Saying Farewell to CRHP

This will be my last blog entry for this trip to India. My time at CRHP has come to an end. I feel truly blessed to have spent the last 6 weeks with the Aroles and the rural people of Maharashtra, India. Their openness and generosity is humbling. The strength and resilience of the rural women, some so badly abused, makes me feel so weak by comparison.

Each day I was in awe of what the impoverished people have accomplished with the help of CRHP. Their dedication to improving the health and overall development of their villages is commendable.

Village Health Workers, women’s group members and men who belong to farmer’s clubs so generously took time out of their harvesting to discuss their approaches to safe drinking water and sanitation, agriculture, economic development, health care, education, environmental protection and so much more.

The project has made a huge difference in the lives of the rural poor in villages around Jamkhed and I am so grateful to have witnessed the many project successes.

I wish Dr. Raj Arole, Ravi Arole and Dr. Shobha Arole continued success with their project and look forward to seeing them again soon.

For more information about CRHP or training and research opportunities visit: www.jamkhed.org

If you would like to contact me directly, I can be reached at lmantini@hotmail.com

Bridging the Primary Health Care Theory/Practice Gap

Although some progress has been made by a few Canadian Universities when it comes to building global health and development into nursing curriculum, there is a long way still to go before all Canadian nursing students have the opportunity to explore nursing from a global perspective.

Most nursing students are exposed to the principles of primary health care, but how prepared are they to take these principles and put them into practice? Bridging the primary health care theory/practice gap can be accomplished through the development of global learning partnerships. Such partnerships allow nursing students to become immersed within a different culture where they can learn about other health care systems and effective and efficient approaches to health improvement and community development.

After spending 6 weeks at the Comprehensive Rural Health Project in Jamkhed, I have learned more about designing and implementing a comprehensive primary health care project than I could ever have learned in a university classroom. What a privilege it has been to share a cup of tea and hear the stories of local villagers intimately involved with this project. Having the opportunity to see how the principles of primary health care have been put into practice to improve the health and living conditions of individuals, families and entire communities, has been an invaluable learning experience.

In 1992, the Jamkhed Institute for Community-Based Health and Development was established as part of the Comprehensive Rural Health Project (CRHP) to train local, national and international students and leaders about the Jamkhed Model of primary health care.

CRHP invites students, faculty, and staff in such disciplines as public health, medicine, nursing, allied health, and development, to come to Jamkhed to take part in a one or two month training course, an elective, internship, or fellowship, or to work on a research project. Internships are also available in North America through Jamkhed International – North America (JINA).

To date, over 2,000 people from 100 countries and 27,000 people from India have been trained at the Jamkhed Institute, including government and non-governmental workers, community members, students, project managers, clinicians, and policy makers.

For more information about CRHP or training and research opportunities visit: www.jamkhed.org

If you would like to contact me directly, I can be reached at lmantini@hotmail.com

Water and Development

Almost 30 years ago, in drought-prone villages like Zikree and Khandavi, impoverished families lived on the brink of starvation. Deaths due to dehydration and malnutrition were a regular occurrence. Subsistence farming was next to impossible because the villages lacked water and were surrounded by infertile wasteland.

Today, although annual rainfall is only 14 inches, Zikree and Khandavi are prosperous farming communities with sufficient water in the village wells to provide all villagers with safe chlorinated drinking water year-round. Sorghum crops are being harvested and many other crops are growing. Villagers are healthy and happy and very proud of their achievements, and so they should be!

With the help of engineers and CRHP, as well as some government funding and food-for-work incentives, 35 villages in rural Maharashtra built continuous contour trenches to keep rainwater where it is needed for crops, and to keep topsoil from eroding during monsoon rains.

Refilling trenches were also constructed. Good soil was kept on one side of the trench and the poor hard soil on the other. In the trenches, villagers planted trees then refilled the trenches with only good soil. In the beginning, villagers carried water to the trenches to keep the trees alive but now the hardwood trees have deep roots and need no care at all. These trees also help to prevent soil erosion.

The monsoon rains carve natural gullies in the soil following the slope of the land. Rainwater, flowing down the gullies, carries away a lot of topsoil. Villagers strategically built gully plugs in several locations along the gullies to a) slow the speed of the water flow, b) encourage water to infiltrate into the soil, and c) capture the eroded topsoil. The gullies were rerouted so rainwater refilled the village well.

Gabion structures were built using local rock bound into square blocks with wire mess making a step like structure on a natural slope leading to a water catchment pond. The rock-steps slow water flow, reducing topsoil loss. Gabion structures were also built for groundwater recharging and stabilizing walls of water channels and catchment areas.

Wooden and concrete check dams and Nala Bunds (mini percolation tanks) were constructed to slow and store water for irrigation and also for ground water recharging.

Armed with hand tools and determination, it took each of the 35 villages about 5 years to get the construction part of the project completed. Patience is a virtue with watershed projects. It takes 15-20 years for the soil quality to improve, but improvement is definitely seen.

In Zikree and Khandavi, as in the other villages, the watershed project:

· Increased the amount of fertile soil
· Improved crop productivity, and
· Increased the water table level

The project increased availability of work close to home, decreasing the need for seasonal migration for work and resolving issues of landlessness and bonded labour.

Implementing a watershed project, where community participation was essential, promoted community organization, engagement and empowerment and started a process of social development, which allowed for progress in the areas of health, education, and income generation.

Zikree and Khandavi now have village health workers, farmer's clubs and women’s groups. With safe drinking water and nutritious foods, these villages are able to run nutrition programs for poor children. All children have the opportunity to go to school because they have a permanent residence. Living conditions have improved with the increase in cash flow. Now homes are constructed of cement, with doors and window screens to protect against mosquitoes-borne illnesses, and there are toilets and soak pits to manage waste water.

Access to water has made starvation and dehydration a thing of the past for the 35 villages involved in the Watershed project. Access to water allowed villages, like Zikree and Khandavi, to develop and thrive.

Appropriate Technology

In a farming village outside Jamkhed, a Village Health Worker and the Mobile Health Team are checking the weights and hemoglobin of adolescent girls and testing glucose levels in the urine of villagers living with Diabetes.

Here are their supplies:

A test tube and metal test tube holder
Locally grown cotton and rubbing alcohol
A bottle of blue liquid labelled ‘Benedict’s Reagent’
A bottle of clear reagent
An old plastic container and a dropper
A rubber tube and lancets
A small black hemoglobin reader, and
A weigh scale

Opps, they forgot the matches….a few words in Marathi are exchanged and in no time, a young boy arrives with a big smile and a small box of matches.

Today will be a light day. It’s harvest time and most of the villagers, including pregnant women, are in the fields, working in 35 – 40 degree Celsius heat harvesting chickpeas and sorghum, one of the top five cereal grains in the world.

About 10 adolescent girls show up at the Village Health Workers home and wait their turn to be tested. They all belong to the adolescent girls group. The older diabetics arrive and ask the girls to sing a Marathi song about what happened to their people during an earthquake many years ago. One by one each girl is weighed and her weight recorded carefully in the Mobile Health Team logbook.

The social worker opens a sterile lancet and pricks the young girl’s finger to get a blood sample. She puts a rubber tube in her mouth and draws some blood up into the tube. She releases the suction and the blood flows into a glass test tube containing a few drops of clear reagent. She rolls the test tube between her hands and places it in the hemoglobin reader. A minute later, she announces for all to hear that the hemoglobin is 9.5 and records the result in the logbook. She will accept a hemoglobin of 10 but 9.5 is too low. The girl gets a gentle, friendly scolding and is told that she has to talk to her mother about making sure she eats more spinach and meat. The Village Health Worker will go and talk to the mother as well and the girl will be retested next month when the Mobile Team returns to the village.

Now it’s time to test an elderly male villager’s urine for glucose. The Village Health Worker puts two fingers of blue liquid in a test tube. She lights a match and ignites a piece of alcohol soaked cotton and places the test tube over the flame to warm the reagent. Next she adds 7 to 9 drops of urine and places the test tube back over the flame until it starts to bubble. Then she removes the test tube and waits to see if the blue liquid changes to green, yellow or red, indicating the amount of glucose in the urine.

With a comical look of disgust on the Village Health Worker’s face, she shows everyone watching that the colour has changed to yellow. After a somewhat heated discussion with the older gentleman, he gets up out of his cross-legged sitting position and walks back to his hut to take the medicine he was given for his diabetes. He had stopped taking his medication because he preferred going to the local healer and taking her herbs instead. Now he and everyone within earshot knows that the local healer’s herbs don’t work and they should listen to the Village Health Worker.

Why, you may ask, are they not sending these villagers to the CRHP lab to get their blood work done? Why aren’t they using dipsticks to test urine? The answer is, that neither of these is appropriate.

Firstly, there are the issues of accessibility and acceptability. This farming village is a good half hour drive from CRHP, which would be hours by ox cart. These villagers need to be working their land and tending their crops to earn their livelihood. Many would choose not to have the blood test done if they had to go to the CRHP hospital lab, which could seriously impact the health of the village.

Secondly, there are the issues of affordability and availability. Health care is provided on a fee for service basis at the CRHP hospital and many of these villagers are living well below the poverty line and would chose having money for food over spending money on doctor’s visits and lab tests at the hospital. The Village Health Worker lives in the village where she works and is available whenever needed. She and the Mobile Health Team offer testing and care that can be carried out close to home and fairly quickly, and it is free of charge to the villagers.

Also, long-term external funding would be needed for CRHP to have a sustainable source of urine dipsticks. Even if the funding was available and the village health workers started using the dipsticks, what would happen if over time, the funding source dried up and no more dipsticks were available? All the village health workers would need to be retrained in the original testing techniques leading to confusion, extra training costs for CRHP and would mean time away from the village for the Village Health Workers to be retrained.

So, although the technology may seem archaic to a westerner, it gives the Village Health Worker the information she needs to care for her community, within the community and to refer villagers to the hospital only when absolutely necessary.

Investing In Women

CRHP, The Comprehensive Rural Health Project, has been investing in women for almost 40 years and the results of their investment is demonstrated in the following prose about the uplifting of the status of women in rural Maharashtra, India.

The Women of India
By: Lee Mantini


I am a woman of India, oppressed and poor. I live in fear. I cook, I clean, I wash. I entertain my husband and care for our children. I am a marginalized woman of India.

I am a woman of India. I cannot read or write but I can think. I listen, I watch, I learn. I try and I can do. I am a changing woman of India.

I am a woman of India. I am not alone. In Jamkhed, I meet with women from other villages. In my village I help form a woman’s group. One branch is weak; several branches bound together are strong. We are the organized women of India.

We are women of India. We represent our villages and receive training. We know how to keep our villages healthy. We know about the importance of safe drinking water and clean living spaces. We know how to protect our environment. We know that the caste system is a barrier to village development. We know about our rights but do not become selfish. We give to others and care about others. We are the self-confident women of India.

We are women of India. We are respected members of our villages. We are role models and Village Health Workers. We share our new knowledge so others can learn to take care of themselves and their families. We teach and practice family planning. Our daughters are valuable. They go to school and often get better graded than our sons. Together we protect our daughters and ourselves. We are the empowered women of India.

We are women of India. We work with men’s groups to organize villagers and plant 100,000 trees. We teach men to promote health and they build wastewater channels, soak pits and toilets. We approach government officials and receive funding for small businesses. We earn wages and improve the lives of our families. We help those less fortunate than ourselves by providing low interest loans and food during droughts. We bring progress to our villages.

We are the proud women of India.

Community Organization: The Key to Empowerment

The village of Kusadgaon is about 10 kilometers from the CRHP compound. It has a population of 1650. Of the 274 families living here, 75 have toilets. There were 30 births in 2009 and no deaths. The village health worker states that all deliveries were safe deliveries and most babies were delivered in the village. Only 32 villagers needed to be hospitalized in 2009. One villager was cured of TB and one is having treatment. In this village, 92% of the children go to school, with 154 girls and 159 boys currently attending classes. The village council puts chlorine in the drinking water daily. These statistics are displayed on a large blackboard and updated regularly.

There is a farmer's club and a women's group in this village. They work together to meet their identified health and village development goals. The mobile health team used to visit the village once a week but village health has improved so much, they now only visit once a month. A woman sings loudly and proudly in Marathi, 'Have a cup of tea instead of children,' a family planning message she has learned.

Children are fairly well behaved here. They are clean and so are their clothes. Their hair is black and shiny. Their skin is soft and their tummies are filled with nutritious foods. The roads are cleared of garbage and are lined with waste-water channels. Alleys behind homes have soak pits so water does not pool in the streets. There are few mosquitoes and no cases of malaria in this village. Cement homes provide adequate shelter from heat and rain. Both men and women are earning income and contributing to the development of their village. The village of Kusadgaon is a Comprehensive Rural Health Project (CRHP) village.

On the contrary, the settlement of Indiranagar is directly across the street from CRHP. In this nomadic community, the population varies as people come and go. Tired looking elders with small children at their sides sit outside tents made of tarps and cloth, which provide little protection from the heat and rain. Some live in metal shacks. There are few cement homes. Waste-water covers the roads and alleyways, providing a breeding ground for mosquitoes, and increasing the risk of malaria. Garbage is strewn about and is mixed with pig and dog excrement.

Thin, dusty children, some with the reddish dry hair typical of vitamin deficiency, play in the dirt in their tattered hand-me-down clothes. Many have runny noses and dry coughs. A fourteen-year old girl begs for help. Her father is working away from the settlement for several months, her mother committed suicide, leaving her the impossible task of caring for her five younger siblings. They live under a blue tarp. Many people in this settlement struggle day after day to survive, living well below the poverty line of 15,000 Rupees per year (approx. $342 CAN).

So why has Kusadgaon progressed while Indiranagar has not?

CRHP never forces itself on a community. The community must invite CRHP to work with them and the people must be willing to make group decisions on what health and development issues they tackle. They must work together and take an active role in improving health and living conditions.

Indiranagar is not a typical rural village with families that have lived in the village for generations. It is more like a transient camp. Families that know each other and care about each other's well being can more easily engage in community action.

There is a local saying that one branch is weak; several branches bound together are strong. Indiranagar has not yet formed a cohesive, strong community. It is a community made up of many marginalized families with no firm roots, families that feel powerless, families that are separated and oppressed by cast discrimination, religious beliefs, and their nomadic lifestyle. There is no glue binding them together. Indiranagar is not an organized community. It lacks consistent leadership. There is no men's group or women's group, no common goals to work towards.

Although CRHP has not yet been invited by the community to bring the Jamkhed Model to Indiranagar, CRHP is helping individual families who have come to them asking for help. Through private donations, CRHP is building homes for several needy families, including one for the young girl and her siblings living under a tarp. The girl's only request was to please have the house built before the next rainy season. How many rainy seasons had these children endured under that tarp? It's heartbreaking.

The yellow CRHP school bus arrives in Indiranagar six days a week to transport children across the busy road to the preschool within the CRHP compound. These children are treated with love and kindness. They sing and dance with each other, oblivious of caste and religious differences. They are responding to gentle discipline and a structured daily routine. They learn about, and practice personal hygiene and receive a plateful of nutritious food with as many refills as their little tummies can handle. The children are growing, they are energetic and they are happy to be in school. Hopefully, over time, these preschoolers will become the branches that will bind together to build a strong Indiranagar.

Until change takes place, too many of India's children will never have the opportunity to go to school. Not only will these children be unable to realize dreams of a better future, India will be denied the creativity, resourcefulness and intelligence that these children have to offer.

Jamkhed Model

As the melodic sounds of male chanting and drumming waft through the cool evening air, I take a moment to reflect on my first days at the Comprehensive Rural Health Project (CRHP) in Jamkhed.

This long-standing Primary Health Care Project, established in 1970, pre-dates the Alma-Ata Declaration of 1978. Taking into account the need for accessible, available, affordable and acceptable health services, indigenous Village Health Workers (VHW) are trained to deliver quality, basic and essential health services and essential drugs in the villages where they live.

These women tend to be lower caste, often illiterate women who are chosen by their village to receive training and ongoing monitoring and support from CRHP. Training takes into consideration community needs and priorities, and focuses on health promotion, and disease and injury prevention, as well as curative and rehabilitative care.

With a trusting relationship built between the Village Health Worker and her local villagers, the VHW begins to raise awareness of local health issues and explains how the villagers can work together to improve health. Particular attention is paid to maternal and child health, family planning, nutrition, and preventing the spread of infectious diseases. Government health workers provide immunizations in the villages. The CRHP hospital is always available to take referrals from Village Health Workers.

The formation of farmers’ clubs and women’s groups has organized and empowered villagers and engaged them in health and income generation project planning and implementation. The VHW works closely with adolescent girls to build self-confidence and self-esteem, and to raise awareness of adolescent health and safety issues. As villagers start small businesses and learn new farming techniques, income and food supplies improve. When families are adequately nourished, and when they have access to safe drinking water and clean living environments, individual, family and village health improves.

You can learn more about the Jamkhed Model at: www.jamkhed.org

I have had the privilege of witnessing the results of the tireless efforts of some Village Health Workers. Adolescent girls from several villages arrived at the CRHP compound for their monthly meeting. In a room filled with foreign university students, both male and female, several girls confidently came up to the microphone to tell their story about how the adolescent girl project has very positively changed their lives. Some proudly presented what they had learned from their Village Health Worker about adolescent health and nutrition. The girls, aged 11 to 18, smiled broadly when it was announced that all of them were attending school.

This, in my opinion, is Primary Health Care at its finest!

Mumbai

Walking around the Bandra District of Mumbai, ones senses are bombarded with new sights, sounds, smells, tastes and textures. The warm morning sun and the chaotic nature of this highly populated area are energizing. The scents of Indian spices, roasted peanuts and fresh fruits mingle with the exhaust filled air. Crows caw loudly overhead, as if they strive to be heard above the constant drone of traffic. Green guava with red pepper and salt is one of many new taste sensations to enjoy. Women dressed in brightly coloured saris and salwars stroll the streets with babes in arms and well-behaved young children at their sides. Men, some impeccably dressed in clean shirts and dress pants, others in tatters covered with the dust of hard labour, smile and nod. Some manage a very pleasant and practiced 'Hello how are you?' all in one breath.

The magnitude of the poverty in Mumbai is overwhelming. A local explained that Mumbai is approximately 60km by 40km in size. Approximately 10 million people live in Mumbai. This number is growing rapidly due to mass migration from rural India. Poverty is visible everywhere. Over-crowded slums and roadside fruit and vegetable stalls contrast sharply with modern high-rise apartment buildings and shopping malls that would put many Western malls to shame.

One must be extremely vigilant when strolling through the streets. In Bandra District, as in most areas of Mumbai, trucks, cars, taxis, auto-rickshaws, motorcycles and scooters merge and cross paths within inches of each other, with drivers honking horns continually, without anger, as they weave their way through traffic congestion that would make a Canadian rush hour seem like a Sunday drive.

On roads that could comfortably handle three lanes of traffic, there are easily five to six lanes of cars and motorcycles. Understandably, about one in three cars have side mirror or side body damage. Traffic fatalities are commonplace. It is not unusual to see a woman sitting side-saddle on the back of a motorcycle holding a newborn with both arms, a child sitting in front of her holding onto the driver. Only the driver is wearing a helmet, a high-speed disaster waiting to happen.

The sun shines brightly during the day and temperatures remain around 30C. An almost tangible pollution haze hangs over Mumbai like a shroud. Garbage pickers, mostly elderly women, the disabled and orphaned children, bed down for the night in the dirt and debris at the roadsides. Other poor families settle to sleep in their tiny apartments provided to them by developers as a relocation incentive because land is precious and their slum can be bulldozed to build another high-rise.

Standing in the midst of this new and unfamiliar environment, I draw in a deep breath but it catches in my chest as I begin to get a sense of the overwhelming need and the obstacles facing social change advocates attempting to develop sustainable poverty reduction strategies in a country plagued by caste and gender discrimination and deeply rooted religious and political ideals, a county where poverty and malnutrition are an undeniable reality of everyday life.