Sunday, September 28, 2008

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.

Monday, September 22, 2008

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.

Sunday, September 14, 2008

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.

Sunday, September 7, 2008

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.