Holy Cow - Jeff's in India

Holy Cow - Jeff's Leaving India

2009-06-18T03:48:00.002-04:00

My strengths lie in speeches, acting and drama. But these are not skills I have known my whole life. These skills have been derived from her taking the time to get to know me and understand what I would be good at. She helped me to learn appropriate facial expressions and gestures. She always strived to make me and others as perfect and whole as possible, never leaving things half-finished or incomplete. She made sure that the same person finishes the task whom she assigned it to, correctly. She was fearless.

Even though she is physically not around us anymore, she still guides all of us, so much so that every single morning I cannot start my work until I pay a visit to her memorial site. I have done this every morning for nine years, and my experience is that work goes much smoother with the leadership she still plays in my life.

- Ganpatrao Waibhat (CRHP Worker since 1971)

I remember a story that has since changed my life: Once, we were a little late to Mandli village and there was a leprosy patient sitting under a tree. His fingers were fully deformed and he was not able to break the bread he was trying to eat. She noticed it and went close to him, took his bread, and broke it for him. The patient said “madam, please don’t do this, what if you get leprosy?” She replied “I cannot get leprosy by touching you or your bread. The disease does not spread like that, so you don’t worry about me getting it.” Her love shown for leprosy patients, displayed to the village by cleaning their feet sores, made me very upset that I avoided touching leprosy patients. Yet such a big doctor breaks the bread for him! Slowly, her examples helped me to start to adapt this way. Today, if any leprosy patients come for x-ray, I feel very comfortable to touch them. For the last forty years, I have been working and chatting with them.

People always said good things about those who have passed away, but I genuinely, from the bottom of heart, thank her for what she has taught me professionally and personally.

- Moses Gurram (CRHP Worker since 1972)

As I leave Jamkhed and begin to head home back to the states, I am given the opportunity to look back on my own personal growth and what I have learned. Perhaps more interesting, though, are those I have learned from. One of the most impressive people I have met since I arrived in Jamkhed has been Mabelle Arole. However, Mabelle died in 1999. Over the past five to six months, I have worked with a social worker to interview and collect the stories and memories of Mabelle from those who knew her best - thirty seven village health workers, villagers and staff members.

One of the challenges that CRHP seems to face in the future is to continue to push the organization forward, be innovative and exemplify a sustainable, equitable and integrated mission. This is still done well but it will become more difficult when the original staff, those who knew the initial struggle s faced by CRHP and the dependence on a vision and values, begin to retire. To help keep Mabelle’s stories alive and her spirit active in new staff, the video hopes to capture the original struggle and soul behind CRHP.

But it is not difficult to still feel Mabelle on campus. Every village health worker continues to speak of her. Her memorial site on campus is visited daily by staff. People live their lives based on the teachings she gave them. Through the interviews, I was amazed at how many little things about Mabelle people remember. It is those small things that really seem to touch people, that people remember the most. Mabelle never wore jewelry, her sarees rarely matched, she at times wore her shoes on the wrong feet, she laughed loudly and openly, she would rush out of bed if a patient came or VHW called, and she lived a simple life. She brought life to villages upon arrival and every visit used to be a community event. People would sit and listen to her speak, believing not only in her intellect but in the fact that she was one of them. And that seems to be one of her biggest contributions – she made each person not only feel empowered, but made them believe that others are equally good. She truly believed in the power, goodness and strength in each person and people feel alive by having known and spoken with her.

A common theme to the interviews was the feeling of one large family. “She cared for her family just as she cared for us. The world community seemed to be her family,” Yamunabai said, a VHW in Ghodegaon for 30 years. And she worked to spread primary health care and women’s rights around the world, working with the local, state, and national government. She was regional director to UNICEF for Southeast Asia, working in Kathmandu, Nepal, and she was a member of the Christian Medical Commission and World Council of Churches. Her greatest legacy, however, lives in those she continues to touch and the leadership she continues to play at CRHP, nine years after her death. “She taught us how to care for the problems of others. How to love others. How to participate in the sorrows of others. She guided us throughout our path. She taught us how to struggle in order to achieve something bigger. She gave us the gift of a lifetime-courage. This will help us as long as we live.” - Sofia Bee Shaikh, VHW in Patoda for 32 years. I feel so proud to have completed a fellowship in her name.

My eleven months in Jamkhed have ended and I almost ready to go. I am excited but very sad and I would certainly be able to stay here for one more year if need be. The people I have met, the things I have done and learned, the projects I have worked on, the food that I have eaten have all been much better than I could have asked for.

Before arriving in Jamkhed, I did not know what primary health care was, but now I hope to dedicate my life to its principles. I had no understanding of community development, yet now I hope to be a doctor to serve the needs of the community. There are a couple key lessons that CRHP has taught me that I will quickly point out:

One – It doesn’t matter how smart you are, or how much money you have, or how well connected you seem to be. What matters when it comes to success is a die-hard commitment to the community, especially those who are most vulnerable and needy. In fact, I have come to find that money and intellect can serve as barriers to really being able to work with the community.

Two – The work done with the community needs to be based not on finances, not on theory or formulas that have been shown to work, not on great ideas, but on values. Values like love, equity, trust, humility and confidence are the pillars of a successful organization and project. Without them, struggles and uphill battles cannot be overcome. And these values need to be reflected in every staff member.

Three – The true caretakers of the community and the family are women, and that very often they get little of the respect they deserve. The women are the ones who are constantly there for their family, who work their butts off to make their family safe and healthy, and yet who rarely share many of the luxuries that us men share. Even in America, I have come to realize that women are often mistreated and not allotted the full status they deserve.

In Jamkhed, I leave behind cows in the middle of the street, tea stalls at every corner, the extremes of rain and heat, and people defecating on the side of the road. And I have little idea how I will be able to readjust back to life in America. Tea is 100 rupees in America (2 rupees here), haircuts are 750 rupees (25 rupees here), and I can’t be stuffed with delicious Indian food for under 1000 rupees (250 rupees here). I leave Jamkhed happy not because I am leaving, but because of all I have gained.

I encourage you to help Jamkhed in the future, visit if you can, or read the Jamkhed book if you have the time. I also ask that you help CRHP financially, with however much money you can give. Every little bit counts and your money will be well spent at CRHP, as their overhead and staff costs are kept at 20%. If you have read this blog, or if you have spoken with me over the past year, you see the incredible work CRHP has done and continues to do. If you are interested in donating anything from $5 to $500, you can visit www.jamkhed.org.

Finally, I want to say thanks to those who have followed my blog and kept up with me over the past year. The blog has given me an opportunity to write down my thoughts and experiences, as well as keep in touch with friends and family back home. These conversations and posts have played a big part in my hope to fully grasp what I am experiencing here.

So now that we’re in rural India, where’s the poverty?

2009-06-15T03:56:00.001-04:00

As you drive from urban Mumbai or Pune into rural Maharashtra, on your way to Jamkhed, the scene changes quite dramatically. Big buildings are traded in for tea stalls and hair cutteries, computer stores for paan and tobacco shops, cars for cows, and traffic five lanes wide for traffic in the game of ‘chicken’ with the opposing driver. Concurrently, the poverty also changes and many might ask where it went. In the city, poverty is in your face – men, women and children sleeping on the streets, claiming a piece of sidewalk as their own, wearing torn clothing and covered in dirt asking you for money. Many have disabilities – no legs, one eye, leprosy, or scars on their face. The concentration of poverty in cities is greater, with slum houses stacked on top of each other and men sleeping in their rickshaws if they can get off the street. For many visitors, urban poverty is overwhelming and leaves you questioning yourself and a system that permits such overt struggle and inequity.

And then you travel to rural areas and that poverty seems to disappear. Sidewalks no longer exist and people do not sleep on the streets. You say that it’s better in rural areas because at least the poorest sleep under a tent made of hay or tarp rather than uncovered on the sidewalk. It is much rarer that someone comes to you asking for money. Twenty years ago, Dr. Arole tells how it was rare to see a village woman without patches in her only saree. Yet today, you’d be hard struck to find a woman who does not own at least two to three sarees, none with patches. Where as twenty years ago people barely had any food, families now have bags of sorghum grain stored for difficult times. Twenty years ago only the rich had goats yet now the majority of families seem to own buffaloes, cows, goats or chickens. Even the poorest of villages can seem better off than the conditions faced by the homeless and poor in the cities. So where is the rural poverty if you cannot see it? How do you explain the statistics of high rural poverty when it is so much more transparent in urban areas?

To understand where poverty exists in rural areas, one must look a little deeper than appearances. One major cause of rural poverty is access – to government services, health facilities, higher education, and transportation. In rural areas, 36.5% of children are immunized and 36.9% of pregnant women receive at least three antenatal care visits, compared to 56.6% and 70.1% in urban areas, respectively. In the public sector there are 1.5 physicians per 10,000 inhabitants. Even when facilities exist in remote or underserved areas, posts often remain unfilled due to the financial draw of private practice, exemplifying why not one caesarean delivery has been done in the Jamkhed government hospital in the past ten years. Doctors, teachers and government officials prefer to live in cities, dragging appropriate health facilities, good educational opportunities and access to government resources away from rural India. The anti-poverty programs that have targeted rural India are ineffective and inadequate, often ending in corruption or mismanagement so that the funds and services meant to assist rarely make it to the needy. No program exemplifies this better than the Anganwadi worker program (established by Integrated Child Development Services) or the National Rural Health Mission and their Accredited Social Health Activist, both of which are meant to combat rural poverty yet are stuck in beaurocracy and inefficiency.

Poverty can also be understood in the dependence on agriculture for income and how unforeseen occurrences in weather and crops can disable a family for years. If there is a famine, or if there is too much rain, or if the cost for machinery is too high, then the crop is disabled or ruined and there is little to sell in the market and thereby no daily wage. For farmers without land, drought or insect infestation can mean no work for two to three weeks. For a typical family with little savings, a bad year or crop can mean taking out money from a bank or money lender and paying it back over one, five, ten or even more years. At times this dependence on the farm for income leads to women or children working on the land. For rural women, this is particularly hard due to their requirements also inside the house and raising children, or if they are pregnant. For children, working often replaces education.

When I asked Dr. Arole why the poverty numbers are so high in rural areas when it seems to have changed so much from twenty years back, he explains that it has much to do with the inequality between rich and poor. In the past twenty years, rural women wear more sarees and eat more consistent grains, yet their growth out of poverty has been much slower than urban growth into wealth. And compared with 20 years ago, the gap between the rich and the poor, even in rural areas, is growing. 21.1% of the rural population lives on less than 356 rupees ($7.5 – rural poverty line) per month, and 15% of the urban population lives on less than 538 rupees ($11 – urban poverty line) per month. And with poor health facilities in rural areas, 77% of outpatient cases in rural areas are seen by private doctors who have bills in the range that only the rich can pay. When a family earns 50 to 60 rupees per day, a medical bill from a private doctor can put you in debt for months to years, considering the average expenditure per hospitalization in rural government hospitals is 3238 rupees ($67) compared to 7408 rupees ($154) in rural private hospitals. Given the low level of services in remote areas, it is little surprise that the infant mortality rate for rural areas is 79.7 per 1000 compared with 49.2 in urban areas.

In addition to debt from unanticipated occurrences such as a medical bill or drought, financial strain also arises from rural families spending for marriages, feasts, or other social ceremonies. If the daughter is due for marriage, her family not only pays for the wedding ceremony but also for the dowry which can range from 10,000 to 500,000 rupees. And considering the fertility in rural areas is 3.07 compared with 2.27 in urban areas, the chance of having to arrange the marriage of two daughters is higher in rural India.

Finally, it is essential to recognize that statistics are just that – numbers. Poverty can be just as debilitating when it is taken as a mindset. For example, I lived with a family in a village for two days and during conversation they said they were poor and wondered how I could live with them. I was surprised to hear this as they ate three meals a day, all the men were employed and their babies looked healthy. They have plenty of space in their concrete house and even had many goats. Over time, I came to find that their lifestyle met basic needs and they had little to no luxuries. One of these luxuries very much includes freedom, something that they see as effervescent in cities.

For women, this freedom and escape is even more evident. While housing and meals are consistent, their life is still very much subservient to that of the husband. Her life outside the house is limited and there was little to take her away from the duties of daily life (the daughter-in-law I observed left the house twice the whole day – once to clean the clothes and the other to fetch water). She never eats outside the house nor travels to cities because of the money associated with a vacation, where as for a man it could be work-related. Yet men very much view their freedoms as limited in villages as well. So while the appearance of poverty may have been reduced, there is still very much the feeling of mental impoverishment. And this mental poverty becomes even more entrenched with debt, unexpected occurrences, and the Hindu philosophy of karma and accepting the circumstances of your life.

Where the average daily laborer makes 50-100 rupees per day working on a farm, the idea that in the cities they can make over 500 rupees per day is always in their mind. If given the opportunity, many men migrate to cities, at times alone and at other times with their families. These migrants tend to make up the urban poverty, as they eventually find their home in slums or on the sidewalk. However, if they get a job as a rickshaw driver or helping to construct a hotel, that brings in more money in three months than would one year of village work. The ambition and dream of many rural boys and girls is to work and live in the cities.

The message I hope to come across is twofold. First, I hope to give a better understanding of the causes of rural poverty and why you may wonder where it is when you come to visit villages. Second, I hope to explain the differences between what poverty is like in rural areas versus in urban settings, and why so many prefer to live in an urban setting, where to us it may seem dramatically worse.

Alcoholism as a symptom of addiction

2009-05-26T00:59:00.002-04:00

Hi. My name is Jeff, and I am an addict. When I was in college, I studied for the MCATs consistently, non-stop for four months. The more I studied, the more I kept on thinking about studying and the more I ended up studying. When I wasn’t studying, I felt that I should be studying to the point of being self-destructive. I was surrendering friendships and fun, losing touch with old friends and not making new ones, besides my MCAT books. My downstairs neighbor commented that she was often in our apartment hanging out but never saw me since I was never there. Instead, I was studying. I stopped exercising, started getting anxious, and I thought it was all normal and that it would only make the test go better. When I took the actual exam, I had actually studied too hard and could not physically put my brain through the verbal section. My brain was fried, burnt out, and said ‘no more’ at the time I needed it the most. I ended up doing poorly on the verbal section, forcing me to retake the MCATs.

My behavior was compulsive, progressive and self-destructive, all signs of an addiction. Was I addicted to studying for the MCATs? No, but my dependence on it does point to an underlying addiction. So how could I be dependant on MCAT studying without being addicted to it? This is an important distinction to make and one that is essential in my alcoholism and deaddiction project in Jamkhed.

What happens when our brain receives information? And how does that information then turn into action? Studies have come to find that our limbic system, or more specifically our amygdale, plays a large role in the actions we make. Previously it was understood that our feelings were simply derived from our actions, yet brain imaging studies have shown that the amygdale actually responds to information collected before the action takes place. Thereby, our actions are in large part a reflection of our feelings. This has had a great deal of importance in addiction medicine, showing that to truly treat an addiction you must go to the root of the cause, which involves feelings rather than simply thought and action.

In our life, we have both good feelings and bad ones. Both are strong, but it is usually the negative ones that burden us. These negative feelings derive from unhealthy relationships with friends, family, money, work, society and ourselves. These negative emotions exist in all of us and drive us to need good feelings, largely determining our behavior in life. With alcoholism, the good feeling is found in a bottle, with the drive to alcohol propagated by our underlying negative feelings. Alcoholism is thereby a dependency on alcohol to achieve that good feeling, similar to dependencies on gambling, drugs, eating, sex, exercising and many other behaviors. The dependency increases as tolerance increases and chemical imbalances create a need for it beyond emotion. Yet originally behind that dependency is a different addiction – a disease of our emotions in which we are reliant upon negative emotions. The dependency can change while the addiction remains, as often we find alcoholics who stop drinking but turn to workaholics, or who stop tobacco yet take on gambling, or quit eating and switch to exercise. The addiction has little to do with the alcoholism but rather the alcoholism serves as a symptom of addiction.

Further, studies have shown that similar chemical imbalances are achieved in the brain by alcohol, working, gambling, shopping, sex and drugs (1). This research has shown that the same pleasures can be achieved regardless of the dependence. The significance is that what is important is not the dependence which creates the pleasure but rather the addiction that drives the need for a pleasure. Therefore, removing the alcohol from an addict may remove that specific dependency but the addiction will drive the man to find a new dependant behavior. This is regardless of the fact that it may be much more difficult for a man to quit his dependence on alcohol or drugs than exercise or eating due to higher tolerance and cravings.

Addiction counseling and rehabilitation must focus on the understanding that the removal of alcohol from the addict will not solve the whole problem but that the underlying negative emotions must be addressed. Deeper examination is necessary of the addict’s relationship with the world around him and with himself. For this reason, the Twelve Step Program (used by Alcoholics Anonymous and other groups) is such a success. The twelve steps focus on the concept that that we are powerless over alcohol. To make amends, we must deeply examine ourselves and repair those relationships that have been harmed and harmful. It is a focus on examining the emotions and the struggle within ourselves, not with the bottle or with the actual dependency.

In Jamkhed, Friday and Saturday were spent with an addiction doctor and counselor from Pune Adventist Hospital. To update from a previous post Beginning part two of the alcohol and hypertension study: a 2^nd and more successful meeting was held with the village where hypertension was discussed, results from the study shared, and the issue of alcohol only touched upon. Connections were kept with the Indiranagar village as we identified men in the village who were open to discussing alcohol. A partnership was made with Pune Adventist Hospital’s deaddiction program and they just recently came to Jamkhed for a two-day session with our three counselors focusing on both theory and logistics.

At this point, the plan is for the counselors to meet throughout the week and continue to discuss the theory behind addiction, using AA’s The Big Book as a guide. Simultaneously, one of the counselors (a recovered alcoholic) will begin to meet with men from Indiranagar who want to quit three times per week, eventually taking them through the twelve steps. Once a solid group has formed, an awareness program will be launched and the Pune Adventist group will return to run a five-day detox center. Most importantly, at this point the outlook looks promising and achievable. If the steps as planned are taken, the project has a bright (although difficult) future for CRHP and the men who deserve the opportunity to quit drinking and treat their addiction if they so desire.

When we tell alcoholics that they are wrong and bad people, we are not only wrong about the alcoholics but we are lying to ourselves. We are all addicts. We all face feelings very similar to those of alcoholics, including fear, sadness, resentment, guilt, insecurity, egoism, irresponsibility and shame. The difference comes in our coping mechanisms, as we are able to deal with and hide these feelings from others and ourselves better than is someone who deals with alcoholism. Because of their impaired coping skills, these universal feelings are expressed more openly, allowing us to label and diagnose an alcoholic as some different than ourselves rather than examining our own relation with those feelings. Alcoholics are not mad or bad people but rather are sick with a disease of the emotions. A great first step in helping recovering alcoholics is to recognize that we are not so different after all, and we all face our own addictions.

These peanuts are making me thirsty

2009-05-19T03:48:00.001-04:00

We walked into the farm beside the new hospital, bent down and grabbed out a couple bushels of plants with roots of peanuts. We sat on the dirt, removing the peanuts from the plant, rubbing the dirt with our hands, opening them and popping them into our mouths. Eating with friends was nothing new, but eating raw food straight from the source was something rarely experienced. At Jamkhed, it has been nice knowing where my food comes from and I have come to appreciate that relationship in health, both by respecting the food and understanding the conditions it came from. The relationship is important at CRHP and is imbedded into us while at Karkut Farm, CRHP’s local farm 20 minutes from the hospital.

All the food made at CRHP comes from Karkut, which I have visited around ten times. At Karkut, we often pick corn from the field and roast it in coal, watch farmers milk cows and place the milk into jars then brought to CRHP, see chickens lay eggs that are put into bags and then into omelets at breakfast, speak with farmers who till the land where eggplant is grown, or walk through fields of sorghum wheat. Karkut serves many purposes, one of which is to provide organic food for the Arole’s, guests and some staff at the CRHP campus.

The farm’s larger contribution comes from harmonizing our relationship with the environment and land. Karkut teaches villagers and farmers about farming techniques, focusing on those which foster a beneficial and sustainable relationship with the environment. Upon initial arrival to Jamkhed, the Arole’s found that men had a rather destructive relationship with their land, unsure of how to best utilize their space and have it provide for them, especially during drought. There was no leveling of land, no water harvesting and farmland was rocky. With the understanding that it was essential to have productive agriculture to reduce child mortality, for families to be happy and mentally at ease, and for nutrition to be discussed, CRHP started the watershed development program and farmer’s clubs. Farmer’s clubs were men who would come together and discuss new techniques and solutions to common problems plaguing their land and crops, as well as displaying good farming techniques. Techniques such as irrigation, farm ponds, proper spacing of land, co-placement of trees and crops and crop rotation are all exemplified and discussed at Karkut.

Karkut also provides the space to be inventive and experimental with farming methods that are affordable and natural. The earth provides for our own needs and when properly utilized can save the trouble, cost and danger of using products usually paid for. The Neem plant, for example, serves many purposes. When planted along the side of the road, it prevents animals from grazing and plant infections from entering. When converted into a liquid, Neem becomes a natural insecticide. When the branches are torn off, many Indians use it as a toothbrush. Or the Moringa tree, which originated from India and is commonly found throughout Africa. The seed pods have been proven to purify contaminated water. The leaves can be prepared similarly to spinach and are low in fats and carbohydrates but contain a high content of protein, calcium, iron, potassium and vitamins A, B and C. Additionally, soil fertilization at Karkut farm is done by worms that eat up old vegetables, soil and cow dung and poop out rejuvenated soil. Thousands of worms squirm away next to the farmhouse producing fertilizer within weeks and at only marginal cost. These methods are all experimented with on the farm and those that are successful then transferred to other farmers.

Karkut also works to reduce stigma associated with HIV/AIDS, as every female farm-worker is HIV positive. Karkut provides them with housing, stability, work and acceptance. This trend started in the mid-nineties when HIV positive women began to present at the hospital sick, stigmatized, alone and depressed. With food, support and love, these women serve an indispensable role in running and maintaining the farm. All receive antiretrovirals from the government and CRHP is not shy to tell their story and raise awareness about their success.

In urban areas, it is all too easy to become disconnected with our food and forget its origins. Living in Atlanta, Boston and New York, I would rarely think about where my food came from, how it got there, who was responsible for growing it, or how my own actions effect its growth. All that was important was my food getting to me when I needed it. Living in a rural area changes this view, not only by eating peanuts straight from the ground or walking on farmland, but from seeing how the rain (and lack of it) affects the mood of villagers, or how suddenly we will not be eating onions because the crop became infected and prices raised. The connection is especially strong from seeing how the health of children and families is dramatically affected by the weather. It is important both as a person and as a doctor to think about the behind-the-scenes view of the food we eat because it is usually grown right next door and plays a large component in our own health as well as that of our community.

It’s more than just a name

2009-05-07T07:56:00.000-04:00

Before the money makes its hands into the pockets of local and national politicians, the ideas behind the money make its way into headlines and speeches that dominate the news before elections. Each Indian has the right to vote and the dalits (untouchable caste) comprise over 16% of Indians. This population is thus targeted during the election, showing that while the caste system has been banished upon independence from Britain, the entrenchment of it in every way of life is still very ripe. Programs dedicated to raising the status of India’s poor, providing them better education, housing and food security all appear. This year the message focused on infrastructure, namely roads and electricity, defined as the hot topics for this election.

Election Day is a madhouse, with a good rate of turnout from all castes and both genders, upwards of 55% in Jamkhed. Advertisements to vote dominate the radio and speeches are made in many villages and towns pre-election. On Election Day, party representatives line the streets handing out money and attracting swing voters. This year’s election is dominated by three parties: United Progressive Alliance, National Democratic Alliance, and the Communist Party. The UPA is largely formed by the Congress Party, started by Nehru (India’s first PM) and Gandhi and synonymous with Indian politics for the last 60 years. NDA is largely formed by the BJP, a more fundamentalist Hindu party attempting, among many other things, to restore power to the Hindu population. The Communist Party is formed by three to four smaller parties on the basis of secularism, including no casteism, in addition to opposing globalization and U.S. relations.

The party that has been most helpful to the dalits is the Congress Party, although many programs instituted to help the neediest of Indians have failed to make their mark, as only 1% of India’s GDP is spent on health while malnutrition is suffered by 55% of children living in rural areas and 45% in urban areas. The caste system is supposed to be banned yet still exists, according to Dr. Arole, in the mind of every Indian in every village. Although land is supposed to be distributed equitably, much of the good farmland in Maharashtra continues to be controlled by Brahmins and Marathas (upper-caste Hindus) and worked on by dalits and Muslims. Although inter-caste and love marriages occur, every parent I have met seems to be faced with the incredible difficulty of pairing their son/daughter with someone on the same caste. For one lower-caste family at CRHP, their daughter is enrolled higher education and they are having difficulty finding a son-in-law in their same caste but of reputable education and standing.

The caste system is set so that it is nearly impossible to escape a line of work simply based on your last name. In Jamkhed, ‘Dadar’ typically cleans roads and works for the municipality, ‘Shindi’ are businessmen, ‘Madari’ are snake-charmers, and ‘Dukre’ are stone workers. It is possible to escape and create your own name, but on the contrary it is sometimes said that this delegation of responsibilities according to last name is good and useful for India, ensuring that every task is accounted for. However, when a system institutes a profession from birth with little chance for individual thinking and felt opportunity, human development becomes static. Much has been written about the social structure of India with its caste hierarchy but a system that enforces a subcaste to clean bathrooms and carry a bucket of human feces on their head keep the spirit stagnant and ignored.

Saying the situation today is as bad as it was when CRHP first entered villages in 1970 is incorrect. When Drs. Mabelle and Raj Arole first went into villages, caste was one of the greatest barriers to overcome and enable health. Low castes usually lived in the outskirts of the village, on area owned by landlords who lived within the village. Dalits were often not allowed to enter the homes of the high caste, or if so, could not touch anything. In some villages, dalits were prohibited from drawing water from the common pump, waiting for a high caste member to come and pump for them. They would not drink from the same cup of water, afraid of contamination. In school, the children would play among their own caste and sit in sections according to caste, at times only taught by teachers from their own caste. Malnutrition and disease was much higher in the dalit section outside the village. Further, the system was reinforced by a belief that this discrepancy in life was deserved from a past life and justified by a belief of moral superiority of the high caste.

To overcome these caste barriers, CRHP used unique techniques. One was use of a water diviner, who was encouraged to place a water well only in the dalit section of the village, forcing the high caste to walk into this section and confront the realities of other villagers. Children were used to break false beliefs about contamination as different castes would bring water from their homes to pour into a cooking pot, sharing the common food together. The village health worker, commonly a dalit, would display her value by entering high caste homes, delivering high caste babies, and proving necessary to rid villages of disease. Over time and with the help of villagers and awareness campaigns, caste discrimination has been lessened while caste distinction still remains. In non-CRHP project villages, caste discrimination continues to remain and CRHP has had to drop projects in some villages because the issue of caste could not be overcome. Government programs plentifully exist that attempt to raise the status of the untouchables, many initiated by Dr. Ambedkar (a hero among Maharashtran’s – his portrait can be seen on the wall of every village house) but it is fascinating to see how villages and events utilize caste to their advantage.

Swimming in sweat and sunscreen, attempting to deal with heat delirium

2009-04-26T08:50:00.000-04:00

Today it reached 115 degrees Fahrenheit. Yesterday it was cool at around 98 degrees. For the past week it has consistently been over 105 degrees. It is a different kind of heat then I am used to, as it is not humid but simply direct from the cloudless sky and constant all day and night. It is debilitating heat, where you have to work to get through it. Resting makes it worse so you must work to try and ignore it but it always seems to be a losing battle. It is quite amazing how much less productive the heat can make you. There are no air conditioners except in some rooms, where at times we huddle together to keep cool and find ourselves getting five times more work done.

If you walk around at one o’clock in the afternoon, you typically find one of two sights: either men lying down under a tree taking a nap or women working in the middle of a farm working. Both acts at 1pm are amazing. The farmer is amazing for being able to work in the heat in the middle of the day, wearing pants or a cotton saree. The napper is laudable for being able to simply sleep more than fifteen minutes. Some days I try to make it through a whole day without taking a nap but rarely last past three o’clock before being drained. However, taking a nap leaves me swimming in my own sweat after fifteen minutes, searching on my bed or chair for a dry spot, trying to ignore how I am more delirious now than before I slept.

A byproduct of the heat are snakes, which have been appearing in high numbers for the past couple weeks. They usually appear in the early morning, around 6am to 7am, when they search for food or a cooler area to spend the day. One morning I was sitting outside my room reading when I heard a rustling behind me. Looking back, I saw nothing. Ten seconds later I heard the rustling again with a hissing sound. Coming around the corner towards my bench was a five foot rat snake, squirming its way quickly. I jumped up and followed it as it made its way right in front of my room, bumping its head against my door. After yelling out “sapa” [snake], a staff member came out of his room with two sticks, handing one to me. On the concrete the snake had great difficulty moving and we were able to handle the snake with little problem. The next day there was another snake outside the staff housing, and three days later a king cobra was found in the evening. I only saw it after it had been badly wounded by the guard who fancies himself a snake-charmer, but the sight of it fully upright was awesome.

The hospital has thus seen an increase in snakebites, complications ranging from two little marks on the ankle from a non-poisenous snake (like a rat snake) to a hemotoxic bite (most due to vipers) causing necrosis and kidney damage to paralysis from a neurotoxic bite (most due to cobras). One patient in the hospital now has swollen hands, paralysis and kidney problems caused by the crate, the most dangerous snake in the area. In addition to snakebites, more patients with severe diarrhea have been presenting in the hospital. It is unclear exactly what has caused the increase but logic seems to say that people are drinking dirtier water since there is less of it. Finally, the heat gives a lot of trouble to pregnant women, especially if they are actively working. They lose water at a rapid pace yet need it more. The doctors are working hard to educate the pregnant women as to the risk factors of working in this heat.

Every year from April to early June, everything seems to just stop around one o’clock in the afternoon. Patients increase in the mornings and afternoons, but mid-day there is a lull, and even the doctors try to catch little naps to reenergize. Farmers have much less work in the fields and are at home more, and kids are off from school and usually running around CRHP throwing stones to knock down almonds from the tree or riding adult bikes too big for them. The women still work very hard, getting water and taking care of the house and kids, cooking and sometimes even tending to the farms. While it has been difficult to get through, understanding how Jamkhed and CRHP make it through these months each year is also an educating experience.

Paint-covered snake-bite patients make great hosts

2009-04-17T05:56:00.000-04:00

I wanted to share three findings:

Interesting Hospital Observations: Working in a hospital brings patients, diseases and complications not ordinarily viewed in daily life. Working in a hospital in a rural village of India breaks the door even further, bringing in patients and infections rarely seen even in the U.S. Over the past eight months, patients with rather interesting histories have walked through the hospital door. Many leprosy patients have come at different stages of complication. One man stands out in particular, as the tissue in his arm had died so that maggots had been living inside and needed to be pulled out. Maggots can be beneficial when eating dead skin but in this case served no good purpose.

Also coming into the hospital was a case of mumps (MMR is not given in India), many patients with typhoid, diabetic feet, lip cancer (due to tobacco), snake bites from cobras to vipers, women and children with second & third degree burns, and large goiters. The most striking case was a child who was delivered and died within three minutes. The baby would not have lived long, though. It was born with a huge abdomen but a chest the width of a baseball, it had no penis but enlarged testicles, and at the end of shriveled arms and legs, each foot and hand had six fingers and toes. The complications were congenital, although the exact cause we did not know.

Would you like extra sugar with your tea? The humility and graciousness of Indian families has humbled me since arriving in India and continues to quiet me to this day. Never have I consistently seen such caring hosts. Families who work on the farm to feed three children and send them to school immediately stop what they are doing when I enter their house to offer me tea and biscuits. Further, they insist we put extra sugar in our tea, a sign of respect and good status for the family. Also customary is on the anniversary of the death of a family member, their memory is honored by inviting guests from the village for dinner and eating to their hearts content. Additionally, the first time I visited a friend’s house for lunch, I was seated and we were both served until we could eat no more. Then I was presented with a coconut, a scarf, a bindi and a farmer’s cap as a sign of welcome. There was no hesitation at all from my friend or from any of the houses I visit, as there seems to be true appreciation in their actions.

It does feel uncomfortable as the family is far from rich and offering you lunch and tea with extra sugar. However, it is only more complicated and ungracious to not accept. It is equally uncomfortable to eat dinner and end up simply being served, mostly by women. Often I sit and eat with the men as the women prepare the food and then serve it. When we are finished, the plates are taken, a water bowl is brought for our hands to wash, and then the wife cleans the dishes before sitting and eating her own meal. This routine is so consistent that it seems to be a sign of a good host. Their actions seem filled with graciousness and placing values over material things. It constantly challenges me to think about my own hospitality and possessiveness, often at the expense of relationships and my own values.

Just don’t let them cover you in the silver paint: In mid-March, the festival of Holi was celebrated. It is a holiday commemorating the burning of Holika, who was burned to death to protect Prahlada, the son of Hiranyakashipu (King of Demons), who was a devotee of Lord Vishnu. The day is richly celebrated by covering others from head to toe in paint. The morning is spent buying the paint powder and mixing it in water bottles with a hole in the cap for spraying. The next eight hours are then spent roaming and searching for friends to spray and color. It was not a choice of whether you wanted to have paint on you or not; rather, it was a choice of how much paint. Even then, those who protested the most were usually sprayed the most.

The fantastic thing about Holi was the universal playful attitude. Those who do not want to be sprayed may protest but eventually they will be sprayed, and when they did they simply smiled. Even today when you walk around Jamkhed, women will wear sarees and men will wear shirts and pants with paint marks covering the back and sides. But I did not see one person who was truly upset about being covered in paint even after protesting for minutes about being colored. That ease made the day very friendly and familial. By the end of the day, after hours of playing, I was unrecognizable – walking through Jamkhed afterwards, I was covered in paint to the extent that people could not tell who I was.

The goal is not an increase in patient numbers but patient care

2009-04-09T00:45:00.000-04:00

Since 1970, CRHP has been a leader in primary health care (PHC) and village level empowerment, especially of women. It has trained over 20,000 people from across the world on its model of equity, integration and empowerment in the hopes of spreading the message of locally-based PHC. By starting at the level of the neediest villager, CRHP has been able to collectively raise the status of the whole village while simultaneously breaking down caste barriers, long-held destructive traditions and the low status of women.

The key player in this primary health program at Jamkhed is the village health worker. She is a woman selected by her villagers to raise not only the health of the village but also its capacity to handle its own problems. At the outset, many of these women were dalits (untouchable caste) and illiterate. She was not accepted, trusted or supported in her village and the knowledge she was had was often overlooked by higher caste villagers. It was not until problems arose that the VHW was given her chance to break through the barriers.

Many of these problems were referred to the hospital, including complicated deliveries, snakebites, and pneumonia. The hospital served not only to care for the referred patients but also to support the village health worker in her decision. Questions asked by the patient’s family would be referred to the VHW, who would give the correct answer and then be supported by the doctor. When a patient was referred, the VHW would be recognized for her work. When complications arose, villagers saw that the doctor taught the VHW and trusted her. The hospital provided an invaluable service in supporting and encouraging the VHW, assisting her to be accepted and recognized in the village. Soon enough, the VHW was allowed into houses, was performing deliveries in high caste homes, and was listened to when speaking on leprosy, snakebites and other health issues.

The secondary care component of CRHP is essential to the success of its primary health program. When a flow chart is constructed of the CRHP model, two adjacent circles are connected by a horizontal line. In one circle is the village & VHW, in the other is the hospital, and in between is the mobile health team. CRHP is known for its PHC program and village work, but its ability to provide low-cost, honest hospital care is invaluable. How effective would the VHW be if she referred cesareans to a government hospital where it cost 10-15,000 rupees ($200-$300) and placed the family in lifetime debt, rather than to CRHP’s hospital for 5000 rupees ($100)? Or to a private clinician who charged extra for leprosy medications rather than to CRHP where the meds were covered by a leprosy fund? Or to a hospital where the staff treated you like an animal, versus CRHP where you were not only respected but you and the village health worker were taught?

The secondary care component, in addition to supporting the VHW and her efforts, provides low-cost hospital care, supports a non-intimidating environment, and allows the villager to learn about medicine, thus breaking down unfounded beliefs. Each year about 26,000 outpatients receive treatment, 350 deliveries take place (usually for high-risk patients), and 500 surgical procedures are performed. Family members are allowed into the operating theater during the procedure and family is expected to care for the patient as a nurse would.

On Sunday, a new 50-bed hospital was opened with a bang at CRHP. Plans have been three years in the making and construction has taken the past year. The hospital is not only bigger but better built. While the old hospital was built thirty years past with tin roofing and one floor, the new hospital is reinforced with plaster and bricks and has two floors with plenty of space, also permitting a much cooler atmosphere in the hot summer months. The larger wards and consulting rooms will allow for better care of patients and the updated surgery rooms (including one for laparoscopy) will make it easier for doctors to operate. Private rooms will provide safety and comfort to patients with burns and smelly wounds. And the building will provide a long-term hospital solution, as the last hospital (while full of character) was not built to last as long as it did.

While CRHP has in many ways set the mould for an effective primary health program, a major focus now is to become a leader in creating low-cost secondary care. Protocols for patient care, drug therapy and operations will accompany the change in space to streamline and improve access and cost. Villagers with little hospital experience but tons of real life experience will be trained to provide patient care. Doctors will hopefully be attracted to the rural setting to provide services to the neediest of Indians – in eye care, dentistry, surgery and pediatrics. The goal for the new hospital is not an increase in patient numbers but rather an improvement and standardization in patient care, something reiterated throughout Sunday’s opening. The opening of the new hospital represents the hope that CRHP will continue to be at the forefront of change in the health sector throughout India and other developing countries.

Spirituality and/in Medicine

2009-03-26T06:21:00.001-04:00

Sultan passed away three days ago today. His condition had been rapidly deteriorating for six to eight weeks since the blood transfusions stopped. When he passed, the 27 year old Jamkhed resident was skinny as a stick, with bad bed sores on his back and arms (despite being moved into a waterbed), barely able to speak, with eyes as mellow but alive as ever. His nails were all raised, his tongue and eyelids pale, and his mother was reliably by his side. It is not the first time someone has died in the hospital since I arrived in Jamkhed, but Sultan was a particularly unusual case, considering he was active, happy and jumping around when I arrived in August.

Around eight years ago, Sultan went to a Jamkhed hospital presenting with kidney problems. He was treated for kidney failure but a side product of the toxic meds soon left him with aplastic anemia, rendering his bone marrow disabled in producing new red (and white) blood cells. Aplastic anemia is a very difficult disease to treat, requiring a bone marrow transplant available for a good amount of money, especially considering the risk after operation. Sultan, nor CRHP, could afford the transplant. Instead, he received blood transfusions every two weeks to reoxyginate his body. Oddly, even with the transfusions he would present with fever, chills, pain and vomiting. He was tested for malaria, typhoid, tuberculosis but none could explain the ongoing sickness, especially with the limited diagnostic equipment available in the hospital. Eventually, Dr. Shobha, Dr. Wout, Sultan and his mother sat down to discuss the options. They decided to take Sultan off blood transfusions and rest until death.

The healthy-looking Sultan soon became bed ridden, quiet and contemplative. He never seemed angry for the decision or for the chances and changes life had given him. There were few palliative medications to ensure he would live out pain-free besides the common pain meds. What seemed to do the most for Sultan, however, were the daily prayer sessions at his bed. During morning and afternoon rounds, the nurses, doctors and patients would stop, some holding Sultan’s hand or rubbing his leg while a nurse or doctor said a prayer. He would close his eyes, seeming to listen deeply, and then open them again to look at us afterwards. The prayer was not an excuse for lack of treatment but was in fact a constructive form of supplemental palliative care.

With Sultan I began to think deeply about the role of spirituality in medicine. It often seems like a taboo subject, a mixture of contradictions and worlds that should not collide. However, it also seems that spirituality should exist in health and the hospital as much as, if not more than, most anywhere else. The hospital is a place of life and death, healing and suffering, crying and laughing, of miracles and catastrophes, family and friends, love and closure, and of searching and retrospection. Something so important, so innate in a patient as their own health deserves to be accompanied by faith, by a belief in truth and security. Health is much greater than the pain and treatment that accompany disease or injury but involves equally mental and social well-being. For most, spirituality (in whatever form it may be) is a determining factor in this well-being which can greatly affect the patient’s compliance, motivation and success in overcoming the pain and disease.

Spirituality is different than religion, and it should not be used as a substitute for rational medicine or in the place of treatment, but it does deserve recognition and a place in healing. Sultan was dying – he knew it, his mother knew it, we knew it and, for him, God knew it. Is it wrong for the doctor to pray with Sultan, asking for his well-being after he leaves this earth? Was it not more comforting for Sultan to know that he was in the hearts and minds of those who were caring for him?

Spirituality, and especially religion, could be dismissed as counter-science and anti-medicine, but rather it is neither – it just happens to be most controversial when difficult decisions need to be made. Normally, though, spirituality helps treatment and medicine by supplementing it with a valuable service in a place where meds cannot reach. Sultan and his mother seemed to be at peace when he died, and I can’t believe it was the doctors, the medications or the hospital that did that for him. Rather, it seemed to be a faith in something larger than just himself and that he was far from dead even after his body left the hospital.

Beginning part two of the alcohol and hypertension study

2009-03-14T08:43:00.001-04:00

The hypertension survey is complete. From mid-December to early-March, three hundred and four men have been visited in their homes, had their blood pressure (BP) checked, and were asked questions relating to exercise, diet, tobacco use, and alcohol use. Initially, the goal was to simply collect data on alcohol use, but the strong alcohol-associated stigma prevented the sharing of honest and reliable answers. Rather, the survey was paired with a hypertension study. Using the local village health worker to gain trust and acceptance, the study focused on blood pressure to reduce the fear of stigma and create an environment where men could be honest. While many men continued to understate the amount they drink or chew, a safer environment was created and reliable data collected. Besides that, the study allowed me to explore the fascinating village and create relationships that otherwise would not have been made.

Of the 304 men, 46% had normal blood pressure, 37% were pre-hypertensive, 12% were stage 1 hypertensive, and 5% were stage 2 hypertensive (BP greater than 160/100 mm Hg). 31% of the men were found to drink at least once per week – 42% of whom drank up to seven glasses per week, 13% up to fourteen glasses per week, and 45% fifteen glasses or more. And this isn’t beer and whiskey but rather country liquor, as 82% drank an odd mix of distilled brown sugar with battery acid, trash, and other things I don’t know about. The more alcohol a man drank, the higher his blood pressure was found to be – of non-drinkers, 52% had normal BP and 10% were hypertensive, whereas of those who drank heavily, 28% had a normal BP and 37% were hypertensive.

77% of the men use a tobacco product, with 85% of these men chewing tobacco (grinded up in their hand) and others using bidi (cheap cigarettes), goa gutka, cigarettes, paan, or marijuana. Of those who drink or use tobacco, 12,045 rupees ($251) were spent on alcohol and 9991 rupees ($208) on tobacco per week. Thereby, 22,036 rupees ($459) are spent in total on both alcohol and tobacco, averaging to 92 rupees per week per drinking and/or chewing man, an astonishing amount considering the average female laborer makes 40-50 rupees per day and male laborer 60-90 rupees per day, five to six days per week. We also found that 90.5% eat mutton at least once per week (counter-intuitive to the western idea that India is a vegetarian country) and 93.5% eat green vegetables at least once per week (mostly palak – a form of spinach).

With the understanding that the data would be used to uplift the health of the village and direct community-inspired interventions, a meeting was held on Thursday for all the men and their families to learn about blood pressure, hear the results from the study and discuss solutions. The week previous was spent up and down the village informing people about the meeting and getting them prepared for it. By 6:45pm on Thursday, two men had shown for the 6pm meeting. Back into the village we went, a pack of six guys encouraging every man we saw to make their way to the hall. That helped to get fifteen men to the meeting. Then the rickshaw (three-wheeled taxi) with a giant speaker strapped to the top rumbled through the village, announcing the meeting that was now taking place at 7pm. The rickshaw, combined with the Hindi music blaring from the meeting site, attracted the other forty people by the 7pm start, many of them drinkers.

The meeting was intended to be led by Dr. Shobha (director of CRHP) and Asha (local VHW) but the meeting soon became dry and information-filled without proper context. So Dr. Arole (co-founder of CRHP) took over and began to place the data in the context of the larger problem, explaining the risk factors and ill effects of hypertension. Unfortunately, once the data regarding alcohol was shared, five men immediately felt targeted and left. The skit by four village health workers on the effects of hypertension and stroke made the situation even worse, as it merged into a skit on alcohol abuse by men, causing ten more men to leave, some taking friends with them. By the end of the skit and song, the safe feeling of the meeting had largely dissipated. The twenty or so men who remained were very interested and some discussion was held but with little lasting effect.

The most discouraging thing from the meeting is not the failure to create a safe environment for those using alcohol but rather the failure to even create a comfortable environment for them. While there were no direct attacks to the men who drank and they have certainly heard that drinking is a problem before, the values that supported and drove the survey to completion were lacking at the meeting. It was a meeting led by data rather than by honesty, trust, support, love and unity, all values that make the information understandable and introspective. Since this was the first meeting with the community, chances of getting full participation is low, so another meeting will be held in the following week to shoot for a different result. This time we hope to build on what was successful, including the informative survey results, and correct the downsides of the last meeting to create an engaging and comfortable meeting.

A matriarchal society outside of Kerala

2009-03-09T08:56:00.001-04:00

Those who live in urban areas, rural settings, and tribal villages – India is largely made up of these three communities. Jamkhed is squarely in the rural setting but across Maharashtra state exist pockets of tribals who have congregated in hills and mountainous regions. While in Gadchiroli in early December, I had the opportunity to visit a tribal village with SEARCH India, learning about the very unique community and their traditions, in addition to the difficult work done by partnering NGOs.

The tribals in India are comprised of the groups declared as tribals by order of the president. The essential characteristics to be identified as a scheduled tribe are: primitive traits, distinctive culture, shyness of public interaction, geographical isolation, and backwardness, both social and economic. In 1991, the tribal population was estimated at 68 million, 8% of total population.

“Do not tell them you are American,” I was warned before exiting the bus into the village. “What should I tell them?” I asked. “Just tell them you are from Jamkhed.” From the beginning, the tribal area looked and felt differently from all the other rural villages I had visited, most prominently by the use of bamboo everywhere – building houses, serving as storage facilities, and as a fence around sheds and the village – anything to protect from tigers and panthers entering from the jungle. The tribal village was a part of the Madiya tribe, a tribe connected with the Naxalite community, a militant group of civilians in central India fighting the police and government for their rights and an independent state.

Tribals are matriarchal where the woman is respected above the man, a rare trait in Indian society. The praise for women seen throughout their beliefs (husband to wife dowry, female politicians, praising of goddesses) was most prominently showcased in two unique traditions. The kurma house is an external hut located in the village where women live for 4-6 days during menstruation. I have seen similar huts where women are kicked out of the house or forced to stay in only one room during menstruation because of its associated dirtiness and contamination. However, the intention of the kurma house was much different. Here, five to six women at a time stayed together to talk, rest, eat, sleep and abstain from work in order to regain energy and strength during this emotional time. In the home, the man would cook the food and bring it to her, take care of the kids, clean the house, and feed the animals.

The second tradition is that of the gotul, a community center located in the village center. Once or twice a year, usually once the harvest is finished, the gotul is set as a social event to bring together boys and girls to dance, sing, drink and socialize. During the event, a courting process initiated over the previous couple months is now cemented, as the interested couple will spend the night together, either going into the jungle or in a neighboring hut to be with each other. After the gotul, the female goes to live with the boy and his family in his house for six to twelve months, evaluating whether the boy and his family are a good fit for her. If so, then the marriage will take place. If not, then she will thank them and give a gift, and the courting process will begin again. As different as it may be, problems rarely arise. If the couple sleeps together post-gotul, it is always consensual (entrusted in the matriarchal society) and there has been little to no history of rape or abuse. If it creates a pregnancy, then the couple is highly encouraged to marry. If on the rare occasion that they do not, then the village will come together to decide who will care for the baby.

The gotul also serves as the center for teaching and tradition, where the history and culture of the tribe is passed down from generation to generation. Every father will take their son into the gotul and share with him the tribal traditions and beliefs. Yet it is all done by word of mouth, as there are no writings and all history is passed down through stories, songs and dance.

During my limited stay, I became very impressed with the ability of the tribals to maintain their unique tradition in a country that is very opposite in many ways. Tribals seem to get a bad rap in India because they are mountainous, segregated from urban life and shy in nature, yet my experience was very positive. The strong sense of belief and tradition has drawbacks, especially since a major part of their resources are used for ritual purposes rather than economic activities, such as in health. The literacy rate of scheduled tribes is around 29.6% against the national average of 52%. More than three quarters of scheduled tribes women are illiterate. In the Madiya community I visited, the three major health concerns were malaria, diarrhea and back ache – malaria due to the large amount of standing water in the open drains, paddy fields and jungle; diarrhea due to the unclean wells and poor sanitation; and back ache due to the constant bending required in farming.

Both SEARCH and CRHP have been working with tribals for years in health and social development. Their work with tribals has been understated by a recognition that education of the villagers needs to take place without stepping on long- and deeply-held traditions. In addition to dealing with disease, social barriers have been addressed, including access to government programs, increasing the rate of (higher) education, and in many cases working with government forest policy and conservation efforts that have divested tribals off almost all their rights in the forest.

On the wrong side of the railroad tracks

2009-03-01T08:05:00.001-05:00

The storage space on the tin roof was tiny, the boxes were warped due to rain from months back, and the tin roof shook as the fifth train went by since I had arrived. I looked down the row of clay and tin houses that bordered the train tracks, as children ran along adjacent tracks chasing tires hit with sticks, mothers beat wet clothes against stone platforms or bathed their children, and some men still passed out, now melting in the sun from the heavy night of drinking. We had stopped to speak with a mother in the women’s group who had no legs, cut off from an accident with a passing train as a child. The slum of Mayapuri in Delhi was not one of the bigger slums, and certainly nothing compared with Dharavi slum of Mumbai (and Slum Dog Millionaire), yet was nonetheless eye-opening. Houses were piled on top of each other and squeezed in between, so that each wall separated two houses. Roofs of tin were covered with bricks, sticks, cartons for storage, trash, or anything else that would weigh the roof down. The inside of the one room house was cozy to say the least, made for five to six people and their clothes, food and other needs, with parents sleeping on the bed and children on the floor or on mattresses.

Mayapuri’s roads had recently been upgraded, thanks in part to Asha - the NGO my supervisor had come to evaluate - so that the main road was concrete and side roads had ditches for water. The ditches were meant to be covered to prevent mosquito breeding but in many plays stood uncovered and unflowing, filled to the brim with dirty, soapy water. Some of the roads had yet to be converted to concrete and it was a jumping maze from one clean area to the next, splashing through mud or dust, walking through dirty water puddles and trash-filled passageways. The kids running around us had no problem as they fought for attention, running through and often falling into the mud, getting right back up and pushing the other kid down, squeezing into the photos we were taking. Clothes filthy, cuts and bruises covering faces and arms yet these kids were nothing but smiles.

The maze was equal for my nose, as different smells competed for recognition by my brain. At times the scent of animals dominated, where as at others metal dust (since the slum was situated next to a metal plant), or sweets and tea, or just of trash that accumulated in muddy piles along the street. In addition to smells, Mayapuri was pocketed with settlements, as most slum residents came from different parts of India in search of work and money. In one section were the Gujurati’s, in another from Uttar Pradesh, in another from Orissa or Bihar – all with different languages, trades, cultures, and work skills. Some helped to build the new upper-class mall, others rickshaw driving, or some in the local metal factory. It is exactly that need for work that drives people to the cities, yet without money they are forced to live in transitory and overcrowded areas, creating a slum. Slums are illegal, yet in places like Mumbai 55% of the population lives in them because other options cost so much money.

The traditional definition of a slum is a run-down area of a city characterized by substandard housing and squalor and lacking in tenure security. Mayapuri is an area of land also owned by the government yet inhabited by squatters, who settle in the very condensed area. As it is so condensed, slums are often subjected to abnormally high rates of disease, most commonly diarrhea (rotavirus), malnutrition, hepatitis, worms (round, hook), tuberculosis, HIV, pneumonia, or at times mosquito-born diseases like malaria, dengue and chickun gunya. As it is illegal, the slum is subject to destruction at the government’s will. Some of Asha’s other slums had been leveled in a matter of hours with a day’s notice because the land was needed, with no assistance in relocation. More than just a slum, the leveling destroys an industrious city-within-a-city, where businesses flourish and essential services provided.

As I looked down the row of shacks strung along the railroad tracks, I recognized the difference in the effect that Asha could make in a slum versus CRHP in a rural village. A slum faces a less united community as it is inhabited by pockets of people and most families are first-generation to the slum. In villages, though, residents know each other and relationships have been built through generations. It is more difficult to map out a slum, coordinate slum dwellers to identify their highest areas of need, and mobilize action when the population is so large, the problems so varied and the community so diverse. And as goals can be longer-term in a village, slums need more immediate impacts and are threatened to be destroyed the next day.

Asha has done great work, using CRHP’s model translated to a slum setting. Each area has a local dispensary, composed of a health clinic and classrooms. On the ground, community health volunteers are elected to monitor the health of 250 houses, performing pregnancies, prenatal care and necessary referrals. Female lane volunteers are further responsible for the health of their local lane of 40-50 houses, reporting to the CHV. Groups of women are organized into Mahila Mandels (for empowerment, decisions, and representation) and adolescents into Bal Mandels (for education on sexual health, diseases and nutrition through street performances). In the dispensary, computer and English classes are set up for the kids, encouraging higher education and career paths. On computers, young kids who cannot read English have learned to input data and write formulas in Excel, create logos on Microsoft Word, create powerpoint presentations with photos and graphics, and use google and check their gmail account – further signs that Indians are just way too smart. Success is on a smaller scale but nevertheless great, as 34 kids from the slum have free rides through college, roads have improved and water cleaned, tuberculosis and malnutrition has reduced, and a strong sense of empowerment, especially among the women who have demonstrated they are not afraid to hold their political representation accountable for problems in their city-within-a-city.

How does the Kinsey scale apply in India?

2009-02-15T04:50:00.000-05:00

A rumble came over the crowd as we entered the outdoor auditorium, packed with students since it was a school dance competition dedicated to the daughter of a CRHP nurse who had passed away in an auto accident a couple years back. We made our way to the front to our usual designated seats with the rest of the CRHP staff as the crowd got more excited after noticing the 6’4” white doctor Wout, from Holland. Among dance contestants in all costumes, including many boys who dressed in saris and danced as girls, the winner was a boy dressed as the PM Manmohan Singh, dancing with a cane and making fantastic facial expressions. During the following winners dance, a roar erupted as Wout, David (American student), and I were pulled up on stage to dance with the boy, stunned as we attempted to move our bodies in front of over two thousand people.

Common to most events, all boys were seated to the left and girls to the right, with a small wooden fence separating them. No fence was needed, though, as the divide between male and female was bigger than just the auditorium. By the fifth dance, all the boys were on the feet, crowding the front and dancing in place and with each other. All were screaming, singing, jumping on each others shoulders, and yelling to get our attention. The girls, however, were all seated in rows, some with their mothers, calmly watching the show and making little reaction, only at times mouthing the words to a song they knew. Sometimes they would peer to the boy’s side and vice-versa, almost curious what it was like on the other side.

Interaction between male and female is minimal and only rarely do I see boys and girls talking or playing with each other, outside of being married or related. Sexuality is rarely discussed and fear exists not only between sexes but even in what happens to your own body, a trend the adolescent girls program at CRHP is changing. Nonetheless, having a boy or girlfriend before marriage does occur, yet it is kept very secretive and both parents and friends rarely know. A friend of mine had a girlfriend for two years when he was twenty one that neither his nor her parents knew about. Despite knowing that she would soon be married off, he loved her even though they rarely saw each other. He told me that often they would look at the other’s school picture while talking on the phone or eating dinner at their homes. They had kissed but sexual relations ended at that, a theme common even in their private intimacy since sexuality is so taboo. Public display of affection rarely is shown and not one couple, married or unmarried, have I seen kiss at all since arriving in Jamkhed, except for my three day trip to Mumbai (where eight hours from Jamkhed can take you into a different world).

The difference in sexuality and intergender relations is fascinating, as most boys are not married until age 22-26. These boys go through the peak years of puberty and adolescence in a state of confusion and sexual fear, bottling up that energy and seeming at times to translate it into their relationships with male friends. Often male friendships are very physical, very touchy, grabbing and loving, past the holding hands and hugging that is also seen in other countries. I find my own level of comfort challenged as friends rub my arm or hand, whisper in my ear very close, or rest their head on my chest while I sit, massaging my neck. Stories are also often told of male friends entering physical relationships with each other in the sheer curiosity of what sexuality is. Nevertheless, when relations between partners and what happens to your own body is not discussed, sexuality gets pushed to the foreground and stigmatized.

As you watch these boys at the competition dance and sing with each other, it is only natural to wonder how much is attributable to a different culture and how much a drastic difference in the relationship between boys confused about sexuality. It is as if the boys are strained to release the sexual tension built up during the most sexual years of their lives, taking it out in odd ways in their relationships with men and perhaps equally affecting their future relationship with their wife, confused about the intimacy that often accompanies marriage.

There does seem to be a shift occurring in this generation, as exposure to western influence increases and Bollywood movies made easily accessible. In addition, attention is being paid to sexual education by NGOs and schools as the issue has additionally become about personal sanitation and health. One NGO I recently visited has worked with local schools to create sexual education classes not only for boys and girls, but another technique which received a very positive response - for students and their parents.

Blessed by drops from the Ganges, then paying 100 rupees for it

2009-02-10T04:07:00.000-05:00

Varanasi – the city of Shiva, one of the holiest places in India and one of the oldest cities in the world. Mark Twain wrote that ‘Varanasi is older than history, older than tradition, older even than legend, and looks twice as old as all of them put together’. It is a city centered around 80 ghats lining the Ganges and inviting Indians from all parts to bathe in the brown and trash-filled water said to wash away sins. At the Manikarnika Ghat, I watched the cremation ceremony of five people at the same time, burnt at varying distance from the Ganges relative to caste. All, however, have being freed from the cycle of reincarnation as long as their ashes make it into the Ganges and past the goats and dogs sifting through and looking for something to nibble on.

Life here revolves around the Ganges, as residents come to say prayers, bathe, wash clothes, light candles, take boat rides, wash their buffalo, meditate, and hold festivals along the river. The sight of such religious ferocity attracts visitors from all countries and makes Varanasi one of the destination spots for most travelers to India, especially for those who come searching for a spiritual awakening. The arrival of many laid-back, soul-searching foreigners has also attracted business-oriented Indians and has given Varanasi the reputation of being a city of scams, a reputation that my experience upheld. I spent one day in Varanasi yet felt harassed for money consistently and scammed at least four times.

“I cannot take you physically to Shanti Guest House because rickshaws are not allowed there but I can take you to Yogi Guest House, which is also in your book,” the rickshaw driver told me as I got off the train. I checked, agreed and after putting my bags into the room I headed out to walk to the Ganges, a supposedly five-minute walk from the hotel. After twenty minutes of walking, I came to realize that this was not the hotel I had been told about. There were at least eight guest houses named Yogi and I was staying in the ‘Old Yogi GH.’ I walked back furious and found the hotel packed with tourists, four more who had arrived since I left. I stopped one girl outside the hotel and asked her if she knew that she had also been scammed.
“Yeah, I realized that four hours after I arrived but I don’t really care.”
“Really,” I said, “it makes me rather upset.”
“Well, me too, but they are nice guys and very relaxed, and they set me up with some really nice bud [marijuana] so I don’t mind. I don’t know how long exactly I am staying for but it’s cool.”
That seemed to be the attitude of most guests and the way that Old Yogi got away with this scheme. Foreign visitors did not want to argue but rather get along with the people and attributed the confusion to culture. It made me even more upset that not only was he tricking tourists into his guesthouse but that this scam was only encouraged by their actions in going along with it.

I quickly picked up my bags from my room and walked out of the hotel 1.5 hours after I had dropped my stuff off. Before I could leave, I was pulled back in by the manager, who asked why I was going and demanding 150 rupees for the room I had booked. I refused to pay since I had been blatantly lied to about the room and had only been there 1.5 hours, which began an hour-long argument. His attempts to physically intimidate me or threatening to cancel my visa only made me more upset and eventually we called the US Embassy to resolve the issue. “You can do two things,” she said on the phone, “either call the police who will come and spend the next three hours with the two of you, or pay him the 150 rupees and move on, regardless of who is correct.” Getting involved with the police, however, was not something I wanted to do, considering I had been previously told not even to stop and help a car that had gotten in an accident because the police would eventually come and harass you not only for time and endless questions but money as well.

This was the first but not the last scam. Later it was at the Ganges, when a man put flowers and a candle into my hand, a red dot on my forehead and said a prayer for my family, enforcing at the time that it was free and he was a religious man. After finishing and while wetting his hands with the Ganges and spraying it onto my head, he told me that unless I gave him money there would be a curse on my family. Also there was the boy who worked on the boat given by the hotel to its guests for free morning rides to view the Ganges at sunrise, who pulled at our clothes incessantly asking for money. Or the man who came and stood at my side while was watching the cremations, explaining the different castes being burnt and then asking for money since “the information was not free.” Or the second hotel attendant who had told me the night before that I could keep my bags in my room until I had to leave at 7pm, although checkout time was at noon, yet the next day claiming he told me to put it in the storage room and for that he needed 100 rupees.

It was a frustrating day in Varanasi yet supportive of a trait characteristic of northern Indians as more aggressive and direct than southerners. This trait was expressed to me as early as six months back by my neighbor on the plane ride from the U.S. and then further while living in Jamkhed. A tension seems exist between the north and south that began as early as 1500 BC with the Aryan invasion from Afghanistan. Not only did the Aryans push the Dravidians (an advanced tribe inhabiting northern India at the time) into the mountainous regions of the south but they also brought the caste system, a feature initially based on color (Dravidians were darker skinned). The clearest difference that exists presently is language as southern languages (ie. Tamil) are of Dravidian origin and northern ones (ie. Hindi) of Sanskrit base. The north and south have progressed at different rates as the prosperity of the south has come on trade and the north more on politics. I have not yet been able to travel through most southern states but the change in feeling as I traveled limitedly throughout the north was apparent.

Welcome to the Himalayas

2009-02-04T04:29:00.001-05:00

Wedged in between two men in a three-row minivan, the twenty Nepali’s and I rode over and around mountains. The road was windy and the driver was not hesitant to take the turns far too quickly, probably accounting for the one bus every three weeks that tips over the mountain and certainly accounting for the girls in the row in front of and behind me burying their faces in plastic bags with uncontrollable vomit. The breath of cold but fresh air was very much welcomed when their mothers would open the window to throw the bags onto the street. The mountains were thick green and covered in agriculture ridges, so that the mountains looked like steps rather than slopes, a tribute to the fantastic job in creating viable farmland in difficult farming conditions. The green farmlands were often dotted with different colors and shades, due to the varied crops or a group of red and yellow houses that constituted a mini-village. They also gave an incredible view on the three-hour journey from Kathmandu to Dhadingbesi, the capital of Dhading district where my Paideia friend Jessie Kaplan was stationed for her ten month stint working at a local school.

To get to her house from Dhadingbesi was an hour and a half trek up a mountain to visit her host-family. We climbed on trails through farmland and forest and along ridges that wound around steep rocky hills, past houses made of red, yellow and grey stones and “namaste”ing the small Nepali women carrying straw baskets strapped to their heads, going up until we arrived at her home. The home was large for a typical Nepali family but what seemed to be typical for Brahmin’s as they were - the first floor made up of the kitchen and the second floor storage, with a small side room for beds. The view was included on all “mountain homes” but it was only the more awesome with goats and chickens hopping around your feet and buffalos and cows eating on grass in the shed next door, waiting to be milked. The family owned farmland but the father was a teacher, so workers were hired to take care of the crops as the mother cared for the house and the livestock.

The experience was refreshing compared with the oncoming heat in Jamkhed, yet the effect of the mountains was highlighted the next day when I visited Anandaban Hospital, a hospital run and started by Leprosy Mission International dedicated to the physical and social rehabilitation of leprosy patients, but also serving all non-leprosy patients. Sakala, a Nepali friend from the two-month diploma course, gave me the tour of the facility, showed me the difference between multi- and pauci-bacillary leprosy, and discussed the difficulties in the holistic treatment of leprosy, accounting for Nepal being one of the few countries that has yet to eradicate leprosy (meaning a prevalence rate < 1 per 10,000).

While leprosy can be detected early, most patients live in villages where, like in Dhading, they walk great distances daily, often uphill, carrying food and water and causing great toll on their bodies. If they contract leprosy, they often hide it for fear of stigma and the need for hospitalization, which affects income. So they wait to report skin lesions, continuing to strain their body and causing eventual deformities since they can't feel their formation. Eventual, the deformities are too hard to ignore and too evident for the community to keep quiet and they are forced to go to the hospital where they remain for an average of twelve weeks for multibacillary treatment.

Five days were spent in Nepal in order to renew my Indian visa, three of which were spent in Kathmandu itself. Throughout my stay and through conversation, it became clear how difficult the situation seems to be in Nepal. The civil war and new Maoist government has spurred the creation of numerous rebel gangs and groups, responsible for murders of journalists, robberies and often for the strikes that seem to inundate Nepal – during my stay it was by road workers who had shut down the main road from Nepal to China. “There are no government programs that effectively assist the needy population in Nepal,” one man told me. While he may be exaggerating, the lack of government intervention is evident as there is no food program for farmers in Dhading, as Anandaban hospital lacks sufficient government funding, and as I had to cover my nose while walking through Kathmandu since trash was collected on the side of roads in huge dirty piles with pigs and dogs scrounging through them searching for food. Nepal, though, was a beautiful country (with equally beautiful women) and my limited stay was very enjoyable.

Marathi shikane mala garajeche ahe, karana mala Jamkhed madhye maza anu bhavayeche ahe

2009-01-20T04:22:00.000-05:00

Learning the language has been invaluable to my enjoyment in Jamkhed. From the start I was dedicated to learning Marathi. Being able to speak Spanish in the U.S. has opened up doors and allowed me to enter a part of America (both North and South) that would otherwise be invisible, especially in the Bronx where over 50% of residents are Latino. Learning a language is more than just acquiring an ability to speak but rather language explains community and tradition that translation cannot convey. How villagers communicate and what words they use to describe situations say a great deal about the values held by that person and in that community.

The first two months in Jamkhed were often spent in the library with Sunil, the fluent-in-English librarian and friend who agreed to teach me Marathi. We went lesson by lesson through a Learning Marathi book, learning vocab and verb tenses to create necessary sentences. At times we sidetracked to the necessary yet inappropriate sentences that for some reason I never had trouble remembering, while “the house is made of wood” never could stick in my mind. My vocabulary grew quickly yet my ability to speak with people and use that vocab in conversation moved unnervingly slow despite my efforts.

Initially I was embarrassed to speak. I thought I had previously overcome embarrassment from speaking Spanish and attempting Chinese. However, struggling through a simple sentence as “I slept well last night” for two minutes with a village health worker staring at you wide-eyed (or at times with a smile she is trying hard to keep down) is difficult. Men, however, were not afraid to laugh and I often felt more relieved with them laughing than with the patience of the VHWs trying to understand me. The embarrassment gradually subsided but my conversation grew equally slow as my vocab continued to improve.

Learning a language seems to be a lesson in overcoming humps. Upon beginning the hypertension and alcohol study in Indiranagar (the slum area across the street from CRHP), I initially went with a social worker named Ratna who translated when I did not understand. Two weeks after beginning the study, however, she could no longer go and I was forced to survey the village with Lalanbai and Asha, two VHWs who spoke zero English. The changeover was the best thing that happened to me. It forced me to speak and get over the fear of speaking not only fluidly but confidently, as the study depended on it. After two weeks of being alone, my Marathi had improved five-fold and I had hurdled the hump. The biggest change has been not in my ability to speak but rather understand. Previously, the accent and quick-speaking scared the hell out of me despite the fact that I knew the vocab. But through continuous conversation their sentences seemed to move slower, not out of their mouths but rather in my mind.

Among the many things Marathi has allowed me to learn, there are a few that stand out in particular. One is the aggressiveness with which Indians speak to each other. There is little politeness in conversations, as questions are screamed at the men and answers are yelled back. Without understanding what is being said, every conversation seems to be an argument when really they may be talking about the effects of high blood pressure. There is also little use of thank you, please, excuse me or I’m sorry in the language. In fact, I have never heard anyone say please in a sentence since I have arrived and an American friend has been told that she should not say thank you so often because “it makes you look weird when no one else says it.”

Another benefit has been the ability to ask follow-up questions. While measuring BPs we have often found ourselves on the floor of straw huts with no electricity and no gas stove. Through conversation initiated from study questions, the lives of the local villagers are elaborated and better understood. One family in particular showed photos of them standing in front of their plastic-covered straw house (plastic from road advertisements to deter rain in the monsoon season), yet they, and their house, were knee-deep in water. They had no where else to sleep, though… “but that is when good work comes,” the father said frankly. Their three daily meals presently consist of Indian flat bread made from sorghum (glutton-free wheat) and chutney, and two meals per week of goat meat.

I am far (very very far) from fluent and often can not hold difficult conversation, but simply being able to continuously speak has not only opened up my world but has shown respect to a community where I am living for one year. Hindi, while perhaps more useful to learn, is not the local language and it does make a large difference to the community whether I choose to speak Hindi or Marathi.

One of my favorite occurrences during the study is when the family I am visiting lays out a floor mat to sit on and I take three minutes to introduce the study, explain its purpose, let them know that I will take their BP first and then ask questions, that their answers are confidential, and that a follow-up will be conducted. After the three minutes, as I unfold the BP cuff to measure, the patient will continue to stare at me and ask “Tumhee Marathi bolata ka?” – “You speak Marathi?” – not because they didn’t understand but rather they couldn’t figure out if I was really speaking Marathi. I have recently begun all conversations with “Me tora Marathi bolato” – “I speak a little Marathi” – yet afterwards and after explaining the study for three minutes, their puzzled face still asks “Tumhee Marathi bolata ka?”… at which point Asha steps in to explain the study.

Auspicious time of the year = A lot of weddings

2009-01-12T08:46:00.000-05:00

I entered the massive outdoor auditorium and found myself among three thousand other people, with the women on the right side and the men on the left. This wedding was held in Beed, a town one hour from Jamkhed, and I soon came to understand that most of these guests did not know either family getting married but were either from the same village or they had a friend who was. Celebrating your marriage with as many people as possible is not only good luck for the marriage but is good for status and social clout. Most weddings do not lack for a rise in social standing. The couple was also fortunate to have held their wedding on what was declared an ‘auspicious day’ by the ancient Hindu scripture.

There are many auspicious days in December and when combined with cooler weather it breeds a perfect time for weddings. Since the end of November, I have attended five weddings, four of which were arranged-marriages and of equal caste. In only two of them did I know the bride or groom yet in each, upon entry, I have been escorted to the front of the crowd to sit in chairs designated for the family I did not know or for special guests. My presence as a white person at weddings is an excellent sign of status for the families and often guests watch me rather than the wedding taking place. As the honored guest, I am often swarmed by people wanting to take photos, children wanting to shake my hand, and men with a tad too much to drink who want to test their English. The benefit is that I have an awesome view of the ceremony and am assured that I will be taken care of, in terms of both food and entertainment.

Weddings are typically paid for by the bride and her family, along with the dowry that the bride gives. In order to please the groom and his family, the wedding needs to showcase as much opulence and wealth as possible. Wedding saris (Indian dresses) are pieces of artwork and are inlayed with gold and have incredible stitch work in vibrant reds and blues. The dowry gifts given to the groom are often on display and have included refrigerators, cars, motorcycles, plates and dishes, and pure gold. The dowry also often includes acres of land, animals and houses that are not found at the ceremony. At the nicer weddings, gifts are also provided for each and every guest. Women usually receive a sari (surprisingly one-size-fits-all) where as for men, food and sweets or cloth suffice.

The most exciting thing about the wedding is the food, as each guest is expected to eat until they burst, a luxury also administered by the wife’s family. I have heard that guests attend weddings simply for the food and in the car on the way there people often discuss their excitement and anticipation for the delicious food. The nicer the food and set-up, the wealthier the family. The most high-caste wedding I attended offered a buffet of platters from not only around India but around the world. Tandoori chicken, Malaysian stir fry, Rajasthani snacks, Kashmiri curry, and Italian ice cream & dessert were all at peak freshness. And each guest had a server who carried your plate and walked with you, suggesting the best food and standing next to your table until you were ready for seconds. At a Jain wedding, there was a fruit bar that not only offered fresh fruit but fresh juices. Even at the least-opulent wedding in a local village, each of the thousand guests ate rice, daal, veggies, chapatti and jilebi (sugar-filled jellies) on a banana leaf plate to their heart’s content.

An ultimate show of wealth and tradition is the entry of the groom. At the Jain wedding, the groom arrived on a horse covered in jewelry and fabric. Before entering the hall, first his and then her family blessed him by feeding him, covering him with water and colored paste/powder, and whispering words of blessing in his ear. Simultaneously, a hired band played in front of the horse with men and boys dancing, of which I joined and was taught how to dance in the Maharashtrian way.

What I have yet to observe are the traditions that take place for days before the wedding ceremony. These events are reserved for family and customs vary by caste, religion, state and village. In most Hindu marriages a wedding pole is made and the bride and groom walk around it seven times in a counter-clockwise direction to sanctify the marriage. These poles are fascinating and intricately carved with symbols and stories that mean more than I understand. In some traditions, I have heard that both the bride and groom are forced to sit on stage as family and friends give them a hard time through jokes and make fun of them through stories, similar to the best man grilling the groom in America.

Following the wedding ceremony is a departure party for the bride and her family. Since the bride goes to live with her husband and his family following marriage, it can often be months or years before the daughter sees her family again. This day is often filled with joy and sadness. Yet all these events bring together friends, family, fellow villagers and me in heaps to celebrate the marriage.

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?"

2008-12-27T07:24:00.001-05:00

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

2008-12-20T01:27:00.000-05:00

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

2008-12-15T07:42:00.001-05:00

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

2008-11-29T06:04:00.001-05:00

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

2008-11-20T21:19:00.001-05:00

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

2008-11-16T10:31:00.001-05:00

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

2008-11-04T08:52:00.000-05:00

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

2008-10-27T12:42:00.003-04:00

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?

2008-10-19T03:49:00.001-04:00

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

2008-10-12T22:47:00.002-04:00

“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

2008-09-28T10:56:00.002-04:00

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

2008-09-22T00:18:00.000-04:00

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

2008-09-14T05:52:00.000-04:00

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?

2008-09-07T22:26:00.002-04:00

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

2008-08-30T02:50:00.000-04:00

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

A Cough Worse Than in Mexico City – My Experience in Delhi

2008-08-23T03:42:00.002-04:00

Before my program in Jamkhed started, I had the opportunity to spend five days in Delhi, the capital of India and one of its largest cities both by population and size. A couple thoughts…

Traffic/Road Safety: Never have I seen such madness on roads as I saw in Delhi. A three lane street would be filled with at least six lanes of cars with every open nook in between filled by motorcyclists, cows, rickshaws or taxi drivers who have gotten out of their cars for a quick pee. With cars going in three different directions on the same side of the road the only thing you can hear are car horns beeping with different ‘horn tunes’, used since many drivers don’t have side-view mirrors and thereby don’t know you are next to them. I was shocked and thrilled every time I got into a car or rickshaw, literally like a rollercoaster ride.

As a tourist, I viewed the traffic and labeled it a part of Indian culture. This mess of the roads wasn’t a problem but it was rather their way of life. The problem, though, is that on average in Delhi, 3 people are killed per day and more injured on the roads. Without a police force monitoring the accidents or any sort of enforcement or accountability, the larger vehicle is placed at the blame, yet with 60% of the vehicles on the road being motorcycles it is often the opposite.

This is what brought IRTE (the Institute for Road Traffic Education) into the picture and on the third day in Delhi I had the opportunity to spend the day with Rohit Baluja, its founder and president. He started the Indian non-profit in 1991 (he is also in the shoe business) and in the past 17 years has seemingly done more for road safety in Delhi than the city government. The Ministry of Transportation, he says, views the auto industry as profit-making and thus spends no time or money investing in their roads and/or drivers, the lifeblood of Indian businesses. And no new law has been passed since the late 1980’s to involve bicyclists or pedestrians in the transportation act. Through training courses (for elementary students, government officials, policemen, and others), speed-monitoring vehicles (an incredible vehicle called the CrashLab was invented by IRTE that can record and analyze vehicle accidents), national and international conferences, meetings with government officials, and a future public health department, awareness that safety on the roads is important is becoming recognized. It is also highly needed.

The Sites: Two of my days in Delhi were spent visiting the incredible monuments and sites that have been preserved for hundreds and even thousands of years. The pride Indian’s have for their country is so transparent in every tour and conversation, and visiting the sites I have read about has shown me why.

While I was touring, I was able to meet many fellow travelers from other countries and we immediately formed a bond, regardless of where we were from. In such a drastically different country as is India, I have found that many travelers bond together for support, which was a really nice part of my stay and I met some great people.

At India Gate I made the mistake of giving a beggar 40 rupees (around $1), as I was then followed around by 4 other beggars for the rest of my 20 minutes there. I literally had a line of beggars following me and people would stop, look and laugh at my misfortune.

Spirituality: A different smell was certainly ever-present in Delhi but so was a feeling of deep spirituality, as so many different religions, temples and people are crowded into the same place. Even greater, these beliefs are literally worn on the faces of the people and illustrated through their clothing. I visited Mosques, Hindu temples, B’nai Temples (awesome faith, fyi), churches, and even ate breakfast with Hare Kirshna’s in their temple. Faith is so present in daily life as it’s needed just to get by in a very difficult city.

On Friday, I flew from Delhi to Pune where I took a 4 hour ride to Jamkhed, which is where I will be for the next 11 months. As a side note, I think I have a permanent cough now due to the dust, pollution and heat. I also love eating with my hands (or rather, right hand), God’s natural forks. And I have photos but the internet connection isn't fast enough here to allow me to post them so I'll have to wait until I get to Pune or Mumbai.

So far so good. Loving India and this incredible opportunity. Feel free to write back or ask questions.

Jeff

Description of Blog

2008-08-16T13:02:00.002-04:00

Hi ya'll,

Thanks for coming to take a look at my blog. This will be the place where I post reflections on my time in India. I encourage and ask everyone to email me and ask whatever questions they have and I'll make sure to respond.

Have a great year,

Jeff