest nation in the world and the friendliest in Africa (I haven't seen the poll, but can bet that Thailand and the Philippines were high up there as well).

(2) The Ghanaian handshake consists of "a limp grip of the hand followed by a snap of the forefingers and thumb." Good to know! When I was in Rwanda, I found out quite awkwardly that the standard shake for women is a handshake and three kisses on alternating cheeks (while still gripping the hand). For men, it's a handshake followed by a head butt. One of countless times I'm glad I'm a woman.

Happy Sunday

The great thing about jetlag is how much it allows you to get done before breakfast! I woke up, did some yoga, chatted with Siobhan, and worked on a presentation, all before 8:30am. Granted, I went to bed at 8pm, but that's another story!

It's a beautiful day in Accra! Of course, I think it has to be, when the hotel you're staying in is on "Mango Tree Avenue."

This morning, a large league of soccer players jogged past by hotel, singing in tandem. They were joined by a drummer in the rear keeping pace. Looking out my window, I saw dozens of children running out of their house, each carrying something made of tin, and banging along with the drummer. The kids were dancing and cheering, and it was impossible not to smile at the scene below. The cutest are the little girls, in their colorful dresses (mostly pink), and incredibly short hair -- cut just like the boys.

I landed in Ghana yesterday, and the first thing that struck me driving from the airport was the massively different color palate from Bangkok. Whereas Bangkok was grey (so much steel!!), Accra's palate is much more earth brown -- punctuated with the brightest purple, green, and red paint on the buildings! Accra, as a city, is so much more flat than Bangkok. I hadn't realized until I noticed the dichotomy, just how tall Bangkok is -- tall buildings all around the city, a whole network of elevated highways... whereas Accra is so much flatter: a few stories most, in the neighborhood I'm in. I couldn't help but stare at the sprawling slum near the airport as we passed it, which seemed to have grown even bigger since the last time I was here last February.

The other huge change has been much more heightened security at the airport. Now, rather than just breezing through immigration, they handprint each and every finger for each passenger! (talk about a bottleneck reaching baggage claim). That's four separate sets of prints (right 4 fingers and right thumb; same on the left). When I asked them about it, they blamed "my government" for forcing increased security measures on them. Interesting. Even getting a sim card was much harder (although not nearly as hard as in India!). There is now a registration and database, which they needed to enter my passport into, matching it with the sim card I purchased!

What hasn't changed, though, is the colorful atmosphere of the city, the extremely friendly sellers of fruit on the streets -- buckets of bananas and fruits atop their heads, blue skies, and music playing everywhere - the soundtrack of the city.

Can't wait to take a walk this morning; it's a gorgeously sunny day outside!

En Route...

Hello Dubai my old friend, I've come to talk with you again.

You know you're traveling a lot when you get a sentimental feeling about going to the Dubai airport. Or maybe it's just the Coldstones there?

A few vignettes from my last day in Bangkok:

(1) I now have a new favorite Thai sign. It used to be the good ole' "No dogs or durian fruit allowed" sign in all the hotels (including the one I just stayed in). This time, I've fallen in love with a sign attached to our van. It shows about 10 pictures with a big "X" through it, telling passengers that smoking, eating, drinking, and standing are all forbidden. The only activity that's allowed? KARAOKE!! Only in Asia...

(2) As I get into my cab to go to the airport, my Bangkok taxi driver asks whether I'm from China. "No," I tell him, "I'm from New York." ... "Oh!!" - he exclaims, finally understanding. "You're from Chinatown!!" I start to correct him, but find it's easier to just smile and nod.

(3) I'm in line at immigration, behind a family with two toddlers -- one boy, who is running around, with his parents in chase; and one girl, standing quietly and inspecting her passport. She sees the immigration official stamping passports up ahead. Her eyes light up, like she's just gotten the best idea in the world. She takes out her sticker book, and proceeds to fill her entire passport with stickers!! Once her mom returns from chasing her brother, she holds up her passport proudly, showing all the new borders she's crossed. The mom does not seem as amused, but I think it's adorable! (or maybe just bemused that I didn't come up with that idea myself when I was 6!)

Learnings

A few pictures of my trip to Bangkok -- here we are yesterday at the National Health Office (a gorgeous campus with four helicopters parked nearby).

Thailand is doing incredible work in the area of universal health care, especially their use of tiered-accreditation to improve quality across hospitals. What impressed me was not just how much they're doing within the Thai system, but also how they're sharing learnings to other countries as well. Delegates from India and Nepal have come to see their system, and they are looking to set up an Academy for Universal Health Insurance, with participants from neighboring countries (e.g. they already have an MOU with Korea), where countries can learn from each other about implementing national health insurance programs.

Linking this with India, the challenge, of course, is that India is not "one" country, especially regarding health care systems -- but rather 28 states (at last count), many large enough to be countries themselves. In a country where over 80% of healthcare expenses are paid out-of-pocket, it is difficult to have any sort of coordinated national response. That's where hospitals like LifeSpring and Aravind can play a role, in terms of keeping prices affordable for low-income families.

I've found it very intellectually stimulating to compare and contrast the various countries' healthcare systems, and looking forward to being in Ghana next week!

Perseverance

In an earlier post, I talked about a group of policymakers we met with, who braved the floods and took a boat to keep their meeting with us... all the while, apologizing that they were 30 minutes late and wearing shorts - instead of their usual business formal attire!

Here are photos from their journey this past Wednesday to meet us:

The perseverance of the Thais that I've met is astounding. I'm used to New Yorkers complaining about the snow storms or Hyderabadis staying at home at any talk of another Telangana strike (which has been an almost daily occurrence for about two years now!) But here are people we have never met, who wade through water (literally) to keep their meeting with us. And then when we meet, they laugh at their experience -- wearing sun hats to keep out the rays, but always armed with a massive beach-sized umbrella (which can serve both as a tool to keep one dry, but also as a measuring stick to test out how deep the waters are before stepping).

Within the organization we met with, half of their staff (nearly 400) had already evacuated their homes from the floods, and are staying with relatives or in hotels. (In fact, many of the Thais staying at my hotel now are staying here due to the floods) The stadium a few blocks away is also filled with evacuees.

The government has imported canned food, bottled water, and eggs from Malaysia. The Thais I've met are confident that this situation will only make them stronger.

Yesterday was Loy Katrong Day, a festival to pay hommage to the goddess of rivers and waterways - which seems both appropriate and ironic. The usual tradition is to float thousands of katrongs (candles atop floating lotus leaves) in the river -- although this year, the government has urged Thais not to do this, for fear of blocking drainages or setting fires in homes (that's how high the rivers are!).

Instead, I watched fireworks going off outside my hotel window. Hopefully, things only get better from here.

Ode to Thai Food

I've been eating the most incredible food. As soon as I arrived yesterday (well, after getting internet in order -- gotta have priorities!), I went to dinner with one of my colleagues on the broader Joint Learning Network project.

To call the dish pad see ew would be doing it a disservice, since it was likely the best noodle dish I've had in recent history. Broad flat rice noodles, stir fried in soy sauce and served with delicious greens like spinach, asparagus, and spring onions, topped with chicken and shrimp.

My favorite were all the accompaniments that come with it -- limes on the side, along with one small dish of red chilis, another of vinegar, another of fish oil, and a last one of sugar (okay, I wasn't a big fan of the last two). But what I love about Thai food done well is that, similar to Vietnamese food, it's all about balancing all the various tastes to create an even richer experience. Hence, the sweet, sour, salty, and bitter.

Tonight's dinner was at a nearby noodle restaurant. Walking along the highway, we passed a long row of street food vendors, which I had to say, smelled absolutely incredible. There was lots of mixing going on in woks, fried animal parts hanging, and spices galore. If not for my peanut allergy and abismal Thai (I think I've finally got "thank you", but I can't be sure) -- I may have been tempted to try. My colleague, Derek, certainly was -- until Kalipso reminded him that the city barely has clean water due to the floods, so probably wasn't the best idea.

At the restaurant, I ordered green noodles (yes, you read that correctly), topped with crispy fried duck, shrimp wontons, and again -- a whole array of spices to choose from. The mushroom soup was comfort food, and the dim sum was delicious. And my banana shake was like a dessert!

Easy verdict: I'd have no trouble gaining weight here!

Bangkok Lessons

24 hours into my five day trip to Bangkok. I'm here meeting with colleagues from the National Institute for Health and Clinical Excellence (NICE International) to learn more about the Thai health system and their initiatives to increase access to health. It's quite impressive, actually; whereas out-of-pocket pay for healthcare in India is somewhere between 80-90%, in Thailand, it's less than 20%. Now the focus is on improving the quality of care.

Needless to say, what has struck me most was the view from the plane flying into Bangkok. Hundreds of miles of flooded fields; incredible that the floods were so visible from up in the air. One of my colleagues from the UK said she even saw the old airport flooded, with water halfway covering the planes themselves.

Suvarnabhumi Airport (BKK), where I landed, was completely dry. This fact was reinforced by the thousands of cars I saw just parked at the airport itself, and lining the highway in refuge from the flooding. Coming from India, I was shocked that the four-lane highway actually had a shoulder lane, enabling cars to park along the elevated highway for miles. Quite a sight.

All talk at lunch today centered around the floods. As we sat eating outside, helicopters appeared overhead, bringing evacuees to the hospitals in the capital.

Interestingly, a Japanese-Thai businessman noted that these floods hit the Japanese economy much harder than the tsunami in Japan itself, as many Japanese factories across automative and computer industries were in Thailand, and particularly in Ayuthaya.

I was completely heart-broken to hear that most of the elephants in Ayuthaya (the ancient capital of Thailand and one of the worst hit by the floods) had died. Clearly this is a very American thing to say (hence, the famous quote that what Darfur needed was more dying puppies, to garner American attention), but I'm just stating truth. I have such happy recollections of riding a beautiful elephant through the ancient ruins and around the temples.

Yet despite the devastation that the floods have wrought, all the Thais I've spoken to are in such incredible spirits, laughing and making jokes about the situation (like fearing for crocodiles lurking outside.. and how expensive our lunch is because of the huge price hike in bottled water).

One of our meetings was with a delegation of policymakers, who literally took a makeshift boat to cross the flooded areas and make it to our meeting... Then they apologized that they were thirty minutes late and all wearing backpacks with extra clothes and provisions!

I spoke to one woman whose house was completely flooded, yet she was smiling and laughing during our entire conversation. "There's nothing we can do! So you just have to smile." When I spoke to the director of another organization of the floods reaching his house, he too, just smiled. "I'm just grateful," he said. "Other parts of the country are so much worse. We have nothing to complain about."

It's a humbling experience, speaking to people whose possessions have been washed away, who speak of this with smiles, laughter, and gratefulness. Seems like a good lesson for all of us.

Social Hierarchies

One thing that I still haven't quite gotten used to is the hierarchy that exists across all aspects of society here in India. It was certainly a bit of a shock to come here four years ago doing social enterprise work, and then have what Indians call a "houseboy" come and bring me tea first thing in the morning (and sleep on the floor of the kitchen at night).

People from home ask me whether the caste structure still exists, and I'm not quite sure how to answer that. Most people I interact with are extremely liberal in their views on caste, yet if probed more deeply, they could also say exactly what caste all of our friends/acquaintances are.

For me, what I can't quite comprehend is how hierarchical the society is, yet at the same time how socialist it is as well. Perhaps it's precisely because levels are more or less "fixed", that there's a sense that the rich should take care of the poor... versus a place like the US, where economic hierarchy can be much more fluid.

There's a funny side to this hierarchy as well.

Exhibit A: Service staff are used to calling everyone at the "top" of the socioeconomic hierarchy as "sir". I don't think it's really occurred to many that there's a gender associated with this as well. Thus, I get called "sir" numerous times on a daily basis!

Exhibit B: The picture speaks for itself. Tyler and I go to meet our friend Rob, who's playing an ultimate frisbee tournament in Gurgaon. The cricket stadium clearly sees the need to offer not just VIP Toilets, but VVIP Toilets!!

Our weekend in meals

It's easy to get into a rut of eating at the same restaurants and cooking the same foods. It's comfortable, it's delicious... but it can also close the doors on really exploring the city. One of my former colleagues at Katzenbach (which had the most intense "foody" culture if I ever saw one!) swears by hopping onto the 7 train in Manhattan, and getting off at any random stop in Queens -- you're destined to have the most amazing, authentic Thai/Korean/Afghani [insert ethnic cuisine here] food in the city.

Unfortunately, it's a bit harder to explore and try new restaurants in India. You rarely can just "pass" some place walking that looks really good. Rather, you need to know that a certain office building just happens to have a delicious restaurant on the top floor (like Angeethi, in Hyderabad), or a certain mall has a good restaurant that's worth the trek (and, worth being in a mall).

This weekend, Tyler and I discovered some new places, and also re-discovered some old, forgotten favorites. Our weekend in meals:

Bukhara:

Practically all good restaurants in Delhi are inside a five-star hotel, and Bukhara is no exception. We take a cab to the ITC Sheraton, knowing we're certain to get in a brawl with security, should we (gasp!!) try to bring our motorcycle helmets inside the hotel. The place is packed with paparazzi -- turns out the West Indies cricket team is staying there. We don't have reservations at Bukhara, but the place is empty as it's relatively early for dinner in India (around 7:30pm). We're happy to get a table, as momentarily, the place gets mobbed with businessmen, tourists, and large Indian families.

We have a perfect table in front of the tandoor grill, where giant skewers of kebab hang from the ceiling, and the chef doles out the most amazing dal. The cuisine is from the Northwest Frontier - now the border of Afghanistan and Pakistan. We order kastoori kebab - the most tender pieces of chicken marinated in ginger and garlic, spiced with peppercorn, half-cooked with flour and then char-grilled with yolk. Absolutely delectable!

Unable to decide between the tandoori aloo (stuffed potatoes) and tandoori phool (cauliflower), we end up getting a half order of both. Of course, no meal at Bukhara would be complete without an order of its famous dal bukhara - which takes 14 hours to cook (and involves simmering black lentils with tomatoes, ginger, garlic, and cashews).

It's "hands only" at the restaurant, and they supply a big apron for each patron to wear. We scoop up our food with naan bukhara and pudina (mint) paratha.

Hell Pizza, GK-1

Delhi is a bit of an insular place. Each (gated) community has its own market -- some better than others. After meeting our friend Rob in Gurgaon, Tyler and I head back to Delhi and decide to try a new pizza place (well, new to me!)

We missed Halloween by a few days, but the food more than made up for its ambiance. Red lights going up the stairs, "Scream" masks abound... and thankfully I didn't realize the severed hand next to my head the entire time I was there.

Tyler and I have a bet on who can make the better pizza. My half is the "Limbo": blue cheese, mushrooms, caramelized onions, tomatoes, and kalamata olives (needless to say, I'm completely shocked this place has blue cheese!)... while Tyler's half (the "Grimm") is apricot sauce, chicken, pine nuts, spring onion, cream cheese, and rosemary.

We both agree that my side wins, but it's clearly eclipsed by our "dessert pizza", the "Unearthly": chocolate and custard to replace pizza sauce, and berries and banana as topping. We take it to go, and eat it watching Rome.

South Extension 1, B-5

And last but not least, home sweet home... Tyler cooks a delicious Moroccan meal on Sunday: cous cous with chicken sheek, broccoli, mushrooms, and almonds. We each eat a huge portion, garnished with yogurt and sun-dried tomato pesto... with jasmine tea and oreos for dessert.

My tummy is happy.

An afternoon break

Over the last few weeks, I've realized that I don't need much to be productive: 1. Good internet; 2. Air conditioning; and 3. a week's supply of Ceres grapefruit juice (realizing that our local grocery store in Defense Colony delivers was an amazing epiphany).

On the flip side, that also means that unless I have meetings around Delhi, I can easily find myself at my desk (less than a foot away from my bed), from about 8am when I start working, until around 7pm when Tyler comes home. Even leaving my desk, there aren't all that many places to go in our cozy "penthouse" studio apartment. As productive as I was today work-wise, I still needed to remind myself to change out of my pajamas somewhere around 11am.

And so around mid-day, when I realized I hadn't moved in quite some time, I decided to go for a walk to get some coffee. But this time, instead of putting on blinders until I reached the fancy coffee shop in our nearby market, I really looked around.

I've come to really love our neighborhood (well, except for all the cars honking... and people singing at 3am). I pass our ironwalla, who irons Tyler's shirts for 6 rupees each (about 13 cents), and delivers it home - even though I've never actually told him where we live (I know this would seem sketchy anywhere else, but this is India!)

I pass the small park nearby, dotted with architectural jewels that look like mini Royal Tombs, with their beautiful onion domes reminiscent of the Taj Mahal. I've tried a few times to learn of their history, but the only signs in the park are those saying that destruction to these architectural works of art can result in a Rs 100,000 fine -- never saying what the works of art actually are!

The market itself is nutty -- somewhere between a parking lot and an actual working road. I've learned to just cover my ears when I walk past, since cars honk at me every time. I take a shortcut to the coffee shop -- a back alley leading to the McDonalds, with a row of stands. The first sells counterfeit Bollywood DVDs, the second advertises "Bombay Bhel Puri" (which actually looks quite good, but I'm reluctant to eat anything that may make my stomach do flips so soon before Thailand next week). Then Tibetan momos followed by another stand for seasoned corn.

I decide I can hold off on coffee, and instead splurge the Rs 50 on corn, perfectly spiced with salt and lemon juice.

I walk back home, humming the whole way.

On the importance of having a goal

Catching up with folks at Columbia, it was exciting to hear that Leymah Gbowee spoke at the business school's Social Enterprise Conference the same day she was notified she won the Nobel Peace Prize, a few weeks back.

I had to smile at her advice to Occupy Wall Street, written about in Al Arabiya News:

“When I wake up in the morning I have goals: women’s rights, peace, security” the 39-year-old social worker told an audience of students at Columbia University who had asked for her advice on activism.

“If you are doing a protest you need to have an agenda. If you wake up in the morning and poke a guitar, take a drum downtown and someone is singing and another one is dancing and movie stars are coming and saying do this, do that... and everyone is confused, you’ll be there for a long time.”

Excuses, excuses...

I just got an email from the Delhi ToastMasters Club with a quote I really like:

"Your potential is limited only by how many excuses you have."

Whenever I feel like there's just not enough time do to x, y, z (which is to say, at least five times daily), I smile thinking about book title I recently read: "168 Hours: You Have More Time Than You Think."

Don Berwick, the founder of the Institute for Healthcare Improvement (IHI) has a saying: "What can you do by next Tuesday?"

Let's see!

Late entrant

I've been resisting joining Twitter for quite some time, fearful it will be just another time-suck a la Facebook, or make me even more ADD than I already am (besides, there was a certain pride in not understanding what all the #s meant...)

But yesterday, in a moment of self-deluded procrastination that this was actually "productive", I gave in. What finally did me in was learning (from my business school alumni newsletter, no less) that the Dalai Lama is on Twitter. How can you not follow that?

I just love the vision of His Holiness the Dalai Lama thumbing a few top-of-mind notes on his smartphone or iPad, on his way to reciting prayers at a Buddhist temple.

His tweet seemed apropos to the angst I've lately been feeling, trying to juggle living in the moment and taking advantage of our last year in India, versus thinking ahead and planning for our new lives back in the US.

He writes:

We should not only cease our negative activities, but also the motivation that gives rise to them.

Now that's worth meditating on.

Fortune at the base of the pyramid?

Really interesting blog post in Next Billion, called "Markets of the Poor: Limits and Opportunities". Reading it definitely resonates with my experience at LifeSpring, particularly the challenge of turning need into demand. For instance, just because there is a need for safe, institutional deliveries, there is not necessarily a market demand that leads to profitability and scale.

There is no "build it, and they will come" model of social enterprise. That's why marketing and customer relationship management teams are necessary: to truly understand who your customers are, and develop innovative, new models based on their needs.

In his post (click here for full article), Aneel Karnani writes:

"There is no fortune at the base of the pyramid. Marketing socially useful products to the poor offers only limited business opportunities. Still, there are some profitable opportunities and we need creative entrepreneurs to design the right business models to serve the poor. It is necessary to understand that unmet needs do not necessarily constitute a market opportunity. A 'market' can exist only if there are buyers willing and able to pay a price that covers the total cost of production, including the opportunity cost of capital used. Unfortunately, due to the very meager income of the poor, markets for many socially useful goods simply do not exist. The French company Essilor found that not enough poor people were willing to pay even $5 for a pair of customized eyeglasses conveniently delivered on the spot. Procter & Gamble found that not enough poor people were willing to pay even $0.01 per liter for clean drinking water.

To serve the markets of the poor, firms have to dramatically reduce costs, by as much as 90 percent in many cases. A significant improvement in technology could reduce costs dramatically, as for example in telecommunications. Unfortunately there have not been such technological leaps in most other product categories. It is thus often necessary to reduce quality in order to reduce costs significantly. This does not imply selling shoddy or dangerous products. To profitably serve the poor, firms need to make the cost-quality trade-off appropriately in order to make the products affordable by the poor; the challenge is to do this in such a way that the cost-quality trade-off is acceptable to poor consumers. A simple or minor adaptation of the business model from affluent markets usually results in products that are too expensive and not affordable by the poor."

True love is...

Forget "love means never having to say you're sorry." True love, India-style, is:

- Fetching a large pail of water for your wife to take a "shower", even as you're running late to work

- Extinguishing an entire ant colony (literally, about 10,0000) descending on the kitchen counter while your wife enjoys Oreos for dessert in the living room

- Telling your wife she's not crazy when she sleepily says: "Was I just dreaming or was there really a group of people singing and chanting at 4am last night?"

And to think, all this happened in the last 12 hours... New York will seem a piece of cake compared to this!