He’s Acting Like a Man

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

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

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

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

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

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

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

Response, Reflection and the Traveler’s Dilemma

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

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

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

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

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

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

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

Terror of the Sasu

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

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

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

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

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

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

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

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

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

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

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

A Group of Four People, Three Countries

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

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

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

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

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

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

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

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

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

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

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

A Tad More Than Just A Disease

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

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

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

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

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

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

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

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

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

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