Monday, July 25, 2011

The Banjara Tales

Banjaras, a semi-nomadic tribe in various parts of India, have a substantial presence in the Chandrapur District of Vidarbha. Known for beautifully bejeweled women and age-old traditions, they work as either agricultural labor or shepherds for their livelihoods.

Their society has a marked 'son-preference', which reflects in the large number of children each family has in the hope of having a male child.

Steeped in traditions and acutely conscious of their 'parampara' (traditional customs) the tribe members still reject efforts to impart health related information and some times even verbally abuse health care workers as they perceive a threat to their cultural integrity.

However, sustained effort by a good team at the nearest PHC and the Ambuja Cement Foundation workers in this area has today started to show results in the form of increased hospital deliveries, complete ante-natal checks and care, and considerably reduced cases of neonatal and maternal mortality.

The commonest occurrence in this area, in relation to mother & child health is deliveries happening on the way to the PHC. And this happens mostly in the lone auto available here (The driver calls himself a 'delivery expert').

The reason of course is clear as one attempts to reach the village on a motorcycle. The road (if one could call it that) could make even a woman who is not pregnant deliver a baby! The picture below is a snapshot of the road that goes on for about 30 kilometers to the nearest PHC.

The lesson seems to be clear. The level of the sub-center, which today seems to be totally dependent on how the 'Nurse' at a particular sub-center is, needs to be strengthened, with increased accountability and more 'systems interventions' so it becomes less individual dictated.

This needs to be also complemented by a better system of ensuring 'safe deliveries' with a flexible approach that combines the role of the trained birth attendant and institutionalization. This choice should in turn be made on a situation analysis of, and adaptation to, the ground realities of the population covered by that sub-center.

And above & beyond all policies, plans, and strategies, each and every employee of the health system, right from the sweeper and aaya to the Minister for Health, needs to deliver the service he or she is being paid to carry out, to make good healthcare delivery a reality.

Sunday, July 24, 2011

The 'Gond' way of life & health

'Gonds', the largest tribe of India, are in a majority among the tribal or adivasi groups living in the villages surrounding Gadchandur.

With a unique language(Gondi), an intricate set of socio-cultural beliefs and practices, these 'Hill People' (As 'Kond' in Telugu means Hills), face unique problems when it comes to healthcare delivery in general and Mother & Child Health in particular.
Religion plays a central role in the Gond way of life, and they worship a deity known as Persa Pen. The strong belief that 'spirits are omnipresent & omnipotent' and that all events in the

world are controlled by the spirits underlies all their practices. Worshipers of the 'female life force', the Gonds believe in sacrificial offerings to please their deities for all events, right from the making a of cow shed to the birth of a child.
Ancient shrines like the one in the picture dot the countryside, and all villages as well as fields also have a central shrine.
Girls, upon reaching the age of their first menstrual cycle are considered to be full-grown and the rite of passage is marked by a sacrificial offering. Even though the age at marriage now slowly seems to be increasing, majority of the womenfolk still remember being married at 14 or 15.
The rituals around the entire process of the female reproductive cycle and child-birth are both intriguing and unique. The women in their menstrual periods are supposed to stay in a verandah of the house, on the floor. They are not allowed to go near the kitchen or cook.
The spirits or 'dev' are believed to protect the pregnant woman and the child and thus nothing external is considered good for the woman. This includes immunizations, ante-natal check-ups, and sonography. Deliveries are mostly conducted at home, on the floor, due to the belief that to appease the 'devs' the mother and child cannot use a bed till one month after the delivery.

Also, as seen in the picture the mother and child have a separate area in the house, where a pit is dug for the mother to wash and clean all the clothes she and the baby use including all the clothes which are used for the post-partum bleeding. The baby is not allowed to wear any clothes for 1 month after birth and is bathed twice a day, everyday.

Another very common practice is the application of a paste of turmeric and oil on the baby's umbilical cord stump to make it heal faster. This however causes infections and sepsis, which has been one of the most common causes for neonatal mortality in this area.

Some of the villages that the 'Gonds' live in are extremely remote and the health services in such areas are practically non-existent. Most of the villages are too small to have their own sub-centers. The one village that does have sub-center has an ambulance only on paper, a medical officer that never actually joined work after visiting the sub-center once the previous year, and absolutely no facilities for referring a patient to the PHC.

My visit to this village, "Bhari", shocked me, not only due to the complete lack of health care of any kind, but also due to the the still existing practice of untouchability there. The community health worker as well as the nurse in this village are from a scheduled caste, and not even allowed in to the part of the village which is inhabited by the Gonds.
Believe me when I say this, I was asked my surname before I could visit the mother and the baby, and the health worker and nurse had to sit outside the house boundary, while we were inside.

'India Shining' indeed.

It would, however, be naive to think that the abysmal neonatal and maternal health in these areas is just a 'fault' of people's belief systems.

The following story, of Savita and her baby boy, is a slap in the face for the so called 'referral-system' in the public healthcare delivery that seems to be more a mechanism to keep under check the no. of deaths RECORDED at each service delivery level than to actually offer better health services.

Doing the absolute right thing, Savita took complete ante-natal care, and delivered her 3 kg baby boy at the nearest sub-center. As the boy was unable to breast feed, the referral system kicked in, with Savita and the baby being carted to the PHC at Jeewti, at a distance of about 25 kilometers. Once the mother and baby reached there, the MO realized there was nothing much he could do and he referred both ahead to the Rural Hospital (RH) at Gadchandur in a vehicle (the diesel to be paid for by the family). There was an obvious delay in any treatment being received by the baby. As the family covered the over 40 kilometers distance and reached the RH, there was no doctor available.

In 1 hour's time, the doctor came (this is at 3:00 in the afternoon on a working day), and examined the baby, and decided that the baby needed resuscitation. As he started to resuscitate the baby, the baby died. Upon the death of the child, he told the family to take the child to Chandrapur (District Hospital) as he wasn't a paediatrician and maybe a specialist would be able to tell them something further. The family knew that the baby was dead and refused to go to Chandrapur, instead focusing on Savita's (seen in the yellow sari) health. The MO said, "Fine, but the baby's death wouldn't be recorded here, as I had referred you BEFORE the death of the child."

As an ashamed member of the medical fraternity, all I can do is look away from Savita while her eyes questioningly look at me asking me what she did wrong. And the system for once can't blame this on her being 'tribal', 'uneducated', or, 'careless'. It is time that doctors, and nurses remembered that they are not 'accountants' but 'life savers'; and the health system enabled this transition.

Thursday, July 21, 2011

Mother & Child Health in the land of the Kolams

Meet Ujjwala, a kolam tribe member seen in the picture above, who delivered a baby boy 8 days back at the place where she is seated now. She has to stay in this KHOPARI (hut) for a period of 15 days from her delivery date while the baby stays in the village with the mother-in-law.

Ante Natal Care recieved by her during the pregnancy was zero, meaning no immunizations, or iron tablets etc. and post-natal care could not be given to either the mother or the child for a period of 7 days after the delivery as no one was allowed to either see or touch them.

In the Kolam tribe, such cases are the norm rather than the exception, and in most cases, the delivery is conducted by the woman alone, and she herself cuts the umbilical cord, using sharp objects such as thin slices of bamboo or sharp stones!

A scheduled tribe with Dravidian features, the Kolams have their unique language (Kolami), a strict religious code of conduct, and a patriarchal and patrilineal organization of society.

In the Vidharbha region of Maharashtra, the Kolam villages are situated mostly in the extremely remote areas of Chandrapur District, in and around a location called Jivati. Their villages are quite unlike the other villages in this region both in the construction of the huts as well as in the level of cleanliness maintained by them. Kolam huts are extremely clean and well-maintained, though the rains do play havoc with the general area's hygiene.

Extremely difficult to reach, with no electricity, most of these villages have treacherous approach roads like the one below, and almost no mode of transport available.

Thus one wonders how the high and mighty health planners and policy makers have conceptualized the health care delivery system based on the population served or the number of people who are to be served by each 'unit' of healthcare delivery, when in areas like this, the distance to the nearest hospital is of paramount importance, and is a much more critical issue. Myopic planning of the public healthcare delivery has not considered the accessibility to the nearest so called 'functional hospital' before forcing 'institutional deliveries' down the throats of the Kolam people.

The picture below is just one part of over 50 kilometers that one has to travel from the PHC (Primary Health Center) to reach this tribal settlement.

How does one even expect a pregnant woman to make this journey??

The Kolams have extremely stringent customs and practices when it comes to the female reproductive cycle. All women of the village, who are experiencing their monthly period are expected to stay outside the boundary of the village in a 'Khopri' or 'Hut', as the one seen in the picture.
This hut is their staying place for the entire duration and they are expected to bathe, carry out their daily ablutions, as well as eat their food in the same place.

The next picture shows the inside of the above 'Khopri' with about 10 women from the village in various age groups.

Any woman in the village experiencing labor pains is also expected to go to the Khopri and carry out the delivery herself.

The delivery is expected to be carried out while the woman is sitting on her hunches and without any interference. Nobody is allowed to touch the woman during or after the delivery. After the delivery, the baby is washed and the woman has to have a bath too, after which elaborate rituals are carried out before the baby can be breast fed. Sometimes, the entire day is spent in these rituals and so the baby is fed up to 10 to 12 hours after the birth. In many villages the baby is still not fed the colostrum or the thick milk that is produced for the first couple of days and instead is given jaggery water or sugar syrup.

The mother has to stay outside the village boundary itself for 15 days after the delivery, while the baby comes inside and is usually with the mother in law. The picture below, shows Ujjawala's mother-in-law Ayu bai, with the 8 day old yet to be named baby boy who has been bathed 6 times a day for the last 7 days, and is not made to wear any clothes, a practice that will continue till the baby is 1 month old.

At the time of the picture being clicked, Ayu Bai was getting ready to carry the baby to the 'Khopri' where Ujjawala was, to get him fed, while it was raining incessantly outside.

A picture of woe and shock? or of the 'force of life' overcoming all odds?? I leave it to you to decide. 

Another India...

6 days old and in high fever....little girls in our country have to fight from the first breath on.

This little baby and her mother stay in their 1 room house which also stores just about 50 bags of fertilizer. The room has no fan, but thousands of flies. This is the village of Sonurli and the baby girl is made to wear no clothes and a wet cloth is wrapped around her head by the mother with the belief that this would bring the fever down. There is no doctor in this village, and the nearest sub-center, which is in another village, stays locked 24 X 7.

At 11 days, this little miracle of nature is being treated not like a blessing but a curse, as she is not the gender the family wanted her to be.

The grandmother can't stop sulking and telling everyone who comes to the house (including me) how unlucky this time has been for them.

The situation in some of these villages is such that people are not ready to let the deliveries happen at hospitals for fear that a woman who delivers in a hospital would bear a girl.

Kolams, a unique people, both in terms of their language and culture as well as their beliefs and practices, have extremely rigid systems of handling both the mother and the child.

Manisha, a 4 month old baby girl, is seen here, happy after her 3rd bath of the day, and relieved after finally being fed after some rituals were completed by her mother.

Tuesday, July 19, 2011

The Gadchandur Chapter

It must have been karma. Getting a posting in tribal Maharashtra, and being a woman.

In a way, I couldn't have been better prepared for this, what with my medical background, public health experience, and the natural advantage to work with maternal and child health, thanks to my gender.

My textbook knowledge was perfect too, mind you. I knew the RCH (Reproductive & Child Health) Programme verbatim, and the provisions of the NRHM (National Rural Health Mission) like the back of my hand. I knew (?) 'rural' and 'tribal' people had too many children, didn't want to go to hospitals provided by the government and were in general, 'non-compliant'. This was my big city education that enabled me to come to Gadchandur, which I couldn't even pronounce or spell for the first few days (it didn't help that everyone whom I spoke to, raised an eyebrow and said, Gadchiroli??). I came armed with the awareness that the field reality wouldn't reflect the textbooks but that they are nowhere in the vicinity of each other was something that the villages around Gadchandur made me learn.

As each day progressed, and I slowly started to 'Unlearn' what years of med school & public health education had taught me, I thought it would be interesting to chronicle my journey for those who can't make it to Gadchandur but would like to be my companions to see health care in general and mother and child health in particular in this area from the viewpoint of somebody who would like to know the truth and be able to make a difference in any way possible.

So, welcome aboard and I hope you are ready to have your beliefs shattered, and your soul shaken up, because health & healthcare in rural/tribal India is not for the faint-hearted!

P.S.: All my experiences and travels are courtesy my work with the Home-Based Neonatal Care Programme of the Ambuja Cement Foundation in Chandrapur District of Maharashtra. I would like to thank the entire ACF, Chandrapur team for making Gadchandur a part of my life.