Who knew healthcare could be so complicated? Snapshots from an American dataset

Just as the distribution of wealth in the United States exhibits dramatic skews – a small percent owns a disproportionate share of the total wealth – so too does the distribution of healthcare expenditures. When individuals in the US population are ranked based on their healthcare expenditures in a particular year, then it turns out that:

1.     The top 1% of individuals account for 22.8% of the total healthcare expenditures
2.    The top 5% of individuals account for 50.4 % of the total healthcare expenditures
3.    The bottom 50% account for only 2.8% of total healthcare expenditures

https://meps.ahrq.gov/data_files/publications/st497/stat497.pdf

(Healthcare expenditures refer to all payments made related to health events – either by insurer or out-of-pocket.)

The estimates are from 2014, but the trends remain quite consistent from year to year. It is true that older individuals are more likely to have higher expenditures. But even if we look only at those over 65, we will still find that a small percent has an outsize impact. There is a fractal-like consistency to the pattern: if we narrowed our search down to the top 1% in a population of 10,000, then among these 100, the top 1-5 individuals will still account for a large percent of the total.

A similar trend emerges when we look instead at the prevalence of health conditions. If we were to plot the percent of individuals in a population (y-axis) who had no health conditions (count=0 on the x axis), exactly 1 health condition (count=1), exactly 2 health conditions (count=2) and so on, we would get something like the graph to the right. About 45% of the population has no apparent health conditions; about 25% has exactly one health condition; 12% has exactly two health conditions. The percentages start to decline as the count of conditions increases, indicative of the few who have 6, 7, 8, 9 or more conditions. We are now at the tail of the distribution where healthcare costs are most likely to be concentrated.    

Because most of us in any particular year are healthy, the challenges faced by this small segment of the population can remain somewhat distant. Yet at some point in our lives – hopefully later than earlier or even better not at all: who can say – there is always a chance that we might join their ranks.

In this column, I will present visualizations of healthcare use by individuals at the tails of the cost and health condition count distributions. I started creating these visualizations while researching a publicly available dataset called the Medical Expenditure Panel Survey - MEPS for short. This is the same dataset that was used to characterize the expenditure distribution above. Aggregate trends are valuable, but it is by looking closely at individual cases that one can begin to sense what is going on. Each year MEPS collects granular data on health events for members of thousands of households across the United States. Households are chosen in the survey to represent the national demographic; each household is compensated for the time spent filling out questionnaires. To protect the identities of those surveyed, the data is anonymized before it is released to the public.

A few limitations first. While I have worked with physicians, nurses and pharmacists on research projects, I do not myself have any clinical training. I therefore cannot make any claims about whether the care received was appropriate or not. Also, I have a sense but not a detailed understanding of the arcane administrative process between insurers, hospitals, doctors' officers, and suppliers of pharmaceuticals that that leads to charges and payments in the United States – or any other country for that matter.

This piece is therefore limited to what I saw in the data. What I saw surprised me – I was somewhat naïve to the complexity of modern healthcare, and it is this complexity that I'd like to communicate through examples.

Example 1

The first example is of a 50-year old female who was #10 when it came to expenditures ($209,370) among 35,313 individuals surveyed in MEPS 2011. The figure below shows a detailed split of her healthcare use in 2011, and how it changed in 2012 (each individual stays in the survey for up to two years).

There were no emergencies or hospitalizations in 2011 or 2012. 95% of the expenditures are on pharmaceuticals: 198 prescriptions were filled in 2011. While this number includes refills, it's likely that the prescriptions are not all of the same drug, but a mix. I say this because the 42 office based visits/consultations with physicians were spread across 6-7 specialties. Each specialist was likely prescribing something different. By downloading the right data files and linking it to this particular individual you can figure out which medicines were prescribed in 2011 and 2012, the diagnoses codes for each doctor visit, how much was paid out of pocket, how much by the insurer etc. Notice how in 2012 there are more office visits/doctor consultations (57) and 4 new outpatient procedures, but the number of prescriptions goes down to 89. Expenditures drop by over $100,000 and the same person is now ranked 81 among those surveyed in 2012.  

Example 2

My second example is of an 82- year man with high blood pressure, coronary heart disease, angina pectoris, and high cholesterol. He had a heart attack at 77, was diagnosed with diabetes the year of the survey. In the figure below, I show how the 75 doctor visits this patient had in a 2-year period were spread across 12 different specialties. The number on each edge indicates how many times the patient visited a particular specialty. Int. Med is Internal Medicine; Onc is Oncology; Orth. Is Orthopedics; Gast. Is Gastroenterology; Urol. Is Urology; ENT is Ear, Nose, Throat; Rheu is Rheumatology; Derm. Is Dermatology; Opth. is Ophthalmology; Card. Is Cardiology; Neph. is Nephrology; and PCP is primary care. 

In the qualitative parts of the survey the patient admits to having walking and vision limitations. It must not have been easy keeping up with so many doctor visits. Imagine setting up the appointments – 75 appointments in 2 years implies nearly 2 appointments every 3 weeks – driving to the clinics at the appointed time, experiencing waits, filling up multi-page forms, answering the same questions again and again, remembering all the medications prescribed. Even if there is a spouse or family member to help, being a patient seems like a demanding part-time or full-time job.

My 83-year old uncle who lives in India once joked that nowadays there is a doctor who can treat the top half of your index finger, another one for the middle section of the finger and so on. He was parodying the proliferation of multi-specialty hospitals in India. I found myself agreeing with him. But I also realized that specialization is an inevitable consequence of how quickly medical knowledge has expanded over the last hundred years. It is unreasonable to expect a single doctor to master all of it. And so when faced with a situation beyond her expertise, the primary care physician – the family doctor or the general practitioner, who is often the first point of contact and who knows the patient's medical history the best – refers the patient to a specialist. When a patient has just one condition, a primary care-specialist pair can work well as a team. But when a patient is seeing 11 other specialists, making sense of the changes in symptoms, the numerous diagnostic test results and medications can be a challenge, even if electronic medical records capture all this information (they often don't).  

Example 3

This leads me to my third example, which gives us a physician's perspective. I am borrowing it from a short article published in the New England Journal of Medicine. Its author, Matthew Press, is a primary care physician (PCP) at the Massachusetts General Hospital in Boston. In the article, titled "Instant Replay: A Quarterback's View of Care Coordination", Press describes the case study of a 70-year old patient whom he calls Mr. K:

"M. K's care was fairly straightforward— I was the only doctor he saw regularly — until the day he came into my office with flank pain and fever. A CT scan of his abdomen revealed a kidney stone — and a 5-cm mass in his liver, which a subsequent MRI indicated was probably a cholangiocarcinoma…Over the 80 days between when I informed Mr. K. about the MRI result and when his tumor was resected, 11 other clinicians [a urologist, a surgeon, a hematologist, a neurologist, a lab technician, a gastroenterologist, an interventional radiologist, an oncologist, a cardiologist, a pathologist, and a social worker] became involved in his care, and he had 5 procedures and 11 office visits (none of them with me). As the complexity of his care increased, the tasks involved in coordinating it multiplied…In total, I communicated with the other clinicians 40 times (32 e-mails and 8 phone calls) and with Mr. K. or his wife 12 times. At least 1 communication occurred on 26 of the 80 days, and on the busiest day (day 32), 6 communications occurred." (Excerpt and figure from Press 2014)

Press kept a running list of all the tasks – emails, phone calls, visits etc related to Mr. K's care. This led to the figure above and an animation on the journal website. It's worth watching how how the figure starts empty but fills up over 80 days. Luckily, Mr. K recovered and responded well to the treatment provided. After the 80-day burst of encounters things settled down. Press goes on to note that:

"Patients can be harmed when the many moving parts of their care are out of sync. We owe it to them to coordinate the care we provide and prevent this type of medical error. For example, on day 32 of Mr. K.'s care, a Friday, I noticed some new electrolyte abnormalities on laboratory tests done before an interventional radiology procedure. First I called the cardiologist who had seen Mr. K. earlier that week, after I learned from the electronic medical record (EMR) that he had prescribed a new antihypertensive. Then I called Mr. K. to arrange to have his electrolytes rechecked, which had to be done at an outside laboratory because by then it was the weekend (this took two calls to the laboratory — one to schedule and one for the results). On Sunday, I had Mr. K. change medications and on Monday asked the interventional radiology nurse practitioner to recheck the labs again before the procedure (two more calls). On day 36, she did, and the electrolytes had normalized."

Because Press had research duties, he worked part time and was the personal doctor for small number of patients. A relatively low workload gave him the time to meticulously track Mr. K's needs. In contrast, a typical doctor who works full time oversees the care of hundreds of patients. Press' article suggests that an overburdened physician will have much less time to coordinate the many dimensions of an individual's care, increasing the risk of serious errors.

Medications and Hospitalizations

There are two other situations in which modern healthcare can get complex. Just as a large number of specialists can become involved in a patient's care, so a patient may be prescribed a large number of unique medications: the former is actually a reliable indicator of the latter. In some datasets I've noticed patients who had been prescribed 15 or more unique drugs. There was one person who was on a staggering 30 unique medications! The trend is common enough to now have it own Wikipedia page and is called polypharmacy.

Other than the difficulty a person faces in remembering what should be taken, at what time of the day, when to refill, and why something is being taken, it made me wonder: how do clinicians and pharmacists weigh the side effects and possible interactions between all these medications? One medication in isolation can be tested in what is called a randomized controlled trial; the interactions between two, three or four medications gets harder, but nevertheless I assume they can be tested. It's mind-boggling to consider how a dozen or two dozen unique medications might interact.

The second type of situation is repeated emergency events and hospitalizations. The image below shows the sequence of events for a 42-year old man surveyed in MEPS 2011. He was hospitalized four times. The horizontal timeline marks the months of the year: J for Jan, F for Feb, and so on; PCP refers to a primary care visit. The last hospitalization happened at the end of December, the most festive time of the year.

 

As with other things we've discussed, repeated hospitalizations and emergency events are prevalent in a small percent of the population. A hospital stay and the period after discharge can be extremely disorienting. Medical issues can be aggravated by disabilities, mental health concerns, substance abuse, absence of a supporting family member, and lack of steady housing. Absent an effective plan on what will happen after leaving the hospital, it is not uncommon for patients to get readmitted within days or weeks of discharge. The sickest patients end up receiving lots of expensive hospital care – which puts them into the top 1-5% - but that care isn't good enough to avoid future hospitalizations.  

Concluding Remarks

To summarize, the healthcare expenditure distribution is highly skewed. The vast majority of the population uses little or no healthcare, which is as it should be. Medicine has made significant progress is curbing infant mortalities and infectious diseases, and this has lead to longer lifespans. For most of that lifespan we can now hope to stay healthy. But it is also true that worldwide, even in developing countries, there's a been a shift from communicable diseases to the slow burn of chronic conditions. These diseases can manifest at any age but particularly when we grow older. Along with diabetes, arthritis, depression and mental health, certain types of cancers are now considered as chronic conditions that need to be managed long term.

The speed of technological advances in medicine and incentives to aggressively market those advances have led to numerous detection and treatment options. These options are supposed to make things easier and they often do. Yet they have also contributed to the complexity of modern healthcare. Many different specialists can get involved in a single patient's care, conduct a variety of diagnostic tests, prescribe a mix of medications. Such an escalation in intensity places a high burden on the patient without necessarily guaranteeing better health. The US Centers for Disease Control (CDC) acknowledges "that as the number of chronic conditions increases, the risks of the following outcomes also increase: mortality, poor functional status, unnecessary hospitalizations, adverse drug events, duplicative tests, and conflicting medical advice".

The medical community recognizes the seriousness of the problem and its outsize impact on healthcare costs. Yet it has struggled to formulate effective responses. This is because the problem is not about tackling one disease in isolation, rather it is about how combinations of diseases collectively impact an individual. Complicating matters are socioeconomic factors and entrenched incentives which do not reward a holistic approach. Nevertheless a range of responses have emerged. I will finish the piece by briefly describing a couple.

One response has been to employ nurses and social workers visit medically complex patients on a regular basis, often in the patient's own home. Their goal is to simplify patient's care to the extent possible, help organize medications, and avoid unnecessary emergencies and hospital visits. They also address issues such as lack of employment, housing, insurance, mental health and addictions. In the process, the nurses and social workers hope to establish genuine relationships with their patients. A prominent illustration of this approach comes from Camden, New Jersey, featured here in a 13-min PBS Frontline video. The Camden initiative, which MIT is evaluating in a research study, explicitly recognizes that medical issues, especially in cities such as Camden struggling with crime and economic decline, are inextricably linked to the social context. Similar approaches are being tested across the country, from urban Houston to rural Montana.

Another interesting response that caught my attention is a conceptual framework called minimally disruptive medicine. The premise of minimally disruptive medicine is that patients can be overwhelmed by the demands that healthcare places on them. In the push to measure this and diagnose that, to try this new therapy or that new medication, what is truly important can get lost. Supporting this view are patient comments such as these:

"To keep myself healthy, I miss out on a lot of things that people my age take for granted – working fulltime, cooking, showering every day, going out to socialize" [25-year old woman from the UK] 

"There is stuff that I am SUPPOSED to do, and stuff that I actually DO.  If I did everything I am SUPPOSED to do, my life would revolve around doctors and tests and such and there wouldn't be very much left for living my life.  So I've made a bunch of choices (with the input of my family and friends, because it's important for me to have their support)." [46-year old woman in the US] 

Beyond a certain threshold the demands of healthcare, rather than make things better, can end up depleting the patient's financial, social and emotional capacity. This in turn makes it less likely that patients will follow recommended treatments. Minimally disruptive medicine asks: Is it possible to reduce the burden of treatment? Is it possible to truly listen to what the patient wants? Can the treatment be better aligned with the patient's goals in life: pursuing professional interests, spending time with family and friends, and having fun?

Perhaps I'll write a piece explaining these ongoing efforts in more detail. In the meantime, I'd love to hear what readers think.

Yelahanka: Sketches of a Neighborhood

My parents live in a two-bedroom flat at the northern end of Bangalore, in a town called Yelahanka. They moved in 2002, two years after I left for grad school in the United States. Over the last fifteen years, as I've continued to live abroad, Yelahanka has become the somewhat unfamiliar home in India, experienced every two years but no more than a few weeks at a time, and always changing each time I visited.

Once a town with a history of its own, Bangalore's explosive growth over the last few decades made Yelahanka part of the greater city. In 2005, when I came to renew my student visa, the highway outside my parents' flat complex, the Bangalore-Bellary road, was being widened in preparation for the new international airport twenty kilometers north. The city seemed then to be splitting at its outer limits: earthmovers raking up heaps of rubble on the roadsides; laborers patiently striking heavy hammers to break existing concrete structures; and uprooted trunks and roots of what had once been massive trees, caked with the red earth of the depths from which they had been dug up. A study based on satellite imagery revealed that Bangalore, once called Garden City for its beautiful parks and tree-lined boulevards, lost 180 square kilometers of its green cover from 2000-2006.  

The new airport got going in 2008. A flyover – a separate airport access road to bypass local traffic – was constructed about 50 feet above, supported by giant pillars. In Yelahanka, these pillars landed on the lower road, splitting it in two. Instead of making things easier, the flyover for a long time felt like a major obstruction to the locals, blocking the view, and reducing access to public buses. The traffic, always notorious in India – an ever present cacophony of honks, a jostling for every inch of space between motorbikes, auto rickshaws and newly acquired cars – only got worse as drivers adjusted to the new u-turns and flows.

Eight years later, things have settled down somewhat. The road from the airport to Yelahanka now has billboards encouraging the wealthy to purchase luxury high-rises that seem to be popping up everywhere. A couple of kilometers farther south are new malls, showrooms, glass fronted buildings of software firms and multi-specialty hospitals. Meanwhile, around the edges of these new developments, the older sections of Yelahanka continue undisturbed: a maze of narrow streets densely packed with homes, roadside businesses, vendor stalls, places of worship, with activities proceeding in an unstructured fashion and at a frenetic pace.

Last August, as I strolled through various parts of town, I kept feeling that there is something very different about Indian neighborhoods when compared to the places I'd lived and visited around the world. But what are those differences exactly? The contrasts with American towns, not surprisingly, are the sharpest. Yelahanka is supposed to be a suburb, but the word suburb in the United States conjures up quiet streets with rows of single family homes, lawns, and parking garages; the mismatch could not be greater. Even the most crowded boroughs of New York City, parts of Brooklyn and Queens, are not quite like their Indian counterparts. Then there are the economically deprived towns across the US with their hollowed out buildings, vacant lots, potholed roads, grasses seeping back into the cracks of pavements – there are some surface infrastructural similarities, but such American towns lack the population densities and thriving small businesses that even smaller Indian towns have.

Other parts of the world come a lot closer: the backstreets of the suburbs of Seoul, Hong Kong and Istanbul, market streets of Oaxaca in southern Mexico, and particularly Yogyakarta in Indonesia. Still, the combination of chaotic traffic and small-scale entrepreneurship gives the Yelahanka-like neighborhoods of India a distinct feel.

Take the bustling side of the road outside my parents' flat complex. This is not a neatly marked pavement dedicated to pedestrians, rather it's an unpaved gray zone that ends up being shared by pedestrians, by vehicles that encroach on it to get ahead of the traffic, by public and private buses that swerve in suddenly to drop off and pick up waiting passengers, and by the vendors and informal businesses that have set themselves up along the edge. (There's also plastic litter everywhere despite the best efforts of the BBMP staff to sort trash and keep things clean -- this is another feature of Indian streets that I did not find in other developing countries, say in Guatemala or Peru, but I won't get into that in this column.)  

The first business to the right is a small tire repair shed. No more than ten feet long and wide, it's a very basic, low-overhead kind of structure. Tires of various sizes and kinds are strewn all around. A lady with a thick ledger sits outside the shed with a pen, keeping accounts; she could be the owner. It's a busy place. A truck or van or auto-rickshaw driver is always looking for a repair. But you'll find absolutely no record of this bustling place online. It's one of the many ‘off-the-grid' businesses: businesses that in a western town would be marked on a map, licensed, reviewed, and taxed, but in Yelahanka are simply part of local knowledge. Google Maps features a blank space along this stretch of the road, but this misses the all the entrepreneurial activity that takes place. Farther down the same stretch, a blacksmith offers his services beneath a square piece of tarpaulin that serves as a roof. In the center of the square patch is a coal pit to heat metal; next to it, an anvil for banging metal into shape.

And so it goes on along the edge of the road: one informal business after another. A woman in her sixties who in the narrow space of a porch sells idlies in the morning and vadas in the afternoon at rates far cheaper than restaurants; a street vendor who positions his food cart outside a small liquor shop, so that the men who come to have surreptitious drink – unlike bars, these liquor shops have no music or social fanfare, drinking here appears to be a personal affair – can purchase the snacks to go with the alcohol. 

The macro numbers only seem to confirm this. India has one of the higher rates of informal sector employment in the world. By definition, these are businesses that are small, easy to set up and dismantle, and do not take up much space. If you are interested in getting a visual sense of how such businesses operate, take a look at this YouTube video, created by Isha Gajjar. It captures numerous street vendors near the main bus station of Yelahanka. I've walked through this part of town many times.

Even the formal businesses in Yelahanka are quite specialized and diverse. There is a small shop, for example, that focuses only on selling varieties of rice; there is a machine shop called GSS Engineering Works which does lathe-based machining; and there are houses from which there comes a clattering sound, as if printing presses are churning out newspapers. But the noise, my parents noted, could also be due to looms: Yelahanka has been known for the quality of its weaving industries for two centuries.

The distinction between the formal and the informal applies to religious places too. In the older sections of Yelahanka, you'll find Hindu temples that span the entire range: from the larger ones with well constructed gopurams (the main structure), to those that you wouldn't formally consider as temples, but nevertheless serve a religious purpose, for example, the base of a tree with a wide, shade-providing canopy where a few idols have been placed; or a simple ochre-colored stone relief by the side of a pathway, accessible to everyone, the relief showing only the abstract outlines of a deity, a few fresh flowers offered by those who sit beside it and pray. Similarly, in the Muslim quarter of Yelahanka, there is a mosque whose prayer calls wake me up before dawn and which everyone knows about, but there is also, not far away, an unnoticed Sufi shrine, a single story structure painted green and with the title "Hazrat Buddhan Shah Wali".

Streets in the old section don't go in straight lines but rather curve and intersect in complex ways. With each random turn, I would discover something new. A utensil shop here, a ladies tailor shop there, a roadside shrine elsewhere. So it goes on and on! To understand this spatial distribution, it might help to consider the following contrast. In supermarkets and shopping malls, we find a dizzying range of catalogued products delivered from various parts of the world, all concentrated in one large air-conditioned room or one large building. Now imagine a more local kind of diversity, a similarly wide range of services, products and places of worship, but spread out in nooks and corners and edges of roads, not catalogued and searchable online, and which can only be known by living there and by learning what the locals know. This is what the older sections of Yelahanka are like.

***

Finally, a few words about the Yelahanka Lake. If I haven't mentioned the lake yet, it is because the traffic, crowds and the maze of streets are always front and center, and it requires effort to look beyond them and notice the natural beauty of the region. Luckily, from the ninth floor balcony of my parents' flat, I've always been able to glimpse the lake and the adjacent high-grass meadow where the cows graze throughout the day, their feet half sunk in the boggy soil. All kinds of migratory birds visit the region's lakes, which is why the neighboring Puttenahalli Lake has been protected as a sanctuary.

Last year, I noticed that the Yelahanka Lake had more water, and a concrete walkway had been constructed along its outer circumference. The plan is to have a boating dock for residents of an unfinished luxury high-rise at the opposite bank. Maybe this will also turn into a thoroughfare eventually. But for now, a walk along that newly constructed lake-side path provides an unexpected and calming counterpoint. Rather than say much about it, I'll close by providing a few pictures.

Quantitative Measures of Linguistic Diversity and Communication

Of the 7097 languages in the world, twenty-three (including the usual suspects: Mandarin, English, Spanish, various forms of Arabic, Hindi, Bengali, Portuguese) are spoken by half of the world's population. Hundreds of languages have only a handful of speakers and are disappearing quickly; one language dies every four months. Some parts of the world (dark green regions in the map) are linguistically far more diverse than others. Papua New Guinea, Cameroon, and India have profusion of languages while in Japan, Iceland, Norway, and Cuba a single language dominates. 

Why are languages distributed this way and why such large variations in diversity? These are hard questions to answer and I won't be dealing with them in this column. So many factors – conquest, empire, globalization, migration, trade necessities, privileged access that comes with adopting a dominant language, religion, administrative convenience, geography, the kind of neighbors one has – have had a role to play in determining the course of language history. Each region has its own story and it would be too hard to get into the details.  

I also won't be discussing the merits and demerits of linguistic diversity. Personally, having grown up with five mutually unintelligible Indian languages, I am biased towards diversity – each language encapsulates a unique way of looking at the world and it seems (at least theoretically) that a multiplicity of worldviews is a good thing, worth preserving. But I am sure there are opposing arguments.

Instead, I'll restrict my focus to the following questions. How can the linguistic diversity of a particular region or country be numerically quantified? How do different parts of the world compare? How to account for the fact that languages may be related to one another, that individuals may speak multiple languages? 

In tackling these questions, my primary source and guide is a short paper published in 1956 by Joseph Greenberg [1]. Greenberg's main goal was to create objective measures that could, in the future, be used to "to correlate varying degrees of linguistic diversity with political, economic, geographic, historic, and other non-linguistic factors." His paper proceeds from the assumption that linguistic surveys have been conducted and data on what people consider their mother tongue/first language, the number of speakers of each language, vocabulary etc. are already available. Ethnologue is an example of such a global survey [2]. 

The Linguistic Diversity Index

The most basic measure Greenberg proposed is the now widely used linguistic diversity index. The index is a value between 0 and 1. The closer the value is to 1, the greater the diversity. The index is based in a simple idea. If I randomly sample two individuals from a population, what is the probability that they do not share the same mother tongue? If the population consisted of 2000 individuals and each individual spoke a different language as their mother tongue, then the linguistic diversity index would be 1. If they all shared the same mother tongue, then the index would be 0. If 1800 of them spoke language M and 200 of them spoke N, then index would be: 

1 – (1800/2000)² - (200/2000)²   = 0.18

In the above, (1800/2000) is the probability that a randomly picked individual speaks M as their first language/mother tongue. And (1800/2000)² is the probability that two randomly picked individuals speak M. Similarly, (200/2000)² is the probability that both the randomly picked individuals speak N as their mother tongue. When we subtract these squared terms from 1, what remains is the probability that the two randomly sampled individuals do not share a mother tongue. In this particular example, the index of 0.18 is low because of the dominance of M. 

If there are more than two languages the procedure is the same. You would have one squared term that needs to be subtracted for every language. In a population of 10,000 where 10 languages are spoken and each language is considered a mother tongue by exactly 1000 speakers, the index would be:

1 – 10 x (1000/10,000)² = 0.9.

This high value reflects both the number of languages and how evenly distributed they are in the population. 

In fact, there are fifteen countries whose linguistic diversity exceeds 0.9, as the table above shows (based on Ethnologue data [2]). The list is dominated by 11 African countries, with Cameroon at number two. India, whose linguistic diversity I experienced firsthand for twenty years, is at number 13. Two Pacific island nations – Vanuatu and Solomon Islands: small islands these, and yet so many languages! – are in the top 5. First on the list is Papua New Guinea whose 4.1 million people speak a dizzying 840 languages! The country's index of 0.98 means that each language has about 5000 speakers on average and that no language dominates as a mother tongue. 

In his book The World Until Yesterday, Jared Diamond, who did a lot of his fieldwork and research in New Guinea, has this startling anecdote:  

"One evening, while I was spending a week at a mountain forest campsite with 20 New Guinea Highlanders, conversation around the campfire was going in several different local languages plus two lingua francas of Tok Pisin and Motu…. Among those 20 New Guineans, the smallest number of languages that anyone spoke was 5. Several men spoke from 8 to 12 languages, and the champion was a man who spoke 15. Except for English, which New Guineans often learn at school by studying books, everyone had acquired all of his other languages socially without books. Just to anticipate your likely question – yes, those local languages enumerated that evening really were mutually unintelligible languages, not mere dialects. Some were tonal like Chinese, others were non-tonal, and they belonged to several different language families."

How different from what the majority of us are used to! 

While New Guinea's linguistic diversity is widely recognized and not in doubt, its high language count and the rampant multilingualism that Diamond observed nevertheless lead to us to two flaws in the linguistic diversity index.  

The first flaw is that the index assumes languages are well defined, mutually exclusive units. It ignores the relatedness between languages and the fact that a dialect may be arbitrarily called a language. What of cases where there is close relatedness and even mutual intelligibility, for example between Hindi and Urdu, or between Spanish and Italian? And what to make of those cases where two dialects may well be closely related, but nevertheless are mutually unintelligible when spoken? Further, the language question seems loaded with the question of identity and politics. Apparently there is a running joke among linguists: "A language is a dialect backed by by an army and a navy."

To partially address this, Greenberg -- who recognized these problems, and was well aware of the difficulties of distilling complex language realities into quantitative measures -- suggested that the resemblance between languages or dialects could be numerically quantified by a value between 0 and 1. This what I understood from his paper: take the combined current vocabulary of a pair of languages and calculate the proportion of words that are common to both languages in relation to the total list of words. This proportion gives us a approximate measure of resemblance. A resemblance close to 1 means that the two languages are virtually identical, and a resemblance close to 0 implies an almost total lack of relatedness. 

The resemblance can then be used to adjust the linguistic diversity index. Suppose there are three languages M, N and O spoken by 1/8th, 3/8th and 1/2 of the population and suppose the resemblance between [M, N], [M, O], and [N, O] is 0.85, 0.3 and 0.25.  The unadjusted linguistic diversity index is 0.593. If we adjust for resemblance, this value drops to 0.381 -- diversity is not as high as it originally seemed. I have explained the calculations at the end of the piece [3].

The second flaw in the index is that, by considering only an individual's mother tongue, it ignores multilingualism. As Diamond's New Guinea anecdote shows, a high linguistic diversity does not necessarily represent a lack of communication. The examples of Indonesia, India and the many countries of Africa show that it is possible to communicate in some common languages, lingua francas that span large parts of the population, while yielding space to local mother tongues. So a different kind of measure is required.  

Index of Communication

To accommodate multilingualism, Greenberg proposed the index of communication. As before, the index is a value between 0 and 1. A value close to 1 indicates high communicability and a value close to 0 indicates the opposite. If I randomly pick two individuals in a population, and each individual speaks one or more languages, then what is the probability that the individuals share at least one language in common? To ensure communicability, only one language has to overlap. (This index too has its problems. One flaw is that it ignores how well an individual speaks a particular language – something that might be hard to elicit in a survey. Another is how to set the threshold of communicability - is knowing a few basic words sufficient?)

Consider the simplest case where a population speaks only two languages, M and N. Using a census, you can calculate the proportion of the population that speaks M only, N only, and is bilingual in M and N. Suppose those proportions are 0.5 (speak M only), 0.3 (speak N only) and 0.2 (speak both M and N). To calculate the index of communication, I simply subtract the cases where the two individuals cannot understand/communicate with each other, which happens when the first individual speaks only M and the other only N, and vice-versa: 

1 – [0.5 x 0.3] – [0.3 x 0.5] = 0.7 

The same idea can be extended to more than two languages. 

I'll try to illustrate the index with a personal example. The engineering college I attended in the south Indian city of Trichy had students from all parts of the country. At the time the college was called Regional Engineering College (REC), it is now called the National Institute of Technology. There was one REC in each major Indian state. The RECs had a unique admission policy. Half of the engineering students admitted each year were from the local state – in the case of Trichy, the home state was Tamil Nadu – and the remaining half were from outside the state. The more populous states, such as Uttar Pradesh and Bihar, got more students, but even far-flung parts, the Northeast and Kashmir, had some representation.

In my first year, all the 400 odd male engineering students were packed into the same hostel (dormitory), with 5 students sharing a room. In what seemed like a deliberate policy at integration, the students were assigned rooms so that 2-3 of the students were from Tamil Nadu and each of the others was from a different state. Since states in India are organized along linguistic lines, you had 3-4 mother tongues in each room. In the corridors you could hear the two dozen major languages of India [4]. 

Despite all this diversity, communication was never a problem. Among the North Indians almost everyone knew Hindi and so Hindi was the bridge between mother tongues. The local state students– they were colloquially called Tambis by the North Indians – spoke Tamil but did not understand Hindi and were even hostile to it (even today, the Indian prime minister Narendra Modi's emphasis on Hindi annoys my Tamil friends). But all students whether North Indian or Tamil, had some working knowledge of English – the language of the textbooks, which everyone aspired to speak well if only to get access to good jobs after graduation. So English – however grammatically inaccurate or spotty – was the bridge between the locals and the North Indians. 

If I randomly sampled two individuals from that student population of 400, then there is a good chance that the two students would have different mother tongues (high linguistic diversity), but due to multilingualism they would have at least one language in common. So the index of communicability was essentially 1, if we ignore the question of proficiency. 

My own case was somewhat different but by no means unique. Although I was born with Tamil as my mother tongue, I had lived mostly in West and Central India and had picked up Hindi, Gujarati and Marathi socially (the last two have dropped off due to lack of practice). I applied to college as an out-of-state student, but was really returning to my home state. In Trichy, I could communicate in Tamil with all the local students. Indeed, my colloquial command of Tamil – all the bad words included –went up! With everyone who was not from Tamil Nadu, I used mostly Hindi or English. I learned, to my surprise, that my ability in conversational English was poor, because I'd never really spoken it socially. 

The college experience I've described applies more generally. Many parts of India are like this: different language communities live together in cities and along borders between states and multilingualism facilitates communication.  

***

To summarize, Greenberg's two indices capture contrasting aspects of language reality in a population. The diversity index captures the number of mother tongues and how evenly represented they are in relation to each other, while the index of communication captures how connected a population is.

In theory, a population could retain its linguistic diversity while also maintaining a high index of communication essential in a globalized world. In practice however, a worldwide rise in communication appears to be happening at the expense of linguistic diversity. The numerous but lesser known languages of Australia, North America, Central and South America are losing ground quickly. Africa is the only continent bucking the trend. India's twenty odd major languages are still doing quite well, but others are not – check out these podcasts (1 and 2) by Padmaparna Ghosh and Samanth Subramanian on the challenges of linguistic surveys and inevitability of language loss.     

Finally, here are brief notes on two different countries: Mexico and United States. I've had a long-standing interest in both these countries. Drawn to its pre-Columbian indigenous past, I traveled to Mexico six times – from Chiapas to Oaxaca in the south, to Michoacán and Mexico City in the center, to Chihuahua in the north. The United States, meanwhile, has been home for the last 16 years.  

Mexico 

In the last section of his paper, Greenberg demonstrates how his two measures – linguistic diversity index and the index of communication – stack up when it comes to the 31 states of Mexico, and Mexico as a whole. To do this, he used bilingual data from a census in 1930. 

Mexico's indigenous languages began to decline after the Spanish conquest of Mexico in 1521. In Greenberg's calculation, Mexico's linguistic diversity index (unadjusted for resemblance) was 0.31 in 1930 while it's index of communication was 0.83. Among individual states, though, there was a great deal of variation. The federal district (DF – Distrito Federal), which includes the highly populous Mexico City had much lower linguistic diversity of 0.12 while its index of communication was 0.99 – virtually 1, which makes sense because Spanish is indispensable in the capital. The state of Oaxaca, which I have visited twice recently and where indigenous groups have a strong presence, had the highest linguistic diversity index of 0.83. In Greenberg's data, Oaxaca's index of communication of 0.47 was the lowest in Mexico. 

But this was in 1930; I am sure things have changed in the last 86 years towards greater communicability and lower diversity as Spanish continues to be dominant. According to Ethnologue, Mexico's language count is 290 but its diversity index is down to 0.11. Most likely – this is a guess – its index of communication, which was already 0.83 in 1930, is well over 0.9 now.    

United States

According to the Ethnologue, the US has 430 languages: 219 of which are indigenous and 211 of them immigrant. North America before European settlement was teeming with indigenous languages from different families. California was one of the most linguistically diverse places in the America with around 70-80 languages from 20 language families. 

Because of the sustained ethnic cleansing that happened after European arrival, the vast majority American Indian languages are now tethering on the brink of extinction. English is dominant, which explains the country's relatively low linguistic diversity of 0.34. English is also why the United States' index of communication is likely to be very high – above 0.9 if not close to 1 (this is a guess and is not based on data). Today an American Indian who speaks, say, Navajo or Cherokee, can communicate in English with a recently naturalized Indian-American whose original mother tongue was, say, Telugu. 

Despite English's dominance, the United States does have a certain linguistic richness to it, thanks to immigrants (citizens or not) from all other continents to make a living here. By some estimates 800 languages are spoken in New York City!

______________________

Reference and Footnotes

1. Greenberg, Joseph H. "The measurement of linguistic diversity." Language 32.1 (1956): 109-115.

2. Lewis, M. Paul, Gary F. Simons, and Charles D. Fennig (eds.). 2016. Ethnologue: Languages of the World, Nineteenth edition. Dallas, Texas: SIL International. Online version: http://www.ethnologue.com.

3. Greenberg's adjustment for resemblance between languages: Suppose there are three languages M, N and O spoken by 1/8th, 3/8th and 1/2 of the population and suppose the resemblance between [M, N], [M, O], and [N, O] are 0.85, 0.3 and 0.25. Then the linguistic diversity index adjusted for resemblance is:

1 – [(1 x 1/8 x 1/8) – (1 x 3/8 x 3/8) – (1 x 1/2 x 1/2)] 

– [(0.85 x 1/8 x 3/8) – (0.85 x 3/8 x 1/8)] 

– (0.3 x 1/8 x 1/2) – (0.3 x 1/2 x 1/8) 

– (0.25 x 3/8 x 1/2) – (0.25 x 1/2 x 3/8) 

= 0.381

The first line is exactly the linguistic diversity index we have already seen, without adjusting for resemblance. There are 3 languages so one squared term for each language. Each term calculates the probabilities that both randomly picked individuals speak the same language. There is a multiplier of 1 since the resemblance of a language to itself is 1. If we used only the first line, we would get an unadjusted linguistic diversity index of 0.593. 

The next 3 lines take care of relatedness between language pairs. The second line calculates the probability that the first randomly picked individual speaks M and the second speaks N, and vice versa. The multiplier of 0.85 indicates that there is a high resemblance, therefore speaking M and N should be treated (almost) like speaking the same language. Lines 3 and 4 do the same for language pairs [M, O] and [N, O] and the respective resemblance multipliers are used. In the end the adjusted diversity index gives us a value of 0.381, significantly lower than the unadjusted value of 0.593.

4. The beautiful Indian language tree illustration is by Minna Sundberg.   

5. This piece was first posted at 3 Quarks Daily.

Four days in Jogja

I was in the city of Jogjakarta (also spelled as Yogyakarta) in May 2015. It was a short stay: I was primarily visiting Hong Kong, but then had to exit Hong Kong to re-enter because my visa-free stay had expired. Nearby countries would have served the purpose, but I chose Indonesia -- six hours south by flight and across the equator -- because I'd always been drawn to its size and diversity: thousands of islands in a tremendous sprawl (if the northwestern-most part of Indonesia started in Alaska, the archipelago would stretch all the way to Virginia); 240 million people, 87% of them Muslim, speaking 700 odd languages (even greater linguistic diversity than India); an unlikely national experiment that began in 1940s after centuries of Dutch colonial rule and a short but painful three years of Japanese occupation.  

There was no way to capture even a fraction of that complexity in four days, but I wanted to start somewhere. Jakarta, the sprawling capital where I stayed the first night, was too daunting; but Jogjakarta, an hour's flight from the capital and which holds a unique place in Javanese culture, seemed more manageable. Here are some informal impressions: nothing very detailed, just a first take.  

1.

The island of Java, studded with volcanoes throughout its length, is one of the most densely populated parts of the world, home to 145 million people. Jogjakarta lies in the central part of Java, but closer to the southern coast.     

The ride from the airport to the hotel was through a bustling thoroughfare, packed with people, shops and malls on either side. So many motorbikes and two-wheelers wove their way around cars that the traffic approached the chaos of Indian roads. Perhaps it was because I had arrived the time of the Waisak holiday – the holiday that commemorated the birth of the Buddha. In a few days, the President of Indonesia, Joko Widodo, was scheduled to visit Borobudur, the famous 9th century Buddhist temple near Jogja. 

That's the kind of place Java is: Islam is the formal faith and widespread, but the Hindu-Buddhist past remains a part of Javanese identity and is celebrated in so many ways. The other major draw in Jogja is the Hindu Prambanan temple, roughly contemporaneous to Borobodur. The Indian influence actually stretches even further back: Sanskrit inscriptions date to the 5th century. Thanks to the seasonal winds which promoted maritime trade, the Indonesian islands have been linked, directly or indirectly to China and India and the Middle East for over two millennia. 

Just to give one example: in the 11th century – when Buddhism and Hinduism were still strong and Islam still hadn't taken hold – cotton that was produced in Gujarat (west India) was shipped to both Egypt and Indonesia. In an effort to be responsive to their markets, the Gujarati producers adjusted the color and pattern of the cloth to suit different preferences: "Green patterns sold well in Egypt. Animal patterns were sent to Southeast Asia, but not to Islamic Egypt."

The major shift towards Islam seems to have happened between the 13th and 16th centuries. This shift was not, as in so many other places, a result of conquering armies, but a gradual bits and pieces affair, the work of a few Sufi mystics who arrived from various parts of Asia. Further, the Islam that came to Java did not erase past beliefs, but blended with them to create a composite faith that borrowed from different strands – something that still persists today.  

2.

Although it was interesting to learn about Java's Hindu-Buddhist past, I wasn't very enthusiastic about visiting Borobodur and Prambanan. I had seen such archaeological sites in other parts of the world – Teotihuacan in Mexico, Machhu Picchu in Peru, Hampi in Karnataka, India – and was somewhat exhausted by the emphasis on past grandeur that only peripherally affected modern realities. But I had few other ideas, so I went in the hope of seeing something of the city, and how Javanese visitors related to the historical sites. 

I took the city bus to Prambanan. The bus took a circuitous route, touching the parts of Jogja where the big universities were. Certainly there was much that reminded me of India that day: the hot day; a higher than average density of people; informal vendor stalls everywhere on the side of the roads; tricycle-taxis pedaled by drivers for short rides; coconut trees; Sanskrit names on storefronts. And then there was Prambanan itself, a Hindu temple at the end of the journey. 

Prambanan's exterior was impressive. Its towers were slightly thinner compared to Indian temples, and all along the circumference of each tower were smaller conical structures pointing upward, which lent the entire complex a certain dynamism when viewed from far. But the interior of the temple, the beautiful reliefs on the walls, the deities that were worshiped – Ganesha, Shiva – felt pretty close to the forms I had known in India. 

Indeed, it felt somewhat strange to encounter the religious tradition I had been born into so far away from home but also reaching so far back in time. Large groups of Javanese school children had come that day, as part of school tours perhaps, to get a glimpse of their island's past. They tramped up and down the steep, black stone steps of towers. What did they make of this place, I wondered. Did it fit into the modern narrative only as a relic of history, beautiful to look at but with no real influence? In India, it's a fair bet a place like Prambanan – like the 800-year old Brihadeeshwara temple in Thanjavur – would still be active as a place of worship. I know that my devout father would immediately begin his prayers if he came anywhere close to Prambanan! 

Hinduism appears to have persisted in Java not through its temples – Prambanan in the 19th century was in ruins and had to be reconstructed – but its major epics, the Ramayana and Mahabharata. The Javanese have made these epics and their central characters their own, weaving them into their most famous art form, the wayang, the shadow puppet theater, which has been popular for many centuries, and still is. A wayang can start in the evening and continue all night, into the morning. The dalang, the puppeteer – the good ones are high in demand these days and well paid – adapts the characters drawn from Hindu epics. 

Image from Wikipedia: Wayang (shadow puppets) from central Java, a scene from Irawan's Wedding, mid 20th century, University of Hawaii Dept. of Theater and Dance

Growing up in India in the 1980s, I learned all the details of the Ramayana and Mahabharata through serials shown on national television on Sunday morning, and through illustrated picture books. Thousands of miles away, a Javanese Muslim growing up at the same time might have have learned about the epics staying up all night and attending a wayang communally with many others. The names differ slightly in Java – Ravana, the demon king of Lanka, is Rahwana; Lanka is Alengka; Sita, the wife of Rama, is Sinta. What you learned depended on how the dalang presented the story. In 1979, VS Naipaul, while visiting a village near Jogja, noted this about a wayang: 

"The good puppet-master, whatever his interpretation of the story, political, mystical, leaves the issues open. Everyone watching responds according to his character and circumstances…Because every character trails his own ancestry and dilemmas, even the wicked Rahwana, even the beautiful Sinta. Everyone is engaged in his own search, and at his appearance in the story is in a crisis; so that, as in the profoundest drama or fiction, every encounter is charged with meaning. The epics are endless. The puppet plays bear any number of repetitions, because the more the audience knows the more it understands; and interpretations of motive, of what is right and wrong or expedient, will constantly change." [From Among the Believers.]   

Wayangs are so popular that even the Islamist Partai Keadilan Sejahtera (the Prosperity and Justice Party, or PKS) which captured a small percent of the Indonesian electorate in 2009 and which held its national convention in Jogja in 2011 – the writer Pankaj Mishra attended the convention – even this Saudi-funded radical group, which might have rejected stories from other faiths, couldn't resist sponsoring for its delegates a wayang based on the Hindu epic Mahabharata!

3.

There was something else going on in Prambanan that day. Near a grassy patch on the outer periphery of the temple, a woman was singing a slow, haunting kind of song while others played modern stringed instruments and a drum. In front of the stage where the singer was seated, a group of boys, dressed presumably in old Javanese style, were dancing and enacting something. I thought maybe this was a rehearsal of the Ramayana ballets that were held on Thursday evenings at Prambanan.   

After a while, I wasn't so sure. The boys seemed to be in some kind of trance. There was an older man who kept running from one boy to another, seeming to stabilize them, monitoring their progress closely. In one case, a boy was sprawled on the ground, and the old man forcibly opened the boy's mouth and removed something that the boy was chewing. Some kind of intoxicant. I learned later that whatever the boys were chewing was meant to promote the trance, and that the man who was running around checking on the boys was a kind of shaman, ensuring that nothing in this initiation got out of control. The woman whose melodious song I had found mesmerizing – I yearned for that song and voice for many days – was meant to keep the boys in their hypnotic state. 

So what I thought was a performance, meant to entertain, was at least in part a ritual initiation ceremony, something related to Java's animist past, in which the boys enthusiastically participated for their own benefit. They cared little about the audience. But there was an audience, perhaps just as fascinated as I was, and it included women in headscarves. Suddenly the visit to Prambanan, which I had been lukewarm about, had turned interesting. For here were all those strands of Javanese faiths: a glimpse of its animist past on a holiday that commemorated the Buddha's birth, at this reconstructed Hindu temple where Ramayana ballets were held regularly – all of this explored and watched intently by visitors who were predominantly Muslim. 

4.

It is this syncretic or composite faith that Java is known for, and which has been threatened by the more radical versions of Islam that have taken root (though not to the same extent as elsewhere). In his essay After Suharto, Pankaj Mishra, who has traveled to Indonesia many times, writes about the "creeping Islamisation": attacks on churches, on members of the minority sects, nightclubs and bars. Elizabeth Pisani who has lived and traveled extensively in the archipelago, points out in her book, Indonesia Etc., that while the syncretic tradition still remains strong,

"Islam in Indonesia has homogenized into something more orthodox than it was since Suharto came to power. Saudi Arabia has been underwriting schools and mosques in Indonesia that teach Islam off a Middle Eastern template. The classic mosques of central Sumatra and Java, with their modest three tiered roofs in terracotta tiles that echo the shape of Indonesia's volcanoes and blend into the villages, are increasingly giving way to variations of the Middle Eastern style -- domed, minarets, ostentatious." 

In my short visit, I sensed this trend on two occasions. The first was in Jakarta, where I shared a ride to the airport with three or four other men, who were likely from the Middle-East. They were all dressed in white and wore white skull caps. They were rehearsing something in Arabic – verses from the Koran perhaps. When one of them forgot a verse or was off track, another would step in to correct. The men were taking a flight to Solo, 60 kilometers away from Jogjakarta. Were they preachers who had come to teach in a mosque or Islamic school in Solo? But the ride was short and I did not have the time to ask. 

The second occasion was a slow-moving motorcycle rally in Jogja, in which the grim-looking bikers, about twenty of them, were covered in shawls or robes of some kind and carried flags with Arabic lettering. The Arabic stood out because most signs in Jogja are in Bahasa, the lingua franca of Indonesia.

5.

In Jogja though, going by its reputation, you are more likely to run into someone steeped in mysticism rather than a hardline Islamic worldview. This is what happened on the fourth and last day of my visit, when I met Raul. 

Raul (not his real name) was the guide who took me to Borobodur. He was about thirty, dark-complexioned and with a square face. He was mostly Javanese, he said, but had a little bit of Chinese ancestry and perhaps a little European too. From the outset, it was clear that he was polite and sincere, and someone who did not impose too much. Perhaps it was the Javanese preference for courtesy and manners. Raul himself said that social interactions in Java had the quality of a ‘drama', an act.   

Within minutes of heading out, he starting describing landmarks. Tugu circle, the intersection where my hotel was, is an important monument, he said. It is actually a lingam. The Sultan's palace (the kraton: a kind of nerve center of civic and religious life in Jogja), the Tugu monument and Gunung Merapi (the still active volcano: image from Wikipedia), are in one straight line, Raul explained, and this assisted the Sultan when he sat down to meditate in his palace. Here again that delightful mix of different strands: lingam, a phallic symbol in Hinduism, adapted here in Java and linked to a sacred natural landmark.

This was Raul the guide, I thought, simply stating facts for the tourist in a detached way. But that impression wasn't entirely right. Javanese mysticism wasn't just something he explained to tourists. He'd experienced strange things himself. He once saw a green light – not an actual light, but a light from a different realm, an aura that's not visible to everyone – descending into someone's home. Puzzled, he had gone to the the Sultan's palace, to check with spiritual advisers there. They were at first surprised that Raul could detect such auras. What color was it, they asked. The green one, it turned out, was something unpleasant that could possess an individual. 

"Such auras are not unusual in Java", he said. "Once I too was possessed by a spirit. It happened when I was driving back home on my motorbike. It was a woman's spirit, and it troubled me for a while. I went again to the Kraton. They asked me not to worry too much about it and to recite the right prayers at the mosque. You know, prayers, the way they are said create certain vibrations which can help. After some time, I was cured. These things happen in Java."

Raul understood that I might be surprised at such claims. But he was unworried what I might think. He stated everything in a matter-of-fact way. He did not linger on these things and I did not delve further. 

The presence of the spiritual advisers, people who had understood Raul's experiences and guided him, suggested a shared culture of mysticism. I later found more evidence of this in Naipaul's Islam-themed travel books, Among the Believers and Beyond Belief. In 1979 and again in 1997, Naipaul had met a successful Catholic poet, Linus, who lived in a village near Jogja. Linus was one of many Indonesians whose stories Naipaul described in detail. In 1997, Linus, much like Raul, had talked of his mystic experiences. In Linus' case, Siddhartha -- the Buddha himself -- came in his dreams, to reveal spiritual insights. But it wasn't a direct revelation and it wasn't just Linus. His friends were involved too. The message that the Buddha gave was typed onto the palm of Linus' friend. Yet another friend, a woman, was the only person who could interpret these messages by looking at the friend's palm. So there had been this group of friends that had met now and then, for many years: as in Raul's case, individual dreams and visions were collectively shared. 

Just as interesting was how Raul's mysticism intersected with the modern world. Raul mentioned how he had seen videos or a research paper online about an experiment that tested the impact of positive words and thoughts. Plants that had been exposed to positive words had developed symmetric and healthy patterns; plants exposed to abusive words had become distorted. Raul also believed that the act of naming something was important. By naming something you determined its destiny. He gave the example of an Indonesian airline that had, true its mythically inspired name, eventually gone out of business. 

Raul had been born in a city about three hours by drive from Jogjakarta. He'd studied tourism at the local university but did not finish. Later, he worked for two years at a cruise ship. He had visited coastal cities in the United States. But the work had been detrimental to his wellbeing. He had a life-threatening health crisis, a paralysis due to a genetic condition, but one that he believed was triggered by an unhealthy lifestyle, eating American-style food at the cruise-ship. He had survived that narrowly. This work as a guide in Jogja was a slow a return to normalcy.

His views now were shaped by that crisis. He was against genetically modified foods. He cited scientific studies he had read on the internet to back his claims. He was against the excessive use of refined sugar. He was concerned about how much plastic was disposed and how it was polluting rivers. The group that he now worked with not only organized tours, but was also involved in addressing such ecological concerns. Outside the entrance to the Borobodur temple – which was abuzz with preparations for President's Jokowi's visit the next day – Raul expressed unease upon seeing caged birds sold by vendors, dozens of small sparrow-like, bright-colored birds, all confined to cages and jostling for space.

Politically, Raul had a left-leaning stance. He was against the landowners who with the help of politicians had deliberately purchased land around the Borobodur and Prambanan temples, calling them amusement parks and thereby inflating the entrance fees (the $30 fee might seem okay by American standards, but a good lunch in Jogja costs less than a dollar or two – that's how cheap things are in Indonesia). Raul spoke fondly of the current President, Joko Widodo, who had been elected in 2014. Jokowi, as he is popularly known, was different because he wasn't from the political or military elite, but from a modest family in the neighboring city of Solo. When it came to Islam, Raul was clear that Sharia law or extremist interpretations had no place in Jogja. 

Meanwhile, the temple at Borobodur, striking though it was – overlooking mountain ranges and fertile green valleys – passed by in a blur. I remember Raul explaining the Buddhist themes of the temple carefully – moving from the realm of desires at the lower level to the top, where nirvana or enlightenment awaited – but my real interest had always been in conversing with and getting to know, even if only for a few hours, someone with a Javanese worldview.

So the grand Borobodur took a backseat that day, and Raul himself was front and center. I wished I could have talked more with him, but we were running out of time. After lunch at a roadside stall in the nearby village, where we had the cabbage-tofu dish, the kupat tahu, we headed back to Jogja. It was a hearty meal, sweet and spicy like many Indonesian dishes. Raul took a nap during the drive back. The next day I flew back to Jakarta.