What makes you "talkative as a parrot and as cunning as a jackal, then roar and fight like a tiger only to end up rolling in the gutter like a pig?"

The metal trash bin was half-filled with jogri (sugar cane juice) when it was covered with a lid and put over a fire. A tube was stuck into the bin around two-thirds of the way up, connected within the bin to a metal plate that condensed the evaporated gas into liquid when water was poured on top. The liquid flowed from the plate, down the tube, into plastic bins and eventually into a glass exchanged for ten rupees (20 cents), and finally into the mouths of what seems to be the majority of the men in Indiranagar.

Alcohol-making is a job usually done by tribal groups and it is no different in the slum area across the street from CRHP. Tribals had settled in some years back and found that selling alcohol to locals was very profitable. As the villagers began to drink nightly, they wanted something that would hit them harder, that would continually take them to a place further from where they were. In response, alcohol-makers began to put all sorts of things into the alcohol to make it more potent – battery acid, trash, detergent. This local brew of alcohol, or moonshine, is very popular among drinkers, who prefer the low cost and high return to the manufactured alcohol available in town at shops, which goes for 80 rupees per bottle. One glass of this moonshine would seem to suffice for one hell of a night for a typical man, but through conversations with villagers I have found that most drink up to six glasses per day, including in the morning.

In the district of Gadchiroli, however, with the highest ratio of tribals to non-tribals in the state of Maharashtra, it has been illegal to sell any form of alcohol since 1996. A pre-ban survey from the early 90s showed that about 100,000 males in the district were frequent drinkers, 10,000 were addicts and a surprisingly high number died of alcohol-related consequences. In addition, annual sale of liquor in the district was about 200 million rupees while the government’s total annual support for all district development programs was 140 million rupees.

This survey and the subsequent community-based movement to ban alcohol were mobilized by SEARCH (Society for Education, Action and Research in Community Health), a voluntary organization started by Drs. Abhay and Rani Bang in 1986 to provide community care and conduct research on the health of women and children. SEARCH served as my last stop after visiting Sevagram.

The anti-alcohol campaign started through village-level meetings with women and youth to discuss health problems, which elucidated the destruction of lives due to alcohol addiction. Men got drunk, did not go to work, failed to support their families, beat their wives, quarreled, fought and even killed each other. Practically all women seemed to have suffered due to alcoholism among men. Many of the men did not disagree, they just didn’t have the power to stop. Using this high community interest among women and youth, SEARCH mobilized villagers to collect data on the problem and then bring it back to each village to see the response.

As awareness grew, boys in two village youth groups organized a ban on liquor – alcohol stores were closed, bottles were broken, drunks were fined. To bring the movement to scale, SEARCH helped to organize 349 villages to pass resolutions to ban all liquor. Anti-alcohol groups sprang up, including a district-level Darumukti Sangathana (Liberation from Liquor). Making of moonshine stopped but manufactured liquor shops stayed open, invariably owned by local politicians making good money. The people decided they could no longer depend on the government to control alcohol so they partnered with local experts and honest officials to start the People’s Liberation from Alcohol coalition. In 1992, they presented an anti-alcohol resolution supported by 10,000 delegates from more than six hundred villages. In 1996, the state government finally banned the sale of alcohol in Gadchiroli, banning locally-made alcohol and closing all commercial liquor shops. Follow up surveys showed that within two years alcohol consumption was 60% less than it had been before the ban.

There are multiple things that really impress me about SEARCH’s anti-alcohol work. Alcohol was a problem identified by the villagers as something that needed to be addressed and Abhay and Rani Bang took it on full-steam, regardless of if it was a problem they identified. Despite the fact that taboo associated with alcoholism and despite the numerous death threats and jailings they had to endure, they pushed on for the benefit of the community. The purpose of the movement was much larger than their reputation and they were willing to put it all at stake for the benefit of the village. In addition, although alcohol has been banned, they recognize that the problem is not solved and that alcohol can still be snuck in or made under cover. To continue to help addicts who want to quit, they run five-day deaddiction camps with detox in the villages themselves, helping people combat alcohol and/or tobacco addictions. The fact that men attend camps in their own village shows the alcohol-associated stigma has been overcome.

Visiting SEARCH and their deaddiction camp also reinforced a desire to understand the scope of addiction and alcohol abuse in the slum area across from CRHP. Along with a staff member familiar with Indiranagar and the local village health worker, we have begun a survey measuring hypertension, tobacco use, alcohol use and diet among all men in the village. Although going into the survey there was a lot of doubt as to the comfort of men to discuss alcohol, we have so far found that (similar to Gadchiroli) men recognize it is a problem and want to quit, but they just do not know how.

Unrelated, I have posted many new photos onto Webshots if you would like to take a look. Click Here to see them.

Even so, 95% of graduates return to an urban practice or hospital

Sevagram, Service Village in Hindi, is a village 12 hours away from Jamkhed. The village served as Gandhi’s ashram beginning in 1936 and also plays host to the Mahatma Gandhi Institute of Medical Science, where I visited after Kanha to learn about the Department of Community Medicine. The department is doing great work on two fronts: first in motivating and encouraging medical students to practice in more rural areas, not only by force but also inspiration, and second by working to build the capacity of the village through CRHP-similar methods. Both these endeavors breathe of Gandhi’s hope for India, and even more his message for Sevagram. In 1945 Gandhi asked Dr. Sushila Nayar to begin a clinic for small infants and women in the village, in hopes of training village health workers and empowering the common Indian village to deal with the core health problems disproportionately affecting the rural population.

The reality is that India graduates roughly 30,000 doctors per year¹ yet hardly any can be found practicing in rural areas, all choosing urban centers instead. To try to curb this trend, the government has set up primary health centers for every 100 villages, creating an auxiliary nurse midwife to provide immunizations and monitor pregnant women, and instituting village-level traditional birth attendants for deliveries not done in the hospital. While this has created more jobs and more locally-available health staff, the effects have hardly been felt. A 2003 study in rural Maharashtra showed that only 12% of pregnant women receive the minimum antenatal care package, even though this is a service provided by the ANM.

To address the inequity in infant mortality and disease transmission, doctors are needed in the rural areas. Doctors are needed where health status is at its most fragile – in the rural village, not in a private practice in Pune. Doctors are needed where the majority of patients are, not where they could travel to, forcing them to miss work and pay unaffordable fees.

The success of CRHP empowering illiterate village women to reduce the prevalence of disease and sickness in their community has been made possible by the low-cost and supportive secondary-care hospital at CRHP Jamkhed that the village health workers can refer to. Without the hospital, patients would have to be referred to the district level hospital one and a half hours away and at times 2-3 times the cost for the same operation (for example–delivering via cesarean at the district hospital: 15,000 rupees or $300. At CRHP’s hospital: 5,000 rupees).

Even with VHWs, ANMs and TBAs, doctors are needed in rural areas to provide the necessary secondary and tertiary care that untrained professionals are not able to care for. Presently, when villagers have serious health problems, there seem to be three options: either they miss work and visit a hospital, they ignore the problem in the hope that it goes away, or they visit a traditional healer or village-level medical provider with no medical training who tends to give antibiotic injections for every complaint. There is little room for easy decisions and every choice has bad implications.

The department of community medicine has responded to this need by instituting programs to orient the students and provide them with a personal experience of rural life. Immediately after admission to MGIMS, first-years have an orientation in Gandhi Ashram for 15 days. Further, all first-years have to live with a family in a village for 15 days to carry out health, sanitation and nutrition surveys, returning each subsequent year for follow up. Finally, since 1992, it has been made mandatory that after medical school, new graduates serve for two years in rural villages, working with Institute-approved NGOs or in a government rural health center.

As I spoke with med students at MGIMS, I asked them what their plans were after graduating and completing their two-year rural fellowship. The first year students expressed their interest in staying rural and practicing medicine in the village. Answers from fourth and fifth year students: two wanted to be orthopedic surgeons, one an optometrist, and practically all said they planned to live in an urban setting. The attraction for doctors to urban life is just too great. If they are originally from an urban area, than they are practically foreigners to village life. If they are originally from a rural area, becoming a doctor is viewed as their way out. Being a doctor in an urban area pays more, as the patients tend to be wealthier and the problems more specialized. Plus, for their family, money is important, as they can now put their children into a private school and “give them a better future,” as one student put it.

Dr. Garg, head of the department, admitted that there is little in the village that attracts doctors to practice there. The education system tends to be worse and the government has set up no incentives to bring doctors away from urban life and into the village. Plus, as an outsider to the village, the doctor has to either find a house (difficult in a small village) or build one (which he/she tends to have little interest in doing). Perhaps the government should set up housing for doctors and compensate them to live in more rural settings? At what cost, though, must you motivate the physician to practice morality and equity? Whatever the solution, it must be accompanied by a change in the mindset of the physician to view medicine not as a lucrative profession but as the opportunity to meet the needs of the sick and enable the village to become healthy and productive.

Dr. Bang from SEARCH-Gadchiroli put it well when he told the story of Akbar and Birbal:

Akbar asks Birbal to find the ten most foolish men from his kingdom.

Birbal went yet was able to find only nine foolish persons; finding the tenth one was becoming a difficult task.

In his search for the tenth fool, he was walking up and down the road of Delhi. The road was in darkness except for a beam of light falling out from a window of a house. A man was bending and seemed to be searching for something. Birbal approached and asked him what he was searching for.

“I have lost my diamond ring and I am searching for it, and am not able to find it.”

“I can see that you are not able to find it. Where did you lose it?”

“In the forest, on the other bank of the Yamuna River.”

“Then, go and search there.”

“There is darkness there, while here there is light.”

The ring was lost in a forest, but it was being searched on a road of Delhi. Birbal found the tenth fool.

Dr. Bang followed by saying – unluckily, most of our medical research is done in this way. Health is lost in the villages but the research is done in the city, where there is light, facilities, air-conditioned rooms, but there are no problems.

Happy Hannukah! Merry Christmas! And a very happy new years!

Stalking Tigers on Elephants

I had already broken into my packet of Tums, trying to persuade my stomach to hold out the thirteen-hour overnight bus journey, when a man plops down beside me on the bed. On overnight buses, you are give a single bed instead of an upright seat, yet as he lied down beside me, giving me the odd look customary to when most see I am not Indian, I came to realize that this small single bed was two seats. Trying to sleep on a bus that is weaving through traffic, catching every bump, with a Bollywood soundtrack blaring from the speakers and a stranger snuggled up next to me is not easy. I turned, tried to get comfortable yet lay awake, wondering how it was so easy for the guy next to me to simply lie on his back, motionless, and fall into a deep sleep. Twenty seven hours and four bus transfers later, I arrived in Nagpur, then Seoni, then Mandla, and finally Kanha National Park, in the state of Madhya Pradesh.

We hopped into our gypsy safari the next morning at 5:30am, dressed in long sleeves and ready to head into the park and hopefully see some tigers. Kanha is a 2000-square-kilometer national park that regularly tops lists of the best places to glimpse a tiger. The park also lays claim to Rudyard Kipling’s Jungle Book, which is based on a case in 1831 of the capturing of a wolf-boy in the Seoni district. To attempt to see a tiger, we were armed with Santos (our knowledgeable driver), a British couple with two cameras and four lens attachments (one of which was bigger than my arm – “just in case the lighting was right,” he said), me and my Olympus auto-focus hand-held, and a guide who was bundled in five layers of clothing and didn’t speak for the first two hours due to the cold.

The park was fantastic as we drove through a virtually-untouched and overgrown forest, searching for tigers but running into hundreds of spotted deer, langur monkeys, peacocks, gaur (big buffalo), turtles, jackals (small wild dogs) and sambar deer. The rarest were the barahsinger deer, which can only be found in Kanha, and were useful since they howled to each other when they sighted a tiger. Seeing a tiger is no easy task and our driver would often stop in the middle of the road for thirty minutes (we could not leave the jeep), waiting to pinpoint the sound of a howling deer or monkey, and then racing over to the closest area to search for paw prints or listen for another hint.

As we gave chase, we ended up running into elephants who had located a tiger within the forest, so we climbed aboard these massive beasts and trekked out in search. As it was late morning, the tiger was already beginning to relax in the heat and we found her lying under some overgrowth, trying to get some sleep despite the huge elephants gathered around her with humans clicking away on giant cameras. We watched it lie there for some minute and then wobbled back to our safari jeep to let others get goosebumps too. In our jeep, we waited for the tiger to get up and walk around, following it down the road and watching it pay no attention to the fifteen jeeps stalking it as it headed down the road.

The next morning we felt not so lucky, as Santos camped out in the road due to the howling monkeys in the trees overhead but the tiger would not come into the open and show itself. After waiting for an hour, disappointed of not seeing one, we decided to head off in search of other animals, but as we drove we nearly ran over a huge male tiger crossing the road. We stopped and for a second were too stunned to even take photos. It went back into the forest, turned to look at us, decided it wasn’t interested, and continued into the forest. Considering the disappointed state five minutes before, the excitement was similar to watching Chipper Jones hit a three-run home run in the bottom of the ninth down by two runs, when you think the game is all but over and now you have newfound life and enthusiasm.

Kanha lasted only two days and before I could regain sleep I was back on the bus, this time headed to the Mahatma Gandhi Institute of Medical Sciences in Sevagram, where Gandhi set up an ashram and where he began the ‘Quit India’ movement. Traveling through Kanha was great, though, and trekking in open-aired jeeps searching for tigers and other animals was surely an awesome experience to say the least.

He’s Acting Like a Man

To start, I want to say that I am fine and the attacks in Mumbai did not affect me as I was in Jamkhed. But they did have an effect on CRHP and some of its guests, and the attacks will certainly affect India, their international business, and relations with Pakistan (although the extent of the ISI’s involvement is not entirely clear). It is of high concern throughout the country and seems to be one of the largest terrorist attacks in a country that has among the highest number of terrorist attacks per year in the world – although Maharashtra, and especially Mumbai, are not usually the locations.

Secondly, pick up this month’s (December) National Geographic magazine! There is a nice article with photos on CRHP Jamkhed and it goes into detail on the history of the organization and its work in the area and abroad. If you’d like to see it online, click here.

This last month since the course ended has centered on the hospital – the first floor of a two-story building, complete with three wards (male, female, maternal), two operating rooms, an x-ray machine and a pharmacy. To say that CRHP and the hospital staff get by with little funding and fewer diagnostic tools does not do the work justification. It has been an eye-opening experience to watch Dr. Wout and others work through differential diagnoses and work with the patient’s family to provide the care needed.

Each hospital bed is like its own family reunion as a schmorgusboard of relatives, friends and fellow villagers sit on the floor for days, weeks and sometimes months with the patient. If transportation is too expensive or the distance too long, then the family is forced to live in the hospital for the time being. CRHP hospital takes advantage of the extra ‘staff’ in the hospital to put them to work and the family members are in charge of giving meds, bathing and feeding the patient, and informing the nurse to fever and unusual pain. This family-provided service is essential to give the limited number of nurses and fewer doctors the time they need to attend to emergencies, incoming patients or surgery.

At first the hospital was overwhelming and even intimidating. I was struck with the incredible number of patients, the variety of disease, the extent to which diseases disabled the patient before seeking care, and just the overall pain that accompanies the third-world hospital. I had never before seen deformities caused by leprosy (feet curled upward, hands = stumps and face sagged to the point of pain), the shrunken look of tuberculosis (often accompanied by HIV), the miniature size of a baby born at 1.5 kg’s (3.3 pounds), or the ease of peeling off the top layer of skin on a child with third-degree burns. The constant loss of light/electricity during surgery, the lack of oxygen tanks when they were most needed, and the absence of splints, crutches and wheelchairs made it difficult to keep sane with so much need surrounding you.

Eventually these difficulties began to fade as I got into the flow of the hospital and triumphs & remarkable patients came to the forefront. The patients are tough as hell and live with excruciating pain for months before coming to the hospital. Patients walk on fractured hips and broken legs, sit on huge pus-filled abscesses, deliver babies without anesthesia, and work in the farm with a miserably-smelling completely-necrosed foot remedied only by amputation. The joys of the patients and families become our celebrations as most recover from the problem that brought them there and they feel emotionally recharged as they have been afforded the care they need and deserve, often regardless of pay (CRHP raises funds to support poor patients). Patients who get better after receiving malaria treatment, having their cataracts corrected, or delivering via cesarean section will graciously thank you and bring happiness and smiles to the hospital and staff.

We have also adopted a new saying in the hospital – “Stop acting like a man” (comparative to the common phrase acting like a women) – when people are crying and need to toughen up. During surgical procedures or in dealing with pain, it is usually the men who whine the most and demand the most attention. In refixing a broken wrist, men will scream in pain as women grit their teeth and get through it. It has become an ongoing joke in the hospital but for me it has become a rather prevalent theme in Jamkhed and I am always humbled by the strength and perseverance of these Indian women.

Response, Reflection and the Traveler’s Dilemma

I wanted to post in response to a comment left by Sheila after the last post on the sasu. If you haven’t read her response, then you can find it by clicking here. I appreciate the feedback and do encourage honest assessment like this from all the readers. It’s not easy to write to someone (and especially on a blog) and portray a point that is counter to the writer but I do think it is important and can serve a much greater purpose than simply rethinking what it is that I wanted to write.

The fact is that all the things I see and learn here are very complex and India is much more of a new world than just a new country. The culture and history here is something that even if I had lived here for twenty years I still would not understand. The subtleties in many Marathi words spoken in Jamkhed is something that even a native Marathi speaker from a Marathi village 15 hours away would not understand. As such, there are many things that as a person who has not grown up here will never understand. This is not to excuse being culturally-ignorant and making broad judgments but it is to say that my blog is not meant to describe the complex intricacies of Indian culture and life. My blog is a method of reflecting on the experiences I am going through here and displaying my own viewpoint on issues that I am learning about and have not yet before been involved with.

I do appreciate the comments and now realize what I wrote can be construed offensively. “Terror of the Sasu” seems to be more of a horror movie than a cultural commentary and certainly there is more to the sasu than just being a terror on the family. The fact that the sasu lives with her son in the first place resembles the strength of the Indian family and the unity that family members hold from generation to generation. The assistance that the mother-in-law provides in raising the children and caring for the home also allows the wife to work/improve her life outside of the home in order to create a better life within the home for herself and her children. And in some instances the mother-in-law relates to and helps the wife in family life and if there are difficulties with the husband. In my earlier characterization of the sasu, I did mean to make it somewhat dramatic and there certainly is a fine line between being pensive and ignorant. I see how my desire to at times be descriptively-exciting can cross the line into hidden meanings and misunderstandings. But it was the radical difference in the sasu’s role in Indian families versus American families that I hoped would come across in the post.

In my three months since I have arrived in Jamkhed, I have heard and read how abusive the sasu can be to the wife. She can create an unhealthy household with a wife who feels trapped and alone, with very little room to turn and no opportunity to peacefully escape, and a husband who is stuck between choosing between his wife and mother. The sasu’s control on many aspects of family life, from how to raise her grandchild to what rooms the wife is allowed to enter during menstruation is that aspect that I do find terrifying. I also wanted to raise the point that CRHP has done great work in changing this difficult family dynamic. As was seen in that hospital experience, Dr. Arole and others seemed to realize that proper health cannot be targeted without including the mother-in-law in family conversations. Through their work they have created these women’s groups where previously-taboo and stigmatized issues like these can be raised without fear of retribution. And now the wives take oaths to be caring to their future daughters-in-law. It is that remarkable aspect of CRHP that I wanted to come across in the post.

The struggle than many visitors to CRHP Jamkhed seem to face is to continually look at the project with an observatory eye without placing our western and personal judgment on what we are seeing, even after months of being here. It is that aspect that in general is most difficult about traveling, but also what makes it so important and rewarding. Visiting new cultures and learning from other people is a fantastic way to open up your mind to new ideas, new ways of life and different forms of happiness and suffering. Traveling pushes you to be accepting of others and appreciating differences rather than judging them.

And there is a fine (but important) line between being culturally-mindful while also maintaining a critical viewpoint on universal values that need to be held by everyone. It is hard to dismiss things that I find wrong (regardless of where I am) as simply being a part of the culture, thus letting it stand as is. This happens in many cases, whether it is the abundant alcoholism in the area or throwing trash on the ground and out windows. And for me it very much held true in the case of the sasu, where it becomes an issue of the wives rights being trampled on because she is trapped to remain a part of the family. It is also that fine-line that I may at times smudge when I do not give the full background to the situation presented.

I hope this blog serves (and has served) to be both a reflection of what I’m experiencing here in India and add some explanation to some of the major differences of Indian versus American life. I try to convey my viewpoints to display my personal values intertwined with this new and unique culture, while being mindful of universal rights. It is this active dialogue with those interested that I very much love, enjoy and appreciate. And if you have any questions or feel I have offended in future posts, I ask that you also let me know so I can clarify if need be. I do enjoy the dialogue and look forward to more.

Terror of the Sasu

As if beginning a King Kong movie, there comes as large a force to be reckoned with as Godzilla… the Sasu, or Marathi for mother-in-law. Just saying the word itself sends shivers down even my own spine and I am brought back to her long and painful role in most Indian families. By mother-in-law, I mean the mother of the husband, and by role, I mean her relationship with her son and even worse, with the daughter-in-law. It is the most interesting family dynamic I have learned about since my arrival in August.

And as much as this story is about the mother-in-law, it is also about the Indian bride, who is not fully accepted in her husband’s home until she produces a male child. When he is born, she is so grateful that she indulges her son to excess (the simple dichotomy between bearing a male versus female child is evident when you see newly-born sons cuddled up with their mother while newly-born daughters are left alone on the other side of the room, distant from the bitter mother). As the boy grows up, he remains close to the mother and distant from the father and a very close-knit relationship forms between mother and son. When the son is married, he is now given to another woman, and the mother often becomes very jealous and envious of this new woman in her son’s life. Since the wife often moves in with her husband and his family, tension is instantly created between the wife and mother-in-law, with the sasu giving the wife hell for everything. The situation deteriorates so much that the son is placed in the middle of the fight, forced to choose sides on many arguments. To maintain the loyalty of his mother who has spoiled him and nurtured him his whole life, he often sides with her, estranging even more his wife who has left her family and now feels alone in her husband’s house. She is often desperate to gain the acceptance of this new family, especially the mother-in-law. And what better way than to bear a son?… so the cycle continues.

In my diploma training course, a 26-year-old Indian wife living in Chennai told me she was desperately trying to move out of her house and find a job away from her husband. They had been married for three years after being in love for eight, and had a two year old daughter. They were an atypical couple because not only had they married out of love (rather than arranged) but he was Hindu and she was Christian. “The love was very strong,” she said. Everything changed after two years of marriage when the husband’s father died, leaving his mother alone. She became ravenous, lonely and manipulative, making unheard-of requests of her son and blaming the wife for the misfortunes of her family. The sasu forced them to change their house to meet Hindu customs, including prayers to Hindu Gods and practices like not entering the kitchen during the period of menstruation. She began to control her son, often taking much of the money that he made and turning him into an argumentative husband. Everything changed and eventually she got so tired that she moved out of the house and in with her parents. Still madly in love with the man she met before his father died, she is confused and angry, hoping that he will soon return to his senses and ask for her back.

Another example occurred while making early-morning hospital rounds with Dr. Wout. A child was admitted the night before with abdomen discomfort, high fever, and trouble peeing. After a physical exam, we realized he had phimosis, a problem where the foreskin at the end of the penis does not retract, thus causing the inability to pass urine and accounting for much of the pain. Wout told the mother that he would simply need a circumcision to correct the problem yet the mother looked terrified and on the verge of tears. The surgery was scheduled but it hit the fan when a woman came storming into the room, yelled at the mother, made a huge racket and started screaming at her and put the mother again in tears. We asked what was happening and the woman began to scream in Marathi at Wout. We came to understand that she was the mother-in-law and didn’t want her grandson getting surgery. Wout re-explained the case to the mother-in-law and the dire need for surgery to remove the pain. With a very doubtful look in the eyes of the mother-in-law, and tears in the mother’s, they both agreed. When we returned to the ward three hours later, the child was gone and her family had packed up and left with no return.

In educated, uneducated, rural, urban, rich, and poor families, this same trend is seen again and again. A wife who has to put up with a difficult mother-in-law becomes an angry sasu herself. For the hospital and for CRHP, it means that the sasu is an essential piece to the puzzle. If we are to provide care or an operation to the child or wife, we must also recognize the influence held by the mother-in-law and include her in that decision. If the Village Health Worker wants the mother to join the women’s group, then a conversation has to be held with the sasu before she is allowed to join. Due to that influence, a major goal of these women’s groups has been to educate mothers to not be so difficult as their sasu was, and most have taken pledges to be different, and they have. They hope to set an example for all to follow.

Mumbai, Bombay… whatever you call it, it is certainly not Jamkhed

To catch a little break from Jamkhed and have a mini-vacation, Wout (Dutch doctor), Thomas (Dutch med student), and I caught a ride to Mumbai last Tuesday. The contrast between rural and urban life in India is amazing and easily visible as large farms are replaced by huge buildings, billboards change from wishing a friend happy birthday to selling a pair of jeans, and the poor who sleep in huts change to the poor who sleep on the concrete sidewalk. The cows still exist in both places, as do the dogs, but there are less of them. The rickshaws (hand-pedaled mini-taxis) and motorcycles still own the road but in Mumbai women riding on the back sit straddling the motorbike rather than both legs off to the side… a big difference in meaning. Mumbai is big, loud, very crowded, more modern but expensive, and dirty dirty dirty, but a great way to get away for a couple days. Jamkhed is a more peaceful and supportive place to live for the year and leaving for Mumbai I did expect the draw I felt taking me back to this little town.

After checking into our budget hotel in Colaba, the main tourist area and center of south Mumbai, we found ourselves with a myriad of restaurants to choose from and every restaurant we chose was fantastic. Indian food made locally is just so good that we ended up eating it for breakfast, lunch and dinner. Each restaurant has its own specialty; all filled with tons of sauces, different red, green and brown spices and tons of oil that often forms the top layer of the dish. But when mixed with chicken, spinach, cottage cheese or goat that sucks in the spice, and then mixing with garlic naan delivered steaming and very crusty, it is an amazing experience for your mouth. And your stomach does not miss out either, as it gurgles non-stop for a couple hours after a good meal, crying for relief. Every meal we stuffed ourselves until we were uncomfortably full and almost regretting it, but the next meal we’d do it all the same again.

The highlight of Mumbai was one morning when we woke up very early to catch fishermen unloading heaps of fish onto Sassoon Docks, a 90,000 square-yard dock at the end of south Mumbai. Hundreds of huge, brightly-colored wooden fishing ships that had arrived at 2am after fifteen days at sea lined the docks with their uniquely-designed flag flapping in the wind. Beginning at 5am, fisherman unload tons of fish off the boats to their fishwives on land who carry it to their little open space on the docks where they auction it off to the thousands of buyers who equally crowd the docks. The scene was chaotic and equally exhilarating as we tried to walk through this mass of people, ankle-deep in fishy water, unable to stop and stand for a second without forcefully being pushed from all sides by fisherwomen rushing to buy the freshest catch. These fisherwomen were amazing – hired by a family or restaurant to buy the freshest fish at the lowest price, they would weave through the crowd, coming within inches from the edge of the dock, while carrying a 50-pound wooden basket on her head filled with fresh and dripping fish. They would rush by, yelling at other women and making their way to the vendors auctioning off the fish. Once a new load arrived, the bidding war would begin as buyers yelled out prices for fish, ranging from tiny shrimp and mackerel to medium sized catfish and pomfret to large sharks and even octopus. After an hour and a half we found ourselves pushed out of the chaos back onto safe land, reeking of fish and wide-awake as if we’d slept 12 hours the night before.

At the end of the five days, the easiest way to get home to Jamkhed was by train to Pune and then by bus or car from there. The train ride was almost as exciting as Sassoon Docks. Since we were only able to buy confirmed tickets, we did not have seats on the five hour train ride and from the hundreds of people standing in the traincar there was no way we were going to find a seat. Fortunately, I sneaked my way to the entrance door of the car where I was able to sit with my legs hanging off the train and the wind blowing in my face. The view was amazing as Maharashtra state is hilly and green and we passed along many small little towns and over mountains and through forests and I had a front row seat for the whole thing. At times the pushing amounted to me almost falling out of the train but with a tight grip onto the handrail the five-hour journey was completed with gusto.

Election, election, election… Everyone I met in Mumbai asked me about the election and even in Jamkhed people understand its significance. And while they don’t know the policies and understand each President, they do comprehend that America’s relationship with India and other countries is at stake. And before I am ever able to state my opinion, every person I speak with, from the Africans to Nepalese to Indians, is pro-Obama. Why, I ask? “We believe what he says, and he has good things to say.” This election is reaching more places than just North America and I can only imagine the tense and exciting feeling in the states. Let’s hope it ends up as well as it can.

A Group of Four People, Three Countries

This two month training course concludes with an plan that has taken up the majority of the last month. Our course of twelve trainees was split into three groups of four and I was in a group with Priya (from Tamil Nadu, India), Suri (Orissa, India) and Sakala (Kathmandu, Nepal). The action plan is meant to be a ‘plan of action’ for empowering your local community to identify and tackle a health-related problem. The methods of community identification, equity, integration of multiple sectors, and empowerment taught during the first month are now implemented into our local community. The month it took to write this action plan was an exciting and difficult experience.

Our group decided to focus on a community that Sakala was working with in southern Nepal. Sakala works with the Leprosy Mission (www.leprosymission.org/) and for the past couple of years has been involved in an unsuccessful community outreach project that had good intentions but failed because of its top-down approach and poor community-based methods. So Sakala came to Jamkhed to learn how to empower the community not to get rid of Leprosy but rather to physically and (more importantly) socially rehabilitate people with disability into the community. The disabled in these caste-driven societies of Nepal and India are so shunned from the community and their family that they are often kicked out of their home and forced to beg on the streets. We understood that there was a lot of social rehab that needed to be done before any physical rehab programs could be initiated.

The action plan became a great learning tool as we realized that in order to have the community invested in the project and create sustainability, an issue that they cared about and identified needed to be the starting point. The same was true when Drs. Mabelle and Raj Arole came to Jamkhed in the early 1970’s. Their mission was to treat and prevent disease but they were forced to start with projects that the community was interested in working with first, like agriculture and employment (food for work program). In Nepal, the community would not be interested in working to rehabilitate the disabled. After some hypothetical community activities (based on historical reality), the village decided that malnutrition was the top health priority. So while we went into the action plan hoping to tackle disability, the rest of it was dedicated to malnutrition. It was a brilliant lesson of equity and started at the level of the community and with their own needs identification. Disability would eventually be dealt with at a later point, but this project would have been as unsuccessful as the first without proper community participation.

The most trying task of putting together the action plan was working as a team and having productive disagreements rather than ranting arguments. Since we come from three different countries and very different backgrounds, we disagreed on a lot. The main issue was how to properly introduce ourself to the community and ensure that the most marginalized were included in our project. With varying levels of English proficiency, computer literacy, community experience and work ethic, we ended up spending most of the time working through arguments to the most agreed-upon solution. Discussing different methods and tactics was a great learning tool but getting frustrated and having them angry with you was not as nice. All-in-all the action plan was a success and if you’d like to see a copy of the 20-page report, let me know and I’ll email it to you.

The two-month training course ended on Saturday and provided me with the grounding to spend the next nine months on community projects and grant writing/fundraising. A major take-away lesson of the past two months is that success in health is achievable by trusting the community, empowering the socially-minded and using appropriate technology.

Everyone Poops – But Why on the Side of the Road?

Since I have arrived around two months ago, I have had a couple observations that have caught me by surprise and that I would like to share.

The World’s Largest Public Bathroom: Everyone poops everywhere. Waking up at 5:00am before the sun rises to walk along the street to a nearby lake is like entering into an open public bathroom stall. Men, women and children are squatted down on the gravel off the road freeing themselves of the previous day’s consumption. We make sure to walk in the middle of the street, simply looking ahead as the bathroom-goers watch us as we pass. The walk back after the sun has risen is the more treacherous time, as traffic forces you onto the side of the road and making you watch every single step.
The odd thing is that many of the villages and even some private homes have bathrooms. In fact, CRHP is actively working with a water and sanitation NGO in India to provide all project villages affordable toilets for at least 70% of the population. Getting the toilets into the villages is not the hard part, though, but rather getting people to use them is the major barrier. Villagers are accustomed to using the area behind their home, on the side of the road, or next to a tree and are not comfortable entering a small room to perform the same act. In most of the villages I have seen the bathrooms are being used as storage areas and filled with boxes.

Speak Softly and Carry a Big Stick: Every Tuesday to Wednesday, the Village Health Workers come from their many different villages for ongoing training at CRHP. Many VHWs who have worked for over 25 years still come every week. And yet during morning service every Wednesday morning as I sit on the floor, I am humbled by their humility and awed by their confidence. Almost all these women have gone through incredibly difficult relationships and experiences, either physically, socially or mentally, but their transformed spirit and their ever-positive view of the world puts me to shame. There’s no real way to describe it and I don’t even fully understand it, but these women come together as best friends every week and sit so tall, always say hello to me, and continue to share stories of the past week and methods to further improve their community.

Two Dogs For Every Cow: For all the cows that I see, there are many more dogs. Almost all are wild and live on whatever scraps people will feed them or whatever meat they can find that isn’t feeding the equally-hungry humans. Thus, many dogs are emaciated, turn aggressive and spread rabies through bites and licks. Thereby, if a dog bites a person, then the dog has to be killed. Unfortunately, a veterinarian or the Municipal Dog Squad is often not at hand, so either the village is forced to kill the dog or a caste group is called who specialize in trapping the dog and killing it.
A couple days ago I had the pleasure of witnessing the stoning of a dog that had just bit a woman’s arm. It was probably one of the more barbaric things I have ever seen. The fact that the dog had to be killed was understandable but the trapping of the dog in a corner, then slamming it into the wall with bricks and raining down on it with stones until it was dead caught me by surprise to say the least, considering the drastic difference in dog care in America. Efforts to limit the population of stray dogs in major Indian cities have been taken up by local governments but many animal rights activists have protested the methods used to kill the dogs. I would imagine that this was one of those methods.

“Primary Health Care: Now More Than Ever”: The World Health Organization recently released their 2008 annual report, this one focusing on the need for primary health care in developing countries. And while a similar message was delivered thirty years ago at the Alma Ata Conference, this time the report represents a renewed commitment with the same necessity for equity, integration and empowerment. Jamkhed has been a leader and model for community-based primary health care since the early 1970’s and the village efforts are still self-sustaining. It’s amazing how such complex vertical programs organized by very well-intentioned and well-funded NGOs can have such a little effect on the overall health of the community while a simple, low-cost solution and idea like primary health care can continue to work after thirty years. To view more info on the WHO Report, click here.

A Tad More Than Just A Disease

“This presentation just failed to discuss the real issues that face leprosy,” Shobha Arole remarked after one of the trainees had finished making her 20-minute presentation on leprosy. Her presentation was just like the three presented the day before – very dry, clinically-based and made for presentation in a hospital. The presentations focused on the signs and symptoms of disease, the treatment, the different classifications (of leprosy) and some barriers to prevention. However, as Shobha acknowledged afterwards, it completely failed to address the reality of leprosy in the village and the situation on the community level. It failed to be practical and address why the disease could not be eradicated in a village that has leprosy medications directly on hand. And finally, Shobha was worried that after one month of the training course we still viewed disease in the same diagnosis-then-treatment fashion.

Leprosy is defined by the bacterium Mycobacterium Leprae but it isn’t the bacterium that keeps the disease alive. Leprosy is kept alive and caused by stigma, by detrimental traditions, by shunning it out of the community. It is caused by lepers being forced to go to leper camps and leprosy-specific hospitals for treatment even though it is much less contagious than tuberculosis or the flu. The perception in the village is that leprosy is incurable, highly infectious and a ‘divine curse’ of the Gods. This understanding leads to a fear of the disease much out of proportion with what is reality. When a villager is found to have leprosy, they are immediately thrown out of the house by their family and shunned from the village by their community. They are now on their own for food, shelter and work. This behavior and tradition keeps leprosy stigmatized, keeps it mystified and leads to future leprosy patients not offering themselves for early diagnosis, only to be exposed when deformity occurs. In reality, though, leprosy can be detected from a simple pale patch on your back or forearm and controlled from this point so it never spreads to the rest of your body and creates deformities (which are not caused by leprosy but rather from misuse due to the leprosy-caused lack of sensation).

How can leprosy truly be cured in these villages? By removing the social factors that keep the disease alive. By destigmatizing the disease and showing that leprosy is a bacterial disease, not a deformity or curse. Efforts need to be made to bring lepers back into the community and incorporated into public life. Once this effort is made, it shows that these are normal villagers who were simply diagnosed for a bacterial infection too late. When the stigma is lessened, the fear of the disease is mollified and villagers will present with possible leprosy at the first sign of a discolored patch to then contain the disease so it never reaches disfigurement. This brings the disease to the open and allows for the possibility of treatment and village eradication, not the antibiotics. The antibiotics have been available for village-use for years, but it is the social determinants that perpetuate the disease, not the medical ones.

The trouble is that all too often we are taught to think of leprosy (and other diseases) by classifications, definitions, medications and treatment. However, in reality, this state of mind takes the focus of the disease away from the social factors, away from the true root causes and the stigma to only further alienate leprosy patients and assist in mystifying the disease as a medical rather than social problem.

In developing countries and among the uneducated population, the true disease is not a virus or a bacterium but rather the ignorance and lack of knowledge/understanding endemic in the community. The availability of medications is not the problem, it’s the social causes that are the problem, and that is what needs to be addressed to cure these diseases.

Doctor Arole often comments that if communities could treat the same disease hundreds of years ago (without drugs) better than we can now (with drugs), then we must not be addressing the necessary intervention. What I understand is that we need to treat the society, not the disease. If we address the social problems, then we cure the disease regardless of drug treatment. Medications are needed but only after behavior modification, which is often a response to societal over medical acceptance.

In some ways these social interventions are viewed as prevention, such as change in diet, spreading knowledge and encouraging safe behavior, but it should also be viewed as treatment. Rather than just treating the disease, though, we are treating the community.

Shobha’s comments helped me to focus my presentation on community involvement and on village-level specifics. Watershed development is not a disease but it certainly is related to health. I decided to do my presentation on watershed development because I knew absolutely nothing about it and have lived in urban settings my whole life. To the average rural villager, though, all your food comes from the farm and your diet is a direct reflection of the crops you and your community grow. So when Doctors Mabelle and Raj Arole went into the villages to educate people on nutrition, they soon realized that they could not give advice on nutrition when people don’t have nutritious food - and in some cases any food at all. Realizing that health and development are two sides of the same coin, they worked with the village to organize community groups that properly intervened in agricultural life and ensured both a higher production of crops and a higher equity of crop distribution.

They achieved both these goals by setting up the watershed development program to minimize ecological degradation and increase economic sustainability. Ecological degradation was solved with three major projects: minimizing soil erosion, properly managing and harvesting water, and increasing the vegetative cover. Economic sustainability was solved by: village-level watershed development committees, payment of workers with food rather than just money, and proper crop rotation to ensure, for example, that a ‘heavy water-needing crop’ was not grown in a low water field. The result of their effort is amazing as they have created a sustainable project that continues to bring benefits year-in and year-out, even in drought-laden years. If you are interested in learning more about the project then feel free to look at the two documents I attached to the email I sent out.

Also, to view the photos I uploaded, you can see them by clicking here.

Just a Typical Day in Jamkhed

Getting shaving cream smeared on my face with a worn-out brush in a little stall right off the road, then having it shaven off using a razor that seemed to have been made 20 years ago, was for me quite a unique experience but just a normal thirty minutes for any resident of Jamkhed. The hair-cuttery shops are really an awesome site in Indian villages – two chairs set up on the side of the road under a tin roof and costing close to nothing. For a surprisingly very nice cut (I can’t imagine they often cut the hair of a white Jew) and a frighteningly-close shave, it only cost 25 rupees (50 cents). Using our limited Marathi, Wout (the Dutch tropical doctor also here for a year) and I spoke with the crowd that had gathered around us as the barbers went to work.

Afterwards, we walked next door to a little tea stall where the owner sat down with us and had tea with milk and five fried potato & onion rolls, also for a total of 25 rupees. The owner was from the village of Rajuri, which is 25 km from Jamkhed and also a CRHP project village, but lives and sleeps in Jamkhed for work and travels back to see his family when he can.

Whatever day it is, there are always crowds of people in town – the women shopping while the men either work in the shops or idle about, talking with friends. Every man is in pants and flip flops, no matter how hot it gets. After tea we bought some apples from a street vendor and took the ten minute walk back to the CRHP campus.

Since today was Sunday, we did not have class. This two-month training course runs six days per week and six hours per day. On the average weekday, I wake up around 6:30am, take a shower and stretch, and then read ‘til breakfast at 8am. Breakfast is usually yellow rice, some strawberry jelly and a cup of tea. At 9am is morning service. The Arole family is Christian and they hold an optional prayer every morning for around 15 minutes that everyone seems to attend. It is far from forced, though, and they have really used their belief in Christianity to guide them in their work with the poorest of the poor in rural India. Never have they demanded that any project village convert but rather see every religion as a search for the answer to what God is and every individual as equal in God’s eyes.

Class runs from 10am-1pm and then again from 3-6pm, with lunch in the middle. The trainings are very interactive with many guest speakers and often involve small group presentations or large group discussions to really absorb the material and relate it to the situation back home, since all the participants are professionals looking to implement primary health care in their own setting. After class we tend to work on our monthly individual projects (my topic is watershed development – more info on that later) which will be presented in the coming week. Dinner is from 7:30-8:30pm and always involves a rice dish. If we’re lucky they’ll make a curry or biryani, but often we eat it with daal (lentils), chapatti (delicious flat bread), and a vegetable dish (cauliflower, squash or moringa drumstick). The food is excellent and always has a very nice spice to it and occasionally a misplaced bone to chip off a tooth. Many of the Africans don’t enjoy the food but I find it much better than anything I have cooked at home and could cook period. After dinner I tend to study Marathi with Peter, a man who works in the library, and then I read until bed around 10:30pm.

Life is quite relaxing but even the most ordinary of days very educational. Things run slower and move at IST (Indian Standard Time, or as they say here, Indian Stretchable Time) which was difficult to adjust to at first but allows for a little time to hear yourself think.

In other news, Happy Rosh Hashanah and Yom Kippur. I will be leading the prayer service on the morning of Yom Kippur which will bring a nice change to the Indian and African gospels. Hopefully this Rosh Hashana will bring about a new year in America and abroad – one filled with a stable financial market, a President we can trust and a commitment to primary health care, or at least healthcare for every American.

Primary Health Care Is Like A Good Microsoft Word Document

As part of the training course, two students are paired up to chair a committee responsible for a certain task throughout the course. I have been put in charge of the social committee (responsible for organizing activities that bring the group together) and on Monday nights we have put together a computer class where me and two others sit down with other trainees and teach them about the computer to raise their ‘computer literacy’. Last Monday was Introduction to Microsoft Word. For forty-five minutes, I sat at the computer in the library circled by three trainees frantically taking notes on everything I said about the functions of the computer, what the different keys on the keyboard meant and how to use them in Word, and what the different icons were on the top of the screen. They copied each function meticulously and at the end thanked me for taking the time to show them, but I expressed that it would really make no sense until they sat down at the computer and practiced it themselves. After the class I went back to my room and read a little (great book – Just and Lasting Change, by Carl and Daniel Taylor) and reviewed some notes from the day, and it hit me how creating a good MS Word document is like implementing primary health care in a community.

A good MS Word document is created by pulling all the different shortcuts, functions and features into one place making it as easy for the reader as possible to understand the information presented. Shortcuts using the ‘ctrl’ key, making things bold or italicized, numbering or bulleting lists, adding tables and graphs with captions – these are all features of MS Word that, when combined together, make a good document. But as I was speaking during the training session, the other trainees couldn’t visualize the ease and possibility of taking the time to see how each shortcut and feature work together. They simply viewed each function as serving that one purpose and as a single intervention that made their Word-lives easier. They were unable to see how building on each accomplished their overall goal and created an effective document. How similar this is to PHC and what I am trying to accomplish here!

Primary Health Care works to bring all the different sectors that affect your health together to improve your situation. The goal is to be mentally, physically and socially healthy and it’s done by combining multiple types of interventions to change the whole person, not simply the illness, or the economic hardship, or the literacy. In the project villages of CRHP, the community has been empowered to initiate income generating programs (to address financial dependency), women’s development groups (to address lack of self-worth and family status), self-help groups (to address lack of social status), farmers clubs (to address agricultural dilemmas) and village health workers (to address poor health and disease). Overall, a holistic approach to health is accomplished through the melding of multiple aspects of health, rather than just focusing in on one intervention that does makes a change in your health but is not sustainable and fails to truly address the underlying problems.

I frantically take notes during trainings, copying down every word that Shobha or Dr. Arole speak, trying to understand what primary health care means. Just like the trainees in the MS Word class, I am trying to learn about every individual intervention (or feature) and how each affects the overall goal of good health (or a good MS Word doc) but not piecing it all together and understanding how each builds on the other. In reality, I will probably not be able to understand what primary health care means or how all the interventions are related until I can visualize the overall goal in my head. Sure, I can see the goal in front of my eyes by visiting the villages (just like I can show the trainees the goal by showing them a good Word document), but until I understand not only what each intervention means but how it builds on and is related to the others, I will not be able to understand how good health (or a good Word doc) is accomplished. The analogy might be a reach but in some ways it really relates.

Thus, this is a major goal of my year in Jamkhed. The training course is doing a great job by first showing us what primary health care means and how Jamkhed has accomplished it, then taking us through each feature of the CRHP model showing how it was accomplished and giving examples of programs that failed to address that aspect of health. In that sentiment, on September 12th, we wished Alma Ata a happy 30th birthday. Thirty years ago in Alma-Ata, former USSR, governments from around the world came together at the public health conference and, for the first time ever, agreed that good health was a fundamental right to all citizens and that it should be accomplished using the model of primary health care. I don’t think it has come to fruition yet. Regardless, we had a nice party with a birthday cake and balloons popped prematurely by the Africans in the party mood. It was tons of fun and can’t imagine that next year I will celebrate so festively.

The more you learn, the more questions you have

Today officially concludes my third week in Jamkhed and my second of the training course. The training course will last for 2 months and so far has given a great introduction and perspective on Primary Health Care and what holistic health means and looks like, at least in rural communities. I am taking the course with eleven other people, all working in developing countries – Nepal, India, Sierra Leone and Liberia. Most are nurses but others are community workers, specialists (like TB, leprosy or HIV), or hospital staff. It’s great because they bring very practical experience and expertise that I more or less lack, where as I bring youthful enthusiasm and the perspective from a developed country (with its many undeveloped areas). But even my youth cannot keep up with most of the Africans, who are incredibly playful and bring a sort of excitement and optimism to every discussion – even though they’ve seen and worked with so much hardship and war. Similar to other Western Africans I have met, there’s never a dull moment when they are in a good mood and they bring a sense of purpose and life to each conversation. They also wear their emotions on their sleeves, which has been both good and ‘interesting’, in that you don’t have to look much past the expression on their faces to understand that the session isn’t too interesting.

Over the past three weeks I have been able to also visit the hospital and observe some operations, many of which have been cesarean sections. And I can say there is no more awesome feeling than seeing a baby come out of a person (usually a woman) and seeing how the doctors here work with such limited resources and finances. Over two days last week, I was able to see 5 deliveries, so that when the Africans arrived, the doctor asked me take to the operating room and explain what was going on during the procedure. It was rather ironic, though, as I have never delivered a baby in my life and these Africans had delivered over one thousand babies combined. But if that was empowerment, I did feel it, even though the Africans ended up educating me much more than I did them.

A key principle to CRHP and to primary health care in general is demystification of medicine. Health has been too often defined as the absence of disease, so that being unhealthy means you have disease or an illness and, thus, you can be cured of this disease with the proper diagnosis and prescription. In this way, we have become so dependant on doctors and on medications to make us free of disease and healthy, which puts all the power away from the average person and into the hands of professionals in medicine and the drug industry. Health, though, is not the absence of disease but is rather the complete state of mental, physical, spiritual and social well-being. CRHP works on the basis of Comprehensive Primary Health Care, where equity, integration and empowerment are the essential components to proper health. Equity (rather than equality) in that those who are most marginalized must be identified first and reached at their doorstep. Integration in that care is provided to the person, not the illness, and that all activities that promote health should be integrated into one service. Empowerment in the realization that even the most illiterate can treat illness and cure poor health as well as (if not better than) any doctor, and knowledge should teach people to care for themselves and not create vertical dependency. Poverty is the biggest reason for ill health and treating tuberculosis with medications while ignoring access to clean water and proper nutrition is doing more harm than good. The problems villagers deal with run much deeper than illness and it is those root causes (such as poor nutrition, lack of income, dirty and static water, discrimination and status of women, hygiene, unhealthy traditions and beliefs) that need to be addressed.

And what’s incredible is that CRHP has put the health of the village on the shoulders of the villagers, so that those who are illiterate, cured of leprosy or in the untouchable caste are taking out loans from banks, fighting for their rights, diagnosing illness & prescribing or referring out, taking care of their own nutrition, creating soak-pits to keep water running and creating watersheds. Primary health care is a very simple concept that takes a lot of time and a lot of dedicated people but the results are there, such as in Jamkhed where there is access to clean water and education and zero TB, diarrhea, infant/maternal mortality, and malaria.

In other news, the food is good here, full of daal (lentils), chapatti (chewy naan), and rice, although I presently have a huge craving for some barbeque and spare ribs which will probably not be served for lunch. They also killed a 5 foot snake two nights ago on the path outside my room. It was a python (but I thought it was a cobra… due to my extensive snake experience) and had huge fangs. Regardless of the fact, it is actually relieving to actually have seen one and thus remove the fear of uncertainty, as it certainly will not be the last snake to cross the path.

Women Can’t Do Everything, Can You?

One topic that I think I will revisit often throughout the year is the status of women in India and how CRHP (the Comprehensive Rural Health Project in Jamkhed) has succeeded in empowering them. The level of disparity in the rights of women versus men is not created by laws but much more socially governed, especially in rural India.

In the towns I’ve visited and from numerous conversations and discussions, I’ve gathered that women are responsible for everything. Women raise the kids from birth and watch over them daily, they prepare three meals per day (of which they eat half of what the man does), they get water from the well in the morning and then go to some manual labor job. They fall asleep late after cleaning and wake up early to cook and make little money from farming another family’s land. After she receives her paycheck, much of it is often taken (or aggressively stolen) by the husband who gambles and drinks during the day.

They seem to do everything for the family but still they have little rights and no respect. They are often beaten by their husband and even by the mother-in-law (common in India where they live with their son’s family). But the women think that being hit is the norm and thus do not complain. If they decide to complain, there is often no one to turn to, as her parents would not support her, telling her that this is her fate and she needs to deal with it to protect the family name. Due to Hinduism and the idea of reincarnation, often the problems that you face in your present life is a reflection of the mistakes and poor decisions that you had committed in a previous life. The woman is thus trapped and often has to live with it.

And even though women seem to carry the family workload, it is still considered a failure of the pregnant mother to bear a female baby. One of the greatest ways to be accepted into the husband’s family is to give birth to a boy, so much so that gender-based abortions have been illegalized in India since 1991 (adoption was legalized in 1974). What happens is that the family will find early in her pregnancy (around 20 weeks) the sex of the child, and if it is female, the family will knowingly have an abortion. This was so commonplace that the ratio of women to men in India was around 945:1000 in 1991 and dropped to 927:1000 in 2001 (the national U.S. average is 1043 women to 1000 men in 2002). In the northern states of Punjab and Haryana, the ratio even reached 793:1000 and 820:1000, respectively. Further, a study from UNICEF stated “A report from Bombay in 1984 on abortions after prenatal sex determination stated that 7,999 out of 8,000 of the aborted fetuses were females. Sex determination has become a lucrative business.”1, 2 And a study by the Lancet published in June, 2006, reported that up to 500,000 female fetuses are aborted each year in India, leading to the birth of nearly 1 million fewer girls over the past two decades.

These are tales and accounts I have heard while visiting the surrounding villages and throughout our training course for the past week. The situation is very grim and sad and in some ways has made me embarrassed to be a man. Of course not all men are like this and I have met men who have supported their wives through thick and thin, but it’s the acceptance of it all that is most disturbing. It is this disenfranchisement and inferiority that has made me uncomfortable and that the CRHP program has sought to reverse.

CRHP realized that very often the health of the mother is directly related to the health of the child, since the mother bears much of the responsibility of raising the child. So to target the health of both the child and mother, initiatives were made to empower women. Some of these I have already discussed, but in particular the Village Health Worker was introduced as the liaison between her village and CRHP. She is responsible for spreading knowledge on nutrition and water cleanliness, checking on pregnant mothers, educating adolescent girls, and pretty much working to have the village care for it’s own health. From the VHW came the women’s groups (known as Mahila Vikas Mandal – Women’s Development Group) that organized the women in the village to stand up for their rights, especially against domestic violence and discrimination. Some villages have even started self-help groups, which are smaller groups of women who help each other when taking out a loan from a bank, starting a business, buying goats or cows, and even starting their own micro-credit finance group.

To see the women in the villages so confident, independent and knowledgeable about their rights is amazing after hearing their stories and listening to their situation ten or twenty years ago. Many of these women have gone against all odds to stand up to sexism and transform their villages around to women’s rights and children’s health. On Friday we went to a village called Kusadgaon, where we heard from one woman who brought her husband to state court (she bypassed the village court) and forced him to pay her 200,000 Rupees (around $5000) for running out on her and their kids. She used the money to buy a house, start a barbershop for her son and fund other start-ups.

A big theme over the past week has been the status of women in India and how CRHP has had to work tirelessly to create slow but progressive change. It’s a fascinating issue and I certainly do look forward to learning more about it in the coming months.

Five Cups of Tea Per Day Should Give You a Caffeine Addiction

So tomorrow officially concludes my first week in Jamkhed, a rural town around 8.5 hours outside of Mumbai but still packed with people. It is actually much bigger than I expected, with a nicely-sized market/town area and men hanging around everywhere (employment is not too high).
The program I am working with is called the Community Rural Health Project (more info on Jamkhed and CRHP can be found on their website here) started by two Indian doctors in the late 1970’s to bring health to the poorest of the poor. What they have succeeded in doing over the last 30 years is to create a health system that capitalizes on the innate strengths of the village that, among other things, has reduced the infant mortality rate from 176 per 1000 to 19 per 1000 births.

Much of my last week has been dedicated to visiting project villages where the health model has been established outside of Jamkhed with the mobile health team. Traveling to these villages is an awesome experience, as I see that really it is not doctors who are needed to affect health but rather health activists. As Doctor Arole pointed out, the three biggest challenges that villages face for sufficient health are:
1) Nutrition. With the limited amount of money the villagers have, most of it is spent on carbohydrates, which gets a bigger bang for your buck. Protein is much harder to get, compounded by the fact that cows are rarely killed for their meat and most people are vegetarian anyway. Thereby, many of the villagers have Zinc, Iron and Vitamin A deficiencies.
2) Environment. In the villages, many of the trees are cut down, the water is dirty and standing, and the air is polluted. Houses are also not built for living in but rather for cooking, storage and animal shelter. There were also no toilets and people would defecate outside their homes and on the roads. Because of this, water spread so much disease and was a source for many mosquito-borne illnesses.
3) Traditions. Women and children were considered lower-class citizens and would not be given rights or freedom (even today, women cannot enter a liquor store), and the fate of one usually directly affects the fate of the other. Medicine was controlled by voodoo healers (charging outrageous prices) and disease was a curse of the Gods, who in turn demanded sacrifices, prayer but no treatment.
So what CRHP has done is demystify everything (esp. medicine) and educate everyone (esp. women). By first empowering village health workers (1-2 women per community, at times illiterate, who were nominated by the community) to take the lead in learning about health maintenance and then educate their community, they have successfully transformed the health of over 50 neighboring villages. Presently, there is relatively no malaria, no diarrheal diseases, zero malnutrition, little tuberculosis, and the caste system is non-existant. Women literally run the village and run it better than before; to hear them speak about their condition 25 years ago is really inspiring.

Travelling to the villages is also a fun experience because, by this point, I have begun to get accustomed to being blatantly stared at wherever I go. There is no modesty here, as people will look at me with a face of sheer confusion and wonder, even when I look at them and ask if everything is all right. It feels as though I’m on the endangered species list and everyone wants to catch a glimpse while they can. Word also travels really fast. Yesterday Wout (a Dutch doctor who’s also at CRHP for a year) and I went to a store to buy shampoo and as we left each store that we passed along the way called out “Shampoo, Shampoo” to us. How they knew we bought shampoo we have no idea but I guess it is now known that white people buy shampoo.

Finally, what’s also fun about going to the villages is the exorbitant amount of tea that we drink. At every house that we stop in, at every conversation, meeting and get-together, tea is given and it is rather rude to decline it. So we drink around 5 cups of tea every day. The tea, though, is made from powder and is drenched with sugar, a symbol of social-status in the village. Thank God the tea is so watered-down otherwise I’d be flying high wherever I go.

So far so good here in Jamkhed. Monday starts the three month training course. They also caught a snake in a female resident’s bathroom yesterday, which is nice. Apparently cobras are everywhere, making falling asleep the most difficult time of the day (the heat helps me, though).

Also, as a side note, National Geographic visited CRHP last month to take pictures of the project and write an article that will be featured in the December edition. Pretty cool and it should be a great fundraising tool. You should check it out.

Be well,

Jeff