Tuesday, December 30, 2008

Think globally, eat Bhakri

My previous post talked about farmers in the Sittilingi valley intercropping millet, onions, and brinjal with cotton and turmeric so that they are food secure.

A millet grown widely in India and in the Sittilingi Valley is Bajra (Pearl Millet). Apparently, you need more energy to mill Bajra than you do to mill rice or wheat. Older ladies in the valley say they used to mill Bajra manually, but younger generations do not have the energy to do this. They also say they used to have the energy because they consumed Bajra!

Not sure if Bajra can make you powerful, but it is definitely healthier than rice or wheat: it has higher fibre content, and whole grain flour always has high levels of iron. Most importantly, it grows easily, even in soil that may be unfertile for other crops.

In the US, I've found millet flour in Whole Foods, though it doesn't say exactly which millet they milled! I've used it, and it's ok, though nothing like the Bajra flour straight from the farm that Suvarna used in Pune-the lady who used to help me with my house work, Suvarna, would bring home Bajra flour milled on her farm near Nasik. She taught me how to make Bajra Rotis, or Bhakris.
Think globally, eat bhakri.

Thursday, December 25, 2008

Doctors with Bags Full of Craft

This is an article from the October 2008 edition of Dishaa. You can also read about community-health workers, flood-relief efforts in Bihar, and a report on widows in Vidarbha in the newsletter.

In 1948, the World Health Organization (WHO) defined health as a “state of complete physical, mental, and social well-being, and not merely the absence of disease.” Since 1993, Tribal Health Initiative (THI) has shown what it takes to achieve this level of health. Working in the adivasi, rural, Sittilingi valley (Dharmapuri District, Tamil Nadu), THI has brought infant mortality down from 150 in the 1990s to 32 in 2007; maternal mortality is now non-existent. Where women used to give birth outside their home – in the dirt – because of a belief that evil spirits are released along with child-birth, they now do so in the presence of a trained birth attendant, called a “health auxiliary” (HA; usually an older woman from their village). These HAs also make sure that women get check-ups during pregnancy and after childbirth. But health is not the only thing these ladies do – when asked what their most important task is, they said in a flash, “promoting organic farming.”

Farmer Thirthan with his Turmeric harvest. Photo: THI

When Regi and Lalitha George, founders of THI, undertook a padayatra to take the pulse of the valley in 2004, the overwhelming issue facing people was getting a good price for their farm produce. “Farmers who practiced chemical-intensive farming found themselves in debt unless they had a very good crop,” says Regi. THI organized multiple workshops on organic farming techniques; now, farmers in Sittilingi valley grow cotton, turmeric and, of late, even rice organically. The costs of inputs have gone down and they now make profits from their farms. “We are into organic farming from the health point of view,” says Lalitha: farmers are urged to intercrop, and brinjal, millets and onions are grown alongside cash crops, promoting food security in the family even as cash crops provide income.

The Lambadi community, with support of the Health Auxiliaries, is reviving its traditional art of embroidery, which has fallen out of fashion with the rise of the sari (the Lambadis are nomads who migrated to the region from western India many generations ago). On Lalitha’s urging, increasing numbers of people in these villages are now rediscovering their art. Embroidered craft items are now sold, and provide extra income for the family. They proudly call their line of craft items Porgai – which means “pride” in the local language. “Our relatives are often surprised when the two of us,doctors,enter their house with bags full of crafts,” laughs Lalitha. Maybe it takes doctors who sell crafts to make social well-being, a key component of the WHO definition of health, a reality.

Tuesday, December 23, 2008

The Story of the Cotton Ambulance

Helping farmers in the Sittilingi Valley weigh their organically grown cotton is a key part of the agriculture initiative of THI; previously, farmers would often get duped by traders to whom they sold their produce. But since THI purchased a weighing machine, farmers know exactly how much cotton they have produced before they go to the trader. Furthermore, thanks to negotiations carried out by THI, organically produced cotton is now sold at Rs. 7 above the market-price for inorganically grown cotton, to Co-optex, the Tamil Nadu government-owned handloom industry, making organic-cotton production lucrative in the valley. Increasing numbers of farmers in the valley are switching to organic farming, and many are looking to get certified as organic under the "group certification" scheme of the government, meant especially for small farmers. Picture: THI.

Monday, December 22, 2008

Where there is no Doctor - in spite of a PHC

As I entered the Primary Health Center (PHC) in Velhe, about 70 kms from Pune city, the nurse asked me, “Will the doctor be in today?” As it was, the doctor arrived on the next state transportation bus from Pune - I can only surmise from her question, that he attended the PHC only irregularly.

As I spoke with him, it became clear that he, with a family to raise, finds it impossible to stay in a remote village where staff quarters are in a state of disrepair – 6 hours of load-shedding a day and no water in their taps – and water needs to be filled from a hand-pump outside the building. The state of their working environment is not much better – the PHC has been under renovation for two months now (and work is at a stand-still at the present time) with no make-shift space provided for health-workers to function in; the PHC has no water, and water at the near-by rural hospital (RH) also comes from the hand-pump. Ironically, the PHC was envisaged in the Indian healthcare system as the most important facility through which people in far-flung villages would be provided outreach healthcare services.

If the clinics and doctors’ residences were provided essential infrastructure such as water and electricity, it would go a long way toward ensuring that people are provided their right to a functioning primary health care system in their villages – doctors would be much more likely to stay on site, and serve at the PHC regularly.

Social Health Activists they are – Will the government accredit them?

SunderBai is a Kokana adivasi lady, and a Pada Swayam Sevak in her hamlet, about 6 kms from the Saiwan Primary Health Center (Dahanu Taluka, Thane District, Maharashtra). She was trained by Support for Advocacy and Training to Health Initiatives (SATHI) to diagnose minor ailments, conduct health awareness, and to undertake activities that are neglected by the government health system, such as chlorinating drinking water. She takes pride in the work she does – she took the initiative to undergo further training, and now makes and dispenses herbal ayurvedic medicines in addition to the allopathic medicines that she learned to dispense as a result of her training by SATHI. She was amongst 48 women recognized in 2003 as Community Health Workers by SNDT University in Mumbai.

KuppiAmma, a health auxiliary in AK Thanda village (Harur Taluka, Dharmapuri District, Tamil Nadu), was trained by Tribal Health Initiative (THI). In addition to diagnosing and treating minor ailments, she makes sure women with infants get post-natal examinations at health camps conducted by THI in her village. She was chosen as a health auxiliary on account of her being trusted in her village; having finished her own child-rearing activities, she is looked up to in issues regarding child rearing. KuppiAmma is also a community organizer, and is now leading her village in its shift to organic farming techniques. Under her leadership, members of her Lambadi tribal community are attempting to re-learn their traditional embroidery that is the verge of extinction. She is a community organizer, health educator, and trusted partner in the village’s social affairs.

If I had to formulate a common designation for these remarkable women, it would be “social health activist.” And they are that because of their stature in their village, their leadership qualities, and the quality of the training they received. Yet, these are not variables considered by the government when filling the post of ASHA – an ‘accredited social health activist’ – under the National Rural Health Mission. The government requires that the ASHA have studied at least till the 8th standard in school. While this requirement has been relaxed if no one in a village qualifies, it imposes a restriction in villages where there may be women who are school-educated – they must be chosen under the government’s requirements, even if it means overlooking a more trusted woman in the village, who might better embody the leadership qualities so necessary in a social health activist. “I applied for the post of ASHA, but was told I was ineligible – unfortunately, I never went to school even though I was trained by good doctors to diagnose diseases,” says SunderBai.

NGOs like SATHI and THI require that a woman chosen to be a Community Health Worker (CHW) fulfill one requirement above all else: that she be trusted by her village. Education level is only secondary, if a requirement at all. In fact, SunderBai and KuppiAmma prove that completely illiterate women can, given the right training (SATHI uses pictorial manuals to train illiterate people), be extremely competent primary health care providers. NGOs who train CHWs also realize the need for compensating them – these ladies maintain an agricultural day-job and need to be compensated for the time they spend mobilizing the community on issues of health. I met community health workers in four parts of India this past summer – none were paid very much (their pay ranged from Rs. 350 to Rs. 700 a month), but this money is important to these women, in addition to the satisfaction and pride that their work gives them. The government’s approach of not paying ASHAs and relying on them to volunteer their time, energy and knowledge, has no basis, either in theory or in the experience of NGOs who have trained CHWs in the past.

By appointing women who may have already been trained in a hamlet (like SunderBai) as an ASHA, the government would not only save time and money needed to train another lady, but would also gain a well-trained and trusted health worker. Furthermore, by using training methods like those that have been used by SATHI to successfully train illiterate women, any requirement for school-education can be removed, thus ensuring that the woman with qualities most suited to the job, is chosen. Finally, the government must remunerate ASHAs for their efforts. Otherwise, the ASHA program runs a risk of failure, much like a CHW program instituted by the government in 1978. Then, 92% of CHWs were male, underpaid at Rs. 50 a month, and under-trained – they received only two weeks of training at the nearest Primary Health Center. The government has done well this time around, to insist on hiring women as ASHAs, and to have continuous training and discussion as part of the training-strategy. However, it would do much better if it compensated ASHAs adequately, and required only that she be chosen by her village Gram Sabha, rather than also impose ad hoc education requirements that put her at risk of becoming simply the lowest rung in the government health machinery.

A shorter version of this article was carried in the Oct 2008 edition of Dishaa