Today, a friend sent me a news article by a colleague, Dr Prabhat Jha, who explains the link between behaviour in Canada and his research on the use and abuse of selective abortion in India. This presented the ideal opportunity to reproduce here a paper I wrote recently about the implications of Dr Jha’s landmark finding that there are millions of “missing” girls in India, due to selective abortion.  Please note that a more scholarly version of the text below has been submitted to a peer-reviewed journal.  Therefore please do not excerpt or cut-and-paste any part of this blog post.  However, linking to the post is fine.  Thanks.

Implications of India’s Skewed Sex Ratio

by Dr Raywat Deonandan

Dec, 2011

In their widely cited 2011 paper, Dr Prabhat Jha and colleagues used publicly available demographic data (the national census and household health survey data) to show that there were likely 4.2-12.1 million selectively aborted girls in India from 1980 to 2010.  The authors convincingly suggested that selective abortion was the primary explanation for a steadily declining female-to-male sex ratio in India, which in turn is driven by cultural factors associated with a preference for boy children.

Their paper was not the first to point to a crisis in India’s sex ratio.  In 2001, the UN estimated that there were 44 million “missing women” in India.  And in 2008, researchers examined hospital delivery data over 110 years to show that India’s national sex ratio fell dramatically after 1980, when ultrasound technology for antenatal sex determination became available.  Many regional studies confirm that this trend is truly national.

Similar trends have been famously seen in other countries, especially in China, where the “one child policy” is thought to have resulted firstly in an epidemic of female infanticide, and secondly, after the arrival of antenatal sex determination technologies, in an increase in selective abortions of female foetuses.

Beyond the moral objections to female foeticide is the demographic crisis represented by a severely unequal sex ratio.  However, the likely impacts of such imbalance are not well known, nor have they been well considered in the wider health literature.   They include:

• Speculatively, a rise in levels of violence amongst unmarried men of reproductive age, as competition for brides increases, although violence always has multifactorial causes.  This is because, in affected societies, marriage and paternity are linked to social prestige among men.

• A shortage of marriageable women may lead to a disavowing of lower class or less socially desirable men, causing social strife stratified to the less economically robust classes.

• An expansion of the sex industry, probably involving coercion and trafficking and possibly contributing to higher rates of sexually transmitted infections.

• An increase in inter-generational relationships, most egregiously manifesting as child marriage.  In India, child marriage (usually involving young girls and much older men) is already such a serious problem that it has attracted the attention of the Clinton Global Initiative and other global NGOs.  Child brides are at greater risk for a host of additional unwelcome experiences, such as reduced educational opportunities, increased economic dependency and greater rates of maternal complication and mortality.

• Parts of India already have a classical history of polyandrous marriage.  While polygyny has been popular in many societies historically, polyandry seems to arise more sporadically and in times of resource crisis or bride shortage.  Recent trends in Indian fraternal polyandry have arisen from a desire to keep ancestral lands from being divided by marriage.  But it is conceivable that such an arrangement might become more commonplace if the sex ratio continues to skew.

• Two possible positive outcomes include a greater tolerance of homosexual relationships and a greater acceptance of cross-class and cross-caste marriages.  However, the latter would likely involve unions between powerful men and vulnerable women, which may only serve to exacerbate existing gender tensions and exploitative relationships.

In India, the social drivers for sex selection are both deeply cultural and shallowly economic.  Amongst orthodox Hindus, the care for elderly parents is traditionally the domain of the eldest son and his wife.  Thus, the economic disincentive for having a girl is reflected in the local saying that raising a daughter is akin to “watering someone else’s garden”.  A preference for sons manifests in many agrarian societies in which a male work force is valued for their wage-earning capacity.  And the tradition of dowry, originally intended as a vehicle for assuring that a new bride had personal wealth, often in the form of jewellery, in the event that she was widowed or abandoned, has mutated into a form a “bride price”, in which families often go into debt to marry off their daughters.   These are all economic disincentives for having girl children.

Interestingly, Dr Jha found evidence that sex selection is most prominent amongst affluent households for whom the economic disincentives are less relevant.  For them, it seems likely that a simple and sexist preference for sons is at play, which has at its heart a cultural bias for the social cache and prestige that sons provide.  The prime distinction between the affluent and the poor in this sense, then, is that the former can more readily afford expensive sex selection technologies.  Importantly, the clustering of the trend in wealthier households also means that India’s vaunted economic expansion, especially in the middle class, is unlikely to assuage the sex ratio situation; indeed, as more families enter the realm of the affluent, it may exacerbate it.

With drivers and incentives for sex selection being social, cultural and economic, policies for addressing the crisis cannot be limited to the medical realm.  In Jha’s paper, it is noted that India’s Pre-Natal Diagnostic Techniques Act of 1996, which seeks to penalize the misuse of prenatal sex determination technologies, is largely unenforced.  The authors suggest that India’s traditional inability or unwillingness to police private medical practice is the greatest hindrance.  The paper’s accompanying commentary recommended better enforcement of existing policies as the appropriate solution.  But it is possible that the desire to penalize sex selection, while evident at the policy-making level, has yet to penetrate to the street level, due to the depth and pervasiveness of cultural and economic drivers.

In the words of one researcher, “It is evident that mere legislation… cannot solve this social evil. Moves to address all forms of gender inequality… are needed to strike at the causes for distortion of the sex ratio.”  Social change for improving women’s rights, both in India and elsewhere, is required.  As noted by another writer, “Nothing can realistically be done in the short term to reduce the current excess of young males, but much can be done to reduce sex selection now”.  While official policies have their place, in India no progress will be made unless the social and economic drivers are addressed.  For the former, this means public awareness and educational campaigns focusing on the value of girls.  And for the latter, it means finding creative solutions to expand employment opportunities for both sexes, and to remake the social welfare infrastructure to limit the expectation of gender-based elder care, inasmuch as such is determined by an expectation of the roles of the eldest son and his wife.

Given the status of India and China as both the world’s fastest growing economies and our most populous lands, the demographic situation faced by both countries is relevant to all of us.  To refer to those nations’ skewed sex ratio as a mere crisis is an understatement.  Such profound demographic change may prove to be the basis for a host of pervasive social, economic and medical woes manifesting as the present generation of newborns reaches reproductive age.

Comments are welcome.

This will likely surprise you, but did you know that infertility is considered to be at epidemic levels worldwide?  This is clearly at odds with our conception of the world as being overpopulated.  But, primarily in wealthier, developed nations, the provision of medical reproductive services to people deemed infertile is now a billion dollar global industry, spurred on both by advances in technology and the emergence of a globalized economy. Unsurprisingly, India is one of the world’s most popular providers of reproductive services, leveraging her medical depth, advantageous currency exchange, and her pervasive poverty.  But when human reproduction meets commerce, gender inequality and wealth disparity, the potential for ethical transgression becomes great indeed.

Someone is considered infertile if he or she has been having unprotected (heterosexual) sex for one year, with an intent to reproduce, without achieving pregnancy.  Conservative estimates hold that at least one billion women worldwide (and an unknown number of men) are presently experiencing a degree of infertility.  This estimate is stunted by the obvious fact that you don’t know if you’re infertile unless you’re actually trying to get pregnant.  The actual number is therefore likely to be substantially higher. The experiences of assisted reproduction clinics suggest that a fair proportion –if not a majority– of infertility issues are actually so-called “male factor” issues, meaning that the problem is often related to sperm quality.  Indeed, semen samples collected over the past seven decades suggest a global, dramatic reduction in semen quality, such that what is considered normal today might not even make the scale 70 years ago. This may be a universal, global human trend, or it may be relegated to the developed world.  We just don’t know yet.

Many theories have arisen for the increase in infertility in both sexes.  Undeniably, women in high income countries are waiting into their 30s and 40s to start their families, and this is dramatically reducing their ability to become pregnant.  The rise of obesity, and with it diabetes, has certainly contributed.  It is possible that soy products, mimicking human hormones, are affecting our reproductive cycles.  Some have theorized that overuse of the female contraceptive pill has made our drinking water more hormonal, or that some artificial compounds, such as plastics, may decay into substances that also mimic hormones.  At this point, all of this is mere speculation.  What is known is that the seeking of assisted reproductive techologies (ARTs) is at an all time high, and shows all the signs of accelerating.

The services sought include in vitro fertilization (IVF) –the classic “test tube baby”– a technology, that has been with us for over 30 years now; fertility drugs; sperm and egg donation; and maternal surrogacy.  The latter is characterized by a woman hiring out her womb to gestate an embryo on behalf of a client.

With the increase in demand, and with the maturation of reproductive technologies and services has come a global industry of cross-border reproductive service provision, rife with philosophical quandaries, legal pitfalls and ethical concerns.  Presently, in terms of financial transactions, the United States is the world’s greatest provider of reproductive services.  But hot on its tail is India, which is fast becoming the undisputed world champion of all manner of ARTs.  This phenomenon is most commonly called reproductive tourism, and is being monitored by ethicists and epidemiologists, myself among them, for its challenges to our ideas about the valuation of human biology.  This is particularly true for maternal surrogacy, since it necessarily involves the biological cooperation of another human being unconnected to the infertile couple.

The power of the industry in India is based upon several factors.  They include: (1) the overabundance of English-speaking, highly trained doctors, as every Indian family strives to have at least one doctor in their midst.  (2) The existing, well developed and recognized medical tourism infrastructure, which includes integrated travel, hotel and insurance services.  (3) An advantageous currency exchange rate leading to a reduction in prices, often by a factor of 10 or more.  (4) A complicit Indian government; and (5) perceptions of Indian women.

The last two are particularly interesting.  The Indian government has actively been promoting its medical tourism services for some time now, for example by sponsoring junkets around the world.  The extent to which the state is complicit in encouraging the growth of reproductive services specifically is a bit more difficult to measure, but may include the nature of India’s adoption laws with respect to surrogates.  A surrogate mother in India loses all rights to a child that is not genetically hers at the point of delivery.  Whereas, in other countries, a surrogate tends to have some time after delivery to decide whether she wishes to state a claim on the child.  It is unclear to what extent the law in India is shaped by the needs of industry, and to what extent it truly reflects the values of Indians.

The perception of Indian women is a subtle and largely immeasurable point.  Poor, village-based Indian women are often perceived in some circles as being ideal surrogates due to their global image as demure and submissive.  Indian women are peceived to be less likely to drink alcohol, to smoke, and to engage in other practices seen to be detrimental to a successful pregnancy.  In other words, it is their powerlessness relative to men and to the structures of their society that make them attractive to this trade.  Hence, maternal surrogacy is where India’s dominance in the world ART market truly manifests, given her abundance of young, poor women.

And therein begins the discussion of the ethics of the international reproductive tourism industry.  When clients from a wealthy country, like the USA, Canada or the UK, seek biological services from vulnerable –and likely uneducated– individuals in a poor country, like India, the opportunity for exploitation, even unintentional, is great.  A maternal surrogate in India is handsomely paid, receiving anything from $2000 to $6000 per pregnancy, which is considerably more than she is typically likely to see in a year.  A strictly libertarian argument holds that “fair” monetary compensation, combined with freedom of choice, obviates any ethical concern.  A more nuanced perspective asks, if the alternative is poverty and death, is there really a choice at all?  This is the classic tension between autonomy and exploitation, in that a desperately poor person can be co-opted to express her autonomy in such a way that it leads to her exploitation.  There are identical scenarios involving international organ tourism, in which th extreme poor are convinced to sell their organs, and in many forms of prostitution.  The fundamental question becomes, is it ethical to seek a profoundly intimate (and sometimes self-damaging) service from a vulnerable stranger, knowing that she likely offers it from a position of desperation?

My work as an epidemiologist and ethicist has been to explore and describe the phenomenon of maternal surrogacy in India, without passing judgement on the service providers, clients or surrogates. I have managed to identify 21 distinct ethical pitfalls inherent in the extant industry.  But I wish to bring readers’ attention to just two of them: insufficient medical advocacy and limited informed consent.

The present commercial model for maternal surrogacy in almost every clinic in the developing world holds that a contractual relationship is forged between the client (usually a woman or couple from a wealthy country), the clinic and the surrogate.  But from a medical perspective, the clinician is directly responsible for the care of both the client and the surrogate, though is being paid by just the client.  This is clearly a conflict of interest.  Consider if a medical situation were to arise in which the clinician must act either to save the life of the fetus or the surrogate.  He has a strong financial incentive to choose on behalf of the the paying client, and thus the fetus. The absence of an independent medical advocate acting on behalf of the surrogate immediately nudges this relationship into the realm of exploitation.

Given that the surrogate is often quite poor, uneducated and semi-literate, it seems unlikely that she is even aware of the dangerous nature of her unequal status in this commercial relationship. This vulnerability further complicates the proper receipt of true informed consent.  In legal terms, informed consent is a process to avoid fraud and the imposition of one party’s will upon another.  In medical ethics, it is the process of a clinician receiving genuine permission from an autonomous person to perform a medical procedure on that person.

Contrary to its portrayal in popular media, informed consent is not simply the receipt of permission.  In TV shows like “House”, informed consent is co-opted from patients who are tricked into giving permission for a dangerous procedure. It is often rationalized away because “the doctor knows best”. True informed consent involves an ascertainment that the patient understands the nature of the procedure and the likelihood of all its known risks.  Illiteracy is but one barrier preventing the communication of such risk.  But when risk is presented in the same package as a significant financial incentive for accepting that risk, the negative consequences are necessarily muted in comparison.

But what are these risks?  Childbirth is, after all, a natural process that pretty much all of these women have already gone through, since proven gestational ability is usually a prerequisite for serving as a surrogate.  However, there is a reason that maternal mortality rates are monitored in every country: pregnancy is an innately dangerous state for a woman, especially in a developing world context.  Surrogates risk metabolic and cirulatory complications, such as diabetes or extreme hypertension.  Death is a small but real risk, as is, through gestational injury, impairment of her ability to have future children.

Those are the known, medical risks that any obstetric specialist knows to communicate to a woman considering pregnancy.  In the case of maternal surrogacy in India, there are social risks that are just as dangerous as the biological ones.  Domestic violence and household strife have been known to arise when a surrogate’s husband dislikes the fact that she is carrying “the child of another man”.  There is one story of a surrogate being forced from her village after her neighbours learned she was carrying the baby of two gay Israeli men.  There is also uncertainty surrounding whether the surrogate will be able to control her diet, or enjoy continuing carnal relations with her husband, or whether her current childcare responsibilities will be interrupted.  These are all downstream negative consequences of the surrogacy procedure that need to be considered when formalizing the contractual relationship, though there is no evidence that these considerations are formally included in existing surrogacy negotiations.

Further complicating the quest for informed consent is the unavoidable power imbalance between doctor, client and surrogate. As the least powerful member of this triad, the surrogate is at risk for being cowed into compliance.  The fear is that unless conscious and overt steps are taken to ensure her full expression of choice and autonomy, a poor, semi-literate village woman will typically accept at face value the estimation of risk presented by a wealthy, educated and typically male doctor.  It takes unusual strrength to find the voice to question points in a formal contract if presented as a fait accompli by an officious clinician. It is in some ways the legacy of India’s colonial heritage, wherein informed consent can literally be coerced by identity; an English-speaking clinician in Western garb weilds extraordinary cultural authority.

A brochure of one Indian ART clinic featured the following quotation from a surrogate who had recently produced a child for an American client: “It’s a miracle.  I myself was wondering how I managed to deliver such a beautiful American, totally white baby.  I couldn’t believe it –I am very happy.”  The statement is presented as a marketing tool for potential foreign clients.  But what should be evident is that this woman failed to understand the genetic realities of the procedure in which she was a central part.  In other words, truly informed consent was not in play.

There is no doubt that maternal surrogacy presents a ripe opportunity for very poor women to make a dramatic improvements in their families’ lives.  So long as infertility remains prevalent globally, and so long as India experiences the tandem of advantageous global prices and widespread poverty, it is assured that India’s reproductive tourism industry will continue to grow.  Our goal, as responsible global consumers seeking to minimize suffering and exploitation, should be to make the process as fair and as safe as possible.  Ultimately, the creation of life is meaningless unless we also strive to respect the living.

—

Dr Raywat Deonandan is an Assistant Professor in the Interdisciplinary School of Health Sciences at the University of Ottawa, the former Chief Science Advisor to Assisted Human Reproduction Canada, and an expert on the global industry of reproductive medical tourism. Links to this post are welcome, but please do not excerpt elements or text without informing the author.  Thank you.

Greetings from onboard a Westjet flight from Ottawa to Vancouver.  Award for funniest line of the morning goes to the Westjet flight attendant who announced, while in mid-air: “Smoking is strictly prohibited on this flight. Anyone caught smoking will be asked to leave the aircraft immediately.”  Okay, so things seem funnier in the air.

The big news in global health and development today is that the UN is due on Monday to annouce that the human population has reached 7 billion people.  The United Nations Population Fund (UNFPA) will publish its insights on this matter in “State of the World Population, 2011.”

Seven billion is nothing to sneeze at.  That’s a lot of people.  In fact, it seems likely that the world will see 15 billion people by the year 2100.  Most likely, the 7 billionth child will be born in India or China.  It’s worth pointing out that, despite those nations’ remarkable economic growth over the past two decades, they still suffer from crippling poverty, due in part to a uneven distribution of wealth and opportunity.  In fact, half of all undernourished children in the world live in South Asia.

When we consider population pressures, two thoughts immediately come to mind: starvation and ecological degradation.  The two items are inextricably linked, of course.  With more people comes increased use of environmental assets, increased pollution and increased weight put upon regional ecosystems.  This also means a decreased ability to potentiate food production, given the increased tendency for people to live upon and build upon arable land.  The irony is that with more people, there are more mouths to feed, and thus a greater need for food production.

In a global health context, when we talk about food security, we usually define it as a construct with two dimensions: availability and accessibility.  The former relates to our ability to produce food, while the latter to social, political and geographical barriers that limit proper food distribution.  Most experts will tell you that accessibility is the true limitation to feeding the world.  In most countries, there is sufficient food for everyone, but due to a variety of factors large numbers of hungry people do not have access to sufficient calories.  Perhaps the most famous person putting forward this view is Nobel prize-winning economist Amartya Sen.

While I agree that accessibility is indeed the dimension of food security we must address first, I think it’s becoming preponderantly more important to consider aspects of food production.  This is because it is inextricably linked to the environment; and given the accelerating negative impact of Climate Change on the most populated parts of the world, I fear that food production will be at a crisis level in a couple of decades, if not sooner.

The reason for this is multifold, but I will list but three points:

1. -One of the great crises in the world is the declining availability of fresh water.  This has a most immediate effect on the growth of agriculture.  Climate Change, pollution and population growth have combined to drastically reduce the world’s groundwater reserves, to render many existing freshwater sources untenable, and to change rain patterns such that previously reliable agricultural zones are becoming less so.
2. -In the past century, human beings have begun doing something really foolish: building on arable land.  In previous centuries, we have lived on rock and barren land, and have reserved arable land for farming.  But due to some strange economics, it has become more lucrative to sell farmland to a strip mall developer than to continue to grow crops on it.
3. -Point #2 seems in conflict with the inexorable truth that the world is increasingly urban.  People the world over are fleeing the countryside to live in squalor in cities, again due to the strangeness of our economic systems.  But an important aspect of this observation is that, while some rural land is being abandoned, other rural land is being absorbed by growing cities to become suburbs and exurbs.

A final thought on this matter is to point out the conflict between our concern over a crisis of potential overpopulation and the demands of our growth-driven economics.   On the one hand, seven billion people represents a strain on our resources and on our ability to manage the planet.  On the other hand, we have created a civilization in which wealth is defined by the sum total of economic activities of its citizenry, meaning that more people often means more sustained wealth.  The Western world bemoans its current demograph trap, wherein the fabled Demographic Transition has created so much personal security and longevity that fertility rates have dropped beneath replacement rates.  There is concern in Canada, Japan and much of Europe that the smaller sizes of upcoming generations are insufficient to pay for the demands of our complex and expensive society.

The obvious solution is two-fold: allow the freer movement of people across borders and seek to recompute how we define wealth.  But both of these require a profound shift in both political will and social vision.  Then again, given that the crisis of Climate Change requires a similar shift, maybe the world is ripe for such a change.

Remember my ongoing issues with mysterious somnambulant injuries?  I reported on my demonic back scratches here and here.  Well, they’re back.  The most recent mysterious and bloody injury is the following gash and bruise on my right bicep, which greeted me yesterday morning:

I will remind the gentle reader that my fingernails are bitten down to nubs, so are poor tools for unconsciously inflicting this sort of injury.  As well, my separated shoulder makes the angle quite painful.  Spoooooky.

In other news, the most hilarious and embarassing thing happened to me recently.  As a professor, I must write frequent research papers and submit them to journals for publication.  The journals send them out for anonymous peer review before deciding whether or not to publish.  I send out a fair number, so some get accepted and some get rejected.

Recently I sent an admittedly poor one to a big name journal.  It was rejected.  But the best part was the external reviewer’s comments.  To paraphrase, he/she said that the paper was poorly written, but that the topic was important.  Therefore, he/she recommended that though the paper should be rejected, the journal should solicit its rewrite from a true expert on the topic.  Then he/she recommended that that expert be…. me.

As a friend commented, it’s a lot like Charlie Chaplin coming third in his own lookalike contest.

In even more news, in response to a special request from a neighbour who has always been curious about the form, I have agreed to put together one last game of Dungeons and Dragons, a good 27 years since the last time I played.  Yes, this is the darkest heart of hardcore geekotry, and not for the even marginally cool.  In preparation for said game, I took a trip to Toronto’s Silver Snail gaming shop and scoped out some of the figurines.

What I found were figurines for UFC fighters:

Then it occurred to me… why not have actual UFC fighter characters play the game?  One’s party could be made up of Tito Ortiz, Randy Couture and Anderson Silva, all choking out kobolds and trolls, and eventually each other.

Hmmm.  Time to pitch this to Hasbro….

Penultimately, as an author, I know how crippling it is to see one’s own books on the bargain shelf of a bookstore.  So this is not meant as a dig, but as a celebration.  My friend Andrew from DC once wrote a great book featuring satellite images of the Earth, called The Earth From Space, which was unfortunately priced rather highly.  I recently saw it on sale.  All this means is that more of you can now afford to own a copy:

Lastly, I copped this article from The Hindustan Times in India (June 4, 2011), relevant to this post.  I don’t agree with a lot of it, but some of it rings true.  Just throwing it out there (click to enlarge):

The Lok Saba in New Delhi

As is my wont, after each trip to India, I try to record my most prominent observations.  I’ve been back in Canada for more than a week now, and am still jetlagged and catching up on work.

As I write this, both CBC and BBC radio are broadcasting features on India.  BBC had a special on the various types of corruption that are endemic across all levels of Indian society.  And CBC has a brief special on a topic I know a tiny bit about, as it abuts my field of expertise: the Indian demographic gender gap.

Wit regard to the latter, many parts of India (predominantly the North) are following China’s demographic trap: generations of sex selection bias against girls has resulted in a bride shortage.  From a feminist perspective, it’s offensive that the dialectic is being phrased as a crisis for men.  From a demographic perspective, it’s interesting to predict the manners in which this gap will manifest upon society.

An acquaintance of mine, Dr Prabhat Jha of the University of Toronto, is the author of a new study in the Lancet that is making the news: Trends in selective abortions in India…

Some have theorized that a shortage of women will mean an increase in women’s power.  Other’s have predicted that it will mean a greater commodification of women.  The “burden” of dowries may be reduced, as brides become more desirable. Interestingly, I am told that we are not seeing young men going abroad to seek wives; they are more likely to cross caste, class and generational lines.

Additionally, we are supposedly seeing a re-investment in the quality of lives of the eldest sons alone.  That is, efforts are made to find spouses for the eldest son; the remaining sons are left to their own devices.  So rather than conceptualizing this phenomenon as the glorification of boys, I think it’s more accurate to say that it’s the glorification of eldest boys.

It’s worth pointing out that the China and India cases are different.  In China, it’s the result of the One Child Policy.  In India, it’s entrenched within the culture of the nation.  Now, there’s no denying that the shortage of girls is troubling for moral, political, social and economic reasons.  At the same time, it’s the fastest way to reduce the populations of the world’s two most populous nations.  But economic wherewithal is still affected in very large part by population size.  So where this all ends up, nobody knows.  Sex selection is not just a phenomenon of India and China, but is prevalent across many countries.

In a future blog post, I’ll try to develop this topic further.

The second theme is corruption.  It’s almost a joke that India’s sole constant is its corruption.  We take it for granted.  While we were in Delhi, “spiritual leader” Baba Ramdev was threatening to start a hunger strike (Satyagraha) in protest against governmental corruption.  I’m not sure what qualifies Ramdev as a spiritual leader, beyond his orange robes; but there’s no denying that he attracted thousands of supporters across the nation, many of whom showed up in Delhi to take part in the hunger strike.

I was surprised to learn that the Satyagraha made news in the West, as well.  Adam and I tried to get to the Turkman gates to watch the protest, but no taxi driver would take us there…  Probably for the best, because the police ended up raiding the site and driving out all the assembled protestors. But the issue is not off the Indian front pages.  As India matures into a global economic and cultural leader, I think it will be corruption that must be the first dinosaur to fall.

Lastly, one observation that still percolates across all of modern India is hierarchy.  We all know of the caste system.  It’s technically illegal, or at least illegal to apply in any formal context.  Yet, the desire to create classes of people is strong in India.  It’s why Western tourists, however horrified they might be by India’s crowdedness, pollution and poverty, are nonetheless privileged to receive extraordinary service and deference.

It’s one thing to see private business exercise their need to reward status.  It’s quite another to see taxpayer-funded institutions do it.

Example: the passport control line at the airport.  There’s actually a first class line at passport control.  Think about that for a second.  Passport control has nothing to do with the airlines, or even the airport.  It’s a government-run, supposedly objective process for assessing the quality and intent of individuals entering and leaving the country.  Yet, if you happened to pay an airline some extra money for a more expensive seat, you get to wait in a much shorter passport control line when you arrive.

This is yet another aspect of Indian society that must –and will- change as India (or at least India’s middle class) enter’s the ranks of the world’s economic and democratic leaders.

Okay, my shoulder is killing me.  Got more to say, but I have to stop typing now!

Here are the photos from the most recent trip.

Congrats to all my students who are convocating today!

Greetings from Beijing airport.  After a month of traveling, this is my last stop before a flight home.  I will have circumnavigated the globe (entirely unintentionally) as of 7pm tonight, Toronto time.

I’m online now via the “free” airport wifi in Beijing airport.  To get a login name I had to scan my passport into a machine.  Who knows what kind of identity fraud I’ve just opened myself up to?  First thing I did was to check my Gmail… in the wake of a series of high profile Gmail hacks originating from China.  I’m sort of surprised that Google products are accessible at all here!

I say that not lightly, because I’ve been unable to access either Facebook or Twitter.  So for my readers who can’t access my “wisdom” in those fora, I say: “Beijing, bitches!”  Happy, now?

After two weeks of interesting, and sometimes frustrating, Indian inefficiency, I was looking forward to some good old-fashioned one-party-rule getting-things-doneness.  The way international transfers work here is that you get off your incoming flight, go to an “international transfer” desk to get your boarding pass for the next flight, then go through Chinese passport control and security before re-entering the departure lounge.

So I arrived at the international transfer desk and proudly presented my passport and itinerary and asked for my boarding pass to Toronto.  It was 12:15 pm.

The fellow said, “Sir, yours is an Air Canada flight. The Air Canada desk is not open yet.  Please wait until 12:20 for that desk to open.”

So I took a seat across from the desk and waited.  And waited.  An hour passed.  So I stood up and asked about my flight again.  Same guy hands me a boarding pass and says, “your flight will leave from gate E14.”

Now, the important part about this story is that nothing had changed.  No one came to the desk, nothing new was printed and there was no phone activity.  He just had me waiting there for an hour before handing me the boarding pass which had been sitting on his desk.

But then the worst part about this segment happened.  Let me preface this bit by saying that you don’t mess with Chinese security.  They take shit seriously.

Now, I’ve been traveling with an Acuball (TM) for nearly 3 years now.  I have two herniated discs, and nothing has given me joy and relief like the Acuball.  I sleep with it and I travel with it.  It’s the perfect back support.  Here’s a pic:

The Acuball comes in a set of two: a large one for the spine and a small one for the foot.  And they’re blue.  (Heh heh.) But I only ever use the large one.

I’ve written about my adventures with my sturdy Acuball before, as in this post.  And I’ve taken it around the world with me.  I think I’ve taken it to over 12 countries and on well over 100 flights.  Sometimes security gives it a shake or asks me about it, but it never goes beyond that.

But in Beijing, the security folks picked it up, examined it, waved a naughty finger at me (seriously), then –gasp!– tossed it in the trash!  THE TRASH!

My heart literally sank.  For one thing, the Acuball goes for something like $75.  The thing ain’t cheap!  And for another…. the trash!  Why?  Was I going to hijack the plane by giving all the pilots better spinal health?

Just met a nice Korean fellow who’s practicing his broken English while taking his family to Oslo.  That kind of courage –to enter a whole new world without the benefit of language– is one of the great things about travelers.  Meeting him helps to quell the absolute anguish I feel over losing my Acuball.

So I will end this post here and go find a bar.  I need to raise a glass to my little blue balls.

These past couple of days have been a whirlwind of work (not so much of activity).  I’ve spent most of my time sequestered in a hotel, writing papers and reports. Hey, I’m not on vacation here!

Had a wonderful lunch with a new colleague at the Centre for Development Studies yesterday.  The CDS is an attractive campus that teaches economics from a development standpoint; its architecture is economical, using building materials meant for low income housing— but done so artistically that it actually looks more expensive than traditional buildings!

And today I gave a lecture at the Achuta Menon Centre for Health Sciences in Trivandrum’s medical college.  It really was a lovely experience.  First, I had a chance to meet with the students, most of whom are medical or nursing post-grads who are currently pursuing MPH degrees.

I was quite impressed by the breadth and depth of their various dissertation topics… and a tad horrified that each of them is required to self-fund his or her research!  This kind of work can get expensive very fast.  I have strong memories of being (literally) a starving student, and I hate to see students pushed further into debt.

This is not a criticism of the Indian system, but rather an expression of concern for all students around the world.  The cost of education, worldwide, is much too high.

Here’s a nice pic of the conversation I had with them:

Meeting with MPH students in Trivandrum

The actual lecture was held in a different classroom (an advanced and large seminar room), with students and professionals from across the city invited to attend.  It was actually quite packed.  And, as usual, I was only vaguely prepared.

See, I have a policy against over-preparing for presentations.  As is my tradition, an hour before the talk, I wrote a few notes down on a bit of paper over lunch.  That would be my outline.  I find an audience enjoys the spontaneity of a reflective speaker who contemplates in the moment.

Before asking a question, one student said something to the effect that, “We are surprised.  We did not expect such a serious topic to be presented.”

This confused me for a while… until I found out that those students have been reading this blog.  Ahhh.  Now I’m embarrassed.

So, to those MPH students still reading today: thank you for attending my talk, and try not to be too shocked by some of the nonsense I write in this space, okay?  I may have a lot of degrees, but at heart I’m just an idiot with a big vocabulary.

Now, our original plan was to head to Rajasthan in the morning, for my final day in India.  Hey, I deserve one day of pure tourism, right?  When I expressed this intent to one of the students, she claimed that she had always wanted to go to Rajashtan.  So I immediately took her photo and promised to digitally add her to the scenes that we would be visiting.

Unbeknownst to her, our plans had to change.  The flights are just not working out.  A back-up plan to drive to Madurai also fell through, as did an unpopular plan to spend the last day in Chennai.  Instead, we are spending our final day in Delhi, before Adam flies off to Toronto and I to Beijing (don’t ask).

So to that student who wished to see Rajasthan, I offer my apologies…. and this:

The statue of Vivekananda, as seen from the Gandhi Memorial, in Kanniyakumari

Back in Thiruvananthipuram, or Trivandrum.  Haven’t been here in 15 years.  When I was here last, I was a student studying at the Institute for Social and Economic Change.  Good times, except for the the episode where a little girl essentially died in my arms after being hit by a bus.  But we won’t talk about that.  Suffice it to say that the place has some strong memories attached to it.

So far, this is my favourite stop in India.  Most of the men, and pretty much all of the women, still wear traditional garb as they go about their business.  English (or indeed Hindi) is rarely heard or seen.  No one takes notice of my Western appearance or of Adam’s whiteness.  It’s as if nothing of the West matters here, which suits me just fine.

I’ve written before that India has a special relationship with feces.  Every traveler here has a death-defying tale of diarrhea.  Due to poor waste management, many parts of Indian cities actually do smell like shit.  Let’s not mince words, okay?  A traveling companion greeted with the following statement:

“You know that feeling after you’ve been drinking too much and you know you’re going to be vomiting for a long time, and you feel as if you’re going to die?  I just experienced that through my anus.”

So beware of the flowery reports of the place.  Yes, I love India.  With every visit I am bewitched by her complexity, subtle beauty, layered complexity and unending depths.  But after a few weeks, almost everyone gets inured to what is obvious upon first arrival: there are serious problems with infrastructure and waste management here.  Garbage is ubiquitous, and no one seems to care.

Yesterday we took a pleasant 3-4 hour train ride to Kanniyakumari, the southernmost tip of India, a place where three oceans collide, and where Mahatma Gandhi’s ashes were scattered.  There’s a brilliant and enormous statue of sage Vivekananda on a rock just offshore.  It captures and holds one’s gaze.

This is part of the illusion –the maya, if you will– of India.  One is so entranced by the wonders that soon one fails to see the less wondrous: the lakes of rubbish at one’s feet.  It’s actually quite amazing the lengths to which one goes to avoid photographing the empty water bottles, newspapers, plastic containers, and so forth.  But the truth is that the garbage is as genuine a part of India as are the temples, statues, gorgeous children and ancient shores.

One important change from previous visits is that the number of beggars and touts is significantly lower.  Yesterday, Adam was beset by a small child beggar who would not leave him alone.  The child was chased away by a passerby who apologized and said, “that is not the real India.”

But it is.  It’s as much the real India as are the thousands of mobile phone stations, the isthmus populated by modern wind turbines, the aircraft carrier patrolling offshore, and the leper whose hand I unthinkingly shook.   It serves no one to ignore one aspect of India in favour of the others.

Garbage is everywhere, even on the train tracks in Trivandrum

Even in a place as lovely as Kanniyakumari, there is rubbish aplenty

We took a harrowing bus ride back from Kanniyakumari to Trivandrum, first stopping in Nagercoil to switch buses.  There comes a point when you have to surrender yourself to the fates, in full appreciation that you have no control over certain forces, specifically the bus, the driver, the roads and the other drivers.

If you’ve never been on a bus or car in India, you’re in for a special experience.  Western rules of the road, or of safety, do not apply.  Your only option is to surrender to the situation.

I’ve got to give a shout-out to Google Maps and my HTC’s excellent GPS system, which allowed me to keep track of our progress at every turn –a remarkable feat when one is traveling in a truly alien land in which one does not speak or read the language.

Adam made a friend on the bus:

Adam's friend on the bus from Kanniyakumari to Nagercoil

One of the few joys of public transportation in India is the ability to buy excellent food from the variety of vendors who are all about.  Here’s a fellow outside out bus in Nagercoil, selling roasted nuts:

Nut vendor in Nagercoil

I will leave you with this eerie photo of the Keralan coast, taken from a moving train through tinted windows:

Flying to Trivandrum in the morning, so have to keep this short.  Had a very productive couple of days, including finishing and submitting one paper and completing the revisions for a second.

But no one cares about my academic career.  What you want to hear about is India.

You can’t visit India and not see a movie in the cinema.  India is the last place in the world that really knows how to publicly enjoy a film.  In the West, cinemas have become the domain of rude teens, people who walk in and out, or who talk throughout the entire performance.  In India, movies are everything.  People pack in, and cheer and clap loudly for what we might consider to be innocuous parts.  Hey, but as long as they are involved with the film, I am totally okay with it.

We saw Hangover 2 in Eranakulam.  The theatre was  jam packed (with almost entirely men).  Seductive Kama Sutra images peppered the walls in the form of sculpture… but this was not a porn theatre.  (No, really.)  Whenever a main character appeared for the first time, the crowd would erupt with cheering.  This really was an interactive audience.

Today was a totally different adventure.  My old friend John, a Keralan I’d known in Ottawa, married his fiancee Kiran.  We hired an all-day taxi to take us the 3 hour drive to the town of Palayur in Thrissur District where the wedding was to take place.  After much hand-wringing and some frantic driving, we arrived precisely on time.

The wedding took place in St Thomas’s church, which is the oldest Christian church in India.  It’s a fascinating historical artifact.  See, Thomas (“Doubting Thomas”, Jesus’s direct apostle) arrived here in the first century AD and started converting people.

The first few Brahmins that he converted to Christianity are supposedly revered to the extent that community leaders still try to trace their descent from them.  As a result of their conversion, ancient Hindu temples began to be transformed into churches.

This was one such church.  The Wikipedia entry suggests that it has both Persian and Hindu designs.  Indeed, the massive lingham now has a cross on it.  The dia, a traditional Keralan Hindu lamp, also now has a cross adhered to it.  The Christian ceremonies themselves, from what I could follow, have elements of Hinduism woven in.  It really was a fascinating blend of ancient Hinduism and early Christianity.

It should be pointed out that Christianity in India predates Christianity in much of Europe!  In fact, when Dutch and Portuguese first arrived here in the 1500s, they were shocked to find Christians already living here… who’d never heard of the Pope!

It’s a strange thought, even for a non-Christian like me, that this little structure in India was where once preached a man who actually personally knew the historical Jesus.  Or at least that’s what they say!

Okay, off to bed.

Wedding attendees inside St Thomas's Church in Palayur

Greetings from Eranakulam, a busy little town in Kerala, most known for its proximity to Fort Kochi (formerly Cochin), one of South India’s grand tourist destinations.

The region has had contact with the West for thousands of years.  Jews first arrived here after the destruction of the second temple around 70 C.E.  Christianity arrived here long before it did in many parts of Europe.  The Portuguese, Moors, Dutch and English have all had their grubby hands on the place.  Ancient Romans started the spice trade here when they discovered the Monsoons would bring them in and take them away like clockwork.  And Cleopatra herself had once planned to re-establish her empire in Kerala, just as Octavian’s armies were closing in on her faltering dynasty.

Why did they all come here?  For the spices.  Originally, black pepper was the lure that drew them.  Later, it was cardamom, ginger, saffron, tea and even imported cinnamon from further south.

Today the tourists flock here for spices, dance culture, some run-down beaches, the pleasant people and for a taste of old India, not quite ancient, not quite modern.

Indeed, at one point while having a snack at a cafe, I did a double take.  I suddenly realized the cafe was in fact the 16th century home of… Vasco da Gama!  Cool.

Yes, I’m working.  I’m holed up in a hotel room breaking all my dietary rules (pasta and Coca Cola), trying to finish a paper.  Yesterday, however, I took the time to see the sights.

No trip to Kochi is complete without seeing the old Chinese-style fishing nets, which are counter-weighted in a clever fashion.  When I was here last, 15 years ago, I was also able to visit an obscure martial arts school which taught Kalaripyattu.  Today, the art has grown in popularity so much that demonstrations are given nightly at the cultural centre.

Kerala is also famous for its tourist-friendly Ayurvedic clinics.  If you’ve never had an Ayurvedic oil massage, it’s something between medicine and molestation.  Thus, I enjoy it.  Had a good one yesterday (the massage, not the molestation, though sometimes it’s hard to tell the difference) and barely made it to a performance of Kathakali dance.

Now, I’m not a big fan of Kathakali.  I’ve seen it before, and I appreciate the discipline and rigour and historical importance, but I always fall asleep during a performance.  This time was no different.

The performance was seriously like a medium-strength acid trip.  The performers emote through make-up and extreme facial expressions.  The backing band for this demonstration were something out of a Wall of Voodoo video.  The lead drummer was expressionless and looked totally stoned.  The second drummer, who looked all of 8 years old, was going nuts on the drums.  The singer, who spent most of the time playing a kind of tambourine, looked both bored and drunk.

But the rhythms were perfect and endless.  Very hypnotic.  Here’s a pic:

This Kathakali performance was like an acid trip

In some circles, Kochi is famous for its 16th century synagogue, situated in “Jew Town”.  Yes, that’s what it’s called.  Nice place, but the walk there is, of course, peppered with souvenir shops manned by the requisite clingy hawkers.

My favourite was the store with the big sign in front that read, “Hassle-free shop!”  It was the one with the loudest and pushiest fellow trying to herd us in.

Oh irony, thine name be India.