Vinay Viswanthat - CH Fellowship Report.pdf
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SIR RATA N TATA FELLOWSHIP IN
C OM MU NIT Y HEALT H
Sep-2004 to Nov-2005
REFLECTIONS AND REPORT
By
Vinay Viswanatha
MENTOR
Dr.Thelma Narayan
Community He alth Ce ll (C HC ),
BANGALOR E
TABLE OF CONTENTS
TABLE OF CONTENTS
2
ACKNOWLEDGEMENTS
6
PREFACE
8
SECTION.1.
MY FELLOWSHIP IN A NUTSHELL
10
THE BEGINNING OF THE JOURNEY….
10
A SHORT ACCOUNT OF MY JOURNEY THROUGH FELLOWSHIP:
12
EXPERIENCES & LEARNINGS DURING THE RATAN TATA FELLOWSHIP IN COMMUNITY
HEALTH UNDER ‘COMMUNITY HEALTH CELL’
13
FIELD EXPERIENCES:
13
TEACHING & TRAINING EXPERIENCE:
18
RESEARCH EXPERIENCE:
18
CONFERENCES & WORKSHOPS:
19
A REFLECTION AT THE END OF THE JOURNEY & A GLIMPSE OF MY FUTURE PLANS:
21
ANNEXURE NO.1. STATEMENT OF OBJECTIVES
25
SELF APPRAISAL OF THE PROCESS OF REALIZATION OF MY LEARNING
OBJECTIVES
29
ACADEMIC DEVELOPMENT:
29
PERSONAL DEVELOPMENT:
36
SWOT ANALYSIS OF CHC FELLOWSHIP IN COMMUNITY HEALTH
38
STRENGTHS:
38
WEAKNESS:
41
OPPORTUNITIES:
41
THREATS:
42
2
SECTION. 2.
TO ‘SEARCH’ IN SEARCH OF KNOWLEDGE, INSPIRATION….
43
BACK GROUND:
43
THE PROCESS OF LEARNING IN ‘SEARCH’:
43
LESSONS LEARNT:
45
CONCLUSION:
45
ANNEXURE No.1. MY REPORT AFTER FIRST WEEK IN ‘SEARCH’
47
ANNEXURE No.2. CASE STUDY OF ‘TRIBAL MALARIA CONTROL PROGRAM’
UNDERTAKEN BY ‘SEARCH’ IN 36 TRIBAL VILLAGES OF GADCHIROLI DISTRICT OF
MAHARASTRA
52
ANNEXURE No.3. REPORT OF MY WORK IN SEARCH DURING LAST ONE WEEK (14-12-2004 TO
20-12-2004)
87
ANNEXURE NO.4. LETTER OF GRATITUDE
89
TSUNAMI RELIEF WORK- A BRIEF REPORT OF THE FIRST TEAM FROM
CHC, BANGALORE
91
BACKGROUND:
91
PLANNING THE RESPONSE:
92
ON THE ‘MOVE’:
93
IN ACTION-AID, CHENNAI:
94
IN THE ‘FIELD’:
95
OUR FIRST-DAY AT WORK:
96
DIALOGUE WITH THE COMMUNITY & THE PROCESS OF COMMUNITY BUILDING:
101
HEALTH RELATED WORKS:
ANNEXURE NO.1. THE LIST OF TEAM MEMBERS & THEIR DETAILS.
ANNEXURE.NO.2. CHECK LIST OF ESSENTIAL ITEMS.
102
105
108
REPORT OF ‘A MEET WITH TSUNAMI DISASTER RELIEF DOCTORS FROM
BMC’ ORGANISED IN BMC
109
PREFACE:
109
PARTICIPANTS:
110
OBJECTIVES OF THE MEET:
110
THE ‘MEET’ PROPER:
111
ISSUES THAT EMERGED FROM THE MEET:
112
CONCLUSION:
APPENDIX 1. DETAILS OF VILUNTEERS
112
113
3
DETAILS OF VOLUNTEER FOR SECOND TEAM THROUGH COMMUNITY HEALTH CELL
(6.1.2005)
115
ANNEXURE NO.2. NOTES FROM ADDRESSES OF DIGNITARIES
117
A BREIF REPORT ON VISIT TO TWO VILLAGES ON INVITATION BY RURAL HEALTH
DEVELOPMENT CELL OF TVS FACTORY IN HOSUR
BACKGROUND:
PURPOSE OF THE VISIT:
THE VISIT PROPER:
OUTCOME:
CONCLUSION:
ANNEXURE NO.1.PREPARATORY DISCUSSION WITH Dr.THELMA NARAYAN
ANNEXURE NO.2.VISIT TO KOTHAGONDAPALLI ICDS PROJECT
ANNEXURE NO.3.THE DIALOUGE PROCESS AT ANDIWADI WITH EXPECTING &
NURSING MOTHERS OF BOTH VILLAGES
120
120
120
120
121
121
122
123
125
PROJECT PROPOSAL FOR ASSESSMENT OF NUTRITIONAL STATUS OF CHILDREN (06YEARS) IN 6 VILLAGES IN HOSUR TALUKA
AIM:
OBJECTIVES:
THE PROCESS:
ASSESSMENT PHASE:
COMPONENTS OF THE ASSESSMENT PHASE:
128
128
128
128
129
130
QUESTIONNAIRE FOR ‘KAP’ STUDY OF CHILD FEEDING PRACTICE
Section A. GENERAL INFORMATION
Section B
SECTION.C.WEANING
133
133
135
138
CASE STUDIES OF MITANIN PROGRAM
140
CASE STUDY 1:
140
CASE STUDY 2:
140
CASE STUDY 3:
140
CASE STUDY NO. 4
141
CASE STUDY NO. 5
142
CASE STUDY NO.6:
143
CASE STUDY NO.8:
144
CASE STUDY NO.9:
144
CASE STUDY NO.10:
145
CASE STUDY NO.11:
146
CASE STUDY NO.12:
146
CASE STUDY NO.13:
147
CASE STUDY NO.14:
148
4
CASE STUDY NO.15:
148
REPORT OF THE WORKSHOP FOR PRIMARY SCHOOL TEACHERS ON
‘WATER & HEALTH’
150
BACKGROUND:
150
THE WORKSHOP:
151
OBSERVATIONS:
152
‘SWOT’ ANALYSIS:
Strengths:
Weakness:
Opportunities:
Threats:
153
153
154
155
156
STUDY VISIT TO ‘HCCRHP’ – A REFLECTION
157
BACKGROUND:
157
THE PROCESS & THE EXPERIENCES:
158
MY LEARNINGS:
161
SECTION.3.PRESENTATIONS
MEDICAL EDUCATION IN KARNATAKA – A CRITICAL REVIEW
TSUNAMI RELIEF WORK- REFLECTIONS IN THE PERSPECTIVE OF
DOCTORS
CONCEPTS FOR HEALTH AND DISEASE- NOTES FOR REFLECTION
5
ACKNOWLEDGEMENTS
This report of fellowship is the first person account of a dream of a young person by
name Vinay (myself). There are wonderful people and ideas in this world that made
this dream come true for me. I would like to thank all of them, in particular:
The team at CHC, for having provided me with the one of the best learning
opportunities in life and making my stay in CHC a memorable experience. If not for
this fellowship, I can imagine myself working my brains out their in the rat race for a
seat in postgraduate medical education. Thank you CHC and team for all the
experiences in the last one year.
All my mentors for their guidance and inspiration. Particularly I would like to thank
my mentor, guide and friend Dr.Thelma Narayan. It was her patient guidance,
incisive critique of my works and the opportunities that she provided me with
during the fellowship period, which have played a crucial role in the success of my
fellowship period. It was also her encouragement and honest appraisal of me as a
fellow that has helped me to shape myself into a responsible professional. Thank you
very much Madam.
All the team members of various organisations and movements- my learnings have
to be greatly attributed to all of them whom I visited and interacted as a community
health fellow. Thank you very much.
All my co-fellows and friends- old and new- for making my experience a pleasant
one and for providing me with that much needed support at times of confusions and
for sharing my happiness as their own.
All those powerful thinkers and community health practitioners- past and present for giving me with ideas and framework to build upon and making me believe that
‘another’ world is possible.
My parents- For that unflinching belief in me in spite of the uncertainties that
haunted their minds regarding my future.
Sir Ratan Tata Trust- For their vision to finance such a scheme and providing the
young minds like myself an opportunity to learn those invaluable lessons in the field
of community health.
6
Dr.Ravi Narayan and Dr.Abhay Bang- The two inspirational figures who have left
an indelible mark in my life and for whose life I look up to for that fire and passion.
All the communities with whom I interacted as a fellow- Most importantly, I extend
my heartfelt gratitude for all the community members with whom I interacted with
for sharing their wisdom and traditional knowledge and for providing me an
opportunity to have a quick look at their lives and understand community and its
dynamics in a better form.
7
PREFACE
I am writing this introductory part of my report for the benefit of all potential
readers of this report to help them with navigate through my report in an effortless
manner.
First of all, I would like to stress on the fact that the report is a ‘first person’ account
of my fellowship experiences and hence the term ‘I’ appears very prominently and
not to the effect of me being an egotistical person. I request the readers to keep this
fact in mind before they make any personal decisions on the reporter i.e. ‘me’.
Section 1 of my report is a first person account of my personal reflections on my
fellowship. It deals with the circumstances under which I joined the fellowship
scheme, my learning objectives and their self-appraisal. It also describes a short
account of my journey through the fellowship. A short ‘SWOT Analysis’ of the
fellowship period is also included with a hope that it would aid CHC and Sir Ratan
Tata Trust to make the fellowship even more robust.
Section 2 of the report deals with the detailed accounts of my experiences as a fellow.
The experiences are presented in a chronological order and most of the reports were
produced at the end of each experience. Hence, these reports deal with both
technical and personal learnings during each fellowship experience. The report on
my experiences as a research assistant of ‘external evaluation team on Mitanin
Program’ is incomplete. This is due to the fact that I am not ethically permitted to
divulge many details as a part of research team in individual capacity. Hence I have
restricted myself to certain case studies I did, with the details leading to person and
place being blocked out. Apart from this chapter, I have tried to be as detailed as
possible while presenting the reports.
Section 3 of my reports includes few of the presentations I made in various forums
whose details have been given in the concerned reports in section 2.
8
However, I acknowledge that my report is not a comprehensive report in terms of all
the activities I undertook as a fellow. There has been an intentional omission of a few
of the experiences as most of them were really short experiences and hence, I felt
they did not warrant a full report.
I hope the report will be of some help to anyone who goes-through it, especially for
the potential fellows. I would be most satisfied if the report succeeds in stimulating
the readers to ask questions, even if the questions pertain to the sanity of my report!
For, the greatest learning of my fellowship has been in inculcating the sense of
‘ENQUIRY’ and ‘QUESTIONING’!!
9
MY FELLOWSHIP IN A NUTSHELL
THE BEGINNING OF THE JOURNEY….
To say that Community Health was ‘the subject’ that enthralled me during my
medical college years would be a blatant lie. I was also interested in Pediatrics. As
my ambition written in Epistyle of 1998-99 batch of BMC points out, I first wanted to
be a Neonatologist and then in the long run the Director General of WHO (I am
rather overtly ambitious!). Hence it is with some nostalgia that I recount my
background and circumstances that led me to take-up the fellowship scheme.
The end of Internship, the ‘honeymoon period’ in a medical student’s life, was very
tumultuous and stressful. Having been graduated as a doctor, we were thrown into
the ‘real world’. The lives of medical students took a bizarre turn and were stripped
off the personal, financial and professional security of the student life. The world
became a rat race for that coveted PG seat in a credible institution. The parental
pressure to settle down early, the societal pressure to earn that ‘degree’ and the
professional pressure to choose ‘the right specialty’ (read high-paying specialty)
bordered on vulgarity. At the same time, the lure of distant lands was something
irresistible. The debates of the futility of a medical practice in India and the obstacles
to move to a western nation in hope of superior education and life style seemed
never-ending. Under such immense pressure, it was the collective decision of some
life long friends that persuaded me to decide to pursue higher education in USA.
However, there was a confusion that remained unresolved. I was torn between my
love for children and clinical practice and my equally strong passion towards
Community Medicine. However the wanderlust in me tilted the balance towards
Community Medicine and I solaced myself by deciding to concentrate on child
health within the broad field of community medicine.
As a result of the above somewhat ill-informed and quirky decisions, I registered for
the GRE examination as the first step towards pursuing a MPH degree in USA.
Coming from a family without a ‘last name’, my registration went haywire and I
ended up being registered and called as ‘Dr.Vinay Viswanatha No Last Name’ in the
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records. I was infuriated. Not just on loosing my money but more importantly on the
absurdity and the brazen impetuousness of the authorities.
It is under these rather peculiar circumstances that I decided to postpone my studies
and gain some experience in the field. I also thought that a stint in the field would
reflect better on my application and some good recommendation letters would help
me to get an admission in a good college. When I began my search, CHC was the
only name that popped up after my exhaustive enquiries with my post graduate
seniors in the department of Community Medicine in BMC and few professors in
various colleges across Bangalore. This made me remember my earlier encounters
with CHC staff, in particular Dr.Ravi during one of the program they had organized
in BMC auditorium. I vaguely remembered the short talk I had with Dr.Ravi in PHM
office and the elated state henceforth the talk.
All the above factors forced me to call Dr.Ravi and fix an appointment with him. I
can still remember that fortuitous day. What was supposed to have been a 30 minute
meting went on for more than 90 minutes. I was mesmerized by Dr,Ravi (Later, I
came to know that it was also my interview). I was transformed to a fantasy world
listening to him. I was informed about the fellowship program and the procedures
for applying. I was asked to come prepared for the fellowship interview with a
formal application articulating my interests in Community Medicine. It was rather
tentatively that I wrote my statement of objectives1. When I met Dr.Thelma Narayan
for the interview, I was apprehensive to say the least. However, the interview turned
out to be a pleasant affair and I felt that I was discussing with one of my friends
about my life and future rather than giving a formal interview for a fellowship. The
interview with Dr.C.M.Francis, though technical, was very enriching. By the time I
finished my interviews, I was looking forward to join the fellowship and the wait for
the call felt like one of the longest waits of my life. I was worried since I was
informed that the fellowship for the season had already started and I was coming in
at an irregular period. However, I had my fingers crossed since I knew my
interviews had gone well and was informed by Dr.Thelma Narayan that there were
few openings always kept for people coming at odd periods like me.
1
Annexure No.1. Statement of objectives
11
And then, my wait turned out to be fruitful. I was informed about my selection and I
started my journey in the new path of life on 6th September 2005. Initially I joined the
fellowship for a period of 6 months which was later extended for 1 year.
Retrospectively, I feel that it turned out to be the watershed event of my life. This I
say because, the fellowship has completely changed the course of my life, both on
personal and professional fronts, the changes being the focus of all my reflections in
this report. The journey in the new path was thus initiated.
A SHORT ACCOUNT OF MY JOURNEY THROUGH FELLOWSHIP:
I was guided by Dr.Thelma Narayan, my mentor through out the journey. It was
with her guidance that I drew out the learning objectives2 for my fellowship period.
The plans for the fulfillment of the same can be greatly attributed to Dr.Thelma who
provided me with countless opportunities and kind guidance for the realization of
the objectives.
The journey through my fellowship period has been an eventful one filled with
moments of ecstasy and agony, moments of great hope and equally strong despair
but singularly for its value in terms of diverse learning experiences it provided me
with at every moment. The journey in professional terms has facilitated me to move
through various phases starting from Preventive and Social Medicine then through
Community Medicine later through Community Health afterwards through the
Public Health and finally through New Public Health. Simultaneously on the
personal front, the journey has been more turbulent for it made me question
everything that was held sacred and inviolable in the deepest recess of my psyche.
The journey of fellowship has opened a new vista and I believe that my life course
has been altered in an irreversible way.
The following pages give a quick glimpse of various activities I undertook as a
fellow of community health:
2
Annexure No.2. Learning objectives of my Fellowship
12
EXPERIENCES & LEARNINGS DURING THE RATAN TATA FELLOWSHIP IN
COMMUNITY HEALTH UNDER ‘COMMUNITY HEALTH CELL’
PERIOD: I year (From September 2004 to November 2005 including a month
long study leave)
MENTORS AT COMMUNITY HEALTH CELL:
Dr.Thelma Narayan (Chief mentor), Coordinator, CHC.
Dr.Ravi Narayan, Global Coorinator, People’s Health Movement
(PHM).
Dr.C.M.Francis: Consultant, CHC.
Mr.S.J.Chander; Mr.Rajendran; Mr.Naveem Thomas- Technical Staff of
CHC
FIELD EXPERIENCES:
SVAMI VIVEKANANDA HEALTH MOVEMENT, HD KOTE, KARNATAKA:
1 week, as an exposure to Community Health Project
Exposure to mobile health services for 30 hamlets of displaced tribal
population
Observations:
1. Operation of a low cost community based hospital services
2. Organization of field based Reproductive & Women’s Health Services
3. Operation of Sanitation & Hygiene program in 100 schools
4. Operation of school & community development training catering for
more than 20000 displaced tribal population
SOCIETY FOR EDUCATION, ACTION & RESEARCH IN COMMUNITY HEALTH (SEARCH),
GADCHIROLI, MAHARASHTRA:
1 month
Mentors: Drs Abhay & Rani Bhang & the team in SEARCH
Undertook a case study of ‘Tribal Malaria Control Program’ undertaken by
‘SEARCH’ in 36 tribal villages of Gadchiroli District Of Maharashtra
Observations & learnings:
13
1. The contours of the practice of community health in field with all its
joys & sorrows particularly the ideas of Community Participation &
Community Empowerment which are ‘the’ critical factors in success of
any public/community health initiative.
2. The concept of ‘action- research’ in community health by perusing the
literature on ‘Daru Mukti Andolan’ (Movement for ban on alcoholism)
which resulted in the ban on sale & use of alcohol in Gadchiroli district.
3. The concept & philosophy of Community Health Workers scheme by a
small study of CHW scheme in 36 tribal villages undertaken by
SEARCH.
4. Community partnership & the need for having sensitive attitude
towards community through study of tribal friendly hospital initiative.
5. The power of original idea & people centric research in Community
Health through my exposure to ‘Home Based Neonatal Care’, a
revolutionary concept in community based child health services.
6. The importance of comprehensive strategies to address socials
problems by participating as an observer in ‘Alcohol deaddiction
program’, both field based & institution based, which boasts of one of
the highest ‘one years sobriety rate’ in the world.
7. The importance of catering to the ‘felt needs’ of the community
through the Sickle Cell Anemia Study in Gadchiroli by SEARCH,
which was a success in scientific community but a failure in the
community for whose benefit it was done.
‘MITANIN PROGRAM’ IN CHATTISGARH:
45 days
Mentors: Dr.Sunil Kaul, MBBS, MPH; Dr.Rajani Ved; Dr.Shyam Ashtekar,
MBBS; Dr.Rakhal Gaitonde, MBBS, MD; Mr.Amulya Nidhi; Dr.Deepti
Chirmuray, MBBS,MD
14
Was involved in the External Evaluation of Mitanin Program3 undertaken
through the coordination of CHC on the request of State Health Resource
Centre, Chattisgarh, Government of Chattisgarh & Government of India.
As a research assistant I was involved in the formation of methodology of
evaluation, development & field testing of the questionnaires, documentation
of various case studies related to the program, & was the contact point for the
group of investigators who came in at different point of the study.
In addition, I accompanied 4 investigators at different periods to 8 out of the
12 blocks in our sample & hence had an extensive experience of the program
across the breadth of the state.
TSUNAMI RELIEF WORKS IN NAGAPATTINAM DISTRICT OF TAMIL NADU:
15 days
Was responsible for motivating & forming a team of 8 doctors, for medical
relief in Tsunami affected areas, from Bangalore Medical College within a day
of the Tsunami Disaster. This team sent under the banner of CHC worked in
collaboration with NGOs & Government in the tsunami ravaged areas of
Nagapattinam district of TamilNadu in the first two weeks after the disaster
struck.
Initial medical relief work covered 18 villages & later 3 villages were taken up
for focused work.
The work, along with the medical relief, mainly revolved around public
health measures to mitigate the effects of disaster to ensure healthy &
hygienic living conditions for the affected population.
Community organization & their meaningful participation of the affected
communities in their own relief works & restoration of the dignity of the
3
‘Mitanin Program’ is a Health Program undertaken in Chhattisgarh state of India. Chhattisgarh is a
predominantly tribal state with 46% of tribal population. The program is a huge Public-Private
partnership initiative in which 60,000 women, both literate & illiterate, health workers were trained
with the help of 2500 trainers across the state to provide first contact curative & preventive care in the
village itself & also as activists to mobilized the community to improve public health services through
cooperation & advocacy.
15
affected population were the guiding principles of our work during the relief
phase.
HOLYCROSS COMPREHENSIVE RURAL HEALTH PROJECT (HCCRHP) IN HANNUR
TALUKA OF KARNATAKA:
I undertook independent participatory training of 32 Health Workers on
various topics (both conventional & unconventional health topics) of Health
including water & health, environmental & personal hygiene and sanitation,
diarrhea & its management, vaccination, alcoholism, child marriage,
reproductive health especially of young girls, child labor, & malaria.
I was also involved in the initiation of ‘Health Promoting School Program’ in
10 primary schools in the taluka. I was a part of the team that was involved in
the formulation of the concept, contents & processes of the entire program.
The program has now been approved by the Government of Karnataka & I
will be working for the success of the same from December onwards as a team
member of HCCRHP.
In addition, I was involved in the Participatory rural appraisal, & subsequent
selection of women health workers in 6 villages of the area.
I personally was involved in the rescue of a 9 year old boy who was held as a
bonded labor in an agricultural field.
I was responsible for the formation of a ‘health monitoring & promoting
committee’ in the residential school of HCCHP catering to the needs of the
children rescued from bonded labor.
IN ANDAROUND BANGALORE:
Study visit to 18 slums in Bangalore as a technical adviser from CHC to
support
action-research project undertaken by ‘Jana Sahayog’ (meaning
Association for people’s co-operation) to study the quality of drinking water
being supplied by the Government to the slum dwelling poor people in these
18 slums. When not a single sample was found fit for domestic usage, leave
alone for drinking purpose, the communities took the fight to the
16
Government. Since, they were armed with the irrefutable evidence,
Government was forced to accept its failure & take corrective measures.
As an observer, I studied ‘Community Health Approach to Tackle Alcohol
related problems’ undertaken by CHC in 3 slums of Bangalore.
Was a part of the team from CHC involved in the Health Education drive in
schools & colleges in Bangalore with a focus on education on adverse effect of
tobacco use & with an intention of reducing the same in young generation
Was a part of the CHC team that undertook a ‘study of nutritional status of 06 year old children in 6 villages of Hosur taluka’ on the request of TVS Motor
industry of the area & the design of an appropriate intervention program to
reduce malnutrition & improve nutritional status of the children in those
villages. I formulated the project proposal & was instrumental in designing
the methodology of the study. I also prepared the questionnaire to study the
knowledge, attitude & practice of child feeding in the area.
I undertook training of 200 primary school teachers in Magadi &
Ramanagaram talukas of Karnataka state, as a resource person from CHC on
the request of Bharat Gyan Vigyan Samithi (meaning in English -India
Knowledge & Science Forum), on the topic of ‘Water, Hygiene, Sanitation &
Health’.
I took initiative to organize ‘A Meet with Tsunami Disaster Relief Doctors
from Bangalore Medical College (BMC)’ in BMC, to share the experience of
volunteers in the disaster relief work with the staff & students of BMC. It was
also an attempt to start a process within the BMC to start a ‘disaster
management cell’ in BMC to be prepared to meet the future challenges of
disasters, both manmade & natural, in India. This process is still on, though
with many difficulties of dealing with the bureaucracy.
I was personally responsible to include the issue of ‘People’s Concern over
privatization & commercialization of Medical Education in Karnataka’ in the
agenda of the 2nd Karnataka State People’s Health Assembly, that took place
as a preparatory meeting for Global 2nd People’s Health Assembly that took
place in Ecuador in July 2005.
17
TEACHING & TRAINING EXPERIENCE:
Involved in the teaching program for 30 MSc (Master of science) students in
‘Psychosocial rehabilitation’ from Richmond fellowship college on the topics
of The concept, definition, determinants & dimensions of Health & diseases,
spectrum of health & diseases, the natural history of diseases, the theories of
disease causation, the concept & levels of prevention, methods of health
promotion, concept & understanding of primary health care, National Health
Programs in India with special reference to Mental health program in India
for two batches in two consecutive years starting from 2004.
Undertook independent ‘participatory training’ of 32 Women Health Workers
on various topics (both conventional & unconventional health topics) of
Health including water & health, environmental & personal hygiene and
sanitation, diarrhea & its management, vaccination, alcoholism, child
marriage, reproductive health especially of young girls, child labor, & malaria
in HCCRHP in Hannur.
AS a resource person from CHC, I undertook training of 200 primary school
teachers in Magadi & Ramanagaram talukas of Karnataka state, on the
request of Bharat Gyan Vigyan Samithi (meaning in English –All India
Knowledge & Science Forum), on the topic of ‘Water, Hygiene, Sanitation &
Health’.
RESEARCH EXPERIENCE:
As a research assistant, I was part of the team that was involved in the
‘External Evaluation of Mitanin Program in Chattisgarh’ & I was involved in
the formulation of methodology of evaluation, development & field testing of
the questionnaires. I also documented various case studies related to the
program, & was the contact point for the group of investigators who came in
at different point of time during the study. I accompanied 4 chief investigators
in the field for more than 25 days & actually visited 8 out of 12 sample blocks
in our study where I was involved in the field evaluation process looking at
18
the perspectives of the community, providers & planners about the whole
program.
Was a part of the CHC team that undertook a nutritional research project in 6
villages of Hosur taluka on the request of TVS Motor industry, situated in the
area, with an aim of assessment of nutritional status of children between 0-6
years of age in 6 villages of Hosur taluka of Krishnagiri district of Tamilnadu
state & to plan & enable interventional measures to mitigate malnutrition in
children & to promote the development of children & ensure them a healthy
childhood. I was on the two member team from CHC which made
preliminary appraisal visits to the villages for situation analysis & I prepared
the project proposal & was instrumental in designing the methodology of the
study. I also prepared the questionnaire to study the knowledge, attitude &
practice of child feeding in the area. Later, I was involved in the design &
implementation of the intervention program.
Study visit to 18 slums in Bangalore as a technical adviser from CHC to
support
action-research project undertaken by ‘Jana Sahayog’ (meaning
Association for people’s co-operation) to study the quality of drinking water
being supplied by the Government to the slum dwelling poor people in these
18 slums. I was involved in the selection of water collection points &
collection of water samples for analysis in the slums. In addition, I was also a
part of the team in CHC that produced the report When not a single sample
was found fit for domestic usage, leave alone for drinking purpose, the
communities took the fight to the Government. Since, they were armed with
the irrefutable evidence, Government was forced to accept its failure & take
corrective measures.
CONFERENCES & WORKSHOPS:
Was a participant in the five days workshop on ‘Basic Training in Ethical
Issues’ in Bangalore jointly organized by University of California San Fransico
Fogatry Training project & Samuha, a Bangalore based NGO.
19
Participated as a student observer in the South Indian regional workshop for
evolution of a ‘national health program for control of non-communicable
diseases’ jointly organized by WHO-SEARO & Indian Council for Medical
Research (ICMR) & hosted by Preventive & Social Medicine department of
St.John’s Medical College.
Participated as the coordinator of the issue of impact of privatization &
commercialization of Medical Education in Karnataka & also was the main
presenter on the topic in the 2nd Karnataka State People’s Health Assembly in
Bangalore.
Personally took the initiative to organize ‘A Meet with Tsunami Disaster
Relief Doctors from Bangalore Medical College (BMC)’ in BMC, to share the
experience of volunteers in the disaster relief work with the staff & students
of BMC. I presented the experiences of the first team from CHC of which I
was one of the members. It was mainly an attempt to start a process within
the BMC to start a ‘disaster management cell’ in BMC to be prepared to meet
the future challenges of disasters, both manmade & natural, in India. This
process is still on, though with many difficulties of dealing with the
bureaucracy.
Participated in the two weeks long ‘orientation program’ for community
health fellows in CHC covering the broad ranging & cross cutting issues of
Public Health.
Participated in the workshop of CHC to formulate the post-relief phase of
disaster management response of CHC in the tsunami affected areas of
TamilNadu. At present CHC has formed an ancillary team based in Chennai
for undertaking the long time developmental work in tsunami affected areas
with special focus on the component of Community Health.
Participated as one of the three fellow representatives in the three day
workshop in CHC for planning the feasibility of evolution of CHC into a
school of Public Health.
Participated
in
the
NGO-Coordination
workshop
in
Bangalore
for
coordinating & prioritizing the response of Bangalore based NGOs in their
20
response to Tsunami disaster to make the response more efficient & people
friendly.
Most of these experiences have been dealt with in-detail in the section 2 of this
report. As the experiences show, I was fortunate to have had one of the most wideranging exposures as fellow traveler in community health.
A REFLECTION AT THE END OF THE JOURNEY & A GLIMPSE OF MY
FUTURE PLANS:
I am finishing my journey in Fellowship in CHC on 5th November & the main
outcome of the fellowship is that, it has helped me to realize my aim in life &
commit myself to be a Community Health Worker for the rest of my life. The
journey through the Fellowship period has been an eventful one, which has not only
resulted in a major professional decision, but also has had a profound effect on my
personal life & value system. It also has helped to further my knowledge of
community health practice & social processes. Among the various processes of
Community Health that I was exposed to, there are two areas to which I would like
to dedicate my life to & which I believe are few of the very important processes to
realize the cherished goal of ‘Health for All’.
Community Health Workers: It all started at SEARCH in Gadchiroli under
the inspiring guidance of Drs Abhay & Rani Bang & grew in me throughout
the last one year- the motif of Community Health Workers as the ‘Change
Agents’ in the society has enthralled me & I think at this point of time, that
CHW is going to be my focus area of work in the future. The philosophy of &
operationalisation
of
the
CHW
scheme
to
promote
community
empowerment, emancipate them from the clutches of western medicine &
to forge a partnership with the community to demand for a ‘more’ free &
fair world, where even the ‘poor people’ matter & health is ensured not as a
21
‘privilege’ of the few, but as an ‘entitlement’ for all has attracted me to it for
no bounds. As a result I concentrated on further understanding of the concept
of CHW during the rest of my fellowship period. The concept & its
understanding was furthered by perusing the available literature, discussions
with experienced people in the topic, & also during my stint in Chhattisgarh,
as the research assistant for ‘External Evaluation of Mitanin Program, one of
the many attempts to scale up CHW program from a small, NGO run
program to huge, Public owned program catering to the entire state. The
culmination of my learning process in the CHW scheme in Fellowship period
came in Holy Cross Comprehensive Rural Health Project (HCCRHP) in
Hannur in Karnataka state of India, where I was involved in the selection,
training, & monitoring of CHW & hence, was able to assess my preparedness
& experience the joys & sorrows of my preferred work.
Health as a Human Right & Equity in Health Care: Another area of
Community Health that has interested & at the same befuddled me is the
issue of Health as a Human Right & the issue of Equity in health & health
care. I cant & don’t understand the ‘real’ reasons behind non-realization of
‘Health For All by 2000 AD’ for, the world has more wealth than it ever had
in it’s history but still the ‘majority’ people are reeling under the burden of
poverty & ill health. It is not just a subject of interest for me but is a
passion, for my blood boils in anger when I look at the injustice in the
world. Hence, I have decided to place all my future work in Community
Health as a part of larger strategy towards actualization of Health as a Human
Right; based on the ideals of equality, justice & freedom.
FUTURE PLANS:
Immediate: From December onwards, I am going back to Hannur & continue
the work in HCCRHP. I am going to get involved in the organisation of
primary health care in more than 60 impoverished villages in the area
22
through the CHW program. In addition, I will also take forward the ‘Health
Promoting Schools Program’ in 10 primary Schools in the area, which I
initiated along with the team at HCCRHP during the period of my Fellowship
Days in HCCRHP. I will also continue my cherished activity of training,
monitoring & understanding of community health workers. At the same time
I would like to put to test the Paulo Friere’s ‘participatory approach of
training for transformation’ & document our local experience of the same.
Short-term: At the same time, I am planning to undertake my higher
education in Public Health in one of the appropriate institutes. During my
reflection period of fellowship, one strong advice I received was to start &
finish my higher education as fast as possible as both Dr.Ravi & Dr.Thelma
(Myself included) felt that I have had adequate field exposure & it would be
unwise to postpone my studies further. After long discussions with Dr.Ravi &
Dr.Thelma, I have decided to apply in Johns Hopkins School of Public Health
(JHSPS), Harvard School of Public Health (HSPH) & London School of
Hygiene and Tropical Medicine (LSHTM). All these schools have an
unmatched reputation as Schools of Public Health & more importantly, the
course contents offered seem to be tailor made for my specific needs.
Long-term: To be a Community Health Activist involved in the evolution of
a method to help people identify tools within themselves, their community
& their state to solve the problems in the most appropriate & sustainable
ways with a special focus on CHW schemes. In the long run, my “goal” is to
develop a comprehensive CHW scheme; building on all the experiences of
all such program across the world. To work towards this goal, I intend to
work for any number of required years in the field.
At the same time, I will continue to work in collaboration with other groups
& movements working towards realization of the dream of ‘Health for All’
with operationalisation of Health as a human right.
23
Ultimately, I would like to continue as a teacher to share & learn with
students of community health, like me, the processes of ‘real community
health’.
24
ANNEXURE NO.1. STATEMENT OF OBJECTIVES
To,
20-08-2004,
The fellowship coordinator
Community Health Cell,
Bangalore.
Respected Sir/Madam,
“Prevention is better than cure”. I know it sounds hackneyed. It has become the most
over used, albeit most misused, statement in the world. But it is this cliché that has
inspired me to write this letter and apply for the fellowship programme offered by
your esteemed organization.
With a good performance in my school days and a good rank in C.E.T., I got
admitted to B.M.C. I pursued my medical undergraduate studies in the prestigious
B.M.C. between 1998 & 2004 and successfully graduated with “M.B.B.S.” degree in
june-2004.
Now, I am standing at the cross-roads of my professional life. With the burden of
selecting a ‘specialty subject’ for myself, I am confused. But, because Community
Medicine is the subject that enthralled me the most during my U-G life and it has a
career prospect that excites me to no bounds, I would like to give it a try.
As a subject, I was always amazed by the simplistic approach of P&SM towards
health, by which it reached to large masses in a single go. It gives me goose bumps to
think that small pox is eradicated; Polio once considered a fatal disease is on the
verge of being eradicated and every day millions of children all over the world are
being saved from mortality and morbidity through U.I.P. It gives me a sense of awe
to read of the astronomical number of people it reaches out to and that too in a non-
25
discriminatory way. The accomplishments of this field of medicine have struck a
cord in me.
I was exposed to field realities of health care system of INDIA during my internship.
What stood out during this period was the relevance and scope of P&SM in health
care delivery. I found the therapeutic approach given in the Park & Park textbook of
P&SM was the most practical and effective. That 1 year was also an eye opener for
me. It showed me the bare realities of our health care system. It is but an irony that
while people are “straightening their noses” for a couple of thousands of rupees,
many are dying for lack of basic medical care. It agonizes me to think of these
inequalities.
Bad experiences, though dominating, were not my only experiences. I was sweetly
surprised to see how a simple method of distribution of IFA tablets through village
health workers has made a substantial improvement in the health condition of
women. School Health Check Up Camps were my favorite activities. It showed me
what a difference a trained and knowledge teacher can make in the young lives. It
was exemplified by an anganawadi teacher I met in a remote village, who insisted
and taught simple ides of hygiene and cleanliness on the part of children. No
surprise, the children were the healthiest among all schools I had visited. At
Pavagoda, a remote place 180 km from Bangalore, I worked as a resident intern in a
Rural Health Centre. It showed me one more facet of P&SM. Through RNTCP
programme undertaken by the centre I learnt how a dedicated team of doctor and
health workers can inspire a community and actively seek their participation in
health care delivery and planning. Also I served as a PHC doctor in Venktapura 14
kms from Pavagoda. It is here I learnt how even a young, inexperienced doctor like
me can make a difference in the community. Even though I stayed there for 7 days, I
was instrumental in training the nursing staff and village health workers in many
minor procedures like dressing of wounds, small abscess drainage, giving first aid to
trauma patients and such others. And it was heartening to see them put to use the
skills with all alacrity, which improved the health care deliverance of the PHC a
couple of knots higher.
26
Among all my postings as an internee, I have enjoyed my P&SM most and found it
the most practical and challenging field of medicine relevant to present day needs.
Also a career in P&SM blends with my personality. I have been a leader of student
community throughout my student days. I am an active participant of extra
curricular activities and am always ready to shoulder any responsibility. As I grew
up I found my interest in community and social welfare increasing further. As a
doctor I want to make a real difference in the life of people and reach out to as many
people as possible, especially the underprivileged and down trodden. How else than
being a community medicine specialist?
With all these ideas in my mind, I came to C.H.C. for further guidance and found my
belief of P&SM being my field of work being further reinforced by the short talk I
had with revered DR.Ravi Narayan. He convinced me beyond doubt that C.H.C. is
the place to start my work in P&SM. This notion was later endorsed by many people
who worked in your esteemed organization previously.
As Galen told, “Since both in time and importance, health precedes disease, we
ought to consider how health may be preserved, and then how one may best cure
the disease”. I would like to give my small contribution towards health and its
promotion. I believe my educational background, my personality and my will to
work for community health and its promotion makes me an ideal candidate for your
fellowship programme. I aver that if selected, I would prove worthy of myself.
Kindly accept my candidature .Thanking you,
Yours sincerely,
Vinay.V.
27
ANNEXURE NO.2. LEARNING OBJECTIVES OF Dr.VINAY.V., AS A
COMMUNITY HEALTH FELLOW IN C.H.C.
The initial learning objectives of Dr.Vinay.V., as a community health fellow in
C.H.C., sponsored by Sir Ratan Tata Trust of Mumbai, as evolved in consultation
with mentor and friend Dr.Thelma Narayan are as follows:
ACADEMIC DEVELOPMENT:
1. To identify my area of interest in Public Health stream of medicine.
2. To understand and broaden my current knowledge of health and its various
determinants and dimensions.
3. To have first hand experience of ‘community’ and its dynamics.
4. To have first hand experience of current health system in place.
5. To develop my skills in academic writing, discussions and presentations.
6. To get the broader and clearer picture of various organizations, public and
private, involved in health action & related social activities aimed towards
‘Human Development’.
7. To foster my skills, especially those important for community based work like
planning, organization, communication, health education, training of health
activists, community needs assessment, evaluation, etc.
8. To understand from practical experience, how a voluntary organization
aimed towards Human Development carriers its activities i.e. to observe
C.H.C. at work.
PERSONAL DEVELOPMENT:
1. To understand ‘Myself’ better and hence to choose my way of life.
2. To identify my strengths & to build on them and to learn about my
weaknesses & to work towards their correction.
3. To improve my communication skills, foster my skills of networking with
people and further my capacity to build inter-personal relationships.
AIM:
To develop myself into a ‘Community Activist’, working towards a healthy and
better community, in a meaningful and effective manner.
These are broad based and basic objectives which can be expanded or modified
further in the process of fellowship in terms of focus, priority and significance; in the
true spirits of ‘interactive’ nature of fellowship.
28
SELF APPRAISAL OF THE PROCESS OF REALIZATION OF MY
LEARNING OBJECTIVES
This is an attempt by me to make an honest & open minded self appraisal of my
Fellowship period, its experiences & the learnings in the light of my Learning
Objectives, set forth at the beginning of my Fellowship period.
ACADEMIC DEVELOPMENT:
1. To identify my area of interest in Public Health stream of medicine.
Even though my fellowship process was designed consciously to have wide ranging
experiences in the field of Community Health, there was always a constant search &
reflection during the entire process to find my focus area for my future work. As a
result, each step in the process was a construction based on my learnings &
reflections of the previous process/ess. Though some of the steps in the process were
not due to intentional planning, like the relief work in Tamil Nadu in the after math
of the Tsunami disaster, they were undertaken with the right spirit & understanding
of the often unexpected emergency demands of the practice of Community Health.
Thus, some of the ‘breaks’ that appear to mar the smooth continuance of my
fellowship period were a sweet serendipity.
My interest in Child Health led me to Society for Education, Action and Research in
Community Health (SEARCH). However, my experiences in SEARCH expanded my
understanding of the practice of Community Health & shifted my focus in
Community Health on the ‘philosophy & operationalization of Community Health
Workers (CHW) scheme’ in communities. The concept & its understanding was
furthered by perusing the available literature, discussions with experienced people
in the topic, & also during my stint in Chattisgarh, as the research assistant for
External Evaluation of Mitanin Program; one of the many attempts to scale up CHW
program from a small, NGO run program to huge, Public owned program catering
to the entire state. The culmination of my learning process in the CHW scheme in
29
Fellowship period came in Holy Cross Comprehensive Rural Health Project
(HCCRHP) in Hannur, where I was involved in the selection & training of CHW &
hence, was able to assess my preparedness & experience the joys & sorrows of my
preferred work.
Another area that has enthralled & at the same time befuddled me is the issue of
Health as a Human Right & the associated themes, particularly the issues of equity
in health & increasing commercialization of medical education & health care in India
& their impact on the Health of Indian communities. At every stage of my fellowship
process, the issues of Health & Health Care in reference to my learnings from my
field visits & discussions were also analyzed, apart from the usual connotations,
with reference to Health as a Human Right & I tried to understand the different
community health processes in this light. It was also a theme which gave me a
deeper understanding of the work of various people & organizations, with whom I
had an interaction with & which seemed miles apart in their focus areas, which are
basing themselves on this motif & hence deriving the necessary strength for their
work. It was also interesting, confusing & infuriating to witness the broken promise
of ‘Health For All by 2000 A.D.’ by all the concerned stake holders, particularly the
State & widening inequity in Health among various communities within India. One
definite outcome of my fellowship is that it has given me one broad framework for
all my activities in Community Health i.e. the framework of Health as a Human
Right; & whether I choose to work directly or indirectly on this theme, it will always
be the guiding principle for all my works towards achieving equity in health.
In conclusion, the fellowship period has helped to find the focus & has laid down the
foundation for my future activities in Community Health namely:
Organization of primary community based health care & realization
of ‘Health for All’, particularly in the underserved & marginalized
communities.
To evolve a model of Community Health Worker scheme that would
help to realize the fond dream of placing the real power & onus of
Health Action back to the communities & enlightened activism.
30
To work towards the realization of Health as a Human Right in India
& elsewhere in the world, & placing Equity as the core issue of all the
Health Actions.
2. To understand and broaden my current knowledge of health and its various
determinants and dimensions.
Without any malicious intent & with all the due respect it deserves, the MBBS course
in Bangalore Medical College (BMC), as anywhere else in Karnataka, was replete
with study of diseases & failed to give a wider picture on the determinants &
dimensions of health. It was only during my chance meetings with the proponents of
Community Health that I was stimulated to think & investigate the various ‘other’
dimensions & determinants of Health, which exposed my little understanding of the
‘real’ issues of Health.
Hence, the fellowship process was also aimed to give me a broader & more
comprehensive picture of Health & its dimensions & determinants. The fact that the
team at CHC & the fellows with whom I shared my fellowship period were from a
multidisciplinary background, including social sciences, went a long way in
realizing this objective. In addition, during all my field placements, I had an
opportunity to interact with the cross section of the organizers & beneficiaries of
various health actions including the members of the community, field workers, field
supervisors, & also the leaders of the projects, which greatly enhanced my
understanding of Health & it’s broader meaning, very different from the narrow
approach of bio-medical sciences approach of health. Furthermore, during all my
discussions, presentations & analysis with my mentors & fellow students, this aspect
was given an important position which reinforced the learnings.
As a result of the above processes, I can see clear differences in my own approach to
various health problems & challenges on the field as compared to my early
approaches. This was particularly evident when I went to HCCRHP in Hannur,
where this particular knowledge came in handy while trying to analyze the reasons
& understand the unreasonable poor health status of the marginalized communities
31
like women, people from lower caste & the poor people as compared to other groups
of the people from the same communities. To highlight some of the very important
learnings on this issue, from among the various learnings, are:
That the issue of economic & subsequent social marginalization, be it
gender related or caste related or in relation to vocational status, is a
reality in India & it plays probably the most important role in
determining the health status of a large majority of community
members & hence, the community. Hence, it requires special
understanding & approaches while planning for a health program
for a particular area & it is pertinent to make conscious special
provisions so as to reach out for these neglected & marginalized
sections of society.
No doubt hospitals and medical & paramedical professional people
are important for a community to maintain health; their role in
promoting, preserving & restoring health in communities is over
estimated. It is not just the ‘germs’ or the genetic factors or the
immunological factors or the idiopathic factors (about which the
‘Medical’ world seems to be obsessed with) that are threatening the
health of communities, but there are equally important social,
economic, political & cultural factors that are undermining the ability
of the people to enjoy a good & healthy life. Hence, it is binding to
have a more participatory, multi disciplinary & comprehensive
Health Actions, if we are serious about achieving Health for All.
That the Health Systems, both public & private, play a very
important role in promoting, preserving & restoring health in
communities. However, one single model for a nation as diverse as
India is a questionable model and there is a need for community
ownership of Health Systems foe it be effective, accountable and
appropriate.
32
3. To have first hand experience of ‘community’ and its dynamics.
It was also pertinent for me to have an experience in the community and its
dynamics from close quarters. Some of the social issues like that of childhood
bonded labor, casteism, gender inequalities, extreme poverty and such others were
not understood corresponding to the gravity they call for. Hence, apart from
knowing the issues through reading and discussions it was critical for me to
experience the same for a deeper appreciation of the social issues.
I was fortunate to have had wide ranging experiences during the Fellowship period.
Starting from Shodhgram in Gadchirolli the journey of my fellowship took me along
the length and breadth of the Chattisgarh and finally grounded me in Hannur. Apart
from these, there were also innumerable number of opportunities to also meet and
learn from different communities in Bangalore and elsewhere.
One definite input of my Fellowship was to develop more sensitivity towards the
cultural, traditional and social diversities of different communities and appreciation
of the fact that one ‘carpet policy’ will not work in India. Also, my interaction with
the tribal communities especially in Gadchirolli and Chattisgarh opened my mind to
the new world of tribals and their tribulations in the present day scenario. The
Gandhian philosophy in Shodhgram was inspiring and has motivated me to know
more about the same. More importantly, the brush-off I had with the extreme
poverty in Hannur region and my personal involvement in the emancipation of a 10
year old child from the bonded labor has been the most disturbing experience and
has furthered my fire to understand the existing world order and the factors that
perpetuate poverty. In addition, the extreme division of the society along the caste
lines and the condition of the dalits in the region of Hannur was shocking and
brought to the fore the realities of social determinants of Health.
4. To have first hand experience of current health system in place in India.
Since my long-term goal at the time of entering the fellowship was concerned with
Health Systems and I had limited experience in the same, this was added as one of
the learning objective.
33
I had a variegated experience of Health Systems across many regions of India in both
public and private, both for and not-for profit, health systems. From the cost
effective, multi-specialty hospital in the rural area of Swami Vivekananda Youth
Movement (SVYM), to tribal friendly hospital and CHW system in SEARCH, to the
huge public health initiative in Chattisgarh, to a ‘model- primary health centre’ in
Ganyari by Jana Swasthya Sahayog (JSS) I was a witness to large number of
initiatives and health systems in India. These experiences have just primed me to
further understand this complex and critical issue in my future.
5. To develop my skills in academic writing, discussions and presentations.
I was providential for having provided with the numerous opportunities during my
fellowship period to hone my academic skills. Reporting of every activity in itself
was a learning experience, for this was a new experience for me and I am thankful
for all my mentors who perused every piece of report I produced and giving me the
feedback on the same. At the same time, the fellowship orientation program was a
golden opportunity in the realization of above objective. The program, with priming
form the mentors followed by presentations and discussions on chosen topics by the
fellows from multidisciplinary background was an enriching period. Also, the
nutrition project in Hosur, 2nd State People’s Health Assembly in Karnataka and
tsunami sharing program in BMC are few of the specific instances that helped me to
achieve the above objective. However, I would say that the feedback from mentors
and fellows was the most critical factor in the realization of the above objective.
6. To get the broader and clearer picture of various organizations, public and
private, involved in health action & related social activities aimed towards
‘Human Development’.
This objective was added as an after-thought since the sphere of human
development had a special place in my heart, for I felt pain when I saw poor people.
There was no special understanding about poverty except the sad feeling I
34
experienced when I met a poor child or a woman. It was this feeling that prompted
me to have the above objective in my fellowship period.
Every organization I visited and every discussion I had with various people on
Health and Development have gone a long way in altering the way I looked at the
world and it’s development. They have basically given me a new framework to
evaluate the necessity and effectiveness of every action I undertake in communities.
I feel at this point of time that every organization I visited was involved in the health
action and most of them linked this with ‘Human Development’. I am using quotes
to put in human development since development is usually spoken in economic
language where trade and commerce become the indicators of development which I
do not agree with. However, with the experiences I had during the last one year
especially the discussions with various people during the course of fellowship; I
believe in human development as any process which will lead to happiness and
contentment of whole communities in a sustainable manner. Taking this definition
into account, health and development become closely related issues where one can
neglect either at the peril of neglecting the both. It is this realization that I value the
most in my fellowship period.
7. To foster my skills, especially those important for community based health
work like planning, organization, communication, health education,
training of health activists, community needs assessment, evaluation, etc.
Since I had a vague idea of the kind of long-term work I wanted to undertake when I
joined the fellowship, these objectives were drawn to equip me with the necessary
skills and knowledge for the same.
The multifarious activities during the fellowship period have provided me with
numerous chances to develop the above mentioned skills. Each activity during the
fellowship has helped me to enhance a particular skill. For instances, the nutrition
project in Hosur gave me a chance to plan and formulate a small study, the Mitanin
Experience was a great learning experience which equipped me with the basics of
35
evaluation methods, the HCCRHP at Hannur gave me the opportunity to involve
myself in the training of Health Activists.
8. To understand from practical experience, how a voluntary organization
aimed towards Human Development carriers its activities i.e. to observe
C.H.C. at work.
I intended to work in a voluntary sector and to understand it is the first step towards
it and hence, this objective. I am grateful for the team of CHC for providing me with
invaluable experience of how CHC functions by allowing me to attend the team
meetings even though I was not, strictly speaking, a team member and understand
the dynamics of it.
PERSONAL DEVELOPMENT:
1. To understand ‘Myself’ better and hence to choose my way of life.
One unique character of the fellowship period is it that it did not just build my
academic interest in the subject of community health but it actually helped me to
understand life and live it accordingly. Even though I was an honest and straight
forward person even before fellowship, this period has been particularly important
in terms of giving me courage to actually live by the principles I valued but found it
difficult to practice. It would also always be remembered fondly for the sheer
number of principled people I met and the interesting lessons learnt from them. The
joy that I derived being with such people is inexplicable and they remain to be my
inspiration.
At the same time, I would also say that this period has been tumultuous for it has
questioned some very basic principles I believed in and has left me shattered at
times by disproving some basic conceptions I had about this world. It is the times
like these that have taught me the value of mentors, friends and books. It is also
these experiences that led me to investigate into the ‘other world’, which is well
hidden from the superficial eyes. It is during these investigations that I discovered
myself, with whatever little knowledge I gathered in these periods, to be a socialist,
36
then a Gandhian and then that I stand for the humanity as a whole. It is this quality
of the fellowship that I found the most challenging; the constant questions that
shatter my beliefs leading to confusion which would further lead to investigation
into the new ideas ending in additional and new knowledge. At the same time, the
greatest lesson I have learnt for the life is that learning is a lifelong process and the
only way for constant personal and professional growth is to be an attentive student
of life at all times.
Thus, the fellowship was a great period in terms of helping me to understand myself
better and for giving me a broad set of principles, equity, justice and freedom, which
will continue to guide all my future works.
2. To identify my strengths & to build on them and to learn about my
weaknesses & to work towards their correction.
The fellowship has also been important in terms of furthering my strengths and
working towards amending my weakness with the help of my mentors, fellows and
all CHC staff. These experiences have been reflected in every report of my
experiences in the fellowship period presented in the section 2. Hence, I believe that
a lengthy appraisal on the same in this part is unwarranted.
3. To improve my communication skills, foster my skills of networking with
people and further my capacity to build inter-personal relationships.
The fellowship period in CHC has been an absolute occasion for building my
communication and networking skills evidenced by the diverse people I now know
all over India. At this juncture I personally feel more confident in accosting people
and initiating conversation, which I used to shy away previously. Apart from this, I
believe it would be more appropriate for the people around me to evaluate this
particular skill of mine rather than me talking about the same.
37
SWOT ANALYSIS OF CHC FELLOWSHIP IN COMMUNITY
HEALTH
STRENGTHS:
Dr.Thelma Narayan and Dr.Ravi Narayan as mentors: I cannot stress more
than enough of the good fortune of fellows to have such wonderful human
beings and such experienced community health practitioners as being our
mentors. Inspite of all their work pressures and time constraints, they always
find time to interact and guide us through all our tribulations and triumphs of
our experiences. It is this personal attention that we get from them that has
greatly helped us to place our experiences in the right perspectives and learn
invaluable lessons from them. The passion of Dr.Ravi and the scientific rigor
of Dr.Thelma have personally inspired me to emulate them.
Multi-disciplinary background of CHC fellows: A blend of fellows from
diverse background has gone a long way in mutual learning process, which I
believe will stand in good stead when we begin our work in communities.
The perspective of each fellow on an issue based on their background and
training has helped to internalize the complexities involved in community
health work and the importance of analyzing situations from various
perspectives and to formulate appropriately solutions.
Flexibility of the program: The most important aspect of the program is the
internal flexibility of the program, in terms of the selection, mentoring and all
other processes of the program. For, if not for that ‘open position’, I would not
have had the opportunity to join the fellowship and would have lost an
opportunity to pursue my interest in community health. It is very important
for the program to maintain this particular flexibility since, many potential
fellows, like me, who would have graduated in times not in league with the
fellowship program would loose out on an opportunity and I believe it will
38
also defeat the purpose of the fellowship scheme to a great extent. In addition,
the flexibility the program presents to the fellows to pursue their diverse
interest in the field of health is the most critical factor for shaping the future of
fellows. It is this flexibility that has helped me for I had a zest to work with
communities but was not sure on the particular area in community health to
work on. The flexibility in the fellowship provided me with wide ranging
experiences which actually helped me to find my focus area for my future
work. It is also the flexibility of the program that was responsible for my
extension of the fellowship period from 6 months to 1 year. Hence, the
flexibility of the whole program should not be tinkered in any major way.
The ‘new paradigm’ approach: Another unique feature of the fellowship
scheme is the introduction of fellows to the ‘new paradigm’ where we are
introduced to the system of holistic approach towards the health. The
paradigm taking into consideration the social, political, cultural and economic
factors apart from the biomedical factors that affect health of communities,
have grounded us on a firm platform for further analysis of community
health problems in all their complexities. This has resulted in shaping us to
get to the root of all problems rather than scratching the surface and dealing
with just the symptoms.
The ‘open-structure’ of the fellowship scheme: In the world where education
and training has become highly structured and constricting, the CHCFS with
its ‘open-structure’ provides unique opportunities to young people like me to
actually explore and find our focus areas for further training and work. My
deepest concern is that when CHC is planning to transform into a
‘Community Health School’, this aspect may be compromised for the sake of
formal degrees. Hence, I request all stakeholders in CHCFS to continue this
program, even if it has to run parallel to the formal degree program, in the
present ‘open-structure’. Minor alterations, if absolutely necessary, can be
carried out to fix certain topics as core requirements and leaving the rest of
39
the time for the fellows to explore the field in a way they would wish to; but
the essential ‘open-structured’ nature of the program should be continued.
CHC contacts and field mentors: I am not able to comprehend the depth and
breadth of the contacts CHC has in the arena of public health and I believe
this places CHC in a unique position to offer fellows with the appropriate
field placement for any type of experience the fellows would request for. This
ability of CHC has blessed me with opportunities to have been mentored by
the likes of Dr.Abhay Bang and other eminent community health practitioners
in India. I am also providential to have come in contact with a large number
of distinguished people with diverse philosophies in community health which
has helped me to learn hard but all important lessons in community health in
the shortest possible time. Thus the system of field mentoring put into place
by CHC has immensely helped me to derive maximum benefit from them.
Introduction to ‘movements’ approach: The initiation to ‘movements’ and
‘activism’ was a totally novel process for me. It is a unique process, atleast for
me, for having a chance to get exposed to ‘movements’ approach from such
close quarters and to get actually involved in them. This has opened a totally
new approach in community health for me and I firmly believe that if not for
CHCFS, I would never have had an opportunity to study and learn about
movements in such an effective manner. I am so impressed by this motif that
it is going to be one of my focus areas of my future work.
Improving analytical capabilities: The fellowship period has an inbuilt
beautiful process pushing us towards investigating ‘true causes’ and
equipping us with the necessary framework to analyze situations, articles and
reports perspicaciously. It has given me the ability to ‘read in between the
lines’ exemplified by the way I view and understand the National Pulse Polio
Immunization Program at present compared to my previous viewpoint on the
same.
40
However, ‘the strength’ of the fellowship, apart from equipping us with the
knowledge and skills for community health practice, lies in its processes
designed to provides us with the inspiration and principles to make a difference
in people’s lives, for a better and just society.
WEAKNESS:
Lack of common quarters for fellows: I felt the lack of common residential
quarters for the fellows when they come together for orientation program and
sharing sessions. I believe that,, had it been the case, it would have provided
us with more time for further discussions and closer interactions.
Lack of computer facilities: Even though CHC as an organization has many
computers, as a fellow I sometimes felt the lack of adequate computer
facilities. This was especially true during the orientation and sharing sessions
when all fellows would come together and would have difficulty having an
access to a computer to write their reports or prepare a presentation.
Lack of a session on ‘research methodologies’ during orientation period:
Even though I understand that CHFS is not a formal course and the
orientation program offers the sessions on widest range of issues and topics, I
felt a lacuna in terms of the absence of introduction to ‘research methods’ in
community health. Even though we get exposed to the methods during the
course of fellowship, it would serve well to have a session on the same during
the orientation period.
OPPORTUNITIES:
CHCFS has an immense potential to make a huge contribution to the
community health field in India and elsewhere. If and when the fellows reach
a critical number and start acting in a concerted manner, there is every
41
possibility for the translation of the ‘new (alternative) paradigm’ as the
guiding and dominant paradigm of community health in India and
elsewhere.
There is also an opportunity to come up with a yearly or a half yearly
publication of unique and powerful experiences of fellows in the field and the
same can be made available in schools of medicine, social sciences and allied
organisations to share their experiences and also to generate interest and
promote the idea of ‘new paradigm’ to larger audience.
CHFS has the potential of altering the public health system for better if it gets
an opportunity to actually induct public sector functionaries also as fellows.
CHFS has the potential to tap into the potential pool of young graduates in
the field of health in India, provided the system is adapted in other states of
India along with the networking with CHC.
It also has a potential to be modified to fit into a formal degree program as
and when CHC will develop into an Alternative Learning Centre.
THREATS:
Exclusive pressure on Dr.Ravi and Dr.Thelma as the chief-mentors cannot
continue for long. There has to be at least two more senior people to share the
responsibility and reduce the inhuman pressures on them.
The evolution of CHC into a school of community health may result in the
sacrifice of the ‘open-structured’ CHFS for more formal degree programs;
which would rob off opportunities for young fellows like me with an open
mind to explore all the possibilities of community health before deciding on a
focal issue.
42
TO ‘SEARCH’ IN SEARCH OF KNOWLEDGE, INSPIRATION….
BACK GROUND:
As a part of my fellowship program in Community Medicine in CHC in collaboration
with Sir Ratan Tata Trust in Mumbai, & in accordance with my learning objectives, I
had a long discussion with my mentor Dr.Thelma Narayan in November identifying
the place for my educational visit, to further my knowledge of Community Medicine
& experience a ‘real’ community health project at work. Since I had ‘Child Health’ as
my priority area, she suggested ‘SEARCH’(Society for Education, Action & Research
in Community Health) located in Gadchirolli district of Maharashtra as a possibility.
She talked with great love & respect about ‘SEARCH’ & Dr.Abhay Bang & Dr.Rani
Bang, the motive forces behind SEARCH. She introduced me to their pioneering work
in the field of Community Health, especially their ground-breaking research aimed at
improving the health status of rural people especially the much neglected woman &
child community, within community setup, using community participation &
community resources as the tools for community empowerment! She also asked me to
read the Anubhav4 series on ‘SEARCH’ to find out more of the same. The book gave
me a bird’s eye view of the works being carried out in ‘SEARCH’ & their research
programs excited me to no bounds. I immediately decided ‘SEARCH’ is one place I
ought to visit & study. With Dr.Thelma Narayan’s help I was able to arrange the same
& Dr.Abhay Bang kindly agreed to take me in for a month, between 23rd November
2004 & 24th December 2004. As agreed, I spent a month in ‘SEARCH’ between
November & December of 2004. I try to look back at my experience in SEARCH
through this report.
THE PROCESS OF LEARNING IN ‘SEARCH’:
My program of learning for the first week of my stay in SEARCH was ready even
before I reached Shodhgram! I was really taken aback by their warm welcome &
diligent planning. Also, I had a chance to meet Dr.Abhay Bang on the first day itself.
4
Anubhav is a series of books published by VHAI to disseminate information about various pioneering NGOs
in health field & their work in brief.
43
The first week of my visit consisted of having a bird’s eye view of all the programs in
progress in SEARCH. The methodologies adapted were:
Presentation of various health programs by the team members undertaking
the program
Discussion of the health programs with the team members
Literature review of the programs
Field visits to different villages under the health program of SEARCH to
practically witness the various health interventions under taken by trained
village health workers
Discussion of the field work with village health workers
Thus at the end of one week, I had a fair amount of knowledge about the various
community health programs undertaken by SEARCH.
I reported my learnings from the enriching experience to Dr.Abhay Bang5 & also
presented to him my learning objectives in SEARCH. He, with a suggestion that the
first three of my objectives as realistic, impressed me of the fact that the process of
learning research methods in community takes lots of time & energy along with
concentrated reading! Also, he felt that the future works I had suggested were not
realistic due to the constraint of time. Instead he suggested me to undertake case
studies of three different community health programs in progress in SEARCH. He
explained to me of the relevance of such a study with following points:
I would vicariously experience the process of planning, implementation,
evaluation & fine tuning of health programs, which is the crux of community
health work.
Also, the process would help me identify the dynamics of the working of an
NGO involved in community health program.
In addition the topics chosen were such that, each topic would take me
through one of the most important determinant of community health. In toto I
was to study the whole range of determinants of community health!
5
Annexure No.1. Learning objectives of Dr.Vinay in SEARCH
44
Study of Tribal malaria control program (TMCP), alcohol deaddiction
program & study of hidden child mortality in Maharashtra were the
programs selected for my study.
I was given freedom & flexibility regarding the methods I would like to use to
do case studies. The various methods I used were identical with the methods I
followed in the first week, already mentioned, but with more depth.
I first undertook the study TMCP6. At the end of study & reporting, the process of
which took me two weeks, Dr.Abhay Bang gave me an option to either follow my
learning program as planned earlier or to continue my study in malaria further & try
& suggest amendments for the short comings I pointed out in my case study. I was
more than happy to continue on malaria program. But in the next one week I was in
SEARCH, due to lack of data, both from SEARCH & Government malaria office, I
was unable to complete the process I had started.
LESSONS LEARNT:
My stay in SEARCH was one of the most productive periods of my life in the sense
of both professional & personal learnings. All my learnings are mentioned in the
reports I am attaching to this as annexures. The lessons learnt cover almost the entire
gamut of learning objectives we (Myself & Dr.Thelma) had set forth for myself at the
beginning of my fellowship in CHC!
CONCLUSION:
My study visit to SEARCH was one of the most profound experiences of my life. I
came back with new found knowledge in community health & also with personal
enrichment. More than anything else, I was enthused to pursue my future life in
community medicine & my earlier decision to do the same was further reinforced.
Retrospectively my study visit to SEARCHI would rate as one of the most memorable
& productive periods of my life, not just for the lessons it taught me concerning
community health but also for its profound effect on my consciousness. It was in
6
Annexure No.2. Case Study Of ‘Tribal Malaria Control Program’ Undertaken By ‘Search’ In 36 Tribal
Villages Of Gadchiroli
District Of Maharastra
45
‘SEARCH’ I visualized my thoughts & dreams in concrete form. It dispelled all my
apprehensions in a single blow & helped me to find the ‘mission of my life’! Thus I
consider my visit to ‘SEARCH’ as a ‘pilgrimage’ rather than a study visit!
46
ANNEXURE No.1. MY REPORT AFTER FIRST WEEK IN ‘SEARCH’
Learning objectives of Dr.Vinay.V. in SEARCH:
1. To have a first hand experience of the dynamics & working of a ‘community
health organization’.
2. To visualize & learn practically the various components of a ‘community
health program’, at the level of community & involving communities
themselves, aimed at improvement & promotion of health status of children
in a community.
3. To understand the formation, functioning & growth of SEARCH as a model
NGO involved in community health research.
4. To learn the skills for research in community health, with special emphasis on
child health.
My experiences in SEARCH so-far:
1. HBNC (home based neonatal care):
•
A novel concept formulated in addressing the much neglected, but a
very vital component of child health i.e. HOME BASED NEONATAL CARE. It
also proved that it is practically possible to place the ‘health’ of communities in
their own hands & it is the surest & cheapest way of achieving ‘Health for All’.
•
HBNC appears to me all the more important & unique because of the
following reasons:
1. It was a long time since there was a felt need within the scientific
community for an affordable, accessible, acceptable & reliable program to
address the health problems of neonates to consolidate & move ahead in
improving the health status of children world wide. To think of SEARCH
based in some remote village with a staff of less than 100 people finds the
solution is unfathomable in the realms of common imagination.
47
2. The ‘operation’ of HBNC is independent of socio-economic status of the
community, both in the process & expected outputs, making it a replicable
model across wide areas of India & the world. Also it means that the
‘confounding’ factor of low SES coming in the way of implementation of
many initiatives is not to be so in HBNC.
3. The various ‘components’ of HBNC are so modeled that even if HBNC
is not adopted as a ‘whole’, even a few components when replicated will
be effective in the improvement of child health status. This type of
flexibility in the operation of the program makes it all the more unique &
important.
4. HBNC symbolizes the true spirit of ‘Community Empowerment’.
2. Multitude of subjects, on which research was & is being done by SEARCH.
3. Field experiences:
1. Visit to Kannar Tola, a tribal village where I had a chance to meet with a
Sanghi named Kunda. I also had a chance to see Youth Education
Program in progress.
2. Visit to Rajghatta & see the female VHW Mrs.Maya Aegnutalwar at
work in HBNC.
3. To see Mrs.Kajubai Undirwada, female VHW of Ambeshivani, injecting
Vit-K to a 6- hour old neonate with the skill of a trained nurse!
4. A small visit to Mr.Purshottam Bavane, a male VHW & to Mrs.Birjulabai Tute,
a TBA.
5. An overview of SEARCH’s fight against the foremost social evil, Alcoholism. I
felt it to be different from other initiatives of the same kind in the following
ways:
1. The movement was able to have a legislation passed from the
government declaring Gadchirolli to be an Alcohol free district, both in
the sense of marketing & drinking of alcohol! The approach of
Dr.Abhay Bang of providing a breakup of the public sector revenue &
48
expenditure due to sale of alcohol to persuade Government is
commendable.
2. The ‘sobriety rate’ achieved by the deaddiction cell of SEARCH (about
58%) is substantially high compared to other such initiatives
worldwide.
6. The fruitful relationship SEARCH has developed with tribal people & the
means of ‘involving tribal community’ in their own health program through
‘Arogya Sansad’ is very interesting & thought worthy.
7. My first experience of ‘community life’.
Lessons learnt so-far:
1.
‘Dreams’, however preposterous they may sound initially, are the ‘Motive
Forces’ behind any human achievement.
2.
I have learnt deal about ‘Community Health’ & its implications & many a
doubts in my mind regarding the working of ‘Community Health’ are
cleared now. To name a few:
•
The initial few years of any community health project though are
frustrating & too often scarcely rewarding in terms of measurable
outputs achieved, are very crucial for the development of good rapport
& partnership with the community. This is the foundation, on the
strength of which the future of the project depends upon.
•
‘Clarity of vision & goal’ is very important while working in a
community or else, we will be so overwhelmed by multitude of
problems beseeching the community that in the process of addressing
them; we may find ourselves lost in the community without any
fruitful progress.
•
‘Prioritizing’ of the problems is very important.
•
‘Patience’ is the key to success in this field of work. With due respect to
Dr.Abhay Bang, if I had the vision of HBNC, probably I would have
rushed up doing it within a year or two (& probably compromised
49
with the quality of work & jeopardizing its success!). But SEARCH,
with its HBNC project has given me the clarity of vision regarding the
conceptualization, formulation, implementation, evaluation & finetuning of a community based program.
•
SEARCH also solved a nagging doubt in my mind regarding the work
of ‘health promoting organization’. My doubt was, whether a
successful & sustainable improvement in the health of people can be
achieved without an ‘ultra-modern, super specialty hospital’ &
substantial change in ‘socio-economic status’ of the community.
SEARCH has effectively demonstrated & proved beyond doubt that
the answer to the above question is a bold ‘YES’.
•
SEARCH has reinforced my faith in rational, systematic & scientific
approach to solve any problem. It has added patience, teamwork&
technical expertise to the list.
•
SEARCHS’s experiments have more than proved to me about the
effectiveness & importance of appropriate technology in addressing
community health problems.
•
‘Prime people’ involved in community health projects should live
within the community.
•
A lot of pre-project preparation & an extreme clarity of ideas is a
requisite for the success of a project.
Probable areas in which I can work:
(This is what I thought of. It needs to be discussed with revered Dr.Abhay Bang &
final decision will be taken in consultation with him, according to his suggestion)
1. Study of the importance & causes of low birth weight in babies & possible
interventions to decrease the incidence of the same.
3.
Evaluation of the effect of health education component of HBNC on the
desirable
course & out-come of pregnancy.
4.
Effect of indoor air pollution on the health status of children.
50
5.
Study of cultural & traditional practices of the community affecting the
pregnancy & pregnancy outcome.
6.
Comparison of children managed for birth asphyxia by VHW with
normal/birth asphyxiated hospital managed children.
7.
51
Preparation of health education materials.
ANNEXURE No.2. CASE STUDY OF ‘TRIBAL
MALARIA CONTROL PROGRAM’ UNDERTAKEN
BY ‘SEARCH’ IN 36 TRIBAL VILLAGES OF
GADCHIROLI DISTRICT OF MAHARASTRA
52
CONTENTS
Abbreviations used in this document
Background
Part one: The conceptualization and implementation of ‘Tribal Malaria Control
Program’
1. Getting started
2. Seeking community participation in the formulation of health program
3. The process of planning the program
4. The ‘program’ proper
5. The process
6. The work in the community
7. The ‘me-too’ syndrome
8. The ‘KAP’ study & fine tuning of the program
9. Moving forward
10. Midterm evaluation
11. The first big jolt to ‘TMCP’
12. Time to pause, reflect, & continue
13. Conclusions & some posers
Part two: ’Tribal Malaria Control Program’ as a model ‘community health program’:
1. A strong & enlightened leadership
2. A
strong
partnership
with
the
community
even
before
the
conceptualization of ‘TMCP’
3. ‘Community involvement’ at each step of the program
4. Importance of understanding & respecting the community
5. Clear vision of ‘oneself’ & the ‘process’
6. Adequate & appropriate support of ‘THV’ by ‘SEARCH’
7. Community capacity building
8. The ‘unique structure’ of the program
9. Facing adversities boldly, admitting mistakes & learning from mistakes
10. ‘Short comings’ in ‘TMCP’
53
ABBREVIATIONS USED IN THIS DOCUMENT
API
Annual Parasitic Index
BSE
Blood Smear Examination
IRS
Indoor Residual Spraying
ITN
Insecticide Treated mosquito Net
KAP
Knowledge, Attitude & Practice
MDS
Maa Danteshwari Sevak
NGO
Non Governmental Organization
OPD
Out Patient Department
SEARCH
Society for Education, Action, and Research in Community Health
Tab.
Tablet
THV
Tribal Health Volunteer
TMCP
Tribal Malaria Control Program
TVHP
Tribal Village Health Program
VHAI
Voluntary Health Association of India
WHO
World Health Organization
54
CASE STUDY OF TRIBAL MALARIA CONTROL PROGRAM UNDERTAKEN
BY ‘SEARCH’ IN 36 TRIBAL VILLAGES OF GADCHIROLI DISTRICT OF
MAHARASTRA
BACKGROUND:
Malaria is an infectious disease caused by parasites of genus Plasmodium & transmitted
to human beings by certain species of infected female anopheles mosquito. Although
the disease is known to mankind & studied with great aplomb since times immemorial,
to both cure & control the disease, it is still the designated ‘The No.1 Priority Tropical
Disease’ of WHO7. The statistics, both from the world & from India, speak volumes for
the justification of the above dubious distinction of malaria. In the world, about 100
countries are malarious with 2.4 billion people at risk, about 300-500 million cases are
reported every year, & 1.5-3 million people are killed annually8. In India, the official
statistics say that there were 2 million cases of malaria with 972 deaths in 20002.
However, with chronic under reporting being a major constraint in India, the deaths
due to malaria is estimated to be 737953 annually. In addition, given the fact that malaria
occurs predominantly in agrarian & tribal regions with lot of morbidity & economic
strain on already stressed people, it has been considered as one of the major public
health problems in India & worldwide, with many resources earmarked to reduce &
control it.
Gadchiroli is one of the underdeveloped, tribal districts of Maharastra with a
population of approximately 9.7lakhs4. Being a tribal district with lots of forested land &
the main occupation of the people being agriculture, both of which are identified risk
factors for high incidence of malaria, it is considered to be an endemic region for
malaria with API>5. Add to this the poor outreach of the health facilities, general apathy
7
8
WHO home website
Park textbook of Preventive & Social medicine, 17th edition
3 Towards an appropriate malaria control strategy, VHAI
4
Statistic information based on 2001 India census
55
of the successive governments to address the problem of tribals, the inadequacy of
successive national malaria control programs, both in design & implementation, & the
repressed voice of tribals & one can imagine the plight of people left to tend for
themselves. No wonder the health indicators of the district are poor & one among the
worst in Maharastra. The incidence of malaria was high with a high case fatality rate, &
very few people assessed the scarce health facilities when sick. In addition, there were
many regular & focal outbreaks of malaria epidemics, resulting in added mortality &
morbidity of the people of Gadchiroli. In toto, malaria was one of the important causes
for the poor health status of the people of Gadchiroli.
It was in 1986 that a NGO by name SEARCH (Society for Education, Action and
Research in Community Health) was setup by a dedicated & inspired doctor couple.
They came to Gadchiroli with two small kids, an ambulance, three assistants, lots of
knowledge & high ideals to start their work in ‘community research & action’ with an
objective of ‘Arogya Swaraj’. Though their first undertaking was a ‘failure’, the sheer
strength of their motivation & dedication had won many a people in the region & they
started their work independently in the community of Gadchiroli. At the same time they
started reaching out to the tribal people in the district through the weekly OPD for
tribals in Chaathgaav, a small village 19 km from the district headquarters & a center for
the tribal villages of the region & organizing health camps within the tribal villages on
demand from tribals & when they were badly affected by epidemics of diseases. Their
working, knowledge & partnership with tribals of the region were further strengthened
in 1993 when SEARCH moved to its own campus ‘Shod gram’, a residential quarters for
the staff of SEARCH along with a ‘Tribal Friendly Hospital’5, just 2kms from
Chaathgaav. A fruitful & faithful partnership between SEARCH & tribals was thus in
place by the end of 1993.
5
Building Community Partnership & bringing in Community Involvement
56
PART ONE: THE CONCEPTUALIZATION AND IMPLEMENTATION OF
‘TRIBAL MALARIA CONTROL PROGRAM
GETTING STARTED:
It was in 1998 that the team in SEARCH decided to work more closely with the tribals &
to take up ‘Community empowerment’ in tribal areas to address their health care needs
& problems. An all-important lesson that, there will be no community involvement in a
health program if the felt need of the community is not addressed, learnt by SEARCH in
1988-89 through their ‘Sickle Cell Anemia Study In Tribals of Gadchiroli’6 was not
forgotten. Keeping this lesson in mind, the team of SEARCH decided to involve tribals
in their own health program from the beginning. To realize the same, a ‘Tribal Jatra’7
was organized for 2 days within the campus of SEARCH in April 1998 & more than
1000 tribals, along with their leaders (zamindar, manzi, bhoomia, patel, traditional
healers), from conveniently & randomly selected 50 tribal villages8 attended the Jatra
with great enthusiasm. The Jatra was used as a platform to sensitize the tribals on issues
related to health & further the bond between SEARCH & tribals. It was during this Jatra
that a ‘Health Assembly’9 of 50 villages, with representatives from all villages, was
formed to provide a platform for the community to address their problems & discuss
the possible solutions. The Jatra was successful & ended with a decision to have the
same annually.
The team of SEARCH was ready to take the big plunge during the 2nd Health Assembly
in April 1999. It asked the community to rank their health problems according to their
own priority i.e. ‘Felt Need’ of the tribals. After a laborious process of ‘Voting’10, three
problems were identified as the priority health problems namely:
Malaria
Diarrhea
Backache
6
The importance of ‘Felt Needs’
The actual process of ‘Community Involvement’
8
The importance of knowing one’s limitations
9
The health assembly
10
Identifying the Felt Needs
7
57
This was a shock to SEARCH, which was thinking of anemia, child health, & such other
‘conventional health need’ as possible outcomes. Nevertheless, SEARCH decided that it
would take up these as the ‘felt health needs of the community’ & try to address them
with ‘active participation’ from the community.
In the staff meeting of SEARCH, that followed the Health Assembly 1999, the following
decisions were taken to address the problems identified:
A ‘Participatory Approach’ to find the solution, will be followed,
A community based solution & not a hospital based solution to be formulated to
address the problems &
A committee for the ‘Tribal Village Health Program’ (TVHP) was formed with
following members
•
Dr.Abhay Bang & Dr.Rani Bang- Chief Advisors & Technical Advisors
•
Mr.Tushaar Ghorkade-Program Coordinator
•
Mr.Mahadev Satpute & Mr.Haridas Sakhare -Supervisors
SEEKING ‘COMMUNITY PARTIPATION’ IN THE FORMULATION OF THE
HEALTH PROGRAM:
To seek the ‘Participation’ of the community in the formulation of the solution &
prepare a comprehensive program to address their health needs, the SEARCH team of
TVHP went promptly to each tribal village with the report of second Health Assembly
& asked their ‘Solution’ to address their own problems7. The tribals initially thought of
camp based medical service as the solution. However, when they were made to realize
the futility of the same in the long run, in terms of sustainability & regularity, they had
to rethink on their solution. Later the tribals came out with the age-old, nevertheless the
best among all possible solutions. They suggested that, they will pick two volunteers
from each village & asked SEARCH to train & supervise them. SEARCH was glad at
such a solution, as it had the same but unexpressed solution in its mind. So a ‘Plan’ of
58
Tribal Health Program with the formation of an army of voluntary health workers was
formalized.
SEARCH, with lessons learnt from the experiences of other NGOs with similar
programs in India & elsewhere, wanted ‘genuine’ community participation & didn’t
want to make the tribals ‘dependents’ on SEARCH11. To materialize the same, it put
forth the following pre-conditions for the tribals:
That any village willing to join the program must select two volunteers from the
village residents themselves & volunteers will not be remunerated by SEARCH
in any ways.
That all villages wanting to join should collect 1kg of rice from each household of
that village, out of which SEARCH will keep 50% & rest 50%, will be given to the
volunteers in recognition of their services.
A consent letter from the village to SEARCH signed by the members, stating their
acceptance of the above.
In exchange, SEARCH agreed to provide the following:
Training to the THV
Supervision of the work of THV in community
Technical assistance
Laboratory facilities for the Tribal Health Program
Medicines to cover the ‘identified needs’
Hospital services to those in need at a nominal cost
Even though the tribals themselves had sought 1 week time to meet the conditions of
SEARCH, it was only after an agonizing wait of 2 months that 14 villages (out of 50
villages!) came forward to join the program with all the prerequisites met! SEARCH was
happy to work with them even though they were less in number than envisaged earlier,
as the work would continue with clear ‘conscience’ that the ‘real community
participation’ has been achieved.
11
How to test the ‘real’ willingness of the community?
59
THE PROCESS OF PLANNING THE PROGRAM:
The process of giving ‘the structure’ to the envisaged Tribal Malaria Control program,
along with two other health problems, began with earnest efforts within SEARCH,
starting with a review meeting to discuss the dialogue that happened with tribals &
formulate the plan of action.
First, to increase the acceptance of Tribal Health Volunteers (THV) & make the program
successful, they were christened as ‘Maa Danteshwari Sewak’ (MDS)12, meaning
messenger of God Danteshwari, the reigning God of tribals who commanded great
respect & belief of tribal people.
The second step was to find the actual situation & reasons behind the high prevalence of
malaria in the communities. With retrospective analysis into the experiences of
SEARCH in these villages & an informal discussion with MDSs, the following ideas
emerged:
The villages were malaria endemic regions, with seasonal type of transmission
of malaria & with the risk for periodic epidemics.
Even though the important strain of Plasmodium in the region was the dreaded
falciparum, there was considerable number of infection due to Plasmodium
vivax also, especially in the months of January & February.
The various reasons for high incidence of malaria in the region were identified
as:
•
The predominant occupation of the people was agriculture.
•
People ventured into the forest frequently with little personal protection
from vectors.
•
A very conducive climate for high transmission of malaria
•
Poor sanitation in villages with problems of ‘open bathroom’ & water
logging providing the perfect setting for breeding of mosquitoes.
•
The ignorance of tribal people about diseases in general & malaria in
specific, reflected in their attitude & behavior towards diseases, such as
12
Importance of understanding & respecting local customs & traditions
60
not using bed nets, opposing IRS, seeking health care from ‘traditional
healers’, etc.
•
The poor outreach of Government health services.
Then, the committee of TVHP of SEARCH decided that all THV would be given
residential, full time training for a week within the campus of SEARCH, to serve as a
link between the tribal community & SEARCH & also to work as village health workers
to cater to the basic health needs of the tribal community in general & malaria, diarrhea
& backache in particular. The two supervisors would supervise the work of THV in the
field & help them in their difficulties & doubts. One weekly meeting of the supervisors
& technical team of SEARCH would be held every Saturday to review the ongoing
program, address any difficulties, & maintain the supply chain. In addition, it was
decided that refresher training would be held for THV every 6 months. The stock taking
was to be at the end of the year & with consultation of the tribal community at the time
of 3rd Health Assembly.
THE ‘PROGRAM’ PROPER:
The final touches for Tribal Malaria Control Program were given after a discussion
within SEARCH considering all the above-mentioned points. It was thought that the
program must be undertaken in a phased manner13, as the ‘capacity building’14 within
the tribals would be a slow process. The final draft for the initial proposed program was
as follows:
AIM: To reduce the incidence of malaria within the intervention villages, by using
participatory community approach, to a level, where malaria ceases to be a priority
public health problem.
OBJECTIVES:
13
14
Importance of Phasing a program
The process of Capacity Building
61
To provide prompt & timely curative services to the affected people in the
intervention villages
INTERVENTIONS:
Training of THV to deal with ‘presumed’ malaria cases & supervision of their
work by SEARCH
Spreading health education within the community with the help of THV, to
suspect malaria & seek timely medical care
Referral health services through the hospital
Setting up of village clinics during epidemics
Ambulance facilities to shift serious & complicated cases, to the hospital
MIDTERM EVALUATION GOAL:
The feedback from the community at the end of one year of the program,
about what is their perception about the mortality & morbidity within their
community due to malaria as compared to previous years, was the proposed
tool for the midterm evaluation of the program.
DUTIES OF THV (UNDER TMCP):
To serve as a link between Tribal community & SEARCH
Diagnosis & treatment of self-presenting & actively detected fever cases
•
Make the diagnosis, take & forward to SEARCH, through supervisors,
the thick blood smear of the patient & give treatment (excepting
pregnant woman whom they were advised to refer to a hospital
directly)
•
Check the response to treatment
•
Refer to a hospital (any hospital including SEARCH), if response to
treatment is not satisfactory or the patient is very sick, with a referral
slip
•
Make inventory of stock of drugs, & reorder as appropriate
62
•
Collect the reports of BSE & give radical treatment to patients with
positive BSE
•
Record & report activities to supervisor
To spread basic health education of malaria within their communities
DUTIES OF SUPERVISORS (UNDER TMCP):
On-field supervision of the work of THV i.e. To acknowledge, react & guide
the THV
A link between THV & SEARCH for exchange of slides & reports
Replenish stock at community level, make inventory of own stock & reorder
as appropriate
Periodic on-field retraining of THV
Consolidation of the work at community level & reporting the same to
SEARCH every week
Observation of current trends of malaria within the tribal community &
reporting the same to SEARCH
COMMITMENT OF ‘SEARCH’ (UNDER TMCP):
Training of the THV
Supervise the work of THV in community through the supervisors & weekly
meetings
Technical assistance in the form of
•
Development of the practical rules for diagnosis, treatment, referral, &
promote their use by one & all involved in the program
63
•
Laboratory support to TMCP
•
Refresher training of the THV incorporating the following:
Revision of their knowledge & skills & fine tuning them
Reporting to them their mistakes, & discussing the possible solutions
Addressing their problems
Up gradation of their knowledge & skills
Restoring & improving their motivation
•
Evaluation of the work of THVs & grading the same with the help of
supervisors
Regular supply of materials required for the optimum working of THV in the
community
•
Supply of medicines
•
Supply of slides, lancets, cotton, spirit & such other materials necessary to
collect blood smear
•
Supply of reference materials for dealing with the community like mass
health education booklets, information sheet on drug dosages, criteria for
referral, etc.
•
Supply of stationery to maintain the records
Ambulance services to shift serious cases to the hospital
Hospital services to those in need, at a nominal cost
Surveillance of the whole program & take appropriate actions when deemed
necessary
In the true spirits of any community health programs, TMCP was decided to be a
flexible & continuously modifiable program in terms of focus, priority, content, actions,
& any such deemed necessary, by the community & SEARCH.
THE PROCESS:
WORKS WITHIN ‘SEARCH’:
TVHP committee in SEARCH met & discussed on the finer aspects of the program. The
list of venue, duration, methods, content, & trainers to be used in the training program
was finalized. The ‘practical rules’ for various activities of THV under TMCP were also
drawn, as follows:
Rules for presumptive diagnosis of malaria:
Fever with chills &/or rigors
Alternate day fever
64
Therapeutic guidelines:
Any case of fever (excepting cases specified under referral guidelines), self
presenting or actively detected, should be started with presumptive treatment
of malaria with Tab.Chloroquine, after the blood smear is taken, outlined as
follows:
Age
of
the 1ST DAY
patient
(Dose
2ND DAY
of (Dose
3RD DAY
of (Dose
of
chloroquine in chloroquine in chloroquine in
mg)
mg)
mg)
>12 Years
1200
600
600
6-12 Years
600
600
300
3-6 Years
150
75
75
1-3 Years
75
75
37.5
0-1 Years
37.5
37.5
18.75
If the BSE of the slide turns out to be positive to malaria parasite, the patient
should be given radical treatment with Tab.Primaquine 30mg/day for 5 days.
Guidelines for referral:
THVs were trained to refer cases with following characteristics to a nearby hospital at
the earliest:
All cases started with the presumptive treatment of malaria & fever not
subsiding within 3 days of starting the treatment
All febrile illness in children with one or more of the following symptoms:
65
•
Altered consciousness, lethargy or coma
•
Convulsions
•
Not able to drink
•
Persistent vomiting
•
Severe pallor/anemia
•
Breathing difficulties
•
Yellow eyes
•
Speech ataxia
All febrile illness in adults with any of the above characteristics &/or dark
&/or limited production of urine
All pregnant women with signs & symptoms consistent with malaria
THV were supplied with referral slips & were informed to use the ambulance facility
provided by SEARCH.
Operational guidelines:
Each supervisor was allocated 7 villages each & were supposed to visit at
least one village each day & hence visit their whole area once every week.
All slides collected in a week by all THV are to be collected by the supervisors
& deposit of the same in SEARCH on Saturday, the weekly meting day. They
also had to collect all reports of the previous week on Saturday & distribute it
to all THV by Monday, so that the maximum lag period for a THV to get BSE
report was not more than a week.
The supply of drugs & other materials & the record of the same was the
responsibility of supervisors
Weekly meetings to be held every Saturday in SEARCH, between supervisors
& other members of TVHP to discuss, evaluate & find appropriates solutions
to on-field problems if any
With all these preparations, SEARCH was now ready to train the THV & carry its TMCP
forward.
TRAINING OF THV:
The first step of the program was to train the THV to carry out their envisaged functions
effectively. SEARCH realized the potential & importance of ‘an army of motivated,
trained, organized, & supervised THV’ to realize the goal of true community
empowerment, it had set forth to achieve. Hence the training proposed by SEARCH
66
included along with the impartation of knowledge & skill, the development of ‘right
attitude’15.
The training was planned to be a full time affair, within the campus of SEARCH for 7
days initially. The trainers were the members of TVHP committee, who had good
experience in the same. The training objective was to prepare & orient THV, to carry out
their envisaged functions (mentioned earlier) effectively. SEARCH consciously avoided
the ‘traditional didactic method’ of teaching & adopted a much more interactive &
mutually beneficial ‘popular (problem-posing)’ method of training16. The various
methods used included role-plays, slide shows, simulation games, demonstration,
group discussions, and case studies. Also the skill of preparation of a thick blood smear
of a patient suspected as a malaria case, was imparted with much delicacy & patience.
The THVs were also informed of the test at the end of the training period & warned
that, any THV failing the test will not be given the title of MDS, until he/she retakes the
test & passes it. It was also seen that the THVs were not overburdened with the amount
of learning, by restricting the ‘classes’ to a maximum of one hour at a stretch with
interspersed sports & games to freshen them up. The training was very participatory &
demonstrative in nature & THV were made to ‘see’ what they learn.
At the end of the training period, an evaluation of the THV was carried out through a
questionnaire designed to test their newfound knowledge & skill. To the astonishment
of SEARCH, all THV passed the test with flying colours! The army was now ready to
undertake the mission of Tribal Village Health Program.
THE WORK IN THE COMMUNITY:
With all the preparations outlined earlier, the TMCP was ready to be implemented in
the 14 villages. The army of young, enthusiastic, trained & prepared THV were let loose
in the field to realize the things they learnt in SEARCH, under the Supervisors. Even
15
16
The ‘unique’ training
Didactic VS Popular method of teaching
67
though there were many initial glitches in the implementation process, THVs carried on
their duties with vigor & were able to overcome most of the glitches through their
newly acquired knowledge, skills & above all, the ‘leadership qualities’ 17imbibed in
them by SEARCH. They were constantly helped by the supervisors in the field & also
encouraged by SEARCH to formulate their own ‘solutions’ to overcome the on-field
problems. Spurred by the enthusiasm & dedication of THV & constant support by
SEARCH, the TMCP along with other components of TVHP became a great success. The
health status of the people of 14 villages saw a dramatic improvement & mortality &
morbidity due to malaria fell sharply (as perceived by the community) within 6 months
of the start of the program. The communities thrived on a new found ‘empowerment’18.
THE ‘ME-TOO’ SYNDROME:
The TVHP had such a visible success that, just after 6 months of its inception, another 22
tribal villages which had not joined the program initially in spite of the invitation by
SEARCH, now realized their mistake & came forward to join the TVHP with all the
prerequisites met! This happened as a spontaneous process following the on-field
implementation of TVHP, without any goading from SEARCH!
This came as a welcome surprise to SEARCH & it decided to accept the request of the
latecomers. At the same time, SEARCH thought that if this was let to continue there
would be the problem of other villages willing to join the program at sporadic intervals
posing an ‘operational difficulty’, & hence decided to restrict its activities to these 36
villages only.
Having decided thus, SEARCH took to training the THV & implementation of its TVHP
in 22 latecomers. Thus by the end of 6 months of initiating the TVHP, 36 villages had
joined the movement & TVHP became active in all these 36 villages.
17
18
The field difficulties & the solutions
The ‘Human Flourishing’
68
THE ‘KAP’ STUDY & FINE TUNING OF THE PROGRAM:
Once the fieldwork by THV started moving smoothly & the problem of treatment of
acute malaria has been addressed, SEARCH started to think of incorporating the much
important & long time solution, ‘preventive practices’ into TMCP & make it a
comprehensive program. As a part of initiating the same, it started a KAP (Knowledge,
Attitude & Practice) study of the people of 36 villages towards malaria, to select &
implement the appropriate preventive practices. The study was done using THVs & its
outcome was as follows:
People’s knowledge of malaria was unacceptably low
People resisted IRS19 from governmental workers because of the following
reasons:
•
Didn’t know the use of spraying
•
Thought that it was an attack on their privacy
•
Complained of bad after effects of spraying like bad after smell, white
spots on the wall, etc
•
Thought that it would destroy the quality of stored food grains
•
As it was against their tradition to let anyone meddle with their ‘place of
worship’
People didn’t know about bed nets & used to sleep in open places
People used to spend most of the times in forest & paddy fields, both of which
were swarming with mosquitoes, with little or no personal protection from
mosquito bite
The general sanitation of villages was poor & offered a fertile ground for
breeding of mosquitoes
Once the study identified the problem areas, it was the time to formulate solutions. The
TVHP committee sat with THV to take stock & identify solutions. The committee
elaborated on the findings & presented to THVs the possible solutions that were in use
19
Importance of assessment of KAP of a community & address them before undertaking any interventions
69
worldwide. THVs were encouraged to go through the suggestions & to pick & suggest
their own solutions appropriate to their community. The solutions emerged were
simple, albeit very effective ones.
Solutions ‘proper’:
To spread health education among the community regarding the mode of
transmission of malaria & to emphasize on them the importance of IRS, personal
protection against mosquito bites by using bed nets & to maintain a clean village
to control malaria.
Encouraging & motivating the communities to take a collective action in the form
of novel ‘Shramadhan’ to improve the sanitation of village.
Interventions & their methods:
Health education both at community group level & individual level, to
emphasize the mode of transmission of malaria, the importance of IRS, use of bed
nets & to maintain a clean village to control malaria. The various methods of
health education used were as follows:
•
At the community level:
Slide shows depicting mosquitoes, their life cycle, breeding
grounds, etc
Role plays to emphasize the disease, importance of seeking care,
personal & community protection against malaria
Demonstrations of breeding ground for mosquitoes in their own
village, the beneficial effect of IRS, etc.
•
Posters spreading more health education on malaria
At the individual level
House to house visit by THV spreading awareness about malaria &
various methods of controlling the disease
The novel concept of ‘Shramadhan’20 was initiated in five villages as a pilot
program to test the strength of ‘united community action’ to its own
20
The strength of united community action & the importance of its use
70
development. It was used as a tool to improve the sanitation of the village by
‘voluntary contribution’ of work by each member of the community, to reduce
the mosquito breeding sites by filling in the water holes & pools in the village
with mud & stones & also to provide a good system of sanitation by proper
channeling of sewage & construction of soak pits.
Outputs:
Demand on the ITN started pouring in
Spraying was accepted within the community & there was even ‘demand’ from
the community for IRS
‘Shramadhan’ became hugely successful & the concept caught up soon with the
well-organized tribal community & many communities took the initiative
themselves & started duplicating the novel process, without waiting for the
SEARCH to suggest them21
More problems!:
SEARCH never wanted dependence & always a participatory approach from the
community. Now, there was the problem of how to meet the demand of ITN,
with the above two principles intact?
Even though IRS was getting accepted from the community, there were many
inherent problems related to it like,
•
The sprayers came in when the community was out in the fields to work
•
Many houses were missed due to various other reasons
More solutions! :
SEARCH with community’s participation was able to make arrangements for the
sale of ITN at a reasonable price of Rs.30 & more than 1500 families brought it! In
addition, THVs were trained to treat the nets at the village itself, thus fostering
real empowerment of the community!
21
This is community empowerment!
71
SEARCH wrote to the concerned department of the Government relating to the
problem faced by the community during IRS & made arrangements to see that
the village would be informed some days before the proposed spraying activity.
Now that the community knew in advance, the date of spraying, they started
taking ‘polo’ (the weekly off-day of tribals) on that day, so that all houses in the
community would have IRS under the strict supervision of THV22!
Now that community had bed nets, SEARCH wanted to know the actual use of the
same by the community. It was surprised that very few homes with ITNs were actually
using it! On enquiring, it found that though the community had brought ITNs, they did
not know how to use it! The onus again fell on SEARCH to teach them to use ITNs23.
MOVING FORWARD:
With so many activities going on in the field, it was the time to 3rd Health Assembly
once again. The activities undertaken by the SEARCH were endorsed in the assembly &
further demands, both by SEARCH & Tribal community, were put forward, &
discussed in the assembly. Some of the important problems addressed in the assembly
are as follows:
SEARCH felt that it was time to have more ‘supervisors’ & it had chosen five
THVs with excellent grading to be elevated to the post of ‘Sanghi’24, which was
accepted & highly endorsed by the tribal community. Since Sanghi was to be a
regular worker & envisaged by the SEARCH, SEARCH offered to pay
remuneration to the cadre. The various activities of Sanghi included:
•
Helping THVs in their difficulties
•
To overcome language barrier between tribals & SEARCH
•
To build rapport & collect information on health issues from tribals in a
systematic manner
•
To spread health education among tribals in a more regular way,
compared to THV
22
The importance of community participation!
The simple thing of understanding the community & the process of decentralization
24
The new human order
23
72
•
To act as links between THV & field supervisors of SEARCH
•
To help field supervisors of SEARCH to organize refresher & other such
trainings deemed necessary for tribals.
A great surprise was in offering to SEARCH! The ‘traditional healers’, whom the
‘civilized world’ despises & deprecates but the tribal community respects, & who
always looked at modern practice of medicine with the sense of a cynic, came
forward voluntarily25 to learn the ‘modern approach’ to tackle malaria! SEARCH
was too glad to let such an opportunity go unheard. It immediately agreed on the
proposal & arranged the training to the group & gave the group all the rights &
responsibilities enjoyed by THV. Thus, a newfound partnership was established
in the community.
Many other important decisions other than those concerning malaria were taken
& the partnership was on its path of further growth.
Following the assembly, the program was carried on with renewed vigor.
MIDTERM EALUATION:
Now that TVHP had firm roots entrenched in the community, SEARCH thought that
the time was ripe to give the program a more scientific & epidemiological touch to
maximize the effectiveness & efficiency of the program. To do the same it needed to
answer two questions namely:
What is the true magnitude of the problem of malaria in the community?
What is the impact of the TMCP on the prevalence & incidence of malaria in the
intervention villages?
To answer the same, SEARCH decided to conduct a cross-sectional study for estimating
the point prevalence of malaria fever in the villages in which TMCP was in progress
compared to adjacent villages without the benefit of TMCP. The study was designed
within SEARCH & using Sanghis, the survey was conducted in two malaria endemic
seasons namely August-2002 & Febrauary-2003.
25
Respecting the community & winning the adversaries
73
The findings of the study were very encouraging. Few important facts that emerged
from the study are as follows:
The point parasite incidence rate of Plasmodium was 0.2 in intervention villages
compared to 0.6 in control villages
Number of children suffering with malaria in intervention villages were 05
compared to 13 from control villages
56.2% of people in intervention villages had ITN compared to just 17.8 in control
villages
The study was a reassurance to SEARCH that all was going well within the TMCP, &
SEARCH continued forward with the program without further changes, until that
fateful year of 2003!
THE FIRST BIG JOLT TO ‘TMCP’:
2003 was a year the TMCP committee of SEARCH is not going to forget in a hurry! The
year did not start auspiciously as tribals were mired in draught due to failure of
monsoons in late 2002. However, as the year progressed & monsoons arrived, the region
experienced more than its normal share of rainfall. With it came the big epidemic26 of
malaria in the late months 2003, which nobody had anticipated. Scores of tribal people
were taken ill & even few deaths occurred due to the epidemic. It was not new to find
the Government apparatus caught off guard. However, it was a new experience for
SEARCH to visualize itself in such a situation.
Shocked as it was, SEARCH responded to the situation with all the urgency & vigor the
situation demanded. It threw open its gates to all the patients suspected of malaria &
the 20-bedded hospital was filled with more than 350 patients, admitted on the same
day. SEARCH mobilized all its resources & attended to all the patients with utmost care.
At the same time, the press spurred by the apathy & negligence showed by the
26
The importance of surveillance
74
Government apparatus in responding to the situation; highlighted the work of SEARCH
& took the Government to task. This coerced the Government to wake up & take
appropriate action. The main objective of epidemic control of both SEARCH &
Government were:
Provide relief to the affected population
Contain transmission, if possible in affected areas
Improve emergency preparedness in order to prevent future epidemics
SEARCH carried out many interventions to control the epidemic namely:
To provide early diagnosis & prompt treatment to suspected cases of malaria
It also arranged treatment camps to badly affected villages
It saw that the supply of drugs was prompt & uninterrupted to THV
It forced the Government machinery to take up IRS on a war footing
It also supplied biotech & other chemicals to control mosquito population
Thus, the epidemic of malaria was controlled with great difficulty & minimum casualty.
It was the right time for SEARCH to do the introspection & take corrective measures.
TIME TO ‘PAUSE’, REFLECT & CONTINUE:
The team in SEARCH was both embarrassed & feeling guilty about the calamity of
malaria epidemic of 2003. However, it faced the situation boldly & was prepared to
learn from the mistake27. It called an emergency meeting of all the members involved in
TMCP & started the retrospective analysis into what went wrong in TMCP. Some of the
questions posed were:
What was the cause for the epidemic?
What deficiencies prevented the prediction of epidemic?
What problems, if any, affected the early detection, confirmation of the epidemic
& timely response?
27
Facing adversity boldly, admitting mistakes & learning from mistakes
75
What rule should be followed in future to avoid such mistakes?
Answers were not forthcoming easily. However, the answers emerged in the end to all
these questions were:
There was no IRS within the village communities even once during 2003
There was no supply of deltamethrin from the government which hampered the
dipping of ITN in the villages
Drought in 2003 followed by heavy rainfall for longer duration in 2004 had
resulted in enormous increase in mosquito population
Complacency among the community about malaria control
Delay in treatment of early cases
By some sheer coincidence, it was vacation time in SEARCH when the epidemic
showed its ugly face
With these reasons, emerged the valuable lessons for SEARCH & it further fine-tuned
the TMCP through the lessons learnt:
It decided to have an early warning system in place
It decided to use the situation as a reinforcement of the value of preventive
measures in the community
It also learnt that proactive measures need to be followed if the Government
doesn’t fulfill its duties
Complacency is a great scrooge for any program was learnt in a hard way &
SEARCH decided to be on eternal vigilance hence forth
With these decisions, SEARCH carried on its TMCP forward & used the next i.e. 4th
Health Assembly to further the program & used the same to reinforce the community of
the importance of Shrmadhan, ITN & IRS use & introduced larvicidal Guppy fishes in
the villages for the control of further breeding of mosquitoes. One more round of health
education of the community on malaria was carried on with much gusto. In addition,
SEARCH started to analyze the data collected by the THVs every month.
76
CONCLUSION & SOME POSERS:
TMCP comes as a well-conceived community health program to address the felt need of
the community i.e. to control malaria. The process has incorporated all the prerequisites of a ‘good’ health program & stands as an example for a ‘model community
health program’. Despite the setback in the form of an epidemic in 2003, TMCP has been
able to largely address the problems posed by malaria in the tribal community. There is
a definite improvement in the knowledge, attitude, & practice of tribals regarding
malaria & its control in the community. There also seems to be a great decrease in
malaria mortality & morbidity in the community, even though the same cannot be
specified in quantitative terms, as there is absence of the baseline data.
In addition, in the process TMCP along with the other components of TVHP have been
able to give an unexpected gain to SEARCH’s vision of ‘community empowerment’.
They have slowly but surely evolved from being the vehicles of improving health to that
of overall community development. It is this aspect of the program that makes them the
‘true representatives’ of a model community health program.
Now, with an epidemic behind them, there is a disturbing trend of THVs demanding
remuneration for their service from SEARCH, the claim of which is being supported by
the community. This surely poses the most vital question of what is really meant by
‘Community Empowerment’? Is any such process, really possible? If ‘yes’, what is the
‘right path’ to do it? TMCP is now in its critical stage to find the answers to these
questions & move forward.
77
PART TWO: ‘TMCP’ AS A MODEL ‘COMMUNITY HEALTH PROGRAM’:
Why did the TMCP develop the way it is? To answer this, an attempt has been made
to step back & identify a list of issues which addresses both the factors that have
contributed to the success of TMCP in addressing the No.1 health problem of the
tribals & the factors that have limited the TMCP in attaining its full potential.
SEARCH has consciously tried to make TMCP a ‘true’ community health program
from times even before its inception. The various factors that classify TMCP as a
‘Model’ community health program are:
A STRONG & ENLIGHTENED LEADERSHIP:
Dr.Abhay Bang & Dr.Rani Bang started SEARCH in 1976. They had understood that,
the usual way of medical care, mainly curative & western medical model, was not
improving the health of the individuals or communities & instead was creating a
system of dependency on ‘the modern medical model’, which was inadequate & illequipped to address the real cause of ill-health in the communities. One of the
missions of SEARCH in addition to ‘action oriented community research in health’
was to enable & empower people & communities to take health into their own
hands.
With such high ideals in mind & equipped with knowledge & motivation to serve
people, the gateway of Dr.Bangs into the community was as physicians. They
understood this very well & started their work in community as such. However,
they always had their ‘goal’ in mind & used every opportunity that came their way
to build inroads into the community & build a strong relationship with them. In
addition, they took the opportunity to understand the community well. During the
same period they were building the ‘core team’ of SEARCH-of dedicated, motivated
& knowledgeable members- on the strength of which the future of their ‘project’
depended upon. The next process was to move into their own campus nearer to the
78
community they envisaged to serve. Then they started the process of long cherished
TVHP.
The above processes amply demonstrate the deep understanding the leaders had in
their mind about their work. It also goes to show the systematic & rational way
adapted by the leaders to address the problems. In addition, the way in which the
doctors learnt the lesson through their ‘Sickle Cell Anemia Study In Tribals of
Gadchiroli’ demonstrates their learning aptitude & humbleness to accept failures.
Their unyielding stand in addressing the ‘Alcohol’ problem in Gadchiroli & their
successful movement to ban alcohol sale & consumption in the district, against the
‘vested’ interest of very influential people, speaks volumes about their
determination, organizational capacity, & tenacity to stand in adversity behind the
values they believe in & cherish.
With such able leadership at the helm & ably backed by a well prepared team it is no
surprise that SEARCH has become one of the premiere ‘Community Health
Organization’ in the country.
A STRONG PARTNERSHIP WITH THE COMMUNITY EVEN BEFORE THE
CONCEPTUALIZATION OF ‘TMCP’:
It is constantly seen that a program is first envisaged in private minds, imposed on
the community & then the process of building ‘partnership’ is undertaken, which
has spelt doom for many good initiatives. However, the case with TMCP was a
different story. SEARCH consciously had stalled the installation of Tribal Health
Programs for a long period (more than a decade!), the time, which it used
judiciously, & carefully to establish a meaningful & mutually beneficial, strong
‘Partnership’ with the tribals in the area.
The process of building partnership, which by no means is an easy work, was
initiated as early as in 1986, when SEARCH started its work in Gadchiroli. It
79
rightfully approached tribal community through its leaders, as it did not have any
direct contacts with the tribals. It showed its genuine willingness to help tribals in
their development through some small & some not so small, but each one a
significant, initiative. To name a few of them:
Organizing OPD services at a place easily accessible & at a price acceptable to
the tribals & also to organize village camps at the time of epidemics, which is
no small work, had earned the respect & trust of tribals
Establishing a ‘Tribal friendly Hospital’: How many of us, the doctors, can
imagine a hospital which looks like a ‘hut’, has a temple for the ‘God’ of
attending patients, a receptionist not so like a ‘model’ & speaking a tribal
dialect, wards that look like the local people’s home & not only
accommodating the patient but also the relatives, & ever obliging ‘staff’ who
respect the patients for the ‘human beings’ they are? Also how many hospitals
are built in consultation with, apart from the architect, the people for whom it
is constructed to? Well here in SEARCH, the people at the helm had
understood the real meaning of ‘community participation’ & built a hospital
acceptable to the people who it was meant to serve. The involvement of the
community & respect for its sentiments right from the design of the hospital
to the consecration of the Temple showed the deep sense of respect &
commitment, SEARCH had towards tribal development. This one act went a
long way in fostering the already established bond between SEARCH &
Tribal community.
It was only because of such a ‘strong bond’ that was in place, SEARCH was able to
undertake all its future programs on Health Promotion of tribal community with full
participation & co-operation from the community.
‘COMMUNITY INVOLVEMENT’ AT EACH STEP OF THE PROGRAM:
Even though the importance of ‘Community Involvement’ is accepted as a
prerequisite in the success of any such program, most of the time, it is paid only lip
service by the program managers. Many a time the concept of community
80
involvement is given a shortcut by most of them as both the concept & the process is
not exactly known to them or they think it is a ‘time wasting tactic’. As a result,
most often than not, the programs end on a disastrous note, as is evident in most of
the National Health Programs of our country. Sometimes it is also seen that
community involvement is sought at only certain stages of the program, thinking
that the community by itself is either ignorant or incapable of knowing its own
problems!
However,
SEARCH
rightfully
involved
the
community
right
from
the
conceptualization of the program through the implementation process & even in the
evaluation of the program! The unique way by which SEARCH was able to involve
the much shy & introvert tribal community through ingenious ideas of Tribal Jatra &
forming their own Health Assembly is another example of pains taken by SEARCH
to involve the tribal community. This process also did not mean just involving the
community in decision-making process, but also utilizing citizens to generate their
own ideas & trusting that the community knows what it needs & has the ability to
achieve it! This one process of ‘complete community involvement’ looks to me the
‘crux’ for the success of TMCP.
(Also, it should be noted that SEARCH did not merely seek community
‘participation’ but ‘involved’ the community in the process of its own
empowerment. This needs to be given some consideration as most of the times
‘participation’ is passive & hence, I think the words used in most textbooks need to
be relooked.)
IMPORTANCE OF UNDERSTANDING & RESPECTING THE COMMUNITY:
Another important feature of TMCP is the deep understanding & respect shown by
SEARCH towards tribal community. They are evident in each step SEARCH took
towards realization of TMCP. Be it constructing a temple in the hospital or
organizing a Jatra to assemble people in one place or naming THVs as ‘Maa
81
Danteshwari Sevak’ to increase their acceptance or taking advantage of the custom
of Community Meetings to shape community opinions or training the traditional
healers to be a part of program or pacing of the program or the methods adapted in
training the THV, SEARCH demonstrates its deep understanding & respect of the
community. By doing so, it enhanced its own position in the community & was also
able to steer the program in the right direction.
CLEAR VISION OF ‘ONESELF’ & THE ‘PROCESS’:
SEARCH also demonstrates the importance of knowing one’s strengths & limitations
& also the clarity of prioritizing the problems it can solve & the process one has to
adapt. This is evident by the fact that even though there are 100 such tribal villages
in the vicinity & some of them are keen to become the part of TVHP, SEARCH is still
skeptical of the possibility. For, it thinks it is unrealistic for SEARCH with the limited
staff to do justice to all of them. Also the fact that TMCP didn’t start with all its
components in one go, but evolved over a period of time, in consonant with the
‘capacity building’ of THV shows the clarity of vision of the process by the team in
SEARCH.
ADEQUATE & APPROPRIATE SUPPORT OF ‘THV’ BY ‘SEARCH’:
TECHINAL:
Adequate & appropriate training, retraining & constant supervision of THV in the
field is probably the most vital factor for the success of TMCP. The methods &
content of the training, which aimed at producing not only knowledgeable & skilled
workers but also workers with the right attitude, should be emulated in all such
programs. In addition, the importance of constant field supervision cannot be
stressed further & the foresight of SEARCH in developing Supervisors among THVs
themselves, may serve as a part of further ‘community empowerment’, also in
making the program sustainable & widely replicable in adjacent tribal areas!
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INFRASTRUCURAL:
The constant supply of drugs & materials required for blood smear collection, from
SEARCH & regular feedback in the form of reports on BSE is a part of the success
story. It not only kept THV ready to face patients in community at any time of the
day but also helped to increase their motivation in work & trust in SEARCH. In
addition, the referral support provided by SEARCH through its hospital &
ambulance service went a long way in strengthening the ground work of THV &
make TMCP a success.
COMMUNITY CAPACITY BUILDING:
Empowerment of the community is essential if malaria control is to be effective.
SEARCH brings us back to the basics of the community organizing, to a process
where communities are challenged, respected, & transformed. From the very
beginning until now, there has been a continual exchange of learning &
understanding occurring between TMCP members & community members, with a
focus on addressing the root cause of the disease. The staff of TMCP had to adapt to
the real needs of the community, to listen, to provide technical assistance when
needed, & help people to create their own change from the ground up! From a stage
where most of the community members didn’t know what malaria is & never cared
to seek health care inspite of severe illness, to a stage where community members
demand for IRS, queue up to do Shramadhan, use their ITN appropriately, & rush to
seek advise from a THV at the slightest hint of fever is no ‘ordinary change’. This is
the essence of TMCP!
THE ‘UNIQUE’ STRUCTURE’ OF THE PROGRAM:
TMCP is a unique program incorporating all the needs for its success, as mentioned
below:
83
It was built to serve the felt needs of a community with full involvement of
the community
The program had a flexible approach right from the inception in the sense that
even though there were ‘fixed’ objectives to be achieved & interventions to be
followed, there was scope for the change of priorities, focus & process in the
program which is very essential in a community health program
The program was designed appropriately keeping in mind of the local needs,
KAP & local capacity i.e. there was the true ‘decentralization’ process
The program was taken up in a ‘phased’ manner in tune with the capacity
building process
There was always the constant vigil on any new intervention planned
regarding its practical implementation & its usefulness in the community. For
instance, when ITNs were promoted in the community, SEARCH did not stop
at just distribution of the same in community, as is the process in Government
programs. It went on to gauge the benefit of the same & then realized even
though ITNs were available in the houses the community members did not
know how to use it! It then embarked on the process of raising the awareness
of the community in using the same.
Even though SEARCH’s experience with the Public sector was bitter, it
involved in a meaningful partnership with the same when the need arose in
TMCP.
It is this structure of the program, which was one of the key factors for the success of
TMCP.
FACING ADVERSITIES BOLDLY, ADMITTING MISTAKES & LEARNING
FROM MISTAKES:
When there was an outbreak of epidemic of malaria in 2003, SEARCH did not
indulge in the blaming game & escape from its own responsibility in the
shortcoming, even though it had valid reasons (as it was the responsibility of the
Government to carry IRS, the absence of which was the main cause for the epidemic)
84
to do so! Instead, it focused on how best it can deal with the unexpected situation &
tide over the crisis. Following the crisis management, it undertook a retrospective
analysis into its program & tried to correct its mistake of not having an early
warning system in place by resolving to develop one in near future! This character of
facing adversities boldly, admitting mistakes, & learning from mistakes i.e. to have
accountability of oneself to the program is a very rare commodity, but essential for
any successful venture!
‘SHORT COMINGS’ IN ‘TMCP’:
For all its spectacular success of TMCP as a model of community health program, the
epidemic of malaria in 2003 stands as a testimonial for some of the short comings of
the program. The few inadequacies that can be listed are as follows:
The absence of an early warning system to predict an epidemic outbreak is
the glaring deficiency of the program. It is true that it is not possible to have
an ‘early warning & monitoring system’ in its truest form in SEARCH,
because of the costs involved & lack of modern technical resources.
Nevertheless, it is possible to have a surveillance system in its simple form,
which can analyze the routine data collected & can serve as the early warning
system. This appears to be the ‘component’, which needs urgent attention if
the 2003 embarrassment is to be avoided in future.
Even though SEARCH has taken pains to know the ‘true’ condition on the
ground, I feel there is a lack of relevant epidemiological data in its complete
form. The epidemiological data is of prime importance in any malaria control
program as it dictates the selection of appropriate intervention measures in
that community.
Since it is an accepted fact that high prevalence of malaria is responsible for
many adverse effects on pregnancy & its outcome, there is a need to evolve a
strategy within TMCP to address this very critical public health problem.
Apart from above inadequacies, I feel that there are a few important facts to be kept
in mind while new strategies are incorporated into TMCP in future:
85
Since the incumbent parasite in the region is the dreaded Plasmodium
falciparum, which is known to develop drug resistance to chloroquine, it is
imperative to have routine information on sensitivity of parasites in the
region to various anti malarial drugs. This may also pave the path for
increased partnership with the public health system.
Also, because the current strain of falciparun is sensitive to cheap & easily
available chloroquine, it becomes important that any future undertakings
under TMCP needs to keep it in mind & try to preserve the status quo. Some
strategies, which foster the development of drug resistance without offering
much benefit to community in exchange, as ‘mass drug administration’ &
such others should be taken up after considering risk-benefit analysis.
Even though health education is already taken up in a ‘big’ way, the interim
report by Mr.Bejoy P. Nambiar of Tata Institute of Social Sciences, Mumbai
indicate that there are still a substantial number of people in the community
with little or no knowledge of malaria as a disease per-se. This needs further
reflection & calls for a fine-tuning in the strategy adapted for health education
in the community.
The use of radical treatment with Tab.Primaquine in all cases of positive BSE,
during all seasons & in the form of fixed 5 days treatment irrespective of the
type of strain of plasmodium, & the use of same in infants needs to be
relooked.
Inspite of these ‘short comings’, TMCP stands as a ‘model’ of ‘Community Health
Program’, for showing to the world that ‘capacity building’ & ‘empowerment’ can
become reality in the community & given a space to speak& be heard, most people
could be their own agents of change.
86
ANNEXURE No.3. REPORT OF MY WORK IN SEARCH DURING LAST ONE
WEEK (14-12-2004 TO 20-12-2004)
(AS SUBMITTED TO DR.ABHAY BANG)
After having submitted my case study of ‘Tribal Malaria Control Program’
undertaken by ‘SEARCH’ in 36 tribal villages of Gadchiroli district of Maharastra, I
undertook the following tasks as suggested by Dr.Abhay Bang:
1. To find & suggest, if possible, an early warning system to malaria epidemic in the
region:
I took an extensive review of available literature both on internet & books on early
warning system to malaria epidemics. Even though there were many systems in
Africa trying to do the same, the initiatives had met with limited success due to
many constraints. Nevertheless, I found the WHO’s modification of Cullen’s method
to detect (not predict!) an epidemic in its most earliest phase is a very practicable
thing to do in SEARCH & worth a try. In addition, a three-tier method to have a
varying scale of alertness depending on various factors affecting malaria epidemics
as followed in Eritrea seems to me a simple & effective method. (I & Meghana would
be giving a report on both of these by 24th of this month)
I tried to go through the available data in SEARCH of last five years to find &
correlate the data to get a possible picture of local condition of malaria. However, as
the data was very incomplete & some of it still not found, I am not successful as of
now in the same task. I think it would be a good idea to enter the weekly data
SEARCH gets from the field into a computer if SEARCH wants to derive any
meaningful use of the same!
2. To suggest an indigenous & cheap method of personal protective measure to
prevent mosquito bites:
Although I tried reviewing the above said topic, my search always ended in NEEM,
a tree not found in local area. However, as neem tree is suitable to grow in the local
conditions, I believe planting innumerable plants of neem in the villages with
87
community partnership would be useful in the long run. In addition, I intend to
continue my search of an indigenous & cheap method of personal protective
measure to prevent mosquito bites suited for the local condition here & if I come up
with an answer I will be communicating it to You at the earliest.
3. Meeting the district NMCP officer:
I tried meeting the district NMCP officer. But, he was not available all throughout
the previous week. The officials in the NMCP were very casual & uncooperative!
Nevertheless, I am still trying to meet the district NMCP officer & seek clarifications
regarding the routine use of Primaquine, current guidelines of NMCP, resistance
pattern of the local malaria parasites & also to try & get data on monthly rainfall of
previous years in the region, if any such things exist in the office!
I was also following the deaddiction camp for alcoholics going on in the campus,
which I am finding to be very different from such initiatives outside, both in the
process & result.
88
ANNEXURE NO.4. LETTER OF GRATITUDE
To,
20-12-2004,
Dr.Abhay Bang,
Shod gram.
Director-SEARCH,
Shod gram,
Gadchiroli(D).
From,
Dr.Vinay.V.,
Fellow of community medicine,
Community Health Cell,
Bangalore.
Respected Sir,
I take this opportunity to gratefully thank You & all the team members of SEARCH
for having provided a young medical graduate like me, exploring the option of
Community Medicine, with a true learning experience & motivation.
When I started my exploration into the world of Community Medicine in
CHC(Community Health Cell) with a special interest in Child Health, my mentor
Dr.Thelma Narayan suggested that SEARCH would be the ideal place to start my
journey. My ever-inspirational figure Dr.Ravi Narayan endorsed her fully. I found
great respect & love when they talked about SEARCH. I now come to understand
the reason behind that love & respect in their voice. SEARCH, under the able
guidance of You & Dr.Rani Bang, is a living example of real ‘community medicine’
at work. I, as a medical student, was never exposed to such monumental work & it
will be an understatement to say that I am overwhelmed by the multitude of
activities going on in SEARCH.
I think it would be futile to try to list all that I have learnt during my short stay in
SEARCH, for the list may run into pages & pages. I think it would be suffice to sum
up my experiences in three little sentences i.e. I have seen a real community health
89
project at work, have been introduced into the world of dynamics of community
medicine & more than all, I have learnt to understand & appreciate the idea of
‘true’ community empowerment.
I take this opportunity to thank all the team members of SEARCH for the wonderful
people they are & for the wonderful work they are doing. They have been great
companions & teachers, at the same time. I am going to miss them for a long time to
come!
More importantly, I take this opportunity to convey my heart felt gratitude to You,
Sir. You had been a great teacher & motivator. I am grateful for the valuable time
You gave me & the invaluable lessons You taught me. Your words have become a
source of motivation for me. The experiences You have shared with me will always
be a guide to me in future. You will remain as one of the ‘teacher’ I value most in my
life. Thank You, Sir.
At the outset, I also hope that SEARCH continues to inspire & teach students like me
in future. With the dearth of ‘model doctor-teachers’ outside, lack of community
health orientation of the present medical education & the lure of ‘private, specialized
practice’, community medicine, though much essential & appropriate, is loosing
attraction in medical undergraduates. It is only when organizations like SEARCH &
its work comes to be widely known in the student community, the revival of
community medicine is possible. Hence I request SEARCH never to turn down the
sincere requests of any student like me willing to learn invaluable lessons in
community medicine. Also, I request Dr.Abhay Bang to continue to guide &
motivate young people like us & dedicate some time in his busy schedule for this
worthwhile cause!
I also take this opportunity to convey greetings & best wishes from all the team
members at CHC. I hope this association lasts long
Thanks once again,
Yours faithfully,
Vinay.V.
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TSUNAMI RELIEF WORK- A BRIEF REPORT OF THE FIRST TEAM
FROM CHC, BANGALORE
BACKGROUND:
Tsunami, an unknown word till recently has imprinted itself in the psyche of all
Indians. When the most powerful earthquake in more than 40 years struck deep
under the Indian Ocean off Sumatra in the early morning hours of 26th December,
the earth wobbled in its axis & the past of thousands of people across more than ten
Asian nations was washed off. The quake measuring 9 on the Richter scale triggered
tsunami as high as 10 m traveling with a speed of 800kmph, obliterating coastal
villages & seaside resorts. Fishermen, tourists, homes, boats, fishing nets & anything
& everything within 0.5-1 km range from the coastal line were swept away by walls
of water that rose from the ocean.
When the waves retreated the smell of death hung in the air. More than 1.5 lakh
people, mostly fishermen & their families, were dead. Many more people were left
with their past wiped off & future bleak & uncertain.
In India the tsunami struck the eastern coast particularly the coastal regions of
Tamilnadu & Pondicharry & the Andaman & Nicobar islands leaving more than
12000 people dead & many more thousands homeless.
The suddenness & ferocity with which the tsunami struck was hitherto unknown to
Indians. But as the news of the disaster slowly spread across the world & after the
grueling & heart-rending scenes reached to every household, the world woke up.
Aid in the form of human volunteers & material help started poring in into the
affected areas at a rate probably never seen before!
Never to be found sleeping in such situations, CHC, a non-government resource
organization working for the promotion of community health, based in Bangalore,
was flooded with calls from people & various organizations, requesting for help &
offering help, at the same time! For Dr.Thelma Narayan & Dr.Ravi Narayan, the
people at the helm of CHC, disaster relief work has become a tradition. True to its
tradition, CHC in collaboration with another NGO Action Aid-Chennai organized a
91
group of 10 volunteers, mostly doctors, to provide relief to the affected people of
Tamilnadu. This is the report of this first team of relief workers from CHC.
PLANNING THE RESPONSE:
As soon as the team 9consisting of 7 doctors, a social worker & a theology teacher
was formulated, Dr.Ravi & Dr.Thelma called the team to CHC for a briefing session
on 27th Dec 2004. The meeting provided the opportunity for all the team members to
get to know each other. Dr.Ravi & Dr.Thelma from their rich experiences of disaster
relief work in the past sensitized the enthusiastic but totally clueless group regarding
the nature & process of the disaster relief work. Some important points stressed
were:
1. The importance of the team to work in a coordinated & complimentary
fashion.
2. The priority of the relief work was to give medical care to the people in need.
But it was also stressed that, the team’s work was not just to treat physically
ill but to provide ‘help’ to the affected population in whatever way deemed
necessary by the team.
3. The importance of psychosocial aspect of health was stressed & restoration of
‘human dignity & self respect’ among the affected population was deemed as
a vital component of our work.
4.
The need for a roving team to constantly move around in a village to assess
the general condition of life of the people & also to have a critical look at the
public health aspects was stressed.
5. The importance of data collection regarding the loss of life & property & also
to keep record of patients being treated was stressed.
6. Also the team was sensitized about the need to take care of themselves & to
have a team meeting every evening after the work to share the experiences &
to formulate the plan of action for the next day. We were made to understand
that the team meeting would serve to improve the morale of the team as a
9
Annexure No.1. The list of team members & their details.
92
whole & also in addressing the problems faced in the field & to arrive at
appropriate solutions to solve them.
7. The importance of working in close collaboration with local groups, resource
mapping of the region we were working in & to be in constant touch with
local government authorities was also stressed. CHC also gave many local
contact numbers to facilitate the same.
8. Lastly, it was pointed out that the work the team does should be
‘complimentary’ to the relief work already going on in the area & the team
was warned against unnecessary duplication of work. Also, the team was
made to understand that the work initiated by the team is not a touch & go
process but the other people coming into our place, as replacements will
continue the work. Hence, it was decided that the team along with providing
relief to acute problems should also build a base in the community for the
next teams coming in to carry on the long-term rehabilitative works.
Also, the CHC team provided all the volunteers with the list of essential things10 to
be carried. Many small manuals regarding disaster response in its earliest phases
were also provided to the team to assist them in their preparations. It also asked one
of the team members to be in constant touch with CHC, updating the CHC of the
works going on in the field & also asked each volunteer to be in constant touch with
their families. A small amount of money was also provided to meet the expenses of
the team. With the best of wishes from all the team members at CHC, the relief team
was ready to move.
ON THE ‘MOVE’:
In the early morning hours of 30th Dec-2004, the team left to Chennai in a vehicle
provided by Action Aid-Bangalore & equipped with medicines & water supply.
There was a sense of apprehension in all the team members regarding the nature of
their work. Nevertheless, each member was enthusiastic about the prospect of
disaster relief work & was really rearing to go to the field. Also the long journey
provided the team members with an opportunity to get acquainted with each other
10
Annexure.No.2. Check list of essential items.
93
& to share with the others one of their special skills. Dr.Keerthi Sunder, an instructor
of first-aid gave a demonstration of the same. Dr.Sri Krishna & Dr.Krishna Murthy
sensitized the team members of the critical factors of public health in disaster
management. Mrs.Susan Bennema, who had worked in a similar situation
previously, shared her experience regarding the data collection in such situations.
Dr.Shilpa helped us to acquire a working knowledge of Tamil.
IN ACTION-AID, CHENNAI:
Mr.Rajendran from CHC who was in the affected area since the disaster struck was
waiting for us in the Action Aid office. Immediately a meeting was held in the office
& Mr.Ajay of Action Aid Chennai who was co-coordinating the relief work gave us a
brief description of the ground situation & the nature of the work expected from our
team. He also said that the situation demanded that we work in the Nagapattinam
district; one of the worst affected areas & gave us the map of villages to be covered
by our team. Some of the important points noted were:
1. He gave us a list of 63 villages along the coast from northern tip towards
south of the Nagapattinam, which had been inadequately covered till then.
He also provided us with a map of the same. It was also decided that the base
camp would be in either Mayiladuthurai or Sirkazhi, two towns situated to
the north of Nagapattinam, whichever the team deemed to be convenient.
2. Even though the mortality had been high, the morbidity especially in terms of
physical injuries was observed to be low. Also as of then, there was no
epidemic reported.
3. The affected population had been shifted to temporary camps housed mainly
in schools, dharmashaalas, choultries, etc. The camps were near to urban
centers & also at least 4 km away from the coastline. He had observed
overcrowding in most camps & said that the sanitation, hygiene & other
public health aspects were greatly neglected. Even though the government
was giving its best efforts to meet the health care demands of the displaced
population, there was a need for more doctors in the region.
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4. He also pointed us of the fact that the fishermen community was a close-knit
group & each village had a leader who commanded great respect from the
villagers. Also, he informed us about a local organization by name ‘Sneha’,
based in Nagapattinam, which had one volunteer in each of the affected
camp. He gave us local contact numbers & asked us to work in tandem with
them.
5. We were informed that NGOs all across the state were working in tandem &
had formed a forum to keep watch on the relief works being carried out in the
area. Also a data collection form was handed to us & informed about the
importance of baseline data in long term.
6. He specially requested us to look into the following aspects:
o Check on availability of the medical personnel in camps
o The issue of overcrowding in the camp
o To be ready to face public health problems in the form of diarrhea,
respiratory problems & warned us of the possible outbreak of malaria.
o Sanitation & hygiene in camps
o Status of villages proper
With these words he wished us all to do a good job. Also, the office in Chennai
provided us with the financial support & medicine supply.
IN THE ‘FIELD’:
The team arrived in Sirkazhi, a small town 20 km north of Nagapattinam on 31st Dec2004. Weary of the long travel in hot & dry climate & with the inevitable
disappointment of not being in the field already, team members were feeling low.
But once we entered Sirkazhi, things started to happen on a fast pace. Dr.Gautham
Mehta, one of the team members contacted the local Jain Community who
generously offered their hospitality. They offered lodging, transport facilities & food
for the entire team for the next one-week. At the same time few members of our
group were able to find the local government CMO & engage him in the discussion.
He promised to provide us with paramedical staff the next day & also to take our
team to the needy areas.
95
We had our first team meeting in the evening. It was decided that the team would
divide itself into two teams, one as a medical relief team & another roving team. The
medical relief team consisting of doctors Krisna Murthy, Gautham, Shilpa, Keerthi,
Raghavendra, Vinay & Pradeep would move with the CMO & provide medical care
to the needy people. The rest of the team would work as a roving team moving from
village to village collecting data & doing needs assessment. It was decided that
depending upon the assessment done by the roving team the strategy to be adapted
in the coming days would be decided. Also the team engaged in sorting out the
medical supplies to be carried the next day. If the morale of the team was low prior
to the meeting, all were on a high with a sense of expectation after the meeting. All
retired to a well-deserved rest to start afresh for the work in hand the next day.
OUR FIRST-DAY AT WORK:
The medical-relief team:
On the first day of the year 2005, the team in tandem with government officials visited four
camps housing displaced population of Palyar, Kottaimedu, Madvaimeedu& Thirumalaivasal
villages. They also visited the devastated villages of Palyar & Thirumalaivasal. The
observations made by the team are as follows:
o The team was sweetly surprised that the affected people had remarkable resilience!
Even though the sea had taken away everything, their will to live & rebuild their life
remained intact.
o The camps were overcrowded
o Mostly women & children stay in the camps during mornings & men only
during nights
o The food was being supplied either through packages or the community
kitchen established by the government in the camps
o Water was mostly supplied in packets. In some places government had made
arrangements to supply chlorinated water through tankers
o The sanitation in the camps was poor & people mostly followed open-air
defecation. Children used to defecate close to living places & played in the
96
soiled area. Also, some places housing the camps had lavorataries, which
were locked! The waste was littered very close to the camps.
o Most camps had medical relief teams of government doctors & some even
had a resident doctor. The medical supplies seemed adequate.
o The relief materials were arriving regularly but the clothes mostly went
unused
o People had little or no knowledge of health & diseases
o That the village leaders of the well-organized villages had actually a census
data regarding the loss of life & property in their villages!
The actual works carried out are as follows;
o A health camp was organized in most of these camps & the people attending
were treated for different ailments. Most important health problems treated
were respiratory tract infections, few cases of diarrhea, scabies, anemia &
fever. Many cases of fractures were also observed.
o Health education regarding cleanliness, hygiene, sanitation & use of ORS
during diarrhea was organized in two camps.
o The locks of the toilets were broken & toilets cleaned with the help of local
community people to make them fit for use.
o Children were involved in the cleanliness drive & were given a practical
training regarding the personal hygiene.
o Chlorination of the water tank in Palyar village was undertaken with
involvement of local municipal authorities.
o
Community leaders were sensitized regarding the placing of kitchen far
away from the toilets, as it was observed that in Kottaimeedu camp, kitchen
was located within 10m of the toilet!
The roving team:
The roving team visited six villages on 1-1-2005 & their observations were as follows:
o There is no need for medical help per-se in most of the villages as the
government had taken I t up in a big way.
97
o Shelter, boats & nets were the biggest problems to be addressed, both on short
term & long term basis.
o Food & water was in surplus at that period of time.
o
Sanitary measures in the camp were poor & the only form of sanitation
followed was in the form of spraying bleaching powder.
o The organization within the community differed from village to village. Some
villagers had themselves organized well whereas some villages were in utter
chaos. In the organized villages the relief work was going on well with each
family getting the relief materials on a regular basis.
o Debris clearance was also thought to be a priority.
o Need for stoves, kerosene, and dry food grains for the next phase of relief was
felt important.
o Need to guard against the rumors require some consideration.
o Discussion with the people yielded some insights into the felt needs of the
community such as:
1. Need for a ‘wall’ along the coast to protect against future fury of the
sea
2. Need an early warning system to be in place to guard their life &
property.
3. Bringing back boats into the inland for repair.
4. Most of the villagers wanted new houses constructed at least 2 km
from the seashore.
o The government had appointed IAS officers as in charge-officers of 6-10
villages & each officer visited the villages at least twice each day to coordinate the relief work.
o Also, the District Commissioner held meeting with all NGOs working in the
district regularly in the evenings.
A team meeting was organized in the evening to discuss all of the above & following
decisions were taken:
o Government of Tamilnadu needs to be appreciated for the good work that is
being done in the affected area. At the same time it was thought that with
98
passing of time, there might be attrition in the response. Hence it was decided
to keep a constant vigil over the government work & to involve the affected
community in the same.
o Since there was no dearth of medical relief, it was thought that to continue
visiting camps would be waste of time & resources. Instead it was decided to
identify two villages in need & undertaking of comprehensive relief works in
them. By this it was thought that our resources could be used in a meaningful
way.
o Also, the work done by roving team came in for a special praise & it was
decided to continue having it in place at least for the next three days, with
three members working for that.
o Kottaimeedu & Madvaimeedu villages were initially identified for our long
term relief work due to the following reasons:
1. Manageable population size
2. Proximity to Sirkazhi
3. ‘Perceived need’ in the community for such a team to be present there
4. Presence of local links in the villages in the form of ‘Sneha’ members
5. Proximity of the two villages to each other
o The work of our team in these villages was decided to be that of the
‘facilitator’ role & the same was defined initially as follows:
1. Community building it terms of organizing them into a powerful well
informed group & enhancing their capacity to deal with their problems
in an effective way.
2. It was also decided that a constant presence of our team in a village
would help to increase our acceptance in the community & also it
would help us in terms of long-term psychosocial rehabilitation.
3. Dissemination of the information regarding the governmental plans for
their rehabilitation.
4. Giving them health education & building their capacity in terms of
taking their health into their own hands.
99
5. To keep a vigil over the sanitation, hygiene, food & water supply in the
community & to take corrective action if any unacceptable practices
were found & involving the community in the same.
6. Also it was decided that any help the community wanted from us, if it
was feasible, would be provided.
7. Also, it was decided that the doctors in the team would be involved
mainly in the provision of medical care & also to keep a watch on
issues of public health importance. The non-medical members were to
secure the social contacts in the community & facilitate the process of
community building.
o If the roving team felt that there is a need for the medical relief team in any of
the village they visited, it would be arranged the next day.
Before the beginning of the meeting, most of the doctors in the team felt sweetly
disappointed that there is not much of work for them to do in terms of ‘biomedical
practice’ of medicine. But once the meeting was over there was a sense of purpose to
their presence in the region & lifted their spirits.
Thus at end of a single day’s work the team was able to formulate the plan of action
for future. This gave a sense of responsibility & usefulness in the members & also a
concrete path to be followed by different members of the team to have maximum
gain for themselves & also the community. Thus with the priorities decided, work
distributed & goals set, the relief work in the affected area began & continued in
right earnest during our future stay in the region. Also, during the visit of the roving
team on 2nd Jan-2005 one more village named Keelamorkarai was found to be badly
organized & the whole team felt the need for our presence there & hence it was
included as the last addition for our long term relief work. The work carried out by
our team in the next 6 days is summarized below.
100
DIALOGUE WITH THE COMMUNITY & THE PROCESS OF COMMUNITY
BUILDING:
Mr.Rajendran, Mrs.Susan & Dr.Shilpa with the advantage of knowing Tamil took the
lead in community building process. They formed a good relationship with the local
Sneha volunteer & also established a firm working relationship with the village
leaders. Also village meetings were organized in all the three villages. Leaders, men,
women, youth & even local government officials attended the meetings. Meetings
provided a platform for the people to come together & express their opinion. They
also helped the people to collectively decide the future of their village. But the most
important purpose served by the meeting was to bring the whole community
together in a place & express their grief in a collective manner. This we think
provided a healing touch beyond any imagination.
Most of these meetings that followed the initial meeting helped the people to
formulate a collective opinion on their future.
Most opinions expressed in the
village meetings were similar & are as follows:
1. People wanted to rebuild their village at least 2km inside the coast line & in a
place with easy assess to roads, hospitals, schools & market place
2. Shelter, both temporary & permanent, was one of the priorities of the
community.
3. Top most priority was given to the issue of livelihood. As most of them had
lost boats & fishing nets & they didn’t have any resources to buy the same,
people expressed their doubts on the means of their immediate livelihood.
Also, they expressed their helplessness regarding their limited skills in areas
other than fishing & wanted a vocational training in fishing related activities
to sustain themselves till they can go fishing in the sea. The problem of
livelihood was further aggravated by the fact that it takes at least 6-8 months
for them to get boats delivered after the order for the same is placed!
4. Women, who were involved in a village meeting for the first time in one of
the villages, requested for the provision of loans to setup business in fishing
related field.
101
5. Women also stressed on the need for basic materials to setup their home like
food grains, kerosene, stove, blankets, utensils & such others.
6. People wanted special schemes from the government to compensate &
safeguard life of orphans, widows & old people who have lost their family.
7. Community also felt strongly about having an early disaster warning system
in place. They also felt that a centralized system without proper
communication channel with the fishing community will be of no help.
Thus the community was involved in a fruitful manner by our team led by
Mr.Rajendran. We also used the opportunity to establish a firm relationship between
the community & ourselves. Also where we found the communities to be
disorganized, we tried to impress upon them the importance of organization for
their own good. We also made them realize the importance of having their own data
records for future reference & while government starts distributing compensation
money. Also, in Madvaaimeedu, we were able to form separate women & youth
groups & arrange weekly meetings with them. The youth group was urged to take
up the job of debris clearing in the village. Women group was introduced to the idea
of micro credit system.
Thus by the time we left the region, we were sure that a firm foundation for
community building was in place & it was to the coming teams to build on it.
HEALTH RELATED WORKS:
We organized a regular OPD in the villages identified for our long term work. Even
though most of the health problems were of regular ailments we understood the
importance of having regular medical care to win the confidence of the community.
Also, Dr.Ravi had stressed on the need to ‘listen’ to the people as this one act of
giving time to people to speak their heart out would help to heal their psychological
wounds! As we made our appearance every day in the village people started coming
out with many real medical problems. We were confronted with fractures,
reproductive tract infections, anemia & many other health problems. However, we
didn’t find psychological problems, at least not overt problems, as was expected.
Also, we kept a strong vigilance for cases of diarrhea, malaria & such other diseases
102
that can develop into epidemics in the community. In Keelamorkarai, when we
found that cattle were sick & dying of diarrhea very close to the camp, we brought
the same to the attention of local authorities. They immediately arranged for the
investigation of the same with a veterinary doctor & also arranged for the proper
disposal of the bodies. Any medicine in short supply was procured with the help of
local authorities & if it was not possible & the team deemed it as an essential need,
the same were procured from our own resources.
More important than the OPD, the health work was carried out on field. Each day
one of us would go on a field inspection of the camp & used to note down the issues
threatening the health of the community. This would then be taken up with the local
authorities, communities themselves & the concerned people. Through this we not
only kept the government authorities on their toes to maintain a healthy camp, we
were also able to improve on some of the prevailing conditions in the camp. Some
examples for our works in this area are as follows:
o Changing the source of water supply in Keelamorkarai camp. Even though
water was being supplied in tankers from surrounding villages, the water
initially supplied was saline. Once we took this to the notice of IAS officer in
charge of the village, he promptly asked the local officials to change the
source of water to a place where water was potable.
o We brought to the notice of the local authorities of the poor sanitation & bad
hygiene of the camp housing more than 100 children in Keelamarkarai. We
suggested them to take up the work of cleaning the surroundings, placement
of dustbins for the litter to be collected, provision of a community soap to
wash the hands of children before the food & provision to be made for
construction of trench latrines. We were surprised the next day to find all our
requests carried out!
o When the community leaders were made to realize the health risk posed to
the community due to the proximity of the community kitchen to the toilets in
Kottaimeedu camp, they promptly shifted toilets to far off place.
o Even though the timing of health education was thought to be inappropriate
& also its effectiveness in the community was doubted, it was thought that
103
atleast some basic health education regarding personal hygiene, sanitation &
ORS use during diarrhea was deemed necessary. Dr.Sri Krishna & Dr.Krishna
Murthy prepared material for the same in English which was translated into
tamil by Mr.Rajendran. Later the local people prepared the charts. With the
help of these charts an effort was made to give basic health education in the
community, especially to the women community & children.
o Health education regarding the precautions to be taken while preparing &
distributing food & also the necessity to maintain personal hygiene was
imparted to the cooks of community kitchens.
Thus we practiced a sweet mix of clinical & preventive medicine.
During all these works we worked in close collaboration with the government
agencies. Whenever needed we offered our services to the local authorities & also
demanded their cooperation when we deemed it to be necessary. At the same time a
resource book regarding the details of all our contacts, demographic data & such
others for the benefit of the teams following us was maintained. The roving team
also collected data from 17 affected villages. Team meetings were held with alarming
regularity! The daily proceedings were also reported to Dr.Thelma & Dr.Ravi daily
& to Mr.Ajay on a regular basis. Also a set of recommendations was formulated to
orient the team following us to the region.
It seemed such a short period when it was time for our team to leave the region.
Most of us felt, in spite of the pathos around, a sense of satisfaction for having
contributed our own small efforts in rebuilding the devastated community. We left
the place with a heavy heart.
-A REPORT COMPILED BY DR.VINAY, FELLOW OF ‘CHC’.
104
ANNEXURE NO.1. THE LIST OF TEAM MEMBERS & THEIR DETAILS.
Volunteer’s
Name
Address and Contact No.
Qualification
Languages
/ Experience
Known
Duration
Mr.s Susan
SAIACS
Medical
Tamil,
Bennema
Po Box 7747,
Psychiatric
Malyalam
Kothanur Post,
Social Worker
and Telugu
BANGALORE – 560 077
Worked in
Ph.: 9844072628
Latur ;
9341324750
Worked in
CORbennema@hotmail.com
Action Aid
Mr. Cornelin
SAIACS
Teaches
English,
Bennema
Po Box 7747,
theology (of
Dutch
Kothanur Post,
Dutch origin,
BANGALORE – 560 077
with a PIO
Ph.: 9844072628
card and
9341324750
Indian driving
CORbennema@hotmail.com
license).
Dr. Keerthi
No. 16, J.C.Nagar,
MBBS
Kannada,
10 – 14
Sunder G.S.
9th Main,
Teaches First
English,
days
Mahalakshmipuram,
Aid and
Understan
BANGALORE – 560 086
Home
ds Tamil.
Ph.: 080-56909701
Nursing at St.
Email:
John’s
keerthigs@indiatimes.com
Ambulance
Association
105
4 weeks
4 weeks
Dr. Gautham
#2nd, ‘B’ Street, Ist Cross,
Kumar
MBBS,
Kannada,
7 – 10
Magadi Road,
English
days
BANGALORE – 560 023
and Tamil.
Ph.: 9886434581 / 23352266 ®
Email: gouthiya@yahoo.com
Dr. Vinay
S/o Viswanatha C.,
MBBS,
Kannada,
Viswanatha
‘Sriniketan’, 23rd Cross,
Community
English,
S.I.T. Extension,
Health Intern
Hindi.
TUMKUR – 572103
at CHC
Can
Ph.: 0816 – 2276539
manage
Email: vviny@yahoo.com
Tamil.
2 weeks
Ph.: 984423113
Dr.
108, 7th Main, 3rd Cross,
MBBS,
English,
PG – MD
Kannada,
RPC Layout,
(Community
Hindi,
Vijaya Nagar II Stage,
Medicine) 3rd
Fairly
BANGALORE –5 60 040
year.
comfortabl
Ph.: 9341236508
Rapid
e in Tamil
Email:
nutrition
dr_krishnamurthy@hotmail.com
assessment in
Krishnamurth KCS Extension,
y
2 weeks
Rajasthan (Jan.
2003);
Uttaranchal
Medical camp
(Oct. 2004).
Dr. Shilpa
60, Shreyus Apartment,
Medical
Govardhan
Door No. 12,
Graduate from Kannada
18th Cross, Malleshwaram,
BMC
BANGALORE – 560 055
Tamil
1 week
English
Hindi
9886107501
106
Ph.: 080 – 23442264®
shilpagovardhan@yahoo.co.i
n
Dr. Srikrishna 944810 7639
Dr. Pradeep
#28, 3rd Cross,
Kumar S.
Anjanappa Layout
English
Attiguppe,
and little
Vijayanagar,
Tamil
MBBS
Kannada,
1 Week
Bangalore – 560 040
Ph.: 984577-976
Email: graynco@yahoo.com
Dr.Raghaven
1249, Ist F Main, 2nd Phase,
MBBS
Kannada,
dra Charan M Girinagar,
English
P
BANGALORE – 560 085
and little
Ph.: 080 – 26721304
Tamil
Mobie: 9341045679
Email:
raghavendracharan@yahoo.c
om
107
1 Week
ANNEXURE.NO.2. CHECK LIST OF ESSENTIAL ITEMS.
1. Torch
2. Personal Medicines (Crocin, Amox 500, Septran, Norfloxacin, Anriemetic,
Rantac, CPM, Bandaid, Cotton, Electral etc.)
3. Mosquito repellant
4. Chlorine/Halogen tablets
5. ID cards/Medical Council Registration.
6. Driving License/Residence Permit
7. Stethoscope
8. B. P. Apparatus
9. Toiletries – Soap, Comb, Paste, Toothbrush, Shampoo etc.
10. Tissue Papers, Towel
11. Mat, Bed Sheet, Blanket, Pillow etc.
12. Washing soap
13. Water bottles (preferably one with nozzle)
14. Clothes, cap, umbrella
15. Shoes (Preferably)
16. Candles, Lighter/Match Box
17. Books – Park Text Book of Preventive and Social Medicine, First Aid, Disaster
Management, WHO Handbook – Emergency Medical Kit
108
REPORT OF ‘A MEET WITH TSUNAMI DISASTER RELIEF
DOCTORS FROM BMC’ ORGANISED IN BMC
PREFACE:
Disaster struck the world in the form of tsunami on 26th December. When the most
powerful earthquake in more than 40 years struck deep under the Indian Ocean off
Sumatra in the early morning hours of 26th December, the earth wobbled in its axis &
the past of thousands of people across twelve Asian nations was washed off. The
quake measuring 9 on the Richter scale (9.3 is the recent estimation!) triggered
tsunami as high as 15 m traveling with a speed of 800kmph, obliterating coastal
villages & seaside resorts. Fishermen, tourists, homes, boats, fishing nets & anything
& everything within 0.5-1 km range from the coastal line were swept away by walls
of water that rose from the ocean.
In India the tsunami struck the eastern coast particularly the coastal regions of
Tamilnadu & Pondicharry & the Andaman & Nicobar islands leaving more than
12000 people dead & many more thousands homeless.
The suddenness & ferocity with which the tsunami struck was hitherto unknown to
Indians. But as the news of the disaster slowly spread across the world & after the
grueling & heart-rending scenes reached to every household, the world woke up.
Aid in the form of human volunteers including medical, paramedical & non-medical
personnel & material help started poring in into the affected areas in a scale
probably never seen before!
Bangalore Medical College (BMC), a prestigious medical college situated in
Bangalore, is known for its academic excellence & committed staff. When
Government of Karnataka requested for a team of health workers to be sent to
tsunami affected regions in Tamilnadu, BMC promptly responded to the emergency
& sent a team consisting of 4 doctors & 16 nurses. At the same time, a group of
young doctors consisting of a Community Medicine postgraduate student, 3 present
internees & 7 recently graduated doctors from 1998-99 batch of BMC were sent in as
disaster relief teams in two batches from Community Health Cell (CHC), a resource
109
group in community health in Bangalore. These teams cumulatively worked in the
affected regions during the first three weeks after disaster.
Medical Education Unit of BMC thought that it is important to provide a platform
for all the team members from BMC, who had been to tsunami relief work, to share
their experience. In addition, it was thought that it should be used as a platform to
bring out a resolution to be sent to Government of Karnataka as a supplement to
their efforts in forming a comprehensive disaster management committee in BMC
for preventing & managing post disaster emergency situations. With the support
from the BMC Students Association & CHC, the MEU of BMC organized the
meeting titled ‘A Meet With Tsunami Disaster Relief Doctors From BMC’ on 31st
January 2005 between 2.30 & 5 pm, at MEU Conference hall in Victoria Hospital.
PARTICIPANTS:
Apart from the team members who had been to Tsunami relief work11
Dr.T.Rajeshvari, Principal of BMC Presided over the function. Dr.Ravi Narayan,
Coordinator, Global secretariat of People’s Health Movement was the Chief Guest of
the function. In addition, Dr.K.S.Siddaraj, Superintendent of Victoria Hospital,
Dr.N.Chandrashekar, Superintendent of Bowring & Lady Curzon Hospital,
Dr.Shashidhar Buggi, Superintendent of SDS T.B. & Rajiv Gandhi Institute of Chest
Diseases attended the meet as special invitees. Apart from the above dignitaries,
many staff members, postgraduate & undergraduate students of BMC were present
in the meet. Dr.T.K.Nagabhushana, coordinator of MEU of BMC facilitated the meet.
OBJECTIVES OF THE MEET:
1. Learning more about Tsunami & post-tsunami management in Doctor’s
perspective
2. Sharing thoughts & experiences about tsunami relief work
3. To bring out a resolution to be sent to Government of Karnataka as a
supplement to their efforts in forming a comprehensive committee for
preventing & managing post disaster emergency situations.
11
Annexure No.1. List of all team members from BMC who went to Tsunami relief works
110
METHODOLOGY:
Presentation, discussion & brain storming session12 were the methods used to share
the experiences of Tsunami relief work & formulation of the resolution to be sent to
Government of Karnataka.
THE ‘MEET’ PROPER:
Dr.T.K.Nagabhushana welcomed the audience & enlightened them about Tsunami
& its various facets. Dr.Veeranna Gowda13, Professor of Medicine, BMC & also the
leader of the official team from BMC shared his team’s experiences in the field.
Dr.Vinay.V. & Dr.Paras, members of the first & second CHC teams respectively,
presented their team’s work & experiences with the help of power point
presentations. These presentations were followed by question & answer session
where the audience posed their doubts to the team representatives for clarifications.
Dr.Ravi Narayan then gave the over view of the work of various disaster relief teams
from CHC, both present & in the past, & highlighted some challenge &
opportunities. Dr.K.S.Siddaraj & Dr.Shashidhar Buggi addressed the gathering &
gave their valuable opinions regarding their impression of the work done by the
teams in the field & also, the work to be undertaken in BMC. Dr.T.Rajeshvari, then
inspired the gathering by sharing her observations of the evening & also, by
proposing to undertake many positive works in BMC to contribute for the
rehabilitation phase of Tsunami disaster. The meet ended with a positive note with
the under taking of a resolution to prevail upon the Government of Karnataka to
develop a disaster management team in BMC! In addition, it was resolved to place
on record the services rendered by all those who went to help the affected
communities.
12
13
Annexure No.2. Notes from addresses from various dignitaries
Annexure No.3. Experience of the official team from BMC
111
ISSUES THAT EMERGED FROM THE MEET:
The various issues that emerged due to consultation & reflections of all the
participants with invaluable inputs from our Principal & Superintendents are as
follows:
1. Dedication of 100 bed ward in the new building (under construction) of SDS
T.B. & Rajiv Gandhi Institute of Chest Diseases for emergency care in disaster
& disaster-like situations (Dr.Shashidhar Buggi).
2. Introduction in the curriculum of both UG & PG medical & paramedical
courses , the topic on ‘disaster preparedness & management”( Dr.Veeranna
Gowda)
3. In the lines of St.Johns medical college’s bold step of considering the service of
medical internees in such situations as a part of Community Medicine
training during 1971 Bangladesh refugee camp relief management, our
Principal promised to look at the same in a positive manner. She even
considered of discussing the same with the university authorities.
4. Also, an idea of bringing a booklet of memoirs of various people from BMC,
who have volunteered in the disaster relief work, with a collection of
experiences
&
issues
faced
in
the
field
by
them
was
mooted
(Dr.T.K.Nagabhushana).
5. In addition, it was agreed that BMC, being a premiere institute of medical
education & health services, will take positive step in setting up a
comprehensive disaster management cell under its banner & a decision was
taken to inform the same to higher authorities to prevail upon the
Government of Karnataka for suitable action.
CONCLUSION:
The meet was a success in fulfilling the objectives set before. In addition, it brought
out many spontaneous good will decisions to the forefront. A consolidated
unanimous resolution for establishment of a cell with ‘be prepared’ motto was
placed on record.
112
APPENDIX 1. DETAILS OF VILUNTEERS
1. DETAILS OF VOLUNTEER FOR FIRST TEAM
THROUGH COMMUNITY HEALTH CELL (29.12.2004)
Volunteer’s
Name
Address and Contact No.
Qualification /
Experience
Languag
es
Known
Duration
of stay
Dr. Keerthi
No. 16, J.C.Nagar,
Medical
Kannada,
10 – 14
Sundar G.S.
9th Main,
Graduate,
English,
days
Mahalakshmipuram,
teaches First
understa
BANGALORE – 560 086
Aid and Home
nds
Ph.: 080-56909701
Nursing at St.
Tamil.
Email:keerthigs@indiatim
John’s
es.com
Ambulance
Association
Dr. Gautham
#2nd, ‘B’ Street, Ist Cross,
Kumar
MBBS,
Kannada,
7 – 10
Magadi Road,
English
days
BANGALORE – 560 023
and
Ph.: 9886434581 /
Tamil.
23352266 ®
Email:
gouthiya@yahoo.com
Dr. Vinay
S/o Viswanatha C.,
MBBS,
Kannada,
Viswanath
‘Sriniketan’, 23rd Cross,
Community
English,
S.I.T. Extension,
Health Intern at
Hindi.
TUMKUR – 572103
CHC
Can
Ph.: 0816 – 2276539
manage
Email: vviny@yahoo.com
Tamil.
Ph.: 9844231137
Hengeru 6th Cross,
113
2 weeks
Nrupathunga Nagar,
Nagarabhavi,
BANGALORE
Ph.: 080 23212202
Dr.
108, 7th Main, 3rd Cross,
MBBS,
English,
Krishnamurthy
KCS Extension,
PG – MD
Kannada,
RPC Layout,
(Community
Hindi,
Vijaya Nagar II Stage,
Medicine) 3rd
fairly
BANGALORE –5 60 040
year.
comforta
Ph.: 9341236508
2 weeks
ble in
Email:
Rapid nutrition
dr_krishnamurthy@hotmail.c
assessment in
om
Rajasthan (Jan.
Tamil
2003);
Uttaranchal
Medical camp
(Oct. 2004).
MBBS
English,
Dr. Shilpa
60, Shreyus Apartment,
Govardhan
Door No. 12,
Kannada,
18th Cross,
Hindi,
Malleshwaram,
Tamil
1 week
BANGALORE – 560 055
9886107501
Ph.: 080 – 23442264®
shilpagovardhan@yahoo
.co.in
114
Dr. Pradeep
#28, 3rd Cross,
Kumar S.
Anjanappa Layout
English
Attiguppe,
and little
Vijayanagar,
Tamil
MBBS
Kannada,
1 week
Bangalore – 560 040
Ph.: 984577-976
Email:
graynco@yahoo.com
Dr.Raghavendr
1249, Ist F Main, 2nd
a Charan MP
Phase,
English
Girinagar,
and little
BANGALORE – 560 085
Tamil
MBBS
Kannada,
1 week
Ph.: 080 – 26721304
Mobie: 9341045679
Email:
raghavendracharan@yah
oo.com
DETAILS OF VOLUNTEER FOR SECOND TEAM
THROUGH COMMUNITY HEALTH CELL (6.1.2005)
Volunteer’s
Name
Dr. Prasanth
Baliga
Address and Contact No.
C/o Dr.Ramesh Baliga,
Language
Duration
Experience
s Known
of stay
MBBS
Kannada,
Rukmini Sadan,
Little bit
Deshpande Nagar,
of Tamil,
Baliga Cross,
and Hindi
Hubli – 580029
Ph.: 0836 – 2252562
9844023205
115
Qualification /
1 week
Dr.Sondev
#1863, 12th Main,
Bansal
5th Cross, Raghavendra
Hindi and
Block,
English
MBBS
Kannada,
5 days
Srinagar,
BANGALORE
MBBS
Kannada,
Dr.Paras
#162 (5/2),
Malhotra
2nd Cross, 2nd Main,
Hindi and
Chamarajpet,
English
5 days
BANGALORE
Dr. Arabind
29, Kanakapura Main
MBBS
Bengali,
Behura
Road,
Hindi,
Basavanagudi
English,
BANGALORE – 560 004
Kannada
1 week
and Oriya
116
ANNEXURE NO.2. NOTES FROM ADDRESSES OF DIGNITARIES
Welcome speech & introduction to the topic by Dr.T.S.Nagabhushana:
Dr.T.S.Nagabhushana, warmly welcomed all the participants to the meet. He
expressed his happiness about the fact that so many doctors from BMC had
responded to the call of distress. Later, he spoke briefly about Tsunami &
enlightened the audience about various facets of the same. He also spoke about the
all important issue of identification & respectful burial of dead bodies in such
situations. He drew the attention of the audience to the WHO guide lines of the
same. He quoted the example of Prof. Dr.Hande, a revered professor of medicine in
BMC in 1980s. When Victoria Hospital was over stretched in 1972 with injured &
dead people due to air bus accident, he arranged for the respectful preservation of
dead bodies & arranged for the identification of most of the bodies. The unidentified
bodies were later given respectful funeral with last rites being performed by priests
belonging to all religions! He spoke of the importance of giving the respect & dignity
to any human, whether dead or alive, as entitled.
Also, he made a very valid point saying that more deaths are taking place due to
man made calamities like war & sanctions! He observed that as doctors with a duty
of ensuring ‘healthy life’ to people around us, we have the responsibility to oppose
& take measure within our limit such mindless activities of humans! He called for
the participants to contribute their little efforts to ensure peace on earth.
He came out strongly against the insanity of the governments in engaging the
precious resources on waging war & destruction. He called for allotment of more
resources towards ensuring health to all the people. Saying that death due to dog
bites & road traffic accidents claimed more life every year in India than tsunami, he
said it was time to spend more energies, time & good sense to take care of these
issues.
Sharing experiences of tsunami relief work by Dr.Veeranna Gowda:
Dr.Veeranna Gowda shared his experiences as the team leader of official team from
BMC. It was touching to hear that he volunteered to go to the affected area in spite of
a crisis in his personal life (he was bereaved due to loss of his mother just recently).
117
He explained that as a leader he had to face many difficulties. First of all,
procurement of medicines was a big problem in a short notice. Also, in field, his
team was scared with rumours of more tsunamis making rounds. As a leader he ably
lead his team & able to convince that they will continue to work in the affected areas
at a safe distance fro the coast. In addition, he felt that it was difficult in such
situations to manage a big team (his team had 18 members) as it was difficult for
such a big team to move from place to place.
He spoke of the works of his team in the area & shared his observation that there
were not many overt medical problems in the sense of physical injuries. At the same
time he praised the efforts, both from the government & civil societies, for their relief
work.
Reflections by Dr.Ravi Narayan:
Dr.Ravi Narayan then presented his reflections on the experiences shared by
different teams. He appreciated the spirit shown by various people associated with
BMC. He also shared his experience of work in disaster like situations. He fondly
remembered his work in East Bengal refugee camps for 3 months. He stressed that it
is one of the situations that one learns more about community medicine with all its
implications & importance. He made a valid point that such opportunities can be
used to train medical students in community medicine. He also endorsed the views
of Dr.T.S.Nagabhushana that even dead people have a right to be buried with
dignity & that we as doctors need to be sensitive to such situations. He appreciated
the efforts of all team members who had lent a helping hand in post tsunami disaster
relief & further stressed the need to evolve a policy to develop a disaster
management team in BMC.
Address by Dr.K.S.Siddaraj:
Dr.K.S.Siddaraj shared his experience as the Superintendent of the Victoria Hospital
how he was requested by the Government of Karnataka to send a medical relief team
with a short notice. He also co related the experience of how difficult it was to
118
arrange a team on such a short notice with the fact that if a disaster was to strike
Bangalore, how inadequately prepared we were to face such a situation! He then
explained about the efforts BMC is putting in to build a well equipped trauma care
& emergency centre in Victoria hospital complete with 8 ambulances!
Address by Dr.Shashidhar Buggi:
Dr.Shashidhar Buggi was very appreciative of the initiative from BMC to provide
relief in tsunami affected areas. He surprised all of us by revealing to all the
participants that the building in which we were having the meet was originally
intended to house the disaster management cell of BMC! He also chose the occasion
to share the fact that SDS T.B. & Rajiv Gandhi Institute of Chest Diseases was
dedicating a ward of 100 new beds in the new hospital under construction was being
exclusively dedicated to emergency care in disaster & disaster like situations! He
also endorsed the idea of formation of a disaster management cell in BMC. At the
same time he pointed out at the long process if we wait for the Government to act &
hence suggested that in addition to sending a proposal to Government BMC has to
start processes in its own capacity to build such a team within its own resources.
Presidential address by Dr.T.Rajeshvari:
Our beloved principal openly expressed her appreciation to all the BMCites who had
been to tsunami affected areas. She also pointed out the importance of holding such
meetings as the present one which will not only help to share the experiences but
also serve as the impetus for new activities in the college. She was impressed of the
model followed by St.Johns medical college during East Bengal relief camp (as
explained by Dr.Ravi Narayan) & offered to take up the issue with the University
authorities. She also was happy that an initiative has been made to develop links
with voluntary organisations & appreciated the idea of having BMC volunteers
having gone through CHC included in the meet in BMC. She also expressed her
interest in developing a disaster management cell in BMC. Overall she expressed
satisfaction on her side that BMC was contributing positively for the growth of our
nation & expressed the confidence that it will continue in future also.
119
EXPERIENCES AS A TECHNICAL TEAM MEMBER OF CHC IN
THE ‘CHILDHOOD NUTRITION PROJECT’ ON REQUEST BY TVSMOTOR INDUSTRY
A BREIF REPORT ON VISIT TO TWO VILLAGES ON INVITATION BY RURAL
HEALTH DEVELOPMENT CELL OF TVS FACTORY IN HOSUR
BACKGROUND:
As a part of ongoing Rural Health Development Program & to plan for future
collaboration & to define the same in terms of focus, concept & activities, the CHC
team was invited by RHDC to visit Andiwadi village to have a direct dialogue with
expecting & new mothers of the village. Since we felt it would be more useful to visit
one of the ICDS project, we decided to do the same also.
PURPOSE OF THE VISIT:
1. To have a direct dialogue with expecting & nursing mothers of Andiwadi &
Kothagondapalli villages.
2. To visit an ICDS project to have a brief situational picture on nutritional & health
status of the attending children.
3. To define & expand the exact nature of collaboration between CHC & RHDC of
TVS factory for future works.
4. To collect demographic data & other data, deemed necessary for future activities.
THE VISIT PROPER:
We, Mr.Chander & Dr.Vinay, the representing team members from CHC had a
preparatory discussion14 with Dr.Thelma Narayan before embarking on the visit..
We first met Dr.Rajan Babu, the Chief-Medical-Officer & person-in-charge of RHD of
TVS factory, who promised to send a formal request for collaboration with CHC.
Later, we visited the ICDS project in Kothagondapalli15 & had a brief encounter with
14
15
Annexure No.1
Details of visit in annexure no.2
120
the staff & children. Lastly, we visited Andiwadi village along with three officers of
RHDC, where we had a very satisfying dialogue16 with expecting & nursing mothers
of the above mentioned villages.
OUTCOME:
1. Dr.Rajan Babu agreed to send a formal request for collaboration.
2. Data pertinent for future action in RHD for Andiwadi & Kothagondapalli
villages collected.
3. Partly successful in establishing a meaningful working relationship with
anganwadi workers & mothers.
4. A very stimulating & informative discussion with the expecting & nursing
mothers of both villages.
CONCLUSION:
Though we were partly successful in carrying out the objectives of the visit in
general, we felt there is a need for defining exactly the nature, scope & terms of
collaboration at the earliest; to have a meaningful & fruitful partnership.
16
Details of visit in annexure no.3
121
ANNEXURE NO.1.PREPARATORY DISCUSSION WITH Dr.THELMA
NARAYAN
A very insightful discussion with Dr.Thelma Narayan, for which Dr.Vinay arrived
late, during which she gave us a overview of what should be our focus during the
visit & oriented us towards the exact job at hand. She even discussed about the
various data to be collected & stressed on the need for formal agreement &
importance of establishing a good rapport with concerned people. She also
cautioned us about carefully selecting the method of pedagogy, appropriate to the
group. The discussion gave us that final ounce of orientation.
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ANNEXURE NO.2.VISIT TO KOTHAGONDAPALLI ICDS PROJECT
Kothagondapalli, a village, is a 10 min drive from TVS Factory, where RHDC of TVS
has been working in various capacities since 1994.
OBSERVATIONS:
1. The anganawadi is housed within the campus of Government school with a
separate room & kitchen to itself.
2. The building as a whole was constructed by the Government. The ‘uplifting’
in terms of painting, maintenance, toilet provision, gardening, enclosure
construction & maintenance of playfield is undertaken by RHDC.
3. The campus as a whole was well lighted & ventilated with pleasant &
salubrious surroundings.
4. The anganawadi was spacious, cleanly maintained with a separate, clean
kitchen with a gobar gas fuelled stove for cooking.
5. There was enough space for children to play within the room, albeit without
enough toys.
6. There is assess to drinking water & clean toilet.
7. There was a low attendance of enrolled children. Out of 35 only 24 were
present, the reason given was the farness of the anganawadi from their
houses.Children present at the time of visit were reasonably healthy & most
of them were well nourished. However there were a few malnourished
children (There is a need for a detailed study of the same which was
postponed due to lack of time).
8. The food being served was hot, but not very inviting. All children were made
to wash their hands & say their prayer before being served food, with each
child getting a separate plate for eating.
9. The children seemed more than ready to cooperate with a stranger & happily
submitted themselves for ‘examination’ by Dr.Vinay.
10. The staff members were cooperative & friendly with us. They seemed very
well informed about their duties & seemed to be doing the same reasonably
well. They also seemed to be genuinely interested in their work. They also
123
reported enough support from Government in terms of supply of food &
medicines.
Various functions performed by the staff as told by them are as follows:
Nutritional supplementation to all children in the age group of 0-6
years & all expecting & lactating mothers. They also followed
differential quantity as prescribed by the authorities.
ANC for expecting mothers including tetanus immunization every 2nd
Monday of the month with help of visiting ANM.
PNC for nursing mothers.
Immunization of all children, as prescribed by authorities, on every 2nd
Wednesday of the month with help of visiting ANM.
Distribution of IFA tablets to expecting mothers & all girls between 1119 years, administration of Vitamin-A to all children at 6 months of age
& then 2ml every 6 months till 5 years of age,distribution of
paracetamol, albendazole & clotrimazole to people in need.
Referral services for sick people.
Health education to all women between 15-45 years.
Non-formal education to all children between 2-6 years of age.
Periodic meetings with women, adolescent girls & with village
legislative council.
Maintenance of records including growth monitoring, general health of
children & performing sensex duty.
11. However, the glaring defect was the inability of the staff to maintain growthcharts of children, a duty so important, due to acute shortage in the supply of
growth charts by the government!
12. The staff was enthusiastic in further improvements of the anganawadi in
general & ready to give help in whatever way they can.
IMPRESSION:
The anganawadi though well maintained, had further scope for improvement &
needs a detailed study before any improvements are suggested.
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ANNEXURE NO.3.THE DIALOUGE PROCESS AT ANDIWADI WITH
EXPECTING & NURSING MOTHERS OF BOTH VILLAGES
Andiwadi, a village situated about 8 kms from TVS factory was the rendezvous for
our dialogue with expecting & nursing mothers of above mentioned two villages.
The meeting was arranged by RHDC & was attended by anganawadi workers of two
villages & 9 expecting & nursing mothers. The meeting took place in the beautiful &
secure anganawadi of Andiwadi village.
The dialogue was held in a very informal manner, with the participants and resource
persons mingling freely. Mr.Chander initiated the dialogue in a captivating manner
by asking the participants of the fate of a planting planted in wilderness & not
cared! It helped to break the ice & also gave the woman an ideal platform to start the
dialogue. Then on, the dialogue continued with good participation & some of the
observations as made by Dr.Vinay are as follows:
1. The participating group was a good mixture of woman from different
economic levels, though it
cannot be said so of their social class.
2. Only 2-3 participants were very active & others answered only when
questioned. There was not
much initiation of dialogue from the side of participants.
3. The coordinator was articulate, expressive & tactful, stimulating the women to
think & participate.
4. The knowledge of most of the participants regarding child health & rearing
was commendable.
Some samples of the dialogue are given below (not an exhaustive list but only a
small part representing the effectiveness of dialogue):
Mr.SJC: Why should you feed children?
Women: “To fill stomach; to help in growth;to maintain health of the
children”.
Mr.SJC: When should breast feeding started? Weaning-When & how?
125
Women: BF just after the birth; no prelacteal feeds to be given; Weening to
start in 3-6 months
With ragi porridge & other soft foods; confusion among the group regarding
marketed baby foods
& on informing, by us, that they are not necessary, one even questioned us by
asking how come then that the doctor prescribes it?; most said they have
never bottle fed their babies!
Mr.SJC: Immunization-When, How many?
Women: Most of them knew of OPV, BCG, DPT, but not many knew of
Measles vaccine. Also they were ignorant of number of doses of each & the
disease against which different vaccines were used. But most mothers agreed
on the importance of vaccination in the promotion of their child’s health.
Mr.SJC: What are their ‘unmet needs’?
Women:1. Only rice not enough, variety of food deemed necessary.
2. Need more playthings.
3. Need to have more plates to serve food for children.
4. Make ‘balawadi’ attractive to children, so that they ‘love’ to come
there.
Mr.SJC: Why do they think some children are not attending anganawadi?
Women: “ Some people think sending their children to anganwadi with all
‘other’ children will make their children dirty”; some fear that there will be
sharing of plates; distance problem; children don’t like to be kept ‘prisoners’
in a closed place, they like to play as ‘free birds’
Mr.SJC: Any other significant problem they wanted to discuss?
Women: Most of them strongly felt something is needed to be done to
children of coolies, as the children will become ‘children of street’, literally
living on their own in the streets, after anganawadi closes till their parents
return home from their work.
Mr.SJC: Why do people send their children to anganawadi?
Women: Food; preschool- so that their children become smart; to see that
‘headache’ is transferred to someone else for atleast sometime!
126
Mr.SJCL: How can they help to address the identified problem?
Women: (After some minutes of silence) “You give the suggestions…..then we
will see how we can help…..”
IMPRESSION:
There is an urgent need to address some of the misconceptions of the mothers about
anganawadis, the most important being the dangerous misconception of Govt.
supplied ‘supplementary nutrition’ as a ‘replacement’ to home nutrition, which
makes the basic objective of ICDS scheme of ‘improving child nutrition’, a distant
dream. Also there is need to further the health knowledge of mothers regarding
doses of immunization & other aspects of child care. It seems necessary to consider
how best can we make anganawadis ‘attractive’ to children & increase the
attendance. What seems to be a real problem, but conveniently overlooked is ‘the
street children’ problem. It is an emergency problem which needs to be addressed on
a war footing. Also it is pertinent for us to now evolve a strategy for effective
‘community participation’ if we are to make Rural Health Development a reality.
127
PROJECT PROPOSAL FOR ASSESSMENT OF NUTRITIONAL STATUS OF
CHILDREN (0-6YEARS) IN 6 VILLAGES IN HOSUR TALUKA
AIM:
Assessment of nutritional status of children between 0-6 years of age in 6 villages of
Hosur taluka of Krishnagiri district of Tamilnadu state & to plan & enable measures
to mitigate malnutrition in children & to promote the development of children &
ensure them a healthy childhood.
OBJECTIVES:
To assess the nutritional status of children aged 0-6 years in 6 villages of
Hosur taluka where health division of Community Development department
of TVS Motors (TVSM) is working.
To identify the various factors; social, economical, political, educational &
cultural; that affect the nutritional status of the children in that area.
To plan & enable the local community & Community Development
department of TVSM to take collective action to adapt & maintain rational &
appropriate nutritional practices of the children to restore their nutritional
status to normalcy & maintain the same.
THE PROCESS:
The whole project will be taken in two phases:
1. Assessment phase including collection & analysis of child nutrition data &
2. Post assessment action phase includes evolving a plan to enable the local
community & health division of Community Development department of
TVSE to take collective action to adapt & maintain rational & appropriate
nutritional practices of the children.
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ASSESSMENT PHASE:
It includes the following processes:
An action based & participatory community approach will be the guiding
principle for the whole process. Meeting the local people & building working
relationship with them will be the first step of the project. Local people
includes the staff at health division of Community Development department
of TVS Motors, the community leaders of all 6 villages, representatives from
parents, women, men, children & elderly groups of the community, the
anganwadi workers & ANMs of the area. The meeting would serve as a place
to:
o Know the willingness of the community to participate in the project
o Inform & discuss, with all parties involved, the objectives &
methodology of the project
o To understand & build rapport with the community
o To involve every stake holder in decision making process
o To finalize the logistics of the assessment phase of the project
o To collect past records, whatever is available, regarding the health
status of the children in the community
o To build a causal model of malnutrition
Methodology used for the assessment of nutritional status of the children
would be a ‘cross sectional study’ of all the children through house to house
visits & recording their weight using Salter scale & height (for children >2
years)/length (for children <2 years) using fibre glass scale/infantometer. The
data will be collected with the involvement of the local people. The data
collected will be collated with the past records of the children to assess the
nutritional status. The NCHS values for weight & height of children, as
recommended by WHO, will be used as the reference values to draw
inferences.
In addition, based on the causal model of malnutrition, a questionnaire
designed to study the various factors; social, economical, political & cultural;
that affect the nutritional status of the children in that area will be
129
administered to a representative sample of the different groups in the
community.
The process will be designed & implemented with full participation of the
local people. The community will be asked on how best can we involve them
in the process (& also will be asked to provide 2 volunteers in each village for
the entire process to move forward. Then, the volunteers will be involved in a
discussion where the whole process of the project will be discussed with them
& their needs identified. In addition, their inputs will be incorporated in the
design of the questionnaire. A training program to build capacity of the
volunteers to undertake the project themselves will be planned.)
COMPONENTS OF THE ASSESSMENT PHASE:
1. Meeting with the local people: Meetings will be held with local communities
& staff members of RHDC of TVSE with the objectives mentioned earlier.
Also, these meetings will be made participatory & will be used to serve the
following requirements:
Build a team within these villages to assist us in the project. In
addition, capacity building of the same to be undertaken during the
process of project execution to enable them to continue the work in
future
Construct a simple & functional
hypothetical causal model of
malnutrition
2. Collection of vital statistics: It is important to have a general picture of the
community in which a health program is being planned. Apart from helping
us in providing on the demographic profile of the region & an approximate
number in the target group (children of 0-6 years), it also helps in giving a
broader picture of the overall health status of the children in the region.
RHDC can obtain the same from the local governmental authorities. The data
deemed pertinent for the project are number of children in 0-6 year age group,
130
sex ratio in the same age group, IMR, 1-4 mortality rate, vaccination coverage,
life expectancy of the area, spacing of the child birth, details of families with
0-6 year old children & any other deemed necessary during actual process.
3. Collection of previous records of the children: Such as growth charts, birth
certificates, under 5 health records, records from pre primary child care
centres & any other records pertaining to the health of the children under
study.
4. Clinical examination: Clinical examination of all the children to search for
specific signs of malnutrition to be carried out. The specific signs of
malnutrition that will be looked in each child will be as follows:
•
Hairs: Sparse, thin, easy pluck ability, hypo pigmentation, without
sheen, flag sign
•
Eyes: Dry eyes, Bitot’s spots, keratomalacia, xeropthalmia, pallor
•
Tongue & mouth: Sore, red & glazed tongue; cheilosis; pallor
•
Skin: Erythema, Hyper pigmentation, raw hypo pigmentation; easy
bruisability; dry, inelastic & mosaic skin; phrynoderma
•
General appearance: Wasted muscles & bony prominences; no fat
under the skin; protuberant abdomen; generally apathetic or highly
irritable child; child which has stopped feeding; oedema;
5. Anthropometric measurements: The height & weight of each child is to be
measured & then weight for age (under weight), weight for height/ weight
for length (acute malnutrition) & height for age/ length for age will be
calculated for a sample of children. The age of the child in question will be
assessed according to the data in birth record or if no such data is available
using the local calendar or an approximate age is calculated using the clinical
examination. All measurements are to be obtained under standard conditions
using standard equipment & standard techniques. The NCHS values of height
& weight for age in children will be used as reference values to draw
131
conclusions. The same will be recorded on a growth chart & the importance of
maintaining the same in future will be stressed. If previous records of weight
& height are available, the same will be collated with the current
measurements to know the trend of nutritional status & to identify the ‘at risk
age’, if any, in the community.
6. Community survey: Once a simple & functional causal model of malnutrition
is built & major determinants for the cause of malnutrition identified, analysis
of the data will be taken up & priority areas for intervention will be identified.
A period of one month is envisaged to be the time period to carry out all the above
activities. Once, the above process is over, the project moves into the postassessment action phase.
132
QUESTIONNAIRE FOR ‘KAP’ STUDY OF CHILD FEEDING PRACTICE
Name of the interviewer: ______________________________ Date: ______________
Village name: ________________
Section A. GENERAL INFORMATION
(Note: interview mothers who have chid/ren below 6 years of age
If the mother has died and the child is raised by a guardian interview the guardian)
1. Name of the respondent* ________________________________ age ______
*Respondent means the mother or the guardian of children below 6 years of age
2. Address
________________________________________________________
________________________________________________________________________
_______
3. Name of the husband ____________________________________age ______
4. Name of the Head of the household ______________________ age _______
Sex ________
Family details
Type of family: a. Joint family b. nuclear family c. single parent
Sl.
No
Name
Age
S Relationship to Educati
e
x
1.
2.
3.
4.
133
HOF
onal
Status*
Occupation
Income
5.
6.
7.
8.
9.
10.
*Record as
A. Just knows to read & write
B. Up to 4th Std
C. Up to 7th Std
D. Up to 10th Std
E. Up to PUC
F. Higher than PUC
6. Type of housing
a. Thatched
b. Semi pucca
c. Pucca
7. Details of children under five years
(Note: fill according to birth order. DOB and weight as the mother remembers, look for any
documentary evidence available)
Sl
Name
DOB
.
Age
Sex
Birth
Whether
if irregular,
weight
attending
reasons
N
school /AW
o
regularly *
1.
2
3.
* R: regularly IR: Irregularly
134
Section B
(Elicit information about baby less than 6 months of age in the family)
1.Did/do you breast feed the baby?
a. Yes
b. No
If yes go to question no 2
If no go to question no 10
2. How soon after the birth was the baby put to breast?
a. soon after birth ( < six hours)
b. First day
c. Second day
d. If > two days .specify _______day/week
3. What did the baby get as first feed?
a. Mothers milk
b. Animals milk
c. Sugar water
d. Any other _____________ ( specify)
4. Was the colostrum fed to baby?
a. Yes
b. No
If yes go to question no 6
If no go to question no 5
5. Why was the baby not fed with colostrum?
135
a. Bad for baby’s health
b. Too thick for baby to digest
c. Colostrums is impure
d. Any other ________________________
6. Baby was exclusively breast fed till _________ months / years
7. Did you stop breast feeding the baby any time during the above period?
a. Yes
b. No
8. If yes why?
Child:
Mother:
a. Had fever
a. Had fever
b. Measles
b. Became pregnant
c. Diarrhoea
c. Cold and cough
d. Cough and cold
d. Breast problems
e. Any other ________________
e. Any other ____________________
9. What was the baby fed with during such episodes?
a. Boiled and cooled water
b. Plain water
c. Sugar water
d. ORS
e. Animal milk
f. Any other _____________________
(Stop the interview if the baby is still on exclusive breast feeding.)
10. If not breast fed, why?
a. Death of mother
136
b. Not able to produce breast milk
c. Specify reasons
11. If not breast fed what did you feed the baby with?
a. Animal milk
b. Milk powder
c. Any other _______________
11. If not breast, how was the alternative food/milk fed to the baby?
a. Bottle
b. Cup and spoon
c. Pallada
d. Any to other
12. If the baby was fed with animal milk/milk powder, was water added for
dilution?
a. Yes
b. No
13. If yes, up to what age did you continue to do that?
Year ________ month _________
137
SECTION.C.WEANING
(Elicit information about the baby started with weaning & less than 2 years of age)
1. At what age did the child started receiving food other than breast milk on a
regular basis?
AGE (in months)
Age when started (Tick
What food is given first?
at the appropriate age)
0-3
4-6
7-9
10-12
12+
2. Did you continue to breast feed the baby even after the baby start receiving other
feed regularly?
a. Yes
b. No
If yes go to question No.3.
If No go to question No.4.
3. Till what age did you continue to breast feed the baby? _____Years____Months
4. List out all the foods your baby received. (Record in the order of first served→ last
served)
Name of the food
Age of starting (In months if , 1
Method of
year, In years & months if >1 year)
feeding*
*Method of feeding: Record as
A if bottle fed
fed with hands
B if fed with pallada
C if fed with cup & spoon
D if
E if any other method is used & specify the method used
138
5. Describe what exactly the baby was fed in the last 24 hours (record in the
chronological order & in as much detail as possible)
Time of serving
Food
Quantity of feed*
Method of
serving**
*Amount of food to be recorded as follows:
Liquids:
in ml/feed (Find out the local measure & usual utensils used to feed the
children & approximate it to the nearest ml)
Solids:
in no of cups/feed (Quantify the utensils used locally to feed the children)
** Method of feeding: Record as
A if bottle fed
fed with hands
B if fed with pallada
C if fed with cup & spoon
D if
E if any other method is used & specify the method used
6. Who fed the baby in last 24 hours? (Record all the people involved. If possible,
identify the mail person who cares & feeds the children most of the time)
a. Mother
b. Siblings
c. Elderly people in the house
d. Any other___________
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CASE STUDIES OF MITANIN PROGRAM
CASE STUDY 1:
Mrs. XXX was selected to be a Mitanin in YYY block and later promoted to be the BRP of
the same block. During the course of her work she became pregnant. But she refused to take
leave and continued to work. It was during her field visit to one of the hamlets, 4 km away
from YYY the labor pains set-in and she delivered a baby boy in the hamlet while on duty!
ZZZ (the new born baby boy) is 8 months old at present and accompanies his mother to all
training sessions and all her field visits. He is fondly called ‘Sangathan ka beta’ by others.
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CASE STUDY 2:
The women’s committee formed by Mrs.XXX, a Mitanin of YYY hamlet, is so strong and
motivated that they successfully acted against the irregular and erring primary school teacher
of their hamlet to mend his old ways and to be regular to the school.
He now sends in regular reports regarding school activities to the women’s committee and
attends school regularly and follows scheduled time for the school. He even writes to them
(for permission on the days he is not able to run the school.
He sent in an attendance report of school children while the meeting was going on, on the day
of our visit.
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CASE STUDY 3:
The school teacher of the Primary School (govt.) at YYY was reportedly a drunkard. He was
very irregular and reportedly ran the school according to his whims and fancies. Most often
he came to school at 11 am or 12 noon and stayed till 2 pm only. It is said that he did not
give mid-day meals to the children regularly and sold the rations in the open market.
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The women in YYY village put up with this helplessly as they didn’t have any information
regarding their children’s right to education and their entitlement for midday meals. This
went on till the Mitanin program was introduced.
Once, XXX was trained to be the Mitanin and she was educated about their rights and
entitlements, she carried the same message to the women’s committee of her village. The
women committee decided to take collective action against the erring teacher and forwarded
a ‘complaint’ to the district magistrate (SDM).
The SDM came to their village and conducted an ‘enquiry’ about the knowledge of the
women and met a few men and sarpanch of the village. These men were supposedly ‘bribed’
by the school teacher with liquor and hence the inquiry produced no results.
XXX and other women were livid when they learnt about this and again forwarded a
complaint to the SDM They also asked him the reasons why they were not informed about
the enquiry? The SDM was taken aback and he went on another enquiry to the village with
prior information to the women’s village health committee.
On the day of enquiry XXX and other women of the village spoke fearlessly to the SDM and
apprised him of the irregularities in the school and mid-day meals program. Also they
accused sarpanch and other men of abetting with the school teacher in front of sarpanch
himself. They were able to convince the SDM about their complaint. The SDM promptly
took action and warned the school teacher of stringent disciplinary action if he didn’t mend
his ways.
School teacher was taken aback by these developments. Nevertheless, he reformed to a great
extent and started opening the school regularly during scheduled hours and also providing
mid-day meals regularly.
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CASE STUDY NO. 4
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The women of YYY Gram Panchayat never attended Gram Sabhas. Gram Sabhas were
never meant for women! It was for the ‘men’ of the village and it was their prerogative to
decide what is good and what is bad for the village.
Then came the Mitanin program and XXX from the YYY hamlet was trained. She organized
a village women’s health committee. Slowly the women started realizing the ‘real’ issues
and also tried to come out of their ‘cocoons’.
XXX and few women mustered enough courage to go to a Gram Sabha meeting. The men
were surprised at their presence in Gram Sabha. Sarpanch asked them caustically “why have
you come here”? Ramabai soije evenly: Why are you sitting here
The ‘men’ of the village realized that there was a change and accepted it graciously. Also,
XXX started bringing good inputs into Gram Sabha. Now she is more than welcome into the
Gram Sabha and pre-meeting information is sent to her to make sure she attends all meetings!
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CASE STUDY NO. 5
The fair price shop catering to the needs of people in XXX hamlet was entirely unfair.
People never used to get the rice earmarked for ‘below poverty line’ card holders (Rs. 3/- per
kg). Also rice priced Rs. 6/- per kg for poor but about poverty line card holders was being
sold as Rs. 9/- per kg and also only a fraction of quantity was available for the poor people.
The remaining of the stock was being sold by ‘seth’ (the manager of the fair price dept) to the
open market.
The women came to know about PDS and its rules and regulations through XXX (the
Mitanin) they discussed of the unfairness of fair price depo and took the issue to district
administrators.
The ‘seth’ was enraged when he learnt about the complaint. He threatened the women (XXX
and two of her associates) of dire conservancies. As a result of which, the women got scared
and did not return to their homes. Instead, they roamed around in the forests with a ‘club’ for
personal protection dreading of ‘arrest’ by the police (as Seth had collusion with state policy
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department). Men from her village didn’t come to her support. But women community
firmly stood behind her and gave her and her associates the much needed support.
The enquiry held by the district administrators was again a dreadful affair for the women.
They were intimated and the whole setup looked very threatening. In spite of perceived
dangers, the women firmly stood their ground during the enquiry and wee able to convince
the district administration about the ‘fraud’ at fair price depo.
As a consequence, the
management of the fair price depo was transferred from the corrupt seth to the sarpanch of
the village and Rs. 3/- kg/rice was introduced.
Presently, people get their entitled rice and other rations at the price and quantity fixed by the
government regularly. Also many eligible people who hadn’t got BPL cards previously have
been distributed cards.
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CASE STUDY NO.6:
AAA, one of the remotest villages in the area had four widely spread out hamlets with more
than 80 houses. It took us almost 120 minutes to travel 18 kms & reach the village in our jeep
from the nearest ‘good’ road.
The village hadn’t seen an ANM since many years without any Public Health facilities
including immunization facilities reaching them. The anganwadi is managed by the helper.
There is a primary & middle school managed by a head master & a teacher. People have to
walk or the patients have to be carried, for 4-5 km to reach the nearest quack, & for 10-12 km
to get a local transport to go to the nearest PHC which is 18 km from the village. On top of it
there is no doctor in the PHC for the past 6 months as the incumbent doctor was deputed on
training without a replacement doctor. The whole PHC is being managed by a single
Compounder who provides Health care to more than 10000 people belonging to 30
surrounding villages!
In this village, two Mitanins were selected & were given two books without any training! In
addition, one of the selected Mitanin was a 65 year old lady who couldn’t walk for more than
half a kilometre & hence not able to go to any outside place for the training. The other
Mitanin is a middle aged illiterate lady who is not interested to be a Mitanin. The Panchayat
member doesn’t know anything about the program!
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CASE STUDY NO.7:
Mrs.XXX was awarded as the ‘Best Mitanin’ & working in AAA block. She is an
enthusiastic Mitanin who has taken her work of Mitanin seriously. She took an initiative to
motivate the men in her village to undergo Vasectomy operation & was responsible for many
a men undergoing the above said procedure. But this brought her in direct conflict with the
ANM. The incentive (Rs.50) was the contentious issue & since the Mitanin was responsible
for motivation she took the incentive. This angered the ANM & she refused to follow up the
‘cases’ in the village & also to remove the sutures. The Mitanin had to take the man in
question to a local doctor for the suture removal using her own money! This issue illustrates
the possible conflicts of interests between the Mitanin & ANM under the present settings &
the issue demands proper attention!
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CASE STUDY NO.8:
The concept of Mitanin being a ‘voluntary health worker’ is not ingrained in the minds of
general Public. She is greatly misunderstood to be a Government functionary & this caused a
lot of problems for the Mitanins.
One example was the refusal to enlist a widowed Mitanin in ‘Food for Work’ program by the
Panchayat, on the basis of her being a government functionary. This particular Mitanin was a
poor widow with very little land & depended on daily wages for her survival! This also
stands as a testimonial for the inadequate involvement of the Panchayat & community in the
program. Also, this stands in stark contrast to the concept of Panchayat support to remunerate
Mitanins !
CASE STUDY NO.9:
XXX is a village in AAA block of YYY district in Chhattisgarh. The village has a primary
school & an anganwadi. However the ANM of the area refuses to visit the village in spite of
easy access to the village. Instead, she has asked all people of the village wanting to avail her
services to travel to the neighboring village ZZZ, which is 1-2 km from XXX, to which she
144
visits once in a week. As a result of this a large majority of children of XXX are under
immunized or not immunized at all. Also, the ANC of pregnant women has also suffered.
Mitanin program was started in this block since November 2002 & 5 women of the village
were selected & trained to be Mitanins. After they have learned the importance of
immunization of the children & ANC of pregnant woman in their training they requested the
ANM to visit their village, for which the ANM refused. Determined not to deny their
community for the access of the all important immunization & ANC, they now take special
care in mobilizing all the children & pregnant women of XXX & take them to ZZZ on the
day of the ANM visit! They are hopeful that a day may come when their village will also be
‘accepted’ by the Public Health System & the community will realize the Right to Health!
CASE STUDY NO.10:
Mrs.XXX is an 8th std pass woman aged 22 years & resides in YYY village of ZZZ block of
Chhattisgarh. Her husband is a post-graduate with MA & LLB degrees & practicing farming
in the village. They have 2 children & totally 6 members live in the family house.
She was selected to be a Mitanin of her village by the Gram Sabha in late 2002 following
Kalajatha in their Panchayat (AAA). She has attended 6 trainings spread over last two & half
years in AAA (1 km from her village) & BBB (1 km from her village). The trainings were
held at irregular intervals & employed mostly ‘book reading’ & lectures by the trainers. She
has received totally 7 books during these trainings. She says she enjoyed the training but feels
she would have learned better if trainings included skits, role plays or audio visual aids & if
they were held regularly.
She comes across as a confident, affable woman who is proud of being ‘herself’. She says the
most satisfying aspect of being a Mitanin was to get to know about her own ‘womanhood’.
On enquiry she also comes across as one of the good Mitanins with appreciable level of
knowledge of health & diseases. She with the other Mitanins of the village has also taken up
initiatives to ensure immunization of children & ANC of all pregnant women of the village.
She also appears to be a strong, empowered lady. During our visit to her house for her
interview, there was a drunkard interfering with our discussion. In addition, many neighbors
had crowded around us & were creating commotion. She deftly handled them & asked the
drunkard to leave the place & asked her neighbors to allow us to discuss without interruption.
145
Her husband was very supportive of her & encouraged her to work as Mitanin. Both of them
felt that she would continue to work as a Mitanin even if no remuneration was given but at
the same time felt that it would be more encouraging to get some remuneration for their
efforts.
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CASE STUDY NO.11:
XXX is a village that falls exactly midway between AAA & BBB. It has a PHC which caters
to the scattered population of more than 13 villages of 7 panhayats in the surrounding areas.
There was no doctor at 4 pm when we passed through the way on 07-04-05. The next day we
visited the PHC at 10 Am & found that 4 staff members were present & the compounder was
involved in the ‘distribution’ of drugs to the patient. The whole building was in a dilapidated
condition with a big polythene sheet covering the roof from inside. The ‘examination’ table
looked like it would break down any moment. There was cold storage box from UNICEF
which was left unutilized. On enquiry we learnt that on an average about 5-10 patients visited
the PHC everyday. In addition the people visiting the PHC & living in the neighboring
houses informed that the PHC doctor came to PHC irregularly & hence the people of the
surrounding village didn’t depend upon the PHC for their health care needs!
The doctor came at about 11.45 AM & she spent 15 minutes with us discussing the Mitanin
program. Even though the program was being implemented in the block by the Public Health
System itself, she knew little about the status of the program in the area & said that the
Mitanins are in the villages & hence the field staff knows them better than the PHC based
staff!
CASE STUDY NO.12:
Dr.XXX is a recently graduated doctor from YYY medical college in ZZZ. She has joined
the Public Health Department of Chhattisgarh state as a Medical officer on a contract basis of
two years. She has been involved in the Mitanin program since July-2003 as a trainer & after
her transfer to AAA in August-2004, as a DRP in AAA block. She is presently involved in
the implementation of the program in AAA block along with the BMO.
146
At the time she came to AAA, the program was almost ‘dead’ with no training for more than
6 months. In addition, many trainers had stopped working due to lack of remuneration. There
was also a high rate of attrition of Mitanins.
But both the doctors took it upon themselves to invigorate the program. Dr.XXX personally
met more than 250 Mitanins & said that she personally could count 70-80 Mitanins who had
ceased to function as Mitanins. They recruited trainers to replace the discontinued trainers.
To mobilize the people & build public interest in the program they planned to have one more
round of kalajatha. Since malaria was the most prevalent public health problem in the area,
they used kalajatha on malaria to rally people around the program. Also many new Mitanins
were selected & given training.
The doctor feels that the program is a very good initiative to reach out health services to the
community & also as a tool of Women empowerment. She feels the program can effectively
help to improve ANC, Immunization & particularly during epidemics as early warning
system & to reduce deaths. At the same time she felt that the program should be given full &
uninterrupted support for at least 5 years before it bears any fruits. She also feels that the
trainers are not able to meet the needs of the Mitanins & trainers themselves need capacity
building. The most important constraint that could damage the program, according to her,
was the irregular financial flow. Until the financial floe is stream lined the program may nod
achieve the desired success. She felt strongly about the long delays in the payment of
Trainers & almost had quit the program herself on this issue! She stated that the Women’s
Health Committees had been formed but were largely nonfunctional as there was no capacity
building of the same.
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CASE STUDY NO.13:
In the block of XXX, rainy seasons were known to cause epidemics of Diarrhea in children
with avoidable deaths of few children even!
After the training & deployment of Mitanins in the block & the early initiation of
management of diarrhea by the Mitanins, the situation has shown a great improvement. The
Mitanins are also vigilant of the situation & inform the Public health functionaries of the area,
of the field situation during rains & alert the system on possible situation of epidemic spread
147
early. This has resulted in the early initiation of preventive & promotive measures to control
& mitigate the effects of epidemics.
This according to the BMO of XXX CHC & YYY has resulted in the ‘zero’ deaths of
children during the rainy season of 2004 due to diarrhea!
CASE STUDY NO.14:
Dr.XXX is a block medical officer of YYY CHC. We (Amulya & Vinay) visited the CHC on
05-04-2005 as part of our formal evaluation process of Mitanin Program. We went to the
CHC at 9.30 AM. The attender of the CHC welcomed us & asked us to wait for the BMO in
his office. When there was no sign of BMO even at 10.15 AM, we enquired of his
whereabouts & were given some unconvincing excuses & we were told that the BMO was on
his way to the hospital. We waited for another 15 minutes before we came to know that the
BMO’s house was in the same street about 200 meters away from the CHC.
Tired of waiting, we decided to meet the BMO in his house itself & went in search of his
house. We were surprised to see a ‘crowd’ of patients in his house waiting for the private
consultation. The doctor was not taken aback when we introduced ourselves & the purpose of
our visit. He asked us to wait near the CHC & informed that he will be coming to the CHC
by11.00 AM. We observed that he collected Rs.100 for every consultation! We took a
photograph of the same & went back to CHC to wait for him.
In CHC we came to know that the story was a regular one & it was 11.45 AM before the
BMO finally arrived in the CHC.
What was striking of the whole visit was the blatant way in which the BMO practiced his
private consultation in the regular hours of CHC & the unapologetic way of the BMO in
receiving us!!
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CASE STUDY NO.15:
XXX is a big village of more than five thousand population in the block of YYY. We visited
the village on 05-04-2005 as a part of evaluation process of Mitanin program. The village had
just 2 Mitanins covering the whole village!
148
To our sweet surprise we found that the village Gram Sabha was having one of its regular
meetings in the school building. We gave a visit to the meeting & met the members of Gram
Sabha. The Sarpanch, the Sachiv & 18 members of the Gram Sabha were present in the
meeting.
The main agenda of the meeting was to send a request to the Government to open a subcentre in their village as they met the requirement & there was a great need of the same in
their village. The Mitanin of the village, who was envisaged to play a key role as a link
between Public health system & the community was not attending the important meeting &
the Gram Sabha didn’t even deemed it necessary to invite her! Also, a request for more tube
wells in their village to improve the drinking water access in the village was on their agenda.
Even though a few of the members knew of the Mitanin in their village they pleaded their
ignorance on the concept, work & operation of the program. They even didn’t know about the
selection process or of the expected work of the Mitanins in their village. Then the
responsibility fell on us to explain to the Gram Sabha of the concept & operation of the whole
program!
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149
REPORT OF THE WORKSHOP FOR PRIMARY SCHOOL
TEACHERS ON ‘WATER & HEALTH’
BACKGROUND:
Bharat Gyan Vigyan Samithi (BGVS) is a nation wide science movement working
towards promotion of scientific thinking & attitude in the people with special
emphasis on school children. It is in the fore front of many programs designed to
address the issue of popularizing scientific thinking & attitude & has taken a
proactive approach for reforms in education system in India. The Karnataka chapter
of BGVS, with many luminary people in its wings, has played a major role in the
reforms of school education in Karnataka to make learning a joyful activity for the
children & also shifting the attitude of teaching from content oriented to attitude
oriented. The ‘Chinnara mela’, the annual ‘Children’s science forum’ organized by
BGVS, Karnataka are two examples of such activities. Through such activities BGVS
has also been successful in having scores of teachers as its volunteers in many of its
activities & is also bringing out a monthly magazine in kannada by name ‘Teachers’
to cater to the needs of teachers in Karnataka.
When UNICEF & Karnataka Rural Water Supply & Sanitation Authority (KRWSSA)
announced pilot projects of ‘School Hygiene Project’ in various schools of Karnataka
BGVS, Karnataka with its rich experience in such activities agreed to test the idea in
three districts of Karnataka. The project involves training of 50 children of a
Government primary school on the topic of safe water, sanitation & hygiene with the
aim of promoting Healthy Way of Life in villages.
As a part of the project, training of Primary school teachers on the same topic was
deemed necessary to have long term sustainability & effect of the program. Magadi
& Ramanagaram talukas of Bangalore Rural District were two such places where the
pilot project by BGVS was going on. It was decided to initiate the training program
for teachers from these two places & BGVS requested CHC for its support. CHC
known in the field for its prowess as a resource group in Community health agreed
to extend help even though the request had a very short leading time of less than 16
hours! As a part of my overall fellowship learning objectives & with personal interest
150
in Child Health, I agreed to be one of the presenters in the Training program. This, I
must say that, I agreed half scared as I didn’t have much time for preparation but
with the encouraging words from the team at CHC, I was ready to learn &
improvise. As a part of it I was involved in training work shop with around 200
primary school teachers as participants in 4 groups of 50 teachers in 4 sessions
spread over two days. This is a report of my experiences of the program.
THE WORKSHOP:
Topic
: Water & Health
Participants : 4 workshops with 2 parallel work shops at 2 centres involving 200
primary school teachers, 100 each from Magadi & Ramanagaram,
with 50 participants in each workshop
Sessions
: 4 sessions per day for 2 days for the participants of each workshop
Venues
: Block Resource centres in Magadi & Ramanagaram of Bangalore rural
district
Dates
: 24th & 27th of June 2005
Methodology:
The workshops started with invocation followed by introduction of the participants
& the resource persons. I would then give a brief introduction to the topic ‘WaterThe source of life’. Later the 50 participants were divided into 5 groups & each group
given a topic. The topics were:
1.
Health & Water: What is the meaning of Health?
What do you understand by the term ‘Pure Water’?
2.
Our Village & Water: The sub topics given were sources of drinking
water in their villages, methods of collection, storage, purification & usage
of drinking water, distance of the sources of water from most homes in the
villages, people involved in the collection of water & mode of excreta
disposal in their villages.
3. Water & its effects on health
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4. Causes for the deterioration of quality & quantity of water in their villages
5. Preventive & remedial measures to be adapted to ensure safe drinking
water in their villages
The groups then would have 20-30 minutes to discuss among themselves &
elaborate on the given topic. They would represent the group’s consensus on a
drawing paper with the help of a marker. At the end of the period each group would
then present their views on the given topic with the chart in the back ground. A
discussion would then ensue with full participation from all the participants on their
views over the topic & inputs from the resource person completing the whole
picture. This way all 5 teams would present their topic & at the end of 90 minutes
period, the topic of Water & Health would have been covered. There would be tea
break followed by presentation on allied topics by other resource persons. Thus at
the end of 2 days, the participants would be given a comprehensive information on
Water, Health & Hygiene.
OBSERVATIONS:
The group of teachers in the work shop seemed genuinely interested & showed great
deal of enthusiasm in their participation in the work shop. Their knowledge levels
were a sweetly surprising revelation for me. ‘The state of physical & mental
wellbeing permitting a person to lead a happy life’-the definition given to Health
showed that their understanding of health, though not complete, had broader view
than the doctors themselves!
They also gave a bird’s eye view of the condition of villages regarding the use of
drinking water & brought to the forum the real picture of villages. Though it can be
said that there has been a substantial improvement of the drinking water situation in
the villages compared to the times of our independence, the situation seems to be far
from ideal & lots deserved to be achieved. The problem of rampant flurosis in
certain areas of Ramnagaram as explained by the teachers needs to be given due
attention on an emergency basis. There is a need for the investigation of the Public
152
health problem of flurosis on a priority basis & formulation of the solutions for the
same.
‘SWOT’ ANALYSIS:
Strengths:
The strength of the whole program lies in the selection of the topic itself. The
topic is a relevant one by the fact that the Water is the source of all life on this
earth & safe drinking water & sanitation are attributed a major chunk in the
improvement of Health status & life expectancy in the world. However in our
nation, majority of the people live in rural areas & only 62% of the villages
have access to safe drinking water .Also the sources of water are fast
depleting both in quality & quantity putting a strain on the life of already
marginalized rural people. In addition, the fruits of growing body of
knowledge on selection & supply of safe drinking water & sanitation have
barely reached our rural masses that are left far behind in the advancing
world. Hence the topic is a highly relevant one in the present context.
The selection of primary school children & teachers as participants is also a
laudable one for the fact that the teachers in Rural India are still highly
respected by the community & their words reach wide & far in the
community. Also, the good practices that are fostered in childhood make a
lasting effect on the life of both individuals & the communities. Also in our
rural settings, messages carried by our children to their homes are given
much importance. This program provides an opportunity to also fill in the
lacuna of scarce health education as a part of regular discourse in our school.
The school teachers attending the workshop were enthusiastic & showed their
willingness in the mutual learning process. They participated with great
enthusiasm & the charts produced by the groups of teacher stood as a
testimonial for their participation. In addition, the knowledge of the teachers
regarding the issue of water & health was commendable. The discussion that
153
followed the presentations was a lively one with many learnings form both
the side.
The teachers also exhibited great level of local knowledge & asked
clarifications for wide ranging issues of health & water. A group of teachers
from the region of Ramanagaram also put forth the problem of rampant
flurosis in the region affecting the health of children & enquired of the
solutions for the same.
The program was taken up in collaboration of many Governmental agencies
including the Education Department & KRWSSA. This is a significant step
forward towards achieving inter sectoral coordination towards realizing
Health for all. The arrangements done by the local BRCs for the program were
also commendable & the rooms of BRC equipped to conduct such training
programs was a sight to behold.
The BGVS on its part had also produced training manual in local language in
a short notice & also many songs & plays on the issue were printed &
distributed. Also, many games had been planned to suit the education
objectives. It is this type of improvisations in the methods of teaching to suit
the needs of children that stood out as unique ones. Also, the topic of Water,
Health & Hygiene was not strictly confined to the bio-medical convention of
water borne diseases & their control but the issues covered also included the
broader picture of water shortage, water pollution &, more importantly, local
problems regarding the same.
Weakness:
•
The planning of the whole program was done within a short period & hence it
suffered in many qualitative aspects. With the resource people being
contacted in the evening of a day before the program, the preparation from
their part was not adequate. Also this resulted in the non-preparation of
audio-visual aids which would have further enhanced the effectiveness of the
program.
154
•
The non-involvement of the local resource persons & public health system is
an important concept that requires considerations. In the context of long term
sustainability & capacity building of the local people for local action, it makes
more sense to involve local people in the program. In addition, involvement
of the public health system which has a mandate to promote school health,
the absence of their involvement needs to be rectified in the future.
•
Time constraint was also one of the factors that affected the effectiveness of
the whole program. Many teachers had to leave by 5 pm to catch the bus for
their village which resulted in incomplete sessions on both the days I
attended.
•
Field visits & on the field demonstration & understanding of the concepts of
health & water would be desirable in future programs.
•
Communication gap resulted in many avoidable delays & hence effective
communication is required for maximum effectiveness of the programs. In
addition, communication of the objectives & goal of such programs need to be
communicated to the participants & resource persons in clear terms well
ahead of the proposed dates to make the program more effective.
Opportunities:
•
This comes as a golden opportunity to address the lacunae of near absence of
Health education in our schools. This opportunity has to be used to
demonstrate the importance & success of such initiatives to push forward the
agenda of introduction of health education as a regular course in school
discourse.
•
This also presents an opportunity to build effective inter sectoral relations
between various governmental departments which is one of the stated
objectives of Karnataka State Integrated Health Policy.
•
This program can also be used as a platform to build health consciousness in
teachers & students & hence increase people’s participation in the promotion
of their own health.
155
•
As already experienced, with increased awareness of health & related aspects
of water, this can be developed into an effective forum to address the village
community’s information needs on issues of health & water, with more
capacity building in times to come.
•
It has been a proven fact that education of children & messages conveyed by
teachers play an important role in the slow process of community
transformation & social change which has to be given due consideration &
acted upon.
Threats:
•
Long term sustainability of the program & frequent reinforcement of the ideas
are the essential pre-requisites for such type of programs aiming at changing
harmful social practices & promoting healthy life styles. In such a scenario, if
the program is continued with help from ‘outside’ resource persons without
development of the local resource people, it puts a question mark over the
long time sustainability undermining effectiveness of the program.
•
The decision making process of the program is also another area which
requires due diligence on the part of the program designers. If the decision
making process continues to be plagued by short time notices & hence
resulting in ad-hoc decision making, it may result in the compromise of the
quality & effectiveness of the whole program.
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STUDY VISIT TO ‘HCCRHP’ – A REFLECTION
BACKGROUND:
‘ASHA’ program, a brain child of Holy Cross Comprehensive Rural Health Project
(HCCRHP) of Hanur, envisages residential training & empowering of young girls to
be ‘Health & Social activists’ in their villages. These girls come from the
marginalized
families
from
impoverished
villages
of
Hanur
taluka
of
Chamarajanagar district of Karnataka state. The girls are variably educated – some
up to 7th standard & only a handful of them up to pre-university college level. It is
understood that the program not only trains the girls for their ‘transformation’ into
becoming responsible & enlightened women & possibly ‘village health workers’, but
also to help them to learn various non-formal skills to aid them to break out of
poverty chain & lead a happy & healthy life. With these broad objectives in mind,
ASHA program was started in Prakash Palya in June 2005 with 35 girls as the first
‘partners’ of the program.
I, Dr.Vinay Viswanatha, a graduate in Medicine from Bangalore Medical College, am
presently undergoing Ratan Tata Fellowship Program in Community Health
through Community Health Cell, a resource centre in Community Health in
Bangalore. The fellowship program has given me, a confused recent medical
graduate, an opportunity to explore the field of Community Health as a profession &
life option. In the last 10 months, since initiation of the program, I have had
innumerable opportunities to witness pioneering works in Community Health from
close quarters & learn invaluable lessons from them. It has also given me an
opportunity to closely interact with the leading Community Health Workers across
the nation, who have left a deep impact on me, apart from leading me in the path of
‘New Community Health’.
During these experiences, the idea of Village Health Workers has captured my
imagination. The Health Worker program at SEARCH & Mitanin Program in
Chhattisgarh have overawed me & stimulated me to explore the concept of
Community Health Workers for a deeper understanding & operationalisation of the
same. It is with this background I came to HCCRHP, to further my understanding of
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the Community Health Worker Program & test my readiness in the participation of
the same. In consultation with my dear mentor Dr.Thelma Narayan &
Dr.Sr.Aquinas, the project co-coordinator of HCCRHP, it was decided that I would
be spending 3 weeks in Hannur. It was also decided that training of ASHA would be
the focus during my learning process in Hanur. Hence this field placement provided
me with an opportunity for actually training the proposed Health Workers &
practically experience the joys & sorrows of the same.
THE PROCESS & THE EXPERIENCES:
Once I reached Hanur, I was given a short orientation about the various Community
Health programs undertaken by the HCCRHP. It was a sweet revelation & a humble
experience for me to witness the wide range of issues of Public Health importance
that were & are being addressed by the small but dedicated staff at HCCRHP. Apart
from the ‘conventional’ health topics like that of Tuberculosis, training of traditional
‘Dais’ (Birth Attendants), the project also gave equal importance to wide ranging
issues of ‘The New Public Health’ domain like that of addressing the issue of
poverty, child labor, educational deprivation of the children, & training of Village
Health Workers. In addition, I was also introduced to the newly started program of
ASHA & Health Promoting Schools program. I was taken around the various
villages in the taluka to gain a first hand experience of the village life in the area. I
also visited the Satvidya School in Prakash Palya where the ASHA trainees were
residing.
Following the orientation, I was given the opportunity to be a ‘Trainer’ of ASHA
girls. This was a new experience for me. Here was an opportunity to actually
implement the knowledge of ‘theory’, which I had gained over the period of
fellowship, visiting similar projects & learning from various books.
Accordingly I spent around 10 days with the ASHA girls trying to teach & learn with
them. Even though I was not predetermined with the topics I would be dealing with,
I atleast was sure about the methodology to be adapted for the training process. I
followed the ‘participatory’ method of training, my own crude version of the PauloFriere method of training for transformation.
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The topics dealt by our group in the short period were varied & interesting. Apart
from the pre-determined topics on Health & hygiene, Environmental sanitation,
Water & health & Diarrhea, there were many off shoots from these topics which are
the burning social issues of the region. The issues of early marriage, problems of
menstruating girls, the low & often neglected social status of the women, child labor,
educational deprivation of the children especially girl children, casteism, the
aspirations, fears & the challenges of the ASHA girls, the meaning & scope of health
& many such relevant social problems were discussed & elaborated for further
understanding of the issues.
As already mentioned earlier, a participatory method of training was attempted. I
made a conscious effort not to look & act like a ‘teacher almighty’, but as a fellow
learner (to what extent I was successful, is a matter for some introspection &
evaluation!). We sat in a circle & often started the sessions with songs on health &
social issues, many times pertaining to the proposed topic of the discussion.
Following the songs, we would get on with a discussion of the topic. Many times we
used to break into smaller groups of 8-9 people & discuss the issue at hand. The
groups would then write down all the points arising out of the discussion in a paper
& one of the members would present their group’s view on the topic. Later, we used
to collate the points to have a clearer picture of the issue & would then embark upon
a lengthy discussion to exchange our knowledge on the topics. The ‘pure’ health
topics would then be dealt from me with short discourses, whereas the social issues
were a real challenge & many would end on an open note after much discussions &
confusions. Further more, when the topics required demonstrations (like preparing
Oral Rehydration Solution at home, looking for signs of dehydration in children,
examining pulse) we used to do the procedures practically. We even had two role
plays, conceptualized & enacted by two groups of ASHA girls, on problems of
menstruating girls in the villages (what is also important is the fact that the role
plays were conceptualized, practiced & enacted within a period of 2 hours!). We also
formed a team of four girls to be the ‘Satvidya hygiene & sanitation monitoring
committee’ who drew the action plan to promote & monitor hygiene & sanitation,
both personal & environmental, in the Satvidya campus. With the insistence of
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‘notes’ from the girls, I prepared one on Diarrhea & Management of childhood
diarrhea. The ‘notes’ on Water, Sanitation & Hygiene is pending which will be given
shortly.
In addition, I was also involved in many discussions with the various staff members
of the HCCRHP. The discussions were an eye opener to me regarding many burning
social issues which have a deep impact on the health of the people. Many issues
which are ‘thought’ to be primitive & hence non-existent in the mindset of urban
people, including me, were discussed with alarming regularity throwing me into the
reality of the rural India. The discussions with Dr.Sr.Auinas on her work in the area,
her impressions of the joys & sorrows of Community Health Work proved to be a
great learning experience. It was reassuring to learn that she faced the same
dilemmas, as I am now facing as a novice, when she started her journey in
Community Health work & the methods that have helped her to resolve many of
them.
Furthermore, I had opportunities to visit the villages in connection with ongoing
Community Health Work of the HCCRHP. These visits brought me in face with the
reality of bonded labor of children which shook my senses & shattered the very
foundation of my understanding of Humanity in general & reality of India in
particular. Also, my visits to some of the villages presented the general conditions of
the villages in the region & the hardships of the people. There is not even a single
woman of more than 25 years of age, who is minimally educated, in three out of the
four villages we visited. Another village had one woman educated up to 3rd
standard. A minority of the present generation of girl children are educated up to 5th
standard. The rest of the girls are like their mothers, without any education &
working in homes & fields waiting to be married off at the tender age of 12-14 years!
The penury of the people is sickening. The back breaking work they do to earn two
half-meals a day compelled me to recall the ‘India Shining’ slogan of our ‘revered’
ex-Government! If this is the condition of the people in the cultivation season, I
couldn’t imagine their plight in the off-season. Forget land redistribution, a distant
mirage, even the minimum daily wages looks like a forgotten promise. People are
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forced to work for Rs.7000-10000 for a year as bonded laborers & send their children
to bonded labor for a pittance of Rs.3000 a year!
I believe a stray dog in Bangalore would have a better life than most people here! If
this is the reality in the so-called better state of Karnataka, what would be the plight
of crores of people in the lands of worse-off states of India? What has happened to
the lofty promises made during our Independence? Which is the India that is
referred to by our Honourable Governments when they speak of ‘a developing,
strong India’? Is this part of India forgotten or is this not India at all? Or is it a
conscious strategy to see that the weakest of Indians are weeded out in this way so
that only the ‘stronger’ Indians survive to make a strong & healthy India?
MY LEARNINGS:
My study visit to HCCRHP as already mentioned was primarily with the following
learning objectives:
1. To further my understanding of the concept & operationalisation of
Community Health Workers
2. To get involved in the training process of Community Health Workers & to
realize my readiness & to put into practice my preparations for the same
During the three weeks of my stay in Hannur, I think, I realized all the above
learning objectives & learnt much more. Retrospectively, I think, my sojourn in
Hannur not only served to realize the above learning objectives, it has also helped to
evolve my understanding of the Humanity in general & the way the society
functions in specific.
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