Day 4: Impact India in the Thane District

I was definitely excited to hear our itinerary had changed and we would be visiting rural communities three hours north of Mumbai. I’ve always been very interested in the cultural differences of rural and urban communities. In college, I worked in an extremely rural Head Start in Ohio’s Appalachian community. Some of the kids traveled 2 hours on the bus to get to pre-school and were very isolated from any other way of life. I saw a lot of similarities between the tribal communities of the Thane District in India and the Appalachian families I worked with in Ohio. One of the main similarities between these two culturally different rural areas is the strong sense of pride as a community. There’s an automatic safety net built in that isn’t as present in urban areas. I think this allows for great opportunity in rural communities as far as health and prevention initiatives because having an established network of support is crucial in educating and promoting health throughout a community.

During our three-hour drive north, we were provided a thorough introduction to all that Impact India is involved in throughout the entire country. Of all the different organizations we’ve read about in class and visited throughout the trip, Impact India was definitely the most impressive. Their mission statement reads: To initiate, augment, and intensify action against those causes of massively prevalent disablement for which there exists a potential for prevention and control, which can be delivered through existing delivery systems and available infrastructure. To treat millions of people who are disabled by curable blindness, deafness and physical handicaps and facial deformities. Through a great example of public/private partnership, Impact India partnered with the Indian railways to make the “The Magic Train of India” or the Lifeline Express a reality.

The Lifeline Express is the world’s first hospital on a train that brings medical services to disabled people living in the impoverished rural communities throughout India. I think what made Impact so impressive to me was in conjunction with the surgical services provided on the train, they’ve established Community Health centers in these rural areas that focus on prevention. Impact is taking that next step necessary to allow these communities to one day provide their own health care with programs that work to prevent illness and disability. The end goal of Impact India is for the Lifeline Express to become obsolete and these community health centers will be the driving force behind reaching that goal.

Rural and Tribal Health, Thane District, Maharashtra

The fifth day brought us respite from Mumbai’s urban jungle as our group headed out into Thane District and rural India. The experiences of this day provided an excellent counterpoint to many of the disheartening conditions observed in the cities.



Our host for the day, Ms. Neelam, Director of Special Projects for IMPACT India took us to visit some very successful public-private partnership enterprises between IMPACT India and the Indian Government (Central and State). We visited a tribal (Adivasi) children’s residential school, a local women’s clinic run by a trained nurse from the Adivasi community, a Government Primary Health Center, and IMPACT India Mobile Eye Clinic, located in various villages about a 100Km outside Mumbai.

Our first stop at the tribal children’s residential school showcased an adolescent girl’s health initiative geared towards providing health education about adolescent health, early marriage and iron/folic acid/multivitamin supplementation. Supplements donated or supplied at low cost by pharmaceutical partners such as CIPLA, are distributed free of charge to the young women who range in age from 10 to 17 years. The girls also undergo periodic check-ups with the government physicians from the local Primary Health Center. One of the most striking things about this experience was how extraordinarily welcoming and friendly the children were and how open the girls especially felt around us. Some of the young women expressed the hope of college studies including medical or nursing school as a means of giving back to their community, yet at the same time they were emotionally attached to their families and wanted to attend only nearby colleges of which only a few exist in rural areas.

Another striking point was how the Government Primary Health Center offered both Ayurvedic and Allopathic medical services as part of the Indian Government’s AYUSH Program. The AYUSH Program integrates traditional Indian medicine systems including Ayurveda, Yoga, Unani, Siddha, and Homeopathy which are primarily used for long-term, chronic treatments. The National Rural Health Initiative includes several sub-programs targeting malaria, leprosy, HIV screening for pregnant women, diarrheal disease, infant and maternal mortality.

A third striking point is the extra-ordinary use of a manual census type system to count and record information on the entire community and jurisdiction served by the Primary Health Center. This detailed, monthly data collection and verification represents updated information that is forwarded to district headquarters for further analysis and allows the Government Health System to modulate services in shorter time spans than the traditional 10-year National Census time block.

The two physicians we interviewed also demonstrated an unique commitment to staying and serving in the rural, tribal areas beyond the requisite 1-year program they signed up for initially after medical school.

All in all, it was very heartening to see tangible evidence of how public-private partnerships can work successfully in the Indian context. Ms. Neelam from IMPACT India further corroborated the importance of these partnership programs as means for the private sector to demonstrate best practices (such as through the LifeLine Train, Mobile Eye Clinic etc) to the Government system and to use the pre-established governmental infrastructure without re-creating systems thereby reducing parallelism and redundancy and possibly increasing confusion.

The long term goals in addition to eliminating and reducing preventable disabilities, is to build local capacity within these rural and tribal communities and to empower them to experience better health outcomes while supporting some (but not necessarily the quackier) of their traditional beliefs and practices.

Is Social Entrepreneurship a Fad?

For today’s blog I was struggling to sift through the ideas and lessons presented from our visit to Dhavari. We were lead by Mr. Vinod Shetty from ACORN India to observe the waste management and engineering savvy implemented by the people of this slum. During the day Dr. Vyas posed the question, “is social entrepreneurship simply a fad?” The sights of the day and the discussion to wrap up our site visit lead to enticing food for thought.

To begin, Dhavari is the largest slum in Asia and home to 1.5 million people. Though this plot of land is a slum, the people have become extremely efficient when it comes to waste management. In fact, their waste management has become a sustainable industry. Over the past 75 years, the people of Dhavari have built a well-functioning society. They have mini factories that process and recycle every piece of cardboard that is found, they make beautifully embroidered clothing, and they even dabble in the dying industry. There are schools in Dhavari, music classes, and doctor and dentist’s offices.

What then is the problem? It took 75 years to get to this point, won’t they only continue upward with time?

No, and the problem is two-fold.

The first half of the problem: the recycling industry resides in the informal sector; the government does not recognize it on any level. These people are considered squatters on the government’s land. They are shunned by society and must struggle for electricity, water, and proper roads. The government could step in at any moment, flex their muscles, and level Dhavari homes to the ground. To prove residency in Dhavari, at least 15 years of dwelling must be provided. The majority of those in this community do not have documentation, in fact, the majority of the population in Dhavari is men who migrate for work and send money home to their families. Documentation is not a commonality. Other contributing factors include a highly Muslim population within Dhavari, creating cultural tension within a mostly Hindu nation and political corruption.

However, the people of Dhavari have created a system that works, for all intents and purposes this community is sustainable. For example, we met a man who owned his own business recycling cardboard. He "owns" the warehouse where he employs 4-6 men who find discarded cardboard in trash heaps and make it usable once again. These men eat, sleep, and work in the same warehouse. Simply put, sustainability is achieved because these men live in the factory. The owner has worked his way up through his industry and may live elsewhere. This hierarchy is replicated in several industries within Dhavari.

—Here in lies the second half of the problem, these slum dwellers have made a sustainable life, but they are not able to come to maximum scale.

--How do you create a better life and cause social change if you can only earn enough to provide for the next day and the next week?

There are two possible solutions; create a revolution demanding change or find an investor.

In our discussion Dr. Parrish framed the challenge well, “have you had enough? It is only when the answer to this question is yes, will things change.”

Let’s first tackle the idea of revolution. Consider the perspective of exploited members of a society where political corruption is prominent, as well as the Karmic belief that reincarnation could bring riches and intelligence in the next life if no harm is done in this life. These political and cultural barriers and infulences alone pose a major challenge.

Next, let’s tackle the idea of investment for this society. This involves understanding and dissecting the difference between social entrepreneurship and pure enterprise. If the idea was strictly profit an investor could come into the slums, see the workmanship involved in the embroidery industry, market and contract the product, produce profit and in return earn more than was initially invested by paying workers the bare minimum. The government does not regulate these people, and there are no unions—profit would be made. However, the goal is scaling up and making social change to better the lives of these slum dwellers. The progression can be viewed as:

Donor invests capitalà workers are trained in a skillà the equipment required to sustain production in this skill is donated to these workersà more workers become trained and achieve sustainabilityà these workers then re-invest capital into their communities in sectors of health and education.

These workers are (1) given the freedom to continue using the skills learned, independent from the initial investor and (2) they are given the choice as to what to do with their earnings. These two factors are key to successful social entrepreneurship.

*Idea for social change + well formulated business plan à sustainable social venture

**An important caveat remains; if people are going to re-invest they must first be invested in their community. This idea might be lost on a population comprised mostly of male, transient-migrant workers.

The sights of the day and conversations had throughout our site visit, debrief, and final evening meeting brought the challenges and promises of the idea of social entrepreneurship into a new light. I have a feeling the surface has only been scratched…

Day 3: Dharavi

It’s taken me awhile to put my experience in Dharavi into words. I’m still having issues sorting through what we saw and the immense socioeconomical implications… so bear with me. After visiting the E. Andheri slums, I was expecting something much different in Dharavi. The first day, in E. Andheri, we were coming in with a medical van and witnessing the immense health and living disparities the residents faced on a daily basis. I felt thrown into the experience with complete sensory overload. In Dharavi, I gained a greater perspective of how the community of 1.5 million plays a role in the larger Indian economy, as well as the impossible obstacles faced by residents of Dharavi to change their socioeconomic status – thus, making the plight of social entrepreneurship even more difficult.

First, we stopped by the ACORN India Foundation offices that sit on the outside border of the slum -- right next to freshly demolished block of land (a scare tactic from the Indian government to show control over the slum). Mr. Vinod Shetty introduced us to the educational programs set in place by ACORN as well as the waste management system implemented throughout Dharavi. Mumbai’s waste was already finding its way to Dharavi, but ACORN was able to systematically legitimize the recycling efforts of Dharavi workers into profitable jobs. It was interesting to hear how ACORN was also working to make the lives of those living in Dharavi more fulfilling through music and sports. Two young boys put on a drum concert with empty barrels to showcase their musical talents developed through the ACORN Foundation.

After learning about ACORN and receiving a brief explanation of the political history surrounding Dharavi, we set out through the industrial side of the slums. It was truly a hidden city within the walls. Small shops lined the mud paths and were filled with workers meticulously sorting shoes, sewing jeans or repairing cardboard. Mr. Shetty emphasized the legitimacy of their work and the importance it plays in the larger economy. The waste from the city was being reused as well as providing the workers a way of life. While these workers have no control over their living conditions, they provide so many material goods to the larger economy – to the point where a majority of the larger industries in India could not survive without them. I couldn’t help but think of the American stereotype of the poor being lazy when I walked through Dharavi… and how untrue that is in this case. The government has excluded these people from society and provided no assistance that they’ve been forced to fend for themselves and have created an entire economy within their community… an economy in which India relies on very heavily.

With each visit throughout our trip, different aspects of social entrepreneurship arise and exemplify the complexity of the field and work involved. It is impossible for immediate change in Dharavi. ACORN and Mr. Shetty (the self-proclaimed bleeding heart) are doing great work enhancing the lives of those within Dharavi but the opportunity to actually change their greater social situation is still lacking. A point that is reiterated throughout this trip is that change takes a significant amount of time in the social sector. That being said, it is important to acknowledge the smaller scale of what ACORN is doing within the community to provide workers with a sense of livelihood and children the chance to take pride in something they enjoy doing – whether it be playing drums or futbol.

Dharavi

Today we visited Dharavi, one of the largest slums in India with a population of over one million people. We met with Vinod Shetty from the Acorn India Foundation to learn about waste management in Dharavi. We all had the chance to learn about Dharavi from the National Geographic film, “The Real Slumdogs,” we watched in class. It was an incredible opportunity to meet with Mr. Shetty and talk to him about his experiences with the Acorn Foundation after having watched the film. Mr. Shetty is a human rights lawyer and has taken an active role in social movements for over 25 years. Only 8% of the workforce is involved in trade unions, and Mr. Shetty is very involved with them. He believes that his organization could bring attention to the workforce in India, which is very important to the survival of the Indian economy. Mr. Shetty mainly utilizes his family and friends as volunteers and to fundraise for the organization. Funds are used to run the community center, pay the salary of one staff member, and the rest is used for basic organizational costs distributed to the various social projects within the Dharavi project. Like most people in this line of work, Mr. Shetty told the group that his motivation for working on the project is because he wants to change the world for the people living in his own city. For him, the only way of living is to be involved in social movements working with people in poverty.

The Dharavi project trains rag pickers in proper methods of waste handling, segregation, and recycling. They use social-impact programs in an effort to change the living conditions of the more than 100,000 rag pickers that segregate waste in and around landfills in Mumbai for a living. There are a lot of negative connotations surrounding slum dwellers as perceived in the movie Slumdog Millionaire. The people living in the slums are there because they don’t have any other choice and the struggle for survival forces them to fend for themselves. Even though they are shunned by much of society, they are fighting for their right to live with dignity. Thousands of tons of waste are processed by rag pickers each day, making this work force essential to the daily operations of society.

Several programs and workshops conducted by the Dharavi project are used to educate and engage young children in music and other arts. When we first got to Dharavi, we visited the Acorn Foundation’s main hub, where two little boys greeted us with friendly smiles. They played their drums and sang for us, and truly sounded amazing. We were all very moved by the performance, and I think that was the moment everything from the last few days really hit me. Watching them perform in all of their innocence made me realize how much potential so many of them have. It is rather unsettling knowing my life is vastly different from theirs, and that all of their potential may go unnoticed or underutilized if social enterprises, like Acorn, fail to succeed in instituting change.

We had the opportunity to walk through the more industrial area of Dharavi. The organization of each industry was not at all what I expected. Even though everything is incredibly dirty and the quality of living is unlike anything we are used to, I was surprised to see how organized each mini industry was, and how efficient their operations were. From an occupational health perspective, I immediately noticed how little to no safety precautions were utilized. Workers do not have gloves, goggles, shoes, or any form of personal protective equipment. The water that runs along the street is stained blue in some areas from dye leaking out from one of the businesses. The noise in some areas was very loud and no workers had any protective ear equipment on. I can only imagine how many occupational injuries take place in Dharavi, and I am sure workplace injuries cause a lot of death and disability.

After having walked through the slums in E. Andheri and now Dharavi, we have witnessed poverty that many endure every day. With so many people living in such a small area, it seems overwhelming that any one non-profit organization or social enterprise could even begin to know where to start and actually make a difference. Especially after the class discussion we had this evening, I am not feeling too optimistic about my ability to design any business model that could actual institute social change and be sustainable for years to come. I know there isn’t much literature available on how to successfully be a social entrepreneur available to teach students, but maybe it is that uncertainty that drew so many of us to take this class. I still feel like I have a lot of unanswered questions and unexplainable emotions, but we are only 3 days in, and each day we learn a little more.

The Women of Aastha Parivaar, and The Women of GW

The past 48 hours in India have exposed me to more diversity than I I have seen in my 28 years on this Earth. The people, the culture, the hardship, the hope, the dignity, the fatigue and optimism we have been seen has undoubtedly been experienced different by each of us on this journey. It is clear that our time here has exposed us to many individuals who are struggling. Whether they struggle with health, violence, cleanliness, harassment, stigma or poverty – they all share a common thread.
Yesterday, we split into two groups and held sessions with Aastha Parivaar. My particular group has the distinct pleasure of meeting with a group of 15 or so commercial sex workers who also had become part of the community based organization (CBO) that educates and supports sex workers throughout Mumbai. Going into our session, I will admit that I was nervous and apprehensive; however, once we arrived it was clear that the women were open-minded, compassionate, positive and genuinely interested and excited to learn from us and to teach us what they know.
Our session was spectacular and was a great success. While we waited for the bus we had the opportunity to sit with three of the sex workers and I used this time to really ask some of the tougher questions that were on my mind, but seemed inappropriate to ask in a larger group. Issues such as violence, the opinions of the husbands of sex workers regarding their profession, family life, career opportunities and harassment were touched upon and it was an incredibly special and moving experience. Of all the questions we asked of them, what the women wanted to know most about us during that small group chat was why we weren’t married with babies yet!
We have had two wonderful yoga sessions since arriving in India and two key takeaways, for me, have been to respect one another and to have an open mind to all different experiences. The women of Aastha Parivaar truly embody these concepts and we could all stand to learn from them. Every day they face hardship, discrimination, harassment and a profession that is challenging in a way we can never truly understand. Each day I am in India, I have tried to remain present so that I can act as a sponge to all of the different interactions we are having and the lessons to be learned from them.
Traveling in a group of almost 20 women, from all different backgrounds and perspectives, can be a challenge. I doubt that anyone on this journey will disagree! The inherent diversity of each individual is what makes for a rich learning environment and I am learning everyday not only from the “India experience” but also from each person I am experiencing India with. What I may see as optimistic and hopeful, a friend may see as depressing – this simply provides a wonderful opportunity for conversation and social learning.
Each day I have been impressed, and sometimes overwhelmed, with this trip as a whole. In our on the ground orientation, Dr. Vyas addressed how each individual here would experience India in their own way. Some may be extremely extroverted about it and want to share every detail and some may be more timid, wishing to process internally and keep their individual feeling to themselves. Both are ok and I certainly find myself wavering somewhere in between.
India is unpredictable, and that is part of the charm. The one thing that I can predict is as we continue on this incredible trip we will be able to learn not only from the meetings and projects that are part of our curriculum, but also from each other.

Day 2: The Empowered Women of Aastha Parivaar

As you’ve heard from the other bloggers, we visited Aastha Parivaar yesterday and gave a presentation on reproductive health to a group of Indian sex workers. It was an incredible opportunity to practice our real-world health promotion and education skills with an extremely at-risk population eager to learn. In most public health interventions or health education programs within the US, cultural differences often create a barrier to effectively communicate with different groups of people. That wasn’t the case at Aastha Parivaar. We were welcomed with smiles and there was an immediate sense of mutual respect.

Our presentation didn’t go quite as planned as we worked through the language barriers and gauged their expectations for our session. It showed how important it is to be flexible and really read your audience in order to get your message across. I’m not going to lie… I was a little nervous going in to the session. Not because I didn’t think our presentation was thoroughly researched or anything along those lines. It was more based on the fact that I’ve never given a reproductive or women’s health presentation before, and given our audience, I just didn’t know how it was going to go. Everyone did a fabulous job presenting the material in a positive, uplifting manner and really engaged the group…. even with the impromptu female condom demonstration. I was very surprised at how many educated questions we received from the women. It was clear that the work Aastha Parivaar has done thus far to educate and empower these women has been extremely effective.

During the introductions for the session, we learned that a lot of women in the group were peer educators and working on different health education topics themselves. When we completed our portion of the presentation, they showed us the different activities they use to inform other sex workers of the risk to their trade. It was clear that the main tenet to their health education is HIV prevention. They demonstrated how HIV can spread through a network of people as well as promoted getting tested for HIV.

As we waited for the bus we were able to sit down with a few women and ask more personal questions about working in the sex trade. It was extremely interesting to find out that these women are the bread winners in their families and therefore find supportive husbands waiting for them at home after they make the 20 kilometer trek into work 7 days a week. They prefer to keep their children unaware of the work they do so they don’t fall into the same circumstances. We asked why not look for some other form of income but unfortunately these women are discriminated against because of what they do. They also wouldn’t be generating the income they do now working anywhere else. Although they feel trapped within their trade, the group we spoke with was empowered through the education they receive from Aastha Parivaar and able maintain control of their bodies even within such a dehumanizing industry. I couldn’t help but leave with a sense of pride for our team of health educators. We're not only learning about Indian culture through experience but also how to work effectively as a team.