Healthy Business: Will Medical Tourism Be India’s Next Big Industry?

No Other Choice: Why Medical Tourism Continues to Thrive: President of the United States Barack Obama recently urged Americans to seek medical treatment at domestic health care facilities, rather than traveling overseas. In India, where so-called "medical tourism" (known internationally as the global health care delivery system) is a booming industry, his statements have created quite a stir. In this opinion piece, Ravi Aron, a professor at Johns Hopkins University and a senior fellow at the Mack Center for Technological Innovation at the University of Pennsylvania, argues that people can't take advantage of something that doesn't exist. Until affordable universal care is a reality in the U.S., Aron says, Americans will continue to travel abroad for health care services.

President Barack Obama has asked Americans not go to India and Mexico for medical treatment. There are reasons why these appeals will have no impact on global health care delivery. Patients do not travel to India for health care services because they have a choice and they choose to go to India. They travel to India because they have no choice. They are either uninsured or grossly under insured and they cannot afford the cost of care in the U.S.
If a consumer exercises choice -- among comparable options -- then he or she can be asked to buy American. But the choice that these consumers of global health care services face is between care delivered overseas (Mexico, India or elsewhere) and no care at all. So asking them to stay in the U.S. is pointless. Until affordable universal care is a reality in the U.S. they will continue to travel abroad for health care services. This is not a discretionary spending that they can postpone or redirect.

Characteristics for Success
The globalization of health care services is inevitable in this environment. What are the characteristics needed for the industry to flourish? Look at it at the level of the multi-specialty hospital. The hospital needs to address the patients' sense of risk. If somebody in frail health is going to fly 12 hours to reach a point on the other side of the globe to get a bypass surgery or a hip replacement done in a country that they know very little about and one with a strange culture, they experience anxiety that stems from risk. Most of us weigh the choice of a vacation destination carefully; these people are literally entrusting their lives and well-being to a hospital and doctors that they do not know. So this is a decision that is characterized by a great deal of risk. Hospitals like Bumrungrad in Thailand go out of the way to address this risk. There are four levels at which they do this:

The Four Levels of Addressing Risk
The physical environment: The hospital lobby and the building feel like an excelsior hotel in a first world country. They go out of the way to showcase the sense of order and calm that prevails everywhere. The western patient would instantly feel at home with the Starbucks Café and Wi-Fi-enabled waiting lounges. The hospital and its lobby, lounges and wards gleam in their antiseptic cleanliness.

Process discipline: Bumrungrad hospital is pretty close to what we call a 360-degree automated hospital. From the point the patient has been admitted (from his overseas location) till discharge, all processes are centrally linked to the patient's records and care delivery, and support services are delivered and monitored at the level of each patient. They have extraordinary efficiency in the way they support clinical care with other services -- travel, hospitality (accommodation), transport within the city, billing and post-procedure follow-up.

Excellence in clinical care: Many of their doctors are board certified in the U.S. and in Thailand and Bumrungrad was the first hospital to get the JCI [Joint Commission International] accreditation in the region. On most parameters of medical care -- these statistics are available at the hospital site -- they compare more than favorably with the median hospital in U.S. and the E.U. (They were in the 90th percentile in patient satisfaction scores compared to similar hospitals in the U.S. and Europe).

Strategic use of IT: They use IT both to offer fine-grained information about the hospital, treatments and procedures at the hospital, and physician background to overseas patients, as well as information as a tool for monitoring and delivering clinical outcomes.

In terms of clinical information, they have been able to automate three crucial elements of clinical information flow: (i) Physician-level information from multiple physicians attending on the same patient; (ii) Information from clinical sources pertaining to a patient (tests, labs, nurses and clinical support services); and (iii) patient case history. This, in turn, has allowed them to implement a variety of innovations in care delivery that minimize medical errors, infection rates, etc. It also allows them to monitor patients and their progress in fine-grained detail. (Automating these three kinds of clinical information flows is very critical not only to deliver higher quality of care, but also to create "patient information portals" where the patient can constantly access his or her EHR (electronic health record) after the procedure from his or her country of origin, as well as schedule repeat check-up visits. Automating these three kinds of information flows is one of the reasons that Bumrungrad is referred to by some as the "gold standard" in global health care delivery).

First World Skills in Emerging Regions
So why is all of the above important? These are first-world institutions of skill and service excellence located in developing regions. The developing region economics makes these regions attractive from a cost (price) standpoint to overseas consumers. The first world skills and service excellence makes them attractive from the standpoint of actual care delivered to patients. For the paying patient, it is important to signal that the hospital is an island of calm and order founded on a reliable first world infrastructure and where care delivery is monitored with great precision and discipline. The patient needs to feel that this hospital has been insulated from its environment.

India is not lacking in clinical skill (quality of physicians). Traditionally, Indian hospitals were seen as weak in post-procedural care delivery (sometimes referred to as "post operative care"). But that, too, is changing. Some hospitals are beginning to get their acts together on post-procedural care in terms of significantly lowering medical errors and hospital infections, and improving nurse and support clinician hygiene standards. There is still much that can be done in this regard.

An area that is often overlooked by the Indian care delivery establishment is that of support services: travel, logistical support, accommodation and hospitality, transport within the destination city, billing, etc. Overseas patients are probably comfortable with the quality of Indian physicians; they are more concerned with clinical post-procedural care, support services and the infrastructure.

Medical services in India are where the IT-enabled services and the business process outsourcing (BPO) industries found themselves in the mid 1990s -- the challenge is to convince the customers that these hospitals are islands of excellence that have been insulated from the frailties of India, even as they draw upon its strengths. These services are not branded as "made in India" as much as "made in spite of India."

The Advantages of India
The one advantage the country has is that a doctor in India -- especially a surgeon -- would have acquired in 10 years' time more experience -- both in terms of scale of procedures done and the exposure to varying levels of complexity -- than what a surgeon in the U.S. would get in, say, 30 years of practice. So a doctor with about 15 years experience will probably be unrivalled in the scope and scale of his exposure.

In the well-run hospitals and multi-specialty centers, they have deep reservoirs of capability to treat patients who come in for a procedure with comorbidities [the presence of one or more disorders in addition to a primary ailment]. Not only can they perform the procedure, but they can also deliver related chronic care where necessary (procedure plus care for cardiovascular disease, diabetes, etc). Specialists are readily available to deliver care for comorbidities from a single location.

Almost all these institutions are private hospitals that cater to the needs of India's wealthy, powerful (Anglophone) elites. They are used to delivering services to a demanding clientele. This serves them well with overseas customers. A large number of physicians in the U.S. and the U.K. and in some Gulf countries are of Indian origin. So, overseas patients do not have the problem of entrusting themselves to Indian doctors.

The doctors of Indian origin can also serve as a distribution channel of sorts to hospitals in India. These institutions can tie up with these doctors to deliver some measures of post-procedure diagnostic care and ongoing care in the countries of origin of the patients.

The Low Cost Is a Given
The other advantage is, of course, cost. But there is no need to stress the difference in costs. The patient is usually acutely aware of the difference in the sticker price for care. The multiples range from eight to one to three to one, even after factoring in travel and other non-clinical costs. There is no reason to draw attention to this. It is far better to highlight capabilities and excellence for two reasons. First and less important, is that this will translate into "capabilities and excellence at an affordable cost" in the patient's mind. Second, and more important, the patient is worried about capabilities and support care and the risk of entrusting his life and well-being to a strange system far away from his home. So it is vital to address those concerns rather than emphasize "cheap." The patient is all too aware of the cost difference anyway.

Finally, the use of web-based channels to inform potential patients is key to running an efficient marketing operation. Hospitals should be able to offer information about JCI certification, physicians' experience and qualifications, the depth of their capabilities in performing specific medical procedures (coronary bypass, hip replacements, etc.) and give patients an accurate estimate of the costs.

Bumrungrad's use of electronic channels is a case in point in effective marketing. The hospital has developed a cost simulation where the patient can key in details of his or her condition and the simulation gives a clear estimate of the cost frontier that he or she will face: it gives the patient a distribution of costs that similar patients in the past faced -- including an average, a high percentile and a low percentile number -- allowing the patient to form his or her own estimate of the costs of care. This electronic estimate is based on actual costs of past patients and it is constantly updated from the hospital's database. Bumrungrad is able to do this because every element of the final cost the patient pays is itemized and categorized in the final invoice. This is yet another example of their strategic use of IT to both serve the customer and market their services effectively.

In the past, U.S. President Barack Obama has singled out India for what he sees as the country usurping American jobs and business. In May 2009, he removed some tax incentives for U.S. companies who allegedly preferred to outsource rather than create domestic jobs. "Buffalo before Bangalore" was his rallying call at the time. Now, India is back in his crosshairs. In April 2011, he told a town hall gathering in Virginia that Americans shouldn’t have to go to India or Mexico for “cheap” health care. "I would like you to get it right here in the U.S.," he said.

"It’s a 100% political statement," Gopal Dabade, convener of the All India Drug Action Network, told weekly newsmagazine India Today. Others in India were equally critical and dismissive. But some have taken more serious objection. "Not acceptable," says federal health minister Ghulam Nabi Azad. Affordable health care does not mean our medicine is inferior to any superpower’s. I would like to say our medicines are indigenous, they are superior, and superiority does not come by escalating costs."

The bone of contention is the word "cheap." Obama probably used the term in the sense of less expensive. But Indians have interpreted it as meaning "tawdry and inferior." Analysts don’t expect Obama’s political posturing to make any difference to the flow of U.S. medical tourists into India. But there is a lurking fear, nevertheless, that a nascent sector could be hamstrung at birth.

There Is No Choice
"Patients do not travel to India for health care services because they have a choice and they choose to go to India," says Ravi Aron, professor at the Johns Hopkins Carey Business School and a senior fellow at The Mack Center for Technological Innovation at Wharton. "They travel to India because they have no choice." Adds Rana Mehta, executive director, PricewaterhouseCoopers (PwC) India: "If patients see value in what India has to offer, they will continue to come."

Indians feel aggrieved that they have been singled out. In medical tourism, the country is still a bit player. According to a report by the Delhi-based RNCOS, which specializes in Industry intelligence and creative solutions for contemporary business segments, India’s share in the global medical tourism industry will reach around 3% by the end of 2013. The December 2010 report -- titled "Booming Medical Tourism in India" – says that the industry should generate revenues of around US$3 billion by 2013. "The Indian medical tourism industry is currently in its early growth stage," says RNCOS chief executive Shushmul Maheshwari.

Guess who’s the biggest beneficiary of medical tourism? It’s the U.S. "The largest segment, with 40% of all medical travelers, seeks the world’s most advanced technologies," says a McKinsey & Co paper titled "Mapping the market for medical travel." "These men and women take their search for high-quality medical care global, giving little attention to the proximity of potential destinations or the cost of care. Most such patients travel to the U.S." What worries the Indian industry is that this is not the first attack on Indian medical tourism. In August last year, leading medical journal The Lancet had published an article about a new superbug which it called the New Delhi metallo-beta-lactamase 1 (NDM-1). "The potential of NDM-1 to be a worldwide public health problem is great, and coordinated international surveillance is needed," said the article. Later, a co-author noted that some material had been inserted into the article without his knowledge; the editor of The Lancet had to apologize for naming the bug after New Delhi, and the Indian ministry of health had to weigh in. "The conclusions are loaded with the inference that these resistance genes/organism possibly originated in India and it may not be safe for U.K. patients to opt for surgery in India," said the ministry. "The medical journal's claim is not supported by any scientific data and thus tarnishes the reputation of the country." Rightly or wrongly, the government and many in India’s medical establishment believe that naming the superbug New Delhi was to keep U.K. medical tourists at home. "The superbug certainly garnered a lot of media attention given its name," says Preetha Reddy, managing director of Apollo Hospitals.

It won’t keep medical tourists at home, just as Obama’s appeal is likely to be ignored. "People will always weigh the cost and the benefit," says Reuben Abraham. "If there is a 10% saving and there is a danger of the superbug then chances are that people will not want to take it. But if you are offering an 80% discount, it is a different matter. If India continues to offer high quality health care at one-tenth the cost in the U.S. then these things will not make an impact."

The Next Big Thing
If all this is going to have limited impact, why is India getting so agitated? The answer lies in the potential of medical tourism. It could easily be the next big thing. Unlike business process outsourcing (BPO), which is on the whole very low-tech, health care -- particularly sophisticated procedures -- is very high-tech. India has not been able to set up an adequate health care infrastructure for its own citizens and it doesn’t have the money to do so. Creation of a sophisticated medical tourism structure will have a trickle-down effect.

"India has the highest potential in medical tourism in the world," says Maheshwari of RNCOS. "Factors such as low cost, scale and range of treatments differentiate it from other medical tourism destinations. Moreover, growth in India’s medical tourism market will be a boon for several associated industries, including the hospital industry, the medical equipment industry, and the pharmaceutical industry."His study shows that CAGR (compound annual growth rates) in revenue in 2011-13 will be 26%. In terms of medical tourists, the number would touch 1.3 million by 2013 at a CAGR of 19%. "Medical tourism can be considered one of the rapidly growing industries in the Indian economy on the back of various factors," he says. "However, the industry is at a nascent stage and requires a few years to reach the platform already established by the IT sector." "India has been ranked among the top five destinations for medical tourism," says Rana Kapoor, founder, managing director and CEO of Yes Bank, which has recently done a study on health and wellness tourism in India along with apex chamber of commerce FICCI.

The ranking by Nuwire Investors, an online source for news on alternative investments, puts Panama on top, followed by Brazil, Malaysia and Costa Rica. "India is looking at exponential growth as far as tourism is concerned," continues Kapoor. "Yes Bank forecasts that there will be an increase in domestic tourist movements over the period (2008-2020) by 118% and foreign tourist inflows over the same period will increase by 71.87%. What the potential for medical tourism from within this growth rate of 71.87% will be depends upon government policies, faith of the patients and many other external factors. We truly believe that this sector will play a significant role as a contributor towards the overall tourism growth in India."

"I strongly believe that many developments across the world will put India in a fantastic position," says Devi Shetty, cardiac surgeon and chairman of Narayana Hrudayalaya. "We produce the largest number of doctors, nurses and medical technicians in the world. Also, we have been traditionally linked with western health care because of the British influence on our medical education and the ability to speak English. This is extremely important for developing [global] health care. Our greatest asset is our ability to produce the largest number of technically-skilled individuals. We also have the largest number of USFDA (U.S. Food and Drugs Administration)-approved drug manufacturing units outside the U.S."

Differences over Terminology
Shetty doesn’t like the term medical tourism. "Medical care is something that is very stressful and people consider this under tremendous pressure," he says. "It is an event where people are scared of losing their lives. It may not be appropriate to call it tourism. Tourism is a different business altogether." Adds Mehta of PwC: "The tourism component is really very weak. Most foreign patients come to India for chronic and serious medical treatment and I would call it medical value travel." Aron of Johns Hopkins has yet another view. "The world over it is known as the global health care delivery system," he says. Reddy of Apollo agrees with Mehta. Says she: "At Apollo Hospitals, we prefer to term this business opportunity as ‘medical value travel’ as people travel to our hospitals for serious life threatening health conditions, which essentially need highly skilled doctors and medical infrastructure and not mere minor treatments like cosmetic enhancements, dental work or wellness which can be coupled with holidays, as the term ‘medical tourism’ implies."

The multiplicity of names is accompanied by a wide range of numbers. The confusion was started by the McKinsey study on Mapping the Market mentioned earlier. The May 2008 report said that "medical travel has captured the world’s attention and imagination". But it went on to explain that the McKinsey definition of medical traveler was very different from what many others thought him to be. The first to be knocked off were expats looking for health care in their country of stay. That accounted for 25-30% of the traditional medical tourist pool.

Then was the segment categorized under emergencies. These were ordinary tourists caught up in accidents. That eliminated another 30-35%. McKinsey estimated the remaining at "between 60,000 and 85,000 inpatients a year", much lower than generally accepted numbers. For instance, a 2008 Deloitte Center for Health Solutions report on "Medical Tourism: Consumers in Search of Value" put the number of Americans who had traveled abroad for medical care in 2007 at 750,000. McKinsey excludes "wellness" tourists (acupuncture, spas, yoga, aromatherapy and the like), patients from neighboring countries, and outpatients -- those who don’t need to check into hospital.

The Deloitte report says that India is stepping on the gas; the medical tourism sector is expected to grow 30% annually up to 2015. An update on the report says that the U.S. recession is driving more people out of the country for health care; U.S. outbound medical tourism is projected to increase 35% annually from 2010-2012. "Medical tourism [today] represents the maturation of a cottage industry," the report sums up.

Maheshwari of RNCOS agrees that economic problems are driving more Americans abroad for health care. "Under almost stagnant salary increments, the disposable income and saving considerations of U.S. citizens are still well below the pre-crisis levels," he says. "In this scenario, the low cost treatment and nearly zero waiting time coupled with its proven track record offer convenient procedures for tourist arrivals from various geographical locations including the U.S."

"Over the past few years, the medical tourism story has changed dramatically in India," says a recent Cover Story in weekly business magazine BusinessWorld. (That it made it to the Cover is a reflection of the growing importance of the sector.) "Not because the government has figured out the solution. But purely because of private enterprise -- with a few corporate hospitals, chemists and freelance agents all working in tandem to build a thriving ecosystem that educates, facilitates and ferries medical tourists from across the world. Last year, this ecosystem was responsible for about 600,000 patients travelling to India and spending US$1 billion in getting treated here. (The numbers are industry estimates as the government does not have any official statistics on the subject.) Corporate hospitals such as Apollo, Fortis Hospital and Max as well as business associations estimate that the business is growing by 40% year-on-year." (Obviously, the growth numbers vary depending on who you talk to.)

Other Markets Will Turn to India
"India’s potential is huge," says Mehta of PwC. "Some 80% of foreign patients coming to India are from the neighboring countries and from Iraq, Afghanistan, the former Soviet Union, etc and now increasingly from Africa. But now with India proving itself as a credible provider of value health care, the western population ageing, and health care becoming more difficult there, I expect more people to come from the U.S. and the U.K."

Mehta says that some things went wrong with the earlier planning. "We expected most patients to come from the U.S. and Europe. We expected people to come for cosmetic and regenerative treatment and this is where there is more potential for tourism. But the majority actually came for cardiac treatment, cancer treatment, knee replacement and other serious ailments. Therefore, tourism was not really of importance. We did not get the cost factor right. We thought that typically in India it costs one-tenth of that in the U.S., so we could cost at 5X. But hospitals have not been able to charge very much. At present, with a foreign patient, there is around 20% more earning."

Cost is, of course, being underplayed in the marketing efforts; this is why the word "cheap" rankles. "The patient is usually acutely aware of the difference in the sticker price for care," says Aron. "There is no reason to draw attention to this.”That’s an area where India enjoys an advantage over other countries too. According to the BusinessWorld report, a heart bypass surgery costs US$144,000 in the U.S., US$25,000 in Costa Rice, US$24,000 in Thailand, US$20,000 in Mexico, US$13,500 in Singapore, and US$8,500 in India. "The quality is excellent," says Maheshwari. In India, there is also less waiting time and personalized services.

Becoming an Industry
Medical tourism is also taking shape as an industry, though there are some who feel that it will eventually fall in many buckets. (The recent FICCI-Yes Bank study talks of wellness tourism, health tourism...) "There are over 3,371 hospitals and around 750,000 registered medical practitioners," says Maheshwari.

Shetty says it is easier to get loans these days. "Earlier, it was difficult for us to mobilize huge financial support to create large hospitals. However, things have changed now," he explains. Indian companies are also taking over hospital chains in Asia -- Fortis has gone on a shopping spree, though it’s not been entirely successful -- and setting up front-ends in other countries for marketing purposes. Apollo has facilitation centers in Oman, Nigeria and the U.S. Max is present in Nigeria, Afghanistan, Bangladesh and Nepal. Says Reddy of Apollo: "There are several key players. Apollo Hospitals continues to attract the largest numbers of international patients followed by Max, Fortis and Workhardt."

"Another opportunity that Indian operators are now seeing is that you don’t have to offer these health care services from India," says Abraham of ISB. "For instance you can offer it from say, Cayman Islands or the Bahamas. Ultimately, the innovation is in the process and as long as you can bring the same process innovation, even if the cost goes up a little as compared to offering it from India, it will still be a substantial saving for the patient."

This is one area where China is no threat. Foreigners in China still rush to Hong Kong when they need treatment because they cannot communicate with local doctors.

But what the budding sector will have to contend with is the Indian government. Take one example. With the intention of making things smoother, the government introduced a medical visa (M visa), which was faster and easier to get. In its wisdom, however, it added a peculiar clause -- "Foreigners coming on M visa will be required to get themselves registered mandatorily well within the period of 14 days of arrival with the concerned Foreigners Regional Registration Office." The end result: even patients who have to be carried into India on stretchers are coming on tourist visas. If the government wants medical tourism to be the next big thing, it has to put its house in order.

As for the immediate controversies, Shetty is very clear. "President Obama’s statement or the New Delhi superbug will not affect medical tourism development in India," he says. "First of all, he was not criticizing India. He was just trying to put his house in order."

India's Corporations Race to Train Workers and Avoid Being Left in the Dust

Infosys Technologies, the icon of the Indian IT industry, has one of the largest corporate training establishments in the world, with more than 320 computer science faculty. At its sprawling 335-acre campus in Mysore, Infosys can train more than 13,500 people at once.

"We have invested over $450 million in our training institute," says T.V. Mohandas Pai, director, and head of education and research and human resource development at Infosys."This is probably the largest investment in education in India's history by any entity, be it government or nongovernment, in a single location." Additionally, Pai notes, Infosys spends about $5,000 training every fresh graduate that it recruits. These new recruits undergo 14 to 16 weeks of training before they start their jobs. This year, Infosys will recruit around 18,000 fresh graduates.

Another Indian IT giant, Wipro Technologies, hires around 14,000 fresh graduates a year and takes them through a training program of 12 to 14 weeks. Wipro spends about 1% of its revenue on training these recruits."This is only the running cost," says Pratik Kumar, Wipro's executive vice president of human resources."It does not include our capex cost."

Practically every major IT company in India spends weeks training its fresh recruits. But it isn't something they do by choice. Even those recruits from some of the best engineering colleges are simply not job-ready. Wipro's Kumar points out that if these fresh graduates were"completely deployable in terms of their technical proficiency," they would need in-house training of only a week or 10 days."The huge training infrastructures that companies have set up are a reflection of the inefficiencies of our educational sector," he says.

The National Association of Software and Services Companies (Nasscom) points out that while more than three million students graduate from Indian colleges and the nation produces 500,000 engineers annually, only a very small percentage are directly employable by industry. Says Nasscom vice president Rajdeep Sahrawat:"Only around 25% of technical graduates and 10% to 15% of general graduates are estimated to be suitable for employment in the offshore IT and business process outsourcing industries."

An Industry-Academia Disconnect
The reasons are many. The nation's education sector is highly government-controlled and therefore subject to a multitude of regulations around such matters as curriculum development and pay scales. The quality of faculty and the teaching methodology are largely inadequate. A focus on soft skills -- those personal and interpersonal attributes of everyday interaction -- is lacking. There is a disconnect between industry and academia. The list goes on.

"As a nation we have underinvested in education and employability," says S. Sadagopan, director of the International Institute of Information Technology, in Bangalore. N.R. Narayana Murthy, chairman and chief mentor at Infosys, agrees:"All the stakeholders -- the government, academia, industry and society -- are responsible for the current state of affairs." He adds a somber note:"If we don't take steps to improve the quality of our engineering graduates, we will soon lose out on our ability to compete globally."

The employability issue is not restricted to the IT industry. Even as India celebrates its strong economic growth and touts its demographic strengths, concern is rising over the suitability of its large workforce for the many new jobs that will be available, especially across high-growth industries such as retail, financial services, telecom and aviation.

Sanjeev Duggal, chief executive officer and executive director of Bharti Resources, a subsidiary of Bharti Enterprises, one of India's leading conglomerates, explains:"The employability issue in India is getting impacted by two different [problems]. One, most of the growth is happening in new sectors which require new skills. So not only do fresh recruits need to gain these skills, but even those already employed need to be reskilled; otherwise they will no longer be employable. Second, a lot of growth is happening in smaller towns and cities, and so there is a need to make the training of these skills available locally."

A social factor also comes into play. By and large, the Indian mind-set is oriented toward acquiring a formal university degree and not necessarily acquiring skills for greater employability. Says Rajen Padukone, president of university programs at Manipal University:"The professional skills and vocational programs need to be linked to a university degree, corporate funding and job placements to make them more acceptable to Indian youth."

Entry-Level Skill Gaps
The employability problem persists beyond the graduate level. B. Santhanam, chairman of the Confederation of Indian Industries' national committee on skills and human resources, points out that a 2006 CII study covering 36 sectors estimated that 80 million new jobs could be created in the next 10 years across India, of which 75% will require vocational skills."These 80 million jobs are going to be created if the growth rate that various companies and industries are assuming actually happens," he said."However, in sector after sector we find that there are tremendous knowledge and skill gaps at all levels of jobs. The employability issue does not concern only graduates; it is even more significant at the grassroots entry level, where we need a large amount of vocational skills."

According to the government's 2007-08 economic survey, 68.4% of the population will be of working age -- 15 to 64 -- in 2026, up from 62.9% in 2006. The survey notes that"for actual tapping of the demographic dividend, it is necessary not only to ensure proper health care, but also [to put] a major emphasis on skill development." The survey warns that"if skills are not adequately created, India could well be facing a demographic nightmare."

The primary responsibility clearly rests with the government and academia. However, the growing realization that industry can harness India's demographic dividend only through the availability of the right training and skill sets is driving corporate India to play a larger role in molding the workforce.

Across sectors, companies and industry bodies are not only beefing up their in-house training facilities, but also developing initiatives to make potential employees job-ready even before they enter the organization. These include tie-ups with educational and training institutes, helping them design the curriculum, training faculty in both relevant content and teaching methodologies, offering internships, and setting up their own training schools and finishing institutes.

Wipro, for instance, has identified poor teaching quality as one of the core reasons for the low employability of engineering graduates. To address this, under an initiative called Mission 10x launched in September 2007, the company has developed a set of teaching techniques to enable faculty members to help students take in higher levels of understanding of classroom subjects while developing key behavioral skills as well.

Under Mission 10x, Wipro plans to train more than 10,000 faculty members in 1,500 engineering colleges over the next three years. The training, for which Wipro bears the entire cost, is spread over five days. Says Azim Premji, chairman and managing director of Wipro:"The quality of education being imparted requires fundamental change. We need to bring about a systemic change in the current teaching-learning paradigm in engineering education."

Training the Faculty
Nasscom's key focus, too, is on upgrading faculty. It estimates that 12,000 to 14,000 faculty members need to be trained in the next three years to increase the employability of students recruited by the IT industry. The group is putting together a plan to work with the government and industry to address the issue, Nasscom's Sahrawat says."It is a very manageable and doable proposition. What it requires is willpower and program management."

Meanwhile, in a move to expand the pool of industry-ready resources for the banking and insurance sector, which is expected to create a million jobs a year for the next five years, leading players are offering industry-specific courses. ICICI Bank, India's largest private-sector bank, for instance, has joined with Manipal University to create the ICICI Manipal Academy of Banking and Insurance to offer a one-year residential diploma program to graduates who are selected through an entrance test. The bank and university have jointly designed the course content.

On completion of this program, which is expected to result in"first-day, first-hour productivity," the candidates will be absorbed in a managerial position in ICICI Bank, which is picking up the entire training tab of Rs 2.5 lakh ($5,425) per student."To fulfill India's global aspirations and sustain the growth trajectory, it is imperative that industry invests in preparing industry-ready human talent," K.V. Kamath, managing director and chief executive officer of ICICI Bank, said in a news release.

R. Bhaskaran, chief executive officer of the Indian Institute of Banking and Finance (IIBF), points out that the need for industry-ready professionals is becoming increasingly important not only because of the sheer numbers required but also because of changes in the banking industry in recent years.

"There has been a paradigm shift within the banking industry," he said."We used to wait for customers to come to us, but now we have to go out and sell. This has also resulted in many specializations within the bank. While in the past anyone could manage any function, we now need specialists." In keeping with this requirement, over the past few years IIBF has introduced diploma courses in such areas as treasury, international banking and microfinance to both fresh graduates and banking professionals looking to enhance their employability.

Modern Retail's Skill Sets
Retail is yet another area undergoing rapid transformation. Organized retail accounts for only 3% of India's retail sector, but that is expected to increase to 20% by 2010. This is expected to result in demand for 2.2 million new jobs. Retail majors including Reliance Retail, the Future Group, Bharti Retail and Shopper's Stop, as well as the Retailers Association of India, have tied up with various universities and training schools to provide course content and internships to students.

Says Biju Kurien, president and chief executive, lifestyle, for Reliance Retail:"Traditionally, retail in India has been in the unorganized sector comprised largely of small owner-driven stores. Modern retail requires very different skill sets, both because of the different nature and size of operations and increasing customer expectations." Kurien says Reliance is likely to employ around a million people for its retail operations over the next five years and is looking to set up its own university for retail education.

Meanwhile, the Bharti Group has created its own training and development company called Bharti Resources, which has set up a Bharti academy of retail in conjunction with the group's retail arm and is creating an academy for insurance in alliance with the group's insurance business. Bharti Resources has also set up 60 learning centers across the country to offer courses in insurance, telecom and retail. The target is to take this number to 100 by the end of this financial year and at least 1,000 in the next three years. Says Duggal of Bharti Resources:"With a lot of growth happening in smaller towns and cities, it is very important to have a huge distribution reach of the training of these skills."

Along with training where people are located, another challenge is the need for short-duration vocational courses for those who have not completed their formal education. To address the issue on a wide scale, CII is helping the government roll out a"modular employable skills" program. It is putting together the curriculum and identifying a set of assessors and the institutes that can carry out this training for different sectors."Our target at CII is to train at least 50,000 people through this program in the current year," CII's Santhanam says.

Upgrading the ITIs
CII is also working closely with the government and large companies in a public-private partnership model to upgrade the government-owned Industrial Training Institutes (ITIs) and align them more closely with the needs of industry. Companies that have adopted ITIs include Bosch, Hero Honda, Ashok Leyland, Larsen & Toubro, and Bharat Heavy Electricals Ltd.

Another key initiative of CII has been to help universities to understand the importance of soft skills and to integrate related courses into the university curriculum. While Madras University has made a soft skills course mandatory for all undergraduate and postgraduate students, other universities in the state of Tamil Nadu have included such coursework as part of their choice-based credit system. CII, which developed the curriculum and is also training the trainers for this course, is now looking at extending soft skills training to universities across other states. Companies working actively on this initiative include Tata Consultancy Services, Cognizant Technologies and Satyam Computer Services.

Says CII's Santhanam:"Never have I seen such a confluence of efforts of private companies, industry bodies, government and academia on the one common issue of skill development. If we can grasp this opportunity fully, we can set in motion something that can completely alter the employability landscape of the country."

Not everyone, however, is so optimistic. Manish Sabharwal, chairman of TeamLease Services, India's largest human resource services provider, strikes a note of caution. Skill development, he says, is only one part of the solution."There are three problems in the current Indian system: matching supply and demand, repairing supply for demand, and preparing supply for demand," he says."What we are all focusing on right now in terms of employability with skill development is only the repair part. This is a low-hanging fruit. But this repair pipeline will run dry if the prepare pipeline, by way of education reforms, is not fixed. And that is something that the government and academia need to work on."

Importing Efficiency: Can Lessons from Mumbai's Dabbawalas Help Its Taxi Drivers?

Mumbai has 150,000 licensed taxi drivers. It has 5,000 dabbawalas, organized porters who carry cooked lunches to office workers. The former, along with about 450,000 auto-rickshaw (three-wheeler taxi) drivers, are constantly in the news for reports of bad behavior, overcharging and even violence. The dabbawalas, on the other hand, are icons of efficiency. They have even made it to the Harvard Business Review as a case study.

Taxis are vital to the city, as public buses cannot cope with rider demand. Mumbai’s local trains transport more than 6 million people each day, according to figures provided by the Maharashtra State Road Development Corporation (MSRDC). At the station of embarkation from the local train, many commuters take a share-a-cab (four to a taxi) to reach their final destination. Anthony Quadros, president of the Mumbai Taximen’s Union, estimates that there are 1.2 million regular taxi users in Mumbai. In this city, nothing is certain but death and taxis.

The dabbawalas don’t have an equivalent in other cities. The 100-year-old organization takes cooked food from people’s homes and supply centers (which could be a housewife-turned-home entrepreneur) and delivers the meals to offices. In this realm, a mistake carries stiff consequences, particularly because religion dictates which foods many people can or can't eat. But the dabbawalas are very close to a no-mistake regime and they have built a great deal of trust.

“The dabbawalas even carry forgotten spectacles and mobile phones,” says Pawan Agrawal, CEO of the Mumbai Dabbawala Education Centre, an offshoot of the Dabbawala Association. “Sometimes, customers even send home their salary with the empty tiffin box. That’s customer service.” Agrawal, who is a spokesperson for the dabbawalas and has done a study on the group's logistics and supply chain management efforts, says that the number of customers in Mumbai has crossed 200,000.

On a superficial level, the two cohorts seem to have a lot in common. Both come from marginalized and oppressed socio-economic groups. Their average education is up to the eighth grade. They belong to a low-skill, working class category and service the city’s middle class. Why, then, are the two groups' reputations so radically distinct?

“The difference stems from the difference in their cultural backgrounds,” says Ramesh Kamble, a professor of sociology at Mumbai University. In India, there are still some professions that are dominated by certain communities. In many Indian cities -- Delhi and Kolkata, for instance -- taxis are run by owner-operators and there traditionally was a preponderance of turbaned Sikhs from Punjab. Today, particularly in Mumbai where the people tend to be a shade more entrepreneurial and adventurous, many of those drivers have moved away, some to the U.S. and Canada.

In Mumbai, most of the taxi drivers are now migrants from the north Indian states of Bihar and Uttar Pradesh (UP). This springs into public consciousness every time the parochial political parties in the state start a “Maharashtra for Maharashtrians” campaign. The first target of the agitating mobs is often the taxi driver. The dabbawallas, on the other hand, belong. According to Agrawal, all but six of the 5,000 dabbawalas come from a particular community of Maharashtrians.

“North India is extremely feudal, with a hierarchical and patriarchal culture. Reclaiming that culture becomes necessary to find space in that group at the place of migration,” says Kamble. “However, in Maharashtra, since the 1920s we have had various kinds of movements, such as the textile workers’ movement, the Dalit [low caste] movement and the feminist movement. The dabbawalas are also deeply influenced by the Bhakti [devotion] movement. Their efficiency is not entirely a management marvel; it is rooted in their cultural values. The same work ethic exists among porters at Mumbai’s railway stations because these working classes have similar cultural contexts.”

But not all seem to agree with the cultural hypothesis. Stefan H. Thomke, a professor of business administration at Harvard Business School and author of a case study titled, "The Dabbawala System: On Time Delivery, Every Time," believes that while the fact that new members are recruited from 30 villages in and around Pune contributes to the organization’s performance, there are many other critical factors that reinforce each other and must be considered. “Most importantly, the dabbawala’s performance can only be understood if we study the entire system -- their culture, management, organization and processes -- and how these factors interact with each other,” Thomke notes. “You cannot copy one single factor ... and hope to replicate performance without regard to others.”

The dabbawalas themselves say that the charge of being a non-inclusive organization is misplaced. Most people believe that you need to belong to the Warkari Sampraday (loosely translated as the Pilgrim Group) to be a dabbawala. Not true, according to Agrawal. The only recruitment criterion is a “guarantee” -- essentially, a verbal assurance of the candidate’s character -- by an existing member. “Most people tend to refer their friends or family members who belong to the same community. It has just worked out like that.”

Advantages of Community
But Agrawal says having employees from the same community has several benefits. “Our values, inclinations and psychology are similar. So there is better understanding and teamwork," he notes. "It doesn’t require talent; it’s just common sense. We wouldn’t be Six-Sigma certified without that coordination. In fact, since we began with one customer and one dabba [lunchbox] in 1890, this has become almost like a family business.”

Quadros of the taxi drivers' union says the one-community culture makes it easier for leaders to manage and retain their employees. “We don’t have that kind of control over our taxi drivers. It’s very difficult, especially with the newer generation.... They drive taxis for about five to 10 years, earn what they can and then do something else. They have no interest in the taxi trade or helping to improve it. The dabbawalas are not migrants; that helps.”

But Varsha Ayyar, an assistant professor in the School of Management and Labor Studies at the Tata Institute of Social Sciences (TISS), notes that even migrant groups have a sense of community. There is also a tendency to join the same profession when they come into a city. Working with others from the same village gives migrants a sense of security when they first arrive. They help to get them a job; a construction worker would be most cognizant of vacancies in his field, for example. And they act as informal mentors, particularly when the newcomer is a relative. In Mumbai, there is a large area known as Sonar Bangla in which illegal Bangladeshis have settled. They number several hundred thousand and tend to stick together.

Migration doesn’t explain everything, continues Ayyar. “The difference is that dabbawalas have more of a sense of autonomy and accountability. The system itself demands that,” she says. “Taxi drivers [in Mumbai] are often not owners of the taxis; there is no sense of ownership and they have to make a minimum amount of money each day, even if it means tampering with the meter.” According to Quadros, taxi drivers are vulnerable. If a driver parks illegally, or merely in the wrong spot, to drop off or pick up a passenger, he often has to bribe the police if caught. Regular extortion for real or imagined transgressions means that drivers must earn more than what is registered on the meter. Fights with passengers, who often know what the exact fare should be, are inevitable. And this adds to the atmosphere of acrimony.

Sense of Social Coherence
But Bino Paul GD, an associate professor at the TISS School of Management and Labor Studies, attributes part of the culture of the dabbawalas to their tremendous sense of social coherence with the city -- they live with their families, eat home-cooked meals and lead respectable lives. “Those factors are more important than community. Taxi drivers have none of these advantages. That seriously affects their morale,” says Paul. Taxi drivers often live in slums with 10 or 15 people to a room. Working conditions are tough -- as mentioned earlier, among the toughest in the world. They don’t have parking space or restrooms. “A lot of them belong to religious minorities,” notes Paul. “They lead anonymous, invisible lives compared to the dabbawalas.”

Then why become a taxi driver at all? That’s a question that could be asked in any large city. “Reservation wage,” says Paul, using a theory from labor economics. “That is the market wage below which people won’t enter the labor force. The reservation wage of Maharashtrians is much higher than that of taxi drivers. Also, there are push and pull factors that facilitate migration. Poverty is a major push factor.”

It’s a tough life. Taxi drivers work 12 to 16 hours a day, seven days a week. They make around US$60 to US$100 a month. Dabbawalas work nine hours a day, six days a week and make US$160 to $US180 a month. They supplement that income by US$80 to US$100 per month doing other jobs, such as delivering newspapers or milk. Some are also part-time taxi drivers. “For [dabbawalas], work is worship,” Agrawal says, citing the group’s credo, “We believe that by serving food, we are serving God. We don’t work for money.”

For the taxi driver, money is a key frustration. “[If a driver doesn’t get enough fares], he gets angry,” Quadros notes, adding that the formula for calculating taxi fares has not been revised by the government since 1996.The taxi drivers’ job, by its very nature, means moving from place to place. Toward the end of a shift, the driver has to maneuver to get back where he started from. In Mumbai, taxis are on the roads 24 hours a day, with one driver replacing the other when his duty is over. The dabbawala on the other hand has a fixed route; his schedule is as regular as a newspaper carrier's. He can tell you where he will be at any given time. The regularity makes for discipline, experts say.

But what about the sheer numbers of taxi drivers as compared with the dabbawalas? Does this have anything to do with their group behavior? Paul of TISS does not think so. “That there are so many more taxi drivers than dabbawalas is not relevant to how well they are able to enforce discipline. When it comes to property rights in terms of ownership or control over vehicles, power lies in a few hands. There are a few [people] that regulate the whole activity, a collective of some interest.”

According to Paul, whether it is taxi drivers or dabbawalas, power structures exist within both organizations. The only difference, he points out, is that dabbawalas have a more formal power structure that is known to everybody. In the case of taxi drivers, there are multi-stakeholder informal power structures.

Is there anything that the taxi drivers can learn from the dabbawalas? Harvard's Thomke views the groups' divergent behavior as a nature vs. nurture battle. “I believe that nature is one input, among many inputs, but it is the nurture -- or the system -- that explains excellent service performance." While he is unfamiliar with the Mumbai taxi trade, Thomke suggests a thought experiment: if the dabbawalas were to run the taxi system, what would they change?

Agrawal says that the taxi drivers' basic organizational structure should be reconsidered. The dabbawalas have several hundred group leaders that are the core of the organization. Each heads groups of 10 to 25 members and is responsible for all their activities. “How can one leader control and be responsible for thousands of drivers?” asks Agrawal. “They should make groups of 20 to 30 drivers reporting to a leader who can properly manage them and inculcate values of honesty and efficiency.”

But Quadros doesn’t think that approach will work. “It is difficult to imbibe the best practices of the dabbawalas,” he says. “Even if I hold a meeting, very few people will show up.”

Diabetes Unravelled

By Aarti Narang

This isn’t someone else’s problem: India has 41 million diabetics. It could rise to 70 million by 2025.

If you have diabetes, the problem is basically this: you have too much glucose in your blood. Glucose is our main source of energy, derived from eating carbohydrates, and is absorbed into our cells with the help of the hormone insulin. If our body has a problem with insulin, the glucose isn’t absorbed.

There’s a range of reasons for this. In some people, their pancreas fails to produce insulin. That’s Type 1. A small number of people become diabetic when their pancreas is destroyed, for example in an accident or during surgery. But for most people with diabetes, the body has problems processing the insulin the pancreas does produce: Type 2.

Actually, within the term “diabetes,” doctors are discovering dozens and dozens of conditions. “The lines are getting fuzzy,” says Dr Sreemukesh Dutta of the Hyderabad-based Research Society for the Study of Diabetes in India, “Earlier, only Type 1 diabetes was insulin-dependent but in the past decade Type 2 diabetes has become insulin-dependent too.”

Adds Dr Greg Fulcher, an Australian expert, “As we learn more, we can identify the conditions more accurately; for example if they’re caused by different genetic abnormalities.

We even talk about a Type 11⁄2, which has elements of Type 1 and Type 2. One day they may become categorized by the underlying abnormalities rather than just being bundled under one issue.”

But for now the big headache for health authorities is Type 2.

That’s where a complicated metabolic process means not enough insulin is produced, or the insulin that is produced doesn’t work effectively.

Type 2 comprises 70 to 80% of total diabetes cases in India, and its incidence is increasing rapidly—so much so that India is often described as the “Diabetes Capital of the World.”

Linked to obesity, the most worrying trend is that it’s being diagnosed in younger and younger Indians. Previously, the onset of diabetes was generally among those above 35. Since the past decade, Type 1 is getting to be increasingly seen among children, while youngsters even in their 20s are developing Type 2. That’s a major problem, since the longer you live with diabetes, the more likely you are to develop complications.

Living with Type 2

When 43-year-old Mumbai businessman Mark Lewis was detected with diabetes in June last year, it came as no surprise. He had already lost his father to complications from diabetes, and at 103 kilos, he too was a potential target for the killer disease. “It was only when I mentioned to my sister that I was forever thirsty and she suggested I get myself tested that we suspected diabetes,” says Lewis.

People most at risk are those that have the classic “apple” physique.

Carrying more fat around the abdominal organs makes insulin less efficient at controlling glucose levels. Routine blood tests in GPs’ clinics pick up most cases, as more often than not the patients have no idea they have diabetes.

When the doctor charted out a plan to control his diabetes, Lewis was determined to follow it diligently.

He was immediately put on medication and followed a 1400-calories-a-day diet set for him. When asked to exercise, Lewis alternated between walking, lifting weights and yoga. By May this year, Lewis had lost 20 kilos. As his blood sugar levels fell, he was weaned off medication. Today, Lewis is keeping his glucose levels in check through the diet and exercise regimen.

People with Type 2 diabetes don’t necessarily need to follow a special diet, but if they are overweight—which over 70% of people with Type 2 are—then it’s important they lose weight.

“Weight loss helps in controlling diabetes and preventing its onset,” says Dr B.M. Makkar, senior diabetologist and obesity specialist at the New Delhi-based Diabetes and Obesity Centre. According to Dr Makkar, a mere 7% weight loss can reduce the risk of diabetes by 58%. In fact you don’t even have to achieve your ideal body weight for it to make a discernible difference.

Most people may think it’s hard to follow a weight-loss diet and exercise regime. But people with diabetes ignore the risks at their peril: all diabetes is serious, and can lead to devastating complications that are usually irreversible and often fatal. Too much sugar in your blood damages the vascular system and organs. That means people with diabetes are much more prone to cardiovascular disease, and are three times more likely than most people to have high cholesterol, high blood pressure or obesity. Many people with diabetes end up dying as a result of a heart attack or stroke.

Blood glucose can also damage the small blood vessels, which causes problems in the eyes (a quarter of patients develop retinopathy, which can lead to blindness), kidneys, feet and nerves. That means that if the diabetes isn’t well controlled, people are looking at kidney failure or lower limb damage requiring amputation.

Exercising and losing weight can reduce the risk of all of these complications, but what many people don’t realize is that their diabetes is a progressive disease. “Only about 10% of patients are able to maintain normal glucose levels with lifestyle modifications, and that too only up to one or two years,” says Dr Makkar. “Most patients will eventually require lifelong medication, not only to control their diabetes but to prevent complications as well.”    

Type 1 Explained

The threat of serious complications weighs heavily on the mind of anyone with diabetes. But it’s particularly tragic when the diabetic is a child.

Childhood is usually when Type 1 diabetes is diagnosed. In Type 1, the body’s own immune system attacks the beta cells in the pancreas that produce insulin. It’s responsible for a majority of diabetes cases.

Type 1 diabetes cannot be prevented. Patients usually have a genetic predisposition but their disease is triggered by something in the environment, such as a virus. Traditionally called “juvenile onset diabetes,” Type 1 can strike at any age. What doctors don’t understand is why it’s increasing. Research is pointing the finger at milk or certain fats inducing diabetes in people with a genetic predisposition, but at the moment these are just theories.

Usually the descent into diabetes is swift and shocking. That’s what happened to schoolgirl Kyra Shroff, diagnosed four years ago at age 12.

Kyra appeared gaunt and would wake up several times in the night to go to the bathroom. Clinical tests revealed her blood sugar count to be 695 mg/dl (the normal fasting blood glucose level is about 100 mg/dl and post lunch blood glucose level is 140).

A controlled diet, constant monitoring of blood glucose levels and insulin injections every few hours brought Kyra’s condition under control. In fact she’s in top form: Kyra recently won the national junior tennis title, and two silvers at last month’s Commonwealth Youth Games in Pune. Unlike Type 2 diabetes, Type 1 is all about controlling the blood—by adjusting the insulin depending on how much carbohydrate is consumed.

People with this disease used to monitor their carbohydrate intake carefully around regular insulin shots. These days, patients are more likely to follow the DAFNE (Dose Adjustment for Normal Eating) plan—they eat anything, as long as it’s healthy, and adjust their insulin intake accordingly.

Though it requires great diligence, Dr Vishal Chopra, diabetes specialist at Dr L.H. Hiranandani Hospital, Mumbai, maintains “DAFNE can be practised if the patient goes to a specialist at an early stage, when the diabetes is easier to control. Unfortunately, most people first go to a GP who may refer them to a specialist only when complications develop.”

The big problem with Type 1 is it’s impossible to accurately supply insulin all the time. If the amounts are wrong, it can be life-threatening: too much insulin will cut sugar levels leading to hypoglycaemia; too little insulin to hyperglycaemia, while a build-up of organic compounds known as ketones in the blood can lead to a ketoacidotic coma.

“We understand the patient’s insulin requirement after two meetings. We determine the requirement after taking pre- and post-meal readings, and monitoring exercise levels, duration and intensity,” says Dr Chopra. “We give them a scale to follow and then it’s not hard to lead a normal life.”

And that’s just what Kyra Shroff is doing. She injects herself with insulin four times a day, after each meal, and keeps a tab on her blood count thrice. Though she cannot take sugar-rich energy boosters as other tennis players do, Kyra continues to train and travel all over for tournaments and manages her school assignments as well. “I’ve learnt that diabetes isn’t an illness,” she says. “It’s just a different way of life that you work around, and it’s no excuse to stop doing other things.”

Adds Firdaus Shroff, her proud father: “Kyra has helped us change our lifestyle too—we now eat healthy and avoid being sedentary.”

Diabetes in Pregnancy
There’s one more cause of diabetes: pregnancy. It’s called gestational diabetes, and the rate is increasing fast—up eight-fold in the last two decades.

The increase might be because women are having babies when they’re older, or because obesity, a risk factor for diabetes, is increasing. The extra stress of pregnancy on the body can cause high glucose levels, but often pregnancy highlights a woman’s predisposition for diabetes: up to 50% of women develop Type 2 within five years of having the baby, not because of the gestational diabetes, but because they were on course to get the disease anyway.

Women with a predisposition to diabetes are at particular risk while they’re pregnant because their energy needs increase, plus hormones pro-duced by the placenta can block the action of the mother’s insulin, causing insulin resistance. These factors mean insulin needs in pregnancy are two or three times greater than normal from about 24 weeks. Up to 16% of women develop gestational diabetes and it’s usually picked up with a routine glucose tolerance test between 24 and 28 weeks of pregnancy.

Alafiya Firoz, 29, a Chennai housewife, is 11 weeks pregnant and has been diagnosed with gestational diabetes. She isn’t surprised—she was diabetic during her previous pregnancy four years ago too. “The diabetes was then diagnosed in the 36th week of my pregnancy. Only one of my grandmothers was diabetic, so I wasn’t really expecting it,” Alafiya says. Immediately, Alafiya started taking a dose of insulin and walking for 30 minutes everyday. She cut sugars from her diet completely and brought her glucose levels under control within a month.

It wasn’t easy, but she had a big incentive: she learnt that babies of women with gestational diabetes could have problems, too. The mother’s glucose crosses the placenta to the baby’s bloodstream, prompting its pancreas to produce more insulin. That can result in larger babies, putting them at risk during delivery. They are also more prone to developing Type 2 later in life.

Women with gestational diabetes have to juggle their insulin resistance with eating a healthy diet for the baby. They are allowed to eat carbohydrates, but are advised to space out their intake: “If the patient is used to eating, say, two chapattis every morning, then we ask them to have one at 9am and the other at 11. This helps keep the sugar levels down,” says Dr V. Balaji, senior consultant diabetologist at Chennai’s Apollo Hospital.

It was a good-news story for Alafiya. Soon after she delivered her first baby, her blood sugar levels were found to be in the normal range: she was no longer diabetic. Doctors warned her that the diabetes could return if she became pregnant again. It has, but Alafiya isn’t too worried. “I’ve kept my weight in check and am restricting my diet,” she says. “I am determined to get rid of the diabetes this time too.”

In fact, many of the health messages that become so important for people with diabetes have relevance for us all. Regular physical activity, a healthy eating plan and keeping an optimum weight are the keys to living healthily with diabetes—and to preventing it in the first place.

THE DIABETES EPIDEMIC
• It’s the fastest-growing disease in the world, with 230 million people already affected.
• Diabetes is the world’s leading cause of heart disease, stroke, blindness, kidney disease and lower limb amputation.
• The incidence of diabetes is five times higher among Asians than it is in white populations.
• By 2025, every fifth diabetic in the world would be an Indian.

CAN DIABETES BE CURED?
A CONCERTED EFFORT IS UNDER WAY TO FIND A CURE FOR TYPE 1 DIABETES. “It’s looking exceedingly promising,” says Australian expert Dr Gary Deed, who predicts it may happen in 10-15 years.

Meanwhile the emphasis is on halting the disease in newly diagnosed cases. Doctors are trying to modulate the immune system so it doesn’t progress to the ultimate destruction of the pancreas.

The other tack is to try to recreate the body’s ability to manufacture insulin, for example by transplanting the pancreas or insulin-producing cells. Stem cell research is also offering hope that these cells may be created in the lab.

As for Type 2, public health messages promoting weight loss and exercise seem to be the best way of stopping the disease in its tracks. International studies have shown that weight loss of just 5-7% and exercising for 30 minutes five times a week lowers the risk of developing diabetes by a massive 60%.

“It may take ten years before Type 2 diabetes stops increasing every year in populations. Then we will see numbers begin to decrease,” predicts Professor Jaakko Tuomilehto, an international authority on diabetes.

THE WARNING SIGNS
Here’s what should ring alarm bells:

TYPE 1
Extreme thirst • Frequent urination
Constant hunger • Blurred vision
Sudden weight loss • Nausea
Vomiting • Infections
Extreme tiredness


TYPE 2
Excessive thirst • Frequent urination
Feeling tired and lethargic
Slow-healing wounds
Itching and skin infections
Blurred vision • Mood swings

GESTATIONAL
Pregnant and over 30 years of age
Family history of Type 2 diabetes

Overweight
Certain ethnic groups including Indian, Vietnamese, Chinese, Middle Eastern, Polynesian/Melanesian, indigenous Australians
Gestational diabetes in previous pregnancy
Previous problems carrying a pregnancy to term

COMMON MYTHS

Myth 1: Sugar causes diabetes.
Wrong. Type 1 diabetes is thought to be caused by genetic factors combined with environmental triggers. Type 2 diabetes is caused by a combination of genetic and lifestyle factors. People with diabetes do need to limit foods that are concentrated sources of sugars, but they can eat small amounts of sugar.


Myth 2: People with diabetes can’t eat chocolates or sweets.
Small quantities of chocolates and sweets are occasionally OK as part of a healthy eating and physical activity plan.


Myth 3: People with diabetes have to eat special foods.
Like everyone, people with diabetes have to eat healthily. That means a diet low in saturated fat and high in fibre and whole-grain foods.


Myth 4: You can catch diabetes.
Diabetes is not contagious.


Myth 5: People can have a “touch of diabetes.”
You can’t have mild or borderline diabetes. All diabetes is serious and, if not managed properly, can lead to serious complications.

The India You Don’t Know

By M H Ahssan

Travellers in India usually have their itinerary all mapped out—it’s generally the tried and tested routes. The Golden Triangle (Delhi-Agra-Jaipur) or Goa. And since unstable Kashmir is out, Kerala is in. That is an Indian holiday in a nutshell. There are a few who do special interest tours.

Lakshadweep and Andamans for the diving, Kipling Country for jungle safaris, the Buddhist pilgrim trail, the heritage train rides. But beyond these busy pockets, there is a vast treasure trove of secret places.

Talk to any Indian about a favourite childhood memory and he or she will wax poetic about their “native place.” Ponds they used to swim in, fruit eaten straight off the tree, family feasts, temple festivals. They may also speak of memorable holidays to special destinations, often very close to home but still unexplored, preserved as if in amber. Here are seven spots off the tourist map but well worth seeking out.

Lucknow, Uttar PradeshFor Mumbai-based model Ashutosh Singh, Lucknow is home. “Whenever I return, it’s as if I’ve never been away. There is an old world courtesy unique to my town.” He says that the frantic development that characterizes other Indian towns hasn’t altered Lucknow’s essential structure. The Old City still preserves the fading glories of this capital of the Nawabs of Awadh.

Towering gates, domes and arches define the cityscape. Even the Charbagh railway station looks like something out of the Arabian Nights. There are also charming havelis with intimate courtyards and interconnected rooms, just like the one where Ashutosh’s own family still stays. In the evenings people would stroll out unhurriedly to socialize over Lucknow’s famous chaat, sweets or paan.

Many of Lucknow’s iconic landmarks have made their presence felt in films like Umrao Jaan and Shatranj ke Khilari:

The Bara and Chota Imambaras, Rumi Darwaza, the labyrinthine Bhool Bhulaiyaa, Chattar Manzil and Jama Masjid. The Bara Imambara complex, which also houses the famous maze, is essentially a Shia Muslim shrine. This grand project was undertaken by 18th-century Nawab Asaf ud Daula to generate employment during a time of famine. While the common people worked during the day, the equally impoverished but unskilled nobility were secretly hired to destroy what was constructed during the night, so that the task would continue till the crisis was over. He was the general architect of much of what we see today. “The magnificent Lucknow University buildings are an architectural marvel, with a vast campus,” says Ashutosh, “I’m proud to have studied there.”

Delhi-based writer and filmmaker Vandana Natu Ghana fell in love with Lucknow while she was a student there. She recommends the old markets of Chowk and Aminabad for delicate shadow embroidery (chikan), rich zardozi and badla work in silver and gold threads. This bustling area also houses the legendary Tunde ke Kebab shop, over a century old. “You can base yourself in Lucknow and do some fascinating day trips out of the city. Barabanki, with its ancient Mahabharat connections, and Malihabad, famous for its mango orchards, are redolent of a bygone era and only 25 kilometres away from the city centre,” she suggests.

There is also the village of Kakori, which has given its name to silken smooth kebabs, created to indulge a toothless nawab. Lucknow is also very much a gourmet destination. Vandana, who has an Army background, advises that I not miss the British Residency, said to be haunted by ghosts of the 1857 Mutiny and siege, and the long drive through the cantonment area to the War Memorial, fringed by laburnum and gulmohar trees. “In summer, the road becomes a carpet of red and yellow flowers. People tend to visit Delhi, Agra and Varanasi and bypass Lucknow altogether. They don’t realize what they’re missing,” she sighs.

Kasauli and other cantonment townsI have always liked cantonments. They stave off rampant development, preserve heritage structures and are often in beautiful locations. If you’re interested in old churches, military graveyards and history, you will definitely have a sense of stepping back in time.

Married to officers of the Indian Army’s Gurkha Regiment, Naji Sudarshan and Daphne Chauhan live in Delhi, but have had homes in cantonment towns all over the country. “It is a world all its own,” says Naji. “We are a stone’s throw away from chaotic towns and crowded metros, but the instant you enter Army territory, everything is disciplined and beautifully maintained.” A cantonment town is a time machine. And still properly British. You need a dinner jacket to dine at clubs where the menus have been the same for generations. Gardeners maintain seasonal flowerbeds with military precision and since wooded areas are protected, you find an astounding variety of birdlife.

Self-contained cantonment towns like Ranikhet, Lansdowne and Deolali have a quaint character all their own. Foreigners are not permitted to visit Chakrata in Uttarakhand, which is a restricted access area while Mhow, near Indore, is actually an acronym for Military Headquarters of War. There are artillery and combat schools, sanatoriums, military colleges and regimental headquarters scattered through all of these.

Army families keep getting posted to far-flung stations, but everything remains reassuringly familiar within the cantonment. “So while you get to discover a different place every time you are transferred, the set-up never really changes. Cocooned within the Army, you couldn’t be more secure,” adds Naji.

Kasauli in Himachal Pradesh is one of Naji’s favourites, a flower basket of a hill station with its typical upper and lower mall roads, a delightful bazaar and Victorian cottages with roses around the door. It is also across the hill from Subathu, where the Gurkha regiment has its headquarters. Daphne returned recently to Wellington, home of the Madras Regimental Centre in the Nilgiri Hills, where they had been posted 20 years ago. “Nothing has changed. It is still the same sleepy town, with perfect weather. Yet it is close enough to the social whirl of Ooty,” says Daphne. “A good place to base yourself for treks and tea gardens. Not many hotels, but there are home stays and farms in Wellington as well as in nearby Coonoor.”

Ashtamudi, KeralaAshtamudi is a sprawling expanse of water, the second largest and deepest wetland ecosystem in Kerala.

Like an octopus, it is eight-armed (ashtamudi literally means eight locks of hair). Vembanad (which includes Kumarakom) is larger and much promoted by Kerala Tourism, but lesser known Ashtamudi has much to offer. All the canals and creeks of these backwaters converge at Neendakara, a hub of the state’s fishing industry.

For Naresh Narendran, a rubber businessman in nearby Kollam (formerly Quilon), Ashtamudi is home territory. “Unlike the other backwaters, you see dense stands of coconut trees, rather than the usual scene of rice paddies,” he says. “There are also sand bars in the estuary which fishermen use. From a distance, it looks like the man is actually walking on water.”

I remember visiting an uncle whose backyard extended to the water’s edge. We could buy karimeen (pearl spot fish) and river mussels straight off the fishing boats. For fresh coconut water or toddy, a man would be immediately despatched up a coconut palm. Much of what we ate was picked from the kitchen garden. Naresh himself is proud of his own “little farm” not far from here, where he experiments with varieties of banana, yam, fruit, and vegetables. This is quintessential, picture-postcard Kerala with palm-fringed lagoons and dense tropical vistas in a hundred shades of green. “You could rent a boat and go around,” suggests Naresh. “But there are commuter ferry services to Alleppey at a fraction of the cost, which will give you much the same views.”

The much-photographed Chinese-style fishing nets of Cochin are seen around Ashtamudi as well. You could use the ferries to visit neighbouring islands, villages and lesser-known towns in and around the backwaters, much as the locals do. There are temples, sacred groves and churches to discover. Water birds like cormorants and herons abound. “I love photographing the backwaters in its many moods. In the monsoon it is quite spectacular,” says Naresh. “A few resorts are coming up here but it is still largely unspoilt.”

Kollam itself is a historic port town worth exploring. The coir and cashew industries made it prosperous but it was well known on ancient trade routes. Marco Polo came here, as did Ibn Battuta, the famed Islamic scholar and traveller. Not far from Kollam town is Thangassery, a little Anglo-Indian enclave that was once settled by both Dutch and Portuguese colonizers. It has a layout reminiscent of towns in Goa, beaches and a stately lighthouse. But the Anglo Indian community which gave it much of its character has largely emigrated.