Putting the Comprehensive in Comprehensive Healthcare

For the past two weeks, Eddie has been wrapping up his time at the Comprehensive Rural Health Project in Jamkhed. This extraordinary organization has improved the health and changed the lives of the 500,000 people who live in an extremely poor, arid region of Maharashtra. I have learned a huge amount about community development and empowerment in speaking with the people who work here and going to the villages that CRHP serves. It is truly an inspiring place. Here Eddie explains:

This morning I traveled with the mobile health team - a group of nurses and social workers that back up the village health worker medically and help organize farmer's clubs, women's groups, and self-help groups - to a village. There we met with the village health worker (VHW) and the women's group. We asked the VHW what she felt were the major reasons the village was so healthy nowadays. She gave a wide variety of answers: her training in safe deliveries, the watershed development programs that increased food production, the sanitation initiatives that cleaned up the village, in general health education, the decrease in dowries here, the increased education of women, the increased delaying of marriage until at least age 18, and the diminishing of casteism. Her answers show the multi-level, multi-sectoral health initiatives of the COMPREHENSIVE health project here.

This has been on my mind in the last few days. A medical anthropologist from Brooklyn College is out here and we have been talking a lot about what has made the place achieve such incredible health such that people here in rural Jamkhed have undergone the epidemiological transition and die of diabetes and cancer, not malnutrition, diarrhea, and infectious diseases. She has brought up the point that we tend to think of good health as something that biomedicine has brought us. Biomedicine, in short, is the system of thought that sees health as the absence of disease and so therefore is focused on treatment and direct disease prevention like vaccines. Some people, however, have pointed out that major improvements in our health and a lessening of disease rates came about before we discovered vaccines, antibiotics, and good treatments. Instead, our good health is tied to improvements in the standard of living: better sanitation, nutrition, and housing. From this perspective, the idea that biomedicine has brought us health is known as the "medical heresy."

It makes sense, though, because caesarians and heart transplants are visible and easy to see. They seem to be what brings us good health. In the beginning, the Aroles (the founders) tried that method but they quickly learned that people just kept on coming back with the same problems. So they expanded their views to be a comprehensive health project.

Therefore, on top of the clinical curative services they offered they also expanded into traditional public health work - sanitation and nutrition - but also into the social determinants of health, or those influences that are socially produced. This is called Social Medicine. For instance, the ratio of men to women in Maharastra is dropping to 850 women for every 1000 men because of sex-selective abortion, female infanticide, and less nutrition and medical care for young girls. Obviously, medical services and public health will have little effect if the low status of women is not addressed head on.

So what does comprehensive mean? It means that this organization has a hospital, a mobile health team with nurses, and trained village health workers (biomedicine); watershed development projects to capture rainfall and increase irrigation, soak pits and sewers for sanitation, and toilets (public health); and women's groups, women's microfinance programs, caste-free nutrition programs, a village health worker who is instilled with anti-caste and feminist values, and dramas to discuss the issues of dowry and baselessness of casteism (social medicine).

How does that shape my time here?
Well, I spend half of my mornings in the hospital on rounds or seeing patients. I have seen cataract surgeries, an amputation of a gangrenous leg, and the breaking and resetting of an arm. I also am learning about safe deliveries, oral rehydration therapy for diarrhea, and chronic disease management.
On other mornings I go out to the village and understand how to build toilets and gain their acceptance, how schemes are organized to build village-wide water projects and sanitation, and the ins and outs of mid-day lunch programs.

And occasionally I get to do what I did this afternoon: spend some time with the village health workers.



The women, all in every hue of sari imaginable, sat tightly together in a circle. Their were many smiles, laughs, and laying together. The group was marked by affection as these people came together to increase the health in their community and produce social change. As many of them said, this is the one place besides their parent's homes (they move to their husband's family after married - often a scary experience) that they are given affection. The way they interacted reminded me of my own experiences in youth groups and the love, support, and affection I felt there. In this space they openly discussed dowry, the (lack of) education of women, the difficulties of convincing their husbands and in-laws to let them come, the freedom found in economic independence, their self-worth, the value of women, and their right to respect. It's a powerful space. Today we have a new generation of VHWs very different from the last. Most of the first batch were illiterate, frightened, and insecure. One even said she considered herself worth less than a rat. Understandable, most of their initial work was in self-development. Now the new generation is educated (literate!) and imbued with an ethic of standing up for themselves and striving for equality. It's quite a different world.

And that is social medicine.

I don't know how the Aroles did it, except I don't think they did this on purpose. They were just dedicated doctors who dealt with the difficulties as they came along. I am the one who is putting their work into the categories of biomedicine, public health, and social medicine. Yet that is my job - to try to understand so that it can be reproduced elsewhere. There are a lot of really wonderful health projects out there in this world but someone thinks this place is so unique that they made sure to set aside $13,000 every year to ensure future doctors like me could have the opportunity to experience this place. I feel very blessed to be this year's Mabelle Arole, and I feel I am coming to understand better what this place is about.

Eddie actually wrote this note in November, 2009. Since then he has spent 6 months developing a curriculum and training the Village Health Workers in mental health counseling. This innovation is the only program of its kind in the world: rural village-based mental health counseling. Although his time here is coming to a close, his impact on the lives of the thousands of villagers in the Jamkhed area will continue.

On the Front Lines

Every morning I rode a bus to the Energy and Resources Institute (TERI) office outside of the city from our guesthouse in Panji. Women’s colorful saris pressed up against me as we all lurched along accompanied by blasting Indian music and passed coconut palms drenched in the tropical sun.

I was spending time at TERI to observe how they use hydrology and geology to implement appropriate technologies in the developing world. Specifically, I was interested in a project demonstrating the efficacy of Riverbank Filtration (RBF) at a site in the neighboring state of Karnataka. RBF uses the filtration and microbial properties of soil to purify water pumped through the riverbank. So far, this description is identical to a borewell tapping groundwater, which is how billions of people all over the world obtain their drinking water. The difference with RBF is that the well is adjacent (60m) to a perennial river, so it draws river water rather than depleting ground water. With funding from the World Bank, TERI has built an RBF well demonstrating that this technology can be used in a monsoon climate, and importantly that it can be run by a committee of villagers in an economically self-sufficient manner.

Veerbaswant Reddy, one of the TERI researchers, accompanied me and Eddie on a site visit of the RBF well. We met the landowner on whose the land the well was drilled, toured the village served by the RBF well, and took some basic dissolved solid, salinity and pH measurements.
In addition to fecal bacteria, the effluent from a nearby paper mill is the primary contaminant to the adjacent Kali River. This is where things get complicated: the paper mill is the major player in the local economy, employing 2000 people including both the landowner and one of his sons. The people in the village served by the RBF actually filed a lawsuit against the paper mill several years ago claiming compensation for the deaths of many of their livestock. Clearly, the mill has a stake in providing clean water to the village, and they have helped with the RBF project in building pipeline for the water and providing laboratory services for analyzing the contaminant levels of the RBF water (although this involves an obvious conflict of interest). Not surprisingly, upon closer investigation the situation is more complex than simply a well that provides clean water for a village in India.

But RBF is a well that provides clean water for a village in India. It appears to be functioning perfectly, and pays for its own maintenance with user fees that are less than what it costs to buy the unreliable water provided by the state. It has definitely succeeded in what it tried to accomplish: demonstrate that RBF can be effective. But it is a demonstration: TERI’s mission is to develop technology, not to directly provide clean water to large numbers of poor rural people.

In addition to observing TERI’s projects, I helped them out during my time in Goa. I worked on a project that has formed a local farmer’s club, encouraging farmers to cultivate their fields. In relatively well-off Goa, the price of labor is so high and the social value of agricultural work is so low that farmers let their fields lie fallow, leading to a lack of food sufficiency within the state. Yogitha, the project leader, asked me to help her to make a digital map of the fields of participating farmers and those who plan to join soon.

On a blazingly hot day punctuated with heavy pre-monsoon showers, I went to the fields, located on a low-lying island in the wide Mandovi River. Following each farmer as she or he walked out the perimeter of her or his field, I marked GPS points for every corner of every field. This level of detail was unneeded because we planned to make the map using GoogleMaps. We really only needed one set of latitude and longitude coordinates for each of the two groups of fields in order find them on GoogleEarth (and then we could find them on GoogleMaps).

I took this experience as an insight into the appropriate use of technology. I could have taken two GPS readings instead of the 35 that I was instructed to, but I believe that the project leader was oriented towards using the highest level of technology even where it wasn’t needed. Thanks to Eddie’s expertise with community-based development, he envisions a different approach involving the farmers themselves drawing a map of their fields in the dirt on the ground. This would not have been any more work for TERI (in fact it would have been less work), and would have given the farmers more ownership of the project. In addition, many of the farmers may not be familiar the abstract graphic representation of land using maps, so the map that we made will be of no use to them.



Despite these frustrations in addition to the missed communications, unchecked batteries and uncalibrated instruments that are the reality of work in the developing world, my time at TERI was extremely valuable. Going to the RBF field site allowed me to ask questions that I would not have thought of without actually being there. How does the Water Users Association work, and where does the power lie within it? (It lies with the one wealthy member, the owner of the land on which the well was drilled) Why would the paper mill pay for pipeline to be laid? (They have had a lawsuit filed against them for contamination of the river water) How do villagers access the water? (In two big tanks) Who uses the extra RBF water? (The landowner, at no cost to himself) Why won’t more RBF be implemented? (Because the villages will have to ask for it, and without outreach to encourage them, they won’t.)

If I choose to go into the field of development, I will have a sharp eye looking out for what type of organization to work with. Working in the field with TERI helped me understand its orientation towards developing and proving the efficacy of technology rather than implementing those innovations for large numbers of people. The two water purification techniques that I learned about at TERI, RBF and a method to remove geologically-occurring fluoride, were both appropriately simple and low-cost for use in the developing world. But only a community-based organization focused on implementing any one of these techniques will actually make a difference in more than 500 people’s lives. There is definitely a need for organizations like TERI to develop these methods, but I think I am more interested in an organization with a community implementation mission.

Goa Portuguesa

Our travels took us next to Goa, which I learned is not a city in itself but a (small) state. The twelve hour train ride south was quite an experience. Luckily we rode sleeper class, which meant that the trip cost a big seven dollars instead of three, and we each had a bench long enough to lie down on. Vendors walked by selling everything from chai and coffee to samosas, lassi and sweet, juicy mangoes. Another key piece of equipment was a battery-powered spray-fan that I had brought from the US. We couldn’t decide which was more dehydrating: to be sweating buckets in the still, hot air on one side of the bench, or to be near the window with the wind sucking all the moisture out of you.

In any event, we switched frequently until we came to our stop: near Anjuna beach, one of the most famous “rave” beaches of the 1970s and 80s. The scene has since toned down, and Eddie actually came through in February when he was traveling with his sister. This time it was the low tourist season, and for good reason: practically 100% humidity and temperatures in the 90s made movement uncomfortable, and the storms signaling the imminent monsoon made the water occasionally too rough for swimming. But we still had fun hanging out for a couple of days, drinking excellent chai, jumping in the waves (although I got roughed up a couple of times) and watching the squalls pass across the ocean.

After a long two days of relaxation, it was back to work! I spent a week working at and learning from an NGO, The Energy and Resources Institute, and Eddie worked with Sangath, an NGO doing mental health counseling. We will devote another blog post to our experiences at these respective organizations, but at the moment I want to describe the city where we stayed for a week, if only to gloat over the beautiful photos I took there.

As both of our organizations were located within a half hour bus ride from Goa’s capital Panji, so we based our operations there. Some of you may know that Goa was under Portuguese administration (/rule, depending on how you look at it) for almost 450 years from 1510 until 1947, and they certainly left their mark. I could easily have believed that we were in southern Europe, among the beautiful gold, maroon and brilliant blue painted houses with wide white trim around the arches around their windows. Alleyways full of potted plants, motorbikes, cats and piercingly bright sunlight cascade down from a leafy hill in the middle of the city. We walked past a courtyard where a parrot was sitting in an old bell-shaped wicker cage, listening to a man wearing only an undershirt tune a dusty violin. It was too picturesque to believe! And I can’t forget the women with short hair (incredibly unusual in the rest of India) wearing those shapeless knee-length dresses with (ugly) flower prints that are so ubiquitous in parts of Italy and Portugal. One evening we came across a group of twenty people standing in a street singing a hymn before an image of the Virgin Mary and a trough filled with fire. Someone set off sparklers nearby. What a vision, in India!

Our excursion to Old Goa was a highlight of our time in Panji. A 30-minute bus ride from Panji, this was the capital of the Portuguese colony from its beginning in 1510 until 1759 when its malaria-ridden swamp site caused the Portuguese to move their capital. And they really did move it, brick by brick, leaving only whitewashed churches poking out of palm trees and overgrown jungle. I’ll let Eddie take over now: It was unlike anywhere else in India and reminded me more of Latin America than India: crumbling cathedrals with smoky murals and dirty gold leafing rising in awe-inspiring magnitude over the viewer. It was, as elsewhere, used to impress and convert the locals when a torturous inquisition couldn’t do the trick. The cathedrals seemed out of place in this country of mostly Hindu temples and Muslim mosques, and it drove home two points for the two of us. One, that such a sight would’ve also seemed strange and out of place several hundred years ago in Latin America when Christianity first started eliminating other forms of worship, a thought that drives home how there used to be something else widespread in those areas. Secondly, that the Christian form of worship – the devout seated in pews for an hour a week – is so different from bowing on a mat in a large open space (Islam) or popping into the ubiquitous temples for a quick puja (prayer) and darshan (eye contact with the gods) before continuing your daily routine. There is nothing like learning from contrasts. In addition, we noticed that the incomplete state of the city gave us an acute sense of what this colonial capital would have been like. We could imagine huge sailing ships pulling up to the dock full with spices, unloaded under the palm trees by gangs of workers.

In all, Goa was like few other places in India. The British ruled 300 million with 30,000 administrators and really didn’t impact the culture the way 450 years of occupation over a small territory did. The Muslims from Persia had a similar impact in the north, but seeing the familiar European influence really showed us the power of trade, cultural exchange, and history in creating our present world.

Maximum City

Hello!

I was hoping to greet you with something more exotic, but unfortunately (or conveniently), "hello" is how they say hello in India. I am starting to understand why everyone who comes here feels the need to describe it and say how amazing it is, even though you've already heard the same thing from everyone else who has visited India. That's because it is SO amazing, and unlike anywhere else.
Eddie met me at the airport in Mumbai on Friday morning, and the hourlong taxi ride back to the center of the city was my introduction to this country. It is incredibly loud, because the drivers beep every time they see another vehicle, just to let that vehicle know they're there, as if everyone were blind. It's kind of like a countrywide, earsplitting version of the kids' game Marco Polo. It's also incredibly hot. A breeze helps, but if you happen to be standing in a pocket of dead air, sweat starts pouring off of every part of your body and your mental faculties begin to leave you. So, there are ways to combat the heat. My favorite is to drink a lassi, a refreshing yogurt drink. In the US I had only tasted mango lassi, but here the plain, "sweet lassi" are the tastiest: thick and frothy with a fresh tangy yogurt flavor. It can also help to step into an air conditioned shop or bank for a few moments to take the edge off the heat and prepare yourself for another plunge. Of course this is only easy because as a Westerner with white skin I am welcome anywhere. A street beggar could never get a respite from the heat by stepping into a nice air conditioned shop.

I am sure it is already a cliche to you, but the vast gulf between rich and poor was particularly vivid on our last day. After stepping over street beggars and passing parapalegics dragging themselves along, as well as using rupee coins with images of fingers held up instead of printed numbers, because so much of the population is illiterate, one of Eddie's friends invited us to a wedding party. His father is a very successful businessman, and his family is part of the "Mumbai elite," of which everyone else at the party was a member of as well - "all multi multi millionaires." The party was in a really fancy hotel with a marble lobby and many conference rooms. The fabrics or the saris were captivatingly bright and beautiful, all covered with sequins and embroidered with gold thread. There was a banquet of fine food and a huge open bar. The servers pushed through the crowd dancing to both Indian and American music, pouring drinks down people's throats in a fit of conspicuous consumption. For example in a bottle of very fine Grey Goose vodka they would add a huge amount of fruit juice until the drink was barely alcoholic, and then come around and pour it down people's throats. So it was more about appearing to be consuming than about actual consumption. What a different world!

To me, the most striking aspect of this country is that it all seems to work. There is so much poverty, so many people, so few resources. Along the train tracks there are huge slums and people defecating on the tracks because there is nowhere else to go. Yet in the places I have been (and yes, Mumbai and Goa are very wealthy), there is running water, electricity most of the time. Once you have reserved train tickets, you find your train car (as the train departs on time,) and there is a paper with your name on it. Oh India! That is quickly becoming a common phrase in my vocabulary as I encounter more of this unique country.

Until later,
Alice