Comprising Study of Accessibility of Health Care to Marginalized Population.

Item

Title: Comprising Study of Accessibility of Health Care to Marginalized Population.
extracted text: Community Health Cell
Community Health Internship

August 2007 - January 2008

Mentor: Dr. Thelma Narayan

Lakshmi E. Prasad

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Preface

My desire to pursue an Internship with the Community Health Cell (CHC) came at a time when I
craved a level of intensity and satisfaction from my work that I was not able find elsewhere. Despite

working at a community health center in a low-income neighborhood in Brooklyn, New York, and
working towards increasing the accessibility of health care to marginalized populations, I felt a
lingering void. This drove me to seek out an Internship in an environment in which I felt culturally

close and comfortable. I felt that an Internship in public health in Bangalore would effectively give

me perspective into South India's social landscape and familiarize me with the conditions of
people's health. Additionally, 1 wanted an experience that would solidify my existing interest to

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pursue higher studies in the public health realm of a developing nation.

My arrival in India in August 2007 was marked by a state of unanticipated culture shock. Since

migrating to the United States in 1992 at the age of 10, I have returned to India 5 times during
summer vacations. This trip, however, had a particularly striking impact on me from the beginning.

I had heard from relatives and friends about the notorious 'westernization' and globalization of

Bangalore, yet I was unprepared to accept the physical changes within the city.

1 arrived at Cl IC in the middle of August to begin my Internship in Community Health. Since I had
approached CHC independently, after learning about the organization through a random Google

search, I was not sure what to expect. From the first day of the Internship, beginning from the
Orientation, it was evident that CHC was a committed and professional organization. I was

immediately struck by the simplicity of the CHC offices, the seriousness of the library and its

literature, and the directness of the staff. I was immediately excited by the unrivaled learning
experience to follow.

As a fresh Intern I came to CHC with a limited definition of health, that it is the "absence of disease".
My quick introduction to the World Health Organization's holistic definition of Primary Health Care

over the next few days helped shape my learning objectives for the next five months and beyond.
Following this definition of health I was able to systematically learn about the various determinants

that affect the health of communities within varying contexts. Visits to rural areas enriched my
learning by illustrating the impacts of inaccessible and sometimes non-existent, fundamental

resources such as shelter, water, sanitation, education, and job security. At the same time, living in

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Bangalore with my family, I experienced the opposite lifestyle of those living in poverty m rural and

urban areas. The ruthless disparity and tire realization that socio-economic status serves as one of
the prime factors in determining the value of an individual within society, and to some extent
his/her fate is heartbreaking.

My experience of working in a low-income neighborhood of a developed nation contrasted with

India showed that there is a large disparity between the provision of basic resources to the poor
population of each country. Those living in Bedford-Stuyvesant in Brooklyn, where I worked, were

provided minimal structural support from the government. Access to water, sanitation, electricity,
and food, though a struggle for the most vulnerable of marginalized communities is accessible to the
remainder of the population. These elements are widely available and regarded as a basic human

necessity. Many social services are adequately provided to the residents of New York City due to
several factors. Some of these factors include the will of political leaders of the city, budget, a

committed not-for-profit sector, and active civil society. Most importantly the combination of these
factors has effectively established a system of checks and balances. I've noticed that even though
money buys power and fuels inequity (just like everywhere else), common minimum standards of
life are not compromised. One reason is that tire United States (in the period following the

exploitation of the aboriginal Native Americans) is a country that was not colonized and exploited of

its resources. Secondly, tire US maintains the Universal Declaration of Human Rights. The UDHR
places importance civil liberties. This coupled with democratic decision making processes (there are
exceptions to the rule i.e. tire Iraq War) gives citizens large ownership of their rights as citizens.

In India, the magnitude of the disparity between tire rich and poor shocked me; however, I was even
more shocked by the disparity between the poor and the poorest. The Constitution of India which

maintains the 6 Fundamental Human Rights does not fully support citizens against poverty and
economic insecurity. It seems that the general state of the nation is due largely to a distracted
government; one which prioritizes the growth of the private sector rather than focusing on
strengthening the structure of basic services. This type of negligence, coupled with other powerful
factors like caste, gender, religion, and corruption perpetuate the cycles of oppression; hinder the

effective implementation of policy, and the pace of social change.

The largest difference that I have noticed in the social mindset of both countries is between
Individualism in the United States and Collectivism in India. The antithetical schools of thought

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place priorities on different values, which output certain distinguishable behaviors. One school
condones dependency and sharing (parent-child relationship), while the other encourages a

survival of the fittest' and capitalistic mentality. These messages of Individualism and Collectivism

are present from the very early age of an individual's life within the household, the educational
system, and the government. I believe that has been the strongest element which has (or has not)

instilled a sense of entitlement to rights within people.

The flexible structure of the Internship effectively fostered my learning of community health and
some of the issues that people in India face. My time with CHC far exceeded my learning objectives.

Field visits were an enormous opportunity to witness, and to briefly experience, some of the tangible

and harsh conditions experienced by communities on a daily basis. For example, at the National
Alliance of People's Movements' Annual Conference in Gulbarga, Karnataka I listened to
testimonials of women who face violence and oppression on a daily basis at their jobs and in their
homes. The Food Sovereignty workshop organized by Svaraj taught me about the direct impact of

Agribusiness on the livelihood of small farmers; and a visit to SIPCOT in Tamil Nadu effectively

portrayed the detrimental health impacts on communities caused by the irresponsible and illegal
behavior of manufacturing and industrial entities.

My time in India during the Internship has inspired me to pursue my graduate studies this year in

the field of Global Health and International Relations. I believe that I will benefit from training and
knowledge in the subjects of Health Financing, Health Economics, and Comparative Health

Systems. After completing my Masters education I hope to work in the field at a community level to
gain an in-depth understanding of the complex issues faced by those most negatively affected. In the

distant future I look forward to utilizing the knowledge gained from community-level experiences
towards a more macro/policy level to improve policy implementation.

This trip to India has affected me greatly on a personal level. It was effective in taking the initial step

to bring me out of my comfort zone, to the forefront of the problems - which is a reality for the
majority of Indians living in India. CHC gave me the opportunity to forge a very valuable

relationship with my homeland. I feel extremely fortunate to have experienced the warmth,
openness, and enthusiasm of all of CHC's staff members and friends. I am grateful to Dr. Thelma

and Dr. Ravi for the opportunity to Intern at CHC. As an individual with the desire to pursue public
health without a medical degree I valued the chance to freely explore my interests in the field. I am

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especially thankful for having had Dr. Thelma as my mentor, who has become a source of support

and inspiration. My time spent with the Technical Team during discussions within and outside of
the 'work' environment has given me hope and excitement.

During my next trip to India, I look forward to involving myself directly in the field. Through this
experience I would like to learn more about:
Effective causes of social change (through the reduction of stigma) on a community-level. How

to emphasize the need for the 'united we stand, divided we fall' philosophy.
Mechanism rewarding people for good behavior in efforts of lessening corruption
Targeting the children at an early age to get them aware and involved

Sustaining mobilization while demanding for conditions that people have never experienced.
I look forward with keen anticipation to foster these friendships and to my next visit back to India.

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Report Contents

The following report outlines my journey through the Community Health Internship with the
Community Health Cell in chronological order. I have documented my impressions and thoughts on
various meetings, field visits, and ideas. All of these experiences caused me to question my own

status-quo and encouraged me to look outside of myself and my world.

Jan Aroghya Andolana Karnataka - Sangama
Indian Civil Society Summit - Ambedkar Bhavan

National Rural Health Mission: Community Monitoring - Ashirvad
Kanakapura
Urban Health Brainstorming Session with Renu Khanna - Community Health Cell
Community Health Insurance - IPHU

Mental Health & The Urban Poor - Basic Needs
National Alliance of People's Movements - Gulbarga

Holy Cross Comprehensive Rural Health Project - Hanur

Chennai

National Bioethics Conference - NIMHANS, Bangalore

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Jan Swasthya Abhiyan - Karnataka Meeting - August 20, 2007

Background

I first learned about the Jan Swasthya Abhiyan (JSA), the Indian Circle of the People s Health
Movement through the Community Health Cell's website. JSA is a movement that consists of over

20 networks and 1000 organizations as well as a large number of individuals who endorse the Indian
People's Health Charter. JSA aims to establish health and equitable development as top priorities

through comprehensive primary health care and action on the social determinants of health.

I attended a meeting of the Karnataka state chapter of the JSA called the Jan Aroghya Andolana
Karnataka (JAA-K). The meeting called together representatives horn various districts of Karnataka

to discuss issues relating to the deficiencies of the public health system in various districts of
Karnataka. The representatives come together periodically to speak about issues in their respective
districts and to reflect and improve up on efforts towards the strengthening of the Primary Health

Center. CHC provides support to these districts through guidance on strategic planning and

mobilization, dissemination of important information and literature, rights education, and through
support in contacting political leaders.

This was my first exposure to a people's movement.

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The all-day Jan Aroghya Andolana meeting, which took place at the Sangama office in Gandhinagar,
was an invaluable opportunity to witness the fruits of JAA-K's labor. 1 found several components of
the meeting to be different from what I have become accustomed to while living in the United States.

Upon arriving at the Sangama office I was struck by the layout of the meeting space, a comfortable

rectangular room with seating pillows arranged at the perimeter of the room. Although this was

somewhat surprising for me (I was expecting a big conference table) it made perfect sense that an
initiative taking place at a grassroots level would appropriately accommodate to the people and

principles of justice and equity, by having equal and communal seating for all.

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1 he meeting began with two women singing a Kannada protest song. I found this to be significant,

because of the impact it had on establishing the culture of the meeting in an informal manner. I felt
that the mission of making matters matter at a community level was indeed happening, that
something like a simple song, which one wouldn't directly associate with the solution for the

betterment of health/hving conditions, is valid in inspiring and maintaining constituent morale.

Next, the members proceeded to introduce themselves by name and by district/organization
represented; members representing 14 districts were present. At this time I was pleasantly reminded

of Kannada being the default language. Following introductions, Premdas, who served as the
facilitator, outlined the agenda for the day. He solicited feedback from the members regarding the
agenda to see if any additional items needed to be discussed. Members agreed that they would
decide upon this matter as the meeting progressed.

The first item on the agenda called for the summarization of events of the previous JSA meeting,
which took place July 15*. After this, representatives informed meeting members of the happenings

in their respective districts; about what action was being taken and the progress that was being

made. 1 had some difficulty in fully understanding what was being said during the meeting, due to
my lack of competency and exposure to the level of pure Kannada which was spoken. My

impression of the districts presentations was positive. I found the members to be outspoken. Mostly
I was happy to see the number of women involved in the initiative, and the diversity in age among

them. All members were emotionally invested in the cause and wanting to create change for
themselves and for their communities. This is obvious just based on their presence at the meeting.
Many traveled long distances just to attend. Additionally, I feel that these meetings are extremely
helpful for the attending district members not just because it helps them receive feedback from a

solid support system, but also because it presents them with a solid opportunity to build their self

confidence in public-speaking, problem assessment and action/implementation.

After lunch, Vinay gave a brief presentation on Community Monitoring. Prasanna, who helped
moderate the remainder of the meeting, made an axiomatic statement on how to approach the

Health for All issue. He explained that as important as it is to protest for rights from the

government, it is also just as critical to work with the government to help properly implement these
rights. This comment helped to facilitate better understanding for the members about their near

future goals. It was important for Prasanna to present this point so that the members do not think of
the government as their enemy, instead as a potential ally for achieving a healthier lifestyle.

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The final hour of the meeting was spent discussing logistical information about the district-level
action that will take place on October 8. Members placed themselves in one of three different

categories expressing the amount of funding they need for transportation, accommodations, and
food. 7 districts said they were able to fully fund themselves, 5 districts requested partial financial

assistance, and 4 districts requested full financial assistance. This last hour of the meeting was the

most vibrant, due to the varying opinions of how money should be acquired and distributed.

Overall, I learned about people's attitudes and perceptions about the health movement through this
meeting, which I would not have been able to grasp simply from the gleaning of written

documentation. I am curious to attend the next meeting to hear follow-up reports from
representatives about the events of October 8* and the reaction of their respective districts.

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India Civil Society Summit Reflection - August 25, 2007

Background

The India Civil Society Summit was organized by a group of NGOs and Civil Society Organizations
and took place at Ambedkar Bhavan on August 24, 25, 26 2007. The summit was a celebration of

survival, resistance, and the continuing struggles for freedom in India. It provided a space for
dissent and raised issues relating to the ongoing struggles for freedom.

The purpose of the Summit was to build relationships across boundaries and to create a platform for
people-centric nation building. The Civil Society Summit brought together nearly 850 participants

representing 67 NGOs from 23 states in India from diverse spheres for a synergy of ideas.

The participants listened to the different points of view of the speakers and the challenges that the
nation faces in ensuring "freedom for all". The overriding theme of the Summit was "displacement'

from land and governance to identity. The emphasis was on the search for solutions and working

together.

Reflection

I attended the second day of the India Civil Society Summit. The session about Urbanization
centered around the challenges of rural to urban migration since independence. A panel of speakers

included Kathyayini Chamaraj from Civic Bangalore.

Kathyayini Chamaraj outlined a set of issues that included the side-effects of 'push' migration of

people from the rural communities to metropolitan areas. The conditions in villages have generally
worsened due to the absence of structured systems like reliable running water, electricity, sanitation,

health care and education. However, migration is taking place due to desperation caused by poor

weather conditions and the advent of private sector presence in rural areas for cash cropping and
SEZs. Those desperate to sustain a minimal livelihood flee to the cities in search of employment just

so they can put some food into their bellies. Most of the time these individuals survive on money

obtained from begging or they are fortunate (relatively-speaking) to work as daily wage laborers in
the country's exploitative informal sector - in factories or construction.

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Bangalore is not equipped with the solid infrastructure needed to support migration on such a large
scale. In addition to the 'push7 migration outlined above, the city also attracts a less impoverished

"puli' population, those who flock to the city for employment within the IT and MNC sector. Not

only is this migration fueling the number of residential development projects around town, but it is

also a) increasing the number of illegal slums and b) displacing previously existing homeless people

who must make way for development projects. Those migrants who do not find space in a slum
resort to squatting in the train stations.

Despite the plaguing problems migrants face in the city, many refuse to return to the rural areas

where they will face a much more difficult and desperate life. If a migrant is fortunate enough to

acquire an identification card to establish urban citizenship then he/she can use it to feed
him/herself and the family on a small amount of food.

This session was appropriate time-wise. I just arrived in India and have been shocked by the

changes that I see: the increase in construction and the increase in panhandlers. The wealth and the

poverty in the city have increased simultaneously. The Summit also served as a good introduction to
the NGO and Civil Society community in India. I was excited to see the large number of people

involved in the organizing of such an event. Even more so I was impressed by the number of people
who attended.

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National Rural Health Mission Dissemination Session - September 4r 2007

Background

The National Rural Health Mission was launched by the Government of India to carry out necessary
architectural correction in the basic health delivery system. The Mission adopts a synergistic
approach by relating health to determinants of good health, such as water, sanitation, nutrition, and

safe drinking water. It also looks at mainstreaming Indian Systems of medicine to facilitate health
care. The goal of the mission is to improve availability and access to quality health care by people,

especially for those residing in rural areas, the poor, women and children.

Reflection

The purpose of the National Rural Health Mission dissemination session, which took place on
Tuesday September 4, at Ashirvad, was to raise awareness about the initiative that aims to increase

the quality of healthcare among inhabitants of rural communities, especially women and children.

Following individual introductions, the session began with a protest song sang by Mr. Basuvaraj. E.
Premdas, who moderated the session followed with an introduction of the speakers: Dr. Thelma

Narayan, Dr. Devadasan, Dr. Vinay, and Dr. Sylvia Selvaraj. Premdas updated participants about

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NRHM having been a long process to work to improve people's health through the People's Health

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Movement, mentioning that policies have already lapsed in two years, therefore, pronouncing the

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importance of starting a voluntary technical group while informing people about NRHM.

Also, Premdas alerted the session participants about a 20-district rally to take place on October 8 in
efforts to demand community health care. Copies of NRHM documents were available in English

and Kannada for the cost of the photocopies. In addition, a draft document had been prepared to
send to the Mission Director requesting the comprehensive and effective implementation of NRHM

and the construction of a website informing the people of this progress information.

Dr. Thelma Narayan: Background & Spirit of NRHM

Dr. Thelma began by providing information about the history of the Jan Swasthya Abhiyan and its

view of "health as a human right". The First People's Health Assembly in 2002 led to the creation of

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the People's Health Charter. Later in 2002, the JSA played an active role in helping to shape the

National Health Policy. Prior to the general elections in 2004, JSA held meetings with health

ministers to strengthen the public health foundation. The Common Minimum Program, which was
produced after the elections, committed to raising the health budget, currently at 0.9%.

The initial approach of the NRHM was to focus on reducing the growth of population. 1 he goals
were later modified to adopt a more holistic community-based method with the utilization of
ASHAs. Dr. Thelma also mentioned that Rs. 32,000 Crores has been allocated for the health sector by

the Cabinet, and that it is crucial for NGOs and CSOs to be actively involved in the implementation
of NRHM and making sure that the funds are effectively utilized. There is an important need for
NGOs to not just offer criticism to the government about tire progress of NRHM, but to also play a

role in creating meaningful Public-Public partnerships. Our relationship with tire frontline workers

is equally important because they essentially serve as tire direct links, transferring health care to the
people. We must plug into the system at every possible level to utilize the scope for participation. In

addition, all NRHM documents need to be translated to Kannada to help foster overall participation.
Dr. Ganapathi asked whether there is a binding timeline for stages of NRHM, to prevent work from
being left to the last minute. Dr. Thelma said that there is a timeline and Chandra mentioned that the

government is keeping up with certain deadlines, however, there needs to be current available

information from the government about progress.

Dr. Devadasan: Overview of NRHM
Dr. Devadasan began by recounting his visits to Orissa, Rajasthan, and Maharashtra and stating that

their progress reports are available on tire website. The NRHM website currently contains all
documents up to June 2007.

The vision of the NRHM is to improve access to health care for rural communities, especially women

and children, while promoting accountability, equity, and affordability. Some goals of NRHM

include the reduction of IMR and MMR by half, universal access to public health, prevention and
control of communicable and non-communicable diseases, population stabilization, revitalization of

local health systems, and promotion of healthy lifestyles. These are to be accomplished with the help
of ASHAs, strengthening of sub-centers, PHCs & CHCs, creation of district health plans, integration

of sanitation & hygiene, public-private partnership, health financing mechanisms, reorienting

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medical education, and strengthening of disease control programs. Community monitoring is an

important component and can be accomplished through a People's Health Watch.

Financing increases by 30% each year until the money allocated towards NRHM is 2-3% of the
budget. Currently, the states are not able to absorb the money; also the money bypasses the treasury

and goes directly to the hands of the state and districts, therefore it is important that it is well

utilized. There are several strengths and weaknesses of NRHM currently. One of which includes the
District Health Officer not meeting qualifications.

Dr. Vinay: Community Action for Health

Community monitoring transfers responsibility to the people. It is a systematic way to gather

information about community needs and provide feedback about key indicators. The model
commands participation from the health system, NGOs/CSOs, and the community. Community

mobilization is required.

Dr. Sylvia: ASHA

Karnataka plans to train 2934 ASHAs in 1931 villages. Karuna Trust has taken the responsibility of 3

districts: Chamrajnagar, Mysore, and Kodagu. There is concern about the selection process of the

ASHAs and the need to not make it political. There is also concern about how the money is being
utilized.

I found the meeting to be loud and boisterous during the discussion phase. It was interesting to see

the interactions of many different ideologically grounded try to agree on an approach for the
NRHM. I was surprised to see the amount of dissent in the process. I had automatically assumed

that the N.G.O. community was fully united for the common cause of providing better social
services for the marginalized populations; however, being present at the meeting made me question

the agenda and context of each organization's involvement in the meeting. This experience was very

important in helping me realize the importance of identifying a personal philosophy for myself and

the necessity of procuring a position at an organization where it can fit.

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Kanakapura Field Visit - September 7, 2007

Background

My visit to Kanakapura was the first trip that I took as an Intern at CHC Looking back I am able to

identify areas for improvement in my field research skills. I enjoyed this visit as an introduction
because it gave me the opportunity to begin the development of my own style of introductory
ethnograplric research. Reflecting on the experience made me realize that there are many things 1
would do differently. This includes asking more questions. However, asking more questions

changes the dynamics of my level of participation from observer to participant. Therefore,

determining a few objectives prior to a visit would make information gathering a more effective
process. Additionally, one visit is never enough.

Reflection

I visited the town Kanakapura through a trip organized by Dr. Saraswathi Ganapathi of Belaku

Trust. We began our day in Kanakapura at an Anganwadi center. The Anganwadi had about 20
children ranging from the age of 3 to 6. The room consisted of a kitchen, a small area for the children

to sit, and a small desk area with file cabinets. The white walls were stained brown and were
covered with a few illustrated educational posters. The kitchen area had a stove that was made up of

a stones, sticks, and paper. There was a big drum of water available in the kitchen, but I don't think
it had a filter. When we entered tire Anganwadi, the children were very excited to see us. In general,

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it seemed to me that the children had more energy than anyone knew what to do with. The children

sang songs for us: tire alphabet song, Kannada numbers. Twinkle Little Star, and Bus Banthu Bus.
They repeated these songs numerous times. I'm not sure if it is because they prefer these songs to
others, or because those are all the songs they know. There were two women who were tending to

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the children. One was the Anganwadi worker and the other was a lady from the community who

helped out. Both women were very amicable and seemed a little bit stressed out from trying to
manage the children. The desk on the in tire Anganwadi center was scattered with record-keeping

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books, which recorded tire immunization and birth and death information of everyone in the village.

After visiting this Anganwadi I strongly feel that it is unfair for both the worker and children to put
so much responsibility on one woman. According to Piaget's Stages of Cognitive Development tire

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pi imary cognitive development of early childhood is language acquisition. The development of
spoken language is dependent on how much the child is spoken to/heard by the age of 5. In a 1995

study by Hart and Risley they found that children who had heard the least amount of words prior to
age 5 had the slowest vocabulary growth rates and knew far fewer words than the children whose
parents talked to them much more. This study was based in the US, therefore I don't think the

results are fully applicable to India, since the culture is already verbally-heavy. However, the study
makes the point that the Anganwadi worker is given far more responsibility than she can feasibly
handle without compromising the attention given to the children. An education plan that utilizes

childrens' time at the Anganwadi center for even an hour a day has the power to give them a
headstart in their cognitive skills. For example, another well-known research effort that reinforces
tlie importance of an early childhood education is the Lifetime Effects: The High/Scope

Perry Pieschool Study Through Age 40 (2005) which examines tlie lives of 123 African Americans born
in poverty and at high risk of failing in school. From 1962-1967, at ages 3 and 4, the subjects were
randomly divided into a program group that received a high-quality preschool program based on

High/Scope's participatory learning approach and a comparison group who received no preschool

program. In the study's most recent phase, 97% of the study participants still living were
interviewed at age 40. Additional data were gathered from the subjects' school, social services, and

arrest records. The study found that adults at age 40 who had the preschool program had higher
earnings, were more likely to hold a job, had committed fewer crimes, and were more likely to have
graduated from high school than adults who did not have preschool.

After the Anganwadi Center we visited an Income Generation Project in the village of Kadahalli

called the Kirana project, which consists of a group of women who were trained to make paper and
paper products like note-pads, writing paper, cards and bags. Attendance seemed to be a problem
with one woman and when asked for the reason she was embarrassed. Later we found out that her
absence was due to marital problems in her home and the issue was not pressed further. From my

vantage point the project seemed sleepy and relaxed. The women seemed to enjoy being out of their
homes and in the company of other women; however, I was surprised by how passive they seemed

when we visited them. Dr. Saraswasthi had to ask them several questions and probe'them to tell us

what they do and show off their products to us. I felt that there was definitely a need for a marketing
channel to engage the women in a business spirit. Perhaps having a regular client base would

establish a sense of purpose and make the work more meaningful for them, rather than just a past-

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toe. Or maybe lire women are no. so much interested in tire production ot paper as they are in

spending lime with their peers and being outside of their homes.
Th. second Income Generation ftoiect, the Deepa Project, was located in the e.ll.ge ot Ha asm

interested in their work. It is possible that they receive more orders than the Kir.na women,

therefore fostering more investment in di. work. Also, the Deepa Project consists of some women
who are older and widowed; therefore the need to be self-sufficient and sustainable ,s greater,

found the products of Deepa to be beautiful and the process of their work metlmd.cal and
organized. 1. is possible that this disparity between die b.0 Income Generation PrOjecB „ due »

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managers of the projects.
in general, the visit was a good introduction to the field and the research tins type of work involves.

The trip helped me get an idea of what to look for tire next time 1 participate in such a v.s.t an I e
type, of Tueshons to ask. 1 feel that! cadi really generalize my experience based sotdy on thrs v.s.

However. I will say that in regards to the Anganw.di Center, even though! understand the nee

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quantity and coverage,! still feel that quality of implementation should also be a priority. Indiaa
huge country. Penetrating a population and introducing a program lakes time and money; therefore

i feel that prior to implementation more time on planning should be spent on the ■whal-.fs that can
arise in the process. 1 don't think it is easy to have perfect implementation; however, streamlmmg

the chatmels for dissemination will help. Although, this is probably more difficult than ,1 soun s

and involves preponderant issues, such as corruption.

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Reflection on Urban Health Meeting - September 11, 2007

Background

1 found the brainstorming meeting for the initiation of an urban health plan to be quite
enlightening. Prior to my arrival at the CHC I was under the impression that establishing a sound

rural health system would be more challenging than tackling urban health. At the time I had not
considered that an urban environment posed many multi-faceted challenges, including issues of
undocumented migration, illegal slum establishment, shortage of land for non-corporate use. It

makes sense that due to the prevalence of health facilities in Bangalore, albeit most of them private,
an effort on the part of the government to accommodate those not utilizing private facilities has been
made.

Reflection

The afternoon's discussion of urban health gravitated towards Bangalore, as an example. I
am still in disbelief that a city with such technological capabilities and a large cosmopolitan
population is not equipped with an infrastructure to provide access of basic services to its residents.

I am in complete agreement with the point that was made during the meeting that some
initiative must be taken by those who are lacking access to such services. I do believe that this is the
organic and sustainable way to create positive change. I, however, sometimes find myself to be

pessimistic about this viewpoint based on my experience in Bedford-Stuyvesant.
Family Support Workers (FSW) solicited women in the community, who were either
pregnant and/or had a child under the age of 4, to join a program called 'Successful Start/Healthy

Start'. Each FSW ensured continuity of care by conducting home visits to learn about each woman's
hardships and offered advice about access to resources when appropriate. Help topics included

regular health checks up for mother and child, nutrition, job preparation and readiness, public

housing, food stamps etc. Periodically, the FSWs organized workshops for the clients at the office.
They provided clients with food and money for transportation. Childcare was also provided at the
office during these workshops. All clients of the program received products such as diapers,

strollers, and cribs for participating.
Based on my observation about this program the rate of adherence and the willingness to
participate regularly was limited to a small minority. I'm not fully aware of all the reasons why

18

adherence was low, but I am convinced that one was laziness. Some of the participants did not want

to be accountable to an outsider questioning their current lifestyle. The point I am trying to make is
that despite all of tire efforts made by the FSWs to help the participants, most did not use the
opportunities. Therefore, I am a little concerned that positive change, which is largely contingent

upon the demands and the initiative of those who need it most, is an uphill battle. Perhaps I am

looking at this from the wrong angle. Maybe positive change is contingent upon and caused by a

committed group of a few, and slowly the rest will follow.
Dr. Ravi suggested that one approach to raising awareness about the right to health in urban
areas is to start small, by having a minimal framework of mandatory services and later expanding

on it. I feel that this is a realistic solution and streamlining tire process as much as possible would be
beneficial to all. Unlike the NRHM it will not require a large amount of start-up time and will be

easy to facilitate participation among many parties. Raising awareness about 5-6 guarantees for
which the government is accountable is feasible. One way this can be done is through public service
announcements, word-of-mouth, and multi-lingual posters displayed ubiquitously. Also, having a

free telephone number for citizens to call and report grievances would allow for direct monitoring

and corrective of the system. Involving the private hospitals in this initiative, as mentioned, is
crucial. I feel that the role of the private hospital in dedicating a certain percent of its beds to tire

underprivileged should be constantly monitored, and there should not be a disparity in the quality
of care provided to patients.
I feel that this minimal rights structure can be effective in slowly and thoroughly engraining

higher standards and expectations in people. If we can create an attitude of demand on a small scale
in at least one area then people will start to question the status quo in other aspects of their life.

19

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Basic Needs: Mental Health
Background

The limited exposure that I have had to mental health in India was my primary incentive for
wanting to visit Basic Needs. After spending a short period of time at CHC I have gained valuable

awareness about the functioning of the public health system in India. This has led to the question: if
vocal and visible communicable diseases are not being effectively prevented and treated by the
public health system, then what is the plight of quiet non-communicable illnesses such as

schizophrenia and depression?
Basic Needs is an organization that works with mentally ill people by helping them to start to earn a
living after they have been given access to regular, community-based treatment. The organization
works with communities to overcome stigma and abuse. Their work strives to make mentally ill

people self-sufficient and independent.
It has been estimated that there are approximately 58 million people in India with some form of

mental illness. There are approximately 3.5 psychiatrists for every 1 million of the population; most
of these psychiatrists are based in cities. This is a problem given that approximately 75% of the
population lives in rural areas.
■

Mental health appears to be better addressed in the southern part of the country, especially
Karnataka, than in the northern states. This is partially attributed to the presence of the National

Institute of Mental Health and Neurosciences [NIMHANS] in Bangalore. Basic Needs in India is
based in Karnataka and therefore has a strong presence in the urban poor communities here.

Reflection on Meeting with Mr. Naidu [Basic Needs] - September 21, 2007

Meeting Mr. Naidu at the Basic Needs office in Banaswadi was an impacting and personal
experience. My intention to visit Basic Needs was to learn more about Mental Health in Karnataka.

However, the conversation I had with Mr. Naidu, took a turn in a more interesting direction. Our
discussion gravitated towards the state of the Indian government and its impact [detriment] on the

people of India.

20

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The discussion probed me to question the role of NGOs in India today. A few months ago I sincerely
believed that all NGOs are benevolent entities committed to the betterment of the lives of

marginalized populations; However, now I skeptical about whether all NGOs are 'good'. For
instance, when I tell friends and distant relatives in India tha11 am involved with an NGO, the

common initial response that I encounter is, "There is good money in that industry". This statement
confuses me because my impression [based on my experience of working in a U.S. non-profit

setting] is that the not-for-profit sector is not affluent. NGOs and non-profits often operate on

external funding sources and employees of NGOs do not make a lot of money.

I later recalled a conversation with Rakhal about the number of new post-tsunami relief NGOs that
sprouted up in Tamil Nadu with the mal-intention of capitalizing on victim-intended funds. These I

would categorize as 'Bad' NGOs. In Brooklyn I have been a part of an NGO that plays a relatively

passive and neutral role within a community - the type of organization that lacks motivation to be

proactive, yet continues to exist because there is a need for the services in the community [and most
likely because they have a steady funding source]. Some presence is better than no presence. Results

of a patient satisfaction survey concluded that 15 out of 85 patients would not recommend the health

center to friends/family, but utilized its service for the lack of other convenient options. These I
would categorize as 'Indifferent' NGOs. Finally, there are those NGOs which actually make a

positive difference. Those truly committed to the mission of improving lives. My question to these
NGOs is how much of a difference can actually be made? How long can this difference sustain?

NGOs are rooted from the humane intention of increasing equity in societies; picking up the slack of
the government by 1) fulfilling its responsibilities or 2) pushing the government to take

responsibility. NGOs attempt to serve as the bridge the rift between what the government is not
doing and the unfulfilled basic needs of the people.

Enthusiasm of NGOs + lack of enthusiasm from government = disempowerment of government +
decreased investment of government in the social welfare of the citizens + decreased interest in
taking matters into their own hands.

of urgency existing within government and
What about the danger that NGOs reduce the sense
t

citizens to provide and demand basic services?

21

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Additionally, how do several distinct NGOs reconcile their agendas, to streamline progress towards
the intended goal? How do we ensure the side-lining of egos and individual agendas to ensure
unanimity and democratic participation?

On a more personal note, Mr. Naidu emphasized the importance to examine [everything] objectively

and also maintain a sense of balance and humor in my work.
Reflection on Slum Visit [Basic Needs] - October 18, 2007

Mv exposure to poverty and public health so far has focused predominately on rural communities.
In an attempt to obtain insight about the lifestyle of the urban poor I visited a slum on Good Shed

Road near the Kempe Gowda Bus Station, where Basic Needs works to raise mental health

awareness.

Basic Needs and other partner organizations like Paraspara Trust and the Association of People with
Disability' [APD] work together within an urban poor community to facilitate the identification of

people with mental illnesses, provide access to resources and support systems, and raise awareness
with community members about mental illness. A voluntary community health worker [chw] from

the slum is chosen from a self -help group to work with the community to achieve the
aforementioned goals. The CHW serves as a go-to person for people who have questions about
symptoms they are experiencing or for information about what to do when family members are

experiencing other mental health symptoms. The CHW is effective in dispelling fears and stigma
about mental health in a community. The individual identified with mental illness has a caretaker

from within the family to ensure treatment adherence and attendance of general visits at
NIMHANS. Additionally, the identified mentally ill and their caretakers have a support network,

which meet periodically to discuss relevant challenges and methods.

Our visit to the Good Shed slum was coordinated by Guru of Basic Needs. From 10am to 1pm we
stopped at 3 households, where an individual with mental illness resided. Good Shed is diverse in

religion and socio-economic status. Muslims and Hindus are segregated and some houses are larger
than others.

22

At the first home we met a 26 year old woman, who has postponed her marriage to care for
her younger brother afflicted with schizophrenia. She decided to defer her marriage till her

brother becomes better established and self-sufficient through work and treatment. The

sister stated that there has been a vast improvement over the past few years in how
community members treat her brother. Prior to Basic Needs' presence in the community, he

I

was taunted and mocked by children throwing rocks at him. After raising awareness about

mental health through self-help groups, groups for young children, and painting projects of

murals, people have started to understand his situation as an illness. The stigma within the

community is also disintegrating as community members are realizing that is not
contagious. Currently, the brother earns money through his work at a factory. A few of his

coworkers also live in the slum and he travels with them to go to work everyday. The sister
recalled there are still a few worries that she faces. She recalled one disturbing incident when

her brother was found at a liquor shop with other men from the slum. Following the

incident, the other men had to be educated that it was not safe for the brother to mix alcohol
with the medication that he was taking. This intervention by the organizations was

constructive and did not place blame, rather it was conducted in a manner that encouraged
openness and questioning. In regards to the treatment, the medication is provided free of

cost by NIMHANS during periodic check-ups. The cost of transportation is provided for by

the partner organizations. Additionally, the sister actively participates in caretaker resource
meetings, which offer her support and guidance.

The second house we visited was occupied by a family of parents and two daughters. The

husband was diagnosed with schizophrenia last year. At that time, the wife was not familiar
with the illness and plotted to escape with her children to her parents' village. After an

intervention by the CHW and the partner organizations, the wife decided to stay. She was
educated about her husband's condition. This was successful in dispelling her biggest fear,

that schizophrenia is contagious. Interestingly enough, despite this acceptance of her

husband's condition the wife opted to send her son away to the grandparents village, while
the daughters remained. When asked why only the son had been sent away she a) is stall not

fully convinced about his condition and b) feels like its more important to protect the son
than the daughters c) sometimes feels unsafe about how her husband might act. The

husband is currently on treatment medication provided by NIMH ANS and both him and his

23

wife attend their support group meetings. He works regularly in a factory and makes

enough money to barely sustain their livelihood.

This was my first time inside a home in a slum. The living room was also the bedroom,

kitchen, and closet. Bathroom facilities are centrally located outside the home and shared by

the entire community. They are supposed to be cleaned by the municipality periodically;
however, this does not happen. Water supply is provided on alternate days and the women

are responsible for collecting it. Electricity is provided in the slums at a subsidized rate.

■

The final home we visited was larger than the previous two. The household occupied two
adjacent homes. The members of the household consisted of a mother, 2 sons, their wives, 1
daughter, and a baby. The sons worked for IT companies; therefore were able to afford a

computer and big television. The daughter, Chitra, 26 years of age, is the youngest of the
siblings. She was diagnosed with schizophrenia two years ago. According to community

members, this was triggered by an incident when a boy she was in love with from a different
community was married to someone else. As far as Basic Needs knows, the family never
acknowledged this incident. Chitra had not been supported by her family from the

beginning. They did not acknowledge her illness and attempted to marry her off. Basic

Needs was able to convince the family to postpone her marriage till she gets better. She is

slowly gaining acceptance from her family, but it has not been sufficient to build her
confidence and desire to get better. She is reluctant to attend support group meetings and is
irregular in her treatment adherence. When asked to promise that she would attend at least

two meetings, she refused. Within her home she does not have the confidence to cook or care

for her brother's child. Chitra is knowledgeable in sewing, but is afraid to visit the office of a
partner organization to acquire a free sewing machine.

I believe that had Chitra been a male her situation would have been much different. Her
family would have been more receptive from the beginning to ensure that her confidence

was built and that care was taken. Now as a 26 year old unmarried woman it is possible that
she is viewed as a burden to her family. Unlike, the first house we visited, Chitra did not

appear to have a strong support system within her own home. Unfortunately, without this I
do not feel hopeful for her.

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National Alliance of People's MovemgntsReflgction^^
My trip to Gulbarga for the NAPM's

October 6 & 7th, 2007
Annual SUte-level Conference was my first time traveling in

mdi. by myself. 1 was excited about my sol. journey and the uncertainty that camo with it After

boarding the bus al Spm on Friday night I realized that 1 was the only iem.le passenger present
This actually turned out to my benefit because the adjacent seal was left unoccupied for what
presume is this reason. The combination of a Kannada film (whose themes included love, vmlms,

and pigeons), people loudly arguing about sea. assigrnnents, and a very bumpy ride gave me the

opportunity fo experience something very rich, semi-chaobc. and uniquely Indian.
, arrived in Culbarg, the following morning a. 7:30.m and caught a rickshaw to the hotel where the
conference was held. 1 was charged too much money lor a very short ncksh»w „de by the

aggressive drivers [there were two of them] who were not interested in hearing my rant. This brref
encounter gently reminded me that 1 was out of my comfort zone and m then territory

Upon my arrival at the hotel 1 realized that 1 had not enquired about the plans pertaining to
accommodations beforehand. Il turned out only two rooms had been reserved for NAPM use. To

avoid confusion! decided to gel my own single room. Taler on I discovered that the two rooms were
shared by many people: some attendees slept on the floor and a few on the terrace In hindsight, ih.s
arrangement made sense to me after 1 became belter acquainted with the split ol NAPM. Even

though having my own room was more convenient than sleeping on the floor 1 realized that! had
prevented myself from having the full NAPM experience.

The conference began on Saturday morning after breakfast. The process of trans.tiomng to an
NAPM state of mind after traveling for twelve hours, and having to switch to Kannada mode was a

bit stressful. There were a total of 77 people who came to the conference. Most attendees had

traveled from southern Karnataka. It did not appear that there were many attendees from the
Gulbarga area.

The first topic discussed was that of Special Economic Zones. 1 learned of the Situation m
Nandigudi, which is 60km from Bangalore, as a proposed site for „ SEZ. The proposal made by
SKIT Infraslructure would displace 73 villages and approximately 1.43 lakhs families. Nandigu

a major supplier to the Hopcoms and vegetable markets in Bangaiore. therefore seizing of ih.s land

25

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for industrial manufacturing purposes can potentially collapse food supplies to Bangalore.
Following a brief discussion with Premdas I learned that NAPM is a rare platform that provides

landowners and farmers an opportunity to fight in unison. In the past [and currently], the two polar

groups face agrarian conflict in terms of unfair treatment, exploitation, and caste-ism. However,
with the onset of globalization they have united against a threat that will paralyze all of them.

1 am disappointed bv the complete disregard of these Indian companies for the negative impacts
they have on communities like Nandigram and Nandigudi. On one hand the intention of building 1

Lakh Rupee cars would accommodate to people's needs and allow more people the opportunity to
enjoy this privilege. However, on the other hand it victimizes an already victimized population of

people. Why must the same group of people always pay a hefty price [in addition to not being able
to enjoy a 1 Lakh car] so that others are convenienced? Why does the government think its okay to

place less value on the lives of those who are already financially disadvantaged? The concept of
SEZs is perpetuating the idea that it is acceptable to accept a dismissive and indifferent attitude

towards those occupying the lower rungs of the socio-economic ladder. What about the
environmental impact of having too many cars - the emissions, overpopulation, having to encroach
upon more villages in order to build more roads/highways to accommodate more cars, and the
development of highways increasing sex work, violence, prevalence of road-side McDonalds which

can lead to obesity and the entrance of more MNCs. Additionally, this development scares me
because it threatens to uproot the values on which India is based therefore turning it into a America

version 2.0. In the near future I am interested in learning about how SEZs have impacted China. Has

the success been more beneficial for industry or for the people? How is it envisioned to work in

India where there is a completely different political system?

Also discussed at the conference was the issue of Women's rights in the work place. I learned about
the situation of garment workers in factories outside of Bangalore. Women work here to earn money

to pay for their rent and pay for their children's school fees. The employees are from both the rural
and urban communities. Groups of women are supervised by a male, who in addition to abusing

them verbally and physically sets a high goal of how many products should be produced by the end

of the day. Often the women end up working additional hours to meet this goal, without receiving

overtime compensation. As a result of staying at work longer, they endure the wrath of their
husbands upon their return home, who question where they have been. Once at home they have to
cook and care for their children and husband. So, basically they are accountable to one man or

26

another throughout the day. Work does not give them humane and fair treatment, wages, and
benefits. This presentation helped me connect my knowledge derived from this session with what I

had learned after attending the Women & Social Security in the Unorganized Sector conference put
on by the National Alliance of Women. I am interested in learning more about what the government

is doing to establish a social security system, aside from self-help groups like the Yeshaswini
Scheme.

The third topic discussed was about the sustainability of people's movements. My understanding of
what was said during this discussion is limbed. A question was raised about how to provoke a sense
of urgency in the next generation to demand their rights. How do you convince people facing these

problems that fighting for rights is a worthwhile investment, while also having to invest time into
sustaining their own livelihood? Pragmatism is good, but what about passion?

The final session of the conference focused on Dalit rights. Through this session I learned about
!

Ambedkar's thoughts about how to eradicate the caste system. Initially, he felt that inter-caste

dining and inter-caste marriage was sufficient to do this, however, he later revised this by saying

that inter-caste marriage would be effective in the eradication only if a higher-caste woman married
lower-caste man. A lower-caste woman marrying a higher-caste man and equal caste man and
a
woman getting married would only encourage [generally speaking] a man s attitude that he's

entitled to treat his wife like a subordinate. I am slowly starting to realize the magnitude of the
impossible challenges faced by Dalit women, and the amount of change that has to take place m our
society to help establish equity.

During tire conference I kept my identity as an American resident concealed because I felt that it

would alter the way people treat me. Based on my experience, a common misconception that people

have is that my thoughts about certain issues are in agreement with what is imposed by the rulers of
the United States. Towards the end of the conference, after a round of introductions my affiliation

with the U.S. was revealed. Contrary to my expectations several people approached me afterwards
to enquire why I was at the NAPM meeting and how I was spending my time in India. They seemed
interested in helping me understand the topics at the conference and a few invited me to visit them
at their work sites [such as Sister Alice from Dharwad and Ms. Sunandra Jayanth (?) from Mandy a].

27

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Even though the first day of the conference was a little stressful for me I enjoyed it immensely.

Reading about issues through journals, newspapers and discussions with intellectuals is helpful, but
having the opportunity to hear about them from the people in the situation made things much more

real for me. I felt this trip was just the tip of the iceberg. I'm looking forward to attending more to
facilitate my understanding of issues and how they fit together in the big picture. The main

drawback tha11 faced over the weekend was the language barrier. I was able to converse with
people to a certain extent, but I had some difficulty in deciphering their long and loaded responses -

both contextually and in definition. Lack of fluency in the language definitely limits the depth of my

interaction. Fortunately, I think this is something I can improve over time.

7 he biggest lesson that I learned from this weekend is that an issue cannot be resolved only when

one group takes on the task of creating change. I feel that there has to be buy-in and investment from

people of various backgrounds and walks of life. We're not isolated from these issues and what
affects one group also affects the other, and if we want change to be sustainable then there needs to

be a solid and holistic effort. Not everyone can understand the pain that marginalized communities
have undergone, however, when there is willingness from different groups to help it should be
captured and utilized.

28

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Holy Cross Comprehensive RuraTHgalthProjecLReflg^
October 24 - October 27

Despite my exponentially increasing confusion regarding India's state of being, my travels around
Karnataka'S rural communitie. have been successful in mitigating the confusion and lac.lttahog a

rudimentary understanding of the dichotomous situation of people in this country (urban nch: rura

poor ratio). I am realizing the importance of understanding common issues and the.r deeply rooted
causes prevalent a, a community (and even individual) level. Despite common themes throughout
Karnataka that affect the health of individuals [caste, gender, socio-economic status), the

opportunity that allows one to make generalizations about the stale ol affairs m a village, stale, m

nation does not exist. 1 am only a little short of being baffled by tfre layers and complexities of the
mindset and social conditioning which is in existence here. This was my biggest lesson m Hanur.

Also to state the obvious, a half hour visit to a Self Help Group meeting was sufficient only to g.ve
me a momentary glimpse of efforts being made at a community level One day in the future 1 hope
to live in a rural environment in Karnataka for an extended period of t.me so that I can observe,

interact, and understand the situation more deeply, without having to settle for the teshmomal. of
SHG members given in the presence of other SHG members.
M, ttip » H»«. to visit the Hol, Cross Comprehensive Rumi Hesl.h Rreieet IHCCRHi 1 was

iniormative and insightful. I found the process of theory application to be affirming to my esr.e of
working within the realm of community health. Similar to my visit to the Bangalore slum, had th

opportunity to witness change and empowerment at a grassroots level through my atfendance at re
SHG meetings and mom effectively, through conversations with the Village Health Workers Based

on the multi-day exposure. HCCRHP has captured the concept of commun.ty

»’ »

and holistic way - through education, hea.th, and child empowerment. With the
exception of a few quotes 1 have not ye, read anything by Paulo Freire, but 1 get the impression
h.s ideas about empowerment Uuoogb edocatf.n and htemcy are .mpiemented by CRHP to no. oniy

help citizens understand their surroundings, but also understand how to make transimma on
within their surroundings.

caved greenery, separation from the maddening traffic, and dean al. The bus ride from Bangalore

29

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was a relatively short and relaxing one - until we had to transfer buses in Kollegal. Every morning at
the Kempe Gowda [Majestic] Bus Station I witness from afar the chaos and insanity that takes place

when people board a bus, however, to have experienced this insanity first-hand, with luggage in
hand was an entirely different experience.

When we arrived in Hanur I was reminded of my grandad's village of Sosale. The bus stop was in

the midst of a commercial area - many little shops, buses, fruit and newspaper stands, a movie
theater etc. It was a lively environment, and despite it being the middle of the day I found the ratio
of males and females outside to be disproportionate - it is possible that this is because it was lunch

time and the women were women were inside their homes cooking. We spent the remainder of the
day at Holy Cross speaking with the sisters and gleaning information on the history of the CRHP
and formulating plans for the next few days. HCCRHP was established by Sister Aquinas in 1997 to
address the health and education needs of the most backwards villages in Chamarajanagar District.

The project evolved from a mobile medical unit and a few sisters randomly educating people in the
villages to the establishment of village health workers, self-help groups, income generation projects,

and a school for rescued bonded labor school children.

The morning of October 25th we arrived at the Satvidhya School for bonded labor children in

Prakash Palya, to attend a program that showcased former Satvidhya students who successfully
completed their year and had since then furthered their education. Satvidhya was started in 2004 by
Sisters Aquinas, Fidelis, Alfie, and Anise as a one year bridge program to get children back into the

formalized education system. Satvidhya is a residential school for rescued rural children who

formerlv did 'coolie' work to sustain their livelihood. 6 teachers in the school educate children in the
3rd, 5th and 7th standard. Their retention rate is about 50% because some children opt out of the

school and return to their families. Some children have trouble adjusting to a lifestyle and unfamiliar

environment without their parents and siblings. The building that houses the school is a former
hospital, however, medical services are still provided to community members who ask. Medication

is supplied by Tow Cost.

There are 14 acres of land surrounding the building where maize, paddy, peanuts, tomatoes, and

lentils are grown. Each child at the school is allocated a small plot of land for gardening. They are

also educated in animal husbandry, plumbing, and electrical works. Satvidhya also has an active

bakery that supplies local vendors with buns, biscuits, and cakes - all of which are delicious. Some

30

some products. In this way
students work in the bakery and are res;iponsible for the preparation of
the bakery provides some vocational training for some selected students.

In my first impression of the children at Satvidhya, I noticed a difference in their behavior compared
to other children I have visited in the pastjin an urban, non-bonded labor setting]. They appeared to

be more wary, less excitable, and more confident. As some time elapsed the children and I became
better acquainted and it turned out that they are versatile, excited, and curious - like all other kids I

have encountered.
A formal ceremony started off the program with a marching band, flowers, and lamp lighting

ceremony In addition, there was a cultural program with 4 student dances followed by speeches by

some of tire Sisters, Vinay, and former Satvidhya students. 1 found the student testimonials to be
moving; they demonstrated perseverance, maturity, and appreciation of the support system they

had had at the school. They encouraged the current students to stay strong through difficult times,
stating that tire success they would encounter in the future would be worth all of their hard work

they put in now.

The former student stories were very inspiring:
. One former student, Shivaraj, is studying his B.Com at St. Joseph's evening college in
Bangalore, while working at an office during tire day. He wanted to study at a Kannada

medium college, but the Sisters encouraged him to enroll in an English medium university.
When he gave his speech I noticed that his Kannada was very similar to mine, infused with

■

many English words.
Another girl who had studied at the school was currently studying to be a Nurse and

working at the Holy Cross Hospital in Kamegere.

From my limited exposure, I found that this program could cause very effective and sustamable

change within a community and within a society. I feel that it is easier to instill confidence and a
sense of leadership and confidence in children than it is in an adult. Additionally, tins type of
intervention can be effective in the eradication of biases relating to caste and gender.

That night we visited the site of a Weaving Income Generation Project in the village of
Chikkamalapura The project site has 16 women. Each woman sat on the muddy ground, without

31

any cushions or a backrest, and let her legs hang in a deep dug out hole in the ground. The weaving
equipment is stationed above the dug out hole and the women work in a pushing and pulling

motion to set the pattern. The work station is not ergonomic, and the women complained about back
aches. The women work from 9:30 in the morning to 6:30 in the evening. They go to their home for

lunch, and in the evenings, upon returning home they cook dinner. Most of the women are married
with children. The are paid Rs.15 for a mat that is 3ft by 1.5ft. On average they make Rs. 500 per

month. The materials [waste cotton] for creating these products are provided by organizations based
in Tamil Nadu. The facilitator of this project also receives a sum for his efforts. The project is situated
on land donated to this cause by the panchayat raj, in addition to Rs.100,00 for the installation of the

equipment. There are some women who have the weaving equipment installed in their own homes
through the help of a loan.

Following the visit at the Income Generation Project we stopped at the home of a Village Health
Worker. We met two workers who had been serving the community for XXXX years. The women

spoke about the financial situation of people in the village. Most women do coolie work and make
about Rs.60 each day.

When asked how the general health of the community has changed since the introduction of the
health workers the ladies agreed that there has been an improvement. Additionally, the village
health workers themselves felt that their knowledge base and confidence has risen since they have

been doing this work.

The following morning a village called Arbikare recently initiated a watershed project. Basuvaraju

from Holy Cross stated that he had spent 2 years building rapport with the people in this village. It
took a relatively long time for him to get acquainted with the community because it is infused with

casteism, and therefore not open to new people joining. After building rapport, Basuvaraju began to
educate landowners in the village about the principles of efficient water management, prevention of

land erosion and rain water harvesting. He said that some landowners were initially resistant to the

new methods of farming, but they were convinced when they saw results after implementation. The
project will take about 5 years before results can be seen. Some issues regulating the issue of land is

that many landowners do not have records proving possession due a fire that burned out the
registry. Back-up deeds are stored in Tamil Nadu, but they are not signed.

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That evening Deepak and 1 attended two Self Help Group meedngs. The first meedng was in a
village called Chikallur. The SHG meets once a week in the evenings. There are IS women in the
self-help group and most of them do coolie work to sustain their livelihood. Any money they

.node toward, savings is documented in the accounts book. The documentadon tat took place

during this meedng was very comprehensive Ou, attendance was recorded and we had to sign the

i

book to verify tat we were present at the meedng. The womens' bank account books were

maintained by the record keeper - who is paid a small sum for her services. The women collechvely

look out a loan to help them cover some incurred expenses. One woman needed money for paymg
her child's hospital bill. Due to the lack of available services at the government hospital she bad to
travel to Bangalore and pay for services at a private hospital. The loan that they are currently

repaying has not been provided at a subsidized interest rate. The women in this SHG appeared to be
frustrated and not fully informed about services offered by the government, such as Yeshaswmt.

The second SHG we visited in Rajappajinagar offered a different perspecdve. This group with 16

women appeared to be more acdve and well-informed than the previous group. This pardcular SHG

had received their second loan, which was subsidized, and the money was used towards building

toilets in their homes and lor the start-up of small businesses. The women were knowledgeable
about ta Yeshaswini scheme and what needed to be done in order to receive those benefits.

Generally, I was struck by the strength of the women in each of these groups. They were outspoken
and bold and seemed comfortable with their responsibilities and very capable of handing much
more. They also seemed frustrated that they were not able to fully spend their energy towards one

cause because of daily duties to feed themselves and their children.
Ata ta SHG meelmg. we visited the home of e village health worker. I.daymar.mma hves with

her younger brother and his wife and has worked as a village health worker for 8 years. She ,s from
the taiga Tribe. J.d.ymaramma ha, never been married and does not have any children, whtch ts

why she believes she ha. been able to continue this work for such a long period of time. She slated

drat the other women who were village health workers were not able to commit to the position tuily
because of their family responsibilities She was very proud of her position in the village and
enthusiastic about helping people when the need atas. When asked if she encountered any

discrimination in the community, J.daym.r.mm. stated that people were initially skepbeM about

her services - p.tally due to caste issues - she was not allowed inside their homes, bo, that over

tire course of time drey began to approach be, with goosdons and access to resources. She also told

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me about several deliveries that she had conducted because it was not possible for the patient to get

to the hospital in time, due to the absence of transportation. In addition to being a village health
worker and a member of a self-help group, she is also involved in an income generation project that

builds furniture from sticks.

Women in the project collect sticks from the forest for a few days at a time, boil the sticks in water to

shed the bark, and begin to build the furniture. There is a systematic schedule for the production of
this furniture. They build sofas, chairs, and bookshelves, and upon completion, the furniture is sold
in exhibitions.

I learned many different components of contributing to the betterment of health in communities in
Hanur and the surrounding villages. Speaking with community members it is evident that positive

change has taken over time. Although these efforts are extremely important I feel like a more

aggressive effort needs to be undertaken to target problems at the root cause. The impact of
globalization is taking place at the rapid speed and in order to keep the rift between Bharat and

India from getting wider I feel that a more aggressive effort needs to be undertaken. We have to

implement proactive measures at the root cause while simultaneously targeting existing symptoms.
From my learnings so far I see that NGOs and CSOs are doing tremendous work in picking up the

government's slack. It frustrates me to think that some effort by the government to provide for its
marginalized population could be miraculous for a large part of India's population - especially
when resources are available - but that time and money is allocated in areas where there is not as

much urgency.

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i

Chennai and Cuddalore Trip November 15 - 17, 2007

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Background

My interest in visiting Tamil Nadu stemmed from a conversation with Rakhal about environmental
health initiatives currently in action at various sites in Tamil Nadu. Community Health and

Environmental Skill Share [CHESS] works in four different sites in Tamil Nadu including
Cuddalore, Mettur, Kodaikanal and . CHESS is a process which serves as a platform for bringing

many of such affected communities together with the activists, the doctors and scientists to
deliberate and share experiences, skills and resources.

Reflection

The trip to Chennai opened my eyes and mind to a reality I would not have been able to
comprehend through readings, videos, and discussions alone.
Day 1 of the visit began at Bala Mandir in T. Nagar, an orphanage that shelters children while

dealing with issues of childcare, family welfare, educational, vocational and rehabilitations

programs. The children are admitted when they are under the age of 5 and cared for until they are
ready to be rehabilitated into society. In some cases Bala Mandir has also financed the education of
its former students at a college level. Bala Mandir operates on funding made by individual donors.

The campus hosts several different organizations including a primary school for children from low
income families and the Madhuram Narayan Center for Exceptional Children.

Upon our arrival at Bala Mandir, we met with Ms. Maya Gaitonde, who heads the parenting
program. The Bala Mandir Resource Centre is a nodal point for knowing more about parenting and
childcare, Among the various teaching and parenting aids available are books in various languages,

recommended by the Maharashtra and Andhra Pradesh Governments for use in anganwadis. The
main focus is in on children below six years of age to identify disabilities at an early age. The

program uses a holistic approach; P.A.R.E.N.T. includes participation from Papa, Amma, Relatives,
Environment, Neighbors, and Teachers. The program is rooted in Canada and has been adopted in

Tamil Nadu and Maharashtra in 2004. Information booklets have been illustrated according to local
culture and translated into the respective languages.

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Following our brief meeting with Mrs. Gaithonde we toured the Bala Mandir facility. We began in
the infant section. There are no more than 9 babies at the orphanage at one time. Bala Mandir is
contacted by local hospitals when patients opt to put their child up for adoption. The facility was

clean and the babies were happy and cared for well. Two women are always present in the facility to
atch the children. Each infant had his/her own cradle, was fed whole milk and dressed in sky blue
shirts. Toddlers, dressed in red shirts are situated in the adjacent room. There were 8 toddlers who

were cared for by 2 women, and each child had his/her own crib. The building also housed children

from the age of 2 to 5.

I .ater, we visited a primary school attended by on-campus residential students, as well as children

who s parents work in the informal labor sector. The school fees are minimal and the education is
good quality, and incorporates technology and the learning of the English language.

In the same building is the Madhuram Narayan Centre for Exceptional Children [MNC]. Established
in 1989, it provides early intervention for children with developmental disabilities starting from

birth to the age of 6. Some disabilities include Autism, Cerebral Palsy, Down Syndrome, and
Attention Deficient Hyperactive Disorders. The program actively involves a parent of the child to

help him/her better understand the child's conditions so he/she can help the child in the best way

to integrate into mainstream society. MNC has a rounded staff consisting of Pediatricians,

Psychiatrists, 1 herapists, and a Geneticist. The program focuses on 5 areas: Motor, Self Help,
Language, Cognition, and Socialization. The school is highly organized and the level of involvement

and attention given to each child is phenomenal. The space is divided into the sections by condition.

The school was bustling with the activity of parents, children, and other caretakers. Aside from the

care provided to children, parents and caretakers are also offered a therapeutic outlet through yoga.

After our tour of Bala Mandir we headed to Besant Nagar to meet Dr. Suchitra, a teacher at The

School - Krishnamurti Foundation. She spoke with us about her involvement in environmental
improvement efforts through the Consumer and Civic Action Group. Some of her projects have
included:

1. Medical Waste Management - surveying and training of government hospital facilities to
install and utilize environmentally friendly waste-treatment mechanisms. They have been

implemental in establishing waste management regulations; however, the ubiquitous

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]

problem of sustainability persists. How does one bring about accountability ,„ the private
sector hospitals when it is non-existent in the public sector?

2.

Blood Bank Regulation System
street Pood Vendor Pro)ee> - an .U-Indi. project to ensure a hygienic shmdard through the

3.
establishment of a licensing system.
4. Consumer Education in Schools and the b.nnmg of junk food in schools and p.ov.smn of

free lunch in government schools.
U- ■ ncHna a nroiect to create regulations about minimal nutrition that
In the future she is interested m initiating a p j

should be offered to children in schools and orphanages.
The most emotion.ily tw.shng hme of

trip took place fre follow,ng day. We went to Cuddle

B Visit the State industries Promotion Corporation of Tamil Nadu, mfmnously known as SIP
According to its website, "SIPCOT is a fully government owned premier .nshlutron, es a ,s e

1972. ha. been a catalyst the development of small, med,urn. and large scale mdustnes ,„ am.
Nadu."

My understand ol SITCOT: an area of land allocated to private industries for the nranufaetunns

products that emit red-level hazardous loams. This is an area that is supposed to be quar.nhne ,
tut is not because the govermnent can charge Rs.20 Lakhs per acre to private indushtes. who are

seeking out land, for exploitation and dump,ng of waste in a unregulated and unaccoun.ab e

numnor. A capitalistic industrial lawless utopia where there is otter disregard for ^u™“„d„g

people, flora, and fauna. A place where emission, are uncontrolled and nnqueshoned by the

.

and the sea serves as a convenient garbage for manufacturing waste.

One objective of SIPCOT listed on their website [www.sipcot.com] states:

-SIPCOT has rendered fruitful services to the state by identifying, developing, mamtammg
industdal areas in backward and most backward tah.kas of the Slate, which had potenhal to grow

This, I find ironic.

The industrial complexes:
1. do not hire inhabitants of the neighboring villages because
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a.

they fear unification of people against a common problem (i.e. environmental rape)
caused by the industries, which can potentially derail their operations

2.

therefore, hire financially vulnerable and desperate migrants from other parts of India as
daily wage laborers

3.

emit detectable [and undetectable] toxins that have damaging health effects on neighboring

communities, therefore, the "eventual growth of a backwards community" will be a benefit

only as long as the surrounding population does not die off from industry emissions.

Our visit was facilitated by the Cuddalore District Consumer Protection Organization, which is

under the umbrella of WECAN [Women development. Environment protection and Consumer].

Arul, our tour guide, is a consumer activist responsible for working the training and outreach in the
Community Environmental Monitoring project in tire villages neighboring SIPCOT. He has been

I

involved in this project since its inception 4 years ago. We drove around the industrial area in a

rickshaw and were exposed to the scents of a wide array of emissions. Documentation of these

smells is done on a regular basis, through a method which likens the emission smells to something

familiar, such as nail polish, rotten cabbage, eggs, and even a dead body.

The emissions penetrate all communities evenly because of constantly changing wind direction. No

one is spared. Air samples are collected by community activists through the usage of simple
contraption [like a plastic bucket with a valve and plastic pouch to collect air] and sent to a lab in

California. Based on the study of these samples, the results yield that that according to the U.S.
Environmental Protection Agency's guidelines the level of toxins present in the air around
Cuddalore is 4000 times higher than the 'acceptable level' in the United States. This data is then

presented to the Pollution Control Board so that action can be taken to regulate these industries,

however, this has not yet been effective in implementing any massive change. As a result, the PCB
makes compliance visits to the industries, but since they are scheduled in advance, the factories can

cleverly adjust their emission output to a less detrimental level. Additionally, the greatest
concentration of toxins is emitted at night, when PCB employees are not working.

Another problem posed for Community Environment Monitoring is that data collected has the likely
possibility of being dismissed as 'unscientific' or 'unofficial'. Unfortunately, there is no independent

environmental research facility in India or even an [effective] India version of the EPA which is
equipped to take on the task of non-partisan sample analysis. Clearly, the PCB is not working out.

38
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Speaking with a farmer and fisherman about the condition of life in a Cuddalore village highlighted
the fact that this is the bane of their existence. Lands have become infertile and tire number of fish in
the sea has decreased. People have been forced to seek out new occupations and find alternative
means of income to sustaining their livelihood.

An interesting point to consider is that some villagers are employed by the factories, causing a
conflict of interest in the Community Environmental Monitoring effort. This creates a rift between
community members who are fighting to improve the condition of the overall environment and
those who are committed to the goal surviving on their daily wage day to day - therefore,

accomplishing industry's goal of thwarting a "united we stand" approach to promote a "divided we

fall" sentiment. In addition, caste and internal politics is another factor that further solidifies tins
dysfunction.

We learned of periodic 'health camps' which are set up by tire industries, advertising specialized

care for the community members. This, however, [I was told] is a farce. Providers present at these
camps are not qualified to handle the cases presented, therefore appropriate medication is not

provided. Even if the cases were identified the B-Complex and expired medicines available at these
camps would not be an effective treatment. Clearly this is an effort of false social responsibility.

Describing my day at SIPCOT as "eye-opening" would be a huge understatement. I'm appalled and

discouraged by the power of money that drives people to abuse and destroy a world that has been
so good to them. My meetings with Nishi and Madhu at the Corporate Accountability Desk the

following morning nicely consummated the brief learning experience about S1PCO1.

I found the conversation with Mahdu to be very interesting when she was speaking about the
trouble she has had so far with the Right to Information Act, and the hostility she has faced as

activist, and the law suit that is pending as a result of it. People from these private industries have
called CAD to enquire about her background and to threaten her because of the work she is doing.

Her fight against SEZs sounded fascinating. Hearing about the premeditated process of preparing

I

the dysfunction of [formerly] perfectly fertile land by private industries - by covertly cutting off

water and electricity supply -10 years prior to acquiring it for manufacturing purposes was
shocking. It gave me a very direct perspective of the hardships faced by activists and the relentless

effort people are willing to put towards a cause they believe in.

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I learned a great deal from my trip to Chennai. I am extremely grateful to CHC for providing me

with the opportunity to witness these difficult realities in a guided manner, and for providing me

with the resources to learn and question why the situation in India is the way it is today.

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National Bioethics Conference - December 6,7,8 2007

The 2nd National Bioethics Conference took place December 6th, 7th, and 8th, 2007 at the National
Institute of Mental Health and Neurosciences Convention Center (NIMHANS) in Bangalore.

The National Bioethics Conference (NBC) is a "broad, multi-disciplinary, independent, participatory
and national bioethics platform of the Indian Journal of Medical Ethics (IJME). The Organising
Committee (OC) of the Second National Bioethics Conference is constituted by 38 institutions and
organizations, including Bangalore Medical College, St. Johns National Academy of Health Sciences,

Community Health Cell, PSG Institute of Medical Schines, Vydehi Institute of Medical Sciences,
Christian Medical College and Hospital, NALSAR Law University, and Christ College.

Approximately 500 people from all over India and internationally gathered for the 3-day event to
understand the various dimensions of health issues, especially the ethical aspect, as being an

important step towards beings a caring, responsible, and considerate healthcare professional.

The main theme of NBC was to address the Moral and Ethical Imperatives of Health Care
Technologies - the scientific, legal and socioeconomic perspectives on use and misuse.

Conference sub-themes included:

• Technologies in medical practice

• Research on health care technologies
• Health care technologies, public health and policies

The NBC was kicked off with a day-long event of the Students Bioethics Forum on December 5th
2007. More than 160 Students from 10 different colleges with multi-disciplinary background in

Bangalore celebrated "SOCH".

"SOCH", which means "to think" in Hindi, was organized to provoke students to reflect, debate and
understand issues of ethics in healthcare. It was organized under the broad canvas of 2nd National

Bioethics Conference to initiate and sensitize students to the vital issues of health and health care

ethics, which they would be encountering in their professional life. The students understanding of

bio-ethics was facilitated through their participation in various cultural and social events including
Debate, Mad Ads and an Art contest consisting of painting, cartooning and collage designed to
stimulate their thinking on ethics in health care.

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Over the course of 3 days I attended several workshops:

Women and Health

Issues discussed during this session included:

■

Sex Selection among South Asian immigrants in the United States by Sunita Puri

■

Ultra-sound and sex-determination in Australia

I learned a lot from the presentation by Sunita Puri, which touched on the topic of the prevalence of
sex-selection in the South Asian communities of New York and New Jersey. Pre-natal and pre

conception methods of sex-determination are illegal in India but legal in the US, therefore used by
some South Asian immigrants as a tool for preference.

Sunita presented her findings based on semi-structured interviews of South Asian women and men
aged 19 to 65 who utilized sex selection clinic services; second-generation South Asian youth who

grew up in families where sex selection was practiced; physician-providers of sex selection; and
primary care physicians who had encountered requests for sex selection among their South Asian

patients. Most of the couples who had been interviewed had female children, but wanted a male
child, they felt their practices were ethical. On the other hand, however, primary care physicians for

South Asian families argued that these services were unethical.

A presentation by Victoria Loblay who discussed ultrasound and sex determination in Australia

painted a different picture. Ultrasounds in Australia are not used to determine the sex of the baby as
much as they are used to ensure good health of the fetus. Given that, there is no regulation of the

practice of sex-determination during routine scans. Generally, individuals are satisfied with the
baby's sex no matter what it is.

Developing a South-North Advocacy for agenda for effective clinical trials: Indian and European
Perspectives

Leontier Leterveer from the WEMOS Foundation spoke of health care as a right. The WEMOS

Foundation aims to strengthen national health systems that contribute to the structural
improvement of people's health in developing countries. They do this by targeting politicians and
lobbyists to influence the health budget, medicines, and human resources. Some European

pharmaceutical companies test their drugs on subjects in developing countries because of lax

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regulations, less expenditure and accountability. Eastern European, Asian, and Central American

subjects living in poverty tend to be the pursued and willing participants because often drug testing

is the only type of treatment they receive. Often subjects are not informed that they are being tested
because fewer people would be willing to participate. 40% of these clinical trials are conducted in

non-traditional areas, as there is no recognized and supervisory regulatory body.

For instance, STENT produced a device that was tested on Indian patients in a Mumbai hospital.

When in trouble for this, the health minister in the Netherlands said that it is the responsibility of the
Indian government to regulate the testing company. STENT was let go with no consequences.

Additionally, Mr. Prathap Tharyan from the Christian Medical College, Vellore, spoke about

prospective trials registration, a central database to record past, current, and future clinical trials, the

negative and positive effects.

My knowledge about Bioethics prior to NBC was limited to an association with stem cells, embryos,

and end-of-life decisions. Following the conference I felt overwhelmed by the range of information I

had acquired about ethics in regards to the health care: the ethical including legal, social and

philosophical. I found the sessions on IPR, Pharmaceuticals and Trade to be technically out of the
scope of my current knowledge-base. Nonetheless, it was interesting and fitting to my future plans

of learning about how decisions made at the macro-level impact those at the community-level.

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Media: Lakshmi E. Prasad 2007-FR 24.pdf

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