The Next Industrial Giant Is ... India? NY Times article

August 31, 2006
The Next Industrial Giant Is ... India?
By KEITH BRADSHER
New York Times
PUNE, India — India's economic advancement no longer rests on telephone call centers and computer programmers.

Among villages with thatch-roofed huts and dirt roads on the outskirts of this city in central India, John Deere and LG Electronics have recently built modern factories turning out tractors and color television sets for sale in India and for export to the United States.

In Hazira, in northwestern India, where some residents still rely on camels to carry traders' goods, the Essar Group is making steel to be used for ventilation shafts in Philadelphia, high-rise structural beams in Chicago and car engine mountings in Detroit.

For decades, India had followed a route to economic development strikingly different from that of countries like Japan, South Korea or China. While its Asian rivals placed their bets on manufacturing and exports, India focused on its domestic economy and grew more slowly with an emphasis on services.

But all that is starting to change.

India's annual growth in manufacturing output, at 9 percent and accelerating, is close to catching growth in services, at 10 percent. Exports of manufactured goods to the United States are now rising faster in percentage terms than China's, although from a much smaller base. More than two-thirds of foreign investment in the last year has gone into manufacturing in India, not services.

"Saying we are a back office and China is a factory is a backhanded compliment," said Kamal Nath, India's minister of commerce and industry. "It's not really correct."

Indeed, in interviews at 18 Indian factories and other businesses in 10 cities and villages scattered across the length and breadth of the nation, the picture that emerges is of a country that is being driven by advances in manufacturing to a much brisker pace of economic growth.

A prime reason India is now developing into the world's next big industrial power is that a number of global manufacturers are already looking ahead to a serious demographic squeeze facing China. Because of China's "one child" policy, family sizes have been shrinking there since the 1980's, so fewer young people will be available soon for factory labor.

India is not expected to pass China in total population until 2030. But India will have more young workers aged 20 to 24 by 2013; the International Labor Organization predicts that by 2020, India will have 116 million workers in this age bracket to China's 94 million.

India's young population will also make it a huge and growing market for years to come, while the engineering skills and English skills of its educated elite will make it competitive across a wide range of industries.

So even though India remains a difficult place to do business, several multinationals have been placing big bets on India this year in hopes of taking advantage of this shifting global dynamic.

General Motors and Motorola are preparing to build plants in western and southern India. Posco of South Korea and Mittal Steel of the Netherlands have each announced plans to erect giant steel mills in eastern India, where Reliance of India will soon construct one of the world's largest coal-fired power plants.

They are finding India's labor force well suited to their goals. When LG set out to fill 458 assembly line jobs at its factory here last year at a starting wage of $90 a month, it required that each applicant have at least 15 years of education usually high school plus a technical college.

Seeking a young work force, the company decided that no more than 1 percent of the workers could have had any prior work experience. Despite the limitation, 55,000 young people met its criteria for interviews.

"In the villages there is little income," said Siddu Matheapattu, 24, in between applying sealant to refrigerator frames. "Here I can earn more."

By contrast, cities in export-oriented Guangdong province in southeastern China raised monthly minimum wages this summer by 18 percent, to $70 to $100 a month, after factories reported that they had 1 million more jobs than workers to fill them. Factories elsewhere in China face fewer labor shortages, but they also are being forced to raise wages.

As India has deregulated its economy, output has gradually accelerated to a growth rate of 8 percent a year, feeding a national euphoria and a few hopes of someday even beating China's annual growth of more than 10 percent.

Plenty of obstacles remain, however, notably India's weak infrastructure. China invests $7 on roads, ports, electricity and other backbones of a modern economy for every dollar spent by India and it shows. Ports here are struggling to handle rising exports, blackouts are frequent and dirt roads are common even in Bangalore, the center of the country's sophisticated computer programming industry.

Pervasive corruption has slowed many efforts to fix these problems. India's labor laws, little changed since they were enacted just after independence in 1947, also continue to discourage companies from hiring workers, by making it very difficult to lay off employees even if a company's fortunes sour or the economy slows.

Still, a new optimism prevails in India, bordering at times on euphoria.

"The Chinese are very good at copying things, but Indians believe in quality work, we believe in meeting pollution norms," said S.S. Pathania, the assistant general manager of the Hero Honda motorcycle factory in Gurgaon, 30 miles south of New Delhi. "I think India will pass China very soon."

An Unexpected Boom In Manufacturing

Sprawling across more than a square mile next to a gray tidal estuary, the scale of Essar Group's complex in Hazira is already impressive. Essar has its own port to bring in iron ore, its own large, gas-fired power plant for electricity. At the steel mill, giant buckets pour 150 tons of molten metal at a time to form slabs two yards wide and up to 10 yards long.

But the complex is just starting to grow. Essar is quintupling steel production and pushing forward a sevenfold increase in power generation, most of it for sale to a national grid desperately short of electricity.

Growth on that scale, especially in industries like steel and power but also in areas like car parts and household appliances, is what India has long lacked. Industrial production accounts for only a fifth of India's economic output, compared to two-fifths of China's. But this ratio is starting to rise in India as manufacturing, led by exports, grows faster than agriculture and even some service industries.

Until recently, legislation effectively barred companies with more than 100 people from competing in many industries. The laws were intended to protect tiny businesses in villages, often employing women and minorities; high tariffs were placed on imports as well.

But the result was hundreds of thousands of businesses too small to be competitive; India lags behind even impoverished Bangladesh next door in exports of garments, a big creator of jobs for China. The Indian government has responded by narrowing the list of protected industries to 326 categories of goods from 20,000 and has lowered tariffs.

Comparing factories in India to their competitors in China, many of the Indian factories are smaller but some appear more efficient.

India's stronger financial system demands higher interest rates than China's state-owned banks, making it costlier to hold the small mountains of components awaiting assembly that are often seen in Chinese factories. The Confederation of Indian Industry, a national trade group, has also been very successful in pushing companies to adopt the latest Japanese lean manufacturing techniques.

The drawback is that the nation's manufacturing boom, built on higher-quality goods made under more modern conditions than in China, is not likely to create as many factory jobs as India needs.

The Essar steel mill, for example, has been replacing old, labor-intensive equipment with more modern gear. "We were having it all done manually, but because the customers demand very high quality, we have to do it automatically," yelled Rajesh Pandita, an Essar manager, over the roar of a house-sized machine that was stretching a minivan-sized coil of steel back and forth through large rollers until it was little thicker than plastic kitchen wrap.

The Whirlpool factory in Pune uses machines, not people, to fold the steel exteriors of refrigerators. It has some of the highest productivity per worker of any Whirlpool factory in the world, with just 208 line workers producing up to 33,000 refrigerators a month.

Meanwhile, labor laws discourage flexibility. They still ban companies from allowing manufacturing workers to put in more than 54 hours of overtime in a three-month period even if the workers want to earn extra money. Firing workers is very difficult.

"Companies think twice, 10 times before they hire new people," said Sunil Kant Munjal, the chairman of the Hero Group, one of the world's largest manufacturers of inexpensive motorcycles.

Hero in Gurgaon, on the southern outskirts of New Delhi, and its archrival, Lifan Group in Chongqing, a city in western China, produce comparable motorcycles but the similarity ends there. Hero markets heavily to its domestic market, protected from foreign competition by high import tariffs, while Lifan emphasizes exports.

With scant ventilation, Lifan's factories are filled with diesel exhaust as workers test engines and ride finished bikes at breakneck speed out the doors, zigzagging past co-workers. Hero's factory in Gurgaon, where Honda holds a minority stake, has far better safety standards and excellent ventilation.

The Lifan factory pays less than $100 a month. The heavily unionized Hero factory pays $150 a month plus bonuses of up to $370 a month; nearly half the workers earn the top bonus, Mr. Pathania said.

Lifan's labor force is quiescent would-be organizers of independent labor unions face long jail terms or worse in China. Hero's workers staged a successful nonviolent protest last year to call for more contract workers to be eligible for the bonuses as well.

Overcoming Many Obstacles To Infrastructure Growth

But the biggest question mark hanging over the rise of manufacturing in India lies in whether the country has enough roads, ports and electricity generating plants to move huge quantities of goods and power the factories that make them.

Captain Abhay Srivastava, an operations manager at India's busiest port, was on duty on a recent afternoon when a phone call suddenly came in from the docks below. An enormous container ship from Qatar needed to slide 35 feet backward along the privately managed dock at the Nhava Sheva port near Mumbai to allow another large vessel to squeeze into the dock in front of it.

Captain Srivastava grabbed his white hard hat and dashed for the elevator. As soon as he reached the water's edge, a dozen laborers in orange jumpsuits began straining to arrange a cat's cradle of heavy, five-inch-thick ropes that would allow the ship to use its powerful winches to pull itself out of the way.

"They are efficient people; they don't speak a lot," said Captain Srivastava, who has visited most of the world's major ports either as a ship captain or for port training exercises. "You go to some places and they just stand around."

The efficiency of the Nhava Sheva port it approaches West Coast ports in the United States in the number of containers moved per hour shows that India is capable of producing world-class facilities.

But big as it is, Nhava Sheva is too small to handle the crush of traffic. John Deere tractors already wait in a container at the dock for one to four days before being loaded on a ship.

"If this pace of growth continues, we will see more congestion at the port," said Raj Kalathur, the managing director and chief executive of Deere's operations in India.

Similar worries prevail in Chennai, formerly Madras. "Another four or five years, we'll be choked," said M. Rafeeque Ahmed, the chairman of the Farida Group, a 9,000-employee shoe manufacturer in Chennai that needs the port for exports.

Infrastructure improvements are particularly important because manufacturing companies are buying more and more components from far-flung suppliers. Making sure all those parts arrive on time requires a reliable transportation system.

"Manufacturing is no longer done all under one roof," said Victor Fung, the chairman of Li & Fung Group, a large Hong Kong-based company that buys goods from factories across Asia for sale to retailers and wholesalers in the United States and Europe.

Indian officials are talking about expansion. Planning is under way for new wharves at Nhava Sheva, but the years-long task of construction has not yet started.

China has faced capacity problems, too. A surge in steel production in early 2004 overwhelmed Chinese bulk cargo ports. Inflation quintupled in a year, to 5.3 percent, as bottlenecks at ports, highways, railroads and elsewhere in the economy drove up companies' costs.

The Chinese response was swift and decisive. The pace of port investment nearly tripled in six months. Work crews labored around the clock to erect more cranes and expand wharves.

The Chinese economy grew at a breathtaking pace of 11.3 percent in the second quarter of this year, but consumer prices were just 1 percent higher in July than a year earlier.

By contrast, India is struggling with 8 percent inflation this summer as bottlenecks have appeared after three years of 8 percent growth.

Belatedly, India's roads and ports are improving. Just four years ago, Sona Koyo Steering Systems, an auto parts manufacturer, incurred hefty financing costs to keep a month's inventory on hand in case deliveries were delayed. Now the company's factory in Gurgaon makes six deliveries a day to a nearby Maruti car assembly plant; the eight-mile drive takes an hour or more because of constant traffic jams, but the deliveries get through.

"I'm not going to deny infrastructure is bad," said Surinder Kapur, Sona's chairman and managing director. "But a lot of our vendors are around us, a lot of our customers are close to us."

India is also starting to address chronic power shortages. But it is still a serious problem in northern India, where Mr. Kapur's steering systems factory is located. He receives electricity from the national grid just seven or eight hours a day. So the factory has three enormous diesel generators, one bigger than a typical Manhattan living room, operating at four times what an industrial user in the United States usually pays.

Despite such obstacles, India's manufacturing sector appears poised for further growth. In a country where the national symbol has shifted from government bureaucrats at aging desks to call center operators in cubicles, the next icon looks like it will be the laptop-toting engineer on a factory floor.

"The old philosophy was, 'I should work in an office, come in at 10 and leave at 4,'" said Nitin Kulkarni, 35, an engineer at the Hazira steel mill. But in recent years, he added, "there has been a revolution."

A Thaw Between India and China - LA Times

A Thaw Between India and China
The developing relationship between the wary Asian giants could shape the 21st century.

By Henry Chu and Mark Magnier
Times Staff Writers

August 25, 2006

NEW DELHI — High atop a snowy Himalayan pass, a lonely road linking Asia's two giants reopened last month after a 44-year diplomatic roadblock.

Leaders in India and China hailed the event as a sign of the growing rapprochement between neighbors that have eyed each other with distrust since a 1962 border war. Officials say the artery along the fabled Silk Road will invigorate trade between their two booming countries.

But the reopened Nathu La pass is an apt symbol of SinoIndian ties in more ways than one. The rough terrain, icy weather and extremely short list of goods approved for exchange are emblematic of the rocky path of limited engagement that Beijing and New Delhi have embarked on after decades of a political deep freeze.

Their evolving relationship may help define the 21st century as the world's two most populous nations — which account for one-third of humanity — try to pull themselves out of poverty and stagnation.

By 2050, some experts predict, the United States, China and India will have the planet's largest economies.

In a noticeable thawing of relations, New Delhi and Beijing have taken steps in recent years to reduce military tension, increase government contacts and expand trade. The two governments declared 2006 their "year of friendship," to be marked by cultural events and a summit of Chinese President Hu Jintao and Indian Prime Minister Manmohan Singh.

But establishing a truly strategic partnership will be no mean feat. Persistent suspicion among hawks on either side, unresolved border disputes, intensified competition for resources such as oil and gas, and influence from Washington could all act as a brake on Sino-Indian cooperation, analysts say.

That both nations stand to benefit from a peaceful, improved relationship is clear.

"In the next two decades, both sides want to be a rising power," said Hu Shiren, a South Asia expert at the China Institute of Contemporary International Relations in Beijing. "To facilitate this, you must have good, stable surroundings. Cooperation is most imperative."

China's communist government, in its rush to remake the country into a capitalist powerhouse, has put a premium on stabilizing relations with neighbors and settling contested borders.

India, too, after years of looking inward, is liberalizing its economy and paying more attention to the region. It's particularly keeping an eye on China, whose economy is nearly three times the size of its own, as it begins flexing its muscles politically, militarily and economically on the global stage.

"They've been a rising power for 20 years, and we didn't notice. We were so obsessed with our little world," said Mohan Guruswamy, head of the Center for Policy Alternatives in New Delhi. "The establishment in India has begun to take note, and it's slowly and lumberingly beginning to change its attitude."

Mention China here and hackles still rise. Official Indian rhetoric on the behemoth to the north remains heavily colored by the 1962 border war that led to the closing of the Nathu La pass, a conflict each side accuses the other of provoking.

In 1998, India's defense minister pointed to China as the country's No. 1 threat. That same year, the Indian prime minister infuriated Beijing by writing a letter to President Clinton citing China as one of two reasons India was conducting nuclear weapons tests.

The other reason was archrival Pakistan, a longtime ally of China whose own nuclear buildup Beijing is accused of aiding.

The Indian military's view of China is one of abiding mistrust.

"It's gospel among the armed forces. It's sacred to the hawks in this country," said Alka Acharya, an expert on international relations at Jawaharlal Nehru University. "They don't budge from that position."

Large swaths of mountainous territory technically remain in dispute between Beijing and New Delhi, despite a breakthrough agreement three years ago to push for a permanent settlement. Several rounds of talks have yielded little substantive progress.

The recent completion of China's Tibetan railway touched off warnings here of easier access to the area by People's Liberation Army troops. China contends that the rail line was built to help develop its impoverished western provinces.

"Some Indians see an ulterior motive, but this is ridiculous," said Hu, the South Asia expert. "If there were a war, of course the railway could serve military purposes; but its main purpose is for the economy."

In contrast to the enduring suspicion among the Indian military's top brass, the reality is far more relaxed. The India-China border, which stretches for more than 2,500 miles, has lain largely quiet for 25 years, to the point that soldiers on both sides of the Nathu La pass engage in friendly sporting matches, celebrate each other's festivals and exchange gifts.

Reopening the pass July 6 represented official recognition not just of greater mutual trust but of the increasing importance of economics in Sino-Indian ties.

Last year, trade between the two nations was estimated at $18.7 billion, up by more than a third from 2004. This year, it is expected to hit $20 billion.

Pharmaceuticals, chemicals and steel flow from India to China; manufactured goods and commodities such as silk come back. Economists expect China soon to overtake the United States as India's biggest trading partner.

In the early 1900s, the Nathu La pass, more than 14,000 feet above sea level, was the most important commercial corridor bridging the two countries, accounting for 80% of bilateral trade, according to some estimates. The land link saves thousands of miles and weeks of travel compared with shipping goods by sea.

But demonstrating the wariness with which the two sides still regard each other, Indian merchants are allowed to export only 29 items, such as rice and flour, across the pass, and their Chinese counterparts must stick to a list of 15 approved goods, including goatskins and yak tails, which are used as fly swatters.

Predictions that trade through Nathu La could reach nearly $3 billion in less than 10 years seem wildly optimistic unless the list of items is greatly expanded and better infrastructure is built.

"It will take time, but it's better than nothing," said Wang Jinzhen, secretary-general of the China Council for the Promotion of International Trade.

Restrictions on trade are not limited to the Nathu La pass. Chinese trade experts say China has lowered its tariffs faster than India and welcomed earlier and greater foreign participation in such important sectors as retailing and auto manufacturing.

Chinese telecommunications companies trying to invest in India complain of being made to jump through more regulatory hoops than American or European firms on the grounds of national security. For example, the Chinese telecom company ZTE's bid to enter the Indian market has been blocked by an Indian government investigation of "safety" issues.

Clashes also have cropped up in the two countries' scramble for sources of energy to fuel their burgeoning economies. Indian and Chinese oil companies have gone head to head several times for access to reserves around the world, including South America and Central Asia, with China almost always emerging the victor.

In January, Beijing and New Delhi agreed to work together in securing reserves abroad. Putting the deal into practice may be difficult, but analysts say both nations need to cooperate in the face of dwindling supplies.

"There isn't enough if you just go and fight for it. We need to pool our resources," said Acharya of Jawaharlal Nehru University.

"Competition is bound to emerge, particularly since we're looking at the same markets, the same sources of technology and energy," she said. "But this is precisely why [China] is the most important potential partner as well. You could clash on energy if you don't work with China. You could clash on U.S. markets if there's not some kind of understanding there. We are both too big to be competing for the same things, in the same neighborhoods, at the same time."

Although the United States' trade relationship with China, at $285 billion last year, dwarfs that with India, the Bush administration has made improving ties with New Delhi one of its top foreign policy priorities, as seen in its push for a civilian nuclear cooperation deal with India, a reversal of long-standing policy.

Senior U.S. officials have openly described improving relations with India as a way to offset China's growing clout in Asia, and building up India's nuclear arsenal as a way to keep Beijing worried more about New Delhi than about Washington.

That kind of talk has stoked Chinese fears of American attempts to "contain" China. At the same time, India has looked askance at Beijing's aid to Pakistan in building a submarine base at Gwadar, in southern Pakistan.

Guruswamy, of the Center for Policy Alternatives here, said diplomacy in the region needn't be played as a zero-sum game.

"It doesn't mean that if you have good relations with America, you have bad relations with China," he said. "That's not required in the modern world."

Establishing a deeper partnership between India and China, however, will require a concerted effort not just to overcome historical obstacles but to sell the idea to the people of both countries.

Chinese tour groups may be hitting popular destinations across the globe, but India isn't among them, and vice versa. There is no way to fly direct between Beijing and New Delhi on any Chinese or Indian carrier; the only way to do so is on Ethiopian Airlines.

But Wang of the China trade-promotion council is hopeful.

"Both are developing countries at a stage that requires cooperation," he said. "Closer ties are good for the region and the world."

*


--------------------------------------------------------------------------------
Chu reported from New Delhi and Magnier from Beijing. Gu Bo in The Times' Beijing Bureau contributed to this report.

12 Planets (and Counting)

A committee of experts appointed by the International Astronomical Union (IAU), has determined that our solar system has 12 planets - for more details see below the excerpt of an article from Knowledge News.

My immediate concern is that this portends extensive unemployment for all our pandits and jyotish's who take great pleasure in informing us common folks about the impact on planets on our lives and our fortunes. Does it not seem strange that Pluto's influence is never mentioned in astrological charts.

I wonder if we will have a whole new class of astrologers who will factor in the new planets. Oh, Planet Ceres please be kind to us humans :-)

=======================================================================

The IAU had asked its committee to come up with an answer to the question "what is a planet?" Surprisingly, there's never been an official scientific definition. As one astronomer has lamented, "It's something of an embarrassment. . . . We live on a planet; it would be nice to know what that was."

Now, we will--assuming the IAU's members vote to approve the committee's recommended definition at a meeting in Prague next week. So, what does the new definition say? And what might a new map of the solar system look like?

Round and Unbound

According to the new definition, a planet is any celestial body that meets three criteria:

It orbits a star.


It's neither a star nor "a satellite of a planet" (a moon).


It's round. More technically, it "has sufficient mass for its self-gravity to overcome rigid body forces so that it assumes a hydrostatic equilibrium (nearly round) shape."
With this definition, the debate over whether Pluto's planetary license should be revoked ends. Tiny Pluto gets to be a planet after all. But so does Ceres, the largest asteroid in the asteroid belt between Mars and Jupiter. It's promoted from "largest asteroid" to "smallest planet" (or, more accurately, restored, since astronomers counted Ceres as a planet when they found it in 1801). Just 590 miles (950 km) wide, Ceres is less than half Pluto's width.

Two New "Plutons"

Along with Ceres, two other known celestial bodies would immediately become planets. One is the frigid, faraway object officially known as 2003 UB313, nicknamed Xena. At least as big as Pluto--and three times more distant--Xena's discovery helped push astronomers to define "planet."

The other is Charon, currently known as Pluto's main moon (Pluto has two other tiny moons, just discovered). Why should Charon count as a planet when our moon doesn't? Because--at more than half Pluto's size--Charon isn't really a satellite of Pluto. Instead, Pluto and Charon continually orbit each other. Under the new proposal, Pluto and Charon would count as a "double planet."

Pluto, Charon, and 2003 UB313 would also be part of a new class of planets called "plutons," which the proposal differentiates from the eight "classical planets." Like Pluto, the plutons take centuries to circle the sun, and their orbits are elongated and tilted compared with those of the classical planets. Scientists expect to find a lot more plutons in the years to come--perhaps dozens more.

Solar System Summary

It all sounds like radical change. But bear in mind that it's mainly a matter of nomenclature. On a journey out from the sun, you'll still find the following in our little solar system:

Four "terrestrial" planets: Mercury, Venus, Earth, and Mars. These planets are made mostly of rock, they have solid surfaces, and they don't have rings.

An asteroid belt beyond Mars and before Jupiter--though on your way through it, you probably won't see a single asteroid. It's far less crowded than you may think. By far the biggest body is Ceres. It accounts for about a third of the entire mass of the asteroid belt.

Four gas giants or "Jovian" planets: Jupiter, Saturn, Uranus, and Neptune. These are big, they're made mostly of gas, and they have rings.

Pluto, Charon, and a growing number of other "trans-Neptunian objects." These bodies are distant, cold, and to blame for our changing conceptions of "planet."
Astronomers didn't discover Pluto until 1930. They didn't discover Charon until 1978. And they didn't discover another "trans-Neptunian object" until 1992. Since then, they've discovered hundreds of them--some as big, or bigger, than Pluto. Whether we wind up calling these objects "planets," "plutons," or something else entirely, they're clearly part of a new astronomical frontier--and we're witnessing its birth.



I guess the all the astrological signs will now have to be revised for this drastic change. Now

McSurgery:A Man Who Saved 2.4 Million Eyes

McSurgery:A Man Who Saved 2.4 Million Eyes

Ophthalmologist in India
Revamped Care for the Poor
By STEPHEN MILLER
August 5, 2006; Page A6
WALL STREET JOURNAL


Today, The Wall Street Journal begins a weekly column that notes the passing of people who have left an imprint on the world of business.

Govindappa Venkataswamy, eye-care pioneer (1918-2006)

With 2.4 million served, the Aravind Eye Care System in India is in a way the McDonald's of cataract surgery: efficient, effective, influential and -- rare for health care in the developing world -- a clear financial success.

It began with one man, Govindappa Venkataswamy, an ophthalmologist who died July 7 at age 87 after a long illness. Dr. V, as he was universally known, created one of the largest eye-care systems in the world, catering largely to the poor in Tamil Nadu, a state in southern India. He was inspired, Aravind says, by the assembly-line model of McDonald's founder Roy Kroc -- learned during a visit to Hamburger University in Oak Brook, Ill.


Govindappa Venkataswamy 'Dr. V' credited the assembly-line methods of McDonald's with the financial success of his eye-care centers, which cater largely to the poor in India.
Building on those lessons, he created a system for sight-saving cataract surgeries that produces enviable medical outcomes in one of the poorest regions of the globe. Its rapid expansion over three decades was not built through government grants, aid-agency donations or bank loans. Instead, Dr. V took the unusual step of asking even poor patients to pay whenever they could, believing the volume of paying business would sustain the rest. Poor people with cataracts in Tamil Nadu can get their sight restored for about $40. If they can't afford that, it's free.

Starting with an 11-bed clinic in 1976, Dr. V's system is now a five-hospital system. His model became the subject of a Harvard Business School case study, and is being copied in hospitals around the subcontinent. The cheap, high-quality implantable lenses the system manufactures are exported to more than 80 countries around the world, Aravind says.

Dr. Venkataswamy's basic insight was that health care can be marketed to the poor if a program is closely tailored to a local niche, something that has come to be known as social marketing. In a country with, by some estimates, 20 million blind eyes -- 80% of them due to curable cataracts -- the appeal for patients was financial. "A blind person is a mouth with no hands," is an Indian saying that Dr. V liked to quote. In India, health professionals say, the years of life left to those who go blind can be counted on one hand. With sight restored, the patient can return to work.

The Aravind system offers services that range from a simple pair of spectacles to optical oncology. The bulk of surgeries are to treat cataracts -- removing the cataract and replacing it with an artificial intraoptical lens.

The assembly-line approach is most evident in the operating room, where each surgeon works two tables, one for the patient having surgery, the other for a patient being prepped. In the OR, doctors use state-of-the-art equipment such as operating microscopes that can swivel between tables. Surgeons typically work 12-hour days, and the fastest can perform up to 100 surgeries in a day. The average is 2,000 surgeries annually per surgeon -- nearly 10 times the Indian national average. Despite the crowding and speed, complication rates are vanishingly low, the system says.

Outside the operating rooms, conditions are as spartan as the tables at a fast-food restaurant: Often only a straw mat on a ward floor for postsurgical recovery. Patients who pay more than the basic $40 -- about 30% of patients -- can receive cushier treatment such as private rooms for extended recovery, and hot meals.

Dr. Venkataswamy was born in a poor rural Tamil Nadu village. A wealthy uncle paid for his secondary schooling. He joined the Indian Army Medical Corps in 1945, where he came down with rheumatoid arthritis that threatened his dreams of a medical career. It was only after long therapy that he trained his gnarled fingers to manipulate a surgeon's scalpel.

As an ophthalmologist, Dr. V was exposed to the enormity that is rural blindness in India. He researched vitamin A deficiency, a major cause of blindness in children, and began organizing rural fairs where peasants gathered for eye treatment. In 1976, at age 58, he opened the Aravind Eye Hospital in Madurai, in Tamil Nadu. With him came two other doctors: his sister and her husband, both eye surgeons. All three took pay cuts to pursue what at the time must have seemed an almost quixotic venture.

Certainly it seemed so to bankers, who wouldn't lend money to a clinic that promised eye care to poor and rich alike, regardless of ability to pay, according to an Indian business journal. So Dr. V mortgaged his house. Within a year, the clinic quadrupled in size. By 1981, a 250-bed hospital was complete, and the basic Aravind model was in place.

Dr. V liked to say that his ambition was to stamp out needless blindness in India, and broaden his model all over the world. "Tell me, what is this concept of franchising?" Dr. V commented to the Harvard Business School researcher who conducted a case study in 1994. "Can't we do what McDonald's and Burger King have done in the United States?"

He has laid the groundwork for it. Aravind says its model has made significant gains in the subcontinent in recent years, with the basic model being adopted in hospitals in Mumbai, Kolkata and Nepal, and the Indian government adopting its medical protocol for training centers around the country.

Teams of Aravind consultants advise hospitals in East Africa and the Far East. Aurolab, the Aravind system's successful manufacturing arm, says it produced 6%-7% of the low-cost lenses world-wide in 2002, and has sold them in 120 countries -- though not in the U.S., where Food and Drug Administration regulations are a prohibitive hurdle.

But Dr. V's dream of McDonald's-style eye-care franchises around the world may prove difficult, because the culture of Aravind involves more than the profit motive and a fast-food manual. Like Dr. V, many of the highly dedicated surgeons and staff are devotees of Sri Aurobindo, a Hindu master for whom the hospital was named. Dr. V has said they are "building an organization that seems to be linked to the higher consciousness."

The work is grueling, and while pay is comparable to that of government surgeons, retention is still a problem. A quarter of the professional staff defects each year to better-paid jobs in the private sector, the system says.

Management is still largely with Dr. V's family. But where are the charismatic capitalists to open new Aravinds abroad? "So far we have not been able to develop entrepreneurs in health from the management side," Dr. V lamented in a 2004 interview with an Indian business journal. "Everybody wants to be an entrepreneur in information technology or an associated field."

A Small Charity Takes Lead in Fighting a Disease

New York Times,
July 31, 2006
A Small Charity Takes Lead in Fighting a Disease
By STEPHANIE STROM

PATNA, India — The drug that could have cured Munia Devi through a series of cheap injections was identified decades ago but then died in the research pipeline because there was no profit in it.

So Mrs. Devi lay limp in a hospital bed here recently, her spleen and liver bulging from under her rib cage as a bilious yellow liquid dripped into her thin arm. The treatment she was receiving can be toxic, and it costs $500. But it was her best hope to cure black fever, a disease known locally as kala azar, which kills an estimated half-million people worldwide each year, almost all of them poor like Mrs. Devi.

Soon, however, all that may change. A small charity based in San Francisco has conducted the medical trials needed to prove that the drug is safe and effective. Now it is on the verge of getting final approval from the Indian government. A course of treatment with the drug is expected to cost just $10, and experts say it could virtually eliminate the disease. If approval is granted as expected this fall, it will be the first time a charity has succeeded in ushering a drug to market.

This novel way of helping people whose needs have not been met by for-profit pharmaceutical companies is gaining traction. Several partnerships are working to develop drugs to fight neglected diseases, underwritten by the Bill and Melinda Gates Foundation, Doctors Without Borders and other groups. Another nonprofit agency, the Aeras Global TB Vaccine Foundation, is searching for a means to prevent tuberculosis.
For its first project, the San Francisco charity, the Institute for OneWorld Health, focused on reclaiming the all but abandoned drug, paromomycin, which research found promising in the 1960’s.

That was the easy part. Its hurdles lay elsewhere. The Internal Revenue Service at first denied the charity nonprofit status, concerned that it looked too much like a for-profit enterprise. The World Health Organization, which controlled the drug, was reluctant to hand over the data needed for further development. And OneWorld Health had to set up clinical trials matching United States and European standards in one of the poorest parts of the world.

Nor was it obvious where the money would come from. The idea of a nonprofit drug company struck many as folly when Dr. Victoria Hale, a former Genentech executive and Food and Drug Administration official, founded OneWorld Health in 2001. So Dr. Hale and her husband started the project using their own money, though they have since won support from the Gates foundation, among others.

“My colleagues and mentors in the pharmaceuticals industry told me it was a wild idea, that it would never work out, that I was jeopardizing my reputation,” Dr. Hale said. “I started this organization knowing our first project had to be a winner or we wouldn’t survive.”



An Ambitious Goal

Dr. Hale hopes to stamp out black fever eventually, a goal that many doctors regard as impossible. “The last disease we truly eradicated was smallpox,” she said. “There’s no urgency to eradicating diseases anymore. Why not?”

Black fever is the second-largest parasitic killer in the world after malaria. It is spread by sand flies, and Banthu, the squalid village about an hour’s drive from here that Mrs. Devi calls home, is an ideal breeding ground for them.

The flies multiply in the cow dung that Mrs. Devi uses as fuel for cooking. They relish the sap in the banana groves and bamboo stands, and they thrive in the thatch used to make the tiny houses. Flies that have bitten infected humans transmit the disease when they bite another person. Smaller than mosquitoes, they can pass through most netting.
Roughly 90 percent of black fever cases worldwide are found here in Bihar State in India and in Bangladesh, Nepal, Sudan and northeastern Brazil.

Mrs. Devi’s daughter was the first in the family to contract the disease, and she died from it. Then Mrs. Devi’s youngest son, Rajesh, got it, and she brought him to the Rajendra Memorial Research Institute of Medical Science here, where he was treated and recovered. Now she, too, is receiving treatment.

It is at the Rajendra Institute, a government research facility, that OneWorld Health set up one of the trials needed to make paromomycin widely available.

Many Early Battles

Dr. Hale first set her sights on the drug after she attended a conference in Belgium in 1999, where Dr. Shyam Sundar, an expert on black fever, was railing against the world’s failure to fight the disease.

“The tragedy, maybe even the crime, is that we have known that this drug is an effective treatment for kala azar since the 1960’s,” said Dr. Sundar, whose free clinic in Muzaffarpur was also a site for a trial by OneWorld Health. “We could do something, but we were choosing not to.”

After visiting Dr. Sundar’s clinic in 2000, Dr. Hale, who was doing consulting work at the time, hired a law firm to help her get the tax exemption necessary to create a nonprofit drug company. The I.R.S. turned her down three times over 10 months, suspicious that her plan was a scheme by the drug industry to shelter profits. The tax agency challenged her to find an example of an existing charity that mirrored a for-profit business.

“It took me five days, and then at dinner, it hit me: N.P.R. and public television,” she said. “They look an awful lot like for-profit radio and television, but they serve a different audience with programs that their for-profit counterparts don’t provide because they can’t profit from them.”

Two weeks later, OneWorld Health received I.R.S. approval and set out to tackle black fever.

The immediate challenge was financing. For a time, OneWorld Health survived on the largesse of Dr. Hale and her husband, Dr. Ahvie Herskowitz. They put up $100,000, signed a $315,000 promissory note, used the ground floor of their house as offices, and worked without pay for two years.

The Gates foundation, which at the time was primarily underwriting vaccines and other preventive strategies, eventually offered a grant of $4.2 million that grew to $47.2 million for the development of paromomycin. Dr. Hale also got help from others, including the Skoll Foundation, which has provided financing to underwrite salaries for new senior executives.

An Abandoned Drug

An initial, formal test of paromomycin, an antibiotic sold in some countries as an oral treatment for diarrhea and as a topical treatment for cutaneous leishmaniasis, which causes lesions, was done in the late 1980’s in Africa, two decades after it was identified as a simple, cheap, effective cure for black fever.

Through a series of company mergers it was consigned to the corporate shelf and forgotten, ending up with the World Health Organization, which lacked the money to develop it beyond the Phase II clinical trials.

But negotiations with the World Health Organization to hand over the data that would allow OneWorld Health to organize the Phase III clinical trials necessary for regulatory approval dragged on for almost two years. At the time, the W.H.O was developing another drug for black fever with Zentaris, a large pharmaceutical company, and the Indian government. That drug, miltefosine, has the advantage of being an oral treatment, while paromomycin is administered by injection.

But miltefosine, an anticancer drug, also has drawbacks. In trials, it caused gastrointestinal problems in one-third of the patients. And patients must be strictly supervised to ensure that they take the full 21-day course of treatment and that women of child-bearing age are using birth control. By contrast, paromomycin has shown almost no side effects in trials.

With a price of $100 to $200 a treatment, miltefosine is out of reach for most patients and government purchasing programs.

Dr. T. K. Jha, a specialist in black fever who oversaw one of the OneWorld Health trials, said the W.H.O. wanted to make sure miltefosine made it onto the market before handing over its data on paromomycin. “Commerce got in the way,” Dr. Jha said.

But Dr. Robert G. Ridley, director of the W.H.O.’s special program for research and training in tropical diseases, disputed that. Dr. Ridley wrote in an e-mail message that the “time lag” had to do with getting financing from the Gates foundation and the process of negotiating an agreement with OneWorld Health.

The subject of the commercial aspects of drugs is a difficult one for OneWorld Health, which is careful to avoid criticism of its for-profit cousins, as well as competition with them.

“We look a lot like each other,” Dr. Herskowitz said. “But we fill a gap pharma companies cannot because they have to make a profit.”

But given the choice of paying more than $100 for Zentaris’s miltefosine or $10 for paromomycin, governments and most patients will no doubt choose the cheaper drug.
OneWorld Health does not intend to gain income from the drug. It has given a license to Gland Pharma, an Indian drug company that has agreed to manufacture the drug and sell it at cost when it is approved. But Dr. Hale can foresee a time when, say, a drug OneWorld Health hopes to develop to treat childhood diarrhea could be sold to travelers by a for-profit drug maker in exchange for royalties that would help sustain her organization’s charitable work.

Still More Difficulties

Approval of paromomycin will not end OneWorld Health’s challenges. Distribution looms as the next hurdle.

In Patepur, a somewhat more prosperous village than Mrs. Devi’s, Dr. Syed Misbah Hassan, a clinical research coordinator for OneWorld Health, diagnosed kala azar in one boy after another.

Dilip Manjhi, who is about 15, lay listless on a string bed as Dr. Hassan examined his abdomen for the telltale signs of the disease, a swollen spleen and liver. Dilip’s spleen extended eight centimeters below his rib cage and was rock hard. His liver protruded three centimeters below his ribs.

Getting paromomycin to remote villages like Patepur at the end of pothole-pocked roads will be difficult. Dr. Hale is trying to enlist a British nonprofit group, Riders for Health, to help. The group uses motorcycles to connect poor people to medical services. In Zimbabwe, for instance, it has taken pregnant women in need of Caesarean sections to hospitals.

“My thinking,” Dr. Hale said, “is that we could equip a motorcycle with a cooler to transport the drug and equip the driver to give the injections and maintain records.”
But first, the Bihar State government and India’s central government must create a system that encompasses diagnosing the disease, buying and administering the drug, keeping records and spraying to reduce the sand fly population.

Some experts wonder whether the government has the will to create such a system, when hundreds of thousands of Indian children die each year of measles, which can be prevented with a 15-cent vaccine. But Dr. C. P. Thakur, a former Indian health minister who oversaw a OneWorld Health trial of paromomycin, noted that black fever was one of five insect-borne diseases the Indian government had pledged to eliminate.

India has also signed an agreement with the governments of Nepal and Bangladesh to eradicate the disease, and the Bihar State government has shown a willingness to work with OneWorld Health.

“The government will be the biggest challenge,” Dr. Thakur said. “But I believe the opportunities to end this disease have never been better, and also that the government’s will has never been stronger.”

In the Land of Four-Star Asceticism

August 13, 2006
In the Land of Four-Star Asceticism
By PATRICIA LEIGH BROWN
New York Times

SHE was Glinda in a sari. Early that morning, she had glided ethereally across the courtyard with her fellow healing goddesses, their feet bare, their flowing white garb edged in gold. The bird trills reverberated off the palace walls.

“Please sit,” she said prayerfully. Soon, thick warm sesame oil infused with medicinal herbs began to permeate my meager muslin thong. She breathed heavily, karate-chopping the oil with the edges of her hands. She gently pummeled me with poultices, hot bundles of herbs resembling bouquets garnis. In the background, I heard oil sizzling. I felt a strange compulsion to go fry myself in a wok.

There is a sign at the entrance to Kalari Kovilakom, the more than 150-year-old palace in the state of Kerala, India, now known as the Palace for Ayurveda, that says “Please Leave Your World Here.” But, having encountered elephants ambling along the highway from the airport, you already have. You have taken the Order, the humble oath of four-star asceticism. You have agreed to forsake all known forms of vacation decadence (rice gruel for dinner, anyone?), to give up meat, alcohol, caffeine, leather accessories, naps, sunbathing, swimming and mindless frivolity in order to purify and balance your whacked-out Western body and soul.

You are here to immerse yourself in ayurveda, the 3,500-year-old herb-based healing tradition that still flourishes in the daily life of India.

Within the palace’s teak-columned halls, with exquisite images of gods and goddesses carved into the ceiling, you are less tourist than nun. Your Patagonia clothes, bought at great expense in anticipation of premonsoon humidity and soaked in a toxic cocktail of insecticide as per your doctor’s instructions, have been exchanged for compulsory no-frills attire meant to relax the mind. These were whipped up overnight by a tailor who came to your room — garments, as one guest from London observed, “that made us look a bit like ‘One Flew Over the Cuckoo’s Nest.’ ”

For pilgrims with deep pockets wanting an authentic immersion into this ancient medical system, including a radical purification and detoxification treatment known as pancha karma, the Kalari Kovilakom — which markets itself as combining “the indulgence of a palace with the austerity of an ashram” — is the real deal. Since the 1970’s, “ayurveda tourism” has drawn Lonely Planet acolytes and Rough Guiders, especially young Germans, to the thatched-hut beaches of southern India, lured by the promise of $5 massages.

But with the reimagining of this historic rajah’s palazzo by the Casino Group — Keralan hoteliers who have shrewdly rechristened themselves CHG Earth — the ante has been considerably upped.

Daybreak finds K. Narayayanan Nair, an ayurvedic chef whose first language is Malayalam, the native language of Kerala, standing barefoot in the kitchen roasting chappatis over an open flame — a scene that would not be found at Canyon Ranch. His vessels are copper, stone and clay. “Aluminum can harm the nature of food,” he explained. “Very bad for stomach.”

The palace lies in “the land of the cloud-capped hills” in the remote Palakkad district against the Western Ghats, the otherworldly mountains bordering Tamil Nadu. Kalari Kovilakom is not exactly a hotel, not exactly a hospital and not exactly a spa, but a weird hybrid with a Mother Superior aura (in accordance with strict ayurvedic principles the establishment requires a minimum 14-day stay).

Along with more conventional upscale resorts like the Kumakarom Lake Resort, nestled in the backwaters south of Cochin, the historic outpost of spice traders on the Arabian Sea, the new ayurveda luxe taps into the country’s growing wave of medical tourism. But instead of a new kidney, ayurvedists — longevity-seekers who are already deeply into the present moment — come to Kerala to detoxify and purify with ayurvedic doctors, the new yogis, for whom mind, body and spirit have been fused for more than 3,000 years.

In 1887, the British administrator William Logan wrote of a native medical system in which the universe, including the human body, is formed by five great elements — space, air, fire, water and earth. Then, as now, Logan observed, ayurveda, which means “knowledge of life” in Sanskrit, was designed to “restore health and establish the digestive powers and likewise create intellectual brightness, personal beauty, acuteness of the senses, and prolongation of life.”

Ayurveda can be difficult to grasp for non-Indians, with hundreds of levels of practice, from learned to folk. It is part of the country’s medical system, with 2,100 ayurvedic hospitals, 196 medical colleges and a dozen major pharmaceutical companies. These join storefront village pharmacies overflowing with dusty medicine bottles and gnarled roots. Even the luxury-tourist experience ricochets wildly, from by-the-book, purer-than-thou abstinence worship to sybaritic resorts where a hit of ayurveda can be had before a poolside Pimms Cup.

Catatonic with jet lag, I arrived at Kalari Kovilakom as the first installment of a two-week trip to India in which I would dip in and out of Ayurveda World. Traveling solo, I chose Kerala not just for ayurveda, which has deep roots here, but also for its tropical cuisine, its history of progressive politics, its 91 percent literacy rate and, not the least, the sensuousness of a culture where even trucks are works of art.

Unlike my Kalari brethren, who were committed to at least two weeks of pancha karma — albeit without the more extreme purges involving induced vomiting and blood-letting with leeches — I was a fallen woman from the start. To supplement strange hot green decoctions of herbs sipped like tea, I secretly mainlined Peet’s coffee from San Francisco with a portable REI French press in my room, an unspeakable act of moral weakness that was ayurvedic suicide.

I hid this from Dr. Rudram Amma Sreelatha, one of two staff doctors, who had a hibiscus on her desk, as she began, as is customary, with a lengthy consultation to determine the elements, or doshas, of my native constitution — a process she refers to as “diagramming the person.”

“Are you tired or fresh when you wake up?” she asked with probing eyes.

“Do you remember your dreams?”

“What were your childhood diseases?”

“How is your sexual life?”

Then it was on to Raj Shekhar, the palace’s gifted yoga instructor.

“Do you prefer foods that are sweet, sour, salt, bitter or chilly?” he wanted to know.

“How is your thirst?”

“Have you had any traumas in childhood?”

Five years of therapy had suddenly collapsed into a single morning. And it wasn’t even lunchtime.

Ayurvedic doctors like Dr. Sreelatha diagnose illnesses and imbalances through darsana, observing the way a person moves, walks and behaves; sparsana, touching; and prasna, interrogating.

The big idea of ayurveda, said to have divine origin, is that health is a state of balance between body, mind and consciousness. Its sister discipline is yoga, which, before it became an industry, was also a science dating back to the Vedic period. One’s constitution is said to be composed of three doshas — vata (air), pitta (fire) and kapha (water) — encoded in every cell. Initial treatment includes a prescribed diet (supplemented with herbs both ingested and applied), yoga, meditation and massages to prepare the body for elimination of agni, or waste. Pancha karma, a specialty of Kerala and no stroll through the park, includes a stamina-challenging sequence of enemas.

“We are not treating part by part and organ by organ,” Dr. Sreelatha explained kindly. “We consider the body and soul.”

Soon I found myself spread-eagled in a muslin loincloth as the beatific 24-year-old Sreeni Gopi lit a candle, said a prayer and anointed the crown of my head with sandalwood paste. With another therapist — there are usually two or more — she began kalari uzhichil, a massage that harks back to kalari payattu, the traditional Keralan martial art that once flourished at the palace and employed ayurveda for optimum health.

On a table shaped vaguely like a human being, hollowed slightly to capture oil, my spine was a cobra unfurling. Then Ms. Gopi led me to what appeared to be a gigantic cabinet, actually an herbal steam bath. Sweat mingled with oil as I sat in a Victrola cabinet of steam.

My vata imbalance — sapping my creativity and “native pitta fire” — melted away under ladlefuls of warm water mixed with green gram, a slightly exfoliating lentil. The goddess, in the act of bathing, had returned me to an infant state.

Mornings unfolded simply, with music from nearby Hindu temples the reveille of India. Yoga began in a deeply shaded sanctum; the heat seemed almost a living being. Breakfast, a steamed rice-flour pancake with a plantain cooked with coconut and brown sugar, arrived ceremoniously on a brass tray, eaten, as is traditional, with the hands. Afterward guests (or were we patients?) drifted maharajah-like across marble floors, polished and fragrant with lemon grass oil.

“It’s not Mauritius or Bali,” observed Patrice Gilbert, a Parisian pharmacist who was completing two weeks of pancha karma with his wife with a farewell dinner of artfully prepared gruel. “It’s a treatment. The most important thing is the quiet, because you are inquiring within yourself. It’s a silent release.”

Allergic either to oil or austerity I promptly broke out in a rash. But Kerala was filled with ardent ayurvedists.

There was Sue Muir, a 54-year-old headhunter from Warwickshire, England, who was seeking relief from asthma and found it with nasal inhalation treatments and “very expensive pummeling.” There was Florence d’Hauterive, a Parisian 50-something human resources executive, who has been to Kerala six times for ayurveda simply to unwind (“I’m not an ashram-type person,” she said of the voluntary severity of a hotel similar to Kalari Kovilakom. “I got so depressed I almost ran away”).

And there was Dr. Irfan Sheikh, an Indian-born English pediatrician who, frustrated by the inability of Western medicine — known in India as “English” or “allopathic” medicine — to address chronic pain, began incorporating both acupuncture and ayurveda in his practice. He was in Kerala having ayurvedic treatments to “kick start” his own immune system after cancer surgery, radiation and chemotherapy. “They offered me anti-depressants,” he said of his Western colleagues. “But I wasn’t depressed.”

In India, and especially Kerala, a relatively rural state with a tropical climate that makes love to practically anything that grows, ayurveda is part of the warp and weft of daily life. When babies are born, their first foods are rice and green gram, known for balancing all three doshas. Spices in the Indian larder, including tumeric, cinnamon, nutmeg, ginger and cardamom, all have medicinal properties. In earlier days, mothers and grandmothers made oil for different kinds of ailments from ghee, coconut and sesame, and even Bangalore tech execs still routinely apply oil to the head before work.

In monsoon season, many Indians go for a “tune up,” when the air is humid and the skin is thought to be more permeable. “Whenever your mother said, ‘this is good for this’ and ‘that is good for that’ she was teaching you ayurveda,” said Joseph T. Joseph, the manager of Kalari Kovilakom, which has a special kitchen for herb preparation.

IN Aranmula, a picturesque hamlet on the Pamba River, Dr. Hari Kumar Bhasker runs the NSS Ayurveda Hospital, where a portrait of Lord Dhanvantari, the physician of the gods, hangs in the entrance hall. Outside are demonstration gardens lush with ayurvedic plants — holy basil (for fever, skin lesions); brahmi ( memory); ashoka trees (mental acuity), Indian gooseberry (an anti-oxidant). He has received financing from the United Nations and the Indian government to conserve and cultivate medicinal plants.

At the Vijnana Kala Vedi Cultural Center in Aranmula, an innovative school dedicated to Keralan traditional arts, including dance and mural painting, Dr. Bhasker teaches a three-week “Ayurveda 101” to students like Kim Berley, a 28-year-old Sacramento waitress, who is convinced that ayurveda is the next yoga — “a way of balancing yourself with your own body and the elements around you,” she said.

Students learn about rejuvenative marmalades and how to prepare decoctions. “In Ayurveda, our medicines aren’t made in glass-walled laboratories with air conditioning,” Dr. Bhasker said in the hospital’s dispensary, pointing out bottles of nerve tonic. “We cook our medicines. There are no standard protocols. It’s intuitive on the part of the doctor.”

Many Indians combine allopathic medicine and ayurveda, going to an “English” doctor for serious illnesses and to an ayurvedic practitioner for arthritis, hypertension and other chronic conditions. But the lack of standardization is one reason why ayurvedic doctors are not allowed to practice medicine in the United States. (Instead, popularized by Deepak Chopra and the Whole Body aisle of Whole Foods, it has largely assumed a day-spa persona.)

With ayurveda tourism booming, the Keralan government has been working to regulate and rate ayurvedic resorts, so the creed is not diluted by unscrupulous operators without professional training. Traditionally, ayurvedic medicine was passed down from father to son, uncle to nephew, but now it is professionalized, with physicians like Dr. Sreelatha earning advanced degrees from five-year ayurvedic medical schools.

But some purists take a dim view of ayurveda tourism all together. “They are doing the safest things, with very little medicinal value,” said Dr. C. K. Krishnan Nair, an associate professor at the Government Ayurveda College in Tripunithura. “They make money. It’s that simple.”

On the way to Kumarakom Lake Resort, accompanied by George Joseph, an astute cultural observer and steely-nerved driver, we passed women with jasmine garlands in their hair, open-air trucks bursting with warty brown jackfruit, markets where men balanced green bundles of curry leaves on their heads, their aromatic trail hanging in the moist air. By a narrow bridge we saw a road sign I took to heart. “Hurry Causes Worry,” it said.

The resort is situated on the backwaters, a languorous tropical labyrinth of lakes, lagoons and shady channels brimming with village life, navigable by dugout canoe or traditional Keralan longboat, called a kettu vallam. Kumarakom Lake mixes no-nonsense ayurveda and palm-fringed restaurants with piped-in Glen Campbell and Kingfisher beer. Fishermen drift past in dugout canoes propelled by poles. The contrasts that make India India are here in abundance.

Like Kalari Kovilakom, Ayurmana at Kumarakom Lake plays up its historic pedigree: its “heritage” building, which was moved to the resort from its original location, is said to be the ancestral home of renowned ayurvedic practitioners. Exhibited in the open-air courtyard, Japanese in its simplicity, is hallowed ayurvediana, including ancient clay vessels storing medicated ghee.

I actually had a vision of Dick Cheney when I finally experienced sirodhara, a signature ayurvedic treatment that Dr. Sreelatha and others had cautioned could lead to emotional melt-down. Warm oil is released above you in a steady pendulum stream, your forehead a windshield and the oil, the wiper.

Feelings of deep panic were eventually supplanted by one of utter defenselessness in which, I was certain, all dark information about my past could be gleaned. Sirodhara struck me as an immensely powerful tool for extracting secrets.

I spent my last day in India at an open-air market in Cochin, marveling at snake gourds and silvery barracudas for sale. For some reason — maybe the heat and dust — after feeling buoyant the entire trip, I almost fainted, transformed into one of those Halloween masks in which the eyes pop out of their sockets.

Weak and woozy, I made my way to Ernakulam, to the branch there of India’s most celebrated ayurvedic hospital and health clinic network, Arya Vaidya Sala Kottakkal.

The doctor on call, V. K. Vinod Kumar, who was barefoot, took my blood pressure and pronounced it low. He told me to lay off masala and oily food. He said I needed more sleep. He wrote me two prescriptions.

As a final suggestion, he recommended that in the summer season, I have sex once every 15 days, and in the winter, every 3 days — at least.

I left India reinvigorated, with a lighter heart. I was dreaming of December.

VISITOR INFORMATION

WHEN TO GO

Though not ideal from a tourist’s standpoint, Keralans regard the summer monsoons as the best season for ayurveda, when the skin is tender and herb leaves are fresh and new. The months preceding the monsoons, which break in June, are uncomfortably hot. November through March is considered peak tourist season, priced accordingly.

HOW TO GET THERE

To fly into Cochin Airport in Kerala, or Coimbatore in Tamil Nadu (convenient to Palakkad district) requires changing planes in Mumbai, New Delhi or Bangalore. You can also fly to Trivandrum, the Keralan capital. Within India, Jet Airways is a pleasure — reliable with fantastic food.

WHERE TO STAY

Kalari Kovilakom: The Palace for Ayurveda, Palakkad. Minimum stay is 14 days; from about $5,000, including meals, treatments, airport pickup, yoga and requisite ayurvedic garb; (91-4923-263737 or 263155; www.cghearth.com).

Kumarakom Lake Resort, Backwaters. Room rates for doubles range from $250 to $650 plus tax through September, higher beginning in October; ayurvedic treatments extra; packages available; (91-481-2524900 or 2524501 or 2525431; www.klresort.com).

Vijnana Kala Vedi Cultural Center, Aranmula. The center, which attracts mostly the young bumming-around-India crowd, provides a rare immersion into Keralan culture, including Hindi and Malayalam classes, cooking, kolams (auspicious designs made with colored powders) and ayurveda. The village is walkable, untouristed and charming; vegetarian cuisine served on banana leaves. Rates vary; (91-468-2310451 or 2214483; www.vijnanakalavedi.org).

INFORMATION

The government ayurveda Web site is a great resource (indianmedicine.nic.in/html/ayurveda/afmain.htm).

I got excellent guidance from Clipper Holidays in Cochin (91-484-2303968 or 2306468 or 3293968; www.clipperholidays.co.in) and Ellison Poe at Poe Travel in Little Rock (800-727-1960; www.poetravel.com).