Interviews

Priya Satalkar: a balance that we need to strike

I met Priya Satalkar at her PhD defense on nanotechnology in Basel. She is born in Mumbai, India, and lives in Zurich, Switzerland. She has studied a lot (3 Masters and now a PhD), also in The Netherlands. But above all, in the context of this research, she already has quite a background in quality of life research. From the slumbs in Mumbai to the impacts of nanotechnology. She looks, with a sharp mind, at the issues from different perspectives. Besides that, Priya is also very open about her own quality of life struggle.

 

Good to see you after the wonderful Basel trip. Thank you so much for letting me be there at your defense. It was very nice to be there.
You know the thing is: I really didn’t feel any different to be honest and I still feel bit in a flux. I started working on the next project but somehow I am still not out of the PhD student mode. So, it seems that I continue working seven days a week. I really don’t have this work life separation and I don’t even work 100% now. I only have a 70% employment but I simply don’t know how to get back in that fixed office hours’ routine. So, I’m bit in a stressful transition in a way. I simply don’t know where do I now fit? Like your colleagues who were before your friends and PhD students are now suddenly distant from you.

Yes?
Your peers don’t know what to do with you.

So, they also have a little bit of, they look at you differently?
Yeah.

But you are still in the same routine?
Yes.

But, you have a different job isn’t it?
Yes. But the thing is: see what happens during the PhD: you really have no time limit because you need to get it done within a certain time that you have money for. So in the last eight months or so, I was practically working seven days a week and that habit becomes a routine. And I have been always terrible at having my weekends free: I could never do that.

I think so, we come back to that one later. There is an enormous list of things that you did
It would be interesting to do a Quality of Life just on my own life: oh, yeah!

Always the last question is a little bit about you personally
Yeah. Reflection.

And then we have a look at that
So what I decided is not to look at my own work or anybody’s work. Because then I knew I would make it into a scientific enquiry and I don’t want to get that way on Quality of Life. So, basically I am going to speak spontaneously from my own experiences and own thoughts.

That’s right, that’s perfect
And we see where it takes us.

I have some major questions; let’s say three or four topics and it depends a bit on how in depth we go but it is also that the Quality of Life interview goes quite spontaneously
Margreet reminded me because I have been interviewing people for about eight years now [laugh].

And now you are being yourself interviewed
Exactly and that’s a bit strange in itself.

So shoot.

 

Can you give a short introduction about yourself? I know you were born in India. You studied in Bangladesh, Italy, Holland, Switzerland. You are living now in Switzerland. Quite recently you got your PhD on nanotechnology. Can you tell a little bit about your life?
Sure. I was born in a middle class family in suburban Mumbai. And like any middle class family in India you were always told that a way to get a better life, a better quality life, is through education. Because if you are smart then the education is your rocket that propels you into a different strata of life, lifestyle as well. Also it improves your financial situation. So, in my family I was that so called smart child and it was very clear then that the focus will be on my education. So, yes, I studied a lot.

I finished my medical education in Mumbai and after my graduation I fortunately had my first work opportunity to work with World Health Organization (WHO) on polio eradication program. Which was interesting because before that I had never seen rural India. So my life, in a way, was an island of Mumbai itself and the whole country looked the same. Those three years took me to north India in rural parts which were far from development compared to Mumbai or any metropolitan city and it was those three years that pushed me to study Public Health in Bangladesh. Because I wanted to see what is it in Bangladesh that they are doing differently that they have better primary healthcare than India?

After Bangladesh, I worked for another three years in India, again in a different context, with HIV and STI (sexually transmitted infections) prevention program. So it required me to work with sex workers, injecting drug users, long distance truck drivers and men having sex with men. Again a population which in many ways is marginalized, stigmatized. So we do have a medically sound public health intervention but I realized in those years that we were not always sensitive to cultural issues that also influence people’s access to health care. That brought me to The Netherlands to study Masters in Medical Anthropology at the University of Amsterdam.

Woow
Then I was almost 30 and there was a pressure now: educated woman, very successful in her profession, so for her good quality of life she should be married and settle down. In between this time, I had actually the next scholarship lined up with Erasmus program which was in three countries in one year. So it was Leuven in Belgium, Nijmegen in The Netherlands and Padova in Italy to do a Masters in Bioethics which was always my interest because when I was studying medicine in India, we were never really discussing medical ethics. That was the least of priority. So when I heard about this program I was like ‘hey, that would be really interesting’ and I was lucky to get a scholarship. So even before I finished my Master in Medical Anthropology in Amsterdam, I had my next program lined up with funding.

Woow
In between this, as I said, it was planned that I would get married and settle in my personal life which eventually I decided not to do and created a scandal back home – at least for a while. So, I found myself back in Europe. It was also time for me to heal my own wounds because suddenly, I was told that I have become selfish, westernized person and it is Amsterdam who basically made me forget the Indian values. Anyway, this Master’s program again gave me space away from that pressure and those social expectations and allowed me to heal and also think about what is really important for me.

After that Masters, I returned to The Netherlands because that’s where I always felt at home. Somehow, I felt that I belong there. I didn’t need to prove to anybody who I was and discuss my choices. So Netherlands was always my first choice to come back to. I had the chance to teach Public Health at Windesheim Honours College in Zwolle. While doing that, my director there, actually she was the one who made me realize that I love teaching and that is great. But with my three Masters, I really can’t have an academic career. So, she encouraged me to take up a Doctoral program saying that ‘with that you would have much more opportunity and we will always be happy to have you back but I think that it is a good time for you to leave: get that degree and come back’.

Then came the question of funding. All my education was always possible if I could get the scholarship. So, I was lucky to get funded program in Switzerland and that’s how I moved from The Netherlands to Switzerland in 2012, September. My PhD was on ethical issues of very early clinical trials of medical nanotechnology. So, all this sounds extremely, in a way esoteric. But for me, what was interesting is that this research project brought together all my previous trainings in one project.

Why?
So it definitely linked with medicine, it linked with anthropology and qualitative research methods, it had strong focus on ethics and it also had impact on public, in general. And that’s what fascinated me the most about this program.

And I know that it wasn’t short but that’s me.

 

I think it is very interesting to know. There seems to be a red line in your life: ethics. It is in your professional career as well as in your personal life. How are they linked to each other?
I think the link is always exploring and challenging the knowns and that had been the theme both in my personal and professional life. So, I never really could fit in the box that we were supposed to fit in. In my professional life, it was always like: I learnt something, I went back to work, new questions came and then I wanted to find answers to those new questions. Often, I answered them partially, but I came up with more questions and then the journey continued. But the theme always has been how could we improve access to health care not just for few sections of the society but across.

Sorry, I don’t understand, is it for a few or overall?
For everyone, so how do we distribute all these benefits that a new technology could bring or health care mechanisms could bring to everybody possible and not just those who can afford it.

Great. So, I wonder what will be the next step
[Laugh] I don’t know actually. In a way, I have achieved all I could, at least on the academic path, in terms of the milestones, like you have a PhD lalala. What I hope to achieve is to continue working in health combining it with research and practice and hopefully striking also a balance with personal life. Because, in all these years, I have really neglected my personal life.

Your own personal life?
Yes. I have been so passionate about my career that it was always my number one focus.

Although you are also happily married. So, you didn’t fully neglect it?
Yeah, it came in quite late but yeah, I am really happy about that and I felt like taking that step. And it wasn’t because my society or my mother expected it from me.

It was your own choice
Yes.

You also say something that triggers me: you were lucky to get and then you went to the next step (e.g. Amsterdam, Switzerland). How does this ‘luck’ develops for you?
The thing is, if I look back at the conditions on which I was born or the economic constraints that I had, I would never have had this life if I couldn’t get these scholarships or if I didn’t meet the people at the right moment who often just directed me or asked me the right questions and that shaped my next path. So, I am sure there are many people who are as capable as me back home but not everybody got those opportunities and then the life changes. Like, it really depends on the context in which you were born and raised and the opportunities that you had. Also I must admit that my parents always taught us to dare to be different. So even if we get the opportunities not everybody takes them and we were raised to take any risk as long as we were prepared for it. So. In that sense I am really lucky and I always think like that when people say ‘I am so successful’ (I mean there are some people who believe that I am really successful).

[Interruption] I also believe that with respect to your track record
A lot of it actually is basically people and opportunity and circumstances who shape that journey and I have been extremely lucky in terms of mentors and teachers. I have had fantastic teachers all along. By teachers, I don’t just mean academic teachers, but also in my work environment, those supervisors that I had: they often saw my potential, even sometimes when I didn’t see it myself and then they pushed me. That has been incredible because otherwise I am a very self-critical person. So, rather than seeing what are my strengths, I would often dwell on what are my weaknesses and if I would not have got this external nudge, or external stimuli, probably I would have been dwelling a lot about what I lack than what I could get on further with.

There has been a tremendous change in your Quality of Life: instead of staying in India, now having a fantastic academic career with three Masters and a PhD. Even if you are self-critical, there must be something in you that other people care for you. They stimulate you to do the right things. I think you work very hard, like you said in the beginning, seven days a week. But, what is that kind of secret thing?
I think I can show my vulnerability and be honest. I am good at sensing people, like, feeling them. Once I feel safe with someone, I can really show my deepest fears and my vulnerability. I am also very good at saying ‘I don’t know this, can you explain me, can you help me? I don’t mind showing my ignorance or just accepting that I simply don’t know it. Basically, then people are open to give you very concrete feedback and also engage in a dialogue from there on. So, these two qualities have helped me to connect with a lot of people in a very deep and meaningful way. And I think that is one of my strengths and also my treasure that I have these people around me.

Also living abroad, I mean in many countries, a lot of Indians do this and I am not bragging about it but one thing I always made very sure is that I want to connect with everyone and not just make islands of Indian community abroad. That helped. Also all these trainings I did or Master programs I did, they were all international programs, so I met people from so many different countries. I mean when you study for a year together, you really get to know each other in a very different way. There is a deep connection.

So, that changed the exposures I got. When I show my vulnerability and connect, people often tend to do the same. So, I could see people in a very genuine, honest, raw, fragile condition. Not just in their personal lives, but also in the country that they come from and the struggles that they face. That enriched life a lot. So, it has been two-ways.

It is true that a lot of people deeply care for me. And they have gone out of their ways to support me because they could see some potential and they also could see areas where they could contribute something, to make me use of my potential fully. I think that always gives everybody a sense of feeling good that they have contributed to something that they can see in front of them. So, maybe that’s why people care about me, I don’t know, but they are caring and they have genuine interest in my well-being. It improves my quality of life significantly. I never felt lonely for example. I always know that I have a least ten people that I can fall back on in case I fall apart either personally or professionally. I know there are people I can reach out to and that gives me a lot of strength to also take the risks.

When you say those things: it touches my heart. You say that it improves your own quality of life but most probably it also improves the quality of life of the people who give?
Maybe. Yeah. It could be. Because I think what is needed is that then you create a safe space. Just the way I can be my true self in relation with others they can also be their true selves. And that gives opportunity to both of us. So, it’s in a way: win-win.

So that openness, that safe space, gives opportunity to both the partners and the relationship.

And what happens then?
Maybe there is then some trust and again coming from India and the intense competition that we are used to, it’s difficult to trust people. I think living abroad and especially in Western Europe, that was one of the challenges that I had to face, and yesterday I was talking about this again to a colleague of mine, Monica and Peter that you met at the defense, how it was difficult for me to trust life and to trust everyday living.

So, Switzerland for example: when I first came in I always had this doubt in my mind, e.g. searching for an apartment and I would wonder like ‘is this really the right rent or are they just telling me this because I am Asian and I am Indian and I am dark skinned and I am not speaking the language?’. These things are very natural for us to think. Because these are the factors that do influence how things work back home.

Somebody, I’m really grateful that he sensed it in me that I was doubting and I was almost being paranoid to some degree and I had all these thoughts in my mind that I am dark skinned, Asian, Indian, foreigner and that’s why probably in Switzerland would get cheated. Without me being aware of it, he actually said to me ‘I have just one word for you: that this is a society that runs on trust. People sense it that you don’t trust them. And that would reflect on how they treat you. So, I know that you come from a different context, maybe you have your personal story where it is difficult for you to trust but this is an opportunity for you in an environment where it is unlikely that you would be cheated. I am not saying that it is completely impossible but the chances are much less. So now, it is your choice whether you still want to go with that doubt and suspicion or you want to open up to the possibility that you can trust people around and you can trust the systems around’.

That helped because this had been a very recent journey in my life: being able to trust and that includes trusting myself and my abilities, trusting life. Like yesterday I said ‘it was actually a Norwegian girl when we were climbing in Norway, she said something like my mantra in life is ‘trust the life’. And I almost looked at her thinking ‘are you mad? how can you trust life? I never trust life, for me, life is something I need to fight’. She looked at me saying like ‘are you crazy? why should you be fighting life?’

For then that walk, I realized that it is so true that we see things based on our context and I always really saw life as something I need to fight so that I could get want I want, so that I could move ahead in life. That had to do probably with the systems and also the competition and the economic hardship of my parents. I knew that only thing I could get a better life for myself and for them if I was the best of the best. And in a country of one billion to be the best…

It’s not so easy [laugh]
And it was like ‘hey, but look, you are out of that country now, you have proven it enough. Why are you carrying that immense load on your back? Why can’t you now try and switch it and try to see how it feels to be, to make life as a friend’. You will have difficult times sometimes because with friends you also will have difficult times. But don’t think of it as something you have to fight against because you are wasting a lot of your energy. And I think with that in my mind I came to Switzerland. Because it was my trip in between. Before moving to Switzerland. this is something that probably relationships also open: the trust aspect.

Then it seems to be that life itself works for you instead of working against you?
Yeah, maybe and I think it is also changing mind set. Because, it is interesting, me and my brother work in the same system but we are different. He is much more capable of trusting life and I see it as being too laid-back actually. But for him it was like ‘look, why do you have to push so hard, I mean, if it has to happen it will happen, otherwise it won’t’. But, I never wanted to take this chance that it won’t happen and of course then it didn’t happen. So it was always fascinating.

It is difficult in India to get visa and that has been my journey now for ten years: getting visa for each of these countries. Always it is stressful and again I’m like using all my engine and fighting with all my energy and he looked at me and asked ‘Have you not learned anything in these years? We always go through this, it is difficult, it is never smooth, but you have never been rejected a visa. Can you try to do it differently once in a while?’

So it is also interesting how individual, personal choice, comes in this as well. E.g., even for their visa for my defense: I was so mad that they were late and I had all these thoughts like ‘yeah, you know, you are dependent on Embassies and they don’t really consider anything so you should have been two weeks in advance’. Then he was like ‘but you didn’t give us the date two weeks in advance’. So, I was so bitter and so stressed about their visa… and they got it without any problems. So, that actually affects my quality of life and also my quality of relationships because at some point I was almost about to fight with my brother ‘that you screwed up my defense and now you are not able to attend it and that’s why I am so mad’ and he was like ‘stop it!’.

So, on the one hand personally you have this openness and making connections to people but on the other hand if you look at yourself looking at life you still have to fight?
And I have to control. So that’s one of my biggest challenges in life. I want to control things and they don’t want to get controlled, I know that, but still I make a lot of effort to control things. So e.g., everybody sees this long list of qualifications but I always had a doubt that it may not work so I always had at least three back-up plans. For me, I say it is being practical and being realistic and being wise that things always do not work out. But many people, especially my closest family like my brother, they always say like ’yeah, it is okay, but you don’t have to have three or ten back-up options, you could have one’.

The few things that I really struggle with is trusting life, not trying to control everything and not being so organized because I understand that these are the qualities that brought me to here but I also see that I don’t need to continue with the same strengths of these qualities. I could more or less let them a little bit down. To make it more easy, not only for me, but also for the people around me.

I want things done when I tell them ‘okay this needs to be paid and if he is one day late: it’s a storm on my brother’ and that really affects people. And the third thing I am really afraid of, but I was way more afraid of than now, is failing. I have a lot of fear of failure. Which is also interesting because what does failure mean? Failure is too big a word: I don’t like to make mistakes. And it was actually during a workshop in Germany where I was helping in the kitchen, so I was a kitchen assistant, and we were serving to a group of seventy people and I was freaking out because I am so obsessed about being perfect, being on time, and there is no scope for making mistakes. So, the lady who ran this workshop- one day she gave me a task saying that by the end of the day I had to report to her three mistakes that I had done. And I freaked out. Because I couldn’t make a mistake. And in the evening I actually went up to her and said ‘I am sorry, I have no mistakes to report’.

Oh, wonderful!
So, see such examples and such people they somehow sense because the thing was she could see that I did everything perfectly but at a huge cost of being stressed myself which according to her wasn’t needed. She was just trying to push me then to do it differently. So, yeah I know I still suck at it.

The same was the case with the defense. I don’t know how or to what extent you will use these details in the interview that you will finally put up, but I am used to be always with the highest grade. Being second feels like failure. For Martin this is unimaginable. He is my husband who is Swiss. He just doesn’t understand it. And then of course, I go and say ‘yeah at one point I was among one billion people and now I am just used to be like this’.

So sometime, last year, he sat me down because I was stressing myself for this grade of Summa Cum Laude and it had a certain requirement that you had to publish many articles. So I was pushing myself too far and he set me down and asked me ’for what? What do you want to prove out of this?’. ‘That I am good’ and he was like ‘seriously, I mean, is this grade that would really tell you that you are good? because in my experience you have had this grade many times, but you never still felt good about yourself, so it is not the grade, what is it?’. ‘Well, but then others got it and my work is not less quality so I should get it too’. And he was again like ‘seriously?’.

For me it is just interesting that he would ask these stupid questions in my mind and then pushed me to think about it. Then he gave me a challenge saying ‘can we put it in this way: whatever you do this time, you do it because you enjoy doing it and not because you have to achieve something and you bring home a 5.5 and I will treat you for that?’. Nobody had ever given me a challenge to be second and ‘I’ll give you a treat’. Actually, I took that offer because it felt like again a competition that I had to bring number two to get that treat. And then he was like ‘no, no, again you are missing the point’.

But then we agreed that it is true that I had seen a lot of PhD students fall apart during PhD. Simply because they are too stressed. Then I set for myself a goal that ‘I am going to finish in time with good enough quality of work that I can live with and without falling sick, physically or mentally, irrespective of the grade that I get’. So I managed to finish it in time. In the days that I submitted I was overwhelmed with the guilt that I am the fraud and it is not a good quality and everybody is going to find it out that it is not a high quality of work. So I failed in my second criteria that it should be the quality that I should be comfortable with but I didn’t fall sick. So, I was really proud of the fact that I could finish in time without falling sick and I think for me that’s the best part of this PhD.

To be honest, really that grade didn’t matter. At least this time, I was calm and peaceful. Because I remember, before, every time I had this Cum Laude, the very same day I would wonder ‘what is that I have to do next to prove to myself that I am good enough?’. That was an endless journey. Whatever I achieved was never good enough and it was not something from others that they were expecting this out of me. It was me that was expecting this out of myself. I just never knew what is it that I am running after? Why do I always feel so empty? There is still some big hole in my being.

Is that a big hole? Is it the emptiness that pushes you that way?
It used to be like that. I remember the Masters before in Padova, my graduation, I was so lonely and in a way sad and out of place because I didn’t know now what next goal I should chase. Fortunately, after my PhD defense a month ago, I was much more relaxed, I could really connect with some people. Because there were so many people who were there who were really interested in me. So it was really a celebration. People who know me closely could see that I was way more relaxed than what I generally am. Because even in that setting I intend to get again in that controlling more of ‘oh, has everybody eaten something? have they tested everything? is it too spicy for them?’. And then people are like ‘hey, we can take care of ourselves, you just relax’.

You enjoy, that’s right
But it is difficult for me to enjoy life. And yeah, sometimes I have to make efforts to enjoy life. So, there was a month, I stayed in The Netherlands, in Groningen, and the friend with whom I was staying: she gave me as task saying ‘I had to find one thing every day that I really enjoyed doing’. I had really difficult time to find those things. Then one day I found ‘oh, I never have jumped on a trampoline. So, she said ‘ok, let’s find you a trampoline’. She found a trampoline but I couldn’t jump right. So, I was so mad that those children really could plunge up and I was just… That failure came back, like ‘shit, I can’t even jump nicely on a trampoline’. She was like ’hey, these children grew up jumping on a trampoline, you are a thirty something, yeah, this is the first time you are on a trampoline’. So, it is tough for me sometimes to enjoy life. It is simply because I am too much of a perfectionist and I am trying to work on it. And I want everything to be organized and structured.

On the other hand, it is the way you are. I can understand that people love you because you are that way and you are open about it. Perhaps, it is not the way to change yourself? Because then you would not be the real Priya again?
But I also know that these people who still love me they somehow are so patient, that they can take this obsessive side of me as well. If I tone this down a bit, I probably make it easier on myself but also on these people. Honestly, my brother has had this storm of me on him so often. That sometimes I wonder like ‘will I stick around with my sister if she was like me?’ Probably not.

I have seen your brother, he is a very kind person, being patient with you
He actually is my biggest strength because even when I called off my wedding, the only person who really understood me and who stood by me was him. Because my mother was really depressed. She almost had suicidal ideations, because everybody said she failed to raise her daughter according to Indian standards. But my brother had a very simple view of life, he was like ‘look, I know you are hurt and you are doubting your decision, I think you did the right thing, here is a bottle of vodka (because I like vodka), here is a sack of chick flicks (because I like chick flicks), sit there, cry if you like, but when the time is right, apply for your visa because it is going to be tough and get out of the country’. Because he was sure I had enough support system in The Netherlands, that people would take care of me and he knew that I would heal much faster if I was away. And I am so grateful that he had that courage to tell me, almost kicked my ass, and said ‘pack you bags, get your visa, get out there’.

And that guy, sometimes I wonder, he is younger than me, and he didn’t study as much as I did, I actually studied for the entire family, one bit for everybody. So in terms of wisdom, in terms of ability to live life, he is way better than me. Also in terms of lot of things, a lot of experiences and exposures abroad opened my mind, made it much broader, but I admire him because he didn’t leave India that often. But he just had it from within. Some need different exposures to learn these things and some just learn it wherever they are. So, yeah, my brother has been a very special person in my life, but he is also the one who gets the major brunt of my anger and irritations.

He receives
Yeah, without complaining. I think he is also very interesting in the sense that he never felt insecure about my achievements or felt jealous. Because I think in many ways under all those achievements he could really see my struggles and my vulnerabilities. So he could connect with that aspect and that’s why our relationship never got spoiled. When two siblings: one overachiever and other normal, I am not saying anything is wrong with that, but even at home everybody is like ‘what does he do?’ and why does he have to match up with what I have done? He is a different person. But that question always comes up but it never affected our relationship. It only made it stronger.

Wonderful that the struggling and the other one seeing the struggle makes the connection
Yeah.

 

Martha Nussbaum and Amartya Sen, two philosophers who worked for the United Nations on a project Quality of Life used the example of an Indian woman Vasanti for improving quality of life. Do you know the story?
Not in detail.

Vasanti lives in India and was married, in a violent marriage, the man was drinking and she decided to divorce. But that is very difficult in India as you know. But the family, her brothers, said ‘we will support you’. So she divorced. That improved her quality of life. But then Vasanti said ‘I am still depending on my family’. With the help of microcredit, she was able to buy herself a sewing machine and make her own living. She couldn’t read and write but step by step she improved her quality of life. Those two philosophers use the example of Vasanti quite often. How do you reflect to this? You did research on quality of life, especially on women in India. Is this also your point of view to look at quality of life?
I probably want to problematize this a bit. I know the case studies have a purpose, they want to make a point. But I often struggle with somebody else, from somewhere else, trying to go and studying somebody else’s quality of life which is a subjective concept.

So, my understanding is that quality of life is very different for each person and what they would consider as a good quality of life compared to somebody else. So when we see it from a particular lens, e.g. this woman getting out of her violent marriage and a supportive family who brings her back and microcredit: that’s one way to look at what is improvement in quality of life. If that matches with the person’s own wishes, then her quality of life has really been improved in this matter: I’m fine with it. But sometimes I also feel that people have different notions of what quality of life means for them. And if we go with our own ideas what improvement in quality of life means we might tend to ignore what they find is important.

So a few examples: my first research. I was interested in quality of care women receive during pregnancy and childbirth when I was studying public health. There was a lot of push on quality of care in health care systems. So what is good quality of care? I decided to look at experience of women when they are in labor, when they are about to deliver a child, they are in a hospital. So far as the doctors, the quality of care is you have trained doctors and nurses and midwives and you have hygienic place and you have all the equipment and you worry about how to explain to the patient. If we can give all of these and all other factors then it’s a good quality of care.

For my research, I decided to look at experiences of women who lived in slums of one section of Mumbai who were mainly immigrants to Mumbai from other states of the country. Who often spoke a different language than the prominent language in the hospital of Mumbai and these are the women who have traditionally known or who have experienced home births in their families back home. Now they land up in hospital in Mumbai- in an environment which is alien for them, the language that they don’t understand: I wanted to know what they would expect to feel good about being in the hospital while giving birth to their child and their expectations were completely different.

They didn’t mind so much that the surroundings were a bit messy or there may be some blood on the sheets or things like that. That was not what was important for them. For them what was important was to have somebody with them who spoke their language, who also connected with them in terms of their notions of what is good thing to do for the mother while giving birth. Which can often be very different than the doctors view of what should or should not be done while giving birth. Somebody who will not shout at them, who will not slap them. Which sometimes happens when doctors want them to push at the right moment so that the baby is not harmed. We, doctors, can get really very paternalistic.

There was a huge gap between the expectations. I think, this was also for me the beginning of a desire to study Anthropology, which tries to understand the local people’s perspective and expectations and experiences instead of we going there because we are qualified, have experience and we try to fix their lives. So, I am a bit reluctant of this approach.

Another example of these public health interventions: we often think that it is a good idea to have closed toilets so that nobody has to go in the open spaces to shit. Or women in a lot of rural areas, not just in India but also in Africa use fire wood for cooking. So, both these examples and I am not encouraging that everybody should be shitting outdoors, that’s not what I mean, but people have got to live with this and have built their life around these practices. These practices come out of constraints that we don’t have the facilities but people have found ways to make the best out of these constraints.

E.g., when people go out to shit in the morning they often go in a group segregated by gender. That’s their opportunity to talk about lot of things that they otherwise can’t talk in their home. That’s their only little social support and counseling system or a place, a space and a time that is theirs. One of the reasons why, even if you build these closed toilets they don’t like, is then the shitting becomes a very personal individual experience and you miss on these social contact with other women. But unless we see and try to understand their perspective and when we take away the opportunity from them and give them healthy options of very closed toilets, their quality of life improves in some ways but deteriorates in the other. But we often don’t pay attention to that other side of it which is equally important, I think, for women to be able to talk to other women.

Cooking with firewood: it is awful. In the rains you don’t get dry wood, you have these wet wood, the smoke. The smoke, we know, has been linked to a lot of blindness and respiratory problems both in women and also in children who are playing around. So there are many reasons why this should be changed. But, there are also reasons why, in spite of that suffering, and even if their quality of life is poor because they are cooking on this firewood, women still would prefer to do so, at least in the beginning, simply because the smoke gives the typical smoky flavor to food that their family is used to. And we often don’t pay attention to these.

So if you give them a solar cooker, first of all it takes time to cook as compared to one with fire, and second the taste is never the same. And at least in many parts in India, I can say even in my house, people are so picky about the kind of taste that they are used to. She has a choice: she could make it easier for herself but knowing very well that her family is not willing to eat because it tastes different. I agree that this could be negotiated, this could be talked about. But it takes time, it takes also engagement from the researchers or public health intervention people’s side to understand what is at stake for them? And then how can we negotiate in a way that both these aspects are somehow taken care of?

Like for me, when I have to cook on an electric stove, I really hate it. Food feels different, cooking feels different, but I know that the electric stove, even the induction stove is much safer, there is no risk of burning or whatever, but I am used to cooking on fire of a gas stove. And here I am, a completely different example, but people have equally strong preferences even if they are living in villages and they have not gone to school but they have built their lives around these circumstances and for me it is very important to listen to what quality of life means to that individual person. And how other interventions, however best intentions might be behind it, could actually affect their idea of what is good for them.

Having said that, I also know as a philosopher or as a policymaker: you don’t want to go with something that is so, like if we have six billion people and if we have six billion notions of what quality of life is, that’s not going to work either. So, that’s my, at least intention, while I was working as a public health professional and that’s where medical anthropology really helped me is always to listen to people. I had something to offer but that was really from my perspective based on maybe research. But research done by people who do not live that life every day. Then we want to go and tell the people who have to live with that life every day how they could do it better.

So, I don’t like that kind of research. I’m a very strong proponent of participation research where the communities actually are co-researchers in the process where they have a voice, where they are not being rescued by the researchers or funding agencies who want to do something good for them. But they can tell, what is their biggest concern and solutions. Because, I often believe there is a lot of wisdom that comes from experience. That may not be backed by science, but these women, if you talk to them, they would come up with solutions and it just takes way more time that we often in our time-bound-programs and funding schedules: we don’t have time for that. So, I would say, the same about quality of life: it has to be really understood also from the perspective of the people. I’m not saying that if a woman continues to be battered in her marriage simply because that’s enough quality of life for her, that’s acceptable. But, I would strongly encourage that we need to have people’s perspective: what this means to them.

This came out very well in my research in The Netherlands when I was talking to people who wanted to bring about a change in euthanasia law to include those who have completed their life, ‘Voltooid Leven’, to also get assisted dying. For me, I wanted to understand, why? I mean if Dutch people already had these provisions to get assistance in dying according to the legislation, why do these people think they have lived enough? And that they also should have access to dignified death. If you listen to them, it is basically their individual preferences and also how they value to shape the kind of life experience that they are willing to have.

E.g., the Dutch people that I interviewed were extremely afraid of being dependent on somebody. Dependent on care givers, dependent on family, dependent for their daily needs, like passing urine of feces, and that fear was so strong because they felt that their quality of life would significantly deteriorate. Now one could argue that we have lot of people with dementia who need all this assistance but they reach a stage when this is not a problem. But that’s when you are demented. If you are not demented at this moment, it could feel and I understand that fear, I would relate to that, because we are so focused on living an independent life. Again, I am not saying this is the right way of doing it and that we should be so obsessive about independence but probably there is space for interdependence. That sometimes we need to let go some of our desire for independence, but also live an interdependent life with others. Which is actually how most of the life is.

So, all I am saying is: we have to have a definition of quality of life so that we could have policy, that we could have intervention, that could be aimed at improving people’s quality of life. But we should also be aware of how those definitions could affect people’s life or even disrupt people’s life.

Microcredits programs in Bangladesh, at least that’s what we learned and heard when we were studying there, initially the focus was on giving the credits to women. Simple reasons: because first it addressed their aim of empowering women. Second, they knew that if you give credits to women the return of credits of the loans was much better if you give it to women than if you give it to men. So the focus of the program was initially on giving credits to women. What did it do? Of course women got empowered and they had more say because they brought the money. But it also disrupted the family balance. Men started feeling neglected. They were kind of pushed off, they lost their control and then they were driven to just sit and retreat and play cards and smoke cigarettes. Frustration built in and then the only way this frustration could get an outlet is if the man can at least physically overpower the woman. Because now they were financially no more dependent on them. And that led to more domestic violence against these women. And then when they realized it, they decided to make the focus of microcredit program on the entire family as a unit and not just one gender. So again, I am not saying that we do this intentionally, but sometimes if we don’t take into account these local dynamics, cultural context, we could do more harm than good.

It’s a very interesting thing. Partly because of this example, the United Nations came up with seven dimensions for improvement of quality of life. I think also their programs are based on those dimensions like health, education, income, political influence, transport, etc. You say something different, instead of looking at the concepts (dimensions), first, you have to connect with the people
Not first, but while looking at the concept and planning an intervention or policy, we have to take into account the local voices, the people lives that you want to change. Also try to find a common point because when people feel heard they are also more likely to accept your interventions rather than you just coming and saying ‘yes, this is what we will do’. But again, I also know how difficult it is to listen to the voices. Whose voices do we listen to? We can’t go to each woman. There will always be most vocal and the quiet ones or the most dominant people who will talk and all these dynamics that need to be taken into account.

Like in inform consent discussion, a lot of people say ‘well in our culture women are never used to giving consent to anything so maybe the husband gives or maybe even the village or tribe head gives the consent about the surgery that’s needed to be done on a woman’. I am not saying that this is right practice, but if we just say ‘no, this is wrong because we believe that individual persons should be able to give consent’: this is a very in a way Western view.

I do feel this tension between Orient and Western. You know even within the West, not everybody feels that they can make a decision on their own. Of course, we can make a decision on their own but then you also live with the consequences of that decision alone. So for lot of people it is actually important to have shared decision making. So in health care and in ethics this is an ongoing discussion that inform consent is very important that you decide whether you want to have a surgery, what kind of surgery, with which doctor. Which was all done, so that the patient feels protected and empowered. But there is also a side effect now that patients might feel very lonely in these extremely difficult decisions that they have to make.

Again there is a balance that we need to strike. I am not saying that the doctor should decide what is good for the patient but if a patient says ‘look, I understand you want me to make a decision but I am not able to do it and I need help’ he should also be able to have that access. But still inform consent has to be given by him. So decision will be taken by him but sometimes we need to involve the others in the decision making process. Whether it is your spouse, your family, your physician, whoever.

I agree. But politicians need general concepts. That’s the difficulty. You also worked for the United Nations: they need checklists of what can be done, who to give money to. Consider the example of Vasanti: it speaks to the imagination and we project our own thoughts on what is improving her quality of life. But I agree with you: you don’t know whether it is improving for her
And whether she sees it as an improvement.

It is just our own projections. So we do it one-way, we broadcast our ideas of quality of life on somebody else
There may not be anything wrong with it as long as we are aware of it that these are our ideas and people might have different ideas and lot of issues in health are actually stuck on this basic distinction. E.g., another very controversial example I am bringing in and that brings again public health and ethics and quality of life: female genital cutting. The world is divided. Many of us think that it is awful, this really affects not just their physical quality of life and sexual quality of life but it is trauma to their womanhood and their sexuality. There are others who try to tell you the other side of it. The good thing at least with female genital cutting is that these alternating voices are being heard. That there are even researchers who are trying to understand from women themselves.

In this research we often find out that the reasons why women think ‘you can’t escape it because otherwise you can’t find a marriage partner in this culture or in this community’ and then the intervention is to actually change the mindset of also men and society in general. But such changes take ages. We want to have effect, let’s say, by next ten years or three years or whatever. So, the only way then that can be done is if, we actually make it a punishable crime if a doctor is found practicing this procedure or the parents will be in prison. That is a solution but is this the best solution? Are we addressing the root cause which is the mentality and ideas of being a good woman or masculinity? Now even for Europe this is important because it is a very multi ethnic, multi-religious, multinational community. So, you would suddenly notice such cases happening in Europe because people come from different context.

The problem is having a good definition on a checklist helps because then the whole planning for these interventions becomes easy. The reality is that is doesn’t work that way. But I don’t have smart solutions how can we do it differently. All I can say is at least in our own little ways, we could also try to be open and listen to people’s views. You may not be able to accept everything but at least you could try and then see if there is a common ground. It is difficult to find this common ground but once you found the common ground: even the intervention is better accepted by the communities. So the long term effect of interventions will be much better.

It is a difficult question because you need the macro way of working on a local basis. Probably it has something to do with approach: how to, because you can have the general concept but then the fulfilment locally
Also there is the requirement of a different level of translation in a local context and I feel there the local health care professionals have major contribution to make. Because, like e.g. me, I can understand and I believe in al lot of these arguments that come from prominently Western research and philosophies. But I have also experienced and I do to some extent understand, tough may not accept it, the realities in which women for example have to make decisions. Then it is my job actually to try to find little bridges in my own work. But, then it has to be done really at individual or at specific program level to be sensitive to these aspects and not just follow something that’s get told by, let’s say, some foundation or some program. At the same time being very sensitive. Because sometime we just say ‘oh, but this is our culture and things we have to do it this way’. I am also against that because not everything that a culture dictates us to do should be done and is right thing to do. But it is a very tricky and grey zone. There are no easy answers to this.

 

I want to share a few conclusions to you that I found out in the Quality of Life project. One of the most important thing is freedom of choice
Okay, I am skeptical of that argument ‘freedom of choice’. I think we live in a system where there is too much of choice and then that too much of choice actually becomes a reason that you are not able to make a sound choice. So I do believe in choice. It is not that you do it this or that. But I also don’t need hundred choices.

Choices also gives stress
Economics prove that we are not able to function. So, freedom of choice is one thing but I also think that we need to have infrastructure systems, families, that are able to support when people make free choices. Sometimes we encourage people to make a free choice. But then we let them face the consequences on their own. And that’s not, in my opinion, a good thing to do.

You said before that shared decision making is important
At least for some people and for those for whom it is important they should have that option and in that sense it is a freedom of choice. If there are individuals who think ‘yes, I can make a decision on myself, I don’t need to consider anybody’, he should have freedom to do that choice. So, that’s what I am saying.

Ruut Veenhoven, the happiness professor in The Netherlands, said that in countries like Japan there is a very tight community who puts a lot of pressure on the person to decide according to the family and system structures. Also from your own experience in India: a prearranged marriage and when you decided to step out of this structure you got into problems. There you have shared decision making but it is not the kind of decision making that you are happy with?
But for some people that same shared decision making might work. So a lot of people in India also go for arranged marriage because then they feel when things go wrong it is not just their responsibility in that marriage but also the family: they have to take the responsibility. So again, in that sense I would say ‘people should be able to choose what works for them’.

These two extremes. Also my research in The Netherlands this came up that why people are so desperate to die if they think they are done and don’t want to be dependent. One of the arguments is that basic failing or weakening of family ties and that leads to lot of loneliness. So we live in those two extreme scenarios: examples of Japan or India where community and families tends to dictate everything or a lot of things and others where we are getting too much of our own, like we are the islands. I think both these positions are not healthy.

Another difficult question is how do we strike a balance between the two. Also like quality of life, Switzerland is often given as an example. They have pretty strong economic status, infrastructure, social welfare, money, nature, beauty. But people are still not very happy. A lot of people say that Swiss people are extremely sad and depressed. It is a country of sad people. So that’s another dimension of it. That quality of life is again a very individual and there is a strong spiritual component to that notion as well. Why is it then with also these opportunities and possibilities and money and wealth, we still feel so empty and lonely and sad?

And for me also that comes in my personal life: I have been living a very privileged life for now, last ten years at least, in developed world. I almost feel a tinge of pain and envy when I see children and women on street or men in India and they somehow have this shine in their eyes or some enthusiasm and energy. And sometimes my brother tells me I am over-romanticizing their lives. Maybe they simply keep going on because they don’t have other options and they know that it is the best they can do and they would deal with it. I look at it from my perspective because there are moments that ‘I feel really like a failure’ or ‘not being good enough’ or all these things that make no sense. And then I look at these people, like a vegetable vendor and she would have a broken teeth and then I would say something to her and she would have that huge smile on her face and her face lights up and you wonder ‘where does that spark come from?’.

I often think, and again I am not romanticizing hardships, but I feel also the struggles and hardships in my life pushed me further. And in many ways now I don’t have those. So I kind of feel, I have nothing to drive me. When I see their lives, I often see like: there it is, that little glimmer of hope that things could be different. And that is then keeps them going and yeah, it’s fun, I often wonder in many ways these women living on streets probably are really less critical about themselves than I am. So, in some ways, I have these problems of luxury or privileges.

A second conclusion that I would like to share with you: if you look at the personal progress in quality of life as a ladder from 0 to 10, you might say that the United Nations dimensions of health, political influence, financial situation, relationship, etc. may bring one from 0 to, let’s say, 6. But how, especially in the Western society, to go from 6 to 8? The people that I interviewed are talking about knowing oneself
S
elf-realization.

They talk about openness, vulnerability, thankfulness, gratefulness, etc. Those are bringing one from 6 to 8 or 9. What do you think about that?
If that’s true then a lot of people back home who in our mind do not have great quality of life have these at their starting points. Often these are the only things that they have. And they are building their lives on these. And that’s where I also think culture and religious philosophy comes in play. Bhutan for example, which is a Buddhist country. It’s again: mindfulness, being grateful, being aware of your death, thinking about your death five times a day and Bhutan is considered as the happiest country because I think spirituality is very much part of everyday life. They may not label it as ‘now I am going to think about my self-awareness’. That self-awareness is very much there in every moment, it is part of their upbringing and everyday life.

So, if this is the case that from 6 to 10 for, let’s say, the Western (and I hate these Western-Eastern because you might find exactly similar profiles with someone in India as in the West but let’s for simplicity say it that way)… So if it’s that these qualities that help people in the developed world to feel good about their quality of life in these last steps, I really feel this is where we start in countries with less privileges. Because then you are least dependent on what state can provide you, what social welfare can provide you and these are the resources you have on your own. And you mobilize these resources on your own.

Some are good at it, some struggle, and I think that’s also makes the difference in their quality of life to begin with: in their approach towards life. Also this approach of being grateful to whatever you have, which includes hardships, then with any slight improvement in their life: people feel so overwhelmed and grateful. What happens in the West? We are so used to having high standards that any slight drop in quality of life: we suddenly feel so awful. The train is five minutes late: we start complaining. That’s the distinction because those who have little, rather than complaining, they intend to enjoy what little that they have and those who have a lot, focus on little things that they lack and that too in a very big way.

So, I never thought about this, this is really spontaneous, and I feel myself stuck in between these two worlds. I often feel lost in this context that I don’t see why there should be any reason I should ever feel low or depressed. I have got so much. But I still feel that way. So, I think that my quality of life is better here, in many ways it is, in terms of physical comfort, or opportunities, but sometimes I miss that thing that moves me, that drives me, that reason why I am alive. Like, I had very strong reasons, very passionate that I wanted to do something for people when I was in India and I miss it because I also don’t have those direct opportunities I got to work with people in the field in very difficult conditions for six years and in those days the hardships were immense. I lived in areas where we had electricity for only four hours a day. But each morning, I woke up feeling really great: ‘what is it that I am going to experience today?’. Now, sometimes I really have to drag myself to work.

To get yourself out of bed, really go there
And it is interesting. I often ask myself ‘what changes?’ And I think it is this that if you have little you are really trying to improve and at a certain stage when you have enough and then you are like ‘oh, now what?’. I mean I checked all the boxes: I studied, I have a job, I am married… now what? And I don’t know ‘now what’. I mean I now made a project that I want to pay attention to my personal life because that it is one thing that still needs to be checked. I want to work on relaxing, and not being so controlling and not being afraid of failure. But after that, I don’t know what next and then there will be a state of like ‘I have no purpose anymore’. I won’t be surprised if I would come into the state that I would say ‘my life is done’, ‘I don’t know how to keep living on because there is nothing more to do’.

So in developed countries, there are the hard targets, the dimensions like the United Nations and the Statistical Institutions are using. On the ladder from 0 to 6. On top of it comes the ‘soft values’ like vulnerability, thankfulness, self-confidence, and so on. What you say is that in the underdeveloped countries: they are starting with those values. If they live around those values then perhaps they have a change to start climbing the hard target steps of the ladder
They build their life further. They are at different levels to begin with and that’s how you see the difference how people excel in their fields. So it is a resource, we can draw on our own, not depending on the state. Of course, your confidence will increase if you know that you can get into school. But you don’t know that and in some ways I do think that competition did bring the best out of me because here I often feel that people are too laidback. Because they don’t have to prove anything to anybody. I really need to learn that way of living, being satisfied and being at peace.

Ruut Veenhoven (from Erasmus University) also said that in The Netherlands there is an open school system: students learn to be more self-responsible and have more decision possibilities. In France or in Japan (probably also in India), only the best survive. This is what pushes the students to be the best. Like you. You stepped up the ladder and moved on. However, the students that are not the best are frustrated and unhappy
Not necessarily. Probably that they did not get what I got but maybe they never wanted it. Women for example, maybe not many women who had similar opportunity like me with three Masters and one PhD, maybe they wanted to have children. And they had it.

I have contact with a lot of my schoolmates, and they talk about really being grounded in the context that they are in, their family, and they are making the best they can in that context. At least that’s what comes out in the interactions/ Maybe they don’t show their deepest desires and their sadness or whatever. But, they come across as very grounded people, unlike me. I still feel I am kind of lost in some ways. I don’t know what I want. Lot of them still talk about being grateful. This is a very recent phenomenon; I don’t think they see themselves as failures. And that’s great. I’m really, really happy about that.

I also was thinking when you said about I moved up that ladder and let see my brother didn’t reach the same level of ladder. He is at his own ladder. It would be interesting to, maybe not for your blog, but just to see the other side of it. Maybe you should skype with him. Ask him what is his quality of life. That would be really a great case study for you.

That would be really nice
He would be happy. Maybe after your project is over. Because nobody has asked him these questions.

It would be very interesting
And he will be very open to talk about it. So, this notion that those who remain behind will be frustrated: some do but some don’t. Do the best that you can with what you have. Those who achieve that, I think, they have a much better quality of life than the others. Because in many ways, me constantly trying to reach somewhere: this significantly affects my quality of life in a negative way. Those who have accepted, I’m not saying you accept the worst conditions in life, but those who are comfortable in their own skin, with what they have and they are willing to live that life fully, probably have a better quality of life than me.

I don’t think so. Your experiences and the struggles are there because you went up the (Western) ladder. Now you start to work on and integrate the soft values. I think you are very fortunate, because you come from a country where those soft values are traditionally more important.
That’s part of growing up. You develop unconsciously from the beginning.

That’s right. You must be very lucky, sounds crazy, you have this struggle because you have already achieved so much on the level of hard targets. Now you start to look again with those soft values and what they mean for you. This will enrich your life so beautiful
I agree with you. I am lucky to have both these experiences and skills needed. But there is also this flipside that I often feel lost. I am really in a no man’s land. I don’t fit in typical Indian context, nor do I fit here. But that’s fine, I chose this. I am happy about it because that keeps me going. That always gives me something else to work on: myself or my professional part.

Actually, I believe that a real progress in quality of life consist of making the best of two ways: the hard dimensions and targets on health, finance, education, etc., and the soft values of enthusiasm, trust, vulnerability, etc. I wonder what is there
Yeah, I don’t know what’s there. We will find out. You should interview me again in another twenty or ten years.

That’s right because this is where you are going.

Thanks a lot Priya for your wisdom. I am so moved because of your openness and vulnerability and why people care for you: that is also so beautiful, it really touched me.