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.